“We Made the Rule, We Have to Stick to It”: Towards Effective Management of Environmental Tobacco Smoke in Remote Australian Aboriginal Communities
2.1. Critical Realism
2.2.1. Policy Environment
|Date||Top End Tobacco Project progress||Selected national and jurisdictional policy development and implementation|
|2007 Jun||Australian Government announces the NT Emergency Response (NTER) to protect Aboriginal children from sexual abuse. |
Includes deployment of army in communities
|Jul||Community engagement visits commenced|
|Aug||Legislation in support of NTER passed including Welfare Payment Reform establishing compulsory income management and suspension of the Racial Discrimination Act 1997|
|Nov||Change in federal government|
|2008 Feb||Prime Minister delivers Apology to Australia’s Indigenous peoples|
|Mar||Statement of Intent between the Government of Australia and the Aboriginal and Torres Strait Islander peoples to achieve equality in health status and life expectancy by 2030|
|Mar||Federal Government commits $14 million to address high smoking rates among Indigenous peoples|
|May||Community baseline surveys commenced|
|Jul||NT Local Government reforms reduce 61 local governing bodies to 16|
|Aug||Community feedback of survey results commenced|
Tobacco Action Group formed in Community 1
Intervention components commenced
|Dec||National Partnership Agreement (NPA) on Closing the Gap in Indigenous Health Outcomes signed|
NPA on Remote Indigenous Housing signed
|2009 Feb||Baseline surveys completed|
|Mar||NT Tobacco Summit develops NT Tobacco Action Plan|
|Jul||NT Health Department implements Smoke Free Policy for all services & facilities|
|2010 Feb||National Coordinator to Tackle Indigenous Smoking appointed|
Start building new houses Community 1
Start building new houses Community 3
|Mar||Smoke-free (SF) house signage Community 1||Formal signing of Local Implementation Plan Community 3|
|May||Announcement of anti-tobacco workforce targeting Indigenous peoples. 82 initial positions nationally|
|Aug||Community follow-up (FU) surveys commenced|
|Nov||Formal signing of Local Implementation Plan Community 1|
|2011 Mar||Formal signing of Local Implementation Plan Community 2|
|Apr||Start building new houses Community 3|
|Jun||SF house signage Community 2|
SF store opens Community 2
|Aug||SF signs Community 3|
|Sept||FU surveys completed|
|2012 Jun||Community 1 Local Reference Group (LRG) reviews Local Implementation Plan, decides to focus on passive smoking|
|Aug||FU survey feedback completed|
Community 1 LRG & TETP workshop to develop Tobacco Action Plan (TAP).
TAP endorsed at LRG General Meeting
2.2.2. The Top End Tobacco Project
- Further selected findings from community surveys of self-reported tobacco use undertaken in 2008/09 in the three remote communities described above. Participants (n = 400 ≥ 16 years) were opportunistically recruited from community members, using quotas to reflect age and gender balances. Those current and former smokers who had made quit attempts were asked to provide information about relapse. They were also asked what their concerns were about tobacco use in the community and to provide suggestions for actions to address these concerns. Using structural coding, responses were grouped into categories agreed upon by authors JR and LS.
- Field notes of direct observations, including transcripts of community-level discussions relating to ETS, made during community visits by the research team over the five year period of the TETP. Three case studies relating to the management of ETS were chosen for this paper in order to try and represent activities across the study communities.
2.2.4. Cultural Setting
3.1. Baseline Survey Data
3.1.1. Quit Attempts and Relapse
3.1.2. Community Concerns about Tobacco Use
3.1.3. Community Suggestions for Action
|Community Concerns about Tobacco Use/Smoking|
|Occasions of Mention|
|Most frequently occurring themes||Female||Male||Total||Selected participants’ comments|
|(n = 136 */194)||(n = 166 */206)|
|Health (own or others)||47||58||105||Shortwind when running. Worry about dropping dead.|
|Dangerous—lots of people short of breathing. Asthma. Cancer. Pregnant smokers have skinny babies|
|Young age of uptake/kids smoking||33||29||62||Kids starting to smoke younger than 10|
|Little kids smoking…watching and copying others around|
|Passive smoking||18||10||28||I worry about breathing in other people’s smoke|
|Young mums smoking around babies|
|Poor role model||6||6||12||Smoking next to kids, that’s not good and they look at us smoking.|
|Little kids…watching and copying others around|
|Addiction||3||8||11||We can’t stop bakki (tobacco), never|
|I can’t sit without ngarali (tobacco)|
|Community Suggestions to Reduce Smoking Tobacco Use/Smoking|
|Occasions of Mentions|
|(n = 113 */194)||(n = 138 */206)|
|Health promotion||25||49||74||Never get kids to light up (others cigarettes for them)|
|Activities||Need to have pictures to see that ngarali (tobacco) is a killer.|
|Make resources in Yolngu Matha (language)|
|Quit support||19||26||41||Need to learn about ways to quit|
|Provide gums and patches. We have enough information now. There is no need for more. Just need to give up|
|Supply reduction||19||13||32||Tell factory not to sell cigarette because it kills people’s hearts and minds|
|Should ban tobacco in the community|
|Ban smokes from the shop|
|Diversionary activities||19||13||20||Go out bush long term. To an outstation for 3 or 4 weeks and give up there. Lots of hunting and fishing and collecting bush tucker. Teach the kids to make spear then get kids off cigarettes|
|Smoke-free spaces||12||3||15||First step is to encourage people to smoke outside—special smoking areas so the butts aren’t everywhere|
|Make the houses and streets smoke-free|
3.2. Observational Data from Intervention and Follow-up Survey Phase
|Analysis of Case Studies Using Critical Realist Approach|
|Case Study1||Community 1|
Couple wanting manage ETS in their home to support smoking cessation
Ceremonial and cultural connections to tobacco
Community 2 & 3:
Wanting to manage ETS in their home due to concerns about passive smoking
Wanting to take stronger steps to managing ETS as shifting into newly built homes
Quit attempt encouraged by smoke-free workplace policy
Use of local language and images of community member
Use of style of speech appropriate to the community
Managing relapse prevention by reducing cue exposure
Negotiation of physical boundaries to manage ETS in homes
Funding supplied by commonwealth tobacco-specific taskforce
|Smoke-free signage for homes|
Theme of signage replicated in other communities
|Case Study 2||Community 2|
Many community members visit store daily or more
Store verandah viewed as public space for socialising
Few public spaces shielded from the sun and rain
Store managers reluctant to enforce legislation under NT Tobacco Control Act
|Strong community leadership (translation to action)|
Local committees/groups with authority for tobacco action (Clan leaders group, Store committee)
Collaborative approach (Clan leaders group, store committee, store management, research team)
Store management actively committed to tobacco control
Effective enforcement strategy included signage and a designated person
|Smokefree policy for community store|
|Case Study 3||Community 1|
Local Implementation Plans that require action on reducing tobacco use up for review.
LRG (community representatives) decides to focus on “passive smoking”
|Local Tobacco Worker LRG member—keeps tobacco on the group’s agenda|
Workshop developing tobacco action plan informed by recent tobacco research in community
Clear sense of ownership of the TETP data by the community
|Community Tobacco Action Plan targeting ETS|
“A policy which is embraced by a Minister, approved by Cabinet, announced publicly, but inadequately delivered is worse than no policy at all…”.Secretary of the Department of the Prime Minister and Cabinet 
5. Conclusions and Recommendations
Conflicts of Interest
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Robertson, J.; Pointing, B.S.; Stevenson, L.; Clough, A.R. “We Made the Rule, We Have to Stick to It”: Towards Effective Management of Environmental Tobacco Smoke in Remote Australian Aboriginal Communities. Int. J. Environ. Res. Public Health 2013, 10, 4944-4966. https://doi.org/10.3390/ijerph10104944
Robertson J, Pointing BS, Stevenson L, Clough AR. “We Made the Rule, We Have to Stick to It”: Towards Effective Management of Environmental Tobacco Smoke in Remote Australian Aboriginal Communities. International Journal of Environmental Research and Public Health. 2013; 10(10):4944-4966. https://doi.org/10.3390/ijerph10104944Chicago/Turabian Style
Robertson, Jan, Boris Shane Pointing, Leah Stevenson, and Alan R. Clough. 2013. "“We Made the Rule, We Have to Stick to It”: Towards Effective Management of Environmental Tobacco Smoke in Remote Australian Aboriginal Communities" International Journal of Environmental Research and Public Health 10, no. 10: 4944-4966. https://doi.org/10.3390/ijerph10104944