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| Journal of the New Zealand Medical Association,
26-November-2010, Vol 123 No 1326
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Heather Gifford, Kiri Parata, George Thomson
Smoking in homes is a crucial factor in starting smoking and
quitting.1–5 For New Zealand youth, the
relative risk of Māori children reporting smoking inside their homes has
been increasing.6 Substantial immediate gains
in preventable mortality and morbidity are possible by reducing exposure to
secondhand smoke (SHS) in homes and cars, particularly from the reduction of the
exposure to children.7–11 There is clear
evidence of higher exposure to SHS in homes and cars for Māori
children.6,12
When Year 10 students were asked in 2008 if there was
smoking in their homes, 36% of Māori students reported smoking in the home,
compared to 18% for European/other students.6
These figures had decreased significantly since 2001, when 48% of Māori
students reported smoking in the home, compared to 27% for European/other
students. Exposure may be compounded for Māori by over representation in
low socioeconomic groupings; for students in the three most socioeconomically
deprived deciles of schools in 2008, 31% reported smoking in the
home.6
Māori children are also exposed to SHS in cars at a
higher rate. When asked in 2006 if someone had smoked while they were travelling
in cars or vans in previous seven days, 43% of Māori Year 10 students
reported exposure, compared to 22% of European/other
students.13
One option for addressing the problem of tobacco smoking,
and specifically the widespread exposure to secondhand smoke, is through policy
approaches. At present, information is lacking on New Zealand
stakeholders’ attitudes and responses to policies on reducing the exposure
of children to smoking behaviour and to SHS, and on the optimal avenues for
introducing such policies. Little work has been done on the processes for new
tobacco policies, or on health policy processes in groups such as iwi (tribal
groups). Research on Māori and Pacific health decisionmakers’ views
is rare,14 and in-depth research about any
Māori and NZ Pacific decisionmakers is
uncommon.15,16 We found no published research
on their views about smoking.
The aim of the research was to determine obstacles and
opportunities within policy processes, for smokefree interventions appropriate
to Māori. In particular, to explore Māori policymakers’ ideas on
how to achieve progress on smokefree homes, cars and community property.
MethodsThis research reports on the results of interviews
conducted with senior Māori officials and Members of Parliament, and
interviews with members of two case studies; one of a tribal health provider
organisation, and the second, a formal collective of senior Māori
policymakers employed by district health boards.
The criteria for interviewee selection included being a
Māori policymaker (senior central government officials or ex-officials, or
a Member of Parliament), closeness to processes relevant to tobacco control, and
ability to articulate information. The sample was selected using purposeful
sampling, including the use of reputational snowball recruitment
methods.17 An advisory group of senior
Māori researchers, including those with policy and tobacco control
expertise, identified an initial list of 28 potential interviewees and four
potential case study groups; this list was used to approach potential
participants. Māori researchers conducted all components of the research,
including formulating the interview schedule, collecting and analysing
data.
The case study sites were selected as formal Māori
collectives with an interest in Māori tobacco control, as accessible within
the research timeframe, and as having the ability to influence policy at a local
and or national level. One case study was a medium size Māori primary
healthcare provider employing approximately 20 employees and servicing
approximately 4000 clients. Six interviews were undertaken with the staff and
tribal elders, who are affiliated with the provider and the governance of the
organisation.
The second case study site was the group of senior
Māori officials of the twenty one district health boards, who meet
regularly as a formal collective to discuss key national health issues for
Māori. Initially it was suggested that a focus group approach would be
undertaken with the collective. However, it was considered by the group that
individual interviews should be conducted with key people to represent the view
of the collective. Three interviews were undertaken with members of the second
case study site. The opportunity to be involved in the research was well
supported by both case study groups.
A semi-structured interview format was created based on
a comprehensive literature review of Māori policymaking and tobacco
control, and was added to as the interviews progressed. The same interview
schedule was used for both policymaker and case study interviews.
Open-ended questions were used to find:
The interviews were not conducted to find the
extent of the policymakers’ knowledge, but their ideas and beliefs.
The interviews were conducted on the basis of
confidentiality, with the results to be anonymous. All data collection occurred
between May 2008 and March 2009. Ethics permission for the study was obtained
through the University of Otago ethics process.
The data was examined for patterns and themes, and then
all the material identified that related to the patterns identified was
gathered.18 The use of semi-structured
interviews, with some open questions, allowed for template analysis to identify
themes. Template analysis is the coding of material within hierarchic groups,
some based on the set questions.19 The
selection of themes was discussed by the research team and advisory group, and
compared to those in the literature available.
ResultsSixteen policymaker interviews were conducted, with 3
politicians and 13 officials/ex-officials. Including the case studies, a total
of 25 interviews were completed.
Several key themes emerged from the research including,
children as drivers for change, strong national and local indigenous leadership
needed for change, delivering smokefree messages as part of wider healthy living
approaches, targeting of the messages for greatest impact for Māori,
central and local government having a significant role in the prevention of
tobacco harm, tobacco tax revenue being spent on tobacco control, and the rights
of children to smokefree environments.
The context for changes around tobacco and
Māori—There was general agreement that tobacco smoking is
highly addictive and requires support and intervention from many, including
whānau. Almost all participants believed that most smokers have a desire to
kick the addiction, but find it difficult to do so:
...It’s got to be more
addictive than heroin because you look around society, when you’re working
in Wellington and you’re walking down Lambton Quay (Central Business
District) and you see seriously intelligent people standing out in the wind and
the rain...and there is all of this public shame but they still do it.
Participant responses were varied on the issue of
normalisation of tobacco within New Zealand and in particular within Māori
culture. Some felt very strongly that smoking was still a normalised part of
some sections of the Māori population, while others believed that tobacco
smoking was now an unaccepted part of Māori society. One interviewee
said.
...The product [tobacco]
within Māoridom was seen as a normal cultural activity, now it’s not
and I think we have to get to a point where we denormalise it.
The majority of participants believed that children have a
fundamental right to be free not only from secondhand smoke but also from the
role modelling of adults smoking. One person stated that it is the role of
whānau (extended family) to ensure their tamariki (children) are
safe.
...Yes, children’s
rights are greater [than adults]. Children have a right to a safe environment
and it’s the adult’s responsibility to ensure this.
Some made the comparison with alcohol policy.
...So if I want to smoke,
more power to me, but I also need to be conscious of the impact that has on
other people ... we [government] certainly do that subtly and also quite
explicitly around our drinking behaviour. So you get to holiday periods and
suddenly you get bombarded on TV with a whole lot of ads around drink driving,
wearing your seat belts, not speeding. So we’re linking our choice or our
decision to have a drink with the impact that it might have on other people once
we do that.
The need for Māori
approaches—All participants argued that general population
approaches (i.e. addressed to the whole population, Māori and non-
Māori) are not the best way to support Māori to reduce smoking. While
the goals for reduction may be the same across the whole population, the
approaches need to take into account the specific social, political, historical
and cultural differences for Māori. Most went on to say that Māori can
make change if the message comes from someone they identify with, and many
believed that a whānau-focused approach is more effective for Māori
than a focus on the individual. One participant spoke of the need to ensure our
legislative responses are meeting the needs of all groups within the wider
population.
...You need to have a policy
that is flexible enough to be able to respond to which ever group needs to use
it. So it’s ... like – got this kete [basket], got all these tools
in it, this particular community can take that kete and go, [but] I want [just]
those 3 tools, the rest I don’t need to use. And government needs to do
that, because it needs to meet the needs of it’s entire population and it
can’t take out one brush or one policy for everyone.
The range of solutions—The majority
of participants interviewed said that children hold the key to making change
within Māori households; largely as a motivator for quit behaviour.
Participants described a duty and obligation to tamariki/children. They said
that almost all whānau /families understood the negative role modelling of
smoking, and that was often a sufficient motive for them to quit. Some
interviewees felt it might be too late with the older generation, but educating
our young ones and using children as “agents for change” was the
best way forward.
...My mother only gave up
smoking once the mokopuna [grandchildren] arrived, it was that easy, she knew it
was wrong and didn’t want to harm them.
Other participants discussed a wider intergenerational
approach.
...If there’s a
whānau focus, ... there is a sense of intergenerational responsibility and
obligation to take care. Particularly for those of us who are in mid adult
years, where we are both caring for children but we are in the process of caring
for our kuia and kaumātua [elders] too. Our health matters. Their health is
dependant on our health, therefore there is that responsibility for getting that
message through.
Many participants believed that Māori leadership at a
national, local, community and whānau level was fundamental to making
change with Māori smoking rates. Almost all those interviewed agreed that
Māori need to take ownership of the situation. They generally advocated
starting locally with leaders within a whānau or hapū, and the need
for them to lead by example, despite the problems with this approach.
...Unfortunately many of the
respected people on a marae[meeting house] or within a whānau are smokers.
It can be difficult to change behaviours and implement rules around smoking if
iwi leaders are smokers themselves .... who’s going to tell a respected
kaumātua what to do?
There was also some debate about the role of individual
responsibility for behaviour change (and sometimes the guilt attached for
individuals who don’t change) and the role of government or wider
structural change. While most saw the use of whānau /families in social
marketing campaigns as positive and educative, a few saw it as unhelpful for
those unable or unwilling to quit, due to a range of pressing and immediate
social and economic challenges.
...It’s a bit like the
cervical screening ads that were very guilt laden, you have to do it for your
family. So what if you don’t? Does that mean you’re bad, that you
have let down your family?
... [Government] needs to be
particularly careful around the assumptions of personal responsibility. Because
while it is true everyone does have personal responsibilities for their own
health and wellbeing, the process of colonisation and the systemic racism that
still exists in both the health and the legal system mean that there are
particular barriers to getting access to ... information [for] Māori. ...
[And] if those systemic failures aren’t recognised, the message does not
get through.
A number of participants talked about the over-use of the
same messages in smokefree campaigns. They spoke of a need to move away from the
specific focus of being smokefree, and wrapping it up in a broader healthy
lifestyle approach, such as the Healthy Eating Healthy Action campaign, (a
national public health campaign to reduce obesity).
...They are sick of it
[smokefree messages]. We had a recent Māori golf tournament and people said
they are sick to death of the same old smokefree messages. It’s been that
way for 10 years now, it’s gone stale.
When discussing a particular after-school and holiday
programme in the Hutt Valley, another interviewee said:
...The kids come together,
they’re off the streets and out of trouble, they learn a number of things
about being healthy, and smokefree messages might be part of that... it’s
kaupapa Māori, it’s about who we are and the kids like it and get
it.
All participants agreed that the government has a
significant role in the prevention of tobacco harm. All agreed that a portion of
tobacco tax revenue should be spent on tobacco control.
...There should be a
hypothecated/tied tax regime. There’s a billion dollar tax take per
year... and just $40 million out of the billion dollar tax take [is being
invested in tobacco control], your math quite easily says this is not
right.
Some believed that a blanket approach, such as legislation
to ban tobacco products from Aotearoa/New Zealand, was the best idea and
believed this could be done within a five year period:
...The only obstacle is lack
of political will. If we had the courage today to pass a piece of legislation to
ban the manufacture and sale of tobacco in Aotearoa, tomorrow there would be
none [tobacco].
Others wished to see local body councils taking a stronger
leadership role, for example by introducing smokefree bylaws for playgrounds and
sports fields. While some participants identified that it would be difficult to
enforce, the promotion of smokefree environments concept and the discussion it
would raise was seen as useful. Some interviewees spoke of their own experiences
introducing smokefree policies on their marae; this was generally positive but
took some time to be adopted.
Other participants thought that it would be inappropriate
for a Council to impose rules on Māori-owned land or resources such as
urupa or Marae; they felt strongly that such changes needed to be owned by the
people involved.
DiscussionThe findings—Māori policymakers
interviewed called for a strong interventionist role for central and local
government in reducing disparities in tobacco smoke exposure. This is not
surprising, when considered alongside a Treaty of Waitangi framework that holds
government accountable for ensuring that Māori experience at least the same
level of health as that of the wider population. There was clearly some opinion
that the emphasis needs to move from constraining the individual to constraining
the market, through managing the supply of tobacco. And that political will
(other than that being demonstrated by some Māori members of
government),20 is currently lacking in this
area.
Māori leadership at all levels was considered critical
to leading change. This included taking ownership of the situation, role
modelling positive behaviours, and helping design tobacco control interventions
in collaboration with tobacco control experts. The implicit Treaty agreement
with government could be: share authority and appropriate levels of resources
with Māori groups for the purpose of tobacco-free change, and Māori
leadership within government and within tribal structures will be responsible
for change.
One of the challenges that currently exists in engaging
Māori leadership in tobacco resistance work is that many of the leaders
smoke; this should not be an impediment to action. Tobacco resistance can take
many forms, including policy level interventions and the creation of smoke free
environments. This work does not require the advocate to be smokefree themselves
but does require a commitment to a smokefree Aotearoa for future generations; a
concept that the majority of Māori leadership may support.
The theme of children as a motivator of quitting has been
found in research of smokers’ quit
reasons.21 There is some evidence from the USA
(with Latinos v whites) that ethnicity can be a factor in the extent to which
smokers quit as an example to children.22 That
Māori policymakers stressed the birth of children and grandchildren as a
strong catalyst for quit behaviour, suggests that there is potential for
advocacy through such policymakers for additional relevant quit
support.
There was a strong theme that the rights of children clearly
outweigh the individual rights of adults to smoke in privately owned spaces, for
instance homes and cars, and that adults have a duty of care to protect children
from harm. However there was no one clear view on how best to achieve changes in
the area of smokefree environments around children. Some thought that the
changes needed to be at a more structural level where the manufacture and supply
of tobacco was limited, others called for a comprehensive approach requiring a
“suite of programmes and responses” needing to be put in place,
others said that we should not legislate for a smoking ban in cars, as people
should be supported to make changes and choices for themselves in their private
spaces.
While this research did not show a consensus on approaches
for increasing smokefree environments for children, other New Zealand research
does indicate strong Māori public and smoker support for a legislative
framework banning smoking in cars with
children.23–25
Policy implications—A total ban on
tobacco products within New Zealand, an approach receiving increasing support by
Māori tobacco control advocates and Māori policy makers over the past
five years,20 was supported by some of the
Māori policy makers interviewed in this research. While a total ban may be
unachievable in the near future, there is an onus on government to show that
their alternatives are effective in reducing disparities for Māori.
Māori tobacco control should be a high priority for
government, including a distinctive indigenous controlled approach to reducing
disparities in outcomes. Approaches need to take into account the specific
social, political, historical and cultural differences for Māori. Greater
funding for various targeted programmes should come from tobacco tax revenue,
and should be reflective of the health significance of high rates of smoking for
Māori.
The call by interviewees, for a move towards a broader
wellness approach for smokefree marketing to Māori, indicates an avenue to
be considered when social marketing and health education messages are reviewed.
Limitations—While the search for
themes used validated qualitative approaches which were conducted rigorously,
the thematic selection from the data by another research group might be quite
different. The small sample size means that the results from the study are not
indicative of the opinion of all Māori policy makers; additional research
is needed to explore the issues raised more widely. We note that contrasting
Māori policy makers’ views with non-Māori policy makers’
would cast further light on approaches to policymaking.
ConclusionsThe results indicate that Māori policymakers consider
indigenous specific approaches and indigenous leadership critical for Māori
tobacco-free advances. In addition, the research supports a strong role for
central and local government to reduce disparities in tobacco smoke exposure.
Funding for interventions could come from dedicated tobacco tax, and the mandate
to act on behalf of children is provided through human rights frameworks.
Harnessing indigenous values and principles related to health, family and
children provides an impetus to change smoking behaviours, and was the preferred
method of these Māori policymakers for delivering social marketing
messages.
Competing interests: The authors have
undertaken tobacco control work for health sector agencies.
Author information: Heather Gifford,
Whakauae Research for Māori Health and Development, Whanganui; Kiri Parata,
Whakauae Research for Māori Health and Development, Whanganui; George
Thomson, Senior Research Fellow, Department of Public Health, University of
Otago, Wellington
Acknowledgments: The Health Research
Council of New Zealand provided funding for this Project. We also thank our
interviewees for their contributions of time and ideas.
Correspondence: George Thomson, Department
of Public Health, Te Tari Hauora Tumatanui, University of Otago, Box 7343
Wellington South, New Zealand. Fax: +64 (0)4 3895319; email: george.thomson@otago.ac.nz
References:
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