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Projecting Future Smoking Prevalence

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The status of health for indigenous people often depend on their political, social, and unique historical circumstances. It also depends on the interactions these indigenous people have with the non-indigenous population. Maori’s travelled to New Zealand through the Pacific 1010 years ago. Initially only a few Maori’s arrived but never a formal data was maintained about the settlement. It was in the 1840’s that the treaty of Waitangi was signed with British Government that was aimed protecting and maintaining the interests of the indigenous population. The Treaty of Waitangi was signed in the year 1840 by the representatives of the Crown (The British Monarchy) and chiefs of the Maori’s. This treaty gave the Maori’s ownership of their lands but it also create an influx of the British nationals (Came et al., 2016).. This caused a decrease in the indigenous Maori’s population. Since the 70’s the public realized that the treaty was not supporting the interests of Maori’s as it is supposed to do. As there were is a significant difference in life expectancies  of Non Maori’s and Maori’s. After reaching a low point it was in the year 1896 that the Maori’s population started to increase. Many programmes that were run by the government along with the appointment of the Maori’s health inspectors helped in contributing to this recovery. In the past decades the demand and self-determination of the Maori people along with the introduction of programme initiatives and social policies have targeted the aspirations and needs of the Maori. In the year 2004 “Portrait of Health Report” showed that in the year 2002-2003 health survey, 12, 929 New Zealanders took part along with 4369 Maori’s that showed that Non-Maori’s rated their health higher than Maori’s. This survey focused on vitality, energy, breathing, mental health, general health, hearing, vision, communication, selfcare, social functionality, usual activities, and pain. The New Zealand government introduced “The Primary Health Care Strategy” or PHCS in the year 2001 that aimed at improving health and reducing inequalities. It was in the year 2002 that Primary Health organizations like Te Kupenga o Hoturoa Charitable Trust and TaPasefika Health Trust were established in the Counties Manukau District Health Board or DHB. By the year 2006 about 81 PHO’s were established and were in operation that had 4 Million Whanau members that were enrolled. In New Zealand community action based projects such as housing, welfare, environment and housing have increased during the current government.

Disparities among the Non- Maori’s and Maori’s has been evident in the colonial history of New Zealand. Various components in a complex mix are responsible for these differences. Since the starting of the 90’s decade New Zealand has recognized the need to reduce the health inequalities through the use of cultural, social and economic determinants of health.  Studies have shown that colonization, alienation and dispossession have had a negative impact on Maori health. Statistics, measures and studies have documented the status of the Maori people facing systematic disparities in healthcare.


In order to understand the factors of the health disparities we have to first understand the Maori’s philosophy of health. They have health models that incorporate the health and wellness of a being. Te Whare Tapa Wh? model is about Taha Tinara that refers to physical health, Taha Wairua that refers to spiritual health, Taha Wh?nau  that refers to family health and lastly Taha Hinengaro that refers to mental health. The model of Te Whare Tapa Wh? conveys the importance of balance. They explain how even when one of the dimensions goes  missing the whole balance is lost and the person becomes ill. This was model was created for the recognition of the spiritual element involved in being healthy and now it is used in mainstream health models. Another Maori health model is Te Pae M?hutonga that uses the image of the southern cross to show the six issues in Maori health promotion. It highlight how Mauriora or cultural identity is related to Waiora or physical environment, Toiora or healthy lifestyle and Te Oranga or participation in the society. Another model of Te Wheke is about the traditional Maori perspectives of the connection in between the spirit, the whanau or family, the physical world and the mind. They complain how western medicines has caused a separation between the connection. He Pou Oranga Tangata Whenua is the model that was developed in order to ensure that the Maori’s traditional institutions, knowledge, and values are recognized for health and wellbeing (toiora). This model creates a direct connection between social determinants and health. These social determinants included culture, language, education and resources. This model also provides the ways practices and actions which can help achieve healthy society.

Maori health promotion is based on the fact of enabling the Maori population to strengthen their community and identity and to increase their control on the determinants of health. This only provides the nature of the health promotion for the Maori’s but we need to consider two main models of health for the Maori’s. One being the Te Pae Mahutonga which is about the creation of an environment that facilitates the human potential (Durie, 2000). This model identifies two prerequisites for health promotion in Maori population. These prerequisites are ‘ng? manukura’ or leadership and ‘te mana whakahaere’ or autonomy. The leadership prerequisite is about the importance of community leadership and how the community leadership is crucial for the successful implementation of any intervention. Through this model they are highlighting the fact that health promotion interventions should include community leadership, tribal leadership, health leadership, cooperative relationships and open communication between key groups and leaders. Autonomy prerequisite is about the need to provide the community with the control of the health intervention. The Te Pae Mahutonga model is about providing Maori’s the access to the social domain in the society where they have the adequate opportunities to express their culture. They should have equal access to services and goods of the society. Since the 20th century the Maori leadership is playing a crucial role in health promotion with in the community.


Maori’s believe in the measure of self-governing which is quite evident in the Ranui Project (RAP) which was set with the aim of enhancing the wellbeing and health of Ranui people had a particular focus on young children, families and children. The Ranui population is diverse with the inclusion of Pacific and Maori people. They have a young profile as more than 50% of the population is under 15 years. They are low income community that have issues such as poor access of health, unemployment, transient school roll, and housing issues. This project is jointly funded by the CYF or the Department of Child, Youth and Family and SCAF (Stronger Community Action Fund. This project is about identifying the issues of health, and acting on these issues with the help of strategies (Adams, 2005). RAP was established as a project that was community based in terms of self-governing entity that is focused in recognizing the local issues and needs. Local members were the initial members who took part in negotiations related to funds. These people found approaches that were tailored for the Maori people. The representatives of the community were at first suspicious of the intentions of the funders so an evaluation plan was developed and involved a group of local members that evaluated the project. This evaluation in the initial level helped assisted in the successful programmed implementation.  This evaluation helped as a “mentor” or a “critical friend” to the project workers. Events and meeting served as an observation points for monitoring the progress of the project. This shows that their prerequisite of autonomy is to give the control of the health intervention to the community. The outcome of the project was measured through interviews with informants that were indirectly and directly involved with the project. Community perceptions were also taken into considerations by telephone based surveys in the year 2001 and 2004. The findings of the interviews showed that this project had a wide reach in the community (Blakely et al., 2010)This project succeeded in engaging a committed and diverse community members in its activities and governance. This project also funded many small scale initiatives that were called “Go Now” initiatives. Some of these projects had an ethnic focus while others were focused on the youth. This project helped in enhancing the skills of Ranui people. This project also faced many challenges in regard to staffing, governance and programme prioritization.

Maori health promotion is about facilitating health lifestyles by targeting individual level behavior. Some of the lifestyle factors were also involved as smoking and the use of tobacco in Maori’s resulted in high percentage of deaths (Salmond et al., 2011). To inspect and inquire about this issue Whakarapopotonga o nga take komiti inquiry was carried out. The aim of this inquiry was to know whether tobacco industry was impacting the health of Maori’s population by promoting tobacco. It also concentrated on developmental, social, economic and cultural impacts that arise from tobacco use. Pacific and Maori people are more likely to smoke than others in the population according to the New Zealand Health Survey 38% of Maori people smoke in comparison to 25% in Pacific people and 15 % of New Zealand European population. Scientific evidence has showed that tobacco control interventions such as media campaigns, smoke free environment legislature, higher taxation on tobacco products and restriction on marketing is affecting the prevalence of smoking in the country (Blakely et al., 2015)., (Blakely, 2002). However there is also growing evidence that shows that the goal of minimizing smoking by the year 2025 is also missing the Maori population by a wide margin (van der Deen FS, 2014), (Ball J, 2016).


Kia Uruuru Mai a Hauora framework is of ecological perspective as it stresses on the determinants of health. Maori’s health promotion is about the connection between the environment and Maori wellness (Ratima M. , 2001). The balance of health can be achieved when we retain and strengthen the Maori’s identity. In this health promotion the health gains are achieved through Maori’s world views. Four core values were identified in this framework that were Maori identity, equity, social justice, and collective autonomy (Ratima, 2004). The expectation that the Maori health promotion has to achieve is that the strategy or intervention should not only be for the Maori but it should also highlight the Maori’s identity. The health promotion can be valued when the power and control is shifted to the Maori’s to control their health. Maori’s emphasis that individual aspirations and needs are below the aspirations and needs of a group. So autonomy is not positioned for an individual but it is positioned for a Maori’s collective. It is based on the value that social justice is about equal worth to every person in an equal way and therefore they should all have equal rights. Equity stands for “fairness” and not “sameness”. Equity here means that Maori should have an equal and fair access to opportunities that gives them the opportunity to fulfil their own potential. The framework of “Kia Uruuru Mai a Hauora” also provides principles like self-determination, quality, holism, diversity, and cultural integrity. Holism as a principle is about four dimensions that are focus, time, sectors and realms. It explains how Maori’s health promotion should include intergenerational connections that identifies the continuity between spiritual realms and material realms. Maori health promotion should always have a “By Maori’s , For Maori’s” approach, this is due to the self-determination principle. Maori’s health promotion should always reinforce Maori’s cultural practices and values. The implication that this principle has is that no health intervention or strategy should be based on stereotypes (Ratima M. , 2004). This framework identifies central processes of medication, capacity building, resourcing, empowerment, connectedness, cultural responsiveness  and advocacy. Empowerment as a process is about increasing the Maori’s control over their health (Craig, 2002). It should focus on both the Maori’s collectives and individual interest. Mediation is the process to facilitate inter and intra sectoralism. Intra sectoralism is about its alignment with Wh?nau Ora which recognizes the mediation between stakeholders and Maori health promoters. Connectedness is a process about intergenerational transfer of values and knowledge while identifying the Wh?nau centered approach. Advocacy is the process that applies the process of political lobbying, public lobbying and lobbying for stakeholder those who are promoting the Maori’s health interventions. (Ratima M. R., 2007)

We have to keep in mind that Maori’s are not at the same point as the other parts of the population . There are certain strategies that are identified to promote health some of them are about shifting the emphasis towards promotion of health, disease prevention and primary health care rather than just concentrating on tertiary care. Another strategy was to increase the participation of the Maori in the society thereby giving them more control over the determinants of health. A developmental approach should be used to ensure that health promotion should benefit the community in a sustainable manner (Labonte, 1996). A public policy is needed that should promote and secure Maori’s identity. The policy should have inter and intra sectoral measures that deal with the political, social, economic and cultural determinants of health. Adequate evidences should be used to provide a relevant resources of Maori’s health.


Community development based on identity is a strategy that will have a positive outcome on the health disparities as these communities are driven (Signal, et al.,2016).. There is a recognition among the promoters that they have to work with the Maori community and they have to strengthen the community towards achieving a self-determining stance. The Ottawa Charter for health promotion is a framework that is used all over the world. It is one of the generic health promotion strategy that the Maori health promotion draws theory from. Out of the five strategies that were listed in the Ottawa Charter for health promotion one is about strengthening the community (Laverack, 2007). This is about supporting the community to take ownership and to control and participate in initiatives. Commission of social determinants of health have proved that circumstances in which the person is born, they live, work and spend their life are responsible for the health inequalities. To curb and to reduce these inequalities in New Zealand it is crucial that government realizes that effective Maori leadership is needed. They need to support the leadership by empowering the whanau members, iwi leaders, local Maori’s and individuals at each level. This will promote a culturally responsive health care that safeguards the high standards of care that the Maori’s hold.



Adams, J. W. (2005). A Report on the Findings of the Ranui Social Cohesion Surveys,. Auckland: Massey University.

Ball, J., Edwards, R., Waa, A., Bradbrook, S., Gifford, H., & Cunningham, C. et al. (2016). Is the NZ Government responding adequately to the M?ori Affairs Select Committee’s 2010 recommendations on tobacco control? A brief review. N Z Med J, 129(1428), 345-348.

Blakely, T., Thomson, G., Wilson, N., Edwards, R., & Gifford, H. (2010). The M?ori Affairs Select Committee Inquiry and the road to a smokefree Aotearoa. N Z Med J,, 123(1326), 26-32.

Blakely, T. (2002). The New Zealand Census–Mortality Study: Socioeconomic Inequalities and Adult Mortality 1991–94. Wellington: Ministry of Health.

Blakely, T., Cobiac, L., Cleghorn, C., Pearson, A., van der Deen, F., & Kvizhinadze, G. et al. (2015). Health, Health Inequality, and Cost Impacts of Annual Increases in Tobacco Tax: Multistate Life Table Modeling in New Zealand. PLOS Medicine, 12(7), e1001856.

Came, H., McCreanor, T., Doole, C., & Simpson, T. (2016). Realising the rhetoric: refreshing public health providers’ efforts to honour Te Tiriti o Waitangi in New Zealand. Ethnicity & Health, 22(2), 105-118.

Craig, G. (2002). Towards the measurement of empowerment: the evaluation of community development. Community Development Journal, 33(1), 124–146.

Durie, M. (2000). Te pae mahutonga: a model for Maori health promotion. Palmerston North: Massey University.

Labonte, R. (1996). Community development in the public health sector: The possibilities of an empowering relationship between the state and civil society. Toronto: York University .

Laverack, G. (2007). Health promotion practice: Building empowered communities. Maidenhead: Open University Press.

Ratima, K. a. (2004). Maori public health action: a role for all public health professionals. Wellington: National Health Committee.

Ratima, M. (2001). Kia uruuru mai a hauora being healthy, being Maori: Conceptualising Maori health promotion. Dunedin: University of Otago.

Ratima, M. (2004). Evidence-based Maori health promotion. Melbourne: World Conference on Health Promotion and Health Education.

Ratima, M. R. (2007). Rauringa raupa: Recruitment and retention of Maori in the health and disability workforce. Auckland: AUT University.

Salmond, C., Crampton, P., Atkinson, J., & Edwards, R. (2011). A Decade of Tobacco Control Efforts in New Zealand (1996-2006): Impacts on Inequalities in Census-Derived Smoking Prevalence. Nicotine & Tobacco Research, 14(6), 664-673.

Signal, L., Bowers, S., Edwards, R., Gifford, H., Hudson, S., & Jenkin, G. et al. (2016). Process,    pitfalls and profits: lessons from interviewing New Zealand policy-makers: Table 1:. Health Promotion International, daw065.

van der Deen FS, I. T. (2014). Projecting future smoking prevalence to 2025 and beyond in New Zealand using smoking prevalence data from the 2013 Census. N Z Med J , 71-79.


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