Health starts where we live, learn, work and play. This is the deliberate reframing of the social determinants of health inequalities by the United States Robert Wood Johnson Foundation, designed to better appeal to politicians, policymakers and the public.1For more than a decade, a more explicit emphasis on the social, economic, cultural and environmental determinants of health has driven the work of the World Health Organization.2 In New Zealand, efforts to reduce health inequalities have been made by ministers, ministries,3,4 district health boards,5 regional public health services, primary health organisations, NGOs6 and public health academics,7-9 who often work in partnership with these other organisations. Recognition of our obligations under theTreaty of Waitangi has helped to focus the activities.Last year, the media reported that, in what seems to be largely an act of self-censorship, words such as ‘the organised efforts of society', ‘public health', ‘inequalities and advocacy', were among the phrases that should no longer be used in Ministry of Health documents.10When explicit discussion of health inequalities and public health is censored, and inequality becomes a politically prescribed word, we run the risk of collective amnesia. Whatever language we use, the underlying determinants of health, the enduring power structures of society, are slow to change. However, we know from work in New Zealand and the United Kingdom—where there is closer, more regular monitoring of policies designed to reduce health inequalities—health inequalities are easier to let grow than to reduce.11 If we do not measure and analyse these trends, we can all too easily find that just like weight gain, the scales, when we finally look at them, are telling us what we would rather not know.Unlike GDP, income inequality is not measured routinely in New Zealand. In the mid-1990s, it was the UK Roundtree Foundation that alerted us to the dubious honour of having the largest percentage point change in the Gini coefficient of inequality in the preceding decade of the OECD's industrialised countries.In the mid-2000s, New Zealand was in the top quarter of the OECD for inequality of incomes, as measured by the Gini coefficient—only below Mexico, Turkey, Portugal, United States and Poland and on par with the United Kingdom.12 It appears that income inequality in New Zealand reduced slightly in the middle of last decade, but associated harmful behaviours, have been slower to decrease.One of the consequences of an unequal distribution of resources in New Zealand in terms of income, wealth, education, employment and home ownership opportunities has been the smoking epidemic which hit the Māori community (tobacco was unknown before European colonisation) after it had already peaked in European men. These inequalities may also prevent more rapid falls in smoking prevalence than might otherwise be the case.Māori once again appear to be the ‘shock absorbers of the economy' with unemployment rates, like smoking rates, over double those for European.13 The additional burden of tobacco exacerbates the costs of widespread unemployment and detrimentally affects whānau (extended family) well-being. The Māori Affairs Select Committee has laudably adopted the Tupeka kore vision of a tobacco-free New Zealand by 2020. Radical action and strong political will is now required to bring this about.In the current NZMJ, Blakely and colleagues, using a thought experiment, pose a counterfactual to the current position, what would happen to health inequalities, if nobodysmoked cigarettes after 2020? Compared to the prevalence of smoking in 2006, ethnic inequalities in life expectancy would fall by 0.3 to 4.6 years (on average 1.8 years, but consistently greater for females). The authors maintain that making New Zealand tobacco-free is one of the most important steps to achieving health equality between Māori and non-Māori by 2040—200 years after the signing of the Treaty.The eminent philosopher John Rawls used just such a thought-experiment as the basis of his theory of justice. He posed a ‘veil of ignorance' as a device, which decisionmakers, for example, could use when considering policy options. If I did not know my position in society, if I had no idea as to whether I was rich or poor, Māori or European, what policies would I favour? Blakely and colleagues' careful social epidemiology over the last decades suggest that rich or poor, Māori or non-Māori, legislating to phase tobacco out as a legal policy in New Zealand would be an important step in reducing health inequalities in New Zealand.In a truly Smokefree New Zealand, we would expect further acceleration of the long-run trend of closing ethnic gaps in mortality that we enjoyed after World War 2 and have recently glimpsed again. The latest New Zealand Values Survey clearly indicates this vision is strongly shared by most New Zealanders.14If we, as health professionals, can find and use words that resonate with the rest of society, the vision of a tobacco-free New Zealand—where life chances are not determined by ethnicity—is indeed possible.

Health starts where we live, learn, work and play. This is the deliberate reframing of the social determinants of health inequalities by the United States Robert Wood Johnson Foundation, designed to better appeal to politicians, policymakers and the public.1For more than a decade, a more explicit emphasis on the social, economic, cultural and environmental determinants of health has driven the work of the World Health Organization.2 In New Zealand, efforts to reduce health inequalities have been made by ministers, ministries,3,4 district health boards,5 regional public health services, primary health organisations, NGOs6 and public health academics,7-9 who often work in partnership with these other organisations. Recognition of our obligations under theTreaty of Waitangi has helped to focus the activities.Last year, the media reported that, in what seems to be largely an act of self-censorship, words such as ‘the organised efforts of society', ‘public health', ‘inequalities and advocacy', were among the phrases that should no longer be used in Ministry of Health documents.10When explicit discussion of health inequalities and public health is censored, and inequality becomes a politically prescribed word, we run the risk of collective amnesia. Whatever language we use, the underlying determinants of health, the enduring power structures of society, are slow to change. However, we know from work in New Zealand and the United Kingdom—where there is closer, more regular monitoring of policies designed to reduce health inequalities—health inequalities are easier to let grow than to reduce.11 If we do not measure and analyse these trends, we can all too easily find that just like weight gain, the scales, when we finally look at them, are telling us what we would rather not know.Unlike GDP, income inequality is not measured routinely in New Zealand. In the mid-1990s, it was the UK Roundtree Foundation that alerted us to the dubious honour of having the largest percentage point change in the Gini coefficient of inequality in the preceding decade of the OECD's industrialised countries.In the mid-2000s, New Zealand was in the top quarter of the OECD for inequality of incomes, as measured by the Gini coefficient—only below Mexico, Turkey, Portugal, United States and Poland and on par with the United Kingdom.12 It appears that income inequality in New Zealand reduced slightly in the middle of last decade, but associated harmful behaviours, have been slower to decrease.One of the consequences of an unequal distribution of resources in New Zealand in terms of income, wealth, education, employment and home ownership opportunities has been the smoking epidemic which hit the Māori community (tobacco was unknown before European colonisation) after it had already peaked in European men. These inequalities may also prevent more rapid falls in smoking prevalence than might otherwise be the case.Māori once again appear to be the ‘shock absorbers of the economy' with unemployment rates, like smoking rates, over double those for European.13 The additional burden of tobacco exacerbates the costs of widespread unemployment and detrimentally affects whānau (extended family) well-being. The Māori Affairs Select Committee has laudably adopted the Tupeka kore vision of a tobacco-free New Zealand by 2020. Radical action and strong political will is now required to bring this about.In the current NZMJ, Blakely and colleagues, using a thought experiment, pose a counterfactual to the current position, what would happen to health inequalities, if nobodysmoked cigarettes after 2020? Compared to the prevalence of smoking in 2006, ethnic inequalities in life expectancy would fall by 0.3 to 4.6 years (on average 1.8 years, but consistently greater for females). The authors maintain that making New Zealand tobacco-free is one of the most important steps to achieving health equality between Māori and non-Māori by 2040—200 years after the signing of the Treaty.The eminent philosopher John Rawls used just such a thought-experiment as the basis of his theory of justice. He posed a ‘veil of ignorance' as a device, which decisionmakers, for example, could use when considering policy options. If I did not know my position in society, if I had no idea as to whether I was rich or poor, Māori or European, what policies would I favour? Blakely and colleagues' careful social epidemiology over the last decades suggest that rich or poor, Māori or non-Māori, legislating to phase tobacco out as a legal policy in New Zealand would be an important step in reducing health inequalities in New Zealand.In a truly Smokefree New Zealand, we would expect further acceleration of the long-run trend of closing ethnic gaps in mortality that we enjoyed after World War 2 and have recently glimpsed again. The latest New Zealand Values Survey clearly indicates this vision is strongly shared by most New Zealanders.14If we, as health professionals, can find and use words that resonate with the rest of society, the vision of a tobacco-free New Zealand—where life chances are not determined by ethnicity—is indeed possible.