The stories shared revealed an expansive and complex spectrum of factors that were associated with smoking in AHWs. A majority of AHWs spoke of a desire to quit smoking, but told of many factors that prompted and reinforced smoking in their lives. Nicotine addiction and individual associative behaviours are but one small part of the story. Rather, multilevel and interrelated sources of stress were evidenced by countless accounts of the burden of chronic disease, family obligations, workplace instability, job demands, social disadvantage and racism, to name but a few. In this context, smoking was used by AHWs as a means to cope with the multitude of life’s challenges. These findings highlight that to view smoking through the lens of nicotine addition and individual choice is myopic. Consistent with prevailing approaches to promoting health in Indigenous populations, a holistic social ecological paradigm clearly positioning the individual within their environmental context is essential to understand the factors that perpetuate smoking in AHWs [22, 42].
AHWs were cognisant of being members of a small and disadvantaged population, and described experiences of racism and discrimination. Institutionalised racism and micromanagement were stressors more commonly identified by AHWs working in government-controlled health services compared to community-controlled organisations. The predominance of these stressors in government health services - where the Aboriginal health team sits within a larger non-Aboriginal workforce - may be precipitated by the tarnished history of colonisation that perpetuates a lack of trust between Aboriginal and non-Aboriginal Australians. It could be that the chronology of repeated abuse, disrespect and dispossession since white settlement and the ongoing traumatisation due to racism and disadvantage may propel Aboriginal people towards seeking connection and belonging through smoking.
A majority of AHWs spoke of widespread acceptance of smoking in Aboriginal families and in the community. The extensive history of nicotine ingestion in traditional Aboriginal society coupled with the promotion of tobacco habituation during colonisation has likely contributed to a normalisation of smoking in contemporary Aboriginal society. Daily exposure to smoking at home, at work or in the community provided constant reminders and frequent opportunities for AHWs to smoke with others. The key role of smoking in promoting social connectivity found in AHWs is consistent with the view of Roche and Ober : ‘Sharing a cigarette has also become one of the ways in which indigenous people have been able to reaffirm, strengthen and maintain their cultural identity in an environment that is often hostile and constantly changing’ (p. 130). Though smoking was viewed as negative in terms of the long-term health impacts, in the short-term it was viewed by some AHWs as an effective health promoting behaviour. There were some respondents who felt that smoking was the only thing in their life that made them feel calm, enabled them to connect with others, and helped them cope with the stress and responsibilities in their life. Similarly, smokers in the general population report benefits from smoking (such as socialisation, stress management and relief from boredom) . Clearly, any strategies to support AHWs to quit smoking must provide healthful alternative means to promote social cohesion and manage stress.
Knowledge of the multilevel factors associated with smoking in AHWs can inform the development of health service smoking cessation programs. Our data suggests that multidimensional programs are needed that target individual factors as well as the social and environmental factors perpetuating smoking in AHWs. This is in line with ecological approaches to prevention aimed at reducing the burden of cardiometabolic diseases in Aboriginal populations by addressing the direct and indirect factors that perpetuate behaviours like smoking . To address the direct response that comes from the habituation of smoking, the findings provide key biological and behavioural targets at the individual level (e.g. Nicotine Addiction
Stress) that may be ameliorated through such strategies as nicotine replacement therapy and counselling (e.g. counselling regarding behaviour change strategies and stress management). A number of strategies can be mounted to address the indirect environmental factors associated with smoking. At the interpersonal level, Co-worker, Family, Friend or Client Encouragement could be addressed through culturally-relevant social marketing campaigns and smokefree workplace policies that challenge the normalisation of smoking at home and at work. Organisational stressors such as Demanding Work and Institutionalised Racism and Cultural Insensitivity could be addressed through organisational change processes where the health service clarifies the scope of practice of AHWs and institutes cultural competency training for non-Aboriginal staff to promote cultural respect in the workplace. In future work, researchers will engage stakeholders to identify culturally-relevant strategies that address the multilevel factors that perpetuate smoking in order to promote cessation and abstinence in AHWs.
The factors associated with smoking for a given individual were uniquely distributed, depending upon their personal characteristics, relationships and environmental context. Hence, programs that can be tailored to local needs are indicated. Given that we comprehensively collected the perspectives of AHWs from a broad range of settings within government- and community-controlled health services, the findings of the study are potentially transferable to AHWs and health professionals in a similar role in other regions across Australia. The findings may also be relevant to Indigenous populations in other countries sharing a similar history of colonization and tobacco use.
Despite a range of strengths, this work has limitations to consider. The interviewers were of non-Aboriginal descent, and this cultural difference could have negatively impacted the data collection process. Perhaps because the Tackling Tobacco Coordinator vouched for the sincerity and credibility of the research team, and because there was a respected Aboriginal person as a chief investigator on the project, the interviewees appeared comfortable with interviewers and were happy to share intimate details of their experiences. The trust afforded by participants may reflect the strengths of the participatory process that guided the project methodology, such as taking the time to develop relationships with the health services and returning the findings to AHWs and Aboriginal stakeholders for interpretation and refinement . However, there are likely to be some individuals who chose not to participate in interviews and discussions because they did not feel comfortable talking about their personal life with a non-Aboriginal researcher. Further, we are likely to have missed the personal views of individuals who felt sensitive about their smoking addiction and unwilling to discuss it (as they would not have volunteered to interviews). The use of shadowed data in this work , where respondents shared stories about the experiences of others, compensates in part for this. In one example, an AHW ex-smoker shared her observations of the quitting challenges of an AHW colleague (who hadn’t volunteered to participate) who was stressed by the workplace environment.