Getting there together: highlights, challenges and opportunities for tobacco control in the Oceania region.

BACKGROUND: The paper focuses on the geographical region of Oceania. We highlight the tobacco control leadership demonstrated in this region and describe the challenges and opportunities to achieving country-specific smoke-free goals. RESULTS: Significant achievements include smoke-free nation goals, world-leading initiatives such as plain packaging, and a bold plan by New Zealand to reduce the retail availability of smoked tobacco products and remove virtually all the nicotine from cigarettes and rolling tobacco. There are significant challenges and opportunities before reaching smoke-free status including implementation pathways requiring strong governance and leadership and compliance monitoring and enforcement. CONCLUSIONS: We conclude that achieving a smoke-free Oceania is possible through already existing bold country and regional smoke-free goals, excellent tobacco control leadership, experience and resources, and an understanding of how to work collectively. However, a commitment to focus tobacco control efforts regionally is required to achieve a smoke-free Oceania together.

Exploring indigenous perspectives on tobacco tax: how some Maori families are responding in Aotearoa New Zealand.

OBJECTIVE: High smoking prevalence rates, combined with a steep tax on tobacco and lower household income, mean that 5% of Maori (indigenous) whanau (family unit) expenditure in New Zealand is on tobacco. This paper outlines whanau perceptions of, and behavioural responses to, increasing tobacco tax. METHODS: This qualitative study was informed by the Kaupapa Maori theory and used a simplified interpretive phenomenological analysis thematic hybrid methodology. A semistructured, open-ended interview guide was designed and used in one-off focus group interviews. SETTING AND PARTICIPANTS: Interviews were separately conducted with each of 15 whanau units. A total of 72 participants, most of whom were smokers, took part in the interviews carried out in two geographical regions: one rural/provincial and one urban. RESULTS: Whanau were concerned about the rising cost of tobacco. However, this concern had not generally translated into quit attempts. Whanau had instead developed innovative tobacco-related practices. Working collectively within their whanau, they were able to continue to smoke, although in a modified fashion, despite the rising costs of tobacco. Whanau thereby resisted the intended outcome of the government's tobacco tax which is to reduce rates of smoking prevalence. CONCLUSION: In the face of significant government disinvestment in New Zealand tobacco control over the last 10 years, hypothecated taxes should be used to scale up Maori-specific cessation and uptake prevention programmes, supporting authentic Maori partnerships for endgame solutions including restricting the availability and appeal of tobacco.

Chronic conditions in the community: Preventative principles and emerging practices among Maori health services providers.

ISSUE: The pressing chronic conditions prevention needs of Maori (the Indigenous peoples of Aotearoa New Zealand) are yet to be adequately addressed using mainstream approaches. This study investigated how Maori health service providers (MHSP) are positioning themselves to better meet the chronic conditions prevention needs of Maori. METHODS: Kaupapa Maori methodology underpinned a three-phase research project that investigated three Maori health service provider-based chronic conditions prevention cases, in different regions of Aotearoa New Zealand, using an instrumental case study design. Two small group interviews with seven participants and 44 individual key informant interviews were conducted. All participants were associated with one of the three MHSP. Document reviews and observations were also carried out. Following the identification of a prevention case study, within each provider, in-depth investigation of prevention practices was undertaken. RESULTS: Achieving well-being through health service delivery is challenging for the three providers which are largely reliant on state funding to support their work through defined contract outputs. The drivers of service delivery norms impacting providers include the dominant medical conditions focused discourse and addressing the high levels of acute need characteristic of provider communities. There are examples of shifts in organisational structure and delivery configurations that demonstrate challenging and reframing these norms. We identified emerging approaches to prevention that move beyond being "the ambulance at the bottom of the cliff" to "building a fence at the top." CONCLUSION: Consolidation of provider prevention approaches, increased resources and a broader health services systems level response that prioritises prevention are required. SO WHAT?: MHSP are reframing services to better meet the well-being needs of the communities they serve.

Smoking prevalence among doctors and nurses-2013 New Zealand census data.

AIMS: To examine recent smoking trends among doctors and nurses in New Zealand. METHODS: Analysis of smoking prevalence in the 2013 New Zealand Census and comparison with previous census data. RESULTS: The 2013 census included 7,065 male and 5,619 female doctors, and 2,988 male and 36,138 female nurses. Non-response to smoking questions was less than 3%. In 2013, 2% of male and female doctors and 9% of male and 8% of female nurses were regular cigarette smokers. This compared with 4% male and 3% female doctors, and 20% male and 13% female nurses in 2006. Psychiatric nurses had the highest smoking prevalence (15% male, 18% female). More Maori doctors (6.8%) and nurses (19.3%) smoked. Around 96% of young (<25 years) doctors and 87% of young nurses had never been regular smokers. CONCLUSIONS: By 2013, New Zealand doctors had achieved the Smokefree 2025 goal of minimal (<5%) smoking prevalence and all nurses except psychiatric nurses were on track to do so. This suggests smokefree cultures can be established among substantial occupational groups. However, smoking among Maori nurses was relatively high. Targeted workplace smoking cessation support may be an efficient means to reduce smoking among key occupational groups, and may help reduce population smoking prevalence.

Process, pitfalls and profits: lessons from interviewing New Zealand policy-makers.

Little has been written about interviewing policy-makers in health promotion and public health research. This article explores the process, pitfalls and profits of semi-structured interviews with policy-makers in 10 research projects conducted in New Zealand. Key members of each research team were surveyed about their research and findings verified against research publications. Key aspects of the process of policy-maker interviews include gaining ethical approval, navigating gatekeepers, using personal contacts and multiple research dissemination methods. Pitfalls of interviewing policy-makers include interviewers not having enough knowledge of the topic so efforts were made to use knowledgeable researchers or up-skill others. Interviews provide access to specialist knowledge of the policy process which cannot be obtained by other methods. While this study was conducted in one jurisdiction, it has implications for other countries. Effective policy-maker interviews in health promotion policy research could contribute to improvements in the quality of data collected and uptake of research by policy-makers.

New Zealand policy experts' appraisal of interventions to reduce smoking in young adults: a qualitative investigation.

OBJECTIVES: Reducing smoking in young adults, particularly young Maori and Pacific, is vital for reducing tobacco harm and health inequalities in New Zealand (NZ). We investigated how NZ policy experts appraised the feasibility and likely effectiveness of interventions designed to reduce smoking prevalence among 18-24 year olds. DESIGN: We used a qualitative design, conducting semistructured interviews and applying thematic analysis. PARTICIPANTS: We interviewed 15 key informants, including politicians, senior policy analysts and leading tobacco control advocates. Participant selection was based on seniority and expertise and ensuring diverse perspectives were represented. INTERVENTIONS: We examined nine interventions that could either promote greater mindfulness or introduce barriers impeding smoking uptake: smoke-free outdoor dining and bars; no tobacco sales where alcohol is sold; social marketing campaigns; real life stories (testimonials); life skills training; raise purchase age to 21; tobacco-free generation; smokers' licence; make tobacco retail premises R18. RESULTS: The policies perceived as more effective denormalised tobacco; made it less convenient to access and use; highlighted immediate disadvantages (eg, impact on fitness); aligned with young people's values; and addressed the underlying causes of smoking (eg, stress). Participants highlighted some political barriers and noted concerns that some interventions might widen ethnic disparities. Exceptions were social marketing campaigns and extending smoke-free regulations to include outdoor areas of cafes and bars, which participants saw as politically feasible and likely to be effective. CONCLUSIONS: Our findings suggest the merit of an approach that combines social marketing with regulation that makes accessing and using tobacco less convenient for young adults; however, political barriers may limit the regulatory options available in the short term. Strategies to support self-determination and address the underlying causes of smoking in young people warrant further investigation. Determining policy acceptability to Maori and Pacific, and likely effectiveness for these populations, should be key priorities.

A qualitative analysis of Maori and Pacific smokers' views on informed choice and smoking.

OBJECTIVES: Tobacco companies frame smoking as an informed choice, a strategy that holds individuals responsible for harms they incur. Few studies have tested this argument, and even fewer have examined how informed indigenous smokers or those from minority ethnicities are when they start smoking. We explored how young adult Maori and Pacific smokers interpreted 'informed choice' in relation to smoking. PARTICIPANTS: Using recruitment via advertising, existing networks and word of mouth, we recruited and undertook qualitative in-depth interviews with 20 Maori and Pacific young adults aged 18-26 years who smoked. ANALYSES: Data were analysed using an informed-choice framework developed by Chapman and Liberman. We used a thematic analysis approach to identify themes that extended this framework. RESULTS: Few participants considered themselves well informed and none met more than the framework's initial two criteria. Most reflected on their unthinking uptake and subsequent addiction, and identified environmental factors that had facilitated uptake. Nonetheless, despite this context, most agreed that they had made an informed choice to smoke. CONCLUSIONS: The discrepancy between participants' reported knowledge and understanding of smoking's risks, and their assessment of smoking as an informed choice, reflects their view of smoking as a symbol of adulthood. Policies that make tobacco more difficult to use in social settings could help change social norms around smoking and the ease with which initiation and addiction currently occur.

A gift and a burden: the purchase and distribution of duty-free tobacco and its potential impact upon Pacific people in New Zealand.

BACKGROUND: High smoking rates among Pacific people living within New Zealand (26.9%) are a significant and poorly understood problem. A proposed approach to tobacco control is to enhance restrictions on or ban duty-free sales, a pertinent notion for Pacific people given their frequent travel between New Zealand and the Pacific Islands. This study examines the purchase and distribution of duty-free tobacco by Pacific people, whether it is being used as a strategy to circumvent the tobacco excise tax increases and how duty-free cigarette sales are perceived within the Pacific community. METHODS: We undertook a qualitative research study using six focus groups with Pacific smokers and non-smokers aged between 18 and 54 years. Half of the focus groups consisted of smokers and half non-smokers. We used a thematic analysis approach to identify, explore and report key themes within the data. RESULTS: Pacific smokers and non-smokers frequently purchase duty-free tobacco when travelling, and the usage of duty-free cigarettes for gift giving is a strongly embedded cultural value for Pacific peoples. However, nearly all participants strongly supported a proposal to reduce or ban duty-free tobacco sales. CONCLUSIONS: The findings suggest a ban on duty-free sales could be an important measure to help achieve the smokefree 2025 goal among Pacific communities in New Zealand. This measure would eliminate duty-free tobacco as a cheap form of supply, and efforts to denormalise the practice of gifting duty-free tobacco among Pacific people may also be helpful in reducing high prevalence rates within these communities.

A qualitative analysis of messages to promote smoking cessation among pregnant women.

OBJECTIVES: Although aware that smoking while pregnant presents serious risks to their unborn children, some women continue to smoke and rationalise their dissonance rather than quit. We explored metaphors women used to frame smoking and quitting, then developed cessation messages that drew on these metaphors and examined the perceived effectiveness of these. PARTICIPANTS: We used a two-phase qualitative study. Phase one involved 13 in-depth interviews with women who were smoking (or who had smoked) while pregnant. Phase two comprised 22 in-depth interviews with a new sample drawn from the same population. ANALYSES: Data were analysed using thematic analysis, which promoted theme identification independently of the research protocol. RESULTS: Participants often described smoking as a choice, a frame that explicitly asserted control over their behaviour. This stance allowed them to counter-argue messages to quit, and distanced them from the risks they created and faced. Messages tested in phase 2 used strong affective appeals as well as themes that stimulated cognitive reflection. Without exception, the messages depicting unwell or distressed children elicited strong emotional responses, were more powerful cessation stimuli, and elicited fewer counter-arguments. CONCLUSIONS: Cessation messages that evoke strong affective responses capitalise on the dissonance many women feel when smoking while pregnant and stimulate stronger consideration of quitting. Given the importance of promoting cessation among pregnant women, future campaigns could make greater use of emotional appeals and place less emphasis on informational approaches, which often prompt vigorous counter-arguments.

Maori nurses and smoking: what do we know?

AIM: A research partnership between NZNO, Whakauae Research, and Taupua Waiora aimed to determine Maori registered and student nurses' smoking behaviours and attitudes to smoking cessation. METHODS: We analysed a national web-based survey that explored the behaviours and views of 410 NZNO Maori 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 Maori nursing students and 20% for Maori 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. Maori nurses see the value in smoking cessation for improving their own and other's health, although many did not necessarily see themselves as effective in supporting Maori with smoking prevention and cessation. CONCLUSION: Prevalence rates for smoking among Maori 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 Maori nurses who are smoke-free will have the added benefit of increasing the efficacy of cessation interventions with patients and whanau (extended families).

Crossing the smoking divide for young adults: expressions of stigma and identity among smokers and nonsmokers.

OBJECTIVES: Denormalizing campaigns reframe smoking as an unappealing behavior, more likely to lead to social exclusion than inclusion. Social identity theory suggests this strategy will reinforce smoke-free norms and, as these become mainstream, decrease smoking prevalence. However, little is known about how these campaigns affect perceptions of smoking among young adult smokers and nonsmokers, or behavior toward smokers. A qualitative study was conducted to a) explore how smokers and smoking were perceived in an environment where smoking has become an increasingly unacceptable social behavior and b) examine whether and how this environment stigmatized smokers. METHODS: About 14 group discussions and 4 in-depth interviews involving 86 participants, aged between 18 and 24 and of Maori, Pacific, and NZ European ethnicities, were conducted as part of a wider study examining young adults' responses to tobacco branding and plain packaging. RESULTS: The themes identified illustrated how nonsmokers' perception of smoking as illogical and self-destructive supported harsh reactions, including stigmatizing behaviors that antagonized smokers. Nonsmokers, who recognized smoking's addictiveness, were more empathic and less judgmental of smokers. CONCLUSION: Including empathic content in smoking denormalizing campaigns may reduce judgmental reactions that inadvertently create a gulf between status of young adult smokers and nonsmokers. A supportive/empathic tobacco-control denormalization approach could enhance young adult smokers' willingness to make the transition from smoker to smoke free and elicit stronger support for their efforts from nonsmokers.

'The times are changing': New Zealand smokers' perceptions of the tobacco endgame.

BACKGROUND: The New Zealand government's goal of achieving a smoke-free society by 2025 reflects growing interest in 'endgame' solutions to tobacco smoking. However, tobacco companies have framed 'endgame' strategies as contrary to individual freedoms and 'choice'; these claims heighten politicians' sensitivity to 'nanny state' allegations and may undermine tobacco control policies. Public support for stronger policies could strengthen political will; however, little is known about how smokers perceive endgame scenarios or the factors underlying their support or opposition to these. METHODS: The authors conducted 47 in-depth interviews with four priority groups: Maori, Pacific, young adults and pregnant women; all were smokers or very recent quitters. The authors used thematic analysis to interpret the transcripts. RESULTS: Most participants strongly supported the 2025 smoke-free goal, recognised the broader social good that would result and accepted the personal inconvenience of quitting. Yet they wanted to retain control over when and how they would quit and asserted their 'freedom' to smoke. Participants identified interventions that would extend current policy and maintain the autonomy they valued; the authors classified these into four themes: restricting supply, diminishing visibility, decreasing availability and affordability, and increasing quit support. CONCLUSIONS: Politicians may have a stronger mandate to implement endgame policies than they appreciate. Participants' use of industry arguments when asserting their freedom to 'choose' to smoke and quit suggests a need for denormalisation strategies that challenge industry propaganda, demonstrate how endgame measures would empower smokers and re-iterate the community benefits a smoke-free society will deliver.

Support for a tobacco endgame and increased regulation of the tobacco industry among New Zealand smokers: results from a National Survey.

AIM: To examine the prevalence of smoker support for a ban on cigarette sales in 10 years time and increased regulation of the tobacco industry and to investigate the independent associations of support for these measures. METHODS: The authors surveyed opinions among adult smokers in two survey waves (N=1376 and N=923) from the New Zealand arm of the International Tobacco Control Policy Evaluation Survey during 2007-2009. The authors report prevalence of support stratified by age, gender and ethnicity. The authors carried out multivariate analyses to identify significant associations among potential determinants (demographics, socioeconomic status, mental health and smoking-related beliefs and behaviours) of support. RESULTS: Most New Zealand smokers supported greater regulation of the tobacco industry (65%) and more government action on tobacco (59%). Around half (46%) supported banning sales of cigarettes in 10 years time, provided effective nicotine substitutes were available. In a fully adjusted model, significant associations with support for greater tobacco company regulation included Maori ethnicity, experience of financial stress and greater awareness about the harms of smoking. Significant associations with support for a ban on tobacco sales in 10 years time included increasing area-based deprivation level, increasing intention to quit and greater concern about the health effects of smoking. CONCLUSIONS: The findings suggest that most smokers will support stronger government action to control the tobacco industry and that many support radical 'endgame' approaches. Greater support among Maori, more deprived and possibly Pacific smokers, is an important finding, which could inform the design and implementation of new policies given the very high smoking prevalence among these groups and hence high priority for targeted tobacco control interventions. Perceived difficulties in gaining public support should not impede the introduction of rigorous tobacco control measures needed to achieve a tobacco-free New Zealand.

Qualitative exploration of public and smoker understanding of, and reactions to, an endgame solution to the tobacco epidemic.

BACKGROUND: There is increasing interest in ending the tobacco epidemic and in applying 'endgame' solutions to achieve that goal at national levels. We explored the understanding of, and reactions to, a tobacco-free vision and an endgame approach to tobacco control among New Zealand smokers and non-smokers. METHODS: We recruited participants in four focus groups held in June 2009: Maori (indigenous people) smokers (n=7); non-Maori smokers (n=6); Maori non-smokers (n=7); and non-Maori non-smokers (n=4). Participants were from the city of Whanganui, New Zealand. We introduced to them the vision of a tobacco-free New Zealand and the concept of a semi-autonomous agency (Tobacco-Free Commission [TFC]) that would control the tobacco market as part of an endgame approach. RESULTS: There was mostly strong support for the tobacco-free New Zealand vision among all groups of participants. The reason most commonly given for supporting the vision was to protect children from tobacco. Most participants stated that they understood the TFC concept and reacted positively to it. Nevertheless, rather than focusing on organisational or structural arrangements, participants tended to focus on supporting the specific measures which a future TFC might facilitate such as plain packaging of tobacco products. Various concerns were also raised around the TFC, particularly around the feasibility of its establishment. CONCLUSIONS: We were able to successfully communicate a complex and novel supply-side focused tobacco control policy intervention to smokers and non-smokers. The findings add to the evidence from national surveys that there is public support, including from smokers, for achieving a tobacco-free vision and using regulatory and policy measures to achieve it. Support for such measures may be enhanced if they are clearly communicated and explained with a rationale which stresses protecting children and future generations from tobacco smoking.