title: Effective strategies to reduce commercial tobacco use in Indigenous communities globally: A systematic review.
abstract: BACKGROUND
  All over the world, Indigenous populations have remarkably high rates of commercial tobacco use compared to non-Indigenous groups. The high rates of commercial tobacco use in Indigenous populations have led to a variety of health issues and lower life expectancy than the general population. The objectives of this systematic review were to investigate changes in the initiation, consumption and quit rates of commercial tobacco use as well as changes in knowledge, prevalence, community interest, and smoke-free environments in Indigenous populations. We also aimed to understand which interventions had broad reach, what the common elements that supported positive change were and how Aboriginal self-determination was reflected in program implementation.
  
  
  METHODS
  We undertook a systematic review of peer-reviewed publications and grey literature selected from seven databases and 43 electronic sources. We included studies between 1994 and 2015 if they addressed an intervention (including provision of a health service or program, education or training programs) aimed to reduce the use of commercial tobacco use in Indigenous communities globally. Systematic cross-regional canvassing of informants in Canada and internationally with knowledge of Indigenous health and/or tobacco control provided further leads about commercial tobacco reduction interventions. We extracted data on program characteristics, study design and learnings including successes and challenges.
  
  
  RESULTS
  In the process of this review, we investigated 73 commercial tobacco control interventions in Indigenous communities globally. These interventions incorporated a myriad of activities to reduce, cease or protect Indigenous peoples from the harms of commercial tobacco use. Interventions were successful in producing positive changes in initiation, consumption and quit rates. Interventions also facilitated increases in the number of smoke-free environments, greater understandings of the harms of commercial tobacco use and a growing community interest in addressing the high rates of commercial tobacco use. Interventions were unable to produce any measured change in prevalence rates.
  
  
  CONCLUSIONS
  The extent of this research in Indigenous communities globally suggests a growing prioritization and readiness to address the high rates of commercial tobacco use through the use of both comprehensive and tailored interventions. A comprehensive approach that uses multiple activities, the centring of Aboriginal leadership, long term community investments, and the provision of culturally appropriate health materials and activities appear to have an important influence in producing desired change.
authors.affiliation: Ontario Tobacco Research Unit, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. alexa.minichiello@mail.utoronto.ca.
authors.forename: Alexa
authors.initials: A
authors.lastname: Minichiello
authors.affiliation: Ontario Tobacco Research Unit, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. lefkowitz.ayla@gmail.com.
authors.forename: Ayla R F
authors.initials: AR
authors.lastname: Lefkowitz
authors.affiliation: Well Living House Action Research Centre for Indigenous Infant, Child and Family Health and Wellbeing,, St. Michael's Hospital, Toronto, Canada. FirestoneM@smh.ca.|Centre for Research on Inner City Health, St. Michael's Hospital, Toronto, Canada. FirestoneM@smh.ca.|Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. FirestoneM@smh.ca.
authors.forename: Michelle
authors.initials: M
authors.lastname: Firestone
authors.affiliation: Well Living House Action Research Centre for Indigenous Infant, Child and Family Health and Wellbeing,, St. Michael's Hospital, Toronto, Canada. janet.smylie@utoronto.ca.|Centre for Research on Inner City Health, St. Michael's Hospital, Toronto, Canada. janet.smylie@utoronto.ca.|Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. janet.smylie@utoronto.ca.
authors.forename: Janet K
authors.initials: JK
authors.lastname: Smylie
authors.affiliation: Ontario Tobacco Research Unit, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. Robert.Schwartz@utoronto.ca.
authors.forename: Robert
authors.initials: R
authors.lastname: Schwartz
mesh_terms: D002170:Canada; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D044382:Population Groups / Q000208:ethnology*; D015995:Prevalence; D012907:Smoking / Q000208:ethnology; D000074606:Smoking Prevention; D014028:Tobacco Smoke Pollution / Q000331:legislation & jurisprudence; D064424:Tobacco Use / Q000208:ethnology* / Q000517:prevention & control*
chemical_list: D014028:Tobacco Smoke Pollution