2

3

4

Wednesday 26th July 2017

Associate Professor Marewa GloverSchool of Public Health

The new compassionate and ethical approach to

achieving Smokefree2025

Twitter: @MarewaGlover

@wehi_nz

Email: M.Glover@massey.ac.nz

Overview

• Slow Reduction in Smoking Rates 1% p.a.

• Strategies to reduce smoking

• Reviewing the ethics of our damaging approach

• Moving to a harm reduction approach for smoking

• Reorienting to a compassionate path to

achieving Smokefree2025Twitter: @MarewaGloverM.Glover@massey.ac.nz

Smoking Prevalence %

Ethnic group Women Men Total Estimated number

Māori 42 34 38 122553

Pacific 23 26.5 25 41142

Asian 2 11 6 26988

European / Other 13 17 14 332349

Total NZ 15 18 15 523032

Source: Derived from 2014/15 New Zealand Health Survey aged 15yrs and over.

NZ Smoking Rates

• Māori smoking rates decreased by 11% between 1981 & 1991

• Māori adults (15yrs+) smoking prevalence:

– 54% in 1993

– 42% in 2006/07

– 38% in 2014/15 = NO SIGNIFICANT DROP from 06/07!

Māori smoking rates

What have we doneto achieve it?

• Continued 10% pa Hikes in Taxation

• Legislation; Bans on smoking

• Mass media campaigns ‘Loser’

• Plain packaging to come

• Cessation (ABC, Incentives for pregnant mums)

• Innovation trials (Incentives, Comps, Quitbus, Apps)

Shame them...

• “Nearly half of Māori mothers giving birth are smokers,

dooming Māori to continued poor health” (Hawke’s Bay

Today, 2014).‘If the aim is to stop adults role-modelling smoking behaviour, and given that 41 per cent of Maori women smoked, perhaps they should be sterilised…’ (Palmerston North City Councillor Bruce Wilson)

Discrimination...Marginalisation...

Auckland CBD, beaches and al fresco dining areas to become smokefree

– Up tobacco tax to 20-40% annually

– Extend bans on smoking to public outdoor areas, parks, footpaths e.g. Wgtn City Council & fine smokers!

– Ban smoking in cars with children present (prosecute in court!)

– Severely restrict retail sales of new harm-reduced products like electronic cigarettes; disallow any other / new products

Further strategies being pushed

Mason: Public Health Ethical Considerations

– do no harm

• Cultural values are endorsed

• Tikanga guides the approach

• Community leadership & priorities are respected

• Implications for future generations have been assessed

• Perverse impacts have been considered

Durie, M. PAE ORA: Māori Health Horizons & the Public Health Workforce. School of Public Health Symposium, Wellington, 30th September 2016.

What are perverse impacts? E.g. Tobacco Tax

• A perverse effect is something that happens that is contrary to what was originally intended (when an intended solution makes a problem worse).

• Assuming people DO NOT stop smoking... What are some of the perverse effects of the current tobacco price increases?

• Increased robberies – up to 2 a week

• Increased incarceration of youth

• Cheaper tobacco on black market & chop chop

• Marijuana &/or P is sometimes cheaper

15

What are perverse impacts? E.g. Tobacco Tax

Cont...

16

• Increased financial strain

• Limited $ → have to choose cheaper high-density high-satiety foods

OR

What should we do instead?

= It’s time to move from a top-down paternalistic Quit or Die approach

17

Harm Reduction?

What are ways you practice harm reduction?

Harm Reduction?

• Seat belts

• Cycle helmets

• Looking both ways before crossing the road

• Passwords

• Life jackets

• Condoms

Harm Reduction in Tobacco Control?

• Reduce consumption

• Swedish Snus – 95% less harmful than smoking = 5% smoking

• Electronic cigarettes– 95% safer than smoking

• New products coming: – Heat-not-Burn Products

– Hybrid HNB + Vapour

Barriers to Switching

• Lack of convenient access:

– to quality information on what to buy & where

– to nicotine e-liquid

• Lack of support to switch

– Stigma, glares & misinformation about risks

– Health professionals refuse to support

– Scare-mongering in the media

– Threats to ban ecigs / vaping

Truman, Fraser, Glover. (2017).

Why are we protecting tobacco smoking?

This is an historical turning point for smoking

• Throughout history we have regularly shifted from riskier more harmful products & behaviour to less harmful options

• For many of these all that’s needed was clear honest information about risk and options & convenient cheap access to the alternative

• When the safer choice is enjoyable, even superior, we just need to support & enhance the movement, & ensure that Māori and Pacific are not left behind.

An ethical approach to achieving Smokefree2025

• From Mason Durie’s teachings:– We need to be making balanced efforts to influence the

social & economic determinants of health inequalities– Every health intervention provides an opportunity to shift

a mauri that is languishing to a mauri that is flourishing– Treating the health problem should be extended to

increasing access to healthier (safer) behavioural choices, increasing health literacy, strengthening identity, encouraging self management, restoring dignity

• A good outcome reflects gains in health status and a strengthened mauri

24

Health & DisabilityServices Consumers’ Rights

• When you use a health or disability service, your rights are include:– a right to receive the information you need to make decisions about

your health and about any tests, procedures or treatments– a right to have information provided in a way that you understand– a right to make an informed choice and give your informed consent

before you undergo a test, procedure or treatment– a right to be treated with respect and dignity, taking into account

your cultural needs and values– a right to have a support person with you, at most times– a right to services being provided with reasonable care and skill– a right to complain about a provider, in a way that is appropriate for

you.

• All these rights also apply if you take part or are asked totake part in teaching or research.

Ministry of Health website, downloaded 25 July 2017.

A compassionate path to Smokefree2025

• Prioritise reduction in inequalities

• Immediate moratorium on tobacco tax increases

• Provide guidance to DHBs, Councils, workplaces, landlords & marae on how to support smokers to switch to vaping* (rather than banning vaping)

• Provide training to Health Professionals & stop smoking services in mana-enhancing non-judgmental tobacco harm reduction

– & consumer rights

26

A community-involved path to Smokefree2025

• Reorient funding from national top-down paternalistic & shame-inducing services to community interventions using a programmatic approach to reducing drivers to smoke while increasing access to harm-reduced alternatives– Social Investment analysis / Life course approach,

proxy-interventions e.g. Roberts, Glover et al, 2017

• Progress legislative change to improve access to harm-reduced alternatives to smoking

• Work with Tobacco Companies on removal

of their combustible products from NZ27

A more honest pathto Smokefree2025

• Service plans to be audited against above Durie points: mauri-flourishing vs languising, reduction of inequalities, perverse effects, impact on future generations

• Monitoring and support of service transition to new approach

• Evaluation & review of different delivery models

28

Smokefree 2025 is a made up aspirational goal –it is not an edict.

There is no evidence to support that it is achievable in New Zealand. Only Sweden who embraced a harm reduction approach (Snus)

over 2 decades ago has reached a near 5% smoking prevalence.

29

30