The impact of racism on subsequent healthcare use and experiences for adult New Zealanders: a prospective cohort study.

BACKGROUND: Racism is an important determinant of health and driver of racial/ethnic health inequities. Experience of racism has been linked to negative healthcare use and experiences although most studies have been cross-sectional. This study examines the relationship between reported experience of racism and subsequent use and experience of health services. METHODS: This is a prospective cohort study design. The 2016/2017 adult New Zealand Health Survey (NZHS) provided the sampling frame and baseline data on exposures, health status and confounders. This stand-alone study invited all exposed individuals to participate when sampled based on their reported experience of racism (ever), stratified by broad ethnic groupings (Maori, Pacific, Asian, European/Other). Equal numbers of unexposed participants were selected for invitation using propensity score matching (propensity to experience racism, based on key available predictive factors). Follow-up was one to two years after NZHS interview. Outcome variables (last 12 months) were: unmet healthcare need (overall, for mental health, for a general practitioner); satisfaction with usual medical centre; and experiences with general practitioners (explaining care, involvement in decision-making, treated with respect/dignity, confidence and trust). Logistic regression models examining the association between experience of racism (at baseline) and health service use and experience (at follow-up) used doubly-robust estimation to weight for propensity scores used in the sampling with additional adjustment for confounders. RESULTS: The study had 2010 participants. Experience of racism (ever) at baseline was associated with higher overall unmet need at follow-up (adjusted OR (aOR) = 1.71, 95% CI 1.31, 2.23), with similar patterns for other unmet need measures. Experience of racism was associated with higher dissatisfaction with a usual medical centre (aOR = 1.41, 95% CI 1.10, 1.81) and with higher reporting of negative patient experiences. CONCLUSION: In line with how racism structures oppression, exposure to racism is largely felt by non-European groups in Aotearoa New Zealand. Experiences of racism potentially lead to poorer healthcare and healthcare inequities through higher unmet need, lower satisfaction and more negative experiences of healthcare. The health system has a critical role to play in addressing racism within healthcare and supporting societal efforts to eliminate racism and ethnic inequities.

Addressing Intergenerational Inequity in Tobacco-Harm: What Helps Children of Smokers to Remain Nonsmokers?

INTRODUCTION: Children of people who smoke are more likely to take up smoking themselves. In Aotearoa New Zealand (NZ), adolescent smoking declined dramatically between 2000 and 2016 despite limited change in parental smoking, demonstrating that the cycle can be broken. AIMS AND METHODS: This study aimed to identify modifiable factors associated with never smoking in Year 10 students (14-15 years) who had at least one caregiver who smoked. We used data from the Youth Insights Survey (2016 and 2018, pooled, N = 5,422) and identified students with at least one caregiver (mother, father, grandparent, other caregiver) who smoked (N = 2,205). To investigate modifiable factors potentially associated with nonsmoking we used logistic regression with marginally adjusted prevalence estimates. RESULTS: Overall, 41% of students had at least one caregiver who smoked. In this group, the majority (65%) had never smoked themselves. After adjustment, never-smoking was more prevalent among students attending low-deprivation (more affluent) schools (73% had never smoked) compared to high-deprivation schools (44%); students not exposed to others' smoking inside the home (72%) or in cars (70%) in the past week compared to those exposed (59% and 51%, respectively); and students whose parents would be upset if they were caught smoking (68% vs 49% for those whose parents would not be upset), or who had high self-esteem (69% vs 55% for those with low self-esteem). CONCLUSIONS: Modifiable factors independently associated with non-smoking in adolescents with caregiver(s) who smoked were: nonexposure to smoking inside the home and in cars, parental expectations of nonsmoking, and high self-esteem. IMPLICATIONS: Even in countries like NZ with relatively low adult smoking rates, children's exposure to caregiver smoking may be prevalent, particularly in structurally disadvantaged populations. This study suggests that action to promote smokefree homes and cars, build high self-esteem in young people, and communicate expectations of non-smoking are likely to help children of people who smoke to remain nonsmokers. A comprehensive approach that also addresses "upstream" factors (eg, socioeconomic deprivation) and underlying causes of structural inequity (eg, institutional racism) is needed. Such policy and community action may help to break intergenerational cycles of tobacco use and health inequity.

Support for and potential impacts of key Smokefree 2025 strategies among Maori who smoke.

AIM: The recently passed Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Act has the potential to profoundly reduce smoking prevalence and related health inequities experienced among Maori. This study examined support for, and potential impacts of, key measures included within the legislation. METHOD: Data came from Wave 1 (2017-2019) of the Te Ara Auahi Kore longitudinal study, which was conducted in partnership with five primary health organisations serving Maori communities. Participants were 701 Maori who smoked. Analysis included both descriptive analysis and logistic regression. RESULTS: More Maori participants supported than did not support the Smokefree 2025 (SF2025) goal of reducing smoking prevalence to below 5%, and the key associated measures. Support was greatest for mandating very low nicotine cigarettes (VLNCs). Participants also believed VLNCs would prompt high rates of quitting. Participants who had made more quit attempts or reported less control over their life were more likely to support VLNCs. CONCLUSION: There was support for the SF2025 goal and for key measures that could achieve it. In particular, VLNCs may have significant potential to reduce smoking prevalence among Maori. As part of developing and implementing these measures it will be important to engage with Maori who smoke and their communities.

Tobacco endgame intervention impacts on health gains and Maori:non-Maori health inequity: a simulation study of the Aotearoa/New Zealand Tobacco Action Plan.

BACKGROUND: The Aotearoa/New Zealand Government is aiming to end the tobacco epidemic and markedly reduce Maori:non-Maori health inequalities by legislating: (1) denicotinisation of retail tobacco, (2) 95% reduction in retail outlets and (c) a tobacco free-generation whereby people born after 2005 are unable to legally purchase tobacco. This paper estimates future smoking prevalence, mortality inequality and health-adjusted life year (HALY) impacts of these strategies. METHODS: We used a Markov model to estimate future yearly smoking and vaping prevalence, linked to a proportional multistate life table model to estimate future mortality and HALYs. RESULTS: The combined package of strategies (plus media promotion) reduced adult smoking prevalence from 31.8% in 2022 to 7.3% in 2025 for Maori, and 11.8% to 2.7% for non-Maori. The 5% smoking prevalence target was forecast to be achieved in 2026 and 2027 for Maori males and females, respectively.The HALY gains for the combined package over the population's remaining lifespan were estimated to be 594 000 (95% uncertainty interval (UI): 443 000 to 738 000; 3% discount rate). Denicotinisation alone achieved 97% of these HALYs, the retail strategy 19% and tobacco-free generation 12%.By 2040, the combined package was forcat to reduce the gap in Maori:non-Maori all-cause mortality rates for people 45+ years old by 22.9% (95% UI: 19.9% to 26.2%) for females and 9.6% (8.4% to 11.0%) for males. CONCLUSION: A tobacco endgame strategy, especially denicotinisation, could deliver large health benefits and dramatically reduce health inequities between Maori and non-Maori in Aotearoa/New Zealand.

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.

The impact of racism on the future health of adults: protocol for a prospective cohort study.

BACKGROUND: Racial discrimination is recognised as a key social determinant of health and driver of racial/ethnic health inequities. Studies have shown that people exposed to racism have poorer health outcomes (particularly for mental health), alongside both reduced access to health care and poorer patient experiences. Most of these studies have used cross-sectional designs: this prospective cohort study (drawing on critical approaches to health research) should provide substantially stronger causal evidence regarding the impact of racism on subsequent health and health care outcomes. METHODS: Participants are adults aged 15+ sampled from 2016/17 New Zealand Health Survey (NZHS) participants, sampled based on exposure to racism (ever exposed or never exposed, using five NZHS questions) and stratified by ethnic group (Maori, Pacific, Asian, European and Other). Target sample size is 1680 participants (half exposed, half unexposed) with follow-up survey timed for 12-24 months after baseline NZHS interview. All exposed participants are invited to participate, with unexposed participants selected using propensity score matching (propensity scores for exposure to racism, based on several major confounders). Respondents receive an initial invitation letter with choice of paper or web-based questionnaire. Those invitees not responding following reminders are contacted for computer-assisted telephone interview (CATI). A brief questionnaire was developed covering current health status (mental and physical health measures) and recent health-service utilisation (unmet need and experiences with healthcare measures). Analysis will compare outcomes between those exposed and unexposed to racism, using regression models and inverse probability of treatment weights (IPTW) to account for the propensity score sampling process. DISCUSSION: This study will add robust evidence on the causal links between experience of racism and subsequent health. The use of the NZHS as a baseline for a prospective study allows for the use of propensity score methods during the sampling phase as a novel approach to recruiting participants from the NZHS. This method allows for management of confounding at the sampling stage, while also reducing the need and cost of following up with all NZHS participants.

Premature mortality resilience and wellbeing within urban Maori communities.

Maori (the indigenous peoples of Aotearoa New Zealand) experience of colonisation has negatively affected access to many of the resources (e.g. income, adequate housing) that enable health and well-being. However Maori have actively responded to the challenges they have faced. With the majority of the Maori population now living in urban settings this exploratory study aimed to understand factors contributing to mortality resilience despite exposure to socio-economic adversity with reference to Maori well-being. Resilient urban neighborhoods were defined as those that had lower than expected premature mortality among Maori residents despite high levels of socio-economic adversity. Selected resilience indicators theoretically linked to a Maori well-being framework were correlated with the novel Maori_RINZ resilience index. Of the selected indicators, only exposure to crime showed a clear gradient across the resilience index as predicted by the Maori well-being framework. Future research is needed as unclear trends for other indicators may reflect limitations in the indicators used or the need to develop a more comprehensive measure of well-being.

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.

Response to an indigenous smoking cessation media campaign - it's about whanau.

OBJECTIVE: To assess any effects among Maori (the indigenous people of New Zealand) smokers and their whanau (the traditional Maori family unit) of a campaign designed to support Maori smokers to quit smoking. METHOD: New Zealand-wide cross sectional population surveys between 2000 and 2002 of smokers and whanau pre- and post-airing of the campaign. Measures included recall and awareness of the campaign; perceptions of the campaign; and campaign-attributed changes in quitting-related attitudes and behaviours. RESULTS: Seventy-eight per cent of smokers and 73% of whanau were able to recall the campaign one year following its launch. The television commercials (TVCs) were consistently rated very believable or very relevant by over half of the smokers who had seen them. More than half of smokers (54%) stated that the campaign had made them more likely to quit. CONCLUSION: This nationwide mass media cessation campaign developed to deliver a cessation message to indigenous people was received positively by Maori smokers and their whanau and played a role in prompting quit attempts. IMPLICATIONS: Social marketing campaigns have an important role as part of a tobacco control program to reduce high smoking prevalence among Maori and inequalities in health outcomes between Maori and other New Zealanders.