1. Smoke, smoking and cessation: The views of New Zealand children with respiratory illness Dr Marewa Glover Anette Kira Julienne Faletau Centre for Tobacco Control Research School of Population Health

2. Asthma is a worldwide public health problem affecting about 300 million people. World Health Organisation recognises asthma as a leading NCD, the poor management of which is undermining achievement of the Millennium Development Goals Poverty, poorly informed, poor provision of asthma medicines

3. Consequences of smoking on respiratory conditions Māori have higher risk of dying from respiratory diseases and have higher rates of hospitalisation and death than non-Māori Source: Robson, B., & Harris, R. (Eds.). (2007). Hauora: Maori Standards of Health IV. A Study of the Years 2000-2005. Wellington: Te Popu Rangahau Hauora a eru Pomare

4. Consequences of exposure to non-smokers Exposure to smoking during pregnancy increases the risk of Respiratory response to low oxygen levels in the bloodstream Respiratory infection Chronic bronchitis, wheezing, lower respiratory tract illness Any asthma Secondhand smoking increases the risk of respiratory problems lung cancer

5. Why this study? Need to urgently reduce smoking among Māori and Pacific Island parents of asthmatic children Need to understand more about children’s exposure to SHS (identified as a research need in the Governments response to the Māori Affairs Select Committee’s Report on tobacco). No research investigating NZ children’s perceptions of parents’ smoking Aim: to explore the attitudes of Māori and Pacific children with respiratory illness towards second hand smoke (SHS), smoking and parental smoking cessation.

6. Method 27 Māori and 13 Pacific children (6-11yrs) were interviewed (7 individually, 34 in focus groups) They were asked: – attitudes towards smoking – how SHS affects them – fears and concerns about smoking for themselves and their parents – how to reduce their exposure to smoking – their experience asking parents to quit smoking Interviews were transcribed, entered into NVivo and analysed using a deductive approach

7. Results SHS made them feel “bad”, “angry”, “uncomfortable”, and “really sick”, making them want to get away from the smoke. They were aware that smoking “is dangerous” and that “you could die from it”. “If you smoke too much you’ll have to go to the hospital and get your body fixed”

8. Results - Fears Children expressed fear for their mother or father or other family members who smoked. “They might get cancer and die and we’ll feel sorry”... “and we won’t have parents to look after us”.

9. Results – SHS Exposure Beliefs of effect of secondhand smoking exposure. The children appeared to extrapolate the potential ill-effects of direct smoking to bystanders exposed to secondhand smoke. “it could’ve got in her… face and then she could’ve got sick… and could’ve died” (8yr Māori M). “The boy might not breathe… like stop breathing… cause the smokes are coming into his nose” (8yr Tongan M).

10. Results – Children’s own experiences Children mentioned that being around smoking gave them a “tight chest” (8yr Māori F), “headaches” (10yr Māori F), it made them cough and smoke made it difficult for them to breathe. “It made my asthma bad and then I coughed hard” “It makes you can’t breathe… and then you have to go to the doctors”

11. Result – Reducing SHS Exposure “I usually just go away” Some children talked about asking smokers to not smoke around them, for example one child says to smokers “you’re not allowed to smoke around me cause I have asthma” Other children did not feel they could talk to smokers, or when they did the response was dismissive or ineffectual. Many of the children believed that there were rules against smoking around children or indoors. “you’re not allowed smoke in the car where babies are” (11yr Tongan M)

12. Result – Experience with Adult’s smoking cessation Many children had experience with people around them quitting : “Mum has tried to give up smoking and she has. So it’s really changed my life. So it’s changed everyone’s” Many children expressed positive feelings when someone had managed to quit smoking: “This time they [mum and dad] have stopped [smoking]. So I gave them a high five. I felt very happy and very proud of them” (6yr Māori F). Some children appeared to be aware that “smoking is hard to stop” one child said about his mother who “started again... But she can’t help it”

13. Result – Ideas for reducing smoking Children’s suggestions for how to increase adult cessation: “talking to them [smokers]” “say please can you stop smoking… because they [the parents] might die” “… you give me asthma” A number of children said to “hide all the smokes away”. However, they also expressed trepidation about doing that: “Last time when I saw my aunties pick her cigarettes, I was like should I pick them up and put them in the bin, and I was like oh nah she might give me a growling” Children also suggested – showing the smoker a “pamphlet of the lungs [affected by smoking]” – “put a sign” – “sticker that says no smoking” – “write a letter to the Prime Minister of NZ, John Key (10yr Māori F) asking him why he won’t ban smoking”.

14. Conclusions The children’s beliefs about the effects of smoking were quite fatalistic, lacking an understanding of risk – the message they receive is not “smoking increases the risk of cancer” but that “if you smoke you will get cancer”. Despite their relatively powerless position in the family to do anything about adults smoking, the children still wanted to help people who smoked to stop. The most common suggestion for reducing smoking prevalence and exposure to SHS was to appeal to smokers.

15. What can be done? The children supported policy measures restricting smoking in certain areas. Health providers and tobacco control providers need to be careful of encouraging ‘pester power’ and need to consider how to enable children to act on their fears for smokers in their life without increasing children’s risk of abuse. It would be safer for stop smoking campaigns to be the voice of the children.

16. What can be done? Health providers could tell parents that children have deep unspoken fears that their parents are going to die Give a clear consistent message to parents to stop smoking; And provide support to quit or referral to a smoking cessation service.