Evaluation of Aboriginal and Torres Strait Islander smoking cessation interventions with pregnant women in Australia: utilising a culturally appropriate tool.

The purpose of this article was to review and evaluate three Australian projects with a focus on smoking cessation and Aboriginal and Torres Strait Islander pregnant women, funded under the Tackling Indigenous Smoking Innovation Grants Scheme, Australian Department of Health. The aim was to determine the impacts of culturally appropriate smoking cessation support for pregnant Aboriginal and Torres Strait Islander women. To provide an equity-focused lens to the review, our team of Indigenous and non-Indigenous researchers utilised an Australian-developed assessment tool: the 'Cultural Identity Interventions Systematic Review Proforma'. The tool was used to measure cultural approaches across a range of domains, and these were independently assessed by two reviewers, along with an assessment of the projects' smoking cessation outcomes. The results were compared to the evidence base in relation to aims, methods, results and conclusions, and consensus for scoring was reached. The review found that these Tackling Indigenous Smoking projects about pregnancy intentionally and effectively incorporated culturally based approaches that sought to work with the participants in culturally informed ways. Each project utilised existing social networks and partnerships to provide their participants with access to a range of community resources, adding value to existing programs.

Smokefree leadership among the Yolŋu peoples of East Arnhem Land, Northern Territory: a qualitative study.

This qualitative study examined smokefree leadership among the Yolŋu people, Indigenous landowners of East Arnhem Land. Despite disproportionately high smoking prevalence, the study found that most people enacted smokefree leadership within families and communities. While there was broad concern about not impinging on the autonomy of others, Indigenous health workers regularly advised clients, family and community members to quit smoking. This followed a general belief that the issue of smoking was best raised by health workers, rather than traditional leaders. Protecting children from second-hand smoke and preventing smoking initiation was important to all participants irrespective of their smoking status. An enduring and highly valued cultural connection to ŋarali' (tobacco) remains an essential part of the sacred practices of the funeral ceremony, an important and unique social utility. The study found consensus among participants that this would not change. Navigating traditional connections to ŋarali' in a context where most people are still addicted to commercial tobacco is challenging and requires respectful and culturally compelling approaches. Tobacco control initiatives with the Yolŋu should therefore utilise existing smokefree leaders within the social context in which ŋarali' is valued and used, an approach that may resonate with other Indigenous Australian nations and communities.

Do the Yolŋu people of East Arnhem Land experience smoking related stigma associated with local and regional tobacco control strategies?: An Indigenous qualitative study from Australia.

In remote Aboriginal communities in East Arnhem Land, Northern Territory of Australia, the Yolŋu people, traditional owners of this remote and isolated region, have a long tradition of ŋarali' [tobacco] use, which is commemorated within funeral ceremony, as manikay [songlines] and buŋgul [dancing]. Today, smoking is very prevalent and a highly normalised social activity among Yolŋu. There are concerns that tobacco control activities aiming to denormalise smoking may lead to stigma in already disadvantaged communities with high smoking prevalence. Interviews were conducted from August 2014 until December 2015 to ascertain whether smokers may have experienced smoking-related stigma through their interactions and engagement with health services and regional tobacco control activities including denormalisation strategy. Informants described their experiences, observations and perceptions of smokefree environments, television and media advertising, and smoking cessation support. We found that while tobacco control denormalisation is not leading to stigma in these communities, some clinical consultations and interactions may have led to feelings of smoking-related shame among Yolŋu health workers who smoked. However, we found that caring, trusting relationships and having the right people communicating the right messages respectfully enabled raising the issue of smoking in clinical consultations without causing shame.

An evaluation of the 'Yaka Ŋarali'' Tackling Indigenous Smoking program in East Arnhem Land: Yolŋu people and their connection to ŋarali'.

ISSUE ADDRESSED: Smoking prevalence estimated between 65% and 84% has been reported among the Yolŋu peoples of East Arnhem Land, Northern Territory. We report on findings of an evaluation of the Yaka Ŋarali' Tackling Indigenous Smoking program in East Arnhem Land. METHODS: Qualitative interviews with Yolŋu (N = 23) and non-Yolŋu (N = 7) informants were conducted in seven communities between June 2014 and September 2015, with the support of Cultural Mentors, in homeland communities throughout East Arnhem Land. The data was coded using NVivo software, analysed line-by-line and categorised by the researcher (MT) under three a priori categories established as evaluation parameters. In addition, the meanings of ŋarali' and Yolŋu cultural obligations to ŋarali' were analysed using an inductive process. RESULTS: Data were coded under three a priori themes: Yolŋu trying to quit smoking (interest in quitting, access to support); the Yaka Ŋarali program (efficacy and recognition); Yolŋu workforce (roles and responsibilities). Yolŋu informants, including Elders and leaders, both smokers and non-smokers uniformly acknowledged the deep cultural and traditional connection with ŋarali' attributing this relationship with its introduction by the Macassans and its subsequent adoption into ceremony. CONCLUSIONS: Given the strong cultural and traditional connection to ŋarali', care must be taken to ensure tobacco control measures maintain congruence with local values and expectations. SO WHAT?: Tailored, localised programs, developed in consultation with communities, Elders and leaders are needed to respect and accommodate the tight connection that the Yolŋu have with ŋarali', maintained over hundreds of years.