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Māori Affairs Select Committee
Committee Secretariat
Bowen House
Parliament Buildings
WELLINGTON
SUBMISSION on the Māori Affairs Inquiry into the Tobacco Industry
in Aotearoa and the Consequences of Tobacco Use for Māori
Introduction
This submission is from the Medical Officers of Health of the Northland District Health
Board (DHB) Public and Population Health Unit. The Medical Officers of Health are
public health physicians who are designated by the Director-General of Health. They
provide independent specialist advice on matters that relate to population health and have
an overall statutory role to improve, promote and protect the health of Northlanders.
The Northland DHB Public and Population Health Unit, one of 12 in New Zealand, is the only
provider of integrated, regional public health services in Northland. The Unit carries out
regulatory activities under the Smokefree Environments Act 1990 and employs health
promotion advisors, smoke-free officers and designated health protection officers with the
overall aim of reducing the impact of tobacco harm in Te Tai Tokerau.
CONTACT DETAILS
Name Dr Jonathan Jarman, Medical Officer of Health
Bridget Rowse, Smoke-free Coordinator
Witi Ashby, Maori Health Advisor
Address Public and Population Health Unit
Northland District Health Board
PO Box 742
Whangarei 0140
Phone 09 430 4100 Fax 09 430 4498
Email Jonathan.Jarman@northlanddhb.org.nz
Smokefreecoordinator@northlanddhb.org.nz
Witi.Ashby@northlanddhb.org.nz
We wish to appear before the committee to speak to our submission.
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SUMMARY
Northland carries a high burden of disease from smoking. Smoking related hospitalisations
in Northland are 1.5 times higher than the national rate. It is estimated that smoking plays a
role in nearly half of all Maori deaths in Northland and is a major factor in the huge difference
of 14.9 years in life expectancy between Maori and non-Maori.
The loss of health and premature loss of life related to tobacco has a significant adverse
impact on the retention of cultural knowledge, language, social well-being, and economic
prosperity for Northland Maori.
Our main recommendation is for the sale of tobacco to be stopped by 2020. This one action
is likely to have a far larger and more immediate impact on reducing health inequalities and
improving Maori health than any other single health intervention.
INTRODUCTION
Tobacco is not a Māori tradition. Prior to European/Pākehā contact there was no smoking of
tobacco or any other substances by Māori. Tobacco was introduced to Aotearoa/New
Zealand in 1769 by early Pākehā explorers and traders, and was used as a currency and
article of trade. The combination of the addictiveness of tobacco, the novelty of tobacco, and
its early demonstration of use by Europeans made tobacco a desirable object for trade. Its
use quickly increased among Māori. 1
Today tobacco use is the leading cause of preventable death in New Zealand, accounting for
around 4,300 to 4,700 deaths per year. 2 3 4 Over 600 of those deaths are Māori who die
prematurely every year. 5 When second-hand smoke deaths are included, this estimate
6 7
increases to around 5,000 deaths per year.
In comparison there are:
· 1064 alcohol related deaths (2000) 8
· 619 deaths from breast cancer (2006) 9
· 294 deaths as a result of traffic accidents (2008) 10
· 116 people died as a result of an accident at work (2006/07) 11
1 Gifford H, Bradbrook S. Recent actions by Maori politicians and health advocates for a tobacco free Aotearoa, a brief review. Wellington: Whakauae
Research Services. Te Reo Marama. Health Promotion and Public Health Policy Research Unit, 2009.
2 Peto, R., Lopez, A.D., Boreham, J., and Thun, M. (2006). Mortality from smoking in developed countries 1950-2000. Second edition.
www.ctsu.ox.ac.uk/~tobacco/, retrieved 24 June 2009.
3 Public Health Intelligence. 2002. Tobacco Facts May 2002 (Public Health Intelligence Occasional Report No 2). Wellington: Ministry of Health.
4 Peto, R. and Lopez, A. 1994. Mortality from Smoking in Developed Countries 1950-2000: Indirect estimates from national vital statistics. New York:
Oxford University Press.
5 Te Reo Mārama website: www.tereomarama.co.nz. Retrieved 9 November 2009.
6 Ministry of Health (2004). Looking upstream: Causes of death cross-classified by risk and condition, New Zealand 1997. Wellington: Ministry of
Health.
7 Tobias, M. and Turley, M. (2005). Causes of death classified by risk and condition, New Zealand 1997. Australian and New Zealand Journal of
Public Health, 29, 5-12.
8 ALAC, Burden of Death, Disease and Disability Due to Alcohol in New Zealand. 2000.
9 NZ Breast Cancer Foundation, 2009. www.nzbcf.org.nz/index.php/about-breast-cancer/information-centre
10 Land Transport Agency, Road Death Statistics, 2009. www.ltsa.govt.nz/research/toll.html
11 Statistics NZ,
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· 117 drowning deaths (2004) 12
· 81 work-related deaths (2002) 13
· 45 deaths from SIDS (2009) 14
Tobacco is a major driver of health inequalities, more than 700,000 New Zealanders still
smoke on a regular basis. 15 Although smoking rates have declined in New Zealand over the
last decade, this has been almost exclusively among non-Maori. Smoking remains the
single most important and preventable cause of inequalities in mortality for Maori. This
means that Maori suffer more from the effects of tobacco than do other groups in society.
Furthermore those in the lowest socio-economic demographic are more than twice as likely
to smoke as those in the highest socio-economic demographic. 16 Cigarette smoking
accounted for 31 percent of all annual Māori deaths during 1989-93 as compared to 17
percent of all deaths in the total population. 17
Northland Impact
In 2007 the prevalence of daily smoking in adults aged 15 years and over was 25.7% in
Northland compared to 20.7% nationally. 18 Northland has particularly high prevalence of
Maori smokers with 46.1% of Maori females, compared to 45.5% nationally, and 40.4% of
Maori males compared to 38.5% nationally 18 .
Smoking in Northland is related to 25% of all deaths (47% of all Māori deaths, and 18% of
non-Māori deaths), 1.4 times higher than the national proportion 19 . It is a major factor in the
huge difference of 14.9 years in life expectancy between Maori and non-Maori 20 .
Smoking related hospitalisations in Northland (1161 per 100,000 hospitalisations) are 1.5
times higher than the national rate 19 . The loss of health and loss of life related to tobacco
has a significant impact on the retention of cultural knowledge and language, social
wellbeing, and economic prosperity for Northland Maori.
SPECIFIC COMMENTS
The Terms of Reference for the inquiry is to gain a comprehensive understanding of the:
1. The historical actions of the tobacco industry to promote tobacco use amongst Māori.
2. The impact of tobacco use on the health, economic, social and cultural wellbeing of
Māori.
3. The impact of tobacco use on Māori development aspirations and opportunities.
4. What benefits may have accrued to Māori from tobacco use?
5. What policy and legislative measures would be necessary to address the findings of
the Inquiry?
12 Water Safety NZ,
13 Statistics NZ, NZ Health Information Service Mortality Collection and ACC.
14 SIDS NZ, http://www.sids.org.nz/site/resources/ 2009.
15 Ministry of Health. 2008. Tobacco Trends 2007: A brief update on monitoring indicators. Wellington: Ministry of Health.
16 Cancer Control Council of New Zealand. 2008. Tobacco Control in New Zealand: A History. Cancer Control Council of New Zealand
17 Te Puni Kōkiri. Cigarette smoking mortality among Maori, 1954-2028. Wellington: Te Puni Kōkiri. 1998.
18 Ministry of Health. 2007. Smoking Prevalence Rates, Census 2006. Wellington: Public Health Intelligence, Ministry of Health.
19 Ministry of Health. 2007.4DHB Tobacco Control Project, Northland Epidemiology. Unpublished report.
20 Northland District Health Board. Te Tai Tokerau Maori Health Strategic Plan 2008-13. Whangarei: Northland District Health Board; 2008.
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The tobacco industry and its products are an impediment to Māori development aspirations
and future driven goals. Māori tobacco related morbidity and pre-mature mortality rates
severely impacts on Māori economic development, health status and on the cultural
knowledge base for the next generations.
These morbidity and premature mortality rates have had a devastating impact on whanau,
the fundamental Maori social unit. This impact includes disruption to the growth and
development of tamariki and taitamariki who lose significant care giving adults from their
lives, including grandparents who traditionally have a vital role to play in child raising.
In addition to the emotional loss and trauma this causes, the whanau economic base is
undermined through meeting the financial cost of tobacco addiction and its subsequent
health effects. Northland households have among New Zealand’s lowest median incomes,
with tobacco addiction creating a drain on household budgets, especially food budgets.
The high rates of smoking among Maori women, our whare tangata, compromise the health
of our future generations pre-birth and in childhood. A baby carried by a smoking mother is
more likely to be born premature and/or low birthweight. In turn, low birthweight has life-long
consequences (e.g. increased risk of heart disease and diabetes in later life). Smoking
during pregnancy also raises the risk of Sudden Infant Death Syndrome (SIDS) once a child
is born. Ongoing exposure to tobacco smoke after birth makes a baby/child more likely to
suffer respiratory infections and asthma, glue ear, and learning and behavioural difficulties.
21, 21, 22
These factors impact greatly on a child’s development and success in life.
Transmission of intergenerational knowledge, including cultural knowledge is also negatively
impacted on due to the premature death or illness of those adults who could and should be
able to carry out kaumatua roles both within whanau and on marae.
Tobacco adds no value to whanau, hapu or iwi.
RECOMMENDATIONS
We believe that the Committee should recommend a comprehensive update of the
Smokefree Environments Act 1990 and other associated legislation to develop a series of
policies that will end the sale of smoked tobacco in New Zealand by the year 2020.
This will require controls on the supply of tobacco and significant price increases. Strong
supports for smokers who wish to quit should also be incorporated.
The following recommendations are presented with the intention to remove the supply of
tobacco from our communities.
· That tobacco supply is restricted using regulations and legislative measures with the
goal of eliminating tobacco by 2020
· Systematic and annual increases in tobacco taxation by 20% per annum increasing
the price for a pack of 20 cigarettes to $20 by 2015
21 DiFranza JR, Aligne CA, Weitzman M. Prenatal and postnatal environmental tobacco smoke exposure and children's health.
Pediatrics 2004;113(4):1007-15.
21 . Haustein KO. Cigarette smoking, nicotene and pregnancy. International Journal of Clinical Pharmacology and Therapeutics
1999;37(9):417-27.
22 Hofhuis W, de Jongste JC, Merkus PJ. Adverse health effects of prenatal and postnatal tobacco smoke exposure on children.
Archives of Disease in Childhood 2003;88:1086-1090.
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Removal of tobacco for supply
There is no discernible public benefit in allowing the tobacco industry to continue exploiting
Māori and non-Māori for profit. Smoking rates for Māori in New Zealand are unacceptably
high. Māori smoking prevalence has only dropped 5% in the last 15 years. There is a need
to restrict then eliminate tobacco for supply.
Annual consumption of tobacco has been steady since 2006 at just over 1,000 cigarettes per
adult (smoking and non-smoking), including both factory-made and roll-your-own cigarettes.
This compares with annual per adult consumption of about 3,200 in 1975, and 1,900 in
1990. 23
Recommendation 1: The introduction of a tobacco licensing system
Currently in New Zealand tobacco retailers and wholesalers can sell tobacco without a
license. However, an outlet that has been shown to sell tobacco to under-age customers can
be subject to a prohibited from selling tobacco, either temporarily or permanently. In practice
this sanction is very rarely applied.
The introduction of a tobacco licensing system that requires all retailers who wish to sell
tobacco should apply for a finite number of tobacco licenses annually. 24 Licensing can occur
for retailers, wholesalers or both. 25 Licensing potentially links tobacco control legislation
compliance with the right to sell tobacco products, and non-compliance (e.g., selling tobacco
to minors) with penalties.
Retailer licensing provides a means to improve the monitoring and control of tobacco
product supply and enforcement. Penalties can include fines, imprisonment and the
permanent or temporary withdrawal of the license to sell tobacco products, encouraging
retailers to comply, removing rogue retailers as well as potentially reducing outlet density.
The advantages of licensing have been summarised as: 25
- Providing health authorities with the addresses of sellers, and in the process:
- facilitating monitoring of their compliance with tobacco control laws
- enabling authorities to communicate directly with tobacco sellers (i.e., to educate and
inform them of changes to the law, etc)
- Providing a regulatory mechanism that allows conditions to be placed upon the manner
in which sales are made and a mechanism by which authority to sell can be revoked.
- Licensing fee set high enough to sufficiently fund an effective programme including
administration of the programme and enforcement efforts
Recommendation 2: The introduction of Plain Packaging for tobacco products
Tobacco packaging promotes the attractiveness of cigarettes. The introduction of plain
packaging would help reduce the attractiveness to and therefore uptake of smoking by
teenagers. 18 The tobacco industry knows that plain packaging will be effective in reducing
23 Ibid.
24 ASH Scotland. Tobacco licensing - a briefing paper. Edinburgh: ASH Scotland, 2008.
25 The Allen Consulting Group. Licensing of tobacco retailers and wholesalers: desirability and best practice arrangements. Sydney: The Allen
Consulting Group, 2002.
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tobacco sales. 26 Introducing plain packs are likely to protect Māori by reducing the
attractiveness of smoking. 27
Recommendation 3: That sales to minors (under age of 18-years) is strictly enforced.
In general, young smokers purchase tobacco themselves. 15–17 year olds were significantly
more likely to get their cigarettes or tobacco from their friends or family. Maori youth, 51
percent reported obtaining tobacco from family members, compared to 12 percent of non-
Maori. Nearly 60% of youth current smokers aged 15 to 17 years reported buying cigarettes
in the past month. 30 30
Two controlled purchase operations (CPO) were carried out in 2009, by the Northland DHB
Public & Population Health Unit, 62 tobacco retailers that were located within 1 km of
schools were visited. Over a quarter of retailers (27%) were found to be in breach of the
Smokefree Environment Act 1990. The decision to prosecute these retailers is still being
determined by the Ministry of Health.
Recommendation 4: That all tobacco displays are removed from point of sale by 2010.
Cigarette displays in retail outlets are a highly effective marketing tool. They create product
awareness, reinforce brand imagery, provide subliminal enticement and encourage sales.
We know that retail displays directly influence young people. Cigarette displays are a
particular issue for children. Research shows displays ‘normalise’ cigarettes for children and
trigger impulse purchases by what the tobacco industry calls ‘learner smokers’ – our
children. 28, 29 Year ten students who are exposed to retail displays more than three times a
week are three times more likely to become smokers 30 . Displays also have a negative
impact on smokers who are trying to quit.
In 2009 Northland DHB undertook educational visits to 49 tobacco retailers all located within
1 km of schools, 33 retailers (67%) were found to be in breach of the Smoke-free
Environments Act 1990 display restrictions. A ban on tobacco displays would make it easier
for retailers to comply with tobacco control laws.
Banning tobacco displays has public support, in 2008, 67% of New Zealanders supported a
ban on tobacco retail displays; 59% of all smokers supported this stance 31 . Over 80 percent
of submissions made during public consultation supported a complete ban on tobacco retail
displays 32 .
26 Beede PC, Lawson RW. Brand image attraction: the promotional impact of cigarette packaging. The New Zealand Family Physician 1991;Spring
1991:175-177.
27 Owen J. Wills New Zealand. [Letter from John Owen to D Bacon regarding copy of the tobacco control regulations]. 22 January 1993. British
American Tobacco. Bates No. 502610649-502610651. http://legacy.library.ucsf.edu/tid/tqs48a99
28 DiFranza, JR, Wellman, RJ, et al (2006) Tobacco promotion and the initiation of tobacco use: Assessing the evidence for causality. Pediatrics 17;
1237-1248
29 Feighery, EC, Ribisl, KM et al (2001) Cigarette advertising and promotional strategies in retail outlets: Results of a statewide survey in California.
Tobacco Control 10: 184-188
30 Paynter, J, Edwards R, Schluter, PJ, McDuff, I. Point of Sale Tobacco Displays and smoking among 14-15 year olds in New Zealand: a cross-
sectional study. Tobacco Control 2009: 18(4): 268-274
31 UMR Research Ltd. Cigarette displays omnibus results: Cancer Society of New Zealand, 2008.
32 Ministry of Health, Review of Tobacco Displays in New Zealand: Consultation Document and Summary of Results of the Consultation Document.
Wellington, MOH 2007
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Countries that have imposed a ban on tobacco retail displays report there has been no
substantive impact on retailers. Northland currently has 16 smokefree retailers, 7 no longer
sell tobacco products and 9 have remove their tobacco from display.
Recommendation 5: The prohibition of vending machines as per Framework
Convention on Tobacco Control (FCTC) Article 16 Sales to and by minors
Taxation
Taxation is the most effective tool in reducing consumption and youth uptake. A substantial
tax increase on tobacco has not been introduced in New Zealand since 2000.
There is a clear inverse relationship between tobacco taxes and tobacco consumption. For
every 10% increase in excise tax, there is up to 5% reduction in consumption 33 . What’s
more, youth, minorities and low-income smokers, including Maori, have been seen to
respond more than other groups of smokers to this type of tobacco control measure.
Recommendation 6: Tobacco tax will be equalized for roll your own and factory made
cigarettes in 2010
73% of Maori smokers use roll-your-own tobacco. 34 Why? Because loose tobacco is taxed
lower than ‘tailor-made’/ manufactured cigarettes. This provides smokers with a cheaper
tobacco product to buy.
Youth aged 15- to 17-year-olds are more likely to smoke roll-your-own cigarettes than 18- to
19-year-olds. A key difference between these groups is that it is illegal to sell tobacco
products to 15- to 17-year-olds. The most common reason given for smoking roll-your-own
cigarettes among 15- to 17-year-olds was that they were cheaper than manufactured
cigarettes. 35
Recommendation 7: That a dedicated tax, from the existing tobacco taxation revenue
be established in 2010.
New Zealand’s tobacco excise tax is not tied to funding for tobacco control or health-related
activities. Māori specific Cessation services/programmes receive approximately $8M from
the $40M budget. Māori smokers contribute over $250M of the $1B collected in tobacco tax
each year. Funding for further Cessation services/programmes can be sourced by
implementing a dedicated tax similar to three health-related dedicated taxes for alcohol,
accident and gambling control.
The dedicated tax is to be used to fund services/programmes ranging from health promotion
programmes, enforcement, cessation/quit services, research and advocacy services. A
substantive budget increase that truly reflects the disproportionate negative impact tobacco
use has on Māori is required.
Recommendation 8: Increase tobacco tax annually, from 2010, by 5%
33 Tobacco Atlas
34 The Quit Group and the Ministry of Health. 2009. Maori Smoking and Tobacco Use 2009. Wellington: Ministry of Health.
35 Ministry of Health. 2009. Tobacco Trends 2008: A brief update of tobacco use in New Zealand. Wellington: Ministry of Health
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Increase tobacco tax annually, from 2010, by 5% as recommended by the World Bank 36 and
the World Health Organization (WHO) 37 along with the current annual CPI adjusted
increases.
Recommendation 9: Introduction of legislation to ban smoking in cars carrying
children
Cars are settings in which children are most likely to be exposed to the highest levels of
second-hand smoke (SHS), where children have no easy way of avoiding it. 38
The main focus of activities has been on promoting voluntary smokefree cars through mass
media campaigns and relying on knowledge and attitude to change behaviour.
In New Zealand, 14.39% of people reported others smoking inside the car. 39 Significantly
more Maori reported others smoking in car (30.1%) than non-Maori (12.6%). 39
In a 1997 Wellington survey, 94% agreed that cars with children in them should be
smokefree (86% of smokers). 40
In a 2004 New Zealand wide survey, 76% disagreed that it
is ‘okay’ to smoke around non-smokers inside cars even when there are windows down. 41
Between March 2007 and February 2008 New Zealand adults over 18-years who smoked
were surveyed asking, ‘do you think smoking should be allowed in cars with pre-school
children in them?’ 95.9% disagreed. 42
These results indicate that there is strong support for New Zealand Government intervention
to protect children from effects of second-hand smoke in cars. There is strong scientific
evidence from overseas and New Zealand studies showing that smoking bans and
restrictions are effective. 43 Why is New Zealand lagging behind 11 states and provinces in
Australia, Canada and the USA, which have all passed laws to protect their children from
smoking in cars? 38
Additional Recommendations
The Smoke-free Environments Act 1990 be extended to include:
· Parks, playgrounds, national and regional Parks.
· Sports grounds and stadia.
· All outdoor events
· Corrections facilities.
· Tertiary educational facilities.
· Motor vehicles transporting tamariki.
· District Health Board premises.
36 World Bank, Curbing the Epidemic: Governments and the Economics of Tobacco Control. 1999.
37 World Health Organization. http://www.who.int/tobacco/mpower/facts_findings/en/index.html 2009.
38 Thomson, G. Wilson, N. 2008. Public attitudes to laws for smokefree private vehicles: A brief review. Tobacco Control published online 3 December
2008; doi:10.1136/tc.2008.027672
39 Ministry of Health. 2007. New Zealand Tobacco Use Survey 2006. Wellington: Ministry of Health
40 Al-Delaimy W, Luo D, Woodward A, Howden-Chapman P. Smoking hygiene: a study of attitudes to passive smoking. N Z Med J
1999;112(1081):33-6
41 Gillespie J, Milne K, Wilson N. Second-hand smoke in New Zealand homes and cars: exposure, attitudes, and behaviours in 2004. N Z Med J.
2005;118(1227). http.//www.nzma.org.nz/journal/118-1227/1782
42 Thomson G, Wilson N, Weerasekera D, Edwards R. 2008. Ninety-six percent of New Zealander smokers support smokefree cars containing
preschool children. NZMJ 7 November 2008, Vol 121 No 1285; ISSN 1175 8716 URL: http//www.nzma.org.nz/journal/121-1285/3358/
43 Ministry of Health. 2004. Clearing the Smoke: A five-year plan for tobacco control in New Zealand (2004 – 2009). Wellington: Ministry of Health.
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· Outdoor and Al fresco dining facilities.
· Within 10-meters of doorways and entrances to all buildings.
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