Document Detail

What potential has tobacco control for reducing health inequalities? The New Zealand situation.
Jump to Full Text
MedLine Citation:
PMID:  17081299     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
In this Commentary, we aim to synthesize recent epidemiological data on tobacco and health inequalities for New Zealand and present it in new ways. We also aim to describe both existing and potential tobacco control responses for addressing these inequalities. In New Zealand smoking prevalence is higher amongst Māori and Pacific peoples (compared to those of "New Zealand European" ethnicity) and amongst those with low socioeconomic position (SEP). Consequently the smoking-related mortality burden is higher among these populations. Regarding the gap in mortality between low and high socioeconomic groups, 21% and 11% of this gap for men and women was estimated to be due to smoking in 1996-99. Regarding the gap in mortality between Māori and non-Māori/non-Pacific, 5% and 8% of this gap for men and women was estimated to be due to smoking. The estimates from both these studies are probably moderate underestimates due to misclassification bias of smoking status. Despite the modest relative contribution of smoking to these gaps, the absolute number of smoking-attributable deaths is sizable and amenable to policy and health sector responses. There is some evidence, from New Zealand and elsewhere, for interventions that reduce smoking by low-income populations and indigenous peoples. These include tobacco taxation, thematically appropriate mass media campaigns, and appropriate smoking cessation support services. But there are as yet untried interventions with major potential. A key one is for a tighter regulatory framework that could rapidly shift the nicotine market towards pharmaceutical-grade nicotine (or smokeless tobacco products) and away from smoked tobacco.
Authors:
Nick Wilson; Tony Blakely; Martin Tobias
Related Documents :
11720409 - Smoking among asian american and hawaiian/pacific islander youth: data from the 2000 na...
14768739 - Environmental tobacco smoke and the risk of pancreatic cancer: findings from a canadian...
982079 - Tobacco and tobacco smoke.
21566789 - The relationship of opium addiction with coronary artery disease.
9232339 - Effects of indole-3-carbinol on the metabolism of 4-(methylnitrosamino)-1-(3-pyridyl)-1...
18165219 - Prevention of tobacco use among medically at-risk children and adolescents: clinical an...
18276959 - The prevalence of dementia in an urban turkish population.
23530609 - The impact of body mass index on maternal and neonatal outcomes: a retrospective study ...
17274739 - Nine-year trends and racial and ethnic disparities in women's awareness of heart diseas...
Publication Detail:
Type:  Journal Article     Date:  2006-11-02
Journal Detail:
Title:  International journal for equity in health     Volume:  5     ISSN:  1475-9276     ISO Abbreviation:  Int J Equity Health     Publication Date:  2006  
Date Detail:
Created Date:  2006-11-22     Completed Date:  2007-07-09     Revised Date:  2009-11-18    
Medline Journal Info:
Nlm Unique ID:  101147692     Medline TA:  Int J Equity Health     Country:  England    
Other Details:
Languages:  eng     Pagination:  14     Citation Subset:  -    
Affiliation:
Department of Public Health, Wellington School of Medicine and Health Sciences, Otago University, PO Box 7343 Wellington South, New Zealand. nwilson@actrix.gen.nz
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Descriptor/Qualifier:
Comments/Corrections

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Int J Equity Health
ISSN: 1475-9276
Publisher: BioMed Central, London
Article Information
Download PDF
Copyright ? 2006 Wilson et al; licensee BioMed Central Ltd.
open-access: This is an Open Access article distributed under the terms of the Creative Commons Attribution License (), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received Day: 17 Month: 5 Year: 2006
Accepted Day: 2 Month: 11 Year: 2006
collection publication date: Year: 2006
Electronic publication date: Day: 2 Month: 11 Year: 2006
Volume: 5First Page: 14 Last Page: 14
ID: 1654162
Publisher Id: 1475-9276-5-14
PubMed Id: 17081299
DOI: 10.1186/1475-9276-5-14

What potential has tobacco control for reducing health inequalities? The New Zealand situation
Nick Wilson1 Email: nwilson@actrix.gen.nz
Tony Blakely1 Email: tony.blakely@otago.ac.nz
Martin Tobias2 Email: martin_tobias@moh.govt.nz
1Department of Public Health, Wellington School of Medicine and Health Sciences, Otago University, PO Box 7343 Wellington South, New Zealand
2Ministry of Health, PO Box 5013, Wellington, New Zealand

Background

As for other countries, the distribution of disease burden in New Zealand is far from equal [1-4]. In particular, there are much higher rates of premature death and of serious chronic diseases for the poorest New Zealanders, for M?ori (the indigenous people of New Zealand), and for Pacific peoples living in this country. M?ori adult mortality rates are at least twice those of non-M?ori in New Zealand. Such inequitable patterns are a concern for the government and the health sector for the ethical reason of ensuring justice but also because the New Zealand Government is committed to improving M?ori health under the obligations of the Treaty of Waitangi (signed in 1840 between the British Crown and M?ori chiefs). In particular, Article Three of this Treaty translates into an obligation for Crown agencies to work to ensure that M?ori citizens enjoy the same rights as others, including the right to good health. Section 8 of the New Zealand Public Health and Disability Act (2000), specifically requires health services to recognize the principles of the Treaty of Waitangi [5].

Other arguments for reducing health inequalities are less prominent in the New Zealand discourse, but include the benefits of enhancing overall public health and social cohesion and the resultant economic benefits. The latter may arise from preventing premature deaths among workers and reducing productivity losses associated with worker illness.

Given these issues, we aimed to synthesize recent epidemiological data on tobacco and health inequalities for New Zealand, and to present it in new ways. We also aimed to describe existing and potential tobacco control responses for addressing these inequalities. Our focus is on socioeconomic and ethnic health inequalities, and we leave other inequalities (eg, gender, regional) to other forums.


Social and ethnic patterning of tobacco use in New Zealand

Many international studies provide strong evidence that smoking prevalence is patterned by socioeconomic position (SEP) [6-10], and the same is true in New Zealand [1,11,12]. There is also evidence that smoking prevalence in this country has become more strongly patterned by SEP over time [11,12]. One reason for this is that the uptake of smoking by young people has declined more steeply amongst those in the highest income level over recent decades [13]. M?ori and Pacific peoples have a higher smoking prevalence than non-M?ori/non-Pacific, partly reflecting relative socioeconomic disadvantage.

Another reason for the increase in the SEP patterning of smoking over time is probably because the quit rates among higher-SEP New Zealanders have increased more than for other groups [13]. The difference in quit rates by SEP may be due to such factors as: (i) the impact of educational level on knowledge of tobacco risks and motivation and knowledge of how to quit; (ii) economic barriers to quitting technologies (eg, the price of nicotine replacement therapy was fairly high until recently and there are still cost barriers for some pharmaceutical aids such as bupropion); and (iii) differential levels of social and other support for quitting. With the latter for example, second-hand smoke exposure is higher in low-income groups [14] and for M?ori [14,15]. Also, the first major smokefree law (in 1990) benefited office workers more than factory workers in terms of reducing exposure to second-hand smoke [16].


Studies on tobacco and health inequalities in New Zealand
Lung cancer as a marker of historic tobacco exposure

Lung cancer is the cause of death that most directly reflects the (historic) burden of smoking. Figure 1 shows lung cancer mortality rates by ethnicity and household income, for the 1980s and 1990s, as calculated from the New Zealand Census-Mortality Study (NZCMS) that uses linked census and mortality datasets covering millions of person-years of observation [17]. Lung cancer mortality rates among M?ori were over four times the non-M?ori/non-Pacific rate for women and over three times for men (for 1996?1999). The rates for Pacific people were also relatively high (at over 2 times for men and 1.4 times for women, compared to non-M?ori/non-Pacific). Over the same 1981?1999 time period, the inequality in male lung cancer mortality rates by household income persisted despite a decline in deaths in all income groups. However, in women there was a large increase among the low-income group compared to a decrease among the high-income group. Over this time period there was also an overall increase in ethnic inequalities in mortality rates from lung cancer (in both men and women). The authors of this study concluded that these inequalities will probably widen in future decades ? unless there is concerted public health action. All these patterns are consistent with differently phased tobacco epidemics [18] by ethnicity and SEP, resulting in changing inequalities in lung cancer over time.

The very large inequalities in lung cancer mortality by ethnicity are probably greater than would result alone from historically (still large) differences in smoking prevalence, pointing to other independent, and likely interacting, risk factors. These may include such factors as: varying passive smoking exposure [14,15], environmental pollution exposure [19] and hazardous occupational exposure such as from asbestos [20]. Diet may also be relevant to this differential (eg, given evidence around fruit intake lowering lung cancer risk [21]) and so might genetics given some New Zealand evidence for variability in nicotine metabolism by ethnicity [22].

Differential survival, due to differential access to care and more advanced stage at presentation will also contribute to ethnic inequalities in lung cancer mortality. M?ori are more likely than non-M?ori to have lung cancer identified at a later stage and have a lower survival rate after diagnosis [23]. Possible factors involved include access to specialised cancer services and the quality of care received [24].

The contribution of active tobacco smoking to mortality burden within ethnic and socioeconomic groups, and the mortality gap between these groups

The NZCMS includes active smoking data for the 1981?84 and 1996?99 cohorts, allowing direct estimations of the active smoking-related burden within and between social groups. The measure of smoking is simply "never", "ex-" and "current" smokers, meaning there will be inevitable misclassification biases of smoking that probably lead to modest underestimates of the contribution of active smoking.

Table 1 shows population-attributable risk percents (PAR%) for 45?74 year olds in 1996?99 from NZCMS output. They are the percentage reduction in all-cause mortality that might be expected if, in a counterfactual world, all people who were either current or ex-smokers had actually been "never" smokers. Because of slightly (and necessarily) different methods between the ethnic and educational group analyses (see footnotes to Table 1), they are not fully comparable. Nevertheless, they do robustly point to the following conclusions:

? active smoking is a major contributor to all-cause mortality in all educational and ethnic groups,

? about a quarter of 45?74 year old all-cause mortality in each educational group is due to active smoking. This figure is slightly higher in lower educational groups, and slightly less in higher educational groups,

? about a third of 45?74 year old all-cause mortality among non-M?ori/non-Pacific is due to smoking. This figure is slightly higher among males, and slightly less among females,

? a fifth to a quarter of 45?74 year old all-cause mortality among M?ori is due to smoking.

These above estimates for M?ori are less than expected based on previous Ministry of Health estimates that a third of all M?ori deaths (not just 45?74 year olds where a greater proportion of deaths will be due to smoking than at other ages) are due to tobacco [25]. There are two key reasons why the more recent Ministry of Health estimates for M?ori are likely overestimates. First, other recent work from the NZCMS finds that the relative risk of death associated with tobacco use varies by ethnic group and over time [26]. All-cause rate ratios (RRs) for mortality associated with smoking were significantly greater within non-M?ori/non-Pacific than within M?ori: 2.22 compared to 1.51 respectively for men, and 2.20 compared to 1.45 respectively for women (for 1996?99). One of the likely reasons for this rate ratio heterogeneity is the greater role of competing non-tobacco causes of mortality among M?ori and Pacific peoples. But other factors may also be relevant eg, different patterns of what cigarettes are used and how they are smoked. Second, the Ministry of Health estimates have used the standard WHO/Peto methodology whereby lung cancer mortality rates are used to estimate the total mortality impact of smoking. However, as mentioned above, M?ori lung cancer mortality rates are higher than would be expected on the basis of tobacco smoking alone, which would lead the WHO/Peto method to overestimate the total tobacco-related mortality burden among M?ori.

What of the contribution of smoking to gaps in mortality between ethnic and socioeconomic groups? Poisson regression analyses adjusting for smoking reduced the all-cause mortality RRs for men with nil educational qualifications compared with men with post-school qualifications from 1.34 to 1.29 in 1981?84 and from 1.31 to 1.25 in 1996?99. This equated to 16% and 21% reductions in relative inequalities respectively. The equivalent results for women were 3% and 11% reductions in relative inequalities for these time periods. Such higher mortality rates for men and women with poorer education were due to the impact of smoking on cardiovascular, cancer and respiratory deaths. The patterns identified in this study were considered to reflect the historically differential phasing of the tobacco epidemic by sex and SEP.

The most recent NZCMS study on smoking examined its contribution to ethnic inequalities in mortality [27]. It found that the apparent contribution of smoking to mortality differences between M?ori and non-M?ori/non-Pacific was greatest for women in 1996?99 (8% reduction in standardised rate difference), and had increased from 1981?84 to 1996?99 for both men (from -1% to 5%) and women (from 3% to 8%). That is, the contribution of smoking to ethnic gaps (in percentage terms) is notably less than for socioeconomic gaps. But a fuller understanding of this requires also considering the actual underlying mortality rates.

Figure 2 attempts to pull together the above findings for 1996?99, and addresses the need to consider absolute mortality rates and absolute differences in mortality rates (as well as relative risks and percentage contributions). It shows actual mortality rates by ethnicity and education (partitioned by the proportions estimated to be smoking- and non-smoking related). A floating column representing the gap in mortality rates is included (again partitioned into smoking and non-smoking-related components). The figure should be considered indicative only. There are unavoidable differences in methodology between: the ethnic versus educational analyses as stated above; the determination of PAR% within ethnic and socioeconomic group versus the percentage contributions to gaps between ethnic and socioeconomic groups; and standardisation versus regression methodologies for different components of analysis behind the figure. Nevertheless, there are a number of robust findings:

? mortality rates for M?ori are 2?3 times greater than non-M?ori/non-Pacific, compared to an approximately 40% higher mortality for people with no qualifications compared to post-school qualifications;

? in absolute terms, the mortality rate attributable to smoking among both M?ori and less educated groups is considerably greater than among non-M?ori/non-Pacific and post-school educated people, respectively ? a different perspective from considering the PAR% estimates in isolation;

? in absolute terms, the gap in mortality rates between ethnic groups attributable to smoking is as great or greater than between educational groups ? a different perspective from considering just the percentage contribution to gaps.

As mentioned already, the estimates above are likely to be modest underestimates due to likely non-differential misclassification bias of smoking status. The analyses did not include the impact of exposure to second-hand smoke, which is more common among M?ori and lower socioeconomic groups [14,15]. This would mean that percentage contributions of active and passive smoking combined to mortality are probably greater than given above. Figure 2 also clearly demonstrates that ethnic gaps in mortality not explained by smoking are much greater than socioeconomic gaps in mortality not explained by smoking. This points to other determinants of health (eg, differential access to health services, racism) that must be more important for ethnic inequalities than socioeconomic inequalities in health.


What can be done to reduce health inequalities from tobacco in New Zealand?

Despite the apparently modest relative size of these tobacco-related gaps, their absolute magnitude means that eliminating them would still be very worthwhile. Reducing these tobacco-related gaps may also be achievable given the strong evidence base for traditional tobacco control interventions and the evidence supporting their cost-effectiveness [28,29]. Nevertheless, many other options for reducing health inequalities could still be progressed at the same time, including: more equitable income redistribution in New Zealand [30], improvements in educational levels, housing policies, policies to reduce unemployment and improving access to and through health services for low-income New Zealanders (eg, see Figure 3). Community-level interventions to enhance trust and promote safe environments have also been suggested for reducing inequalities and lowering smoking ? given evidence that low social capital may be independently associated with higher smoking prevalence [31]. Improving work conditions may also be relevant to reducing tobacco use disparities, given United States work in this area [32].

These actions would also probably help reduce ethnic inequalities in health, as (presumably) the type of mechanisms on the pathway from ethnicity to health are similar to those for the pathways from SEP to health (Figure 3). The important differences, though, are the role of racism and ethnicity and the mix of pathway mechanisms (eg, access to health services may be more relevant to ethnic inequalities in New Zealand [23,24]). Reducing discrimination could potentially assist in reducing smoking rates if the psychosocial stress associated with discrimination contributes to smoking given the New Zealand data on the adverse impacts of racism on health [33,34]. Also, more specific measures are required to continue to address past injustices (eg, through the Waitangi Tribunal). Fortunately, there is evidence that gaps between M?ori and non-M?ori are starting to decline for health, employment, educational and income achievement [4,35,36]. This may partly reflect specific policy initiatives and/or be an outcome of broad economic and social trends.

The need to reduce health inequalities attributable to smoking is recognised in the Ministry of Health's five-year plan for tobacco control which has specific targets for such inequalities [37]. Some of the specific interventions that could be considered are detailed below and some of these are already included in the Ministry of Health's plan:

Enhanced tobacco regulation

There have been arguments in the New Zealand context for having a Tobacco Authority type agency [38] with a public health mandate to control the marketing of tobacco. This approach has also been proposed by others internationally [39,40]. Such an agency could allow the nicotine market to be realigned to strongly favour (in terms of price and availability) pharmaceutical-grade nicotine, over smoked forms of tobacco. Such a market could also favour reduced-harmed tobacco products such as nasal or oral snuff, though the idea of health sector endorsement of such a market is controversial in New Zealand. Nevertheless, a switch to snuff could plausibly facilitate reductions in overall harm to the health of users [41,42] and facilitate quitting [43,44] and therefore health inequalities attributable to tobacco use. Any shift to smokeless forms of nicotine or tobacco would also be likely to reduce the health inequalities associated with different levels of exposure to second-hand smoke. A key aspect for maximising the impact for reducing inequalities would be the extent to which the price differential could be managed given the suggestive evidence that low-income and M?ori populations are more price sensitive (see the discussion around taxation below). This shift to alternate forms of nicotine or tobacco could also be accelerated by increasingly tight restrictions and raising the price of smoked tobacco.

In the long-term however, if a large proportion of low-income New Zealanders remained dependent on pharmaceutical nicotine or snuff ? then this could still represent a drain on their financial resources (if the price was not kept relatively low). Such issues could be further explored by modelling work and studies on the price elasticities and acceptability of these alternative nicotine products to low-income New Zealanders.

Finally, enhancing tobacco regulation will inevitably be a political decision. Debate and discussion is therefore essential not only among the tobacco control community, but also politicians and the public at large. It is imperative that tobacco control advocates reinforce at all times that ridding New Zealand of tobacco smoking will benefit all sectors of society, and reduce inequalities ? a win-win situation.

Substantially enhanced comprehensive tobacco control policy

New Zealand could more intensively pursue all the key components of a comprehensive tobacco control programme (eg, tax policy, smokefree environments, and smoking cessation support ? as detailed below). All these could be funded by increasing the relatively low level expenditure on tobacco control, currently less than 3% of tobacco tax revenue [45]. Added to these interventions could be litigation against the tobacco industry by government and a more strongly industry-focused approach to tobacco control [46].

Tobacco taxation policy

There is some international evidence that tobacco taxes are relatively more effective in reducing tobacco consumption among low-income or poorly educated populations [47-49]. There are also some New Zealand data to support this differential benefit for low-income groups and M?ori [50,51]. Other New Zealand modelling work [52] provides some justification for tobacco taxation, as it indicates that the harm from smoking for low-income New Zealanders greatly exceeds the likely harm from financial hardship that is associated with the tax. Despite this, there is concern regarding the potential for increased economic hardship (with subsequent impacts on health) among low-income groups from increased tobacco taxation in the future. If tobacco taxes were to be increased, it would be necessary and ethical [53] for a greater proportion of the tax revenue to be used for smoking cessation support, especially for M?ori, Pacific and low-income New Zealanders. Indeed, this country previously introduced a programme of providing heavily subsidised nicotine replacement therapy in the year of the last tax increase (ie, 2001).

Smokefree environments

In late 2004 a new smokefree law came into effect in New Zealand and the evidence to date is that it is working well [54-56]. This law covers all indoor workplaces and hospitality settings which suggests that it should reduce exposure to second-hand smoke among low-income workers and patrons of venues such as bars, clubs, and casinos. In addition, recent government-funded mass media campaigns may be contributing to increasing smokefree homes among low-income families (though post-campaign follow-up data have not yet been published). There is some indirect evidence for benefit from such campaigns internationally on smokefree homes [57].

The prevalence of smoking in cars amongst people from more deprived areas in New Zealand is significantly higher than less deprived areas [58]. While some campaigns have incorporated the hazard from smoking in cars in New Zealand, these have been of low intensity. Nevertheless, laws have now been passed in other jurisdictions (eg, Arkansas, Louisiana and Puerto Rico) and this approach could be considered in New Zealand.

Mass media campaigns (smoking cessation)

There is evidence that mass media campaigns (both generic and those designed by M?ori) are effective in stimulating calls to the national Quitline from M?ori and other low-income New Zealanders who are the priority audiences for this service [59,60]. Evaluation work has also shown that culturally appropriate mass media campaigns are regarded as acceptable to a M?ori audience [61,62]. A recently launched media campaign with a Pacific peoples focus [63] has also successfully stimulated increased call rates to the Quitline [Personal communication, Helen Glasgow, Director Quit Group, 28 March 2006].

Smoking cessation services

The national free-phone Quitline service has been successful in reaching a M?ori audience [60,64]. The popular uptake of heavily subsidised smoking cessation services provided via the Quitline [65] also suggests that it is reaching low-income New Zealanders. However, the idea of building long-term relationships with smokers and recruiting them as volunteers to promote smoking cessation services [66] has yet to be tried in this country.

Culturally appropriate smoking cessation services such as the Aukati Kai Paipa services for M?ori women have been evaluated and found to be acceptable and effective [67]. New Zealand has also had some success with running quit and win contests [68] which may differentially appeal to low-income smokers (although this aspect has not been studied). A randomised controlled trial of bupropion for M?ori smokers has reported successful smoking cessation outcomes in this population [69].

Other countries are also trying to reduce health inequalities associated with tobacco. A review of 16 studies that aimed to reduce smoking in low-income groups found that half of these had demonstrated effectiveness [70]. Out of another nine studies that were not actually targeted at low-income groups, in five of these the intervention was at least as effective in low as in high-income groups. Nevertheless, in four of the studies, including one New Zealand study [71], the intervention was less effective for those in low-income groups. In particular, there is evidence from the United Kingdom that smoking cessation services are reaching disadvantaged communities [72], that the services to such communities are qualitatively better [73], and that these services are reducing inequalities in smoking prevalence rates [74].


Conclusion

There is extensive evidence that demonstrates that smoking prevalence is higher amongst those with low socioeconomic position (SEP), and M?ori and Pacific peoples (compared to those of "New Zealand European" ethnicity) in the New Zealand setting. There are also many studies that indicate that the health burden attributable to tobacco is higher amongst these populations and that the associated relative health inequalities appear to be increasing. The estimated contributions of smoking to inequalities in mortality by SEP and ethnicity stand out relative to the many other drivers of health inequalities (ie, at 21% for SEP in men, and 8% for ethnicity in women). This should make the tobacco contribution worthy of the attention of policymakers, especially given the evidence for the effectiveness and cost-effectiveness of tobacco control interventions. Another reason for attention to this role for tobacco is the likelihood that, under business as usual, tobacco will probably grow in importance as a contributor (in relative terms) to health inequalities. Besides the ethical arguments for reducing inequalities to achieve justice, there are additional arguments in New Zealand for such actions. These include obligations under the Treaty of Waitangi for the government and the health sector and the need to address past harms associated with colonisation.

There is some evidence from New Zealand and elsewhere for health sector actions that reduce smoking by low-income populations and indigenous peoples. These include tobacco taxation, thematically appropriate mass media campaigns, and appropriate smoking cessation support services. There is however, major scope for improvements in tobacco regulation and better resourcing of a more intensive and comprehensive tobacco control programme in this country. In particular, there is potential for a tighter regulatory framework that could rapidly shift the nicotine market towards pharmaceutical-grade nicotine (or smokeless products such as snuff) and away from smoked tobacco.

Disclaimer: The views of the authors do not necessarily reflect the views of their employing organisations ? including the New Zealand Ministry of Health.


Competing interests

The author(s) declare that they have no competing interests.


Authors' contributions

This article was conceived by TB and MT. The first draft was written by NW and TB. All authors contributed to subsequent drafts and approved the final manuscript.


Acknowledgements

This work was funded as part of contract between the New Zealand Census-Mortality Study (NZCMS), Wellington School of Medicine & Health Sciences with Public Health Intelligence, New Zealand Ministry of Health. The NZCMS is part of the Health Inequalities Research Programme, principally funded by the Health Research Council of New Zealand. Helpful comments on the draft were received from three anonymous journal reviewers and three colleagues in New Zealand: Dr Ricci Harris, Dr Sarah Hill and Des O'Dea.


References
Howden-Chapman P,Tobias MI. Social inequalities in health: New Zealand 1999. 2000Wellington, Ministry of Health;
Blakely T,Tobias M,Robson B,Ajwani S,Bonne M,Woodward A. Widening ethnic mortality disparities in New Zealand 1981-99Soc Sci Med 2005;61:2233–2251. [pmid: 16005132] [doi: 10.1016/j.socscimed.2005.02.011]
Blakely T,Fawcett J,Atkinson J,Tobias M,Cheung J. Decades of Disparity II: Socioeconomic mortality trends in New Zealand 1981-1999. 2005Wellington, Ministry of Health;
Fawcett J,Blakely T,Robson B,Tobias M,Pakipaki N,Harris R. Decades of Disparity III: Overlapping Ethnic and Socioeconomic Mortality Inequalities in New Zealand, 1981-1999. 2006Wellington, Ministry of Health;
Durie M. Providing health services to indigenous peoplesBmj 2003;327:408–409. [pmid: 12933709] [doi: 10.1136/bmj.327.7412.408]
Stellman SD,Resnicow K. Tobacco smoking, cancer and social classIARC Sci Publ 1997:229–250. [pmid: 9353667]
Cavelaars AE,Kunst AE,Geurts JJ,Crialesi R,Grotvedt L,Helmert U,Lahelma E,Lundberg O,Matheson J,Mielck A,Rasmussen NK,Regidor E,do Rosario-Giraldes M,Spuhler T,Mackenbach JP. Educational differences in smoking: international comparisonBMJ 2000;320:1102–1107. [pmid: 10775217] [doi: 10.1136/bmj.320.7242.1102]
Giskes K,Kunst AE,Benach J,Borrell C,Costa G,Dahl E,Dalstra JA,Federico B,Helmert U,Judge K,Lahelma E,Moussa K,Ostergren PO,Platt S,Prattala R,Rasmussen NK,Mackenbach JP. Trends in smoking behaviour between 1985 and 2000 in nine European countries by educationJ Epidemiol Community Health 2005;59:395–401. [pmid: 15831689] [doi: 10.1136/jech.2004.025684]
Huisman M,Kunst AE,Mackenbach JP. Educational inequalities in smoking among men and women aged 16 years and older in 11 European countriesTob Control 2005;14:106–113. [pmid: 15791020] [doi: 10.1136/tc.2004.008573]
Galea S,Nandi A,Vlahov D. The social epidemiology of substance useEpidemiol Rev 2004;26:36–52. [pmid: 15234946] [doi: 10.1093/epirev/mxh007]
Hill SE,Blakely TA,Fawcett JM,Howden-Chapman P. Could mainstream anti-smoking programs increase inequalities in tobacco use? New Zealand data from 1981-96Aust N Z J Public Health 2005;29:279–284. [pmid: 15991779] [doi: 10.2105/AJPH.2003.025882]
Borman B,Wilson N,Maling C. Socio-demographic characteristics of New Zealand smokers: results from the 1996 censusN Z Med J 1999;112:460–463. [pmid: 10678209]
Hill SBlakely TThomson GHowden-Chapman PSmoking Inequalities: Policies and patterns of tobacco use in New Zealand, 1981-1996. Wellington, New Zealand: Department of Public Health, Wellington School of Medicine and Health Sciences, University of Otago. http://www.wnmeds.ac.nz/Academic/Dph/Publicationsreports/Smoking%20Inequalities%20Report,%20MoH,Final_pdf.pdf2003
Whitlock G,MacMahon S,Vander Hoorn S,Davis P,Jackson R,Norton R. Association of environmental tobacco smoke exposure with socioeconomic status in a population of 7725 New ZealandersTob Control 1998;7:276–280. [pmid: 9825423]
Gillespie J,Milne K,Wilson N. Secondhand smoke in New Zealand homes and cars: exposure, attitudes, and behaviours in 2004N Z Med J 2005;118:U1782. [pmid: 16372031]
Brander P. Evaluation of the smoke-free environments legislation affecting workplaces.. 1992Wellington, Health Research Services, Department of Health,;
Shaw C,Blakely T,Sarfati D,Fawcett J,Hill S. Varying evolution of the New Zealand lung cancer epidemic by ethnicity and socioeconomic position (1981-1999)N Z Med J 2005;118:U1411. [pmid: 15843840]
Lopez AD,Collishaw NE,Piha T. A descriptive model of the cigarette epidemic in developed countriesTob Control 1994;3:242–247.
Woodward A,Boffetta P. Environmental exposure, social class, and cancer riskIARC Sci Publ 1997:361–367. [pmid: 9353677]
Smartt P. Mortality, morbidity, and asbestosis in New Zealand: the hidden legacy of asbestos exposureN Z Med J 2004;117:U1153. [pmid: 15570336]
Miller AB,Altenburg HP,Bueno-de-Mesquita B,Boshuizen HC,Agudo A,Berrino F,Gram IT,Janson L,Linseisen J,Overvad K,Rasmuson T,Vineis P,Lukanova A,Allen N,Amiano P,Barricarte A,Berglund G,Boeing H,Clavel-Chapelon F,Day NE,Hallmans G,Lund E,Martinez C,Navarro C,Palli D,Panico S,Peeters PH,Quiros JR,Tjonneland A,Tumino R,Trichopoulou A,Trichopoulos D,Slimani N,Riboli E. Fruits and vegetables and lung cancer: Findings from the European Prospective Investigation into Cancer and NutritionInt J Cancer 2004;108:269–276. [pmid: 14639614] [doi: 10.1002/ijc.11559]
Lea R,Benowitz N,Green M,Fowles J,Vishvanath A,Dickson S,Lea M,Woodward A,Chambers G,Phillips D. Ethnic differences in nicotine metabolic rate among New ZealandersN Z Med J 2005;118:U1773. [pmid: 16372023]
Robson B,Purdie G,Cormack D. Unequal Impact: Maori and Non-Maori Cancer Statistics 1996-2001. 2006Wellington, Ministry of Health. http://www.moh.govt.nz/cancercontrol;
Jeffreys M,Stevanovic V,Tobias M,Lewis C,Ellison-Loschmann L,Pearce N,Blakely T. Ethnic inequalities in cancer survival in New Zealand: linkage studyAm J Public Health 2005;95:834–837. [pmid: 15855462] [doi: 10.2105/AJPH.2004.053678]
Ministry of HealthInhaling inequality. Tobacco's contribution to health inequality in New Zealand. 2001Wellington, Ministry of Health;
Hunt D,Blakely T,Woodward A,Wilson N. The smoking-mortality association varies over time and by ethnicity in New ZealandInt J Epidemiol 2005;34:1020–1028. [pmid: 16030152] [doi: 10.1093/ije/dyi139]
Blakely T,Fawcett J,Hunt D,Wilson N. What is the contribution of smoking and socioeconomic position to ethnic inequalities in mortality in New Zealand?Lancet 2006;368:44–52. [pmid: 16815379] [doi: 10.1016/S0140-6736(06)68813-2]
Jha P,Chaloupka FJ. Curbing the Epidemic: Government and the economics of tobacco control.. 1999Washington DC, The World Bank;
Hopkins DP,Briss PA,Ricard CJ,Husten CG,Carande-Kulis VG,Fielding JE,Alao MO,McKenna JW,Sharp DJ,Harris JR,Woollery TA,Harris KW. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smokeAm J Prev Med 2001;20:16–66. [pmid: 11173215] [doi: 10.1016/S0749-3797(00)00297-X]
Blakely T,Wilson N. Shifting dollars, saving lives: What might happen to mortality rates, and socio-economic inequalities in mortality rates, if income was redistributed?Soc Sci Med 2006;62:2024–2034. [pmid: 16242825] [doi: 10.1016/j.socscimed.2005.08.059]
Siahpush M,Borland R,Taylor J,Singh GK,Ansari Z,Serraglio A. The association of smoking with perception of income inequality, relative material well-being, and social capitalSoc Sci Med 2006;63:2801–2812. [pmid: 16971030] [doi: 10.1016/j.socscimed.2006.07.015]
Sorensen G,Barbeau E,Hunt MK,Emmons K. Reducing social disparities in tobacco use: a social-contextual model for reducing tobacco use among blue-collar workersAm J Public Health 2004;94:230–239. [pmid: 14759932]
Harris R,Tobias M,Jeffreys M,Waldegrave K,Karlsen S,Nazroo J. Effects of self-reported racial discrimination and deprivation on Maori health and inequalities in New Zealand: cross-sectional studyLancet 2006;367:2005–2009. [pmid: 16782491] [doi: 10.1016/S0140-6736(06)68890-9]
Harris R,Tobias M,Jeffreys M,Waldegrave K,Karlsen S,Nazroo J. Racism and health: the relationship between experience of racial discrimination and health in New ZealandSoc Sci Med 2006;63:1428–1441. [pmid: 16740349] [doi: 10.1016/j.socscimed.2006.04.009]
Statistics New ZealandDemographic Trends 2005. 2006Wellington, Statistics New Zealand;
Ministry of Social DevelopmentThe Social Report 2005: Indicators of social wellbeing in New Zealand. 2005Wellington, Ministry of Social Development. http://www.socialreport.msd.govt.nz/;
Ministry of HealthClearing the smoke. A five-year plan for tobacco control in New Zealand (2004-2009). Wellington: Ministry of Health, 2004. http://www.moh.govt.nz/moh.nsf/0/AAFC588B348744B9CC256F39006EB29E/$File/clearingthesmoke.pdf2004
Thomson G,Wilson N,Crane J. Rethinking the regulatory framework for tobacco control in New ZealandN Z Med J 2005;118:U1405. [pmid: 15843834]
Borland R. A strategy for controlling the marketing of tobacco products: a regulated market modelTob Control 2003;12:374–382. [pmid: 14660771] [doi: 10.1136/tc.12.4.374]
Callard C,Thompson D,Collishaw N. Transforming the tobacco market: why the supply of cigarettes should be transferred from for-profit corporations to non-profit enterprises with a public health mandateTob Control 2005;14:278–283. [pmid: 16046692] [doi: 10.1136/tc.2005.011353]
Hatsukami DK,Lemmonds C,Zhang Y,Murphy SE,Le C,Carmella SG,Hecht SS. Evaluation of carcinogen exposure in people who used "reduced exposure" tobacco productsJ Natl Cancer Inst 2004;96:844–852. [pmid: 15173268]
Foulds J,Ramstrom L,Burke M,Fagerstrom K. Effect of smokeless tobacco (snus) on smoking and public health in SwedenTob Control 2003;12:349–359. [pmid: 14660766] [doi: 10.1136/tc.12.4.349]
Furberg H,Bulik CM,Lerman C,Lichtenstein P,Pedersen NL,Sullivan PF. Is Swedish snus associated with smoking initiation or smoking cessation?Tob Control 2005;14:422–424. [pmid: 16319367] [doi: 10.1136/tc.2005.012476]
Ramstrom LM,Foulds J. Role of snus in initiation and cessation of tobacco smoking in SwedenTob Control 2006;15:210–214. [pmid: 16728752] [doi: 10.1136/tc.2005.014969]
Wilson N,Thomson G. Tobacco tax as a health protecting policy: a brief review of the New Zealand evidenceN Z Med J 2005;118:U1403. [pmid: 15843832]
Thomson G,Wilson N. Directly eroding tobacco industry power as a tobacco control strategy: lessons for New Zealand?N Z Med J 2005;118:U1683. [pmid: 16224507]
Farrelly MC,Bray JW,Office on Smoking and HealthResponse to increases in cigarette prices by race/ethnicity, income, and age groups--United States, 1976-1993MMWR Morb Mortal Wkly Rep 1998;47:605–609. [pmid: 9699809]
Townsend J,Roderick P,Cooper J. Cigarette smoking by socioeconomic group, sex, and age: effects of price, income, and health publicityBmj 1994;309:923–927. [pmid: 7950662]
Chaloupka FJ. Rational addictive behavior and cigarette smokingJournal of Political Economy 1991;99:722–742. [doi: 10.1086/261776]
Thomson GO'Dea DWilson Net alThe financial effects of tobacco tax increases on Maori and low-income households. Wellington: Department of Public Health, Wellington School of Medicine, 2000. [http://www.wnmeds.ac.nz/Academic/Dph/Publicationsreports/index.html]2000
Darroch J. Taxation: does it reduce tobacco consumption? (Unpublished report). 1999Dunedin, Department of Marketing, University of Otago;
Wilson N,Thomson G,Tobias M,Blakely T. How much downside? Quantifying the relative harm from tobacco taxationJ Epidemiol Community Health 2004;58:451–454. [pmid: 15143110] [doi: 10.1136/jech.2003.011528]
Wilson N,Thomson G. Tobacco taxation and public health: ethical problems, policy responsesSoc Sci Med 2005;61:649–659. [pmid: 15899323] [doi: 10.1016/j.socscimed.2004.11.070]
Thomson G,Wilson N. One year of smokefree bars and restaurants in New Zealand: Impacts and responsesBMC Public Health 2006;6:64. [pmid: 16533408] [doi: 10.1186/1471-2458-6-64]
Asthma and Respiratory Foundation of New ZealandAotearoa New Zealand Smokefree Workplaces: A 12-month report.. 2005Wellington, Asthma and Respiratory Foundation of New Zealand. http://www.asthmanz.co.nz/files/PDF-files/Aotearoa_NZ_Smokefree_Workplaces_12_month_report.pdf;
Ministry of HealthThe smoke is clearing: Anniversary report 2005. 2005Wellington, Ministry of Health; http://www.moh.govt.nz/moh.nsf/0/7EC01E1971949178CC2570D20019E782/$File/SmokeClearing.pdf;
Thomson G,Wilson N,Howden-Chapman P. Population level policy options for increasing the prevalence of smokefree homesJ Epidemiol Community Health 2006;60:298–304. [pmid: 16537345] [doi: 10.1136/jech.2005.038091]
Martin J,George R,Andrews K,Barr P,Bicknell D,Insull E,Knox C,Liu J,Naqshband M,Romeril K,Wong D,Thomson G,Wilson N. Observed smoking in cars: A methodology and differences by socio-economic areaTob Control 2006;15:409–411. [pmid: 16998177] [doi: 10.1136/tc.2006.015974]
Wilson N,Grigg M,Graham L,Cameron G. The effectiveness of television advertising campaigns on generating calls to a national Quitline by MaoriTob Control 2005;14:284–286. [pmid: 16046693] [doi: 10.1136/tc.2004.010009]
Wilson NThe impact of television advertising campaigns on calls to the New Zealand Quitline. Wellington: The Quit Group, 2004. http://www.quit.co.nz/documents/FINALMediaStudy.pdf2004
Barnes HMMcPherson MMaori Smoker and Whanau Response to "It's about whanau" Television Commercials. Auckland: Whariki Research Group, SHORE Research Centre, Massey University, 2003.2003 [pmid: 12850908]
Waa AGrigg M "Its about whanau": Views of smokers and whanau. In: Proceedings of the Tobacco Control Research Symposium, September 2002. Wellington: Health Sponsorship Council, 2003: p19-21.2003
St John P,Tasi-Mulitalo L. New Zealand: Pacific islanders' smoking targetedTob Control 2006;15:148–149. [pmid: 16728734]
Quit GroupThe Quit Group update - July 2004. Wellington: The Quit Group, 2004. http://www.quit.co.nz/documents/Monthly-call-stat-2004.pdf2004
Grigg M,Glasgow H. Subsidised nicotine replacement therapyTob Control 2003;12:238–239. [pmid: 12773740] [doi: 10.1136/tc.12.2.238-a]
Hastings G,McLean N. Social marketing, smoking cessation and inequalitiesAddiction 2006;101:303–304. [pmid: 16499501] [doi: 10.1111/j.1360-0443.2006.01371.x]
BRCEvaluation of Culturally Appropriate Smoking Cessation Programme for M?ori Women and their Wh?nau: Aukati Kai Paipa 2000. Wellington: Ministry of Health, 2003. http://www.moh.govt.nz/moh.nsf/7004be0c19a98f8a4c25692e007bf833/50be7bea182bcb5bcc256d6c000c5408?OpenDocument2003
Milne KInitial results from Quit and Win 2002. [Presentation] Tobacco Control Research Symposium, Wellington: 11 September 2002.2002
Holt S,Timu-Parata C,Ryder-Lewis S,Weatherall M,Beasley R. Efficacy of bupropion in the indigenous Maori population in New ZealandThorax 2005;60:120–123. [pmid: 15681499] [doi: 10.1136/thx.2004.030239]
Platt S,Amos A,Gnich W,Parry O. Mackenbach JP and Bakker MSmoking policiesReducing Inequalities in Health: A European Perspective. 2002London, Routledge;
Brown J,Parr W,Bates M. Evaluation of a smoking cessation programme that uses behaviour modificationN Z Med J 1999;112:399–402. [pmid: 10606401]
Chesterman J,Judge K,Bauld L,Ferguson J. How effective are the English smoking treatment services in reaching disadvantaged smokers?Addiction 2005;100 Suppl 2:36–45. [pmid: 15755261] [doi: 10.1111/j.1360-0443.2005.01026.x]
Healthcare CommissionImprovement review into tobacco control. 2006London, Healthcare Commission. http://www.healthcarecommission.org.uk/serviceproviderinformation/reviewsandinspections/improvementreviews/tobaccocontrol.cfm;
Lowey H,Tocque K,Bellis MA,Fullard B. Smoking cessation services are reducing inequalitiesJ Epidemiol Community Health 2003;57:579–580. [pmid: 12883060] [doi: 10.1136/jech.57.8.579]
Blakely T,Wilson N. The contribution of smoking to inequalities in mortality by education varies over time and by sex: two national cohort studies, 1981-84 and 1996-99Int J Epidemiol 2005;34:1054–1062. [pmid: 16109733] [doi: 10.1093/ije/dyi172]

Figures

[Figure ID: F1]
Figure 1 

Age standardised lung cancer mortality rates in New Zealand by ethnicity and household income, males and females (per 100,000 population). Source: Data derived from: [17]. The bars indicate 95% confidence intervals. Note the different age range for ethnicity and household income. The ethnic mortality rates were calculated using adjustment factors (from the NZCMS) for historic undercounting of M?ori and Pacific deaths [2, 3], and the income mortality rates were calculated directly from linked census-mortality data. Rates by household income are standardised or both age and ethnicity. Ethnicity definitions: The definition of ethnicity progressively changed from fractionated ethnic origin in the 1981 census (eg, 7/8 European, 1/8 M?ori), to multiple self-identified ethnicity in 1996 elicited by the question: "Tick as many circles as you need to show which ethnic group(s) you belong to". This change in the question and secular trends in how people viewed their own ethnicity led to a disproportionate increase in the M?ori population (than expected on the basis of demographic projections alone). However, trends in mortality rates shown above are largely unaffected, as the numerators have been adjusted to be consistent with the denominators.



[Figure ID: F2]
Figure 2 

The contribution of active tobacco smoking to 45?74 year old age-standardised mortality rates, and gaps in mortality rates, in 1996?99, by ethnicity and education (with the latter as a marker for SEP). Sources: Data derived from: [75] and [27]. nMnP ? non-M?ori non-Pacific (ie, mainly "New Zealand European" ethnicity). See the footnotes to Table 1 for ethnicity definitions.



[Figure ID: F3]
Figure 3 

Simplified causal/intervention model for pathways between ethnicity and socioeconomic position to mortality. * Direct interpersonal racism and institutional racism probably has a diffuse impact on many causal processes represented by this diagram, including the unequal distribution of socioeconomic resources, the quantity and quality of "stress" and "psychosocial resources", "access to/access through the health system", and patterns of drug use ? including smoking. There are New Zealand specific data on racism and health and racism and smoking [33, 34].



Tables
[TableWrap ID: T1] Table 1 

The estimated percentage decrease (population-attributable risk percent (PAR%)) in 45?74 year old mortality rates during 1996?99 had all current and ex-smokers actually been never smokers


Men 1996?99 Women 1996?99


Within educational group ? PAR% in total population PAR% within educational group PAR% in total population PAR% within educational group


Nil School Post-school Nil School Post-school
(ii) All current and ex-smokers become never smokers in each educational group (ie, historically smokefree). 26% 29% 26% 23% 25% 27% 24% 23%


Within ethnic group ? PAR% in total population PAR% within ethnic group PAR% in total population PAR% within ethnic group


M?ori nMnP M?ori nMnP

(ii) All current and ex-smokers become never smokers in each ethnic group (ie, historically smokefree). 33% 21% 36% 28% 25% 28%

? Source: Table 4 from [75].

? Source: PAR% calculated from data in: [27].

NB: The educational PAR% estimates are calculated using Poisson rate ratios adjusted for age and ethnicity, whereas the ethnic PAR% estimates are based on age-standardised mortality rates.

nMnP ? non-M?ori non-Pacific (ie, mainly "New Zealand European" ethnicity).

See the footnotes to Figure 1 for ethnicity definitions.



Article Categories:
  • Commentary


Previous Document:  Attachment as an organizer of behavior: implications for substance abuse problems and willingness to...
Next Document:  Genomic presence of recombinant porcine endogenous retrovirus in transmitting miniature swine.