Comparison of ten policy options to equitably reduce children's exposure to unhealthy food marketing.

OBJECTIVE: Reducing children's exposure to unhealthy food marketing is crucial to combat childhood obesity. We aimed to estimate the reduction of children's exposure to food marketing under different policy scenarios and assess exposure differences by socio-economic status. DESIGN: Data on children's exposure to unhealthy food marketing were compiled from a previous cross-sectional study in which children (n 168) wore wearable cameras and Global Positioning System (GPS) units for 4 consecutive days. For each exposure, we identified the setting, the marketing medium and food/beverage product category. We analysed the percentage reduction in food marketing exposure for ten policy scenarios and by socio-economic deprivation: (1) no product packaging, (2) no merchandise marketing, (3) no sugary drink marketing, (4) no confectionary marketing in schools, (5) no sugary drink marketing in schools, (6) no marketing in public spaces, (7) no marketing within 400 m of schools, (8) no marketing within 400 m of recreation venues, (9) no marketing within 400 m of bus stops and (10) no marketing within 400 m of major roads. SETTING: Wellington region of New Zealand. PARTICIPANTS: 168 children aged 11-14 years. RESULTS: Exposure to food marketing varied by setting, marketing medium and product category. Among the ten policy scenarios, the largest reductions were for plain packaging (60·3 %), no sugary drink marketing (28·8 %) and no marketing in public spaces (22·2 %). There were no differences by socio-economic deprivation. CONCLUSIONS: The results suggest that plain packaging would result in the greatest decrease in children's exposure to food marketing. However, given that children are regularly exposed to unhealthy food marketing in multiple settings through a range of marketing mediums, comprehensive bans are needed to protect children's health.

The association of social and food preparation location context with the quality of meals and snacks consumed by young adults: findings from the MYMeals wearable camera study.

PURPOSE: This study examined the association of social contexts and food preparation location with the quality of meals and snacks (predominately from the five food groups (FFG) versus discretionary foods) in a sample of young Australian adults (18-30 years old) using wearable camera technology. METHODS: A sub-sample from the cross-sectional MYMeals study wore a wearable camera that captured images every 30 s for three consecutive days. Eating episodes from 133 participants (55% female) were classified across 4 domains: food quality (observed proportion of FFG and discretionary items), preparation location, social interaction, and screen use. Socio-economic status (SES) was assigned using residential postcode and gender self-reported. Associations of contexts and demographic factors with food quality stratified by meal type were determined using mixed binary logistic regression models. RESULTS: Of the 1840 eating episodes identified, 1775 were included in analysis (n = 8 preparation location and n = 57 food components that could not be identified were excluded). Food prepared at home was more likely to be from the FFG at lunch (OR = 4.8 95% CI 2.7-8.6), dinner (OR = 14.8 95% CI 7.6-28.6), and snacks (OR = 3.2 95% CI 2.2-4.8). Participants from higher SES areas were more likely to consume breakfasts (OR = 3.2 95% CI 1.4-7.4) and lunches (OR = 1.9 95% CI 1.0-3.7) predominately from the FFG. Females were more likely to consume lunches (OR = 2.0 95% CI 1.1-3.8) that was largely from the FFG. Social interaction and screen use were not associated with meal or snack quality. CONCLUSION: Wearable cameras have verified the importance of addressing meals and snacks prepared outside of home as an important contributor of discretionary food.

Generating political priority for skin cancer primary prevention: A case study from Aotearoa New Zealand.

ISSUES ADDRESSED: Skin cancer is highly prevalent but preventable, yet little research has been done on the challenges in generating political priority for skin cancer prevention. This qualitative study aimed to identify the political challenges to, facilitators of, and strategies to strengthen skin cancer prevention. The focus was on the case of Aotearoa New Zealand (NZ): a country with high skin cancer rates, but limited investment in primary prevention. METHODS: Data sources included 18 national key informant interviews and documentary analysis. Data were analysed inductively for emerging themes and framed using a conceptual framework of political priority. RESULTS: Challenges to advocates for skin cancer primary prevention include limited resources and competing priorities. Political-level challenges include a lack of quick results compared with other initiatives vying for political attention, lack of negative externalities and, in NZ, misalignment with health system priorities. Challenges in the evidence base include the perceived conflict of sun protection with Vitamin D and physical activity, the lack of data on the financial burden of skin cancer and relatively low temperatures in NZ. Facilitators include strong policy community cohesion and issue framing, and weak opposition. Promising strategies to strengthen skin cancer prevention in NZ could include network building, using framing that resonates with policy makers and addressing key knowledge gaps in NZ, such as the financial burden of skin cancer. CONCLUSION: Advocacy for skin cancer prevention faces challenges due to advocates' limited resources, political challenges such as lack of quick results and gaps in evidence. Nonetheless, the initiative encounters little opposition and can be framed in ways that resonate with policy makers. SO WHAT?: Skin cancer is highly preventable, but advocates for prevention initiatives have struggled to gain political traction. This study identifies several strategies that could help raise the political profile for skin cancer prevention.

Ensuring the right to food for indigenous children: a case study of stakeholder perspectives on policy options to ensure the rights of tamariki Maori to healthy food.

BACKGROUND: The United Nations Convention on the Rights of the Child confirms a child's right to adequate food, and to the highest attainable standard of health. For indigenous children, these rights are also recognised in the UN Declaration on the Rights of Indigenous Peoples. However, Indigenous children endure higher rates of obesity and related health conditions than non-indigenous children, including in Aotearoa New Zealand (NZ). For indigenous tamariki (Maori children) in NZ, high levels of obesity are interconnected with high rates of food insecurity. Therefore there is a need for action. This study aimed to investigate policy options that would safeguard the rights of indigenous children to healthy food. We explored with key stakeholder's policy options to ensure the rights of indigenous children to healthy food, through a case study of the rights of tamariki. METHODS: Interviews were conducted with 15 key stakeholders, with experience in research, development or delivery of policies to safeguard the rights of tamariki to healthy food. Iterative thematic analysis of the transcripts identified both deductive themes informed by Kaupapa Maori theory and literature on rights-based approaches and inductive themes from the interviews. RESULTS: The analysis suggests that to ensure the right to adequate food and to healthy food availability for tamariki, there needs to be: a comprehensive policy response that supports children's rights; an end to child poverty; food provision and food policy in schools; local government policy to promote healthy food availability; and stronger Maori voices and values in decision-making. CONCLUSIONS: The right to food for indigenous children, is linked to political and economic systems that are an outcome of colonisation. A decolonising approach where Maori voices and values are central within NZ policies and policy-making processes is needed. Given the importance of food to health, a broad policy approach from the NZ government to ensure the right to adequate food is urgent. This includes economic policies to end child poverty and specific strategies such as food provision and food policy in schools. The role of Iwi (tribes) and local governments needs to be further explored if we are to improve the right to adequate food within regions of NZ.

Using wearable cameras to monitor eating and drinking behaviours during transport journeys.

PURPOSE: Young adults are vulnerable to weight gain and dietary behaviours such as 'eating on the run' are likely contributors. The objective of this study was to examine eating and drinking behaviours during transport journeys in a sample of young adults using wearable cameras that take continuous images every 30 s. METHODS: Seventy-eight 18-30 year olds wore an Autographer wearable camera for three consecutive days. Image coding schedules were designed to assess physical activity (included transportation) and diet. For the general description of data, frequency analysis was calculated as image number (percentage) and mean (± SD) or median (IQR) when appropriate. RESULTS: A total of 281,041 images were coded and 32,529 (14%) of images involved transport. The median (IQR) camera wear time was 8 h per day (7-9 h). The camera images identified 52 participants (67%) either eating or drinking during transport (excluding water). A total of 143 eating and drinking occasions were identified, averaging 3 occasions per person over the three study days. Fifty five (38%) eating episodes were identified by the camera images of which 27 (49%) were discretionary and 88 (62%) drinking episodes were identified of which (45%) were discretionary. CONCLUSION: This study confirms that transport is a potential setting for intervention. Young adults are consuming discretionary food and beverages during transport which may contribute to energy-dense diets and compromise diet quality. Substituting unhealthy with healthy food advertising and potentially prohibiting eating and drinking whilst on public transport is suggested.

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.

Where do the children play? An objective analysis of children's use of green space.

Green space is important for health, yet, objective research on children's use of green space is sparse. This study aimed to objectively assess children's use of green space in both public and private settings during their summer leisure time, using wearable cameras. Images from cameras worn by 74 children were analysed for green space use over 4 days. Children spent an average of ∼1/10 h of leisure time in green space in the summer months, were physically active 68%, and with others 85%, of the time. Green spaces are important places for children's health because they are places they frequent and places where they are physically active and socialize. Wearable cameras provide an effective method for objective assessment of green space use.

Improving management of comorbidity in patients with colorectal cancer using comprehensive medical assessment: a pilot study.

BACKGROUND: Screening for and active management of comorbidity soon after cancer diagnosis shows promise in altering cancer treatment and outcomes for comorbid patients. Prior to a large multi-centre study, piloting of the intervention (comprehensive medical assessment) was undertaken to investigate the feasibility of the comorbidity screening tools and proposed outcome measures, and the feasibility, acceptability and potential effect of the intervention. METHODS: In this pilot intervention study, 72 patients of all ages (36 observation/36 intervention) with newly diagnosed or recently relapsed colorectal adenocarcinoma were enrolled and underwent comorbidity screening and risk stratification. Intervention patients meeting pre-specified comorbidity criteria were referred for intervention, a comprehensive medical assessment carried out by geriatricians. Each intervention was individually tailored but included assessment and management of comorbidity, polypharmacy, mental health particularly depression, functional status and psychosocial issues. Recruitment and referral to intervention were tracked, verbal and written feedback were gathered from staff, and semi-structured telephone interviews were conducted with 13 patients to assess screening tool and intervention feasibility and acceptability. Interviews were transcribed and analysed thematically. Patients were followed for 6-12 months after recruitment to assess feasibility of proposed outcome measures (chemotherapy uptake and completion rates, grade 3-5 treatment toxicity, attendance at hospital emergency clinic, and unplanned hospitalisations) and descriptive data on outcomes collated. RESULTS: Of the 29 intervention patients eligible for the intervention, 21 received it with feedback indicating that the intervention was acceptable. Those in the intervention group were less likely to be on 3+ medications, to have been admitted to hospital in previous 12 months, or to have limitations in daily activities. Collection of data to measure proposed outcomes was feasible with 55% (6/11) of intervention patients completing chemotherapy as planned compared to none (of 14) of the control group. No differences were seen in other outcome measures. Overall the study was feasible with modification, but the intervention was difficult to integrate into clinical pathways. CONCLUSIONS: This study generated valuable results that will be used to guide modification of the study and its approaches prior to progressing to a larger-scale study. TRIAL REGISTRATION: Retrospective, 26 August 2019, ACTRN12619001192178.

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.

Space-time analysis of unhealthy food advertising: New Zealand children's exposure and health policy options.

Reducing children's exposure to unhealthy food advertising is an accepted strategy to end childhood obesity. This study aimed to (i) measure children's space-time exposures to unhealthy food advertising in public outdoor spaces, using GPS and wearable cameras; and (ii) test effectiveness of banning options. We compiled data (collected July 2014-June 2015) on 138 12-year-old children in Wellington, New Zealand, using wearable cameras and GPS devices worn over 4 days. In 2017-18, we linked 59 150 images taken in public outdoor spaces to GPS data. Of these, 1631 contained unhealthy food advertising exposures, defined as ≥50% of an advertisement observed in each image. We examined spatial patterns using kernel density mapping and graphed space-time trends. We interpolated a kriged exposure rate across Wellington to estimate exposure reductions for potential bans. Children were exposed to 7.4 (95% CI 7.0-7.8) unhealthy food advertisements/hour spent in outdoor public spaces. Exposures occurred in shopping centres, residential areas and sports facilities, commonly involving fast food, sugary drinks and ice cream. Peak exposure times were weekend afternoons/evenings and weekdays before/after school. In Wellington, we estimated that banning such advertising within 400 m of playgrounds would yield a 33% reduction in exposure, followed by in residential areas (27%), within 400 m of schools (25%), and 50% for a ban combining all above. This work documents the extent of children's exposure to unhealthy food advertising and the potential impact of bans. Given the ubiquity of advertising in public spaces, this New Zealand research offers innovative methods and findings likely relevant in other jurisdictions.

An objective methodology capturing online commodity marketing and other harms.

Increasingly life is lived online, yet little is known about the actual nature and extent of online content that people view due to the difficulty of recording real time exposure. This includes people's exposure to harmful commodity marketing. This study aimed to develop a methodology to assess the nature and extent of exposure to, and engagement with, unhealthy commodity marketing and other public health harms online, particularly children's exposure. A convenience sample of 16 young adult participants (aged 21-29) recorded their device usage for 2 days using Zoom software. Data were coded and analysed to assess the nature and extent of marketing for alcohol, gambling, junk food and smoking products. Four focus groups were conducted with participants to explore their data collection and coding experiences, and results assessed using thematic analysis. The study found that, with some modifications, this method was feasible for gathering real-time objective data from the online world that can be analysed for a range of public health harms, including marketing of unhealthy commodities. Larger studies are recommended to build global evidence for public health action in the online world.

Children's healthy and unhealthy beverage availability, purchase and consumption: A wearable camera study.

Children's sugar-sweetened beverages (SSBs) consumption presents significant risks for obesity, type 2 diabetes and dental health. But there is a lack of objective data on beverages in children's overall environments. This study aimed to determine the nature and extent of children's beverage availability, purchase and consumption, throughout their day, using wearable cameras for data collection. Data were sourced from 'Kids'Cam NZ', a study in which randomly-selected New Zealand children (n = 168; 11-14y, mean 12.6y) wore cameras for four days (Thursday-Sunday), automatically taking a photo every 7s. Using content analysis, Thursday and Saturday images (n = 700,201) were systematically analysed. On average, 18.9 (95% CI 16.8, 21.4) drinks/day were available to the children (n = 158), of which 7.5 (95% CI 5.8, 9.7; 39.7%) were non-core drinks, including 6.4 (95% CI 5.0, 8.3; 33.9%) SSBs. At school and home, core drinks (water and unflavoured milk) were the most available. In all other locations in which children spent time (e.g., recreation venues and food retail outlets) non-core drinks dominated, at rates 1.5-5 times that of core drinks availability. Almost all drinks (n = 17; 10.8%) the children purchased were non-core. On average, children (n = 111; 70.3%) consumed a drink 2.6 (95% CI 2.1, 3.1) times/day, including one (95% CI 0.7, 1.3) SSB. At school and home core drinks predominated. SSBs were available to most children in all locations in which they spent time, and dominated their drinks purchases and consumption. SSBs appear to be a typical feature of children's everyday environments, almost certainly making it difficult for children's beverage intakes to align with guidelines. The findings support calls for governments to urgently enact the SSB-related actions in the WHO Commission's Ending Childhood Obesity implementation plan and, in turn, improve child health.

Competing teammates: food in New Zealand sports settings.

Despite the global popularity of sport, we know surprisingly little about food in sports settings. This two-phased study analysed the foods available in New Zealand sports settings. Phase one included a systematic literature review and 18 interviews with key informants from national and regional sporting organizations. Phase two involved 37 key informant interviews with stakeholders from two exemplar sports, rugby and netball and direct observations at netball and rugby venues. This study found most foods and beverages at New Zealand sports events were energy-dense and nutrient-poor. Caterers' control over food provision, socio-cultural attitudes which view unhealthy foods as normal, and a dominant profit motive, appear to be the key factors influencing the food environment in sports settings. Food environments in sport settings provide frequent opportunities to purchase and consume energy-dense, nutrient-poor foods. The research shows we have competing players in the sports context-unhealthy food and healthy physical activity. Achieving sustainable healthy change in sports settings will be challenging when the prevailing attitude normalizes the unhealthy environment. Nutrition policies in sports clubs are urgently needed to increase the availability of healthy food. This requires support from health agencies and leadership from national sports organizations. Given the international nature of the food industry and sport, these findings from New Zealand may assist other countries to better understand the nature of food in sport and adopt appropriate interventions to reduce the obesogenic environment that is sport.

Studying third-parties and environments: New Zealand sun-safety research.

Wearable cameras have been used to study health behaviours, but their utility in assessing third-party behaviours and the built environment is uncertain. This paper reports on the feasibility of using wearable cameras for this purpose in a study of sun-protective behaviours and shade availability during school lunch-breaks. The Kids'Cam study provided 168 children (aged 11-13 years), recruited from 16 randomly selected schools in the Wellington region of New Zealand, with wearable cameras. The devices automatically captured images every 7 s from the child's perspective. Images captured during school lunch-breaks by a random sample of 15 children who took part during terms 4 and 1 (October 2014-April 2015) were selected and assessed for usability. The feasibility of studying third-party sun-protective behaviours and school shade availability was assessed for a subset of 320 images. Of the 3492 eligible lunch-break images, 96.4% were useable; the remainders were excluded due to obstruction, blurriness or unsuitable camera position. Overall, 1278 children and 108 shade structures were observed in the sample images. The use of shade, hats, sleeves, collars and sunglasses could be determined for 97.0%, 77.2%, 74.4%, 47.6% and 54.9% of children, respectively. All shade structures could be classified according to type, and canopy composition could be assessed for 95.4% of structures. Wearable cameras are a feasible tool for assessing sun-safety, particularly shade availability, hat wearing and shade use. This methodology could be used to objectively study other third-party health-related behaviours, and other features of the built environment.

Are children smoke-free at home? Using wearable cameras to study children's exposure to smoking and smoking paraphernalia in private spaces.

BACKGROUND: There is limited evidence available on the nature of children's exposure to smoking and smoking paraphernalia in private spaces (homes and cars). We aimed to evaluate the extent and nature of children's exposure to smoking in these settings using image data captured by wearable cameras. METHODS: One-hundred and sixty-eight children wore wearable cameras for 4 days that automatically took pictures every 7 s. Images captured in private spaces (n = 140,818) by children living in households with a smoker (n = 34) were screened for instances of smoking and smoking paraphernalia. RESULTS: A total of 37 incidents of smoking-four indoor, 21 outdoor, and two in-vehicles-and 62 incidents of smoking paraphernalia were observed. Most smoking incidents in homes (21 of 33) took place outdoors. CONCLUSIONS: The findings support health promotion efforts to make smokers more aware that smoking paraphernalia may normalize smoking for children. The methodology (wearable cameras) appears to have high utility for studying health behaviours in private spaces.

Wide-ranging impacts reported by NZ cancer survivors: is supporting cancer survivor resilience a health sector role?

PURPOSE: Cancer survivor numbers are on the rise but little is known about New Zealand (NZ) survivors' experiences with management of cancer-related impacts and vulnerability. This study explored the experiences and resilience of NZ cancer survivors and the experiences of healthcare practitioners who work with cancer survivors. There is a focus on indigenous Maori survivors. METHODS: This study used qualitative methods to explore survivors and healthcare practitioners' views on cancer-related impact and management strategies. Two focus groups were conducted with mainly colorectal cancer survivors residing in the central regions of NZ. There was one Maori-only group (n = 6 participants) and one multicultural group (n = 18 participants). The Maori-only focus group was purposefully organised to provide a culturally safe setting for the research. In addition, 12 in-depth interviews were conducted with healthcare practitioners between October 2011 and March 2012. RESULTS: Wide-ranging survivorship impacts were described by survivors across physical, emotional, spiritual and social domains. Shame resilience and relationships, particularly with healthcare practitioners, were indicated as useful supports. Healthcare practitioners' time constraints and role priorities were identified as barriers to their ability to provide survivorship support. CONCLUSIONS: This study generated qualitative data on survivorship impacts and components of survivor resilience in NZ. It also provided insights into the need for better strategies and pathways to help the NZ health system be more responsive to both Maori and non-Maori survivors. IMPLICATIONS FOR CANCER SURVIVORS: Survivor impacts create vulnerabilities that are experienced and described differently by individuals and groups in NZ. Tailored survivor support that can enhance resilience and support relationships is needed in NZ.

Quantifying the Nature and Extent of Children's Real-time Exposure to Alcohol Marketing in Their Everyday Lives Using Wearable Cameras: Children's Exposure via a Range of Media in a Range of Key Places.

AIMS: Children's exposure to alcohol marketing is typically measured using self-report data, television viewing data or street marketing audits, which are subject to bias and often do not provide quantifiable measures of daily exposure. This article describes an innovative methodology to capture the world in which children live using wearable cameras. SHORT SUMMARY: Children wearing wearable cameras were exposed 4.5 times per day to alcohol marketing in multiple places and via a range of marketing media. The results reinforce calls for legislative restrictions and a global response to alcohol marketing in order to protect children and reduce alcohol-related harm. METHODS: Children aged 11-13 years (n = 167) wore cameras that automatically captured images approximately every 7 s for a 4-day period between June 2014 and July 2015. Content analysis of images (n = 700,000) was manually undertaken to assess children's exposure to alcohol marketing. RESULTS: On average, children were exposed to alcohol marketing 4.5 (95% CI: 3.3, 6.0) times per day, excluding within off-licence retailers, on screens and product packaging. Children were exposed at home (47%), on-licence alcohol retailers (19%), off-licence shop fronts (16%) and sporting venues (12%), and via sports sponsorship (31%) and shop front signage (31%) and merchandise (25%). The highest exposure rates were found among Maori (5.4 times higher than New Zealand European) and Pacific (3.0 times higher than New Zealand European), and boys (2.0 times higher than girls). CONCLUSIONS: These findings highlight the urgent need to implement strict legislative restrictions on all forms of alcohol marketing to fulfil the World Health Organization Global Alcohol Strategy.

International trade and investment law: a new framework for public health and the common good.

BACKGROUND: International trade and investment agreements can have positive outcomes, but also have negative consequences that affect global health and influence fundamental health determinants: poverty, inequality and the environment. This article proposes principles and strategies for designing future international law to attain health and common good objectives. ARGUMENT: Basic principles are needed for international trade and investment agreements that are consistent with the common good, public health, and human rights. These principles should reflect the importance of reducing inequalities, along with social and environmental sustainability. Economic growth should be recognised as a means to common good objectives, rather than an end in itself. Our favoured approach is both radical and comprehensive: we describe what this approach would include and outline the strategies for its implementation, the processes and capacity building necessary for its achievement, and related governance and corporate issues. The comprehensive approach includes significant changes to current models for trade and investment agreements, in particular (i) health, social and environmental objectives would be recognised as legitimate in their own right and implemented accordingly; (ii) changes to dispute-resolution processes, both state-to-state and investor-state; (iii) greater deference to international legal frameworks for health, environmental protection, and human rights; (iv) greater coherence across the international law framework; (v) limitations on investor privileges, and (vi) enforceable corporate responsibilities for contributing to health, environmental, human rights and other common good objectives. We also identify some limited changes that could be considered as an alternative to the proposed comprehensive approach. Future research is needed to develop a range of model treaties, and on the means by which such treaties and reforms might be achieved. Such research would focus also on complementary institutional reforms relevant to the United Nations and other international agencies. Advocacy by a range of communities is needed for effective change. Reform will require informed debate, determined engagement with decision-makers and stakeholders, and some agreement across health, social and environmental sectors on alternatives. CONCLUSIONS: Current frameworks of international law that govern trade and economic development need radical change, in relation to treaty processes, content, and contexts, to better attain public health objectives.

Appetite for health-related food taxes: New Zealand stakeholder views.

There is increasing discussion globally of the value of health-related food taxes and subsidies to address obesity and noncommunicable diseases. In order for such policies to be successful it is important to understand the positions of key stakeholders. This research investigated New Zealand (NZ) stakeholders' views on the feasibility and acceptability of selected health-related food taxes and subsidies over the next 5 to 10 years. Twenty semi-structured interviews were undertaken by telephone from November 2014 to May 2015. The purposive sample of key stakeholders included politicians, bureaucrats, public health experts, food industry leaders and consumer representatives. Prior to interviews participants were sent summary information on the estimated impacts of a range of health-related food taxes and subsidies on dietary intake and mortality. According to key stakeholders there appears to be little appetite for taxes on foods high in saturated fat or salt in NZ. Stakeholders largely agreed that a tax on sugar-sweetened beverages (SSBs) and a subsidy on fruit and vegetables were both feasible and likely acceptable. There was strong support for starting with a SSBs tax, possibly framed around protecting children and dental health. Addressing obesity and noncommunicable diseases is a multidimensional challenge. A tax on SSBs and a subsidy on fruit and vegetables, possibly in tandem, could be part of the solution in NZ. There is growing interest in, and evidence for, health-related taxes and subsidies internationally. Given the critical role of stakeholder support for such policies similar research on stakeholders' views may assist the implementation of health-related food taxes and subsidies in other jurisdictions.