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.

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.

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.

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.

Tobacco branding, plain packaging, pictorial warnings, and symbolic consumption.

We use brand association and symbolic consumption theory to explore how plain cigarette packaging would influence the identities young adults cocreate with tobacco products. Group discussions and in-depth interviews with 86 young adult smokers and nonsmokers investigated how participants perceive tobacco branding and plain cigarette packaging with larger health warnings. We examined the transcript data using thematic analysis and explored how removing tobacco branding and replacing this with larger warnings would affect the symbolic status of tobacco brands and their social connotations. Smokers used tobacco brand imagery to define their social attributes and standing, and their connection with specific groups. Plain cigarette packaging usurped this process by undermining aspirational connotations and exposing tobacco products as toxic. Replacing tobacco branding with larger health warnings diminishes the cachet brand insignia creates, weakens the social benefits brands confer on users, and represents a potentially powerful policy measure.

Young adults' interpretations of tobacco brands: implications for tobacco control.

INTRODUCTION: Marketers have long recognized the power and importance of branding, which creates aspirational attributes that increase products' attractiveness. Although brand imagery has traditionally been communicated via mass media, packaging's importance in promoting desirable brand-attribute associations has increased. Knowledge of how groups prone to smoking experimentation interpret tobacco branding would inform the debate over plain packaging currently occurring in many countries. METHODS: We conducted 12 group discussions and four in-depth interviews with 66 young adult smokers and nonsmokers of varying ethnicities from two larger New Zealand cities and one provincial city. Participants evaluated 10 familiar and unfamiliar tobacco brands using brand personality attributes and discussed the associations they had made. RESULTS: Participants ascribed very different images to different brands when exposed to the packaging alone, regardless of whether they had seen or heard of the brands before. Perceptual mapping of brands and image attributes highlighted how brand positions varied from older, more traditional, and male oriented to younger, feminine, and "cool." CONCLUSIONS: Our findings emphasize the continuing importance of tobacco branding as a promotion tool, even when communicated only by packaging. The ease with which packaging alone enabled young people to identify brand attributes and the desirable associations these connoted illustrate how tobacco packaging functions as advertising. The results support measures such as plain packaging of tobacco products to reduce exposure to these overt behavioral cues.

Daring to dream: reactions to tobacco endgame ideas among policy-makers, media and public health practitioners.

BACKGROUND: Tobacco control strategies have mainly targeted reducing demand. Supply-side focused measures, though less familiar, deserve consideration, particularly to achieve 'endgame' tobacco control aims (e.g. achieving close to zero smoking prevalence). We explored attitudes towards supply-side focused 'endgame' tobacco control approaches and how they can be best communicated with senior policymakers, journalists, and public health practitioners. METHODS: We identified five supply-side focused approaches which could potentially lead to the tobacco endgame: two structural models and three discrete actions. The structural models were: (i) a Nicotine Authority to coordinate tobacco control activities and regulate the nicotine/tobacco market for public health aims; and (ii) a Tobacco Supply Agency acting as a monopoly purchaser of tobacco products and controlling the tobacco supply for public health aims. The actions were: (a) allocating progressively reducing tobacco product import quotas (the 'sinking lid') until importation and commercial sale of tobacco products ceased; (b) making tobacco companies responsible for reducing smoking prevalence with stringent financial penalties if targets were missed; and (c) new laws to facilitate litigation against tobacco companies. These approaches were presented as means to achieve a tobacco free New Zealand by 2020 to 19 senior policymakers, journalists, and public health physicians in two focus groups and eight interviews, and their reactions sought. RESULTS: The tobacco-free vision was widely supported. Participants engaged fully with the proposed tobacco control approaches, which were viewed as interesting or even intriguing. Most supported increasing the focus on supply-side measures. Views differed greatly about the desirability, feasibility and likely effectiveness of each approach. Participants identified a range of potential barriers to implementation and challenges to successfully advocating and communicating these approaches. The current framing of tobacco as a risky but legal commodity was noted as an important potential barrier to implementing endgame approaches. CONCLUSIONS: Endgame tobacco control approaches were considered to be viable policy options. Further policy analysis, research and public discussion are needed to develop endgame approaches. A significant change in the public framing of tobacco may be a prerequisite for implementing endgame solutions.

Characteristics of smoker support for increasing a dedicated tobacco tax: national survey data from New Zealand.

AIM: To examine smoker support for tobacco tax and for increased dedicated tobacco taxes, along with associations forany such support. METHODS: The New Zealand (NZ) arm of the International Tobacco Control Policy Evaluation Survey utilizes the NZ Health Survey (a national sample). From this sample, we surveyed adult smokers (N = 1,376). RESULTS: Most smokers considered that the current level of tobacco tax is "too high" (68%), but a majority (59%) would support an increase in tobacco tax if the extra revenue was used to promote healthy lifestyles and support quitting. There was majority support for a dedicated tobacco tax increase among all sociodemographic groups of smokers (including Maori, Pacific, and Asian smokers). In the fully adjusted multivariate model, significant associations with support for a dedicated tax increase included higher deprivation level (adjusted odds ratio [AOR] = 1.15) and suffering one form of financial stress (AOR = 1.81, 95% CI = 1.18-2.78). Other significant associations with support included concern about the smoking impacts on health and quality of life (AOR = 1.41), expressing support for tobacco control regulation (AOR = 1.83), and strength of intention to quit (AOR = 1.30). DISCUSSION: A majority of smokers from all sociodemographic groups supported an increase in tobacco tax if it was dedicated to quitting support and health promotion. The higher support among smokers with stronger intentions to quit is consistent with other evidence that smokers value tobacco control regulation such as high taxes to help them achieve their long-term quitting goals.

Public, private and personal: qualitative research on policymakers' opinions on smokefree interventions to protect children in 'private' spaces.

BACKGROUND: Governments use law to constrain aspects of private activities for purposes of protecting health and social wellbeing. Policymakers have a range of perceptions and beliefs about what is public or private. An understanding of the possible drivers of policymaker decisions about where government can or should intervene for health is important, as one way to better guide appropriate policy formation. Our aim was to identify obstacles to, and opportunities for, government smokefree regulation of private and public spaces to protect children. In particular, to seek policymaker opinions on the regulation of smoking in homes, cars and public parks and playgrounds in a country with incomplete smokefree laws (New Zealand). METHODS: Case study, using structured interviews to ask policymakers (62 politicians and senior officials) about their opinions on new smokefree legislation for public and private places. Supplementary data was obtained from the Factiva media database, on the views of New Zealand local authority councillors about policies for smokefree outdoor public places. RESULTS: Overall, interviewees thought that government regulation of smoking in private places was impractical and unwise. However, there were some differences on what was defined as 'private', particularly for cars. Even in public parks, smoking was seen by some as a 'personal' decision, and unlikely to be amenable to regulation. Most participants believed that educative, supportive and community-based measures were better and more practical means of reducing smoking in private places, compared to regulation. CONCLUSIONS: The constrained view of the role of regulation of smoking in public and private domains may be in keeping with current political discourse in New Zealand and similar Anglo-American countries. Policy and advocacy options to promote additional smokefree measures include providing a better voice for childrens' views, increasing information to policymakers about the harms to children from secondhand smoke and the example of adult smoking, and changing the culture for smoking around children.

What is behind smoker support for new smokefree areas? National survey data.

BACKGROUND: Some countries have started to extend indoor smokefree laws to cover cars and various outdoor settings. However, policy-modifiable factors around smoker support for these new laws are not well described. METHODS: The New Zealand (NZ) arm of the International Tobacco Control Policy Evaluation Survey (ITC Project) derives its sample from the NZ Health Survey (a national sample). From this sample we surveyed adult smokers (n = 1376). RESULTS: For the six settings considered, 59% of smokers supported at least three new completely smokefree areas. Only 2% favoured smoking being allowed in all the six new settings. Support among Maori, Pacific and Asian smokers relative to European smokers was elevated in multivariate analyses, but confidence intervals often included 1.0.Also in the multivariate analyses, "strong support" by smokers for new smokefree area laws was associated with greater knowledge of the second-hand smoke (SHS) hazard, and with behaviours to reduce SHS exposure towards others. Strong support was also associated with reporting having smokefree cars (aOR = 1.68, 95% CI = 1.21 - 2.34); and support for tobacco control regulatory measures by government (aOR = 1.63, 95% CI = 1.32 - 2.01). There was also stronger support by smokers with a form of financial stress (not spending on household essentials). CONCLUSIONS: Smokers from a range of population groups can show majority support for new outdoor and smokefree car laws. Some of these findings are consistent with the use of public health strategies to support new smokefree laws, such as enhancing public knowledge of the second-hand smoke hazard.

Beneficial impacts of a national smokefree environments law on an indigenous population: a multifaceted evaluation.

BACKGROUND: Smokefree environments legislation is increasingly being implemented around the world. Evaluations largely find that the legislation is popular, compliance is high and report improved air quality and reduced exposure to secondhand smoke (SHS). The impact of the legislation on disadvantaged groups, including indigenous peoples has not been explored. We present findings from a multifaceted evaluation of the impact of the smokefree workplace provisions of the New Zealand Smokefree Environments Amendment Act on Maori people in New Zealand. Maori are the indigenous people of New Zealand. The Smokefree Environments Amendment Act extended existing smokefree legislation to almost all indoor workplaces in December 2004 (including restaurants and pubs/bars). METHODS: Review of existing data and commissioned studies to identify evidence for the evaluation of the new legislation: including attitudes and support for the legislation; stakeholders views about the Act and the implementation process; impact on SHS exposure in workplaces and other settings; and impact on smoking-related behaviours. RESULTS: Support for the legislation was strong among Maori and reached 90% for smokefree restaurants and 84% for smokefree bars by 2006. Maori stakeholders interviewed were mostly supportive of the way the legislation had been introduced. Reported exposure to SHS in workplaces decreased similarly in Maori and non-Maori with 27% of employed adult Maori reporting SHS exposure indoors at work during the previous week in 2003 and 9% in 2006. Exposure to SHS in the home declined, and may have decreased more in Maori households containing one or more smokers. For example, the proportion of 14-15 year old Maori children reporting that smoking occurred in their home fell from 47% in 2001 to 37% in 2007. Similar reductions in socially-cued smoking occurred among Maori and non-Maori. Evidence for the effect on smoking prevalence was mixed. Maori responded to the new law with increased calls to the national Quitline service. CONCLUSION: The New Zealand Smokefree Environments Amendment Act had a range of positive effects, including reducing SHS exposure among Maori communities. If the experience is replicated in other countries with indigenous populations, it suggests that comprehensive smokefree environments legislation will have beneficial effects on the health of indigenous groups and could contribute to reducing inequalities in health within societies.

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.