Richard Edwards on behalf of the Smokefree Amendment Act Evaluation Team

Health Promotion and Policy Research Unit (HePPRU)Department of Public HealthUniversity of Otago, Wellington

richard.edwards@otago.ac.nzThe impact of the 2003 Smokefree Legislation on Mori

After the Smoke has Cleared: Evaluation of 2003 Smoke-free Environments Amendment ActAvailable on : http://www.moh.govt.nz/

AcknowledgementsMinistry of HealthHealth Sponsorship CouncilASH New ZealandQuit GroupKamalesh Venugopal, University of Otago

OutlineContext and provisions of 2003 Smokefree Environments Amendment Act (SEAA)Evaluation design and methodsResults of evaluationAttitudes towards and support for SEAAMori stakeholder views about SEAA and implementation processSHS exposure in the workplaceSHS exposure in the homeSmoking prevalence and behavioursImplications and discussion

Background Smokefree legislation is increasingly implemented around the worldEvaluation is generally positivee.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

What did the SEAA do?Introduced in Dec 2003, but most provisions implemented in Dec 2004Smokefree 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 restaurantssmoking 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)

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

Mori population in New ZealandMori are the indigenous people of New Zealand),15.3% of NZ populationSmoking rates among Mori women are among the highest in the worldAdult smoking prevalence in New Zealand was 24.1% in men and 22.9% in women in 2006, but among Mori was 50.6% among women and 40.7% among menSmoking rates are reflected in adverse health effects including very high rates of lung cancer mortality

Process and outcome indicatorsProcess and short term outcome indicators:Public and stakeholder attitudes and support for smokefree policiesDissemination of information, participation, enforcement activities and compliance monitoringCore intermediate and long-term outcome indicators:Exposure to SHS in the workplace (principal outcome measure)Health impacts attributable to active smoking and SHS exposureNon-core intermediate and long-term outcome indicators:Exposure to SHS in public places and private places such as homesSmoking prevalence and smoking-related behavioursEconomic impacts

Process and outcome indicatorsProcess and short term outcome indicators:Public and stakeholder attitudes and support for smokefree policiesDissemination of information, participation, enforcement activities and compliance monitoringCore intermediate and long-term outcome indicators:Exposure to SHS in the workplace (principal outcome measure)Health impacts attributable to active smoking and SHS exposureNon-core intermediate and long-term outcome indicators:Exposure to SHS in public places and private places such as homesSmoking prevalence and smoking-related behavioursEconomic impacts

MethodsMultifaceted evaluationIdentification, review and additional analysis of existing data sources Specially commissioned studies for additional evidenceIn-depth interviews with key stakeholdersAir quality studies in the hospitality industry and other settingsTrends in hospitalisation data to explore health impacts

Data sourcesHSC Monitor Surveys (2003-6): Nationally representative telephone surveys with 2-2500 adults aged > 14 yrs Boosted Mori 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 Mori stakeholdersQualitative study with 8 Mori stakeholders (part of a larger study for the SEAA evaluation)National Quitline dataNumber of calls and NRT vouchers issued to callersNew Zealand Tobacco Use SurveyNationally representative interview surveys of 5700 adults aged 15-64 yrs

Public attitudes towards and support for smokefree policies

HSC Monitor SurveysLarges increases in support for SEAA and underlying principles among Mori and non- Mori smokers and non-smokers before and after SEAA implementationE.g. support for right of bar workers to work in a smokefree environment increased between 2003-6 from 84% to 93% in non-Mori and from 57% to 83% among Mori respondents

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

Experiences & attitudes of Mori stakeholders to implementation of the SEAA MethodsIn depth qualitative interviewsPurposively selected interviewees 4 key personnel in Mori health/tobacco control NGOsDHB public health manager involved with implementation of SEAAMori smoking cessation worker/consultantUnion official Bar manager

Experiences & attitudes of Mori stakeholders to implementation of the SEAA (cont)ResultsMostly very positive and supportive of the SEAA and its implementationPerception that SEAA was mostly supported by Mori and had had positive impacts on Mori communities and smokersMori health worker interviewees argued sufficient information and support available for implementationSEAA had enabled a new level of discussion among Mori communities about issues like smokefree homes and introducing tobacco control policies

Experiences & attitudes of Mori stakeholders to implementation of the SEAA (cont)Results (cont)Some dissent from this positive view, focusing on:Lack of information about the changesFailure to include maraes in smokefree legislationContinued role modelling of smoking to children, exacerbated by increased smoking outside

Exposure to SHS in the workplace (principal outcome measure)

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

Exposure to SHS in private places such as homes

HSC Monitor Surveys (2003-6)Steady increase in proportion of homes reported as smokefree among Mori and non-Mori, and reduction in self-reported smoking in home in last weekSmoking in home more common among Mori households but decrease in absolute differenceASH Year 10 surveys (2001-6)Less marked decrease in smoking in the home reported with similar decreases among Mori and non-MaoriSmoking in home reported more commonly by Mori students (40% vs 25% for all students in 2006)Tobacco Use Survey (2006)70.3% of Mori vs 85.1% of non-Mori respondents reported no smoking occurring in the home

Source: ASH Year 10 Surveys

Source: HSC Monitor Surveys

Source: HSC Monitor Surveys

Smoking and smoking-related behaviours Little evidence of impact of SEAA on smoking prevalence, smoking among Mori 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 QuitlineProportion of calls to the Quitline by Mori 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 Mori and non-Mori to a similar degree

Smoking prevalence in NZ, 1985-2006

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

Conclusions First in-depth data on the impact of smokefree legislation on an indigenous populationFindings of SEAA evaluation mostly very positive, with positive results generally mirrored among Mori Smoking and SHS exposure among Mori remains a priority public health issueSome limitations e.g. quanitative data for impact on Mori in economic analysis

Limited data on acceptability of implementation and participation was mostly supportiveCant assume that findings are generalisable to other indigenous peoplesEvaluation of tobacco control interventions like smokefree legislation should include an assessment of impact on indigenous and minority communities

The 1990 provisions included smoking bans in public facilities (including retail areas), most shared offices, and partial restrictions ( half of the area non-smoking) for work cafeterias, restaurants and meal-serving areas of pubs and other licensed venues but did not include restrictions on non-meal serving areas of pubs, members clubs, nightclubs or casinos. Self-reported workplace exposure in HSC Monitor SurveysSHS exposure indoors at work in the previous week fell from 20% in 2003 to 8% in 2006 among employed adults Decline in SHS exposure greater among Mori, so that differential in SHS exposure almost abolished by 2006 Tobacco Use Survey (2006)12% of Mori vs 8% of non-Mori reported SHS exposure indoors in the workplace (time period unspecified)

The increase was greater when a reduction in marketing of the Quitline in the period after implementation of the SEAA is taken into account.Constant proportion of Mori callers suggest SEAA = equal stimulus to quit