Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697642147783.pdf (Australia)
5th November 2020 To the Australian Select Committee on Tobacco Harm Reduction This submission is being made on behalf of Professor Marewa Glover, Director, Centre of Research Excellence: Indigenous Sovereignty & Smoking, I wish to make a public submission to the Australian Select Committee on Tobacco Harm Reduction.
My submission mostly speaks to the related importance of reducing inequitable smoking prevalence rates between non-Indigenous Australians and the Aboriginal and Torres Strait Island peoples of Australia.

Thank you for the opportunity to contribute.
Dr Marewa Glover 1 Tobacco Harm ReductionSubmission 223 Contents Introduction ............................................................................................................................................ 3 Aboriginal and Torres Strait Islander health ........................................................................................... 5 Denormalisation ...................................................................................................................................... 6 Smoking and pregnancy .......................................................................................................................... 7 Recommendations .................................................................................................................................. 7 Disclosures .............................................................................................................................................. 8 References .............................................................................................................................................. 9 2 Tobacco Harm ReductionSubmission 223 Introduction Tobacco smoking is a leading cause of chronic disease and premature death amongst several colonised Indigenous peoples in the world, including the Aboriginal and Torres Strait Islander people of Australia.
Aboriginal and Torres Strait Islander peoples have had disproportionately high rates of use of multi-national tobacco company cigarette and loose tobacco products dating back to the early days of European arrival and colonisation of Australia.

tobacco by to become consumers of As in New Zealand, in addition to men, Aboriginal and Torres Strait Islander women were encouraged the missionaries, entrepreneurial settlers, and plantation and station employers (who used tobacco to pay for labour) (Brady, 2002).
Thus, the smoking of European introduced mass manufactured tobacco, and later cigarettes, was established among both Aboriginal and Torres Strait Islander fathers AND mothers for about a century before European / Western women took up smoking (i.e.

in the 1920s-30s).

This is important for understanding higher uptake of smoking among Indigenous youth over generations – there is a dose response relationship between youth initiation to smoking and parental smoking.
The risk of uptake is higher if one parent smokes, and doubles if both parents smoke (Scragg & Glover, 2007).1 A further historical factor contributing to higher smoking prevalence among Australian Indigenous people is that there were cultural precedents for the use of smoke in cultural meetings and celebrations, spiritual, birthing and protection ceremonies, funeral ceremonies and healing.

Some plants endogenous to the land also contained nicotine and some tribes used these plants for various purposes.
The work of Moana Tane, that reports on the relationship of tobacco to the Yolŋgu people in East Arnhem Land, Northern Territory is important for understanding that a very different story from that told by the small number of Anglo-Australian academics who dominate the tobacco control narrative exists and should be heard (Tane, 2020; Tane et al., 2020; Tane et al., 2019; Tane et al., 2018).
On pituri, I recommend the committee refer to Sylvia Lockyer’s work: ‘From nature to addiction: Nicotine use in Aboriginal Australia, an indigenous perspective on the literature’ (2013).
Having said that there was a cultural precedent for the use of smoke, and for the use of nicotine or tobacco among some of the Indigenous tribes of Australia – similar disproportionately high smoking rates exist among Māori in New Zealand (who did not have a nicotine containing plant or a native tobacco), and First Nations people of Canada, and Native American tribes of North America (Glover, Patwardhan & Selket, 1 This research determined whether parental smoking is a consistent risk factor for adolescent smoking in a multi-ethnic sample, and whether maternal and paternal effects combine additively or multiplicatively.
Maternal smoking and paternal smoking were associated separately with increased risk of daily adolescent smoking in all ethnic groups, except paternal smoking in Asian youth.

The relative risk of adolescent daily smoking was significantly higher for maternal only smoking.

The net effects of maternal and parental smoking are additive among European, Māori and Pacific Island students, but multiplicative in Asian.

Overall, about 40% of adolescent daily smokers could be attributed to parental smoking.
3 Tobacco Harm ReductionSubmission 223 2020).

The two main types of tobacco smoked globally today originated in South America (Russell & Rahman, 2016).
Rather than there being pre-existing use of nicotine or tobacco, the devastating effects of colonisation and Anglo-Western dominance over all of societies institutions is the most likely common denominator explaining the ongoing inequity in smoking prevalence rates between Indigenous people and non-Indigenous in these colonised nations (Glover, Patwardhan & Selket, 2020).

Improving physical health is a priority for all Indigenous peoples but health is conceived of more broadly by Indigenous cultures.
An Indigenous worldview of health and well-being understands that ‘good’ health is an outcome of the interdependent physical, mental, familial, social, spiritual and environmental realms (for example see Glover 2013).
The contemporary availability of greatly risk-reduced alternatives to smoking tobacco, such as electronic nicotine vaporisers, oral pouched nicotine/tobacco products, and tobacco heating devices have the potential to deliver a disproportionate benefit to Indigenous people – because of the higher smoking rates among them.

One Indigenous success story is that of the Saami (of Sapmi lands spanning what has now been divided between Norway, Sweden, Finland and the Russian Federation).
Saami reportedly use the greatly risk-reduced Swedish snus (a pasteurised powdered pouched tobacco product) at a higher rate than non-Saami.

This is partly due to climate and historic familiarity (The Scandinavian Magazine Tobak & Mer, 2019).
In New Zealand, Māori (the indigenous people making up 15% of the population) have a higher rate of having tried vaping, though recent prevalence of current and daily use have been found to be similar between Māori and non-Māori in the 2016-2018 ITC survey (Edwards et al., 2020).

Aboriginal Australians similarly have shown a keenness for switching from smoking to vaping.
One of the first workplace programmes to support staff to switch from smoking to vaping – in the world – was run by an Aboriginal Drug and Alcohol Service (Glover, 2018).
Fatally for many Australians, the Anglo-Western dominated tobacco control sector in Australia appear to have decided that any risk-reduced alternative to smoking, any harm reduction approach, anything but continuing to smoke till death or quitting via the less effective business-as-usual cessation methods (Walker et al, 2020; Hajek et al., 2019; Hartmann-Boyce et al., 2020) is the only option they will allow.
Obstructing Aboriginal and Torres Strait Islander people of Australia from switching to risk- reduced noncombustible alternatives should be viewed as a breach of their human and Indigenous right to health (Glover, 2018).

The decision to employ a tobacco harm reduction approach, such as vaping nicotine, should be a decision that Aboriginal and Torres Strait Islander communities get to make for themselves.
But, this would necessitate that they have access to the most up- to-date unbiased scientific assessments of the evidence, such as those conducted by at: England Public (available Health 4 Tobacco Harm ReductionSubmission 223 https://www.gov.uk/government/publications/vaping-in-england-evidence-update- march-2020).

It is my experience that this information is being deliberately kept from Aboriginal and Torres Strait Island communities by non-Indigenous tobacco control leaders.
In 2018, Associate Professor Colin Mendelsohn and I, with Scott Wilson of the 5th National Indigenous Drug & Alcohol Conference, presented a special workshop on vaping.

A non-Indigenous Australian Government health official (representing the sponsors of the conference) attended the workshop and after, expressed strong disapproval that the topic was included on the programme.
The following year I, and other Indigenous, speakers were prevented from speaking about tobacco harm reduction at the International City Health Conference in Melbourne.

The threat of reprisals that could impact funding, speaking engagements, reputational damage and potentially future employment, has created a “chilling effect” which has caused some influential Aboriginal spokespeople I know to stay publicly silent on the topic.
The use of bullying by some of the tobacco control leaders in Australia has been documented in a PhD thesis by Hoepner (2017).

I am personally aware of a lot of Aboriginal stakeholders who do want nicotine vaping to be an option – some of them have successfully stopped smoking or have family members who have successfully stopped smoking thanks to vaping.
I expect the Select Committee will not hear from many of them because of the professional risk they face if they speak in opposition to the dominant Anglo-tobacco control people who also control the Tackling Indigenous smoking funding policies.

Of high relevance to Australia - the New Zealand Government has weighed the evidence and decided that, on balance, confirming legal secure access to quality vaping products would most likely deliver a positive net benefit to public health.
The New Zealand Parliament concluded that legalising nicotine vaping is more likely, than business-as-usual (tax + shaming mass media campaigns + environmental bans on smoking), to get New Zealand closer (and more rapidly) to its aspirational goal of ‘Smokefree 2025’ (i.e.

a smoking prevalence of 5% or below by 2025).


One of the deciding factors was that allowing nicotine vaping would have a disproportionately higher impact on reducing Māori smoking rates, thus assisting to reduce the persistent and widening inequity between Māori smoking rates and NZ European smoking rates.

Thus, in August Parliament passed the Smokefree Environments and Regulated at: Products http://legislation.govt.nz/bill/government/2020/0222/latest/LMS313857.html).
Amendment (available (Vaping) Bill Aboriginal and Torres Strait Islander health A health gap exists between Aboriginal and Torres Strait Islander peoples and non- Indigenous Australians, this is despite efforts to bridge this gap and address health inequities.

These inequalities exist because of ongoing colonization (Kairuz et al., 2020) and institutional racism (Glover, Dudgeon & Huygens, 2009).
As for many other Indigenous communities globally, the effects of colonisation involving ongoing stigmatisation, institutionalised racism, and multiple negative economic and social 5 Tobacco Harm ReductionSubmission 223 determinants present a significant barrier to quitting for Aboriginal and Torres Strait Islander peoples (Glover, 2018; Glover, Patwardhan & Selket, 2020).
Smoking rates have been on the decline among Indigenous people in Australia - from 49% in 2002 to 39% among those aged 15 years and older in 2014–15, though rates continued to be approximately three times higher compared to the general non- Indigenous population (Chamberlain et al., 2017).

More recent figures for 2018-19 of 40% for adult current daily smoking prevalence confirm that smoking prevalence rates have stagnated with no reduction since 2014-15 (Maddox et al., 2020).
A) The treatment of nicotine vaping products (electronic cigarettes and smokeless tobacco) in developed countries similar to Australia (such as the United Kingdom, New Zealand, the European Union and United States), including but not limited to legislative and regulatory frameworks; Denormalisation In western countries, denormalization-led legislation to deter smoking, use of oral nicotine, and tobacco products (e.g.
snus) and vaping is frequently accompanied by public health campaigns drawing on a ‘pedagogy of disgust’ (Lupton, 2015).

Consequently, anti-smoking and anti-vaping campaigns reinforce negative class, race, gender, and unwellness perceptions (Frohlich et al., 2012).

This contributes to stigmatising people who smoke or vape, thereby becoming the target of abuse and isolation, which can lead to feelings of shame and further isolation from support services (Glover, Patwardhan & Selket, 2020).
The potential harms that could result from placing further restrictions on vaping will be particularly harmful to groups who already experience multiple marginalities e.g.

Aboriginal and Torres Strait Islanders as well as other marginalised communities and people with mental health conditions (Glover, Patwardhan & Selket, 2020).

The decline in tobacco smoking is not taking place across all populations at an equitable rate.

Marginalised groups are being left behind.


This is especially true for Indigenous peoples who need to be far better supported and given greater opportunities to develop their own culturally-based solutions to reduce harm from smoking tobacco amongst their people.

If Australia truly wants health for all people then they must reject all regressive tobacco control policies, stigmatising, shaming, and or socially isolating people who smoke.
We recommend more humane approaches that acknowledge and respect Aboriginal and Torres Strait Island peoples and that relate to people with dignity (Glover, Patwardhan & Selket, 2020).
b) the impact nicotine vaping products have had on smoking rates in these countries, and the aggregate population health impacts of these changes in nicotine consumption The rate of decline of smoking in Australia is slower than in England (Public Health England, 2017) and the United States, where smokers are now vaping in their millions.
If Australia continues on its trajectory of obstructing smokers from switching to nicotine vaping with the implementation of the proposed draconian policy, 6 Tobacco Harm ReductionSubmission 223 Australians will face major barriers to smoking abstinence (e.g.

Morphett et al., 2019; Yuke et al., 2017).

Smoking and pregnancy The harms of smoking during pregnancy are well established.
A review of smoking in pregnancy among Indigenous women in four high income countries including Australia (Gould et al., 2017) suggested that strategies to support abstinence from smoking in this group needed to be multifactorial and consider the social determinants of smoking, including historical antecedents, community norms, cultural strengths and the needs of individuals and communities.
A recent review of the effects of nicotine on pregnancy outcomes concluded that there was insufficient evidence to quantify any risks of the use of noncombustible tobacco and nicotine products during pregnancy (Glover & Phillips, 2020).

We concluded: “The use of smoke-free nicotine products almost certainly has less effect than smoking on pregnancy outcomes (most of which are negative, but there are some positive effects), but any use of nicotine is probably worse for the fetus than none.
This review reinforces both the validity of that advice and the fact that more precise advice cannot be offered.

There is certainly no basis for offering the advice that the benefits of avoiding these products exceed the costs without understanding the costs for any particular individual.
This review demonstrates that the evidence does not support denying pregnant women the use of smoke-free products if the alternative is that she would continue to smoke.” Recommendations I strongly recommend that the Australian Government align with New Zealand’s adoption of a harm reduction approach to reduce smoking.

This means ensuring that quality nicotine vaping products and tobacco heating devices be confirmed legal for import, at least in-store marketing, and sale to adults.
All people who smoke should be encouraged to stop smoking or to switch to any, or a combination of, the greatly risk-reduced nicotine and tobacco products that exist.

Access to risk reduced alternatives to smoking needs to be as convenient as, and cheaper than, buying a pack of cigarettes is now.

That is, the products should not be regulated harsher than smoking tobacco products are.
7 Tobacco Harm ReductionSubmission 223 Disclosures This submission was prepared by Dr Marewa Glover, Director of the Centre of Research Excellence: Indigenous Sovereignty & Smoking in New Zealand.

Dr. Glover is a Professor of Public Health with 30 years experience in smoking cessation and tobacco control.

Dr Glover is an Indigenous behavioural scientist, and the most senior Indigenous expert on the reduction of smoking harms in the world.
She has been involved in, and or led the conduct of, many studies and intervention trials to reduce tobacco smoking and she is a lead author or co-author on over 100 scientific journal articles.

In 2019, Dr Glover was one of three finalists in the prestigious New Zealander of the Year Awards.
After 17 years in academia, with the help of a researcher-initiated grant from the Foundation for a Smoke-Free World, Dr. Glover established her own research centre focused on reducing the harms of tobacco use amongst Indigenous peoples worldwide.
The research produced by the Centre of Research Excellence: Indigenous Sovereignty & Smoking, the contents, selection, and presentation of facts, as well as any opinions expressed on the Centre’s website, or in its presentations and publications are the sole responsibility of the Centre and its authors and under no circumstances shall be regarded as reflecting the position of the Foundation for a Smoke-Free World, Inc.
The Foundation for a Smoke-Free World has no input into the conception, conduct, analysis or decision to publish any of the Centre’s work.

8 Tobacco Harm ReductionSubmission 223 References Brady M. (2002).

Health Inequalities: Historical and cultural roots of tobacco use among Aboriginal and Torres Strait Islander people.

Australian and New Zealand Journal of Public Health, 26(2):120-4.

Chamberlain et al.
Chamberlain et al.

(2017) Evidence for a comprehensive approach to Aboriginal tobacco control to maintain the decline in smoking: an overview of reviews among Indigenous peoples.

Systematic Reviews.

Vol.

6, pp:135-163.

Edwards R., Stanley J., Waa AM., White M., Kaai SC., Ouimet J., Quah AC., Fong GT.

(2020).

Patterns of Use of Vaping Products among Smokers: Findings from the 2016– 2018 International Tobacco Control (ITC) New Zealand Surveys.

Int.

J. Environ.

Res.

Public Health 17, 6629.


Frohlich KL., Mykhalovskiy E., Poland BD., Haines-Saah R., Johnson J.

(2012).

Creating the socially marginalised youth smoker: the role of tobacco control.

Sociology of Health and Illness.

Vol.

34, pp.

978–93.

doi:10.1111/j.1467-9566.2011.01449.x Glover M. (2013).

Analysing smoking using Te Whare Tapa Wha.

In Banwell C., Ulijaszek S., Dixon J.

(Eds).

When culture impacts health: Global lessons for effective health research.
Elsevier Publishers, pp.

115-128. doi:10.1016/B978-0-12-415921- 1.00011-7 Glover M. (2018).

No excuse for high smoking rates among Indigenous people.

The Australian Tobacco Harm Reduction Association (ATHRA).

Available at https://www.athra.org.au/blog/2018/11/14/no-excuse-for-high-smoking-rates-among- indigenous-people/?fbclid=IwAR1DvfiGBijTddVTc85q334nlErcTdXIMKN4TVhe_c22m4700VT_0ERyS78 Glover, M., Dudgeon, P., Huygens, I.

‘Colonisation and racism’.

In Prilleltensky, I., Nelson, G. (2004).


Community Psychology: Wellness & liberation.

Australia, Palgrave MacMillan Publishers, 330-344, reprint 2009.

Glover M., Patwardhan P., Selket K. (2020) Tobacco smoking in three “left behind” subgroups: indigenous, the rainbow community and people with mental health conditions.

Drugs and Alcohol Today.

Vol.

20 Iss.

3, pp.

263-281.

DOI 10.1108/DAT- 02-2020-0004 Glover M., Phillips CV.

(2020).
(2020).

Potential effects of using non-combustible tobacco and nicotine products during pregnancy: a systematic review.

Harm Reduct J 17, 16 https://doi.org/10.1186/s12954-020-00359-2 Gould GS., Patten C., Glover M., Kira A., Jayasinghe H. (2017).

Smoking in pregnancy among Indigenous women in high income countries: a narrative review.

Nicotine & Tobacco Research 19(5):506–517.

doi:10.1093/ntr/ntw288.

Hajek P., Phillips-Waller A., Przulj D et al.

(2019).
(2019).

A randomized trial of e-cigarettes versus nicotine- replacement therapy.

New England Journal of Medicine.

Vol.

380, pp: 629-637.

9 Tobacco Harm ReductionSubmission 223 Hartmann-Boyce J, McRobbie H, Lindson N, Bullen C, Begh R, Theodoulou A, Notley C, Rigotti NA, Turner T, Butler AR, Hajek P. (2020).

Electronic cigarettes for smoking cessation.

Cochrane Database of Systematic Reviews Issue 10.

Art.

No.

: CD010216.

DOI: 10.1002/14651858.CD010216.pub4.

Hoepner, JE.

(2017).


‘You need to shut up’: Research silencing and what it reveals about academic freedom.

Canberra: Australian National University, PhD thesis.

Available at: https://openresearch-repository.anu.edu.au/handle/1885/121823 Kairuz CA., Casanelia LM., Bennett-Brook K., Coombes J., Yada UN.

(2020).

Impact of racism and discrimination on the physical and mental health among Aboriginal and Torres Strait Islander peoples living in Australia: a protocol for a scoping review.
Syst Rev 9, 223. https://doi.org/10.1186/s13643-020-01480-w Lockyer S. (2013).

From nature to addiction: Nicotine use in Aboriginal Australia, an indigenous perspective on the literature.

(Master's thesis).

University of Otago, Wellington.

Lupton D. (2015), The pedagogy of disgust: the ethical, moral and political implications of using disgust in public health campaigns, Critical Public Health, Vol.

DOI:10.1080/09581596.2014.885115 25, 10.1080/09581596.2014.885115.

4-14, No.

pp.
4-14, No.

pp.

1, Maddox R., Thurber KA., Calma T., Banks E., Lovett R. (2020).

Deadly news: the downward trend continues in Aboriginal and Torres Strait Islander smoking 2004– 2019.

Australian and New Zealand Journal of Public Health Online, Commentary.

Morphett K., Weier M., Borland R., Yong H.‐H., Gartner C. (2019).

Barriers and facilitators to switching from smoking to vaping: advice from vapers.

Drug Alcohol Rev.

Vol.

38, pp: 234–43.

Public Health England.

(2017).


Highest smoking quit success rates on record.

https://www.gov.uk/government/news/highest-smoking-quit-success-rates-on- record Russell, A., & Rahman, E.

(Eds.).

(2016).

The master plant: tobacco in Lowland South America.

Bloomsbury Publishing.

The Scandinavian Magazine Tobak & Mer.

Samers övergång från rökning: en inhemsk framgångshistoria, September 2019.
Scragg, R., Glover, M. Parental and adolescent smoking: does the association vary with gender and ethnicity?

Results from the 2002-2004 New Zealand national surveys of Year 10 students.

New Zealand Medical Journal 120(1267), pp.10, 2007.

Tane MP.

(2020) Talking About Smoking in East Arnhem Land: Indigenous Australian Cultural Mentors and a Decolonized Research Methodology.

Research Methods Cases Part 2. https://dx.doi.org/10.4135/9781529742558 Tane MP., Hefler M., Thomas DP.

(2018).
(2018).

An evaluation of the ‘Yaka Ŋarali” Tackling Indigenous Smoking program in East Arnhem Land: Yolŋu people and their 10 Tobacco Harm ReductionSubmission 223 connection to ŋarali’.

Health Promotion Journal of Australia.

Vol.

29, pp: 10–17.

http://dx.doi.org/10.1002/hpja.1 Tane MP., Hefler M., Thomas DP.

(2019).

Smokefree leadership among the Yolŋu peoples of East Arnhem Land, Northern Territory: a qualitative study.
Global Health Promotion Vol 27, Issue 2, pp: 100-108. doi.org/10.1177/1757975919829405 Tane MP., Hefler M., Thomas DP.

(2020).

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.

Global Public Health.

Vol.

15, Iss.

1, pp: 111-120, DOI: 10.1080/17441692.2019.1649446 Walker N, Parag V, Verbiest M, Laking G, Laugesen M, Bullen C. (2020).
Nicotine patches used in combination with e-cigarettes (with and without nicotine) for smoking cessation: a pragmatic, randomised trial.

Lancet Respir Med.

8(1):54-64. doi: 10.1016/S2213-2600(19)30269-3.

Epub 2019 Sep 9.

PMID: 31515173.

Yuke K., Ford P., Foley W., Mutch A, Fitzgerald L., Gartner C. (2017).

Australian urban Indigenous smokers’ perspectives on nicotine products and tobacco harm reduction.

Drug Alcohol Rev.

Vol.

42, Iss, 6, pp:1225–32.

11 Tobacco Harm ReductionSubmission 223