By Public Health Expert 28/05/2021


Andrew Waa, Heather Gifford, Shane Bradbrook

The recent release of the Government’s “Proposals for a Smokefree Aotearoa 2025 Action Plan” (the  Plan) represents a significant step forward in how we think about tobacco control1. The Plan specifically references eliminating smoking related inequities, strengthening Māori governance and fulfilling government commitments to Te Tiriti o Waitangi as an essential part of achieving our Smokefree 2025 goal (SF2025). This blog considers the implications of the measures described in the plan for Māori.

 

We start this blog by reviewing the background that led to Māori leaders mooting kaupapa Tupeka Kore and the eventual government commitment to the SF2025 goal. We then discuss the implications of the Action Plan in relation to kaupapa Tupeka Kore and high rates of smoking among Māori. The views offered in this blog are those of the authors only and may not represent the views of Māori in general.

Business as usual tobacco control measures not enough to address smoking disparities.

Traditional, business as usual (BAU), tobacco control measures have had a strong emphasis on changing individual behaviours (e.g. encouraging youth to resist influences for taking up smoking or supporting smoking cessation). While important, these measures tend to target more superficial aspects of tobacco control (e.g. motivations to smoke) or address the symptoms (e.g. helping people to quit smoking) but not the fundamental causes for why people take up or continue to smoke (e.g. how easy it is to access tobacco or the role of the tobacco industry in creating an addictive and harmful product). These measures rely on individuals having the capacity and personal resources to carry out the desired behaviours. However, the capacity and resources (e.g. income, access to support) of individuals and whānau may differ from group to group within society2. Such differences are potential reasons why smoking among Māori has not changed significantly in recent years while the rest of the population has seen consistent declines in their smoking rates3. The Action Plan recognises shortcomings of individualistic based approaches and the need to create supportive environments as part of the rationale for its proposed measures:

…we must take measures that alter the broader environment in which people live, to make it easy for young people to remain smokefree and for smokers to quit, rather than only focus on measures that have an influence at an individual level. p71

An alternative to business as usual: Kaupapa Tupeka Kore

By the mid 2000’s it was clear that BAU measures were not enough to address persisting smoking disparities and the subsequent harm they cause to Māori4. This was a key reason why Māori Party MP Hone Harawira proposed a private members bill to make tobacco sales illegal.

…the tobacco companies can go to hell. We will no longer sacrifice our generations so you can make profits…5

Shortly after the bill was presented to Parliament co-author of this blog, Shane Bradbrook, then Director of Apaarangi Tautoko Auahi Kore (ATAK, later renamed Te Reo Mārama) first mooted kaupapa Tupeka Kore (“No tobacco”) at the 2006 National Smokefree/Auahi Kore conference. This kaupapa was grounded in a holistic Māori worldview of health that was guaranteed within Te Tiriti o Waitangi. This worldview was described in ATAK’s National Māori Tobacco Control Strategy:

Māori do not just have specific health needs but more fundamentally a right to be healthy. The right to good health encompasses wellness in its fullest sense and includes the physical, spiritual and cultural well-being of Māori as individuals and as a collective. Indeed the two are interlinked – a well collective ensures a healthy individual, and an individual capable of exercising rights and fully participating in the life of society strengthens the collective. (Jackson cited in ATAK6)

By linking tobacco use to Te Tiriti recognised its close association with Māori experiences of colonisation7. In this context nicotine addiction among Māori can be seen as a contemporary marker and reminder of not only our colonial past but colonial practices that continue to this day. The impact of introducing kaupapa Tupeka Kore cannot be understated and it effectively prompted serious discussions about working towards ending tobacco use in Aotearoa. In 2010 recommendations from a Māori Affairs Select Committee (MASC) inquiry8 culminated in the Government’s commitment to achieving an essentially Smokefree Aotearoa by 2025.

The impact of changing tobacco control landscapes on kaupapa Tupeka Kore

While SF2025 was a world leading goal in 2010 an actual plan by Government to achieve it did not materialise in the decade that followed9. This decade also coincided with the proliferation of alternative nicotine delivery devices in Aotearoa and in particular electronic cigarettes (ECs). The availability of ECs introduced ‘harm minimisation’ to the tobacco control debate10. ‘Harm’ was mainly defined in the context of reducing the significant impacts of tobacco use on illness and death in our society. Broader recognition of the impacts of nicotine addiction on spiritual or cultural wellbeing have received less recognition in official reports. The Action Plan discusses ECs in the context of providing an alternative for smokers who are unable to quit their nicotine addiction. Such an approach is consistent with Māori principles of manaaki, however we acknowledge there may be a diversity of views on this. We suggest framing ECs as an alternative, interim, measure is consistent with kaupapa Tupeka Kore, so long as it does not create a barrier for those pursuing the broader Tupeka Kore goal.

Māori who smoke support key Action Plan measures

There is support for two key strategies proposed in the Plan among those most likely to be affected, Māori who smoke. The first of these measures is reducing the content of nicotine in cigarettes to non-addictive levels and the second is markedly reducing access to tobacco retailers. Preliminary findings11 from a study by this blog’s authors suggest more Māori who smoke support than oppose both of these measures. Study participants were three and a half times more likely to support reducing nicotine levels than oppose. The impacts of reducing nicotine could be significant as well with over half (54%) of participants reporting they would either quit (40%) or switch completely to e-cigarettes (14%). Similarly, over half of participants (55%) reported they would either cut down the amount they smoked (37%) or quit smoking (19%) if access to tobacco from retailers was markedly reduced.

Done “by” not “on”: The importance of Māori leadership and governance

A notable feature of many of the strategies outlined in the Plan are that they would be implemented at a national level through laws, regulations and policies. This is to ensure that the impacts of these measures would be equitable across the whole population and as discussed not privilege those sectors of society already with greater capacity or access to resources to help make any desired changes. For some Māori these types of measures may be a challenging prospect as they could cut across their personal, whānau or even iwi sense of tino rangatiratanga (self-determination). Commitments within the Action Plan to strengthen Māori governance in tobacco control could go some way towards alleviating these concerns. While Māori leadership has and continues to be an enduring feature of tobacco control the ability of Māori to influence and participate in tobacco control was severely eroded in the decade that followed the Government’s commitment to the SF2025 Goal. This included government defunding tobacco control advocacy including Te Reo Mārama (the Māori Smokefree Coalition) and instead focusing on contract driven individualistic smoking cessation interventions12. The commitment to Māori governance in the Plan therefore presents an opportunity to consider how Māori interests, aspirations and perspectives can best be represented at community, regional, national and even global levels. For this opportunity to be fully realised will require inclusive processes that engage Māori at all these levels. This could include participating in key decisions around how and what measures are designed, implemented and evaluated and ensuring that these are grounded and take account of Māori community realities and experiences.

Leadership is not about what is done for us or to us – it is about what is done by us.   That, indeed, is the very basis of self-determination. (Dame Tariana Turia)13

The Action Plan: An opportunity for change

The Action Plan presents an unprecedented opportunity to address physical harm from smoking for Aotearoa and, in particular, to eliminate smoking disparities for Māori. This is because the strategies proposed in the plan are likely to have equitable reach and impact on all people who smoke. The Plan represents a very significant stepping-stone towards achieving the kaupapa Tupeka Kore vision. Strengthening Māori governance as proposed in the Plan would be essential to ensure it retains a focus on equity, achieves Māori tobacco control aspirations and that it is not done ‘for’ or ‘on’ Māori but ‘by’ Māori.

 

Acknowledgements

Study findings reported in this blog were drawn from the Health Research Council of New Zealand funded Te Ara Auahi Kore (TAKe) project. TAKe was made possible through our collaboration with community based and academic organisations in New Zealand and Australia. Special thanks to our partner organisations: Whakauae Research for Māori Health and Development; Mahitahi Hauora PHE; National Hauora Coalition; Ngā Mataapuna Oranga; Ngāti Porou Hauora; Ora Toa PHO; Tākiri Mai Te Ata; Tu Kotahi Māori Asthma Trust, Kōkiri Marae Keriana Olsen Trust; Hāpai Te Hauora; and our Australian based colleagues at Menzies School of Health Research and Australia National University.

 

References

  1. Ministry of Health. Proposals for a Smokefree Aotearoa 2025 Action Plan: Discussion document. Wellington: Ministry of Health 2021.
  2. Poata-Smith ETA. Inequality and Māori in Rashbrooke M (ed) Inequality: A New Zealand Crisis (ed Rashbrooke M). Wellington: Bridget Williams Books 2013.
  3. Ministry of Health. Annual Update of Key Results 2019/20: New Zealand Health Survey, 2020 [Available from: https://www.health.govt.nz/publication/annual-update-key-results-2019-20-new-zealand-health-survey accessed 17 May 2021].
  4. Gifford H, Bradbrook S. Recent actions by Māori politicians and health advocates for a tobacco-free Aotearoa/New Zealand: A brief review. Occasional Paper 2009/1: Whakauae Research Services, Te Reo Mārama, Health Promotion and Public Health Policy Research Unit (HePPRU), University of Otago, 2009.
  5. Thomson A. Ban smoking anywhere, any time, says Māori Party The New Zealand Herald: 2006.
  6. Apaarangi Tautoko Auahi Kore. National Māori Smokefree Strategy. Wellington. Apaarangi Tautoko Auahi Kore 2003.
  7. Reid P, Pouwhare, R. Te Taonga mai Tawhiti (The gift from a distant place). Auckland. Auckland: Niho Taniwha 1991.
  8. Māori Affairs Committee. Inquiry into the tobacco industry in Aotearoa and the consequences of tobacco use for Māori. Wellington: NZ Government.
  9. Ball J, Edwards R, Waa A, Bradbrook SK, Cunningham C, Gifford H, Hoek J, Blakely T, Wilson N, Thomson G, Taylor S. Is the NZ Government responding adequately to the Māori Affairs Select Committee’s 2010 recommendations on tobacco control? A brief review. N Z Med J. 2016 Jan 8;129(1428):93-7. PMID: 26914199.
  10. Cahn Z, Siege, M. Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or a repeat of past mistakes? J Public Health Pol2011; 32: 16–31. doi: https://doi.org/10.1057/jphp.2010.41
  11. Waa A, Johnson E, Robson B, Stanley J, Edwards R. Unpublished preliminary analysis from TAKe study. 2021
  12. Chapman S. Has New Zealand lost its way in tobacco control? The Conversation, 2016 [Available from: https://theconversation.com/has-new-zealand-lost-its-way-in-tobacco-control-62178; accessed 17 May 2021].
  13. Turia T (Dame). Key-note presentation. Tobacco-Free Aotearoa Conference. Wellington: HPA.