Deadly declines and diversity – understanding the variations in regional Aboriginal and Torres Strait Islander smoking prevalence

Tobacco use among Aboriginal and Torres Strait Islander peoples has declined over the past two decades, from 50% of adults smoking daily in 2004–05 to 40% in 2018–19.1,2 This included a 12% decline among those in urban/regional areas (49% to 37%) while there was no detectable change in remote areas (52%).2 Tobacco use is influenced by a range of factors, including the ongoing impacts of colonisation which entrenched tobacco use through tobacco rations in lieu of wages until the 1960s,3 with half of all Aboriginal and Torres Strait Islander deaths attributed to smoking among those aged 45 years and over.4Aboriginal and Torres Strait Islander tobacco control requires a comprehensive, multifaceted, locally tailored approach while addressing the social determinants, including economic and educational exclusion.5,6 National policies and programs include the regional Tackling Indigenous Smoking (TIS) program and whole of population tobacco control measures.7-9 Priority investment in Indigenous tobacco control commenced in 2008 with substantial policy shifts and funding declines over the subsequent period of implementation.8 There was a 9% decline (52% to 43%) from 2004–2018, compared to a 3% (55% to 52%) decline from 1994–2004.10TIS funds local organisations to develop population health tobacco control initiatives. This flexible delivery promotes self-determination with community-controlled programs meeting local needs and contexts. The challenge comes when evaluating the impact on Aboriginal and Torres Strait Islander smoking nationally, with this diversity concealed in the aggregated figures. Further, while TIS is a national program, there is not national program coverage and over one quarter of Aboriginal and Torres Strait Islander peoples live in areas outside the TIS serviced regions.11,12In 2017, Wright et al.13 explored the potential for tobacco policy to be informed by more granular estimates, at the Indigenous Region level.14 However, no significant differences in smoking prevalence in any Region between 2012–13 and 2014–15 were detected.13 We updated this work to include 2018–19 data, and explored if any changes had occurred in smoking prevalence in the 37 Indigenous Regions from 2012–13 to 2018–19.