As the Smokefree Coalition prepared to wind down its operations – a victim of its own success – Hauora’s Jo Lawrence-King talked to its outgoing Executive Director, Dr Prudence Stone, about the Smokefree movement as a health promotion initiative.
Smoking cessation as a health promotion intervention
Dr Stone believes both tobacco control and smoking cessation exemplify health promotion. Together they empower communities with knowledge, evidence and resources to take control back from the ‘Big Tobacco’ industry; allowing those who smoke to free themselves from an industry that seeks to keep them addicted.
As a sociologist Dr Stone says she is fascinated with what motivates people. She believes this fascination has helped her in her approach to health promotion. “My sociological imagination really helps me to stay aware of the cultural dymanics and structures underlying people’s motivations. So it was really great when Professor Marmott came to town and spelled out to our public health community the ‘social determinants’ of health and health inequalities. I was already applying this framework when I was rallying submissions from the membership to the Maori Affairs Select committee Inquiry.
“I believe there are too many people in health promotion with qualifications in only health promotion. This area of expertise, from what I have seen, can be counter-intuitive to their role in engaging communities and influencing peoples’ choices and behavior.”
She cites many examples of health promotion messages that presume people simply need to know the right choice to stay healthy, and they will make that right choice. But, she says, health is not what motivates people. “People are unconscious of their health!” She claims. “Asking someone to engage consciously with the healthy choice for the healthy choice’s sake makes the one who asks it seem wacky at best, annoying at worst.” Instead Dr Stone asserts people become conscious of their health only when it is gone, and they become sick.
For this reason, she believes raising the price on tobacco is the single most effective measure that can be taken to reduce demand for tobacco. “The prospect of losing money is what motivates people – the prospect of saving money is what motivates people: effective health promotion ditches the language we learn in the classroom about why it’s necessary for society, and starts talking directly to the values embedded in that society.”
Looking back on the success of the Smokefree Coalition
The bad news for the Smokefree Coalition is that its funding has come to an end. The good news is that this is due to its enormous success: achieving record lows in smoking in Aotearoa New Zealand. “I feel very proud of the unity of voice we’ve demonstrated and the impact it has had on helping New Zealand reach this point,” says Dr Stone.
A longstanding child advocate, Prudence cites as a measure of the Coalition’s success the record low in year 10 children who have never smoked. “I believe we’ve reached a tipping point of public support for further measures [to support the Smokefree movement],” she says. “There is an acceleration of expansive Smokefree environmental policy at local government level, a burgeoning groundswell of retailers removing tobacco from their stores, and a commitment to an endgame from our government leaders.”
But there is a cautionary note from her as well: “so long as there are New Zealanders addicted to tobacco and a marketplace saturated with tobacco products, there is a need for health professionals to lead and coalesce, and develop a cohesive strategy for effective support and advocacy,” she warns.
The Smokefree movement is personal and poignant
Always acutely aware of injustice and the imbalance of power, at university Dr Stone focused on an area of sociology called the political economy of information. This is the field of study that exposes the way multinational corporations manipulate the information the public receives, to keep it unaware of injustices in their business practices and the truth behind their products. “You could say I was in training at university for a job fighting Big Tobacco.”
When Prudence was 11 years old, she was the first to wake up one morning and find her grandmother – ‘my best friend’ – dead. “Her pack of smokes was right there beside her and I still remember seeing the longest line of ash on the butt of a cigarette in the ashtray. She had lit it up and then died before it had gone out.” Prudence later named her daughter after her beloved grandmother.
Smoking cessation measures favour non-Maori populations
Dr Stone is anxious to answer claims that the tax measures and price rises are racist. The claim is based on the fact that Maori are more highly represented than non-Maori in smoking statistics; giving rise to the (misguided) belief that tangata whenua are being targeted with punitive measures.
Looking at the data alone it’s easy to see that proportionally more Māori than non-Maori tend to smoke. “Claims that tax measures are racist go against robust evidence to the contrary.” Says Dr Stone. “People making these claims fail to notice to the government’s ‘population-based approach’ to cessation advice and triage, which by its nature fails to reach a significant proportion of Maori.
The government programme is provided only to those who visit primary and secondary care facilities. According to Prudence up to a quarter of the New Zealand population does not visit a primary or secondary care facility in a given year. She believes much of this sub-section of the population consists of Maori; many of whom have no money to afford healthcare, or whose past experiences with the health system have caused them to lose any faith in it to serve them with cultural competence. Dr Stone postulates that these are the very people the government’ describes as ‘hard to reach smokers’.
What’s impossible to observe from the data, she says, is the story of colonisation, and the introduction of tobacco via trade. “Wahine Maori became addicted to tobacco long before it was considered acceptable for European women to smoke. That background is very important to understand. These are the two hundred year-old social determinants that underlie today’s data.”
The price of tobacco is set in place to motivate those people who are not reached by other cessation programmes, she says.
During her time at the Smokefree coalition Dr Stone has worked hard to frame the inequities of government policy and statistical inequalities in a more constructive way for tangata whenua, but she fears the risk of misinterpretation remains.
Seven years to make significant improvements
Prudence Stone began her solo role at the Smokefree Coalition nearly seven years ago in 2009; the same week Maori Affairs called for submissions to its public inquiry on the tobacco industry and the consequences of tobacco use for Maori.
Over the next few years she built the Coalition to over 50 members; in the process justifying a second staff member to assist her. Her work unified the efforts of the Coalition’s members to support a range of measures that have led to a massive reduction in smoking rates in this country. “The Smokefree Coalition is small and cost-efficient when it comes to its operations, but vast and nationwide when it comes to its broad membership and scope of influence.”
Dr Stone is quick to acknowledge that she and her colleague were strongly supported by a board, active key members and “incredible” DHB and PHU stakeholders. “The readiness and responsiveness of our sector makes it feel as if we’re one awesome whanau.”
Where to next for Dr Stone?
As Prudence prepares to finish her work at the Smokefree Coalition she is eyeing her future with energy and determination. Advocacy will remain central to her, but she is also not ruling out the idea of entering politics one day. “There is just so much I want to get done before I die,” she enthuses. “Luckily I’m a great planner and strategist, so I have the fortune of seeing at least a tenth of it achieved by now. I love to help, I love great ideas, and I’m not jealous at all about whose great idea it is. If it’s someone else’s great idea, I just want to play a part in helping seed it on some fertile ground.”
She cites her children as her motivation. “There’s a world to leave behind, and for now it’s a mess and needs cleaning up!”
About the Smokefree Coalition
The Smokefree Coalition was established back in the ‘90s to be a united voice for action and advocacy for evidence-based tobacco control measures. The premise is that while so many organisations have a vested interest in tobacco control, their core business is focused on representing a particular health-related workforce or a specific non-communicable disease: for efficiency’s sake you need one organisation focused on uniting them all and coordinating their activities for maximum influence and clarity of message.
The Smokefree Coalition is itself a member of the Framework Convention Alliance, a global coalition of organisations supporting and informing the implementation of the World Health Organisation’s Framework Convention on Tobacco Control (FCTC). This Framework provides the raft of evidence-based measures to take, and guidelines for signatory nations in order to implement them. Prudence believes New Zealand is only ‘pretty good’, in staying faithful to the FCTC. “Perhaps only because members of the Smokefree Coalition are vigilantly holding our government representatives accountable to it.”
Members of the Smokefree Coalition have supported and informed all the legislative measures that have been put in place in New Zealand: the Smokefree Environments Bill Amendments which have
- made bars and restaurants Smokefree,
- banned tobacco’s promotional retail display,
- reduce allowances of duty-free tobacco
- raised tobacco’s excise tax,
- currently; introducing standardised packaging of tobacco and banning smoking in cars carrying children.
In 2009 the Smokefree Coalition published a landmark document, Achieving the Vision: Tupeka Kore Aotearoa 2020
which members used to advocate a radical idea: regulating tobacco’s supply and eliminating demand for tobacco altogether, to return Aotearoa to its original state, free of tobacco. This vision was well-received during the Maori Affairs Select Committee’s Inquiry on the tobacco industry and the consequences of tobacco use for Maori. It was this select committee’s Inquiry report which inspired government’s commitment to making Aotearoa a Smokefree nation by 2025.