Data from the focus groups and individual interviews were similar in providing individual, personal experiences, with the exception that the clinician's focus group also discussed issues from the perspective of people providing community services. While there was some variation in responses between older women and younger women, as reported here, there was no clear pattern by parity or location. Women who had never smoked reported different personal experiences to those who smoked, but their views of the factors influencing smoking behaviour were similar to those who smoked.
Results on environmental factors influencing smoking are presented first, to provide the context for smoking behaviour, followed by the results specific to smoking initiation. In the following sections we elaborate on the four themes which provide insights into the social context in which Aboriginal girls in these communities start smoking: colonisation and the introduction of tobacco; separate Aboriginal social networks and normalization of smoking within these networks; disadvantage and stressful lives; and the importance of maintaining relationships.
Contextual factors contributing to the high prevalence of smoking
Colonisation and introduction of tobacco
European colonisation created extensive disruption to Aboriginal society including dispossession of traditional lands, movement of people, removal of children, loss of traditional lifestyle and introduction of tobacco and alcohol[
49]. The introduction of tobacco by Europeans together with other lifestyle changes, were raised by participants in each of the focus groups and by some older women in interviews. People no longer live traditionally and with the lifestyle changes, women reported less respect for elders and the loss of other traditional behavioural constraints. It was recognised that traditional smoking had occurred in other parts of Australia, but in the context of ritual and ceremony, with limits around smoking which no longer apply. Tobacco is now readily available with few social proscriptions on its use.
So there was things that were in place, there were controls put in place, whereas now we have no controls. Stuff comes in, anybody can smoke anything,... there's no rituals.....
Clinician's focus group
We never had smoking from our previous ancestors, we never had smoking. It has a lot to do with Western society bringing it,...... If it was never introduced, same as alcohol, then maybe we probably wouldn't have people smoking, yeah........ It's changed our whole way.
41 year old ex-smoker, mother of 6
Social networks and community norms
Despite mostly living in towns with large populations of non-Indigenous people, the Aboriginal population tends to remain relatively socially separated from the non-Indigenous population. This, combined with different social norms regarding smoking creates a situation where many people have limited interaction with non-smokers. The participants described very separate Aboriginal social networks embedded within the broader community. The CRG discussed this issue extensively and confirmed that local Aboriginal people mainly interact with other Aboriginal people. They indicated that this is partly due to a preference for socialising with relatives and others who share similar culture, values and history, and the strong social support gained through these networks. However, it was also thought to be due to experiences of exclusion or marginalisation from mainstream society in regard to participation in work, school and other civic activities. While some Aboriginal people in the community have jobs, many do not. For these people there are limited opportunities for interaction with the broader community's social institutions and people, and the extent of social separation is greater.
The participants reported a high prevalence of smoking within the Aboriginal networks which then leads to a perception that smoking is normal and part of Aboriginal identity. The limited interaction with the broader community also limits exposure to non-smokers and to changing attitudes to smoking. Women reported that smoking was generally acceptable provided household rules around smoking outside or away from children or sick people were respected.
When you don't smoke you stand out a bit, you feel a bit odd.... Cause everyone around you smokes. Everyone that I know smokes. There is not one person that I know in [town] who doesn't smoke. So like, it is a bit hard [not to smoke].
24 year old smoker
I reckon about 95 per cent of Koori people smoke........Every household just about like I say, 95 percent have got people smoking.
33 year old smoker
Disadvantage and stressful lives
Women in these communities suffer from excessive levels of daily stress as a result of numerous social, emotional and financial pressures. High unemployment and associated poverty lead to difficulties finding affordable housing. Overcrowding is common as extended family and friends frequently stay for lengthy periods, exacerbating financial and social pressures. Relationship difficulties and loss of family members through death or removal of children further contribute to high stress levels. Participants considered that these frequent daily stressors contributed to the high prevalence of smoking and other substance use, as these were used to provide temporary relief.
Many participants spoke about grief and loss in their everyday lives. During the period of data collection there were many deaths in the Aboriginal community, including two of the participants. The frequent and often premature deaths mean that funerals become an everyday event, which both bind the community together and cause considerable grief. Several of the women interviewed had lost one or more of their parents as children, either through death or being removed from parental care. Others had experienced removal of their own children, and there were many stories of physical and sexual abuse of children. Many women had also experienced violence and/or sexual abuse as adults.
I was only with this bloke for 2 months - I got kicked out of my place, he had holes in my walls. I just left everything all my possessions,... and went to where I could get support from family..... Now back on my feet now all I need to do is get a place.
and
I was molested by the same people that looked after me, my mum's sister's husband. My mum died when I was like 8 and we didn't pretty much know dad. He died.... I nearly tried to kill myself.
Interviewer: And what did your aunty do...?
She didn't know nothing. I didn't tell her because she was dying of cancer...... I kept strong for her, held it in you know.
28 year old smoker
They also described experiences of perceived racism including difficulties finding housing and jobs, police harassment and being confronted with negative stereotypes. They felt this reflected the lack of interaction between Aboriginal and non-Indigenous people. The experience of racism, combined with grief and loss, ongoing violence, high unemployment and lack of housing, created high levels of stress in the women's lives on an ongoing basis.
Maintaining relationships and sharing
Relationships with other members of the extended family and community are highly valued in Aboriginal culture and may be given priority over individual needs. Maintenance of these relationships involves considerable social interaction and reciprocity with obligations to share time and resources, including food and accommodation. Participants described extensive and complex relationships, both within the extended family and the larger Aboriginal community, with family and friendship networks extending over large geographic areas. Obligations to give cigarettes to others were described by nearly all participants and many also described an obligation to accept offered cigarettes. Sharing a cigarette and having a yarn, was an important social activity, contributing to a sense of belonging to the Aboriginal community.
While providing cigarettes to others was sometimes resented due to their high cost, they were seldom refused. Older women mentioned family arguments resulting from the obligation to share cigarettes, and themselves resorting to hiding part of a packet in order to reduce this obligation. The willingness to share appeared more common among younger women who possibly had fewer financial responsibilities or less established nicotine dependency.
Don't believe in arguing over smokes, you got it, you give it, you don't, you can't.
17 year old smoker
They'll ask (partner) and they'll get him on his own when I'm not around.... When he gives out smokes that's when I get shitty. Don't give them smokes, come back here and gives us smokes first and then we'll give you a smoke, 'cause we ain't rich......
28 year old smoker
Initiating smoking
The 20 ever-smokers among the women interviewed individually reported starting at a mean age of 15 years (range 12-21) and becoming regular smokers at a mean age of 16 years (range 12-21). Every participant expressed the view that children were starting smoking at a younger age now than previously, with many children starting at age 12 or 13, and some starting younger.
Within the context of separate Aboriginal social networks, considerable disadvantage, and a high prevalence of smoking, young girls use smoking to attain status and assert their group membership and Aboriginal identity. Family and social structures, while providing strong supports, limit the capacity of individual parents to influence their children not to smoke, and provide children with ready access to cigarettes. The experience of marginalization is considered to contribute to limited opportunities and aspirations for young people, leading them to seek pleasure in the present rather than having goals for the future. We elaborate on these themes below.
Peer influences and needing to belong, smoking as status
Peer influences were manifested through girls wanting to be like others, socialise with them and belong to their group rather than through overt peer pressure. Transition from primary school to high school was a particularly vulnerable point where girls negotiated new relationships and used smoking as symbolic 'adult' behaviour to gain status and be accepted. In describing their own experiences, women emphasised the role of Aboriginal peers, particularly cousins and friends, in influencing them starting smoking. Most reported having their first cigarette because of the social aspect of smoking, wanting to fit in with their friends and belong to the group. Some women reported having their first cigarette while drinking with friends or family and that smoking was just part of the whole social process. While most women did not feel pressured to start smoking, a few did describe feeling pressured, and despite not wanting to, smoking in order to belong. However, the emphasis expressed by the vast majority related to the desirability of belonging and participating in the social activities of the group, more than a pressure to smoke.
Friends, friends. Because when I first started smoking my influence was my friends were smoking and I thought well they're smoking so I've got to start smoking. Yeah, so it's more a friends thing, and sometimes it can be you see your parents do it as well.
24 year old, started age 15
Although they described some mimicry of smoking and experimentation with cigarettes among very young children, regular smoking among primary school children was uncommon and children would often tell adults they shouldn't smoke. However, once children went to high school they rapidly took up the habit. Many participants felt that the main motivator among young high school students was to appear older, 'cooler' and to be accepted by older adolescents in the school. The transition to high school was difficult, particularly for children who didn't engage well with the school system, and smoking was thought to be used by children to attain higher or 'adult' status.
Participant 1 As soon as they hit high school, that's when they're into it straight away.
Participant 2 Some of the young ones, like some young ones at home, that hang around with high school ones... and they think they're real deadly and they'll give them a couple of draws but they might not full on start, but once you get to high school - its gone!
Young women's focus group
When I was a young girl, I was in this group and most were older than me and it was like a cool thing, all your friends are doing it. I felt left out so I just started asking. I thought I was a big
woman [laugh]. I was only 13. I didn't like it though
33 year old smoker
Development of identity
Growing up in a marginalised social group where smoking is a normalised and common behaviour, children are socialised to smoking from an early age and may incorporate it into their sense of identity. Internalisation of a smoking identity as part of their overall identity was described by many women and discussed by the CRG. For children growing up in Aboriginal families where smoking is common, smoking becomes incorporated into their identity and becomes blurred with their Aboriginal identity. The women felt that there was an unspoken expectation that children would become smokers.
Your mob smokes, so it's in your blood to do it.
19 year old smoker
I dunno it's almost expected isn't it like?... I dunno, I never thought about that, but yeah. Probably it's almost expected.
33 year old smoker
Social structure and parenting
The extended family structure and communal network among Aboriginal people are strong in both the geographically isolated communities and within the larger towns. Many households are large and fluid, with people coming and going, and extended family members of multiple generations living together for lengthy periods. Raising children is often communal, with extended family members or friends frequently caring for children. The social structure of Aboriginal communities and shared child-raising, when combined with the high smoking prevalence, was identified as contributing to children initiating smoking. Individual parents have less control over their own children's behaviour, and there are fewer clear behavioural limits with children frequently exposed to many people smoking.
[People start smoking] younger in the Aboriginal community, because they're all around each other.... all their family is one big family.... all together.... Most of the parents out there don't teach their kids or it's other people doing it for them. It's other people because mainly someone's always watching them.
23 year old smoker, mother of 2
Women expressed paradoxical views regarding parental ability to influence their children's smoking behaviour. Although most women felt that the high prevalence of smoking among their parents and extended family had been influential in normalising smoking and making it more acceptable for them to start, they did not think that parents could influence children not to start smoking. Only one woman thought she would be able to influence her children not to smoke because neither she nor her partner smoked. Most women who were parents were resigned to the idea that their children would smoke.
Yeah I always think to myself I don't want my boys to smoke cigarettes... but like if they're going to do it then they're going to do it. I can't stop them from doing it. I'll try, but I know I'm not going to be able to.
24 year old smoker, mother of 4
When asked where children obtained cigarettes the smokers reported that they had obtained cigarettes from friends and cousins, or by taking them from adults' packets. The high prevalence of smoking, combined with the highly connected communal structure meant there were many possible sources of cigarettes. No one was aware of shops which sold cigarettes to minors, but some reported adults buying packets for children, or giving them single cigarettes, particularly if they were related to them and felt obliged to share their cigarettes. Others reported that adults were less likely to give children cigarettes now than in the past, due to increased awareness of the problems with smoking.
Lack of opportunity and present orientation
Limited opportunities for adolescents in rural towns and villages are exacerbated by marginalisation and felt more profoundly by disadvantaged groups with limited resources. Lack of opportunities may create boredom, limit aspirations and lead to a focus on immediate gratification. Participants believed that limited opportunities for Aboriginal children and adolescents in the region contributed to early initiation of smoking. In smaller communities, lack of local sports facilities combined with poor public transport, made it very difficult for children to engage in sports or other activities. The clinician's focus group and some older women also thought that lack of employment prospects resulting from limited social connections and racism played a role, as it inhibited the ambitions of high school children. These children then perceived little benefit from applying themselves in school and had few aspirations for their future. The clinicians reported difficulty motivating children and adolescents, as it was difficult to demonstrate success.
How are we supposed to stop people from having anything like that when, you know, it's hard to even get them to keep going to school....... when they're closer to leaving school age, and they know there's nobody in their family or anybody has got a job...
Clinician's focus group
The boredom and lack of routine among unemployed adolescents who had left school also contributed, with some young people living hedonistic lifestyles with little concern for the future. The participants in the young women's focus group expressed an orientation toward pleasure rather than concern for their future health.
Participant1 That's how you think - I'm going to die anyway, I might just do what I'm enjoying.
Participant 2 Like we gunna die of something
Participant 3 Yeah, instead of thinking 'Oh, I could give up and go and have a really good, happy, healthy life and live longer'....... Like you don't really think that way, you just think I enjoy this, I'm going to do it whatever.
Young women's focus group
Protective influences
Anti-smoking parental advice and role modelling; and success in school, sports or other activities provided a protective effect from early smoking initiation for girls. Involvement in competitive sports gave girls an incentive to keep fit, friends who were non-smokers and disapproved of smoking, and alternative ways to gain acceptability and status. Several women reported only initiating smoking after discontinuing competitive sports, and consequently had started later than the other participants. The women who had continued their education to year 10 or beyond had also started smoking later than women who left school earlier.
Sport tends to help them. If they're very into sport that usually will help them find another avenue, and also other non-smokers to go with. So it's not cool then. They might say they're bloody stupid or something.
Clinician's focus group
I started when I was 21.... I wish I was still fit, that I didn't start smoking....because I never was interested in smoking, like I wasn't even really into boys....I was worried about school and my sport.
24 year old smoker
The two participants who had never smoked had been involved with sports, and one continued to play several sports. One also expressed concern with her health and emphasised the importance of her family influences - neither of her parents smoked and they had educated their children about the dangers of smoking, none of whom took up smoking. She described warning her own children about the dangers of smoking, and trying to ensure they weren't exposed to other people's smoke.
I didn't like the stuff. And my parents made us aware of it growing up. They just, you know told us if you want to smoke you know it's bad for your body, bad for your lungs and it's better, best to be clean.
25 year old, never smoked