FormalPara Key Points

  • “Commercial tobacco” is a harmful product made and distributed by the tobacco industry. Commercial tobacco does not include “traditional,” “ceremonial,” or “sacred tobacco” used by Indigenous peoples and communities for ceremonial and cultural purposes.

  • Commercial tobacco, addiction, and dependence on nicotine products are closely linked to colonization for many Indigenous peoples.

  • Commercial tobacco and its derivatives, including derived products and associated toxicant(s), impact physical, social, emotional, and spiritual wellbeing.

  • Commercial tobacco is the leading cause of preventable lung cancer and contributes to a significant portion of global cancer deaths.

  • Despite colonization and active targeting by the tobacco industry and affiliates, there has been progress in reducing smoking prevalence in Indigenous communities. To help accelerate and eliminate reductions in tobacco-related disease and death and improve the health and wellbeing of Indigenous peoples and future generations, Indigenous-led programs and policies, along with structural reforms, are essential.

Indigenous peoples encompass a diversity of nations, practices, languages, knowledge systems, experiences, and relationships that bring vibrant diversity to the world. Indigenous peoples across the world have unique practices and relationships, particularly in relation to the natural environment and its flora and fauna [1]. It is important to recognize this diversity, including diversity and relationships with tobacco. Accordingly, it is important not to conflate commercial tobacco with ceremonial tobacco [1].

The word “tobacco” has roots in Taíno, a language of the Arawakan people of the Caribbean, but it was appropriated by the Spanish in 1550 [1]. The claiming of words from languages was a mechanism of colonization. European settlers continued colonial practices by modifying and industrializing tobacco production as a plantation crop, leading to the mass production of adulterated tobacco, which became cheap, widely available, and easily accessible [1]. To further lower costs and increase availability, the tobacco industry and its affiliates carefully and purposefully increased the nicotine content and addictive properties of tobacco, using additives to mask its smells, make it more palatable, reduce production expenses, and make products more easily accessible. Today, the mass production, promotion, and distribution of adulterated tobacco pose a direct threat to the sacred nature of tobacco for many Indigenous peoples [1].

The production, promotion, and distribution of commercial tobacco globally and the resultant addiction among Indigenous peoples and communities have been described as a form of modern colonization and subjugation [1, 2]. Indigenous knowledges and practices, such as ceremonial tobacco use, have been suppressed [2]. For example, across Turtle Island (North America), the Code of Indian Offenses in 1883, the Indian Act of 1885, and associated amendments prohibited ceremonial practices involving tobacco but allowed commercial tobacco use [1]. The suppression of ceremonial practices led to the systematic embedding of commercial tobacco into ceremonial practices, acutely undermining the connection of Indigenous communities with the native tobacco plant [1].

The machinery of colonization is often implicated as a “fundamental cause” that leads to the unequal distribution of the social and economic determinants of health and wellbeing. The unequal distribution of the social and economic determinants of health drives commercial tobacco use, such as socioeconomic status (SES) [3], alongside issues such as the forced removal and relocation of Indigenous peoples from their land, the removal of children, exclusion from education systems, and exclusion from the cash economy [3, 4]. In Australia, commercial tobacco was used as a form of payment and rationing of food in lieu of wages until the late 1960s, actively embedding and valuing commercial tobacco use from an early age [4]. As a result of colonial machinery, Indigenous populations have tended to report lower socioeconomic status, which is a risk factor for commercial tobacco use, impacting individual and collective agency to stay nicotine free. Low SES among Indigenous populations is a common consequence of colonization that has persisted across generations, eroding power and influence, social structures, and community resources. While the drivers of commercial tobacco use are similar for Indigenous and non-Indigenous peoples, Indigenous peoples are disproportionately exposed to them.

Commercial Tobacco-Related Mortality

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) recognizes the disproportionate harm caused to Indigenous peoples by commercial tobacco use and promotes the participation of Indigenous peoples and communities in developing, implementing, and evaluating tobacco control programs and policies [5]. The tobacco industry and its affiliates continue to fuel the tobacco epidemic, with commercial tobacco smoking being one of the single largest causes of preventable disease and death, including cancer. More than eight million people die as a result of commercial tobacco use each year, including 1.3 million people whose deaths are due to secondhand smoke [6]. A large proportion of these deaths are from early heart attacks, chronic lung diseases, and cancers.

Commercial Tobacco and Cancer

The landmark 1964 Surgeon General’s report Smoking and Health concluded that commercial tobacco smoking was a cause of lung cancer [7]. Since then, researchers have continued to advance their understanding of the mechanisms of tobacco-related diseases, including cancer [8]. This has reaffirmed the notion that there is no safe cigarette [9]. When individuals inhale commercial tobacco smoke, whether directly or passively, they are exposed to over 7000 chemicals, with hundreds of these being hazardous and at least 69 recognized as carcinogens [8, 10]. Further, the carefully and purposefully modified and enhanced addictive properties of commercial tobacco make it more difficult to abstain from and lead to greater exposure to toxicants, both for the person who smokes and for others around them. These chemicals are rapidly assimilated by cells within the body, leading to cellular alterations that give rise to diseases [8]. Polyaromatic hydrocarbons (PAH), N-nitrosamines, aromatic amines, 1,3-butadiene, benzene, aldehydes, and ethylene oxide are among the most important carcinogens in commercial tobacco because of their potencies and levels in commercial tobacco smoke. The major mechanisms through which commercial tobacco smoking causes cancer include:

  • Exposure to cancer-causing substances (carcinogens).

  • Formation of DNA adducts by linking these carcinogens to DNA.

  • Accumulation of lasting genetic mutations [8].

Commercial tobacco use causes at least 12 different types of cancer, accounts for 25% of all cancer deaths globally, and is the biggest cause of lung cancer—causing at least 80% of global lung cancer incidence [8, 10]. Commercial tobacco use has a well-established causal relationship with head and neck, pancreatic, liver, and colorectal cancers [8, 10] and is responsible for over 60% of cancers in the larynx, oral cavity, and esophagus [10]. Figure 36.1 uses flowers to demonstrate how smoking affects lung health.

Fig. 36.1
3 photos depict a bouquet of flowers arranged in the shape of lungs. The deterioration of the left side flora is highlighted.

Changes in lung health depicted using flora native to Australia. (Photo: Claudine Thornton Creative)

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People who smoke commercial tobacco are at increased risk of death. Two-thirds of all people who smoke commercial tobacco long-term will die from smoking-related diseases [9]. Eliminating commercial tobacco would save approximately 22,000 lives per day worldwide, equating to over 900 lives every hour [6]. In Australia, this includes 37% of all Indigenous Australian deaths, and 50% of deaths of Indigenous Australians aged over 45 [11]. In Aotearoa New Zealand, approximately 13.4% of deaths between 2013 and 2015 were linked to smoking, including 22.6% of deaths among Māori and 13.8% of deaths among Pacific peoples. Smoking contributed 2.1 years to the life expectancy gap in Māori men, 2.3 years in Māori women, 1.4 years in Pacific men, and 0.3 years in Pacific women [12]. Thus, the impact of commercial tobacco use—on Indigenous and non-Indigenous peoples and communities—is catastrophic [3, 6] (Fig. 36.2).

Fig. 36.2
An illustration of the human body with the internal organs labeled. The organs labeled are the oral cavity, pharynx, trachea and bronchus, lung, stomach, bowel, ovary, and bladder.

Cancers related to commercial tobacco use. (Design: M Morton Ninomiya)

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For people who smoke, quitting is beneficial for their health and wellbeing [8,9,10]. The quantity and duration of commercial tobacco use have a significant impact on an individual’s susceptibility to cancer, with a dose-response relationship. In other words, the risk of cancer increases linearly with commercial tobacco smoke exposure. Reducing the amount of commercial tobacco consumed, ultimately to the point of complete cessation, is a vital step toward better health and wellbeing.

Commercial Tobacco Use: A Public Health Crisis

The substantial harm of commercial tobacco use has been understood since at least the 1950s. When commercial tobacco is used as “directed,” it kills [7, 8]. Despite this understanding and the WHO FCTC, commercial tobacco use continues to be an international public health crisis [5]. Furthermore, it has a disproportionate impact on the health, economic, and cultural wellbeing of Indigenous peoples due to the disproportionately high drivers of commercial tobacco use experienced by Indigenous peoples [3].

Monitoring the drivers of commercial tobacco use and prevalence can assist in developing, implementing, and evaluating tobacco control programs and policies, including measures to reduce supply and demand [5]. Approximately 50% of the world’s population is regularly surveyed regarding commercial tobacco use, including adolescents and adults [5]. In Australia, data suggest that there was a significant decline in smoking prevalence among Indigenous Australians from 2004 to 2018 (52% to 43%). This reflects the focus, efforts, and leadership in prioritizing smoke-free norms for Aboriginal and Torres Strait Islander communities [4]. In Canada, commercial tobacco prevalence is 40% among First Nations people, 49% among Inuit, and 37% among Métis [3]. In Aotearoa New Zealand, 21% of Māori people smoke, while in the USA, 32% of Indigenous American and Alaska Native populations smoke [11]. These figures are a stark contrast to smoking prevalence among the general populations in these countries, which vary from 12% (Aotearoa New Zealand) to 18% (Canada) [3, 11].

Commercial Tobacco Control Programs and Policies

The WHO FCTC recognizes the critical importance of engaging Indigenous peoples in developing, implementing, and evaluating tobacco control programs and policies. Self-determination is crucial for the health and wellbeing of Indigenous peoples, and communities should be actively involved in commercial tobacco control decision-making processes. Successful programs and policies for Indigenous peoples should consider [4]:

  • Cultural safety: programs and policies should respect and align with the cultural values, beliefs, and practices of Indigenous communities to ensure acceptance and relevance.

  • Holistic approaches to health and wellbeing: programs and policies should take into account the overall wellbeing of individuals and communities, recognizing that health and wellbeing are interconnected with various aspects of life, including social, spiritual, mental, and physical wellbeing.

  • Multifaceted approaches: programs and policies should employ a variety of strategies and support, recognizing that there is no one-size-fits-all solution to addressing commercial tobacco use for any single Indigenous person or community.

  • Indigenous ways of knowing, being, and doing: policies and programs should incorporate Indigenous worldviews and address the social determinants of health and wellbeing.

  • Self-determination: Indigenous peoples need to be at all decision-making tables when programs and policies about commercial tobacco are discussed.

An example from Australia is the Tackling Indigenous Smoking program [13], which incorporates self-determination and opportunities for collaboration and coordination with different sectors. Programs like this help ensure that Indigenous peoples are decision-makers and foster smoke-free norms, ultimately preventing uptake and generating a supportive environment to quit and stay quit [4].

Indigenous Excellence: Accelerating Reductions in Commercial Tobacco Use

In Aotearoa New Zealand, after decades of Indigenous leadership, research, advocacy, and calls from communities, significant structural changes are expected through the Smokefree Aotearoa 2025 Action Plan [14]. This plan was designed to eliminate smoking in Aotearoa New Zealand by 2025 and help mitigate the structural drivers of commercial tobacco use that has disproportionately impacted Indigenous peoples. It had four key components:

  • Making commercial tobacco less addictive by making the only commercially available cigarettes with very low nicotine [13].

  • Reducing access to commercial tobacco through retail outlets [12].

  • Preventing younger people and future generations from taking up smoking by implementing a “smoke-free generation” (ending the sale of tobacco to anyone born after 31 December 2008) [14].

  • Ensuring key populations, including Indigenous peoples, are actively involved in driving programs and evaluation in a way that is consistent with Te Tiriti o Waitangi (Treaty of Waitangi) obligations and the FCTC [5, 14].

Around the world, Indigenous peoples continue to call for commercial tobacco control measures that will fundamentally change the nature and supply of commercial tobacco to ultimately eliminate its harm and the associated racialized health inequities [14, 15].

Bringing tobacco control into the twenty-first century requires ongoing resourcing and substantial funds for commercial tobacco control reforms. For Indigenous peoples, in particular, reducing smoking rates will have a critically important impact on health and wellbeing. The commitment required to ultimately eradicate commercial-tobacco-related cancers and other health impacts for future generations cannot be overstated. Any steps in the right direction will bring a monumental change for generations to come [14].

Relationality

This chapter was guided by the priorities, practices, and rights of Indigenous communities, aligned with the UN Declaration on the Rights of Indigenous Peoples (UNDRIP), the WHO FCTC, and principles of ethical conduct. It was conceptualized with Indigenous leadership, including (but not limited to) our own Indigenous lived experience.

Recognizing the significance of relationality and acknowledging our roles, responsibilities, and obligations to our communities, who we are, and where we come from are fundamentally important. This involves understanding our connections, recognizing our biases, and being aware of our worldviews [16].

Relationality is a distinct Indigenous social research presupposition that supports knowledge generation within specific contexts, times, places, and lands. The importance of valuing and respecting the distinctive ways in which individuals and communities acquire and generate knowledge is critical [16]. By valuing and adhering to our unique ways of understanding and acquiring knowledge, we gain insights into the relationships we have and those who recognize and relate to us in that context. This is a matter of ontology and epistemological consideration. Our being and how relationality informs Indigenous social research paradigms are critical to this chapter.