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As healthcare practitioners, Mori nurses (and community health workers) are strongly positioned to influence wider whnau (extended families) and Mori communities about smoking cessation. Each interaction with a patient provides Mori nurses with the opportunity to offer a smoking intervention. Currently 3487 registered nurses identify as Mori1, of whom, almost 3000 belong to the New Zealand Nursing Organisation (NZNO). Despite Mori nurses potential to be influential in smoking prevention and cessation, those who smoke are disadvantaged personally and professionally they are at risk of poorer health, suffer disapproval and misunderstanding of non-smoking colleagues,2 and have difficulty giving smoking prevention and cessation information.3-5 Earlier research has shown that nurses who smoked believe they were inadequate role models, and that their smoking affected their ability to effectively work with patients who also smoke.4,6 The high prevalence of smoking among Mori generally (41%),7 Mori women (44%),7 and nurses (30%)2 calls for targeted smoking cessation support8 and mechanisms that are sensitive to the difficulties they encounter, as healthcare practitioners, when quitting.9,10 Unsuccessful smoking cessation programmes for Mori have been attributed to their individual focus11 and their lack of relevance.12,13 Therefore, to optimise Mori nurses as role models and increase the impact of cessation advice, they need support to become and stay smokefree. The overarching goal of the research is for Mori nurses to be in a stronger position to realise their potential in the prevention of smoking uptake and healthcare promotion more widely. This survey is the first stage of research that will inform the design of a supportive smoking cessation intervention for Mori nurses who smoke. Method A national web-based survey collected demographic and baseline data, and determined the smoking behaviours and attitudes among Mori nurses who are members of NZNO. The 111-item survey was iteratively designed with a team of Mori, nursing and tobacco control researchers using elements from validated smoking surveys (e.g. New Zealand Tobacco Use Survey), and informed by the Mori, literature about smoking and quitting behaviours. Questions were selected based on their relevance to the studys aim and for comparability. Demographic questions included nursing scope, field, and employment, and were replicated from previous NZNO surveys. The survey collected information about smoking behaviours and activities; motivation to quit; lapse/relapse triggers during previous attempts; and the impact of environmental and social triggers for quitting. Ethical approval was gained from the AUT Ethics Committee (12/190). NZNO, with the endorsement of Te R\u016bnanga o Aotearoa, distributed the survey to Mori registered and student nurse members with e-mail addresses (N=1796). Whilst responses were received from 24 community health workers and midwives, the main focus was on nurses. The survey was advertised in Kai Tiaki Nursing New Zealand and on the NZNO web site. Reminder emails were sent 2 weeks after the initial invitation. Descriptive statistical analysis was performed using EXCEL. Non-Mori and non-nurse/nursing student responses received were excluded from the analyses. Results Demographics We received 386 responses from nurses and nursing students, and 24 responses from midwives and other community/healthcare assistants who identified as Mori. The 23% response rate was consistent with other NZNO member surveys (25-35%), and represents approximately 12% of the Mori nursing workforce. Most respondents (96%) were female, similar to the total nursing population (92.6%).1Registered nurses comprised 63% of the respondents, while 25.5% were student nurses the remainder included enrolled nurses and other community health workers. Table 1 shows most nurses were employed by DHBs in inpatient (n=108) or community settings (n=43), with 61 employed by Mori and Iwi health providers. Most nurses worked in mental health and addictions (n=43) and primary health or practice nursing (n=38) areas (Table 1). Table 1 shows the majority of respondents (77.1%) total annual income was more than $41,000 per year, and that 60.8% had children and/or adults dependents. The respondents were a younger age profile than the total nursing population 58% were less than 45 years of age, compared to 43.7%.1 The majority (73.2%) were currently employed, while 20.5% (some students were currently employed) indicated they were student nurses. The geographical distribution (Table 1), determined by District Health Board (DHB), represented the NZNO geographical spread. Table 1. Respondents demographics Demographic Percentage (%) Number (n) Demographic Percentage1 (%) Number (n) AGE PROFILE (n=410) TOTAL INCOME PER YEAR (n=407) Age Range (years) 16-25 yrs 10% 41 <$10.000 3.7% 15 26-35 yrs 20% 83 $11,000-$40, 000 19.2% 78 36-45 yrs 28% 116 $41,000-$70,000 34.2% 139 46-55 yrs 27% 112 $71,000-$100,000 19.4% 79 56-65 yrs 13% 53 >$100,000 13.8% 56 >66 yrs 0.5% 2 Prefer not to say 9.7% 40 No response 0.7% 3 GEOGRAPHIC DISTRIBUTION (n=324) FINANCIAL DEPENDENTS (n=407) Greater Auckland 25% 81 Dependent children only 45.4% 186 Central 13.9% 45 Dependent children & older adults 10% 41 Greater Wellington 13% 42 Dependent older adults 2.7% 11 Hawkes Bay 12.7% 41 Other 2.7% 11 Te Tai Tokerau 10.2% 33 No responsibilities 38.4% 158 Bay of Plenty 10.2% 32 Midlands 9.6% 31 SCOPE OF PRACTICE (n=410) Canterbury 9.6% 31 Registered Nurse (incl. Nurse Practitioners) 62.9% 258 South 7.1% 23 Student Nurses 25.6% 105 Lakes 6.5% 21 Enrolled Nurses 5.6% 23 Top of South Island 1.4% 5 Community Health Workers 2.9% 12 West Coast 0.3% 1 Others (incl. Midwives, Kaiawhina) 2.9% 12 MAIN PLACE OF EMPLOYMENT (n=391) MAIN FIELDS OF PRACTICE (n=312) DHB - Inpatient 27.5% 108 Mental health/addictions 43 Other*3 14.2% 56 Primary health/practice nursing 38 Mori and Iwi health provider 11.4% 45 Aged care 27 DHB - Community 10.5% 43 Community nursing 26 Education institution 7.7% 30 Medical incl. educating patients 22 Aged care provider 5.9% 23 Child health/neonatology 16 NGO 4.6% 18 Education incl. clinical 16 Mori and Iwi based community health 4.1% 16 Emergency & trauma 12 PHO provider 3.6% 14 Non-practising 12 General practice 3.1% 12 Other3 100 Other4 6.5% 26 Note: 1Percentages have been rounded to one decimal place. 2Includes student nurses who may affect the income distribution. 3Other includes accident and medical centre (n=2); community hospital (rural) (n=4); government agency (MOH, ACC, prisons, etc) (n=6); nursing agency (n=5); Pacific health provider (n=1); private surgical hospital (n=3); self-employed (n=5). 4Other includes assessment & rehabilitation (n=8); cancer nursing (n=2); district nursing (n=7); family planning/sexual health (n=3); infection control (n=2); intellectually disabled (n=3); intensive or coronary care/high dependency unit (n=6); nursing administration/management (n=9); nursing professional advice (n=3); obstetrics/maternity (n=4); occupational health (n=2); other - nursing (n=11); palliative care (n=3); perioperative care/theatre (n=8); prison nursing (n=2); public health (n=10); school nursing (n=8); surgical (n=9). Smoking behaviours We found 21.5% of respondents currently smoked, with 16.6% smoking at least once a day (Figure 1). Figure 2 shows 75% of respondents smoked \u226410 cigarettes a day. The majority of registered nurses (52.6%) no longer smoked, although 20% currently smoked and 12.8% smoke at least once a day. However, just over a third of the student nurse group smoked, with 36.2% aged between 26 to 35 years. Figure 1. Frequency of respondents smoking Figure 2. Number of cigarettes smoked per day Figure 3 shows 87% (n=356) declared they had \u2018ever smoked. Of these, 65.8% had smoked more than 100 cigarettes of those, 68.5% did not currently smoke and 5% smoked at least, or less often than, once a month. Tailor-made cigarettes were preferred by most respondents (59.1%) (Figure 4). While only 16% (n=8) of respondents smoked inside their house, 40% (n=23) smoked in the car and 16% (n=14) did this frequently. Figure 3. Ever smoked status Figure 4. Type of cigarette smoked Quitting Just over 50% indicated they were thinking of quitting, and nearly 18% were thinking of quitting within the next 30 days. Figure 5 indicates the most common reasons for quitting was personal health (78%). Of the respondents who had previously attempted or successfully quit (n=279), few had used cessation interventions, such as Aukati Kai Paipa (14%, n=20), Quitline (25%, n=42), or nicotine replacement therapy (15%, n=129) [calculated on the total of 6-items that related to the various forms of nicotine replacement therapies]. Most respondents (an average of 82%) did not use any interventions. Figure 6 shows 64 had made multiple quit attempts. Figure 5. Main reasons for trying to quit Figure 6. Previous quit attempts made (n=64) Nurses and smoking The majority of nurses agreed that stopping smoking was a priority for Mori health (84%) and that helping people to quit was important (94%) (Table 2). While 44% agreed Mori nurses were more effective in providing smoking cessation advice to Mori than non-Mori, 40% responded neutrally. We found 73.5% indicated that smoking did not help them in relating to their clients. Being a nurse and a smoker was a conflict for 68% of the nurses, while 44% reported that nurses smoking compromised the provision of effective smoking cessation advice to others. Table 2. Views about smoking cessation role and nurses who smoke Nurses Role in Smoking Cessation Percentage (%) Agreement/Disagreement Strongly Agree Agree Neutral Disagree Strongly Disagree 1 Mori nurses give more effective smoking cessation advice to Mori than non-Mori nurses 19 25 40 13 1 2R Stopping smoking is a priority compared to other health needs of Mori 55 29 6 6 4 3 Smoking helps me relate to my clients better 1.7 8 16.5 22 51.5 4 Helping people to quit is really important thing I can do to help improve their health 67 27 5 0.7 0 Nurses Who Smoke 5R There is conflict between being a nurse and being a smoker 33 35 18 10.8 4.5 6 Id feel guilty if I was seen smoking while wearing my nurses uniform 65 19 11 3 2 7 Nurses who smoke can give effective advice to others about smoking cessation 10 24 21 20.5 24.5 Note: 1 Percentages were calculated to first decimal point Smoking cessation strategies - Table 3 shows the majority of respondents thought smokefree workplaces helped to reduce smoking. According to 61% of respondents who smoke, increasing tobacco tax punishes smokers and makes them poorer, although 47% of respondents thought increasing the cost would assist quitting. One in three smokers indicated that being told not to smoke made them more determined to smoke. Almost 50% thought being told not to smoke in their cars was excessive. Removing visibility of cigarettes and the branding on packaging had little influence on reducing of the temptation or appeal of cigarettes for most smokers. Table 3. Views about smoking cessation View Total Respondents (n=410) (%) Nurses Who Smoke (n=88) (%) 1 Increasing the tax on tobacco just punishes smokers and makes them poorer 47% 61% 2 Increasing the cost of smoking will be the extra push some will find helpful to quit 66% 47% 3 I think employers are right to refuse to employ nurses who smoke 32% 16% 4 A smoke free workplace makes it easier to cut down 76% 61% 5 Being told you cant smoke in your own car is going too far 45% 49%

Summary

Abstract

Aim

A research partnership between NZNO, Whakauae Research, and Taupua Waiora aimed to determine Mori registered and student nurses smoking behaviours and attitudes to smoking cessation.

Method

We analysed a national web-based survey that explored the behaviours and views of 410 NZNO Mori nurses, student nurses and other health workers using descriptive statistical analysis.

Results

Findings confirm a smoking prevalence rate of 21.5% for all respondents 32% for Mori nursing students and 20% for Mori nurses. Of smokers, 75% of nurses smoke fewer than 10 cigarettes per day, 84% smoked outside their homes, and almost 20% indicated they were considering quitting within the next month. Most nurses who had attempted to, or had, quit did not use the range of smoking cessation interventions available. Mori nurses see the value in smoking cessation for improving their own and others health, although many did not necessarily see themselves as effective in supporting Mori with smoking prevention and cessation.

Conclusion

Prevalence rates for smoking among Mori registered nurses was lower than previous research and many of those still smoking indicate a strong intention to quit. Quit attempts in this occupation group could be better informed by evidence. Increasing the number of Mori nurses who are smokefree will have the added benefit of increasing the efficacy of cessation interventions with patients and whnau (extended families).

Author Information

Heather Gifford, Research Director, Whakauae Research Services , Whanganui; Denise Wilson, Associate Professor Mori Health, AUT University, Auckland; Amohia Boulton, Senior Researcher, Whakauae Research Services , Whanganui; Leonie Walker, Principal Researcher, NZNO, Wellington; Wiki Shepherd-Sinclair, Masters Student, AUT University/Health Promoter, Auckland Regional Public Health Services, Auckland - Heather Gifford, Denise Wilson, Amohia Boulton, Leonie Walker, Wiki Shepherd-Sinclair-

Acknowledgements

We thank the Health Research Council for funding this project and NZNO (Te R\u016bnanga o Aotearoa) for initiating the research and partnering with Whakauae and Auckland University of Technology to undertake the project.

Correspondence

Dr Heather Gifford, Whakauae Research Services , PO Box 102, Whanganui 4540, New Zealand

Correspondence Email

heather@whakauae.co.nz

Competing Interests

None identified.

'- Nursing Council of New Zealand. The New Zealand nursing workforce: A profile of Nurse Practitioners, Registered Nurses and Enrolled Nurses 2011. Wellington, New Zealand; 2012. Ponniah S, Blomfield A. An update on tobacco smoking among New Zealand health care workers, the current picture, 2006. N Z Med J. 2008; 121(1272). Available from:http://journal.nzma.org.nz/journal/121-1272/3023/ Wong G, Fishman Z, McRobbie H, et al. Smoking and Nurses in New Zealand. ASH-KAN Aotearoa: Assessment of smoking history, knowledge and attitudes of nurses in New Zealand. Auckland, New Zealand: ASH New Zealand; 2007. Radsma J, Bottorff JL. Counteracting ambivalence: Nurses who smoke and their health promotion role with patients who smoke. Research in Nursing & Health. 2009;32:443-52. O'Donovan G. Smoking prevalence among qualified nurses in the Republic of Ireland and their role in smoking cessation. International Nursing Review. 2009;56:230-6. Slater P, McElwee G, Fleming P, McKenna H. Nurses' smoking behaviour related to cessation practice. Nursing Times. 2006;102:32-7. Ministry of Health. The health of New Zealand Adults 2011/12: Key findings of the New Zealand Health Survey. Wellington, New Zealand: Author; 2012. Available from:http://www.health.govt.nz/publication/health-new-zealand-adults-2011-12 Edwards R, Peace J, Stanley J et al. Setting a good example? Changes in smoking prevalence among key occupational groups in New Zealand: evidence from the 1981 and 2006 censuses. Nicotine and Tobacco Research. 2012;14:329-37. Berkelmans A, Burton D, Page K, Worrall-Carter L. Registered Nurses smoking behaviours and their attitudes to personal cessation. Journal of Advanced Nursing. 2011;67:1580-90. Pipe A, Sorensen M, Reid R. Physician smoking status, attitudes toward smoking, and cessation advice to patients: An international survey. Patient Education and Counseling. 2009;74:118-23. Barnett R, Pearce J, Moon G. Community inequality and smoking cessation in New Zealand, 1981-2006. Social Science & Medicine. 2009;68:876-84. Fernandez C, Wilson D. Maori women's views on smoking cessation initiatives. Nursing Praxis in New Zealand. 2008;24:27-40. Resnicow K, Baranowski T, Ahluwalia JS, Braithwaite RL. Cultural sensitivity in public health: Defined and demystified. Ethnicity & Disease. 1999;9:10-21. Hung WT, Dunlop SM, Perez D, Cotter T. Use and perceived helpfulness of smoking cessation methods: results from a population survey of recent quitters. BMC Public Health. 2011;11:592. Lindson-Hawley N, Aveyard P, Hughes JRC. Reduction versus abrupt cessation in smokers who want to quit. Database of Systematic Reviews. 2012;11. McRobbie H, Bullen C, Glover M et al. New Zealand smoking cessation guidelines. New Zealand Medical Journal. 2008;121:57-70. Glover M. The effectiveness of a Mori noho marae smoking cessation intervention: Utilising a kaupapa Maori methodology. Auckland, New Zealand: University of Auckland; 2000. WERO group quit smoking competition goes national. Scoop Health Independent News. Wednesday, 3 July 2013, 1:49 pm. Accessed 20th September 2013;http://www.scoop.co.nz/stories/GE1307/S00020/wero-group-quit-smoking-competition-goes-national.htm Grigg M, Waa A, Bradbrook SK. Response to an indigenous smoking cessation media campaign-It's about whanau. Australian & New Zealand Journal of Public Health. 2008;32:559-64. Hoek J, Maubach N, Gendell P, Gifford H, Erick S, Edwards R, Newcombe R. Consumer Testing of Terminology and Key Messages for Smoking Cessation-Report commissioned by Ministry of Health. Wellington; 2012. Ban smoking in cars. Thursday, 15 August 2013, 11:40 am Press Release: The Asthma Foundation. Accessed 23rd Sept 2013. http://www.scoop.co.nz/stories/GE1308/S00084/ban-smoking-in-cars.htm Griffith D. Major employer considering ban on hiring smokers. HR Development [serial on the Internet]. 2011 14 July]: Available from: http://www.hrdevelopment.co.nz/2011/07/major-employer-considering-ban-on-hiring-smokers/-

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As healthcare practitioners, Mori nurses (and community health workers) are strongly positioned to influence wider whnau (extended families) and Mori communities about smoking cessation. Each interaction with a patient provides Mori nurses with the opportunity to offer a smoking intervention. Currently 3487 registered nurses identify as Mori1, of whom, almost 3000 belong to the New Zealand Nursing Organisation (NZNO). Despite Mori nurses potential to be influential in smoking prevention and cessation, those who smoke are disadvantaged personally and professionally they are at risk of poorer health, suffer disapproval and misunderstanding of non-smoking colleagues,2 and have difficulty giving smoking prevention and cessation information.3-5 Earlier research has shown that nurses who smoked believe they were inadequate role models, and that their smoking affected their ability to effectively work with patients who also smoke.4,6 The high prevalence of smoking among Mori generally (41%),7 Mori women (44%),7 and nurses (30%)2 calls for targeted smoking cessation support8 and mechanisms that are sensitive to the difficulties they encounter, as healthcare practitioners, when quitting.9,10 Unsuccessful smoking cessation programmes for Mori have been attributed to their individual focus11 and their lack of relevance.12,13 Therefore, to optimise Mori nurses as role models and increase the impact of cessation advice, they need support to become and stay smokefree. The overarching goal of the research is for Mori nurses to be in a stronger position to realise their potential in the prevention of smoking uptake and healthcare promotion more widely. This survey is the first stage of research that will inform the design of a supportive smoking cessation intervention for Mori nurses who smoke. Method A national web-based survey collected demographic and baseline data, and determined the smoking behaviours and attitudes among Mori nurses who are members of NZNO. The 111-item survey was iteratively designed with a team of Mori, nursing and tobacco control researchers using elements from validated smoking surveys (e.g. New Zealand Tobacco Use Survey), and informed by the Mori, literature about smoking and quitting behaviours. Questions were selected based on their relevance to the studys aim and for comparability. Demographic questions included nursing scope, field, and employment, and were replicated from previous NZNO surveys. The survey collected information about smoking behaviours and activities; motivation to quit; lapse/relapse triggers during previous attempts; and the impact of environmental and social triggers for quitting. Ethical approval was gained from the AUT Ethics Committee (12/190). NZNO, with the endorsement of Te R\u016bnanga o Aotearoa, distributed the survey to Mori registered and student nurse members with e-mail addresses (N=1796). Whilst responses were received from 24 community health workers and midwives, the main focus was on nurses. The survey was advertised in Kai Tiaki Nursing New Zealand and on the NZNO web site. Reminder emails were sent 2 weeks after the initial invitation. Descriptive statistical analysis was performed using EXCEL. Non-Mori and non-nurse/nursing student responses received were excluded from the analyses. Results Demographics We received 386 responses from nurses and nursing students, and 24 responses from midwives and other community/healthcare assistants who identified as Mori. The 23% response rate was consistent with other NZNO member surveys (25-35%), and represents approximately 12% of the Mori nursing workforce. Most respondents (96%) were female, similar to the total nursing population (92.6%).1Registered nurses comprised 63% of the respondents, while 25.5% were student nurses the remainder included enrolled nurses and other community health workers. Table 1 shows most nurses were employed by DHBs in inpatient (n=108) or community settings (n=43), with 61 employed by Mori and Iwi health providers. Most nurses worked in mental health and addictions (n=43) and primary health or practice nursing (n=38) areas (Table 1). Table 1 shows the majority of respondents (77.1%) total annual income was more than $41,000 per year, and that 60.8% had children and/or adults dependents. The respondents were a younger age profile than the total nursing population 58% were less than 45 years of age, compared to 43.7%.1 The majority (73.2%) were currently employed, while 20.5% (some students were currently employed) indicated they were student nurses. The geographical distribution (Table 1), determined by District Health Board (DHB), represented the NZNO geographical spread. Table 1. Respondents demographics Demographic Percentage (%) Number (n) Demographic Percentage1 (%) Number (n) AGE PROFILE (n=410) TOTAL INCOME PER YEAR (n=407) Age Range (years) 16-25 yrs 10% 41 <$10.000 3.7% 15 26-35 yrs 20% 83 $11,000-$40, 000 19.2% 78 36-45 yrs 28% 116 $41,000-$70,000 34.2% 139 46-55 yrs 27% 112 $71,000-$100,000 19.4% 79 56-65 yrs 13% 53 >$100,000 13.8% 56 >66 yrs 0.5% 2 Prefer not to say 9.7% 40 No response 0.7% 3 GEOGRAPHIC DISTRIBUTION (n=324) FINANCIAL DEPENDENTS (n=407) Greater Auckland 25% 81 Dependent children only 45.4% 186 Central 13.9% 45 Dependent children & older adults 10% 41 Greater Wellington 13% 42 Dependent older adults 2.7% 11 Hawkes Bay 12.7% 41 Other 2.7% 11 Te Tai Tokerau 10.2% 33 No responsibilities 38.4% 158 Bay of Plenty 10.2% 32 Midlands 9.6% 31 SCOPE OF PRACTICE (n=410) Canterbury 9.6% 31 Registered Nurse (incl. Nurse Practitioners) 62.9% 258 South 7.1% 23 Student Nurses 25.6% 105 Lakes 6.5% 21 Enrolled Nurses 5.6% 23 Top of South Island 1.4% 5 Community Health Workers 2.9% 12 West Coast 0.3% 1 Others (incl. Midwives, Kaiawhina) 2.9% 12 MAIN PLACE OF EMPLOYMENT (n=391) MAIN FIELDS OF PRACTICE (n=312) DHB - Inpatient 27.5% 108 Mental health/addictions 43 Other*3 14.2% 56 Primary health/practice nursing 38 Mori and Iwi health provider 11.4% 45 Aged care 27 DHB - Community 10.5% 43 Community nursing 26 Education institution 7.7% 30 Medical incl. educating patients 22 Aged care provider 5.9% 23 Child health/neonatology 16 NGO 4.6% 18 Education incl. clinical 16 Mori and Iwi based community health 4.1% 16 Emergency & trauma 12 PHO provider 3.6% 14 Non-practising 12 General practice 3.1% 12 Other3 100 Other4 6.5% 26 Note: 1Percentages have been rounded to one decimal place. 2Includes student nurses who may affect the income distribution. 3Other includes accident and medical centre (n=2); community hospital (rural) (n=4); government agency (MOH, ACC, prisons, etc) (n=6); nursing agency (n=5); Pacific health provider (n=1); private surgical hospital (n=3); self-employed (n=5). 4Other includes assessment & rehabilitation (n=8); cancer nursing (n=2); district nursing (n=7); family planning/sexual health (n=3); infection control (n=2); intellectually disabled (n=3); intensive or coronary care/high dependency unit (n=6); nursing administration/management (n=9); nursing professional advice (n=3); obstetrics/maternity (n=4); occupational health (n=2); other - nursing (n=11); palliative care (n=3); perioperative care/theatre (n=8); prison nursing (n=2); public health (n=10); school nursing (n=8); surgical (n=9). Smoking behaviours We found 21.5% of respondents currently smoked, with 16.6% smoking at least once a day (Figure 1). Figure 2 shows 75% of respondents smoked \u226410 cigarettes a day. The majority of registered nurses (52.6%) no longer smoked, although 20% currently smoked and 12.8% smoke at least once a day. However, just over a third of the student nurse group smoked, with 36.2% aged between 26 to 35 years. Figure 1. Frequency of respondents smoking Figure 2. Number of cigarettes smoked per day Figure 3 shows 87% (n=356) declared they had \u2018ever smoked. Of these, 65.8% had smoked more than 100 cigarettes of those, 68.5% did not currently smoke and 5% smoked at least, or less often than, once a month. Tailor-made cigarettes were preferred by most respondents (59.1%) (Figure 4). While only 16% (n=8) of respondents smoked inside their house, 40% (n=23) smoked in the car and 16% (n=14) did this frequently. Figure 3. Ever smoked status Figure 4. Type of cigarette smoked Quitting Just over 50% indicated they were thinking of quitting, and nearly 18% were thinking of quitting within the next 30 days. Figure 5 indicates the most common reasons for quitting was personal health (78%). Of the respondents who had previously attempted or successfully quit (n=279), few had used cessation interventions, such as Aukati Kai Paipa (14%, n=20), Quitline (25%, n=42), or nicotine replacement therapy (15%, n=129) [calculated on the total of 6-items that related to the various forms of nicotine replacement therapies]. Most respondents (an average of 82%) did not use any interventions. Figure 6 shows 64 had made multiple quit attempts. Figure 5. Main reasons for trying to quit Figure 6. Previous quit attempts made (n=64) Nurses and smoking The majority of nurses agreed that stopping smoking was a priority for Mori health (84%) and that helping people to quit was important (94%) (Table 2). While 44% agreed Mori nurses were more effective in providing smoking cessation advice to Mori than non-Mori, 40% responded neutrally. We found 73.5% indicated that smoking did not help them in relating to their clients. Being a nurse and a smoker was a conflict for 68% of the nurses, while 44% reported that nurses smoking compromised the provision of effective smoking cessation advice to others. Table 2. Views about smoking cessation role and nurses who smoke Nurses Role in Smoking Cessation Percentage (%) Agreement/Disagreement Strongly Agree Agree Neutral Disagree Strongly Disagree 1 Mori nurses give more effective smoking cessation advice to Mori than non-Mori nurses 19 25 40 13 1 2R Stopping smoking is a priority compared to other health needs of Mori 55 29 6 6 4 3 Smoking helps me relate to my clients better 1.7 8 16.5 22 51.5 4 Helping people to quit is really important thing I can do to help improve their health 67 27 5 0.7 0 Nurses Who Smoke 5R There is conflict between being a nurse and being a smoker 33 35 18 10.8 4.5 6 Id feel guilty if I was seen smoking while wearing my nurses uniform 65 19 11 3 2 7 Nurses who smoke can give effective advice to others about smoking cessation 10 24 21 20.5 24.5 Note: 1 Percentages were calculated to first decimal point Smoking cessation strategies - Table 3 shows the majority of respondents thought smokefree workplaces helped to reduce smoking. According to 61% of respondents who smoke, increasing tobacco tax punishes smokers and makes them poorer, although 47% of respondents thought increasing the cost would assist quitting. One in three smokers indicated that being told not to smoke made them more determined to smoke. Almost 50% thought being told not to smoke in their cars was excessive. Removing visibility of cigarettes and the branding on packaging had little influence on reducing of the temptation or appeal of cigarettes for most smokers. Table 3. Views about smoking cessation View Total Respondents (n=410) (%) Nurses Who Smoke (n=88) (%) 1 Increasing the tax on tobacco just punishes smokers and makes them poorer 47% 61% 2 Increasing the cost of smoking will be the extra push some will find helpful to quit 66% 47% 3 I think employers are right to refuse to employ nurses who smoke 32% 16% 4 A smoke free workplace makes it easier to cut down 76% 61% 5 Being told you cant smoke in your own car is going too far 45% 49%

Summary

Abstract

Aim

A research partnership between NZNO, Whakauae Research, and Taupua Waiora aimed to determine Mori registered and student nurses smoking behaviours and attitudes to smoking cessation.

Method

We analysed a national web-based survey that explored the behaviours and views of 410 NZNO Mori nurses, student nurses and other health workers using descriptive statistical analysis.

Results

Findings confirm a smoking prevalence rate of 21.5% for all respondents 32% for Mori nursing students and 20% for Mori nurses. Of smokers, 75% of nurses smoke fewer than 10 cigarettes per day, 84% smoked outside their homes, and almost 20% indicated they were considering quitting within the next month. Most nurses who had attempted to, or had, quit did not use the range of smoking cessation interventions available. Mori nurses see the value in smoking cessation for improving their own and others health, although many did not necessarily see themselves as effective in supporting Mori with smoking prevention and cessation.

Conclusion

Prevalence rates for smoking among Mori registered nurses was lower than previous research and many of those still smoking indicate a strong intention to quit. Quit attempts in this occupation group could be better informed by evidence. Increasing the number of Mori nurses who are smokefree will have the added benefit of increasing the efficacy of cessation interventions with patients and whnau (extended families).

Author Information

Heather Gifford, Research Director, Whakauae Research Services , Whanganui; Denise Wilson, Associate Professor Mori Health, AUT University, Auckland; Amohia Boulton, Senior Researcher, Whakauae Research Services , Whanganui; Leonie Walker, Principal Researcher, NZNO, Wellington; Wiki Shepherd-Sinclair, Masters Student, AUT University/Health Promoter, Auckland Regional Public Health Services, Auckland - Heather Gifford, Denise Wilson, Amohia Boulton, Leonie Walker, Wiki Shepherd-Sinclair-

Acknowledgements

We thank the Health Research Council for funding this project and NZNO (Te R\u016bnanga o Aotearoa) for initiating the research and partnering with Whakauae and Auckland University of Technology to undertake the project.

Correspondence

Dr Heather Gifford, Whakauae Research Services , PO Box 102, Whanganui 4540, New Zealand

Correspondence Email

heather@whakauae.co.nz

Competing Interests

None identified.

'- Nursing Council of New Zealand. The New Zealand nursing workforce: A profile of Nurse Practitioners, Registered Nurses and Enrolled Nurses 2011. Wellington, New Zealand; 2012. Ponniah S, Blomfield A. An update on tobacco smoking among New Zealand health care workers, the current picture, 2006. N Z Med J. 2008; 121(1272). Available from:http://journal.nzma.org.nz/journal/121-1272/3023/ Wong G, Fishman Z, McRobbie H, et al. Smoking and Nurses in New Zealand. ASH-KAN Aotearoa: Assessment of smoking history, knowledge and attitudes of nurses in New Zealand. Auckland, New Zealand: ASH New Zealand; 2007. Radsma J, Bottorff JL. Counteracting ambivalence: Nurses who smoke and their health promotion role with patients who smoke. Research in Nursing & Health. 2009;32:443-52. O'Donovan G. Smoking prevalence among qualified nurses in the Republic of Ireland and their role in smoking cessation. International Nursing Review. 2009;56:230-6. Slater P, McElwee G, Fleming P, McKenna H. Nurses' smoking behaviour related to cessation practice. Nursing Times. 2006;102:32-7. Ministry of Health. The health of New Zealand Adults 2011/12: Key findings of the New Zealand Health Survey. Wellington, New Zealand: Author; 2012. Available from:http://www.health.govt.nz/publication/health-new-zealand-adults-2011-12 Edwards R, Peace J, Stanley J et al. Setting a good example? Changes in smoking prevalence among key occupational groups in New Zealand: evidence from the 1981 and 2006 censuses. Nicotine and Tobacco Research. 2012;14:329-37. Berkelmans A, Burton D, Page K, Worrall-Carter L. Registered Nurses smoking behaviours and their attitudes to personal cessation. Journal of Advanced Nursing. 2011;67:1580-90. Pipe A, Sorensen M, Reid R. Physician smoking status, attitudes toward smoking, and cessation advice to patients: An international survey. Patient Education and Counseling. 2009;74:118-23. Barnett R, Pearce J, Moon G. Community inequality and smoking cessation in New Zealand, 1981-2006. Social Science & Medicine. 2009;68:876-84. Fernandez C, Wilson D. Maori women's views on smoking cessation initiatives. Nursing Praxis in New Zealand. 2008;24:27-40. Resnicow K, Baranowski T, Ahluwalia JS, Braithwaite RL. Cultural sensitivity in public health: Defined and demystified. Ethnicity & Disease. 1999;9:10-21. Hung WT, Dunlop SM, Perez D, Cotter T. Use and perceived helpfulness of smoking cessation methods: results from a population survey of recent quitters. BMC Public Health. 2011;11:592. Lindson-Hawley N, Aveyard P, Hughes JRC. Reduction versus abrupt cessation in smokers who want to quit. Database of Systematic Reviews. 2012;11. McRobbie H, Bullen C, Glover M et al. New Zealand smoking cessation guidelines. New Zealand Medical Journal. 2008;121:57-70. Glover M. The effectiveness of a Mori noho marae smoking cessation intervention: Utilising a kaupapa Maori methodology. Auckland, New Zealand: University of Auckland; 2000. WERO group quit smoking competition goes national. Scoop Health Independent News. Wednesday, 3 July 2013, 1:49 pm. Accessed 20th September 2013;http://www.scoop.co.nz/stories/GE1307/S00020/wero-group-quit-smoking-competition-goes-national.htm Grigg M, Waa A, Bradbrook SK. Response to an indigenous smoking cessation media campaign-It's about whanau. Australian & New Zealand Journal of Public Health. 2008;32:559-64. Hoek J, Maubach N, Gendell P, Gifford H, Erick S, Edwards R, Newcombe R. Consumer Testing of Terminology and Key Messages for Smoking Cessation-Report commissioned by Ministry of Health. Wellington; 2012. Ban smoking in cars. Thursday, 15 August 2013, 11:40 am Press Release: The Asthma Foundation. Accessed 23rd Sept 2013. http://www.scoop.co.nz/stories/GE1308/S00084/ban-smoking-in-cars.htm Griffith D. Major employer considering ban on hiring smokers. HR Development [serial on the Internet]. 2011 14 July]: Available from: http://www.hrdevelopment.co.nz/2011/07/major-employer-considering-ban-on-hiring-smokers/-

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As healthcare practitioners, Mori nurses (and community health workers) are strongly positioned to influence wider whnau (extended families) and Mori communities about smoking cessation. Each interaction with a patient provides Mori nurses with the opportunity to offer a smoking intervention. Currently 3487 registered nurses identify as Mori1, of whom, almost 3000 belong to the New Zealand Nursing Organisation (NZNO). Despite Mori nurses potential to be influential in smoking prevention and cessation, those who smoke are disadvantaged personally and professionally they are at risk of poorer health, suffer disapproval and misunderstanding of non-smoking colleagues,2 and have difficulty giving smoking prevention and cessation information.3-5 Earlier research has shown that nurses who smoked believe they were inadequate role models, and that their smoking affected their ability to effectively work with patients who also smoke.4,6 The high prevalence of smoking among Mori generally (41%),7 Mori women (44%),7 and nurses (30%)2 calls for targeted smoking cessation support8 and mechanisms that are sensitive to the difficulties they encounter, as healthcare practitioners, when quitting.9,10 Unsuccessful smoking cessation programmes for Mori have been attributed to their individual focus11 and their lack of relevance.12,13 Therefore, to optimise Mori nurses as role models and increase the impact of cessation advice, they need support to become and stay smokefree. The overarching goal of the research is for Mori nurses to be in a stronger position to realise their potential in the prevention of smoking uptake and healthcare promotion more widely. This survey is the first stage of research that will inform the design of a supportive smoking cessation intervention for Mori nurses who smoke. Method A national web-based survey collected demographic and baseline data, and determined the smoking behaviours and attitudes among Mori nurses who are members of NZNO. The 111-item survey was iteratively designed with a team of Mori, nursing and tobacco control researchers using elements from validated smoking surveys (e.g. New Zealand Tobacco Use Survey), and informed by the Mori, literature about smoking and quitting behaviours. Questions were selected based on their relevance to the studys aim and for comparability. Demographic questions included nursing scope, field, and employment, and were replicated from previous NZNO surveys. The survey collected information about smoking behaviours and activities; motivation to quit; lapse/relapse triggers during previous attempts; and the impact of environmental and social triggers for quitting. Ethical approval was gained from the AUT Ethics Committee (12/190). NZNO, with the endorsement of Te R\u016bnanga o Aotearoa, distributed the survey to Mori registered and student nurse members with e-mail addresses (N=1796). Whilst responses were received from 24 community health workers and midwives, the main focus was on nurses. The survey was advertised in Kai Tiaki Nursing New Zealand and on the NZNO web site. Reminder emails were sent 2 weeks after the initial invitation. Descriptive statistical analysis was performed using EXCEL. Non-Mori and non-nurse/nursing student responses received were excluded from the analyses. Results Demographics We received 386 responses from nurses and nursing students, and 24 responses from midwives and other community/healthcare assistants who identified as Mori. The 23% response rate was consistent with other NZNO member surveys (25-35%), and represents approximately 12% of the Mori nursing workforce. Most respondents (96%) were female, similar to the total nursing population (92.6%).1Registered nurses comprised 63% of the respondents, while 25.5% were student nurses the remainder included enrolled nurses and other community health workers. Table 1 shows most nurses were employed by DHBs in inpatient (n=108) or community settings (n=43), with 61 employed by Mori and Iwi health providers. Most nurses worked in mental health and addictions (n=43) and primary health or practice nursing (n=38) areas (Table 1). Table 1 shows the majority of respondents (77.1%) total annual income was more than $41,000 per year, and that 60.8% had children and/or adults dependents. The respondents were a younger age profile than the total nursing population 58% were less than 45 years of age, compared to 43.7%.1 The majority (73.2%) were currently employed, while 20.5% (some students were currently employed) indicated they were student nurses. The geographical distribution (Table 1), determined by District Health Board (DHB), represented the NZNO geographical spread. Table 1. Respondents demographics Demographic Percentage (%) Number (n) Demographic Percentage1 (%) Number (n) AGE PROFILE (n=410) TOTAL INCOME PER YEAR (n=407) Age Range (years) 16-25 yrs 10% 41 <$10.000 3.7% 15 26-35 yrs 20% 83 $11,000-$40, 000 19.2% 78 36-45 yrs 28% 116 $41,000-$70,000 34.2% 139 46-55 yrs 27% 112 $71,000-$100,000 19.4% 79 56-65 yrs 13% 53 >$100,000 13.8% 56 >66 yrs 0.5% 2 Prefer not to say 9.7% 40 No response 0.7% 3 GEOGRAPHIC DISTRIBUTION (n=324) FINANCIAL DEPENDENTS (n=407) Greater Auckland 25% 81 Dependent children only 45.4% 186 Central 13.9% 45 Dependent children & older adults 10% 41 Greater Wellington 13% 42 Dependent older adults 2.7% 11 Hawkes Bay 12.7% 41 Other 2.7% 11 Te Tai Tokerau 10.2% 33 No responsibilities 38.4% 158 Bay of Plenty 10.2% 32 Midlands 9.6% 31 SCOPE OF PRACTICE (n=410) Canterbury 9.6% 31 Registered Nurse (incl. Nurse Practitioners) 62.9% 258 South 7.1% 23 Student Nurses 25.6% 105 Lakes 6.5% 21 Enrolled Nurses 5.6% 23 Top of South Island 1.4% 5 Community Health Workers 2.9% 12 West Coast 0.3% 1 Others (incl. Midwives, Kaiawhina) 2.9% 12 MAIN PLACE OF EMPLOYMENT (n=391) MAIN FIELDS OF PRACTICE (n=312) DHB - Inpatient 27.5% 108 Mental health/addictions 43 Other*3 14.2% 56 Primary health/practice nursing 38 Mori and Iwi health provider 11.4% 45 Aged care 27 DHB - Community 10.5% 43 Community nursing 26 Education institution 7.7% 30 Medical incl. educating patients 22 Aged care provider 5.9% 23 Child health/neonatology 16 NGO 4.6% 18 Education incl. clinical 16 Mori and Iwi based community health 4.1% 16 Emergency & trauma 12 PHO provider 3.6% 14 Non-practising 12 General practice 3.1% 12 Other3 100 Other4 6.5% 26 Note: 1Percentages have been rounded to one decimal place. 2Includes student nurses who may affect the income distribution. 3Other includes accident and medical centre (n=2); community hospital (rural) (n=4); government agency (MOH, ACC, prisons, etc) (n=6); nursing agency (n=5); Pacific health provider (n=1); private surgical hospital (n=3); self-employed (n=5). 4Other includes assessment & rehabilitation (n=8); cancer nursing (n=2); district nursing (n=7); family planning/sexual health (n=3); infection control (n=2); intellectually disabled (n=3); intensive or coronary care/high dependency unit (n=6); nursing administration/management (n=9); nursing professional advice (n=3); obstetrics/maternity (n=4); occupational health (n=2); other - nursing (n=11); palliative care (n=3); perioperative care/theatre (n=8); prison nursing (n=2); public health (n=10); school nursing (n=8); surgical (n=9). Smoking behaviours We found 21.5% of respondents currently smoked, with 16.6% smoking at least once a day (Figure 1). Figure 2 shows 75% of respondents smoked \u226410 cigarettes a day. The majority of registered nurses (52.6%) no longer smoked, although 20% currently smoked and 12.8% smoke at least once a day. However, just over a third of the student nurse group smoked, with 36.2% aged between 26 to 35 years. Figure 1. Frequency of respondents smoking Figure 2. Number of cigarettes smoked per day Figure 3 shows 87% (n=356) declared they had \u2018ever smoked. Of these, 65.8% had smoked more than 100 cigarettes of those, 68.5% did not currently smoke and 5% smoked at least, or less often than, once a month. Tailor-made cigarettes were preferred by most respondents (59.1%) (Figure 4). While only 16% (n=8) of respondents smoked inside their house, 40% (n=23) smoked in the car and 16% (n=14) did this frequently. Figure 3. Ever smoked status Figure 4. Type of cigarette smoked Quitting Just over 50% indicated they were thinking of quitting, and nearly 18% were thinking of quitting within the next 30 days. Figure 5 indicates the most common reasons for quitting was personal health (78%). Of the respondents who had previously attempted or successfully quit (n=279), few had used cessation interventions, such as Aukati Kai Paipa (14%, n=20), Quitline (25%, n=42), or nicotine replacement therapy (15%, n=129) [calculated on the total of 6-items that related to the various forms of nicotine replacement therapies]. Most respondents (an average of 82%) did not use any interventions. Figure 6 shows 64 had made multiple quit attempts. Figure 5. Main reasons for trying to quit Figure 6. Previous quit attempts made (n=64) Nurses and smoking The majority of nurses agreed that stopping smoking was a priority for Mori health (84%) and that helping people to quit was important (94%) (Table 2). While 44% agreed Mori nurses were more effective in providing smoking cessation advice to Mori than non-Mori, 40% responded neutrally. We found 73.5% indicated that smoking did not help them in relating to their clients. Being a nurse and a smoker was a conflict for 68% of the nurses, while 44% reported that nurses smoking compromised the provision of effective smoking cessation advice to others. Table 2. Views about smoking cessation role and nurses who smoke Nurses Role in Smoking Cessation Percentage (%) Agreement/Disagreement Strongly Agree Agree Neutral Disagree Strongly Disagree 1 Mori nurses give more effective smoking cessation advice to Mori than non-Mori nurses 19 25 40 13 1 2R Stopping smoking is a priority compared to other health needs of Mori 55 29 6 6 4 3 Smoking helps me relate to my clients better 1.7 8 16.5 22 51.5 4 Helping people to quit is really important thing I can do to help improve their health 67 27 5 0.7 0 Nurses Who Smoke 5R There is conflict between being a nurse and being a smoker 33 35 18 10.8 4.5 6 Id feel guilty if I was seen smoking while wearing my nurses uniform 65 19 11 3 2 7 Nurses who smoke can give effective advice to others about smoking cessation 10 24 21 20.5 24.5 Note: 1 Percentages were calculated to first decimal point Smoking cessation strategies - Table 3 shows the majority of respondents thought smokefree workplaces helped to reduce smoking. According to 61% of respondents who smoke, increasing tobacco tax punishes smokers and makes them poorer, although 47% of respondents thought increasing the cost would assist quitting. One in three smokers indicated that being told not to smoke made them more determined to smoke. Almost 50% thought being told not to smoke in their cars was excessive. Removing visibility of cigarettes and the branding on packaging had little influence on reducing of the temptation or appeal of cigarettes for most smokers. Table 3. Views about smoking cessation View Total Respondents (n=410) (%) Nurses Who Smoke (n=88) (%) 1 Increasing the tax on tobacco just punishes smokers and makes them poorer 47% 61% 2 Increasing the cost of smoking will be the extra push some will find helpful to quit 66% 47% 3 I think employers are right to refuse to employ nurses who smoke 32% 16% 4 A smoke free workplace makes it easier to cut down 76% 61% 5 Being told you cant smoke in your own car is going too far 45% 49%

Summary

Abstract

Aim

A research partnership between NZNO, Whakauae Research, and Taupua Waiora aimed to determine Mori registered and student nurses smoking behaviours and attitudes to smoking cessation.

Method

We analysed a national web-based survey that explored the behaviours and views of 410 NZNO Mori nurses, student nurses and other health workers using descriptive statistical analysis.

Results

Findings confirm a smoking prevalence rate of 21.5% for all respondents 32% for Mori nursing students and 20% for Mori nurses. Of smokers, 75% of nurses smoke fewer than 10 cigarettes per day, 84% smoked outside their homes, and almost 20% indicated they were considering quitting within the next month. Most nurses who had attempted to, or had, quit did not use the range of smoking cessation interventions available. Mori nurses see the value in smoking cessation for improving their own and others health, although many did not necessarily see themselves as effective in supporting Mori with smoking prevention and cessation.

Conclusion

Prevalence rates for smoking among Mori registered nurses was lower than previous research and many of those still smoking indicate a strong intention to quit. Quit attempts in this occupation group could be better informed by evidence. Increasing the number of Mori nurses who are smokefree will have the added benefit of increasing the efficacy of cessation interventions with patients and whnau (extended families).

Author Information

Heather Gifford, Research Director, Whakauae Research Services , Whanganui; Denise Wilson, Associate Professor Mori Health, AUT University, Auckland; Amohia Boulton, Senior Researcher, Whakauae Research Services , Whanganui; Leonie Walker, Principal Researcher, NZNO, Wellington; Wiki Shepherd-Sinclair, Masters Student, AUT University/Health Promoter, Auckland Regional Public Health Services, Auckland - Heather Gifford, Denise Wilson, Amohia Boulton, Leonie Walker, Wiki Shepherd-Sinclair-

Acknowledgements

We thank the Health Research Council for funding this project and NZNO (Te R\u016bnanga o Aotearoa) for initiating the research and partnering with Whakauae and Auckland University of Technology to undertake the project.

Correspondence

Dr Heather Gifford, Whakauae Research Services , PO Box 102, Whanganui 4540, New Zealand

Correspondence Email

heather@whakauae.co.nz

Competing Interests

None identified.

'- Nursing Council of New Zealand. The New Zealand nursing workforce: A profile of Nurse Practitioners, Registered Nurses and Enrolled Nurses 2011. Wellington, New Zealand; 2012. Ponniah S, Blomfield A. An update on tobacco smoking among New Zealand health care workers, the current picture, 2006. N Z Med J. 2008; 121(1272). Available from:http://journal.nzma.org.nz/journal/121-1272/3023/ Wong G, Fishman Z, McRobbie H, et al. Smoking and Nurses in New Zealand. ASH-KAN Aotearoa: Assessment of smoking history, knowledge and attitudes of nurses in New Zealand. Auckland, New Zealand: ASH New Zealand; 2007. Radsma J, Bottorff JL. Counteracting ambivalence: Nurses who smoke and their health promotion role with patients who smoke. Research in Nursing & Health. 2009;32:443-52. O'Donovan G. Smoking prevalence among qualified nurses in the Republic of Ireland and their role in smoking cessation. International Nursing Review. 2009;56:230-6. Slater P, McElwee G, Fleming P, McKenna H. Nurses' smoking behaviour related to cessation practice. Nursing Times. 2006;102:32-7. Ministry of Health. The health of New Zealand Adults 2011/12: Key findings of the New Zealand Health Survey. Wellington, New Zealand: Author; 2012. Available from:http://www.health.govt.nz/publication/health-new-zealand-adults-2011-12 Edwards R, Peace J, Stanley J et al. Setting a good example? Changes in smoking prevalence among key occupational groups in New Zealand: evidence from the 1981 and 2006 censuses. Nicotine and Tobacco Research. 2012;14:329-37. Berkelmans A, Burton D, Page K, Worrall-Carter L. Registered Nurses smoking behaviours and their attitudes to personal cessation. Journal of Advanced Nursing. 2011;67:1580-90. Pipe A, Sorensen M, Reid R. Physician smoking status, attitudes toward smoking, and cessation advice to patients: An international survey. Patient Education and Counseling. 2009;74:118-23. Barnett R, Pearce J, Moon G. Community inequality and smoking cessation in New Zealand, 1981-2006. Social Science & Medicine. 2009;68:876-84. Fernandez C, Wilson D. Maori women's views on smoking cessation initiatives. Nursing Praxis in New Zealand. 2008;24:27-40. Resnicow K, Baranowski T, Ahluwalia JS, Braithwaite RL. Cultural sensitivity in public health: Defined and demystified. Ethnicity & Disease. 1999;9:10-21. Hung WT, Dunlop SM, Perez D, Cotter T. Use and perceived helpfulness of smoking cessation methods: results from a population survey of recent quitters. BMC Public Health. 2011;11:592. Lindson-Hawley N, Aveyard P, Hughes JRC. Reduction versus abrupt cessation in smokers who want to quit. Database of Systematic Reviews. 2012;11. McRobbie H, Bullen C, Glover M et al. New Zealand smoking cessation guidelines. New Zealand Medical Journal. 2008;121:57-70. Glover M. The effectiveness of a Mori noho marae smoking cessation intervention: Utilising a kaupapa Maori methodology. Auckland, New Zealand: University of Auckland; 2000. WERO group quit smoking competition goes national. Scoop Health Independent News. Wednesday, 3 July 2013, 1:49 pm. Accessed 20th September 2013;http://www.scoop.co.nz/stories/GE1307/S00020/wero-group-quit-smoking-competition-goes-national.htm Grigg M, Waa A, Bradbrook SK. Response to an indigenous smoking cessation media campaign-It's about whanau. Australian & New Zealand Journal of Public Health. 2008;32:559-64. Hoek J, Maubach N, Gendell P, Gifford H, Erick S, Edwards R, Newcombe R. Consumer Testing of Terminology and Key Messages for Smoking Cessation-Report commissioned by Ministry of Health. Wellington; 2012. Ban smoking in cars. Thursday, 15 August 2013, 11:40 am Press Release: The Asthma Foundation. Accessed 23rd Sept 2013. http://www.scoop.co.nz/stories/GE1308/S00084/ban-smoking-in-cars.htm Griffith D. Major employer considering ban on hiring smokers. HR Development [serial on the Internet]. 2011 14 July]: Available from: http://www.hrdevelopment.co.nz/2011/07/major-employer-considering-ban-on-hiring-smokers/-

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