The stories shared during the interviews and focus groups highlighted an array of factors related to smoking in AHWs. Some factors were frequently or consistently identified, and others were unique to particular interviewees. Factors associated with smoking were depicted as (1) perceived environmental and individual stressors that elicit a stress response (i.e., frustration, anger, anxiety) in AHWs, (2) social norms or expectations that elicit socially acceptable behaviours in AHWs, (3) environmental cues that elicit a conditioned response in AHWs (e.g. drinking, gambling); and (4) a biological response to the addictive properties of nicotine. The former three classes of factors associated with smoking are indirect with their origins located in the environment while the latter class reflects a direct biological response that comes with the habituation of smoking. All these factors, whether direct or indirect, play a role in the maintenance of smoking, including smoking relapse. Figure 1 depicts the factors associated with smoking in AHWs, present at various levels of influence in the social ecological framework. In particular, it illustrates the range of factors related to smoking that exist beyond the level of the individual.
Given that the analysis sought to identify the factors that perpetuate smoking, and these were often related to life stressors, the findings presented here paint a somewhat pessimistic view of some aspects of Aboriginal society and experiences. As such, the discussions that follow neglect elaboration of the positive characteristics of Aboriginal life. This is not meant to imply a resounding negativity in relation to AHWs and their lives but rather reflects the biases and focus of the research. Indirect and direct factors associated with smoking are highlighted in bold italics in the text that follows and are contextualised with evidence from other population samples where relevant.
Personal factors
Stress emerged as a pervasive trigger for smoking in the stories shared by the participants. Sources of stress varied greatly; they included, for example, stress due to relationships and family issues, financial problems, community issues, and work challenges. Mark and colleagues [11] also identified stress was related to smoking in their small study of AHWs, and Lindorff et al. [30] found that stress was the primary reason why the general Aboriginal and Torres Strait Islander population smoke. AHWs spoke about smoking as a means to cope with stress:
It just seems to relax me when I’m experiencing those high level stress situations, I know it’s bad for me and yet I do it.
Features of life present at the individual and five peripheral levels of influence (family, the health service, and so on) indirectly perpetuated smoking behaviours through increasing stress in AHWs. In these instances, smoking was used as a stress management strategy. For example, a small number of AHWs identified that they smoked as a means to cope with having Poor Health (e.g. anxiety, depression, chronic disease, back pain). As an AHW smoker described:
It helps me deal with the pain stuff because the pain makes me feel more agro and niggly towards myself and I get a bit weird and just snapping at other people and in my head I have convinced myself that a cigarette will stop me from doing that and calm me down.
Several Associative Behaviours triggered AHWs to smoke such as getting in a car, watching television, and drinking alcohol or caffeinated drinks (i.e. coffee, coke). Even going outside prompted the desire to smoke in some AHWs. Furthermore, a Tactile Habit was mentioned by some AHWs as a reason for smoking.
As soon as I get home and I put a coffee on or have wine or something, a beer or whatever, I want a smoke. So it must be something associated just with drinking or something in my hand.
Participants frequently identified Boredom as a trigger for smoking. Given that AHWs also spoke about high work demands, the somewhat contradictory notion of boredom as a reason for smoking was further explored in focus group discussions. It became apparent that “boredom” was used to represent having time on ones hands, such as when waiting for a client. It is possible that awareness of nicotine cravings heighten in idle times, which triggers the desire to smoke. Relief of boredom is a key smoking motive in the general population, and is positively correlated with both daily cigarette consumption and nicotine dependence [31].
Patterns of tobacco use were highly variable in participants (e.g. smoking occurred only on the weekends, or only during the working week) suggesting that smoking in AHWs was not universally motivated by a biological addiction to nicotine. Nicotine dependence as a driver of smoking behaviours has been identified in community members and health care staff in a remote Indigenous community [32]. In this study we found a conscious awareness of Nicotine Addiction was present in only two interviewees. These individuals identified that they could sense when nicotine levels were low and that they smoked to “get the taste back” or “top up”.
Family
The family is central to Aboriginal conceptualisations of health and wellbeing. Social and emotional wellbeing is defined as “a community where everyone feels good about the way they live and the way they feel” and dependent upon “connectedness to family, control over one’s environment and exercising power of choice” (p.6) [33]. Hence, when the health of an Aboriginal person’s family is threatened, so is their personal wellbeing. A range of features of family life increased the stress of AHWs and indirectly prompted smoking.
The burden of chronic conditions is great in Aboriginal communities [5], and stress due to Chronic Disease Burden in the families of AHWs was ever present and deeply felt in the stories shared. Respondents frequently spoke about the negative impact of heart disease, emphysema, diabetes, cancer and other diseases in their extended family.
The reduced life expectancy of the Aboriginal population [4] was reflected in comments made by participants. Many spoke of the death of family members due to chronic diseases and identified that distress due to Grief and Loss (particularly premature loss of parents) was associated with increasing the number of cigarettes smoked (in current smokers), or a relapse of smoking (in those that had quit).
Many AHWs also told of a high degree of Caring for Family responsibilities within their immediate and extended family. The three predominant responsibilities related to health support and advice, financial obligations and housing. Many AHWs spoke of the need to monitor the health of family members and provide management advice. Some AHWs shared that they were one of few individuals in their extended family who had a stable job and income, so their family frequently called upon them to loan money to those unemployed or on lesser incomes. The burden of providing extended family members with housing support was not commonly identified by AHWs, but for those that did have such responsibilities the impact on their wellbeing was dramatic.
I used to have 18 people living with me and they were all on medication. I had a breakdown myself so I had to change my lifestyle.
Many AHWs spoke of happy marriages and family relationships and the support that their family provided in their lives. However, some AHWs identified that a Breakdown of Family Dynamics caused distress and prompted them to smoke. Isolation from family was one feature of disrupted family dynamics. It occurred in a geographical sense (as a result of moving away from home and family) and also occurred in the form of comprehensive alienation from family due to forced removal by government agencies. The lifelong trauma experienced by Aboriginal Australians forcibly taken from their family - known as Stolen Generations - has been well documented [34]. A relationship between forced removal and smoking has also been demonstrated elsewhere [35]. The second feature of disrupted family dynamics was divorced or single parent families. The supportive role of smoking in the life of a single parent is aptly described in this account:
But yeah I’ve tried to give up smoking and because I don’t go out, I’m home all the time and I’ve got to have something to comfort me you know, because I’m a single mum trying to make it good for the children.
Interpersonal processes
In interpersonal relationships, smoking emerged as a potent enabler of Socialisation and Connection. Participants referred to smoking as a “social lubricant” that enhanced interactions with family, friends, co-workers, clients and strangers. In many health services, staff members commonly smoked and socialised together. In some settings terminology such as “the smokers” was used to describe those who congregated over a cigarette. Smoking has likewise been described as a “collective social practice” (p.60) [36] and “an activity linked to notions of belonging to a group” (p. 92) [37]. As one interviewee described in relation to AHWs:
The smoking gives them a common bond with other people and it’s like you’re in a club.
Some participants felt that smoking was at times motivated by a need for a Debriefing Opportunity. That is, AHWs used smoking as a reason to leave the health service since it enabled a more private setting to talk through issues. The distinction between this and the ‘Socialisation and Connection’ motive is that in this instance smoking occurred following specific experiences that caused distress, whereas the socialisation motivation wasn’t related to a desire to talk about particular concerns. Individuals spoke of going outside to have a cigarette in order to “get stuff off their chest” or “let it out”.
Individuals are more likely to smoke if they have a twin, sibling, parent or friend who also smokes [38]. In our study, individuals expressed they smoked when they were exposed to Co-worker, Family, Friend or Client Encouragement. Many AHWs told of being surrounded by smokers in their family and social circles. Some noted that clients liked smoking with them, and that clients were more likely to be open and talk about their issues during a shared smoke. AHWs noted that at times people close to them would actively encourage them to go outside and smoke; however passive encouragement also existed where simply knowing that a person close to them was smoking prompted their desire to have a cigarette.
You might be sitting down doing your work and then you get someone, “come out to have a smoke”, oh yeah, get up and go. So it’s just being around people, you know, being influenced by them I think.
Disputes and challenges in interpersonal communication emerged as a common stressor that promoted smoking behaviours in AHWs. First, there were some AHWs who observed their smoking was associated with Domestic Disputes. In one case, an AHW used smoking as a means to cope with the stress provoked by arguments and also as a reason to go outside to escape confrontation within the home. Second, a burdensome level of client expectation and in some cases unfair treatment by clients was described by a small number of respondents. Experiences of Client Expectations and Ill-treatment were described by AHWs where clients refused to be treated by them, accused them of breaching confidentiality or expected them to “always find the solution”. Third, a negative effect of a top-down approach to policy implementation was evident. Specifically, Lack of Communication between Policy Makers, Management and Health Workers was identified as a source of stress for some AHWs since they were left with an appreciation of what had to be done but not why. Finally, a majority of AHWs and other health service employees spoke of supportive and collaborative relationships with colleagues. In some instances, though, disagreements with co-workers or lack of acknowledgement by co-workers were identified as stressors that promoted smoking, as was being micromanaged by a more senior colleague. Staff Disputes and Micromanagement were more commonly mentioned by respondents working in government-controlled health services, possibly reflecting greater intercultural challenges between AHWs and their non-Aboriginal colleagues in these settings.
I was micro managed at work and after so long of being micro managed and not getting supported, I actually increased dramatically the smoking and it wasn’t good.
The health service
There were a range of features of work and the work environment that increased the stress levels of AHWs. In times of heightened stress, some AHWs reported using smoking as a means to cope. Elaboration of work-related stressors is therefore necessary to understand the full range of factors that indirectly perpetuate smoking in AHWs. Demanding Work was frequently reported as a source of stress that triggered smoking. Features of demanding work included: excessive scope of practice and lack of role clarification; complex practice (e.g. dealing with multiple health issues); insufficient resources; excessive workload; difficulties in having positive impact on health outcomes; and challenges in bridging the cultural gap. Work demands varied greatly, however, and were dependent upon the work setting, the job specifications of the AHW, and their experience. The demands of an excessive scope of practice, commonly mentioned by respondents, is mirrored by the reflections of Mitchell and Hussey [8] who describe that AHWs are "asked to take on many roles at once” and be “everything to everyone” (p.529). Many AHWs also described burdensome Out of Hours Work when community members approached them for advice in public spaces, such as the supermarket, or even came to their home. This latter occurrence was mentioned by AHWs working in small communities.
I was getting a few of my clients starting to come home and wanting to get support and even though I did that, that would impact on me at times … and then I went back smoking again.
A predominance of short-term contracts and uncertainty regarding contract renewals lead to some concerns about Job Insecurity and Financial Insecurity. Precariousness of employment caused financial stress in AHWs due to concerns about meeting financial obligations and obtaining bank loans. Participants from two different regional areas identified Salary Disparity as another source of stress. Specifically, inequity in pay between AHWs and other health staff (such as registered nurses) or between AHWs in community-controlled versus government-controlled health services was distressing. Similarly, Mitchell and Hussey [8] observe that “remuneration in the community sector is not progressing in line with government-employed health workers” (p.530). In some health services, general Workplace Instability was troubling. The predominant features of workplace instability included frequent changes in management and loss of staff. Such cut backs were described by respondents employed in two health services visited in this study.
Yeah look we haven’t had a solid foundation in the last 2 years, it’s changing, this is worse than ‘Days of our Lives’ [soap opera] coming into this place, something’s different everyday, you know.
No Training or Promotion or Staff Support was identified as a stressor by some AHWs who were concerned by a lack of opportunity to progress in their career. Inequity in employment and training opportunities for the Aboriginal compared with non-Aboriginal health workforce has previously been identified [39].
I’ve seen the effect it has on new Aboriginal health workers that feel a sense of powerlessness, a sense of hopelessness within their own workplaces so our feeling is that we are just forced to be kept at a certain level and we’re not allowed to go beyond a certain line.
Stress due to Institutionalised racism and cultural insensitivity was acutely felt by some AHWs. In one instance an AHW described being judged and mistreated by employees of social welfare services. Racism was commonly experienced in government-controlled health services through the comments and actions of non-Aboriginal staff.
It’s probably in a work context as well, massive institutionalised racism, I’ve not just seen it here; I’ve seen it in a lot of places I’ve worked. I’ve even had it directed at me, comments like are you 5% Aboriginal?
The community
At the community level, a range of stressors were reported by AHWs and other participants. Dispossession of land was reported by a small number of respondents as an injustice that continues to disadvantage Aboriginal families. AHWs spoke of the negative implications of lack of land ownership for future generations who have no inheritance (such as reduced financial opportunities and education). Also, while grief and loss was articulated at the family level, Collective Grief and Loss had negative repercussions at the community level.
There’s a lot of grief and loss and talk about collective trauma that’s in Indigenous communities and populations and people come in and one of the ways they'd, you know, debrief was to sit down have a yarn and, you know, have a cigarette perhaps while they’re doing it.
Prevalent Racism in the community was described by some AHWs in the forms of name calling, denial of cultural identity and discrimination (in relation to housing, job seeking and when attempting to use community services). Social marginalisation and racism is believed to lead to self-harming and substance misuse [40]. In fact, systematic review evidence demonstrates that self-reported racism is consistently associated with smoking tobacco [41].
Participants were commonly distressed by the array of Social Disadvantage characteristics present in Aboriginal communities. Features such as poverty and homelessness, unemployment, chronic disease, drug and alcohol abuse, housing issues, gambling, violence, imprisonment and lack of education and recreation opportunities were identified both in the general community and in family members (highlighting the proximity of social disadvantage to AHWs). Empirical data demonstrates an association between social economic position and smoking in Indigenous Australians. Higher social economic position, assessed using nine separate markers (such as income, education, employment, financial stress, etc.) is consistently related to non-smoker status [35].
Public policy
Short Term and Insecure Funding was a macro level stressor infrequently described by respondents. Funding insecurity perpetuates other proximal stressors such as job insecurity and workplace instability that promote smoking behaviours through creating stress in AHWs. The challenges of funding insecurity were described in this account:
"If you want to build an economic stability for yourself, don’t build it around an Aboriginal organisation, because we’re fearful that if our board stuffs up, they’ll take the money away from us. If we stuff up, they’ll take the money away from us. If our community disagrees with the way that we’re going, they’ll take the money away from us. [Note: the term “stuff up” is an Australian colloquialism referring to inadequate practices such as mismanagement or clinical error]"
Thematic summary
Following collective consideration of the data, five underlying themes emerged. First, experiences of Stress predominated in the stories about smoking. Stressors were perceived in multiple contexts and were an ever-present feature of life. There was a sense of Burden in the lives of AHWs due to the multitude of stressors faced and the extensive responsibilities and obligations within the family, the workplace and the community. In deconstructing and examining the events and experiences that precipitated stress it is evident that many were outside the control of AHWs. For example, AHWs spoke of an inability to exert influence over the premature death of loved ones, job insecurity, inadequate training and promotion opportunities and institutionalised racism. Hence a sense of Powerlessness prevailed in the stories shared by AHWs. A perceived Lack of Value and Recognition was also observed where AHWs spoke of getting the blame if anything went wrong and not being acknowledged for what they do. When considered together, the experiences of client mistreatment, lack of training or promotion opportunities, micromanagement, inequitable salaries and job insecurity demonstrated to AHWs that they were not valued within the health care system. Finally, Connectedness, or the lack thereof, influenced smoking behaviours in a range of environments. Specifically, smoking was motivated by a desire for connectedness (e.g. socialising, debriefing) and also prompted by distress due to a lack of connectedness (e.g. breakdown of family dynamics, staff disputes). In summary, smoking fulfilled two primary functions in AHWs including providing a means to enable socialisation and connection and a means to cope with stress, burden, powerlessness, lack of value and recognition, and disconnection. Smoking therefore is perpetuated by the accepted use of cigarettes to promote socialisation and connection in Aboriginal society and the multitude of personal, social and environmental stressors faced by AHWs.