Teresa Butler started smoking at 8 years old.

Her mother would give her five dollars to go to the shop in Christchurch, New Zealand, and buy a pack of cigarettes — "then I would buy some lollies with the change," Butler recounts. At home, her job was simple: Run the lighter and cigarettes to her mother every hour or whenever she yelled out, " 'Teresa, bring me my smokes!' "

And she didn't just bring the cigarettes. When grabbing the pack, "I would take the cigarette out, put it on my mouth, light it and take the cigarette to her. I knew how to inhale it," Butler says. "She had no idea or didn't care."

Butler doesn't blame her mother for introducing her to tobacco. In the 1980s, when she was growing up, cigarettes were a way of life, with over half of New Zealand's indigenous Māori population smoking. Prior to colonization, Māori were one of the few societies in the world with no history of using tobacco, alcohol or other intoxicants. That all changed when the Europeans arrived in the late 1700s.

According to Butler, a member of the Ngāti Porou and Te Arawa tribes, the intergenerational trauma of colonization, from cyclical poverty to systemic racism, meant there was little to no education among Māori that smoking was harmful, let alone the resources to quit. "My mother had to feed seven of us," she says. "Now when you have to feed seven children, you don't eat." But cigarettes, at two dollars a pack, were a cheap way for her mother to alleviate the stress and distract from the hunger pangs.

Growing up in a household of smokers, Butler soon became addicted to cigarettes herself. At 36 years old, she took a pregnancy test and found out she was going to be a mother, a cigarette in one hand and beer in the other. "I remember just having a puff of smoke," Butler says, "and going, 'It doesn't count until I go and see the doctor on Monday.' " Her mother whacked the beer out of her hand but not the cigarette. She believed alcohol was bad for the baby — but smoking was okay.

New Zealand's bold goal to snuff out smoking

In 2011, New Zealand set one of the most audacious public health targets in the world: to slash its cigarette smoking rate to 5% by 2025.

The rate was 18% at the time. Fast forwarding over a decade later, the country seems on track to reach this goal ahead of the 2025 target — but only for its European and Asian populations. Māori, on the other hand, had the country's highest smoking rate at 20% in 2021, and they are expected to reach the 5% goal only 40 years later in 2061 per government modeling. According to Andrew Waa, a member of the Ngāti Hine tribe and an associate professor of public health at the University of Otago, the data underscore a bitter story: Māori communities have been left behind yet again.

Every year, 4,000 Māori die in New Zealand, and cigarettes are responsible for nearly a quarter of these deaths, according to an estimate in The New Zealand Medical Journal. The study also found that smoking explains a third of the seven-year life expectancy gap between Māori and other New Zealanders.

Still, Waa sees reason for hope. Last December, in an all-hands-on-deck effort to get Māori across the 2025 finish line, New Zealand passed one of the strongest anti-tobacco laws in global history.

Specifically, the legislation limits the amount of nicotine in cigarettes to non-addictive levels and reduces the number of retailers allowed to sell cigarettes from 600 currently to 60 by July 2024.

Most remarkably, the law bans the next generation of New Zealanders — anyone born after 2008 or currently 14 years old or younger — from ever buying cigarettes in the country. "The denicotinization and retail reduction are important for us to get to the lower than 5% smoking rate," says New Zealand's Health Minister Ayesha Verrall, "and then the smoke-free generation policy is to keep us there."

With this experimental legislation, Māori have the most to gain but also, by extension, the most to lose. Although Waa supports the new law, he's concerned that vulnerable communities might suffer unintended consequences from its "sledgehammer measures," such as Māori suffering because they do not have sufficient resources to quit smoking.

I interviewed a smoker, a community advocate, a researcher and a politician from the Māori population to learn how they think this bill will impact their communities. Beyond their various concerns, they all emphasized one key requirement for the success of New Zealand's tobacco law. With Māori making up less than a fifth of the country's 5.2 million population and their voices long subjugated by the European majority, "this has to be done with Māori, not on Māori," Waa says.

Fears that the crackdown on smoking will backfire

Tobacco regulation is like a game of whack-a-mole: Knock a product out of one market, and it'll usually pop up in another possibly illegal transaction. In 2019, illicit tobacco represented almost 12% of New Zealand's consumption, and this new legislation may further relegate tobacco to the black market, according to Māori physician and Parliament member Shane Reti, who has tribal affiliations to Ngā Puhi, Ngāti Wai, Ngāti Hine and Ngāti Kura. What he's particularly concerned about is that, given high rates of tobacco addiction in his community, this expanded black market will disproportionately impact Māori via more dangerous cigarettes and police crackdowns.

Take the example of 41-year-old Rora Morice, a member of the Ngāti Porou tribe who has been smoking since she was 15. She doesn't usually purchase cigarettes from the local convenience store because it would cost her $30 a week given the country's high taxes. Instead, she usually gets her tobacco in a "big black bag," with someone in her community doing a smash-and-grab burglary and selling tobacco for cheap on the streets.

She's not worried that the government will be reducing the number of shops carrying cigarettes or the amount of nicotine within cigarettes because "we do know a few girls that are trying to be air hostesses so that they can bring shit back home." Morice further speculates, "there will be crime, and there will be a black market of people selling to make quick money."

The risk of such smuggled tobacco, Reti points out, is that it would exist wholly outside New Zealand's safety regulations. As such, he posits that these cigarettes would be more addictive and toxic for Māori who continue to smoke, with higher levels of nicotine and heavy metals like lead. (It is presently illegal to import tobacco into New Zealand without a permit.)

On the supplier side, organized crime syndicates, which are responsible for large-scale cigarette smuggling, may also surge. "We have some of the highest cost of living and the highest inflation we've had in decades in New Zealand," Reti says, "and what we know is that vulnerable groups who are desperate turn to crime." Given New Zealand's incarceration rates — over half of prisoners are Māori despite representing only 17% of the country — Reti worries that an invigorated black market will lead to a disproportionate crackdown in his community and an even higher percentage of Māori prisoners.

A shortage of cessation services

Waa isn't terribly concerned about the black market; he thinks the tobacco industry and its supporters are hyping that fear to undermine regulations. But he is worried that bold anti-tobacco policies are being enacted without sufficient support systems for Māori trying to quit.

Take the government's denicotinization requirement, which would essentially eliminate the pleasure-inducing part of smoking cigarettes. No country has previously tried this policy before, but it is projected to reduce New Zealand's tobacco usage by 90% based on randomized controlled trials and modeling estimates. Waa says that "the rates of smoking literally drop off a cliff, so you could expect to have that reduction achieved within six months to a year."

Currently, the Ministry of Health offers a call-in Quitline and face-to-face programs to help New Zealanders quit smoking. However, Waa estimates that reaching the Smokefree 2025 goal would require five times more smoking cessation services for Māori as New Zealand currently has. As Waa wrote in a 2018 research study in The New Zealand Medical Journal, the "increase required in service provision and supported quitting ... seems unrealistic" absent "massively increased investment."

But Waa argues that the government has not yet sufficiently scaled cessation services, so he worries that Māori will face undue stress when trying to quit.

A threat to neighborhood convenience stores

Reti is also concerned about the economic impact on New Zealand's dairies because the anti-tobacco legislation reduces the number allowed to sell cigarettes by 90%. (Dairy is the term New Zealanders use for neighborhood convenience stores.) That might be problematic because tobacco makes up a substantial proportion of dairies' revenue, with estimates ranging from 14% to 47%. If dairies can't find other ways to increase sales, this policy "will almost decimate the small retailers, those small corner dairies," says Reti.

Correspondingly, it might become more difficult for some Māori to buy milk, eggs and other groceries given that dairies are disproportionately located within their communities. "Where do the vulnerable go? Few of them have vehicles; few of them can afford the petrol to go further. Where do they get their staples in life once this policy has removed their closest shopping outlet?" Reti asks.

But just as he isn't concerned about the black market, Waa thinks these economic arguments are similarly overblown. "This is my conspiracy hat on, but we suspect that a lot of these arguments are put up by the tobacco industry" to keep their product in stores. Waa points to how dairy owners submitted some 1,000 complaints to the government, all of them following a single template. In any case, Waa has little sympathy for retailers insisting on selling tobacco "because they're making money out of my people dying."

Why the Māori feel left out

Ultimately, the four Māori individuals I interviewed — Butler, Waa, Reti and Morice — all emphasize that navigating these potential pitfalls, from the black market to Māori quitting smoking without sufficient support to the closure of vital corner stores, will require a culturally competent approach.

Historically, smoking cessation has been a one-size-fits-all endeavor in New Zealand, with messages targeted toward the majority European population and neglecting Māori values. "Whānau, or family, is the atomic unit for Māori," Reti says, "and so if you want to shift behavior, you don't shift it with the individual, you shift it with the family."

Waa describes the "It's About Whānau" media campaign as a particularly successful way to have Māori quit smoking. Launched in 2001, the campaign leveraged interviews with real Māori smokers to frame quitting as protecting one's family. In addition to print and radio advertisements, 15 television ads were produced and broadcast nationally, all ending on the line, "It's about whānau, call the Quitline on 0800 778 778." As Waa reported in the Australian and New Zealand Journal of Public Health, 54% of Māori smokers reported this campaign made them more likely to quit, with 51% of their families agreeing.

Despite these successes, Waa says that the New Zealand government has historically underinvested in these Māori-focused campaigns. That may now be changing, however, with the Ministry of Health in 2021 devoting $14 million to support greater smoking cessation services and recruiting Māori people as counselors to ensure these services respect the culture.

Indeed, as a Māori physician, Reti emphasizes the importance of prioritizing whānau within clinical practice. "If I want to affect, for example, diabetes, I need to have the wife and family in the room along with the diabetic husband," he says, so that the whole family engages in healthier behaviors and ultimately motivates change in the patient.

The Te Hā – Waitaha Māori quit-smoking service takes a similar family-centered approach, with one-on-one support alongside home visits and community clinics. Critically important, Te Hā – Waitaha doesn't measure success only in terms of quitting, instead focusing on reducing patients' number of cigarettes and saving them money. In this harm reduction framework, nicotine gum, patches, lozenges and vapes are offered free of charge, with the goal of meeting patients where they are and providing them whatever resources they need.

These types of Māori-specific programs, however, are not yet widespread across New Zealand. Morice, for instance, told me how her white European general practitioner talked to her about quitting smoking but never followed up.

"If [Morice] was a non-Māori female, it would be jumped on, and that person would get full support," says Butler. "She doesn't."

Beyond a family-centered approach, antismoking efforts can also lean into the competitiveness and inter-tribal rivalry of Māori culture to change people's behavior, according to Marewa Glover, director of the Centre of Research Excellence: Indigenous Sovereignty & Smoking. "This rivalry and competition is not a means of excluding others," she wrote in a 2013 research paper in BMC Public Health, "rather it develops and maintains a sense of collective unity, loyalty and belonging within the group." This competitiveness and community participation has been previously leveraged to support weight loss and seatbelt use among teenagers.

Take kapa haka, traditional Māori performing arts with competitions attracting up to 60,000 attendees, or Smokefree Rockquest, a nationwide battle of the bands with the government's antitobacco campaign in its name. Both have sought to integrate competitiveness, culture, community participation and public health to drive smoking cessation.

A by-Māori for-Māori approach

In general, the more ambitious a campaign, the greater the potential for miscalculation. But Waa argues that these risks are manageable with more vigilance, intentionality and strong Māori leadership.

For decades already, Māori have independently worked to address their community's high smoking rates. Any additional help is welcome — and Butler says she is excited about the antitobacco bill. However, she doesn't trust the government to implement it on its own. She offers an anecdote from late February: A non-Māori Ministry of Health official led a meeting of Māori community leaders — "she doesn't follow our tikanga [customs and traditional values]; she has no understanding of the Māori words we're saying!" — and how a government official flew into her community in Christchurch, took a photo with Māori residents, and then left after two hours. "That plane ticket, flying down and flying back, could have gone into the community. It would have been thousands."

A Ministry of Health spokesperson notes that this meeting was organized by Māori staff, writing in an emailed statement that "appropriate tikanga was observed for the setting." While the spokesperson did not dispute the allegation that the meeting was led by a non-Māori official, she emphasized that the Ministry of Health has been organizing various forums to engage Māori communities and seek their feedback on proposals. In fact, last year the New Zealand government established the Te Aka Whai Ora (Māori Health Authority) as an independent board working with the Ministry of Health in order to ensure a by-Māori for-Māori approach.

Butler, who recently joined the Māori Health Authority, is emphatic that this approach is the only path forward to reducing smoking rates below 5%. "My job is to help our whānau come off this hideous addiction so that they can live longer to be with their children," says Butler. She adds optimistically, "we know our people; we can support them the best because we're on the ground."

Simar Bajaj is an American freelance journalist who has previously written for The Atlantic, TIME, The Guardian, Washington Post and more. He studies the history of science and chemistry at Harvard University and is a research fellow at Massachusetts General Hospital.

Copyright 2023 NPR. To see more, visit https://www.npr.org.

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