The US Surgeon General has reported that smoking causes many different chronic diseases and cancers, harming almost every organ in the body, and also the early and sustained health benefits of quitting smoking at any age, with quitting before 40 preventing 90% of the excess mortality due to continued smoking.1,2
Nicotine-containing plants, including pituri, have long been chewed in Aboriginal communities, especially in Central Australia.3 Before British invasion and colonisation, Indonesian traders introduced smoked tobacco to Northern Australia.4 Colonisation led to smoking becoming widespread as tobacco was exploited by the colonisers (eg as rations) and then through mass-marketing by the tobacco industry.
The Australian Institute of Health and Welfare estimated that smoking caused more than 23% of all Aboriginal and Torres Strait Islander deaths in 2018.5 Using different methods, a longitudinal study estimated that half of all deaths in New South Wales (NSW) Aboriginal adults aged ≥45 years were due to smoking.6
Daily smoking prevalence among Aboriginal and Torres Strait Islander adults is high but falling, from 50% in 2004–05 to 34% in 2022–23, demonstrating that further improvements are achievable.7,8 This improvement in smoking prevalence has not been uniform, and has mainly occurred in towns and cities, with no improvement in remote areas. However, there have been reductions in smoking initiation among children in both remote and non-remote areas.9
Aim
This paper summarises the evidence and recommendations about smoking in the 4th edition of the National Aboriginal Community Controlled Health Organisation and the Royal Australian College of General Practitioners’ National Guide to Preventive Healthcare for Aboriginal and Torres Strait Islander People (The Guide).10
Public health approaches
Australian anti-tobacco mass media campaigns, pack warning labels, restrictions on tobacco advertising, price increases of tobacco through tax rises, smoke-free regulations and cessation services have contributed to Australia’s low national smoking prevalence.11 There is some evidence that such population health approaches also motivate Aboriginal and Torres Strait Islander people who smoke to quit.12–17 Since July 2025, these have been updated and expanded to warnings on cigarette sticks, new pack inserts about quitting and only restricted and standardised cigarette stick and filter design and flavours.18
Since 2010, the Australian government has funded regional Tackling Indigenous Smoking teams to provide health promotion activities across the country.19 There is strong community preference for such local culturally responsive health promotion, and smoking cessation, activities, but as yet no strong evidence that they are more effective than other services.4,20
General practitioners (GPs) can contribute to these evidence-based public health tobacco control activities by promoting anti-tobacco marketing and messaging and smoke-free rules in their health service and around their community.21 GPs should have no contact with the tobacco industry and support further restrictions on the tobacco industry, such as tobacco endgame proposals.22
Clinical approaches: Ask, Advise, Help
While most people successfully quit smoking without the assistance of health practitioners, including most Aboriginal and Torres Strait Islander people, GPs can play a vital part by routinely offering brief advice and behavioural and pharmacological therapies that have been shown to increase successful cessation.16,23,24 Annual health checks are an excellent opportunity for multidisciplinary teams of GPs, Aboriginal health practitioners and other health practitioners to support smoking cessation. GPs can be encouraged to support smoking cessation knowing that a national survey of Aboriginal and Torres Strait Islander people found that most (70%) smokers reported wanting to quit.25 The most common reasons smokers and ex-smokers gave for quitting were concern for their health, cost, and setting an example for children.14
The Guide’s recommendations are structured around the three-step Ask Advise Help model (Box 1). This is consistent with the current national Australian guidelines and like long-established three-step approaches in New Zealand and Britain.24,26,27
| Box 1. Preventive activities recommended in National Aboriginal Community Controlled Health Organisation and The Royal Australian College of General Practitioners National guide to preventive healthcare for Aboriginal and Torres Strait Islander people10 |
| Who/target population |
What |
When |
People ≥10 years
|
Ask all patients if they smoke tobacco and record/update smoking status in clinical record |
- Opportunistically
- Review smoking status at least annually for people who smoke or who have recently quit
|
| Children aged ≤15 years |
Ask parents and carers if they smoke, and whether they smoke inside the home or car and advise about harms of second-hand smoke to children |
Opportunistically |
| Adults who smoke |
Advise all adults who smoke to quit and on the most effective methods to quit |
Opportunistically, whenever possible |
| Young people aged 11–17 years |
Advise all young people who do not smoke to not start smoking |
Opportunistically |
| Adults who smoke |
Help adults to quit by recommending multi-session behavioural support using individual or group counselling, Quitline, text messaging (eg QuitTxt), internet programs (eg QuitCoach or iCanQuit) or incentives for cessation support |
Opportunistically following brief advice |
| Non-pregnant adults who smoke |
Help non-pregnant adults to quit by recommending smoking cessation pharmacotherapies. If nicotine-dependent, the most effective pharmacotherapies are combination NRT (patch and oral) and varenicline. Single-form NRT and bupropion are also effective |
Opportunistically following brief advice |
| Non-pregnant adults who smoke |
If above pharmacotherapies unsuccessful, consider use of nicotine e-cigarettes after discussion of lack of information about long-term risks of e-cigarettes |
After unsuccessful use of other smoking cessation pharmacotherapies |
| Pregnant and breastfeeding women who smoke |
- If behavioural support is not successful, consider NRT after explanation of risks and benefits. Intermittent use formulations such as gum, spray or lozenges rather than continuous use patches are preferred
- Do not use varenicline or bupropion in pregnant or breastfeeding women
|
At each pregnancy care visit |
| Young people <18 years who smoke |
- There is insufficient evidence to recommend whether to use NRT in children and young people <18 years who smoke
- Do not use varenicline or bupropion
|
N/A |
| All people |
Complement the above individual-based preventive activities with support for comprehensive public health approaches to smoking prevention |
Opportunistically |
NRT, nicotine replacement therapy.
Adapted from National Aboriginal Community Controlled Health Organisation and The Royal Australian College of General Practitioners. National guide to preventive healthcare for Aboriginal and Torres Strait Islander people: Recommendations. 4th edn. RACGP, 2024. |
Ask
Ask all patients if they smoke and ensure that their current smoking status is recorded in the medical record.24,26–28 Regularly (at least annually) update the smoking status in the medical records of anyone who smokes or has recently quit.26 Following the launch of the National Lung Cancer Screening Program in July 2025, assess all current and ex-smokers for eligibility for lung cancer screening.29
It is also important to ask all parents and carers of children if they smoke and whether they smoke inside the home or car.24 It is important to advise them to quit to protect their children, as not smoking inside reduces exposure to second-hand smoke, but does not provide complete protection.30
Advise
Advise all people who smoke to quit in a clear, non-confrontational way – for example, ‘The best thing you can do for your health is to quit the smokes’.24 This advice can be as brief as 30 seconds, and should be given at every visit and followed by offers of assistance to quit.26 Provide brief advice to all people who smoke whether they want to quit or not; there is no need to first assess ‘stage of change’.26 Aboriginal and Torres Strait Islander people who recall being advised to quit are 2.0 times more likely to have made a quit attempt in the past year than those who did not.31
Advise all children who do not smoke to not start smoking. However, it is important to note that reducing smoking prevalence among parents and carers has the clearest impact of any intervention on preventing youth uptake of smoking.24
Help
Behavioural support
Help all adults to quit by providing or referring to multi-session behavioural support using individual or group counselling, Quitline, text messaging (eg QuitTxt), internet programs (eg QuitCoach or iCanQuit) or incentives for cessation support. Quitline (phone 137848 or 13QUIT) offers cessation counselling from trained Aboriginal and Torres Strait Islander counsellors who will call the person who smokes following referral from a health practitioner (www.quit.org.au/referral-form/) or self-referral.24
More sessions of counselling and advice increase successful cessation.32,33 Four or more sessions have been recommended.26 Agree on a quit day, provide strategies for managing smoking triggers, mobilise support from family and friends and at follow-up visits provide encouragement and support, reviewing progress and problems.24 A meta-analysis of 194 studies showed that counselling increased cessation.33 Similarly, two randomised controlled trials at Aboriginal Community Controlled Health Services showed that patients who were allocated to more intensive multi-session face-to-face counselling and support were more likely to successfully quit.34
Written self-help material (eg pamphlets) has only a minimal additional effect on successful cessation, even though 49% of Aboriginal and Torres Strait Islander people who had been advised to quit reported being offered a pamphlet.31,35 Similarly, reviews have found no effect on smoking cessation of biofeedback (eg using carbon monoxide monitors, known as Smokerlysers), smartphone apps, acupuncture, hypnotherapy or exercise programs.35–37
Medications
Help non-pregnant adults to quit by offering smoking cessation pharmacotherapies to all nicotine-dependent people who smoke. Nicotine dependence can be assessed by asking three questions (Box 2).24
| Box 2. Assessing nicotine dependence |
Nicotine dependence can be assessed by asking three questions:
- How soon after waking do you have your first cigarette?
- How many cigarettes do you have each day?
- Have you had cravings for a cigarette, or urges to smoke and withdrawal symptoms when you have tried to quit?
|
| Smoking within 30 minutes of waking, smoking more than 10 cigarettes per day and withdrawal symptoms are indicators of nicotine dependence, with the first being the most reliable indicator.24 |
All three smoking cessation pharmacotherapies available in Australia increase cessation: nicotine replacement therapy (NRT), varenicline and bupropion.35 Combination NRT combines a patch with a faster-acting oral form (gum, spray, or lozenge), which can be used to deal with breakthrough cravings and withdrawal symptoms, and is more effective than a single NRT.35 Shared decision making can assist smokers to decide between the two most effective pharmacotherapies (varenicline and combination NRT), based on patient preference and their past experience.24
These medicines can often be dispensed at no or reduced cost to Aboriginal and Torres Strait Islander patients, either through Remote Area Aboriginal Health Service programs in remote areas or elsewhere through the Closing the Gap Pharmaceutical Benefits Scheme Co-Payment measure.38
There is insufficient evidence that NRT is effective in increasing smoking cessation in pregnancy from a review of only five placebo-controlled trials, in contrast to the effectiveness of behavioural interventions in pregnancy (97 trials).35,39 However, if counselling has not been successful it is reasonable to consider using oral NRT, after explanation of risks and benefits.24 Do not use varenicline or bupropion in women who are pregnant or breastfeeding.24
There is insufficient evidence that cessation support is effective in children aged under 18 years from a review of nine trials of behavioural interventions and only one trial of NRT patches.40 NRT may still be used following careful discussion with the patient (aged 12+ years) and their carer, but varenicline and bupropion are not approved for use in people who smoke aged under 18 years.24
E-cigarettes
The benefit from vaping nicotine-containing e-cigarettes to assist quitting remains contentious. However, if the above pharmacotherapies are unsuccessful, consider use of nicotine e-cigarettes after discussion of the lack of information about long term risks of e-cigarettes.24 The most recent Cochrane review of six trials found nicotine-containing e-cigarettes increased cessation compared with non-nicotine e-cigarettes (ie placebo).41
The Guide found almost no high-quality research about what works to prevent patients starting to vape or to help quit vaping.42 This will change, just as the design of e-cigarettes and Australian e-cigarette legislation has been evolving.
Conclusion
GPs can support and enhance public health approaches to reduce Aboriginal and Torres Strait Islander smoking by promoting activities of Tackling Indigenous Smoking teams and using the evidence-based Ask Advise Help model of smoking cessation support described in The Guide.
Key points
- Harms of smoking and benefits of smoking cessation are well-established.
- National Aboriginal and Torres Strait Islander smoking prevalence is high but is decreasing.
- GPs can promote anti-tobacco messaging and smoke-free activities led by Tackling Indigenous Smoking regional teams.
- All health practitioners, including GPs, can support their patients to quit smoking using the Ask Advise Help model described in The Guide.
- There is strong evidence for behavioural support and medications to support smoking cessation among adults.