Williams L. The impacts of colonization on the inequities of smoking during pregnancy in Aotearoa. HPHR. 2021;34.
Smoking during pregnancy is one of the most common preventable causes of pregnancy complications and remains a significant health issue worldwide (Glover, Nosa, Watson, & Paynter, 2010). Maternal smoking increases the risk of infant mortality (Centers for Disease Control and Prevention, 2016), stillbirth, intrauterine growth restriction (Rodriguez-Thompson, 2018), and preterm birth (Pollack, Lantz, & Frohna, 2000). Children born to mothers who smoked during pregnancy are at increased risk of sudden unexplained infant death (SUID) (Anderson et al., 2019), respiratory disorders (Braillon, Bewlet, & Dubois, 2010), obesity (Oken, Levitan, & Gillman, 2008), and poor neurodevelopment (Cornelius & Day, 2009). Moreover, smoking during pregnancy has been associated with adulthood obesity, metabolic disorders and cardiovascular disease (Humphrey, Rossen, Walker, & Bullen, 2016).
Despite a decline between 2008 and 2015 (Ministry of Health, 2017), the prevalence of smoking during pregnancy in Aotearoa (original name given to New Zealand by Māori, the indigenous people of Aotearoa) remain significant, with 11.7% of all women smoking during pregnancy. Unfortunately, inequities exist between Māori and non-Māori in the burden of smoking during pregnancy, with 31.8% of all women who identified as Māori smoking during pregnancy (Ministry of Health, 2018). This, in turn, perpetuates inequities in perinatal outcomes in Aotearoa. Babies of Māori māmā (mothers) are more likely to be born preterm (Ministry of Health, 2017), and are at increased risk of neonatal death (Perinatal and Maternal Mortality Review Committee, 2018). Moreover, of the 68 neonatal deaths from SUID between 2007 to 2016, 45 of these were babies born to Māori māmā (Perinatal and Maternal Mortality Review Committee, 2018).
To understand why these inequities exist, we must have a framework for considering the factors that influence health. One such model is the rainbow model, which hypothesizes that the determinants of health of the general population are organized into rainbow-like layers of influence, with the individual placed at the center (downstream determinants), and in the periphery are general socioeconomic, cultural and environmental conditions (upstream determinants) (Dahlgren & Whitehead, 1991). The colonization of Aotearoa by Pākehā (Europeans) in the late 1700s and subsequent events marked a significant transition in the socioeconomic, cultural and environmental conditions experienced by Māori (Ministry for Culture and Heritage, 2016). Put aptly by Reid and Robson (2006): “it is impossible to understand Māori health status or intervene to improve it without understanding our colonial history” (Reid & Robson, 2006). As such, the aim of this essay is to consider the impacts of colonization on the inequities of smoking during pregnancy that exist between Māori and non-Māori. The author acknowledges that the links between Māori health and colonization are extensive, and that it would be impossible to cover all points in-depth. However, the author wants to discuss three pertinent topics in as much detail as is practicable: 1) the introduction of tobacco with colonization and its initial impact; 2) the marginalization of Māori with colonization and its links to smoking in pregnancy; and 3) why smoking cessation interventions are not effective for Māori hapū māmā (pregnant mothers).
Tūpeka (a transliteration from tobacco) was first introduced to Māori when Pākehā arrived in Aotearoa in the late 1700s. By the early 1800s, it became a standard trade item for Pākehā, who used it to pay Māori (including children) for services and resources. Moreover, when tūpeka plants became available, they were planted by Māori in the community gardens (Cook, 2013). Eventually, smoking became prevalent amongst Māori, and its use amongst Māori was not restricted by sex or age as it was with Pākehā. In the 19th century, where it was unacceptable for Pākehā wāhine (women) to smoke, Māori wāhine were often photographed or painted with smoking pipes. Māori children also smoked, but its prevalence was not known (Cook, 2013). By the mid-20th century, tūpeka and smoking had become embedded in Māori communities (Cook, 2013).
Although speculative, one interpretation of the ‘societal norms’ administered by Pākehā is the belief of their own superiority: that Pākehā wāhine are too good for tūpeka but Māori wāhine are not. It has been noted that colonization is based on dehumanizing indigenous peoples, which is dependent on the colonizers holding the belief that they are superior (Reid & Robson, 2006). The standards for smoking in wāhine set by colonizers established a difference in smoking prevalence between Māori and Pākehā wāhin that is still present today, with important ramifications as mentioned above.
The colonial beliefs about wāhine smoking and the trends that occurred subsequent to introduction of tūpeka can be viewed as the event responsible for the inequities that exist between Māori and non-Māori hapū māmā that we see today.
As referred to earlier, the colonization of Aotearoa brought about significant changes to the socioeconomic, cultural and environmental conditions that Māori had previously enjoyed. Upon their arrival, Pākehā established a multitude of new systems that outlined how the acquisition and (re)distribution of resources was to occur, and to whom these resources were allocated. These systems were constructed to benefit Pākehā and afford them privileges over Māori (Reid & Robson, 2006). From the 1840s, there was a steady and marked loss of Māori land through Crown purchase, land confiscation and the Native Land Court. Between 1840 and 1865, Pākehā acquired Māori land under the principle of ‘Crown pre-emption’ – that only the Crown had rights to end Māori customary title to their lands. This allowed the government to acquire Māori land at low cost, “and then on-sell it to settlers at a higher price, with the profits supporting the costs of immigration by British settlers” (Boast, 2008). Using Crown pre-emption, Pākehā acquired almost the entire South Island and significant areas in the North Island (Boast, 2008).
In the early 1860s, Parliament passed the New Zealand Settlements Act, which allowed for the confiscation of Māori land in order to punish tribes that ‘engaged in open rebellion against Her Majesty’s authority.’ Pākehā settlers would then occupy the confiscated land (Adds, 2005). Following this, the Native Lands Act produced the Native Land Court in 1865. This legislation made it easier for Pākehā to purchase Māori land by converting traditional communal landholdings into individual titles, and by maintaining that judgements could only be based on evidence before the Court. With Court attendance being mandatory, many Māori amassed large legal bills and were forced to sell the land they had been defending in order to settle their debts (Taonui, 2012).
The loss of land led to the displacement of a significant proportion of Māori, and “deprived of their land, tribes were in many instances reduced to poverty, with no option but to live in overcrowded and unhygienic conditions” (Pool, 2011). Equally important was the cultural poverty that Māori suffered. With colonization came the development of a new history centered around Pākehā, and with this, Māori beliefs and knowledge were “relabeled as myths, legends and superstition” (Reid & Robson, 2006).
The poverty suffered by Māori following colonization has had intergenerational impacts, with the effects of colonization still present today. Māori are more disadvantaged than non-Māori across a range of socioeconomic indicators, including unemployment, income and overcrowding in households (Ministry of Health, 2016b). This is important, as “tobacco and poverty have become linked in a vicious circle” (World Health Organization, 2018). The prioritization of spending on tūpeka with limited income means that whānau (families) living in poverty have less expendable income for other necessities such as food, education and healthcare. Additionally, smoking is more prevalent amongst deprived populations (World Health Organization, 2018). The intergenerational poverty resulting from colonization, along with the integration of smoking in Māori communities, has established intergenerational use of tūpeka. As one Māori wahine (woman) stated:
“Well, the majority of Māori people are brought up around alcohol and drugs and cigarettes. Like you’re born into it. And then you’ve got Māori people who have nothing, like they live in poverty… Then that is your life. Like that becomes your life. And that is what you know, so you smoke” (Ministry of Health, 2016a).
Ultimately, the colonial systems designed to benefit Pākehā have exacerbated the inequities in smoking during pregnancy between Māori and non-Māori through marginalization and intergenerational poverty.
Numerous smokefree interventions have been introduced in Aotearoa. In 1990, Parliament passed the Smoke-free Environments Act, which requires smokefree workplaces, schools and early childhood centers, limits tobacco advertising and promotion, and restricts tobacco sales to those ³18 years old. Under the same Act, tobacco packs are required to have graphic health warnings, with current warnings including pictures of gangrenous feet, rotting teeth and cerebral infarcts (Smokefree, 2019). Aotearoa also introduced standardized packaging for tobacco in 2018, which restricts the appearance of brand names on tobacco products, and requires pictures and health warnings to cover at least 75% of the front of tobacco packs (Smokefree, 2019).
Yet, the presence of inequities between Māori and non-Māori with regards to smoking during pregnancy demonstrates that current interventions are insufficient, and that national interventions specifically designed for Māori are urgently required (Glover et al., 2013). It has been found that many Māori wāhine were not aware of the interventions available to them, and the interventions that they had trialed had not been successful (Ministry of Health, 2016a).
Another reason current interventions are unsuccessful is that they fail to acknowledge the negative impact that environment has on smoking cessation efforts. Many Māori wāhine begin smoking because of their whānau. As smoking is so pervasive in many day-to-day situations for these wāhine, smoking cessation is made much more difficult. Moreover, these wāhine face other complex challenges on a day-to-day basis as a consequence of intergenerational poverty, and use smoking as a coping mechanism in lieu of other effective social supports (Ministry of Health, 2016a). Consequently, smoking cessation may not necessarily be a priority for these wāhine, and “forcing smoking cessation to the fore without addressing the wider conditions and circumstances is likely to be counterproductive and alienating” (Ministry of Health, 2016a).
The development of regional, whānau-centric interventions specifically targeted for Māori wāhine, that also acknowledge the impact of environmental factors, has shown promise. In the Waikato region of Aotearoa, Te Puna Oranga (Māori health service providers) have based their Māori antenatal classes (Hapū Wānanga) on Te Whare Tapa Whā, a Māori health model that considers not only the physical aspect of health, but also the whānau, emotional and spiritual aspects (Pollock, 2011). Alongside these classes, smoking cessation services are provided. ‘Once and For All’ is an incentive-based smoking cessation intervention available in the Waikato and Tairāwhiti regions of Aotearoa. Hapū māmā receive NZD $50 on signing up and a further NZD $250 if they remain smoke free for four weeks (Pinnacle Midlands Health Network, 2016). These interventions have been immensely successful: prior enrolment in the wānanga, 11% of hapū māmā considered smoking cessation, which increased to 89% after enrolment Unfortunately, the Māori-centric design of such interventions appears to be an exception rather than a rule, and until targeted interventions that address upstream determinants become the norm, a reduction in the inequities currently affecting Māori hapū māmā is unlikely.
There is hope though, with governmental inquiries into the historical injustices by Pākehā that have produced the smoking inequities in Aotearoa. Recently, the Waitangi Tribunal started the kaupapa (thematic) claims inquiry programme, which includes the Health Services and Outcomes Inquiry. Established after the Treaty of Waitangi Act (1975), the Waitangi Tribunal is “a permanent commission of inquiry that makes recommendations on claims brought by Māori relating to Crown actions which breach the promises made in Te Tiriti o Waitangi (The Treaty of Waitangi)” (Ministry of Justice, 2019a). Claims brought to the Tribunal are that breaches of Te Tiriti o Waitangi by the Crown have caused suffering by Māori. Once the Tribunal issues its report, claims are often settled following negotiations that involve cultural, financial and cultural redress by the Crown (Ministry of Justice, 2019b).
In 2017, the Tribunal began the Health Services and Outcomes Inquiry, which involved “claims concerning grievances relating to health services and outcomes and which are of national significance.” (Ministry of Justice, 2019c). This inquiry included the issue of tobacco abuse, with the Tribunal addressing questions such as “to what extent have Crown acts or omissions, if any contributed to disparities in health services and outcomes between Māori and non-Māori with alcohol, tobacco and substance abuse issues and how are these recognised and addressed?” (Waitangi Tribunal, 2018).
Smoking in pregnancy is associated with many consequences at all phases of life and development. Using the rainbow model, the inequities that exist between Māori and non-Māori regarding smoking in pregnancy can be traced back to the colonization of Aotearoa. The introduction of tūpeka, the marginalization of Māori, and the development of Eurocentric smoking cessation interventions has placed a much greater burden on Māori hapū māmā. Until interventions are developed using a Māori worldview, these inequities will continue to affect future generations of Māori.
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All named authors have contributed to the creation of the submission, and grant HPHR permission to review and (if selected) publish their work. The authors do not have any personal, commercial, academic, or financial interests that influence the research and opinions represented in the work submitted to HPHR. The submission is not currently under consideration by another publication and/or has not previously been published elsewhere.
Logan Zane John Williams is with the Faculty of Medical and Health Sciences, The University of Auckland, New Zealand.