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010 VOL. 34 NO. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 4 © 2010 The Authors. Journal Compilation © 2010 Public Health Association of Australia Lessons for Aboriginal tobacco control in remote communities: an evaluation of the Northern Territory ‘Tobacco Project’ David Thomas, Vanessa Johnston and Joseph Fitz Menzies School of Health Research and Institute of Advanced Studies, Charles Darwin University, Northern Territory T obacco use is the single most important risk factor for excess mortality and morbidity among Indigenous people, responsible for one-fifth of Indigenous deaths in 2003. 1 Indigenous smoking rates are highest in the Northern Territory (NT), where 54% of adults are daily smokers. 2 In some remote NT communities, the prevalence of smoking is even higher. 3 A comprehensive approach, with many different elements of tobacco control, is promoted as the most likely to succeed. 4 A literature review has inferred which tobacco control activities are most likely to be effective in Aboriginal communities, with evidence usually coming from research in other populations given the paucity of Aboriginal tobacco control research. 5 Nevertheless, evaluations of multi- component tobacco control interventions in Indigenous communities have identified only small impacts on smoking. A study of three intervention and three matched control NT communities only found a reduction in tobacco consumption in one intervention community compared to its matched control. 6 In eight north Queensland Indigenous communities, smoking fell from 61% (of 698) to 57% (of 596). 7 Similarly, a Cochrane systematic review of multi- component community interventions found only minimal differences in smoking in intervention and control communities, including the two most rigorous studies. 8 Nevertheless, the Australian Government has announced more than $10 million for such Submitted: December 2008 Revision requested: April 2009 Accepted: August 2009 Correspondence to: Dr David Thomas, Menzies School of Health Research, PO Box 41096, Casuarina, NT 0810; and Institute of Advanced Studies, Charles Darwin University, NT. Fax: (08) 8927 5187; e-mail: david. [email protected] Abstract Objective: To evaluate a Northern Territory (NT) government-led pilot ‘Tobacco Project’ in six remote communities. Methods: Monthly surveys of staff, semi-structured interviews with staff and community members, observation of the delivery of tobacco control interventions, review of Project documents, and monitoring of tobacco consumption using sales (or wholesale orders) of tobacco. Results: There was a substantive amount of tobacco control activity delivered in three of the Project communities. In two of these locations, the majority of work was primarily driven and undertaken by resident staff. Overall, most of the Project’s efforts related to community education and awareness-raising. There was variable impact of the Project on tobacco consumption across the six communities. More tobacco control activity was consistently associated with a greater reduction in tobacco consumption. An important predictor of local activity was the presence of strong community drivers. A significant obstacle to the Project was the lack of new resources. Conclusions: Despite the minimal impact of this Project on tobacco consumption overall, there was a consistent association between on-the-ground tobacco control activity and reductions in tobacco consumption. Implications: New initiatives will not only need to provide new funding, but identify and then support local staff, who are central to improving local tobacco control activity and so reducing smoking and smoking-related illnesses and deaths. Key words: smoking, tobacco, Indigenous, evaluation, remote. Aust NZ J Public Health. 2010; 34:45-9 doi: 10.1111/j.1753-6405.2010.00472.x multi-component interventions in Indigenous communities. 9 This paper evaluates a recent multi-component tobacco control project in six Indigenous communities, and will further add to our understanding of the impact of such projects, and the key enablers and obstacles of their impact on smoking, in the context of this new policy initiative. The Tobacco Project The Northern Territory Department of Health and Families (NTDHF) (formerly the Northern Territory Department of Health and Community Services) ran a pilot ‘Tobacco Project’ in six remote Aboriginal communities from January 2007 to June 2008. The Project was supported by the National Heart Foundation and local councils, health clinics and health boards in the six communities. The communities were asked to prioritise and plan tobacco control activities from a list of tobacco control interventions, for which the Project could provide support. Each community had a different range and intensity of tobacco control activities; there was not a single Project package that could neatly be evaluated in each site. Importantly, no new NT government resources were put towards the Tobacco Project; the Project could only co-ordinate and redirect the existing resources of the NTDHF Programs in these communities. 10 While the Project was associated with considerable planning and co-ordination activity in Darwin, the lack of specific additional Project resources Article Indigenous issues

Lessons for Aboriginal tobacco control in remote communities: an evaluation of the Northern Territory ‘Tobacco Project’

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�010 vol. 34 no. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 4�© 2010 The Authors. Journal Compilation © 2010 Public Health Association of Australia

Lessons for Aboriginal tobacco control in

remote communities: an evaluation of the

Northern Territory ‘Tobacco Project’

David Thomas, Vanessa Johnston and Joseph FitzMenzies School of Health Research and Institute of Advanced Studies, Charles Darwin University, Northern Territory

Tobacco use is the single most

important risk factor for excess

mortality and morbidity among

Indigenous people, responsible for one-fifth

of Indigenous deaths in 2003.1 Indigenous

smoking rates are highest in the Northern

Territory (NT), where 54% of adults are daily

smokers.2 In some remote NT communities,

the prevalence of smoking is even higher.3

A comprehensive approach, with many

different elements of tobacco control, is

promoted as the most likely to succeed.4

A literature review has inferred which

tobacco control activities are most likely

to be effective in Aboriginal communities,

with evidence usually coming from

research in other populations given the

paucity of Aboriginal tobacco control

research.5 Nevertheless, evaluations of multi-

component tobacco control interventions

in Indigenous communities have identified

only small impacts on smoking. A study

of three intervention and three matched

control NT communities only found a

reduction in tobacco consumption in one

intervention community compared to its

matched control.6 In eight north Queensland

Indigenous communities, smoking fell from

61% (of 698) to 57% (of 596).7 Similarly,

a Cochrane systematic review of multi-

component community interventions found

only minimal differences in smoking in

intervention and control communities,

including the two most rigorous studies.8

Nevertheless, the Australian Government has

announced more than $10 million for such

Submitted: December 2008 Revision requested: April 2009 Accepted: August 2009Correspondence to: Dr David Thomas, Menzies School of Health Research, PO Box 41096, Casuarina, NT 0810; and Institute of Advanced Studies, Charles Darwin University, NT. Fax: (08) 8927 5187; e-mail: [email protected]

Abstract

Objective: To evaluate a Northern Territory

(NT) government-led pilot ‘Tobacco Project’

in six remote communities.

Methods: Monthly surveys of staff,

semi-structured interviews with staff and

community members, observation of the

delivery of tobacco control interventions,

review of Project documents, and

monitoring of tobacco consumption using

sales (or wholesale orders) of tobacco.

Results: There was a substantive amount

of tobacco control activity delivered in

three of the Project communities. In two

of these locations, the majority of work

was primarily driven and undertaken

by resident staff. Overall, most of the

Project’s efforts related to community

education and awareness-raising. There

was variable impact of the Project on

tobacco consumption across the six

communities. More tobacco control activity

was consistently associated with a greater

reduction in tobacco consumption. An

important predictor of local activity was the

presence of strong community drivers. A

significant obstacle to the Project was the

lack of new resources.

Conclusions: Despite the minimal impact

of this Project on tobacco consumption

overall, there was a consistent association

between on-the-ground tobacco control

activity and reductions in tobacco

consumption.

Implications: New initiatives will not only

need to provide new funding, but identify

and then support local staff, who are

central to improving local tobacco control

activity and so reducing smoking and

smoking-related illnesses and deaths.

Key words: smoking, tobacco, Indigenous,

evaluation, remote.

Aust NZ J Public Health. 2010; 34:45-9

doi: 10.1111/j.1753-6405.2010.00472.x

multi-component interventions in Indigenous

communities.9 This paper evaluates a recent

multi-component tobacco control project in

six Indigenous communities, and will further

add to our understanding of the impact of

such projects, and the key enablers and

obstacles of their impact on smoking, in the

context of this new policy initiative.

The Tobacco Project The Northern Territory Department of

Health and Families (NTDHF) (formerly

the Northern Territory Department of

Health and Community Services) ran

a pilot ‘Tobacco Project’ in six remote

Aboriginal communities from January 2007

to June 2008. The Project was supported by

the National Heart Foundation and local

councils, health clinics and health boards in

the six communities.

The communities were asked to prioritise

and plan tobacco control activities from a

list of tobacco control interventions, for

which the Project could provide support.

Each community had a different range and

intensity of tobacco control activities; there

was not a single Project package that could

neatly be evaluated in each site. Importantly,

no new NT government resources were put

towards the Tobacco Project; the Project

could only co-ordinate and redirect the

existing resources of the NTDHF Programs

in these communities.10 While the Project

was associated with considerable planning

and co-ordination activity in Darwin, the

lack of specific additional Project resources

Article Indigenous issues

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4� AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH �010 vol. 34 no. 1© 2010 The Authors. Journal Compilation © 2010 Public Health Association of Australia

and funds constrained the intensity of tobacco control activity in

the communities.

Menzies School of Health Research was invited to evaluate the

project. While the aim was to evaluate the impact of the Tobacco

Project, this could not always be neatly separated from activities

that would have occurred without the Project.

Context – the six communitiesFive of the communities (A, B, C, D and E) were located in

the Top End of the NT and the sixth (F) was in central Australia.

Community F joined the Project significantly later that the other

five, in late 2007.

The Project communities ranged in population from 130 to

more than 2,000. Community A is a cluster of four main sites,

three of which have mostly Aboriginal residents. Community E,

the smallest of the Project communities had no store. By contrast,

in Community B there were five different tobacco retail outlets

operated by different local organisations and an established health

centre and Aboriginal-controlled Health Board.

In all but two communities (A and C), there had been little

concentrated effort on tobacco control in recent years.

MethodsThe evaluation used a mix of data:

• Monthly staff questionnaires of tobacco control activities

delivered.

• Semi-structured interviews with 25 Indigenous adults in two

communities.

• Semi-structured interviews with 19 health and welfare staff.

• Observation of and participation in monthly Steering Group

meetings and review of meeting documents.

• Observation of tobacco control activities in three

communities.

• Sales (or wholesale orders) of tobacco at community stores

and takeaways (except in Community E, where there was no

community store).

Sampling of community members for interviews took place

at three sites (although most (n=21) occurred in one large Top

End community). Health and welfare staff interviews included

government and non-government workers living in, or who visited

regularly, all of the Project communities.

We described the range of tobacco activities delivered; it

was not appropriate to present statistical data on the intensity

of activities across the communities because the data was of

insufficient quality.

Tobacco sales or wholesale invoices from each site were

converted into cigarette (stick) equivalents, with 0.8g of loose

tobacco equivalent to one cigarette, consistent with national

reports.11 If sales data were not available, we described monthly

tobacco consumption using three-month rolling averages of

wholesale invoices. We have shown elsewhere that the average

of three months’ wholesale invoices provides a close estimate of

monthly tobacco sales.12 We compared the total sales (or wholesale

invoices) of tobacco products in the 2006/07 and 2007/08 financial

years, and in the last six months of 2006 and 2007.

ResultsOf the 19 staff interviews, 15 were town or bush-based NTDHF

staff (nine women and four Indigenous staff were included).

Twenty-three health staff consented to providing feedback on

their activities via a monthly questionnaire, but nearly half (11/23)

resigned, took extended leave or moved to different positions

during the Project. The response rate to the monthly questionnaire

was variable and was particularly poor for the last six months

of the Project (monthly response rates between 20 and 40% of

consenting staff, January-June 2008).

1. Tobacco interventions delivered by the Tobacco Project

The range of tobacco interventions delivered by the Tobacco

Project

Across all six communities, most of the Project’s tobacco control

efforts related to community education and awareness-raising

(Table 1). This included group information sessions, the use of

specific health promotion media (e.g. posters, pamphlets, visual

displays), tobacco education as part of general health promotion

and the use of traditional storytelling to reinforce anti-tobacco

messages. These interventions were directed at a range of target

groups: adults, pregnant women and children.

During the Project, a media campaign was launched that targeted

Indigenous youth, the ‘I’m Smarter than Smoking’ campaign.

NTDHF evaluated this campaign by using a survey of 820 NT

Table 1: Tobacco control activities.

Community A Community B Community C Community D Community E Community F

Category of tobacco control activity Increase exposure to ++ +++ + + ++ +++ tobacco control messages

Increase provision of smoking ++ ++ + + + ++ cessation interventions

Increase smokefree areas + ++ + 0 + ++Reduce store display of + + + 0 N/A 0 tobacco products

Notes: +++ = significant activity; ++ = some activity; + = little activity; 0 = no reported activity; N/A = not applicable

Thomas, Johnston and Fitz Article

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�010 vol. 34 no. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 4�© 2010 The Authors. Journal Compilation © 2010 Public Health Association of Australia

Indigenous issues Evaluation of tobacco project in the Northern Territory

students to assess their attitudes towards this campaign compared

with other advertisements. There was no assessment of the impact

of the campaign on smoking initiation or cessation. There were no

changes to NT tobacco control legislation during the Project, and

taxation on cigarettes only increased in line with CPI.13

Where did most activity occur?

There was a substantive amount of tobacco control activity

delivered in three of the Project communities (A, B, F). In two of

these communities (A and B), the majority of work was primarily

driven and undertaken by resident staff and for the most part,

happened alongside (rather than because of) the NTDHF Tobacco

Project.

In Community B, the local health board ran a tobacco control

program from July-December 2007 (the ‘Smokebusters’ Project),

funded independently of the NTDHF Tobacco Project, which

employed two locally based staff members (one full-time Project

Coordinator and one half-time Tobacco Support Worker). This

project was associated with the most intense tobacco control

activity of all participating communities, delivering a diverse

number of tobacco interventions that included: providing free

NRT and counselling to community members; running smoking

cessation courses and one-on-one sessions with clients; providing

education in the school; running a community awareness campaign

to reduce secondhand smoke exposure of children; working with

different community organisations to comply with tobacco control

legislation; working with the clinic to promote brief intervention;

and applying for funds to sustain local tobacco control activity.

In Community A, a high level of activity (including NRT

education, subsidisation and distribution, strong support for

smokefree public areas and work sites, and ongoing education)

was also reliant on resident health staff who were committed to

Aboriginal tobacco control and had longstanding relationships

with community members. Successes here included the cessation

of sales of cigarettes at a supermarket (after lobbying from the local

doctor), and the heavy promotion of ‘No Smoking’ areas on clinic

grounds and at the airport. In this context, the NTDHF Project was

able to support and foster activity that was already happening in the

community, even though the Project did not initiate a significant

amount of additional tobacco control work.

Community F was a slightly different story again. In this

community, interviews indicated that the Tobacco Project acted as

a significant driver to scale up NTDHF Alcohol and Other Drugs

program work on Aboriginal tobacco control. Activity included

the provision of group information and education sessions, heavy

promotion of smokefree areas at the council, clinic and youth

services, and efforts to engage the clinic in increasing the use of

smoking cessation pharmacotherapies and brief interventions.

This local activity was supported or driven by visits from NTDHF

staff from Alice Springs, with strong involvement from several

local organisations: the council, the local youth program and the

store.

In the three other Project communities (C, D and E), there was

comparatively little reported activity. For example, in Community

D, there were only two visits by NTDHF staff during the course

of the Project; this was partly attributed to difficulties engaging

with the clinic staff at this site.

2. Tobacco consumption Data from six Project sites (two sites in the community A cluster,

and all other communities excluding community E, where there

was no store), demonstrated a 1.2% reduction in daily tobacco

consumption in 2007/08 compared with 2006/07. And there was

a 5% reduction in tobacco consumption in the second half of

2007 (when most project activity occurred) compared with the

same time in 2006.

Tobacco consumption decreased in both the 12-month and six-

month comparison in only three locations (Table 2). The greatest

relative reduction in tobacco consumption occurred in Community

F. However, because community F is a small community, this was

only associated with a very modest absolute reduction of less than

a packet of cigarettes every day.

Community B had the greatest absolute reduction in tobacco

consumption in each comparison. In 2007/08, 182,077 less

cigarettes were sold than in 2006/07. Indeed, if the results from

community B are excluded, there was an overall 3.5% increase

(rather than a decrease) in tobacco consumption in the remaining

four locations (2007/08 vs 2006/07), and only a small 0.6%

reduction in the six-month comparison.

In community B, the sharpest decline in consumption coincided

with the start of increased local tobacco control activity, and the

employment of a public health nurse and tobacco community

worker in mid-2007, followed by a period of consistently lower

consumption. Tobacco consumption returned to previously higher

levels of consumption soon after the local activity and Project

collapsed at the end of 2007. There was no such neat temporal

Table 2: Comparisons of tobacco consumption.

Average number of % change in Average number of % change in cigarettes/day cigarettes/day cigarettes/day cigarettes/day

2006/07 2007/08 July-Dec 2006 July-Dec 2007

Community A

Site 1 1,838 1,865 -1.4% 1,976 1,819 -7.9%

Site 2 1,696 1,984 +17.0% 1,876 1,954 +4.1%

Community B 12,661 12,129 -4.2% 11,840 10,849 -8.4%

Community C 2,931 2,786 -4.9% 2,952 3,040 +3.0%

Community D 1,603 1,733 +8.1% 1,790 1,766 -1.4%Community F 374 352 -5.7% 382 342 -10.6%

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correlation between reductions in tobacco consumption and

Project activity in other sites.

3. Perceptions about enablers and obstacles to tobacco control

Community readiness for tobacco control

The places where most activity took place (communities A,

B and F) were where stakeholders across the community (e.g.

council, clinic, school) were stated by health staff to be ‘ready’

to prioritise tobacco control. They had identified tobacco control

as a priority, developed local strategies and had dedicated staff

available to deliver services.

‘Community readiness’ was supported by strong local drivers

of tobacco control, who, particularly in Community A, had been

working hard on the issue for years. These stakeholders (usually

clinic or council staff) had established trusting relationships with

the communities in which they lived and could act as a conduit

for further activity delivered through the Project. We observed

that key to the success of these local drivers was that they were

resident in communities and had dedicated duties to tobacco

control (either part or full time). Developing local Aboriginal

capacity was also reported as important in the success of local

efforts in the long term.

Lack of resources Overwhelmingly, health staff reported that a lack of resources

undermined the success of the Tobacco Project and tobacco control

more generally. For the Project, lack of new resources impacted

on the type of tobacco interventions that the Project delivered and

the time spent by staff delivering these. The perception of senior

Departmental staff was that they were still ‘fiddling around at the

edges’ of tobacco control. Budgetary constraints also affected

time staff spent on the Project, while balancing other demands

(this was reported at all levels of staff involvement); the AOD

Community Support Officers who conducted much of the field

visits reported feeling particularly stretched. It also effected travel

and time spent in communities, with the centralised rapid fly-in,

fly-out model perceived as increasingly ineffective in connecting

with community people.

The interviews also identified examples of both successful

collaboration and poor collaboration and conflict between Project

partners, and generic problems encountered in working with these

communities (e.g. seasonal access), in addition to the particular

disruption of the NT Emergency Response. These data are not

elaborated on here (but are available from study authors).

The Aboriginal community informants provided little useful

data on the processes used for this project, beyond being generally

supportive of the community-driven project in community

B, where most interviews were conducted. These informants

however, provided useful data on why remote Aboriginal adults

smoke,14 as well as general perceptions of different tobacco control

interventions.

DiscussionData limitations

The low and variable staff response rate to monthly questionnaires

means that some tobacco control activities may not have been

identified by the evaluation. However, interviews and informal

discussions with health and community staff, as well as regular

attendance at Project Steering Group meetings, provided the

evaluation team with other sources of information about what was

delivered in each of the Project communities, reducing the final

amount of missing data.

Similarly there were limitations of the tobacco consumption

results: the most significant is that there was no fixed denominator

for these consumption results. The potential impact of population

changes means that particular caution should be exercised in

the interpretation of the results, particularly from community F,

where the departure of just one or two pack-a-day smokers from

this location could explain the apparent decline in consumption

in that community. However, local informants in community

B had noticed no significant population change to account for

the dramatic reduction in tobacco consumption associated with

increased tobacco control activity in the last six months of

2007.

Tobacco consumption data from community A need to be

interpreted with caution, as we were not able to report on data

from two of four sites in the cluster. And residents of community

F and Site 1 community A are close to tobacco retail outlets where

we did not access store data because they also service many non-

Aboriginal clients. Nevertheless, store-based indirect measures

of consumption are the preferred measure of consumption in this

setting. In contrast, self-reported numbers of cigarettes smoked

in surveys in remote Aboriginal communities are only weakly

correlated with cotinine levels,15 and estimates of cigarettes

smoked per smoker have demonstrated to be both higher6,16 and

lower17 in surveys compared to store-based estimates. At the

national level, estimates of consumption based on self-report

under-estimate consumption by 26% compared to estimates

based on tax receipts (which are analogous to our store-based

estimates).18 Finally, the study did not include control communities

unlike the two previous studies.6,7 Delays in collecting tobacco

consumption data from other sites meant that there was insufficient

data to make meaningful comparisons.

In spite of these limitations, some clear messages emerge from

the results.

Lessons from the Tobacco ProjectMore tobacco control activity was associated with a greater

reduction in tobacco consumption. While we were not able to

neatly quantify the intensity of tobacco control, we could compare

both places and periods with clearly different intensities of tobacco

control activity. Community B and F, where significant tobacco

control activity occurred, were also the locations with most

consistent reductions in tobacco consumption. Additionally, there

was a greater (5%) reduction in combined tobacco consumption

Thomas, Johnston and Fitz Article

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�010 vol. 34 no. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 4�© 2010 The Authors. Journal Compilation © 2010 Public Health Association of Australia

when we just looked at the last six months of 2007, the period of

greatest reported tobacco control activity, than when the whole

12 months of 2007/08 was examined (1.2%).

The three communities (A, B, F) that saw most activity over

the life of the project were places most ‘ready’ to tackle the issue,

that is, these local communities had prioritised tobacco control,

key stakeholders were on board and resources and staff time were

mobilised. In two of these communities (A and B), health staff and

management had made tobacco control a clear priority and had

allocated additional resources for tobacco control; in community

B, led by the local Aboriginal community controlled health board.

The north Queensland study had similarly suggested that lack of

local ownership of their project had limited its impact.7 In contrast,

the Cochrane review found no relationship between community

involvement and the impact on smoking outcomes.8

The lack of dedicated new resources for the Project was a major

impediment to increasing tobacco control activities. Other low

intensity multi-component community tobacco control projects

in remote Indigenous communities had similarly modest overall

impacts.6,7 In this context, the apparent impact on consumption,

especially in Community B with its significant additional

resourcing is encouraging. Similar levels of additional resourcing

in other communities could lead to significant reductions in

Aboriginal smoking in the NT. The need for adequate new

dedicated funds is supported by American research that showed

that increases in State tobacco control program expenditures

were independently associated with overall reductions in adult

smoking prevalence.19 The planned new multi-component tobacco

control initiatives will not only need to provide new funding, but

identify and then support local staff, who we found were central to

improving local tobacco control activity and so reducing smoking

and smoking-related illnesses and deaths.

AcknowledgementsThis research was supported by a grant from the Cooperative

Research Centre for Aboriginal Health (No. CD 216) and a

NHMRC GP Clinical Research Grant (490300). The NT DHF

contributed additional funds to cover the six-month extension

of the evaluation. David Thomas was supported by a NHMRC

Population Health Capacity Development Grant (#256235).

The evaluation team would like to thank all the participating

Aboriginal communities, community residents and staff, NT

DHF staff, participating community organisations, and stores

and wholesalers.

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2. Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Health Survey 2004-5. Canberra (AUST): ABS; 2006.

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9. Snowden W. $10.7M Available to Reduce Indigenous Smoking Rates:13 July 2009 [media release on the Internet].Canberra (AUST): Minister for Indigenous Health, Rural and Regional Health and Regional Services Delivery; 2009 [cited 2009 July 17].Available from: http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr09-ws-ws08.htm

10. Northern Territory Department of Health and Community Services. Tobacco Strategy Project: Briefing Document. Darwin (AUST): NTDHCS; 2008

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Indigenous issues Evaluation of tobacco project in the Northern Territory