Richard Edwards on behalf of the Smokefree Amendment Act Evaluation Team

1. The impact of the 2003 Smokefree Legislation on Māori Richard Edwards on behalf of the Smokefree Amendment Act Evaluation Team Health Promotion and Policy Research Unit (HePPRU) Department of Public Health University of Otago, Wellington richard.edwards@otago.ac.nz

2. Richard Edwards George Thomson Nick Wilson Andrew Waa Chris Bullen Des O’Dea Heather Gifford Marewa Glover Murray Laugesen Alistair Woodward After the Smoke has Cleared: Evaluation of 2003 Smoke-free Environments Amendment Act Available on : http://www.moh.govt.nz/

3. Acknowledgements • Ministry of Health • Health Sponsorship Council • ASH New Zealand • Quit Group • Kamalesh Venugopal, University of Otago

4. Outline • Context and provisions of 2003 Smokefree Environments Amendment Act (SEAA) • Evaluation design and methods • Results of evaluation • Attitudes towards and support for SEAA • Māori stakeholder views about SEAA and implementation process • SHS exposure in the workplace • SHS exposure in the home • Smoking prevalence and behaviours • Implications and discussion

5. Background • Smokefree legislation is increasingly implemented around the world • Evaluation is generally positive • e.g. legislation is generally popular, compliance is high, air quality is improved and exposure to SHS reduced • The impact of the legislation on indigenous and ethnic minority groups has been little explored

6. What did the SEAA do? • Introduced in Dec 2003, but most provisions implemented in Dec 2004 • Smokefree provisions of SEAA 2003: • all schools and early childhood centres from (1/1/2004) • nearly all other indoor workplaces from 10th December 2004, including bars, casinos, members’ clubs and restaurants • smoking allowed in outdoor ‘open’ areas, including where semi-enclosed (complex definition) • partial exemptions e.g. prisons, hotel and motel rooms, residential establishments • NB Extended existing restrictions introduced in the 1990 Smoke-free Environments Act (indoor public facilities, most shared offices, partial restrictions in meal serving areas)

7. What were the guiding principles? • None in the SEAA • Derived from various strategy documents: • promote equity in health by improving health among groups disproportionately affected by tobacco smoking and SHS exposure, such as Māori, Pacific Island peoples, and low income groups. • congruence with the principles and provisions of Treaty of Waitangi • Founding document of NZ and basis for relationship between Crown and Iwi • Ensuring Māori participation, active protection of Māori interests and reduction of inequalities between Māori and non-Māori (He Korowai Oranga – Māori Health strategy, 2002)

8. Māori population in New Zealand • Māori are the indigenous people of New Zealand),15.3% of NZ population • Smoking rates among Māori women are among the highest in the world • Adult smoking prevalence in New Zealand was 24.1% in men and 22.9% in women in 2006, but among Māori was 50.6% among women and 40.7% among men • Smoking rates are reflected in adverse health effects including very high rates of lung cancer mortality

9. Process and outcome indicators • Process and short term outcome indicators: • Public and stakeholder attitudes and support for smokefree policies • Dissemination of information, participation, enforcement activities and compliance monitoring • Core intermediate and long-term outcome indicators: • Exposure to SHS in the workplace (principal outcome measure) • Health impacts attributable to active smoking and SHS exposure • Non-core intermediate and long-term outcome indicators: • Exposure to SHS in public places and private places such as homes • Smoking prevalence and smoking-related behaviours • Economic impacts

10. Process and outcome indicators • Process and short term outcome indicators: • Public and stakeholder attitudes and support for smokefree policies • Dissemination of information, participation, enforcement activities and compliance monitoring • Core intermediate and long-term outcome indicators: • Exposure to SHS in the workplace (principal outcome measure) • Health impacts attributable to active smoking and SHS exposure • Non-core intermediate and long-term outcome indicators: • Exposure to SHS in public places and private places such as homes • Smoking prevalence and smoking-related behaviours • Economic impacts

11. Methods • Multifaceted evaluation • Identification, review and additional analysis of existing data sources • Specially commissioned studies for additional evidence • In-depth interviews with key stakeholders • Air quality studies in the hospitality industry and other settings • Trends in hospitalisation data to explore health impacts

12. HSC Monitor Surveys (2003-6): Nationally representative telephone surveys with 2-2500 adults aged > 14 yrs Boosted Māori population sample of 900 (500 in 2003) Analysis weighted to the age, sex and ethnicity distributions of 2001 census ASH Year 10 Survey (1999-2006) National questionnaire survey of 14-15 yr old children with > 30,000 participants (70% of eligible students) Interviews with Māori stakeholders Qualitative study with 8 Māori stakeholders (part of a larger study for the SEAA evaluation) National Quitline data Number of calls and NRT vouchers issued to callers New Zealand Tobacco Use Survey Nationally representative interview surveys of 5700 adults aged 15-64 yrs Data sources

13. Public attitudes towards and support for smokefree policies HSC Monitor Surveys • Larges increases in support for SEAA and underlying principles among Māori and non- Māori smokers and non-smokers before and after SEAA implementation • E.g. support for right of bar workers to work in a smokefree environment increased between 2003-6 from 84% to 93% in non-Māori and from 57% to 83% among Māori respondents

14. Support for bans on smoking in restaurants and bars before and after implementation of the Smokefree Environments Amendment Act Source: HSC Monitor Surveys Key: Support defined as those who strongly agreed or agreed with a ban on smoking in each setting

15. Experiences & attitudes of Māori stakeholders to implementation of the SEAA Methods • In depth qualitative interviews • Purposively selected interviewees • 4 key personnel in Māori health/tobacco control NGOs • DHB public health manager involved with implementation of SEAA • Māori smoking cessation worker/consultant • Union official • Bar manager

16. Experiences & attitudes of Māori stakeholders to implementation of the SEAA (cont) Results • Mostly very positive and supportive of the SEAA and its implementation • Perception that SEAA was mostly supported by Māori and had had positive impacts on Māori communities and smokers • Māori health worker interviewees argued sufficient information and support available for implementation • SEAA had enabled a new level of discussion among Māori communities about issues like smokefree homes and introducing tobacco control policies

17. Experiences & attitudes of Māori stakeholders to implementation of the SEAA (cont) Results (cont) • Some dissent from this positive view, focusing on: • Lack of information about the changes • Failure to include maraes in smokefree legislation • Continued role modelling of smoking to children, exacerbated by increased smoking outside

18. Exposure to SHS in the workplace (principal outcome measure)

19. Secondhand smoke exposure indoors at work in previous week by ethnicity Source: HSC Monitor Surveys

20. Exposure to SHS in private places such as homes HSC Monitor Surveys (2003-6) • Steady increase in proportion of homes reported as smokefree among Māori and non-Māori, and reduction in self-reported smoking in home in last week • Smoking in home more common among Māori households but decrease in absolute difference ASH Year 10 surveys (2001-6) • Less marked decrease in smoking in the home reported with similar decreases among Māori and non-Maori • Smoking in home reported more commonly by Māori students (40% vs 25% for all students in 2006) Tobacco Use Survey(2006) • 70.3% of Māori vs 85.1% of non-Māori respondents reported no smoking occurring in the home

21. Source: ASH Year 10 Surveys

22. Source: HSC Monitor Surveys

23. Source: HSC Monitor Surveys

24. Smoking and smoking-related behaviours • Little evidence of impact of SEAA on smoking prevalence, smoking among Māori remains very high (46% in 2006) • For 6 mnths after SEAA implementation in Dec 2004, evidence of increased caller registrations and issuing of NRT vouchers through Quitline • Proportion of calls to the Quitline by Māori throughout 2002-6, and including the 6 mnths after SEAA implementation of the SEAA, was around 20% • Socially-cued smoking in hospitality settings declined substantially between 2003-4 and 2005-6, and among Māori and non-Māori to a similar degree

25. Smoking prevalence in NZ, 1985-2006

26. Socially cued smoking (% reporting smoking > normal) when visiting bars & nightclubs Source: HSC Monitor Surveys

27. First in-depth data on the impact of smokefree legislation on an indigenous population Findings of SEAA evaluation mostly very positive, with positive results generally mirrored among Māori Smoking and SHS exposure among Māori remains a priority public health issue Some limitations e.g. quanitative data for impact on Māori in economic analysis Limited data on acceptability of implementation and participation was mostly supportive Can’t assume that findings are generalisable to other indigenous peoples Evaluation of tobacco control interventions like smokefree legislation should include an assessment of impact on indigenous and minority communities Conclusions