Food tax policies in Pacific Island Countries and Territories: systematic policy review.

OBJECTIVE: To systematically identify and review food taxation policy changes in Pacific Island Countries and Territories (PICTs). DESIGN: Food taxation polices, regarding excise taxes and tariffs applied from 2000 to 2020 in twenty-two PICTs, and their key characteristics were reviewed. The search was conducted using databases, government legal repositories and broad-based search engines. Identified documents for screening included legislation, reports, academic literature, news articles and grey literature. Key informants were contacted from each PICT to retrieve further data and confirm results. Results were analysed by narrative synthesis. SETTING: Noncommunicable diseases (NCD) are the leading cause of premature death in PICTs and in many jurisdictions globally. An NCD crisis has been declared in the Pacific, and food taxation policy has been recommended to address the dietary risk factors associated with. Progress is unclear. RESULTS: Of the twenty-two PICTs included in the study, fourteen had food taxation policies and five introduced excise taxes. Processed foods, sugar and salt were the main target of excise taxes. A total of eighty-four food taxation policy changes were identified across all food groups. There was a total of 279 taxes identified by food group, of which 85 % were tariffs and 15 % were excise taxes. Individual tax rates varied substantially. The predominant tax design was ad valorem, and this was followed by volumetric. CONCLUSIONS: A quarter of PICTs have introduced food excise taxes from 2000 to 2020. Further excise taxes, specifically tiered or nutrient-specific designs, could be introduced and more systematically applied to a broader range of unhealthy foods.

Equity of Cancer and Diabetes Co-Occurrence: A National Study With 44 Million Person-Years of Follow-Up.

PURPOSE: The co-occurrence of diabetes and cancer is becoming increasingly common, and this is likely to compound existing inequities in outcomes from both conditions within populations. METHODS: In this study, we investigate the co-occurrence of cancer and diabetes by ethnic groups in New Zealand. National-level diabetes and cancer data on nearly five million individuals over 44 million person-years were used to describe the rate of cancer in a national prevalent cohort of peoples with diabetes versus those without diabetes, by ethnic group (Maori, Pacific, South Asian, Other Asian, and European peoples). RESULTS: The rate of cancer was greater for those with diabetes regardless of ethnic group (age-adjusted rate ratios, Maori, 1.37; 95% CI, 1.33 to 1.42; Pacific, 1.35; 95% CI, 1.28 to 1.43; South Asian, 1.23; 95% CI, 1.12 to 1.36; Other Asian, 1.31; 95% CI, 1.21 to 1.43; European, 1.29; 95% CI, 1.27 to 1.31). Maori had the highest rate of diabetes and cancer co-occurrence. Rates of GI, endocrine, and obesity-related cancers comprised a bulk of the excess cancers occurring among Maori and Pacific peoples with diabetes. CONCLUSION: Our observations reinforce the need for the primordial prevention of risk factors that are shared between diabetes and cancer. Also, the commonality of diabetes and cancer co-occurrence, particularly for Maori, reinforces the need for a multidisciplinary, joined-up approach to the detection and care of both conditions. Given the disproportionate burden of diabetes and those cancers that share risk factors with diabetes, action in these areas is likely to reduce ethnic inequities in outcomes from both conditions.

Using household economic survey data to assess food expenditure patterns and trends in a high-income country with notable health inequities.

This study aimed to identify dietary trends in Aotearoa New Zealand (NZ) and whether inequities in dietary patterns are changing. We extracted data from the Household Economic Survey (HES), which was designed to provide information on impacts of policy-making in NZ, and performed descriptive analyses on food expenditures. Overall, total household food expenditure per capita increased by 0.38% annually over this period. Low-income households spent around three quarters of what high-income households spent on food per capita. High-income households experienced a greater increase in expenditure on nuts and seeds and a greater reduction in expenditure on processed meat. There was increased expenditure over time on fruit and vegetables nuts and seeds, and healthy foods in Maori (Indigenous) households with little variations in non-Maori households. But there was little change in processed meat expenditure for Maori households and expenditure on less healthy foods also increased over time. Routinely collected HES data were useful and cost-effective for understanding trends in food expenditure patterns to inform public health interventions, in the absence of nutrition survey data. Potentially positive expenditure trends for Maori were identified, however, food expenditure inequities in processed meat and less healthy foods by ethnicity and income continue to be substantial.

Progress in the Pacific on sugar-sweetened beverage taxes: a systematic review of policy changes from 2000 to 2019.

OBJECTIVE: To systematically characterise sugar-sweetened beverage (SSB) tax policy changes in Pacific Island countries and territories (PICTs) from 2000 to 2019. METHODS: Medline, Google Scholar, Pacific Islands Legal Information Institute database, Factiva and news and government websites were systematically searched up to October 2019. Information was extracted on the date and SSB tax level change, tax type, included beverages, and earmarking; and checked for consistency with local experts. RESULTS: Three-quarters of PICTs had an SSB tax (n=16/21) and 11 of these were excise taxes that included both imported and locally produced beverages. The level of tax was over 20% in 14 jurisdictions. SSB tax was increased by more than 20 percentage points in eight PICTs. Most taxes were ad valorem or volumetric, three were earmarked and only two taxes targeted sugar-sweetened fruit juices. The majority of countries (14/21) had different tax rates for imported and locally produced beverages. CONCLUSIONS: More than three-quarters of PICTs have SSB taxes. More than one-third increased these taxes since 2000 at an amount that is expected to reduce soft drink consumption. Implications for public health: Despite high-quality tax design elements in some PICTs, SSB control policies could generally be strengthened to improve health benefits, e.g. by targeting all SSBs and earmarking revenue for health.

Impact of sugar-sweetened beverage taxes on price, import and sale volumes in an island: interrupted time series analysis.

OBJECTIVE: To evaluate the impact of changes in import tariffs on sweetened beverages. DESIGN: Interrupted time series analysis was used to examine sweetened beverage tariff increases of 40-60 % in 2008 and to 75 % in 2012, and an approximately 11 % decrease in 2014 when an excise tax replaced the tariff. Post-tax trends were compared with a counterfactual modelled on the pre-tax trend for: quarterly price of an indicator beverage, monthly beverage import volumes (both 2001-2017) and quarterly sales volumes (2012-2017). In a controlled analysis, taxed beverage imports were compared with a sugary snacks control. SETTING: Cook Islands. PARTICIPANTS: NA. RESULTS: In the first year, after the 2008 tariff increase the price of the selected indicator soft drink increased by 7·3 % (95 % CI 6·3 %, 8·3 %) but after the 2012 tariff increase it decreased by 13·9 % (95 % CI -14·9 %, -12·8 %). At the same time, the import volumes of taxed beverages decreased by 13·2 % (95 % CI -38·1 %, 17·8 %) and 2·9 % (95 % CI -41·6 %, 72·5 %), respectively, and decreased by 24·8 % (95 % CI -36·9, -9·8) and 10·2 % (95 % CI -37·1, 37·5) in the controlled analysis. After the 2014 tax decrease, the price of the indicator soft drink decreased by 23·6 % (95 % CI -26·0 %, -21·1 %), sweetened beverage imports increased by 4·5 % (95 % CI -39·5 %, 156·0 %) and sales of full-sugar soft drinks increased by 31 % (95 % CI -21 %, 243 %). CONCLUSIONS: The increased import tariffs on sweetened beverages appeared to be effective for reducing import volumes, but this was partly reversed by the reduced tax/tariff in 2014.

Equity of expenditure changes associated with a sweetened-beverage tax in Tonga: repeated cross-sectional household surveys.

BACKGROUND: The aim of this study was to examine changes in beverage expenditure patterns before and after a T$0.50/L sweetened-beverage (SB) excise was introduced in Tonga in 2013, by household income, household age composition and island of residence. METHODS: Two cross-sectional surveys involved households being randomly sampled (the Household Income and Expenditure Surveys in 2009 (n = 1982) and 2015/16 (n = 1800)). Changes in soft drink (taxed), bottled water, and milk (both untaxed) expenditure were examined namely: (i) prevalence of households purchasing the beverage; (ii) average expenditure per person (inflation-adjusted); (iii) expenditure as a proportion of household food budget; and (iv) expenditure per person as a proportion of equivalised income. RESULTS: The pattern found was of decreases in all soft drink expenditure outcomes and these appeared to be greater in low-income than high-income households for purchasing prevalence (- 30% and - 25% respectively, t-test p = 0.98), per-capita expenditure (- 37% and - 34%, p = 0.20) and food budget share (- 27% and - 7%, p = 0.65), but not income share (- 6% and - 32%, p = 0.71). The large expenditure increases in bottled water appeared to be greater in low-income than high-income households for purchasing prevalence (355 and 172%, p = 0.32) and food budget share (665 and 468%, p = 0.09), but greater in high-income households for per-capita expenditure (121 and 373%, p < 0.01) and income share (83 and 397%, p = 0.50). CONCLUSIONS: The sweetened-beverage tax was associated with reduced soft drink purchasing and increased bottled water expenditure. Low-income households appeared to have slightly greater declines in soft drink expenditure.

Sweetened beverage taxes and changes in beverage price, imports and manufacturing: interrupted time series analysis in a middle-income country.

BACKGROUND: The Pacific Island nation of Tonga (a middle-income country) introduced a sweetened beverage tax of T$0.50/L in 2013, with this increasing further in 2016 (to T$1.00/L), and in 2017 (T$1.50/L; US$0.02/oz). Given the potential importance of such types of fiscal intervention for preventing chronic disease, we aimed to evaluate the impact of these tax changes in Tonga. METHODS: Interrupted time series analysis was used to examine monthly import volumes and quarterly price and manufacturing 1 year after each tax change, compared with a counterfactual based on existing trends. Autocorrelation was adjusted for when present, and adjustments were made for changes in GDP per capita, visitor numbers, season and T$/US$ exchange rate. RESULTS: In the year after the 2013, 2016 and 2017 tax increases, the price of an indicator soft drink increased by 16.8% (95%CI: 6.3 to 29.6), 3.7% (- 0.6 to 8.3) and 17.6% (6.0 to 32.0) respectively. Imports of sweetened beverages decreased with changes of - 10.4% (- 23.6 to 9.0), - 30.3% (- 38.8 to - 20.5) and - 62.5% (- 73.1 to - 43.4) respectively. Juice imports changed by - 54.2% (- 93.2 to - 1.1), and sachet drinks by - 15.5% (- 67.8 to 88.3) after the 2017 tax increase. Tonga water bottling (T$) increased in value by 143% (69 to 334) after the 2016 tax increase and soft drink manufacturing increased by 20% (2 to 46, albeit 5% market share). CONCLUSIONS: Consistent with international evaluations of sugar-sweetened beverage taxes, the taxes in Tonga were associated with increased prices, decreased taxed beverages imports, and increased locally bottled water.

Changing social inequalities in smoking, obesity and cause-specific mortality: Cross-national comparisons using compass typology.

BACKGROUND: In many countries smoking rates have declined and obesity rates have increased, and social inequalities in each have varied over time. At the same time, mortality has declined in most high-income countries, but gaps by educational qualification persist-at least partially due to differential smoking and obesity distributions. This study uses a compass typology to simultaneously examine the magnitude and trends in educational inequalities across multiple countries in: a) smoking and obesity; b) smoking-related mortality and c) cause-specific mortality. METHODS: Smoking prevalence, obesity prevalence and cause-specific mortality rates (35-79 year olds by sex) in nine European countries and New Zealand were sourced from between 1980 and 2010. We calculated relative and absolute inequalities in prevalence and mortality (relative and slope indices of inequality, respectively RII, SII) by highest educational qualification. Countries were then plotted on a compass typology which simultaneously examines trends in the population average rates or odds on the x-axis, RII on the Y-axis, and contour lines depicting SII. FINDINGS: Smoking and obesity. Smoking prevalence in men decreased over time but relative inequalities increased. For women there were fewer declines in smoking prevalence and relative inequalities tended to increase. Obesity prevalence in men and women increased over time with a mixed picture of increasing absolute and sometimes relative inequalities. Absolute inequalities in obesity increased for men and women in Czech Republic, France, New Zealand, Norway, for women in Austria and Lithuania, and for men in Finland. Cause-specific mortality. Average rates of smoking-related mortality were generally stable or increasing for women, accompanied by increasing relative inequalities. For men, average rates were stable or decreasing, but relative inequalities increased over time. Cardiovascular disease, cancer, and external injury rates generally decreased over time, and relative inequalities increased. In Eastern European countries mortality started declining later compared to other countries, however it remained at higher levels; and absolute inequalities in mortality increased whereas they were more stable elsewhere. CONCLUSIONS: Tobacco control remains vital for addressing social inequalities in health by education, and focus on the least educated is required to address increasing relative inequalities. Increasing obesity in all countries and increasing absolute obesity inequalities in several countries is concerning for future potential health impacts. Obesity prevention may be increasingly important for addressing health inequalities in some settings. The compass typology was useful to compare trends in inequalities because it simultaneously tracks changes in rates/odds, and absolute and relative inequality measures.

Impact of sugar-sweetened beverage taxes on purchases and dietary intake: Systematic review and meta-analysis.

The aim was to conduct a systematic review of real-world sugar-sweetened beverage (SSB) tax evaluations and examine the overall impact on beverage purchases and dietary intake by meta-analysis. Medline, EconLit, Google Scholar, and Scopus databases were searched up to June 2018. SSB tax evaluations from any formal jurisdiction from cities to national governments were eligible if there was a comparison between pre-post tax (n = 11) or taxed and untaxed jurisdiction(s) (n = 6). The consumption outcome comprised sales, purchasing, and intake (reported by volume, energy, or frequency). Taxed and untaxed beverage consumption outcomes were examined separately by meta-analysis with adjustment for the size of each tax. The study was registered at PROSPERO (CRD42018100620). The equivalent of a 10% SSB tax was associated with an average decline in beverage purchases and dietary intake of 10.0% (95% CI: -5.0% to -14.7%, n = 17 studies, 6 jurisdictions) with considerable heterogeneity between results (I2  = 97%).The equivalent of a 10% SSB tax was also associated with a nonsignificant 1.9% increase in total untaxed beverage consumption (eg, water) (95% CI: -2.1% to 6.1%, n = 6 studies, 4 jurisdictions). Based on real-world evaluations, SSB taxes introduced in jurisdictions around the world appear to have been effective in reducing SSB purchases and dietary intake.

Socioeconomic and Tobacco Mediation of Ethnic Inequalities in Mortality over Time: Repeated Census-mortality Cohort Studies, 1981 to 2011.

BACKGROUND: Racial/ethnic inequalities in mortality may be reducible by addressing socioeconomic factors and smoking. To our knowledge, this is the first study to estimate trends over multiple decades in (1) mediation of racial/ethnic inequalities in mortality (between Maori and Europeans in New Zealand) by socioeconomic factors, (2) additional mediation through smoking, and (3) inequalities had there never been smoking. METHODS: We estimated natural (1 and 2 above) and controlled mediation effects (3 above) in census-mortality cohorts for 1981-1984 (1.1 million people), 1996-1999 (1.5 million), and 2006-2011 (1.5 million) for 25- to 74-year-olds in New Zealand, using a weighting of regression predicted outcomes. RESULTS: Socioeconomic factors explained 46% of male inequalities in all three cohorts and made an increasing contribution over time among females from 30.4% (95% confidence interval = 18.1%, 42.7%) in 1981-1984 to 41.9% (36.0%, 48.0%). Including smoking with socioeconomic factors only modestly altered the percentage mediated for males, but more substantially increased it for females, for example, 7.7% (5.5%, 10.0%) in 2006-2011. A counterfactual scenario of having eradicated tobacco in the past (but unchanged socioeconomic distribution) lowered mortality for all sex-by-ethnic groups and resulted in a 12.2% (2.9%, 20.8%) and 21.2% (11.6%, 31.0%) reduction in the absolute mortality gap between Maori and Europeans in 2006-2011, for males and females, respectively. CONCLUSIONS: Our study predicts that, in this high-income country, reducing socioeconomic disparities between ethnic groups would greatly reduce ethnic inequalities in mortality over the long run. Eradicating tobacco would notably reduce ethnic inequalities in absolute but not relative mortality.

The long history of health inequality in New Zealand: occupational class and lifespan in the late 1800s and early 1900s.

OBJECTIVE: As relatively little is known about how socioeconomic position might have affected health prior to the Second World War, we aimed to study lifespan by occupational class in two cohorts in New Zealand. METHODS: The first study included men on the electoral rolls in Dunedin in the period 1893 to 1902. The second study used an established cohort of male military personnel who were recruited for the First World War. Linear regression was used to estimate lifespan by occupational class. RESULTS: The first study of 259 men on the electoral rolls found no substantive lifespan differences between the high and low occupational class groups. But the second study of 2,406 military personnel found that men in the three highest occupational classes lived 3.5 years longer (95%CI: 0.3-6.8 years) than the three lowest classes (in the multivariable analysis adjusting for age in 1918 and rurality of occupation). CONCLUSIONS: We found no significant lifespan differences in one cohort, but a second cohort is the earliest demonstration to our knowledge of substantial differences in mortality by socioeconomic position in this country prior to the 1960s. Implications for public health: This study provides historical context to the long-term efforts to address health inequalities in society.

Changing smoking-mortality association over time and across social groups: National census-mortality cohort studies from 1981 to 2011.

The difference in mortality between current and never-smokers varies over time, affecting future projections of health gains from tobacco control. We examine this heterogeneity by sex, ethnicity and cause of death on absolute and relative scales using New Zealand census data. These data included smoking status, and were linked to subsequent mortality records in 1981-84, 1996-99 and 2006-11 for 25-74 year olds (16.1 million person-years of follow-up). Age-standardised mortality rates and rate differences (SRDs) were calculated comparing current to never-smokers, and Poisson regression was used to adjust for multiple socioeconomic factors and household smoking. We found that mortality declined over time in never-smokers; however, mortality trends in current-smokers varied by sex, ethnicity and cause of death. SRDs were stable over time in European/Other men, moderately widened in European/Other women and markedly increased in Maori men and women (Indigenous population). Poisson smoking-mortality rate ratios (RRs) increased from 1981-84 to 1996-99 with a moderate increase from 1996-99 to 2006-11 (RRs 1.48, 1.77, 1.79 in men and 1.51, 1.80, 1.90 in women). Socioeconomic confounding increased over time. In summary, this marked heterogeneity in smoking-mortality RRs over time has implications for estimating the future health and inequality impacts of tobacco control interventions.

Changing ethnic inequalities in mortality in New Zealand over 30 years: linked cohort studies with 68.9 million person-years of follow-up.

BACKGROUND: Internationally, ethnic inequalities in mortality within countries are increasingly recognized as a public health concern. But few countries have data to monitor such inequalities. We aimed to provide a detailed description of ethnic inequalities (Maori [indigenous], Pacific, and European/Other) in mortality for a country with high quality ethnicity data, using both standard and novel visualization methods. METHODS: Cohort studies of the entire New Zealand population were conducted, using probabilistically-linked Census and mortality data from 1981 to 2011 (68.9 million person years). Absolute (standardized rate difference) and relative (standardized rate ratio) inequalities were calculated, in 1-74-year-olds, for Maori and Pacific peoples in comparison to European/Other. RESULTS: All-cause mortality rates were highest for Maori, followed by Pacific peoples then European/Other, and declined in all three ethnic groups over time. Pacific peoples experienced the slowest annual percentage fall in mortality rates, then Maori, with European/Other having the highest percentage falls - resulting in widening relative inequalities. Absolute inequalities, however, for both Maori and Pacific males compared to European/Other have been falling since 1996. But for females, only Maori absolute inequalities (compared with European/Other) have been falling. Regarding cause of death, cancer is becoming a more important contributor than cardiovascular disease (CVD) to absolute inequalities, especially for Maori females. CONCLUSIONS: We found declines in all-cause mortality rates, over time, for each ethnic group of interest. Ethnic mortality inequalities are generally stable or even falling in absolute terms, but have increased on a relative scale. The drivers of these inequalities in mortality are transitioning over time, away from CVD to cancer and diabetes; such transitions are likely in other countries, and warrant further research. To address these inequalities, policymakers need to enhance prevention activities and health care delivery, but also support wider improvements in educational achievement and socioeconomic position for highest need populations.

A screening program to test and treat for Helicobacter pylori infection: Cost-utility analysis by age, sex and ethnicity.

BACKGROUND: The World Health Organization recommends all countries consider screening for H. pylori to prevent gastric cancer. We therefore aimed to estimate the cost-effectiveness of a H. pylori serology-based screening program in New Zealand, a country that includes population groups with relatively high gastric cancer rates. METHODS: A Markov model was developed using life-tables and morbidity data from a national burden of disease study. The modelled screening program reduced the incidence of non-cardia gastric cancer attributable to H. pylori, if infection was identified by serology screening, and for the population expected to be reached by the screening program. A health system perspective was taken and detailed individual-level costing data was used. RESULTS: For adults aged 25-69 years old, nation-wide screening for H. pylori was found to have an incremental cost of US$196 million (95% uncertainty interval [95% UI]: $182-$211 million) with health gains of 14,200 QALYs (95% UI: 5,100-26,300). Cost per QALY gained was US$16,500 ($7,600-$38,400) in the total population and 17% (6%-29%) of future gastric cancer cases could be averted with lifetime follow-up. A targeted screening program for Maori only (indigenous population), was more cost-effective at US$8,000 ($3,800-$18,500) per QALY. CONCLUSIONS: This modeling study found that H. pylori screening was likely to be cost-effective in this high-income country, particularly for the indigenous population. While further research is needed to help clarify the precise benefits, costs and adverse effects of such screening programs, there seems a reasonable case for policy-makers to give pilot programs consideration, particularly for any population groups with relatively elevated rates of gastric cancer.

Changing socioeconomic inequalities in cancer incidence and mortality: Cohort study with 54 million person-years follow-up 1981-2011.

Cancer is increasingly responsible for the mortality gap between high and low socioeconomic position groups in high-income countries. This study investigates which cancers are contributing more to socioeconomic gaps in mortality and how this changes over time.New Zealand census data from 1981, 1986, 1991, 1996, 2001 and 2006, were linked to three to five years of subsequent mortality and cancer registrations, resulting in 54 and 42 million years of follow-up cancer incidence and mortality, respectively. Age- and ethnicity-standardised cancer mortality rates and the slope index of inequality (SII) by income were calculated.The contribution of cancer to absolute inequalities (SII) in mortality increased from 16 to 27% for men and from 12 to 31% for women from 1981-84 to 2006-11, peaking in 1991-94 for men and in 1996-99 for women and then levelling off, parallel to peaks in lung cancer inequalities. Lung cancer was the largest driver of cancer inequality trends (49% of the cancer mortality gap in 1981-84 to 33% in 2006-11 for men and 32 to 33% for women) followed by colorectal cancer in men (2 to 11%) and breast cancer in women (declining from 44 to 13%). Women in the lowest income quintile experienced no decline in cancer mortality.The contribution of cancer to income inequalities in all-cause mortality has expanded in this high-income country. Action to address socioeconomic inequalities should prioritise equitable tobacco control, obesity control and improved access to cancer screening, early diagnosis and high quality treatment for those with the lowest incomes.

Ethnic inequalities in cancer incidence and mortality: census-linked cohort studies with 87 million years of person-time follow-up.

BACKGROUND: Cancer makes up a large and increasing proportion of excess mortality for indigenous, marginalised and socioeconomically deprived populations, and much of this inequality is preventable. This study aimed to determine which cancers give rise to changing ethnic inequalities over time. METHODS: New Zealand census data from 1981, 1986, 1991, 1996, 2001, and 2006, were all probabilistically linked to three to five subsequent years of mortality (68 million person-years) and cancer registrations (87 million person years) and weighted for linkage bias. Age-standardised rate differences (SRDs) for Maori (indigenous) and Pacific peoples, each compared to European/Other, were decomposed by cancer type. RESULTS: The absolute size and percentage of the cancer contribution to excess mortality increased from 1981-86 to 2006-11 in Maori males (SRD 72.5 to 102.0 per 100,000) and females (SRD 72.2 to 109.4), and Pacific females (SRD -9.8 to 42.2) each compared to European/Other. Specifically, excess mortality (SRDs) increased for breast cancer in Maori females (linear trend p < 0.01) and prostate (p < 0.01) and colorectal cancers (p < 0.01) in Maori males. The incidence gap (SRDs) increased for breast (Maori and Pacific females p < 0.01), endometrial (Pacific females p < 0.01) and liver cancers (Maori males p = 0.04), and for cervical cancer it decreased (Maori females p = 0.03). The colorectal cancer incidence gap which formerly favoured Maori, decreased for Maori males and females (p < 0.01). The greatest contributors to absolute inequalities (SRDs) in mortality in 2006-11 were lung cancer (Maori males 50 %, Maori females 44 %, Pacific males 81 %), breast cancer (Maori females 18 %, Pacific females 23 %) and stomach cancers (Maori males 9 %, Pacific males 16 %, Pacific females 20 %). The top contributors to the ethnic gap in cancer incidence were lung, breast, stomach, endometrial and liver cancer. CONCLUSIONS: A transition is occurring in what diseases contribute to inequalities. The increasing excess incidence and mortality rates in several obesity- and health care access-related cancers provide a sentinel warning of the emerging drivers of ethnic inequalities. Action to further address inequalities in cancer burden needs to be multi-pronged with attention to enhanced control of tobacco, obesity, and carcinogenic infectious agents, and focus on addressing access to effective screening and quality health care.