Pacific Peoples and Alcohol: a Review of the Literature Vili Nosa, Gemma Malungahu, Janine Paynter, Dudley Gentles, David Newcombe

article

Pacific peoples and alcohol: a review of the literature Vili Nosa, Gemma Malungahu, Janine Paynter, Dudley Gentles, David Newcombe

ABSTRACT AIM: To present a review of recent research exploring alcohol use by Pacific peoples in New Zealand. The review builds on a comprehensive narrative review of research and literature on Pacific peoples and alcohol use, Pearls Unlimited (2009). METHOD: We conducted a scoping review of published and grey literature written and published between 2009 and 2019. Research was included if the study population, or a clearly identified subgroup of the study population, included one or more Pacific ethnicities and addressed alcohol use. RESULTS: There were 30 relevant articles covering a large range of aspects of alcohol consumption by Pacific youth and adults. Alcohol consumption by Pacific men has declined significantly to 60% from 70% in 2006/07. However, of those who consume alcohol, 46% meet the threshold for hazardous consumption. Alcohol consumption by Pacific youth has also declined. CONCLUSION: While there has been some notable research and in-depth exploration of alcohol use and Pacific people, persistent inequity in hazardous alcohol consumption indicates that an evaluation of the current interventions to prevent and service unmet needs of Pacific peoples are overdue.

n 2009, Pearls Unlimited1 was published and alcohol consumption in the Pacific in order to draw together disparate youth population and, finally, the Iinformation on Pacific peoples and alco- aspects of acculturation contributing hol use. This paper provides an update on to greater alcohol consumption. research on alcohol use by Pacific peoples 2. Treatment and prevention options, since that report was published. such as the role the church can play in prevention or treatment of alcohol Previously problems, what treatment models are most successful for Pacific users highlighted gaps of alcohol and other drug treatment in the research services, the most effective mecha- Pearls Unlimited identified a number of nisms for dealing with alcohol abuse gaps in research that fell across different and alcohol related violence in Pacific areas of alcohol use.1 These were the broad communities, gender focused inter- areas: ventions and assessment of primary care models. 1. Motivations, reasons and context for drinking by Pacific peoples: these 3. Up-to-date trends in alcohol use include the history of alcohol use and consumption, particularly for in different Pacific communities, different Pacific ethnicities. Related to cultural expectations and obligations this was research to make the Alcohol relating to alcohol, life challenges that Use Disorders Identification Test may lead to alcohol use (eg, unem- (AUDIT) more culturally appropriate. ployment), resiliency and risk factors 4. A measure of the burden of hazardous in each different Pacific ethnicity, rela- alcohol consumption on Pacific tionships between sporting culture communities.

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(by authors GM and JP), thirty resources Methods were eligible for this study. These included This was a scoping review to give an journal articles (n=19), reports (n=10) and a update on the developments in research book (n=1). that have happened since Pearls Unlimited was published.1 A broad Google search of Results ‘Alcohol New Zealand’ was done to establish the current context for alcohol literature Prevalence of past-year alcohol relating to Pacific peoples in New Zealand. consumption This was also a starting point for the grey The New Zealand Health Survey provides literature search. Two other searches were recent data on alcohol consumption in New ‘Pacific people health New Zealand’ and Zealand.2 In 2017/18, around 79% of New ‘Pacific people alcohol’. Documents from Zealand adults reported consuming alcohol these searches contributed to the literature in the past year. This is similar across age review if they met the criteria or were used groups from 25– 64 years. Prevalence is to identify other eligible literature. higher for the 18–24 age group and lower for The databases used were Ovid Medline, older age groups (65+ years). After adjusting Embase, Scopus, Kiwi Research Information for age, results show that Pacific adults are Service, Cochrane, Index New Zealand, significantly less likely to have consumed PubMed, Google Scholar and ProQuest. alcohol in the past year (54%) compared to Targeted health website searches were also 85% of non-Pacific ethnicities (eg, European/ conducted (Table 1). other). Literature was included if it was published There has been a significant decline during the period of 2009–2019, written in alcohol consumption by Pacific males in English, included the Pacific population when comparing 2017/18 (60.0%) with in New Zealand and had a primary focus 2006/07 (70.5%). There was minimal change on alcohol use. Some earlier studies (pre- in alcohol consumption among Pacific 2009), or studies undertaken outside of women from 2006/07 (49.2%) to 2017/18 New Zealand, are cited to provide context (49.4%). Over the same period, there was for the included studies. Searches yielded a significant decline in proportions of both 846 items. Following removal of duplicates European men and women who consumed and exclusions based on titles and abstracts alcohol.

Table 1: Targeted health websites searched.

Organisation or resource Alcohol & Public Health Research Unit

Centre for Social and Health Outcomes Research and Evaluation

Centre for Applied Cross-cultural Research (CACR)

Health Services Research Centre

Health Research Council of New Zealand

Le Va

Matua Raki National Addiction Treatment Workforce Development Programme (NATWDP)

Mental Health and Wellbeing Commission

Ministry of Health

New Zealand National Drug Policy

New Directions in Pacific Health

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Prevalence of hazardous alcohol New Zealand Health Survey (2016/17) and consumption the Youth’12 The Health and Wellbeing of Secondary School Students in New Zealand Hazardous drinking in people aged survey. The New Zealand Health Survey, 15 years or older is measured using the as reported online, does not provide data 10-question Alcohol Use Disorders Identifi- broken down by ethnicity.2 cation Test (AUDIT) developed by the World Health Organization, and in the New Zealand A report by Fa’alili-Fidow and colleagues6 Health Survey a score of eight or more is based on the Youth’12 The Health and Well- considered hazardous drinking. While Pacific being of Secondary School Students in New adults were less likely than European adults Zealand survey provides the most up-to-date to have consumed alcohol in the past year, details on youth drinking by ethnicity. those who did drink were significantly more Secondary school students aged 12–18 years likely to have been hazardous drinkers (36%) were invited to participate. The Pacific than European adults (25%). Among Pacific Island ethnicities represented in the survey men who drink, 46% reported hazardous are Samoan, Tongan, Cook Island, Niuean, drinking compared to only 25% of women.2 Tokelauan, Fijian and a small number of other Pacific Island ethnicities. The specific Unmet need ethnicities within this survey that are large The 2007/08 New Zealand Alcohol and enough to provide reliable subgroup esti- Drug Use Survey measured the proportions mates are Samoan, Tongan and Cook Island. of people who wanted help within the last The other Pacific Island ethnicities are 12 months to reduce their level of alcohol or combined. drug use but did not receive it. Pacific peoples (4.8%) and Māori (4.2%) were more likely In 2012, the proportion of Pacific students than European/other (1.7%) to have wanted who reported that they consumed alcohol help to reduce their level of alcohol or drug weekly or more often was 5.9% (95% CI use in the past year but not received it.3 3.9–7.9). The proportion of Pacific students who reported binge drinking within the Pacific users of alcohol and drug treatment previous four weeks was 18.4% (95% CI services report making repeated, unsup- 15.1–21.6). There has been significant ported and unsuccessful attempts to cease declines in the proportions of Pacific alcohol and substance abuse before finally students who report regular alcohol connecting with a treatment service.4 consumption or binge drinking since A study exploring conceptualisation of 2001 and particularly since 2007. Pacific deliberate self-harm among Pacific popula- students were less likely to report drinking tions in New Zealand was conducted because alcohol weekly or more often compared to current clinical definitions of deliberate their European counterparts (5.9% (95% self-harm (DSH) do not incorporate a Pacific CI 3.9–7.9) versus 9.5% (95% CI 8.2–10.8), 5 perspective. Nineteen semi-structured inter- respectively). Pacific students are also views were conducted with Pacific health less likely to report binge drinking in the professionals. It was felt that the current previous four weeks compared to European definition of DSH was too narrow. From a students ( 18.4% (95% CI 15.1–21.6) versus Pacific perspective, indirect and longer-term 24.9% (95% CI 22.8–27.0), respectively). self-harm, such as alcohol and drug abuse, Comparisons between the specific Pacific should be considered as part of the concept. ethnic groups found that Cook Island Conceptualising alcohol abuse as an attempt students were slightly but significantly more to self-harm may provide a pathway to likely to report binge drinking compared to healing or reconciliation via development of Samoan students. church or community initiatives promoting Most students (Youth’07 survey) who the cohesion of Pacific people’s families, reported binge drinking got their alcohol culture and spirituality.5 from friends (71%), someone else who Youth alcohol consumption, bought it (43%), brothers and sisters (34%), behaviours and harms another adult they know (29%) or their The two best sources of current data parents (26%), or they bought it themselves on alcohol consumption by youth are the (22%), took it from home (17%) or stole it

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(11%).7 Equivalent data from the Youth’12 able to fulfil their obligation of taking their survey specifically for Pacific students has families (specifically their mothers) to not been reported on; however, a report that church on Sunday due to drinking heavily focused on students with problem substance the night before. Their Pacific value systems use from the Youth’12 survey found that and their holding of at least a bicultural friends were still the main source of alcohol or multicultural identity, their affiliation for students with very high substance use with church and their family ties give rise (51%) and for students with lower levels to the protective factors that neutralise the of substance use (42%). Around 46% of negative risks, such as alcohol related harm, students with high substance use report that associated with heavy drinking.13 they get someone else to buy it for them. Risk factors for youth This is lower (25%) for students with lower Teevale et al7 found that binge drinking levels of substance use.8 occurs more frequently among Pacific Students in the 2007 survey reported that students from relatively well-off neighbour- they normally drank alcohol with friends hoods. This may reflect the transitional (88%), followed by family (52%), other nature of Pacific communities in New people (40%) and lastly ’by myself’ (11%).7 Zealand with “the more affluent and What was concerning was that one in four middle-class adopting mainstream use of Pacific students reported experiencing alco- alcohol.” This trend has not emerged among hol-related harm. The most common harms Pacific adults. People living in the most for Pacific students was doing things that deprived quintile are significantly more could get them into trouble (29%), having likely to report hazardous drinking or binge unsafe sex (28%), having friends and family drinking. This measurable inequality by talk with them about reducing their alcohol deprivation is stronger for young men. consumption (26%) and getting an injury Frequent supply of alcohol by parents, because of their alcohol use (25%).7 friends or others was also a signif- Protective factors for youth icant predictor of all drinking measures Factors associated with a lower risk of among teenagers.14 Most participants in binge drinking were age (younger pupils Greenaway’s15 evaluation on the social were less likely to binge drink), culture and environment of alcohol supply in Māngere, parenting style. Students with parents able Auckland, identified as Cook Island, Niuean, to speak a Pacific language were less likely Samoan, Tongan and Māori. Parents to report binge drinking. Students whose reported feeling helpless, due to the constant parents knew where they were after school social supply of alcohol. This influenced or at night were less likely to report binge some parents to supply alcohol to their drinking.7 Weekly church attendance was a young adults in an environment where they protective factor after controlling for other could monitor them. Some of the partici- variables.7 The majority of Pacific people are pants reported underage access to alcohol affiliated with at least one religion and the was inevitable and had become accepted use of alcohol is discouraged in alignment and normalised. This was compounded by with religious beliefs.9–12 the high number of alcohol outlets in the A qualitative study13 explored factors that neighbourhood and the lowering of the 15 support abstinence and responsible drinking purchase age to 18 years old. behaviour among Pacific youth living in A 2011 study investigated the impact of Auckland. Young people highlighted three recent migration and acculturation on ciga- main communities that helped support rette, alcohol and marijuana use by youth.16 abstinence and responsible drinking. These Pacific youth were less likely to consume communities are family (including extended alcohol frequently compared to European family), peers and church. Most of the youths. Experiencing ethnic discrimination participants referred to their practices of was associated with a higher risk of frequent toka’i (respect and honouring others) and alcohol consumption. First generation the social shame that would be directed migrants were less likely to report more towards their parents if they were to drink frequent alcohol consumption compared and behave drunk. This was associated to youth born in New Zealand . However, with feelings of guilt when they were not acculturation seemed to attenuate this

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association, and youth who reported that more when they were with their Pacific they felt more comfortable in New Zealand peer group, which was related to feeling European social settings and spoke English comfortable ‘letting their hair down’, having at home were less likely to report more fun, excitement and the desire to achieve frequent alcohol consumption.16 ‘the buzz’ for relaxation and socialisation.20 Gender and alcohol This uptake of the New Zealand drinking culture by young Pacific women is still A report examining women, alcohol use challenged by Pacific cultural opposition to and harm was published in 2013.17 The female drinking, such that Pacific women report draws out specific Pacific perspec- who avoid drinking around family, partic- tives on woman and alcohol where literature ularly elders and men.20 This has been is available and with specific Pacific focus observed in studies of Niuean women9 and groups. Although Pacific women have in Tongan women.21 Hutton and Wright20 did general and historically consumed less not indicate whether Pacific women in the alcohol than men, this has changed. The study were born in New Zealand or in the proportion of young women (16–17 years) Pacific. Future research needs to identify who reported harmful alcohol consumption whether the cultural pressure opposing exceeds the proportion of young men who drinking is different for Pacific-born women reported harmful drinking in 2011. Pacific compared to women born in New Zealand women were more likely than New Zealand born.9 European women to be non-drinkers or drink less often, but they consumed more Research by Manuopangai21 investigated on a typical occasion. These factors vary the consumption of alcohol among Tongan by ethnicity among Pacific women. Pacific females aged 16–25 years in Auckland. The women participating in focus groups qualitative study included interviews with 20 reported that they had observed increasing Tongan females that attended a Tongan Meth- alcohol consumption and more drunkenness odist church. The study revealed five key among women. Alcohol marketing, outlet themes related to alcohol use by the Tongan density, low prices, social inequity and women: contemporary drinking style, trauma were all considered influences on cultural and religious influences, gender alcohol consumption. The women felt that roles, knowledge of alcohol use and the alcohol consumption eroded family cohesion associated harm experienced by the women. and cultural wellbeing, and they specifi- A key finding from the study indicated how cally mentioned sexual abuse, unplanned the brother–sister relationship restricted pregnancies, fighting by young women and women’s alcohol consumption in the expulsions from tertiary education.17 presence of their brothers and male cousins. The Tongan value faka’apa’apa (respect) In many cultures, including Pacific in the brother–sister relationship inhibited ones, alcohol is “one of the more powerful alcohol consumption among the female symbols of gender roles and identities.”18 cohort, whereby women did not consume For Pacific cultures, there is a gender- alcohol in front of their male brothers and based double standard. For example, it is cousins as a sign of respect and dignity.21 The acceptable for males to go out at night and females in the study perceived drinking as engage in alcohol drinking, whereas for bothgood and bad.21 ‘Good’ was perceived as females this is less acceptable.19 This double everyone having a good time and enjoying standard may provoke a rebellion among themselves, whereas a ‘bad’ time was when females, particularly Pacific females born in one or more drinkers became annoying, New Zealand, who then drink in defiance, noisy, caused trouble and behaved in a with or without parental consent.19 shameful manner.21 Most of the participants 20 Hutton and Wright conducted an ethno- from the study viewed a ‘cool drinker’ as a graphic study of Māori and Pacific women’s person who could consume a lot of alcohol drinking practices. The findings indicate but still control their behaviour, socialise that Pacific women often drink as a group, and have a good time with others.21 Similar where the notion of peers belonging to the to other findings,20 this may in part be seen same sex and ethnicity provided a sense of as an incentive to act like a ‘cool drinker’ 20 safety and security for the young women. and not become the drinker who becomes The women in the study reported drinking annoying and shameful.

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The church’s disapproval of drinking did Samoan fathers all reported making a not always lessen alcohol use by females conscious effort to educate their children affiliated with the church. For example, about risky health behaviour such as study participants reported that attending alcohol use and smoking. Acculturation church with a hangover from the night (loss of some Pacific Island culture in the before was common among the young process of fitting in to or adopting New people. In addition, conversations about Zealand culture) is generally associated with previous drinking events were common increases in risky health behaviour, such as among the young females. Drinking culture harmful alcohol use and smoking. However, among some groups of females affiliated Tautolo24 reported that Pacific Island culture with the church had become normalised for one participant was connected nega- and accepted. In turn, this indicates how tively with harmful alcohol consumption, for this group of females religion was due to an alcoholic and abusive grandfather. not a protective factor against alcohol Many participants reported that they curbed consumption.21 their alcohol consumption as part of their An initiative within the church, an annual efforts to be good fathers. four-day camp for youth, was provided to Unfortunately, the New Zealand Health help reduce alcohol and drug consumption Survey doesn’t provide data on alcohol (‘Apitanga Tapu Inukava Malohi Faito’o consumption disaggregated by Pacific Konatapu & Tapaka). However, it was ethnicity. Two studies provide disaggregated perceived by the females as ineffective in Pacific ethnic data on alcohol consumption, reducing their alcohol intake. The camp was and one of them found significant differ- attended primarily to socialise with their ences.25,26 Tongan parents generally had peers from other churches; despite this, the lower rates of alcohol consumption females in the study recommended that the compared to Samoan and Cook Island Māori. camps should include inspirational speakers Prevalence of harmful drinking was signifi- to share their experiences of alcohol use cantly higher among Cook Island parents and their successful restriction of alcohol compared to Tongan and Samoan parents.25 consumption. Other recommendations were This survey found lower rates of alcohol to incorporate more information in English consumption compared to the New Zealand about the definition of a standard drink and survey,3 and that both mothers and fathers to define moderate drinking.21 moderated their drinking in response to Parenting, family and alcohol parenthood. The authors also suggested a need for alcohol and drug service interven- The New Zealand Alcohol in Pregnancy tions meeting specific ethnic and parent Study was a representative sample of New needs. Zealand women aged 16–40 years and included Pacific Island participants.22,23 This Family influence on substance use was study explored awareness of the safety of explored in a qualitative study of users alcohol consumption during pregnancy enrolled in drug treatment services.4 Sixteen and opinions of warning labels as a source participants provided detailed narra- of information on the dangers of alcohol tives (talanoa) of their lives and substance consumption during pregnancy. Pacific abuse. A dysfunctional family or family Island women were significantly more member was often the source of alcohol supportive of warning labels on alcohol and contributed to persistent use. However, (OR 2.13, 95% CI 1.13–4.01) compared to their own new family connections, children European/other ethnicities.22 They were and supportive partners, and the desire to also significantly less likely (OR 0.53, 95% create stability and healthy relationships in CI 0.30–0.93) to consider it safe to consume contrast to their past, were strong motives to alcohol during pregnancy compared to cease substance use. European/other ethnicities.23 Public policy and inequities A qualitative study of Samoan and Cook Liberal alcohol policy changes (eg, price Island fathers from the Pacific Islands decreases) and increases in accessibility Family Study explored broader influences (eg, increased outlet density) have been on mental health and risky behaviour, associated with increases in alcohol-related including alcohol consumption.24 The harm in other countries, such as Scandi-

navia and the United States.27–29 Access to Law and research on interventions and promotion of alcohol has increased that target or include Pacific in New Zealand in the last three decades, and during this time there have been peoples In recent years, there has been an measurable increases in alcohol-related increased effort to reduce alcohol-related harm.30 However, our review did not find harm in New Zealand through the Sale and much research that explored the influence Supply of Alcohol Act 2012 (which regulates of these policy changes on Pacific people’s the supply of alcohol in New Zealand), the attitudes and behaviour towards alcohol Local Government Act 2002 and a recent and alcohol-related harm. A recent survey of national commitment to reducing alcohol-re- attitudes to local alcohol policy had minimal lated harm, the National Drug Policy 2015 to Pacific representation.30 A report by the 2020.33 Despite these interventions, there has New Zealand Medical Association (2015) been no significant decrease in hazardous states that alcohol-related harms do not drinking among Pacific men and women only reflect existing inequalities between since 2012/13.2 The National Drug Policy sets ethnic groups but are also driving inequal- out the government’s approach to alcohol ities.31 Their stance therefore is to advocate and other drug issues, with the overarching for improved policies to reduce alcohol-re- goal of minimising alcohol and other drug lated harms, as stated in their 2011 position harm and promoting and protecting health statement on equity: and wellbeing. In addition to the National 13 Clause 32 “[u]rges clinical doctors Drug Policy, there is a guide to priority and public health specialists to work outcomes, specifically for Pacific health and together more closely in shaping wellbeing.34 services and developing programmes Alcohol Healthwatch and Women’s Health to promote and protect people’s Action17 say wide consultation with Pacific health, prevent ill health and tackle peoples is needed to identify how policies health inequities, and address and services can better meet their needs and the broader social and environ- expectations and address inequities. A key mental factors that are influencing recommendation of the organisations was to individuals’ health, choices and increase funding and support for alcohol-re- behaviour.”31 lated research, programmes and services that The impact of alcohol-outlet density address the needs of Pacific communities. and the distance to the nearest alcohol Screening tools within a primary care outlet in New Zealand communities was context can be an important mechanism examined in a 2014 study.32 Data on alcohol to connect people who have problematic outlets were obtained from liquor licensing alcohol use with treatment services.35 authorities and linked with alcohol Newcombe et al tested the validity consumption data from the 2006/07 New of Alcohol, Smoking and Substance Zealand Health Survey. New Zealand’s most Involvement Screening Test (ASSIST) with deprived neighbourhoods had the highest Samoan, Tongan, Niuean and Cook Island density, at 15 alcohol outlets per 10,000 Māori participants.35 ASSIST is recom- people. This study had reasonable Pacific mended for use as a screening tool with ethnicity representation. Young Māori and Pacific people in a New Zealand context.35 Pacific males living further from alcohol outlets were significantly less likely to Injury is a large contributor to New report hazardous alcohol consumption, Zealand’s alcohol-related burden of disease, even when the data are adjusted for depri- and alcohol is a lead risk factor for injury. vation compared to those living closer. Therefore, trauma care settings offer an There was a gradient (ie, as the distance opportunity for screening and brief inter- from alcohol outlets gets longer, reports of ventions aimed at reducing hazardous 36 hazardous consumption get significantly alcohol consumption. These settings lower) culminating in a 70% reduction for may be useful for engaging Pacific Island those living the farthest distance from an people who may not access primary care 37 alcohol outlet compared to those living as frequently. At present, screening in closest.32 trauma care settings is not routine in New

Zealand, due to lack of resources and training for health professionals. To remedy Conclusion this, a mobile text messaging intervention to Cagney and Alliston1 identified a number reduce alcohol-related harm was developed of gaps in research on alcohol use and and tested in New Zealand.36 Pacific Island Pacific peoples. Some of the gaps have been participants (Cook Islands n=1, Niuean addressed since 2009, such as the data on n=1, Samoan n=3) were represented in the consumption patterns in adults and youth. qualitative evaluation and were interviewed These are provided by the New Zealand by a Pacific Island researcher. Two positive Health Survey and the Adolescent Health features of the intervention from a Pacific Research Group’s Youth2000 Survey Series. perspective were the tailored greeting and They also provide some insight into differ- the privacy afforded by the intervention.36 ences between New Zealand’s larger Pacific groups, such as Tongan and Samoan. Deeper “Different greetings… Because it’s just qualitative exploration of alcohol and the sense of them knowing who you drinking culture among Pacific women, and are and where you’re from. They’ve particularly young women, has been added done the research in terms of under- to the discourse. standing what ethnic background you are.” (Male, Samoan, inpatient, Surveys on alcohol consumption show hazardous drinker)36 limited improvements in hazardous alcohol consumption by Pacific men and women. “… Pacific Island culture in general Pacific men and women are more likely to it’s like there are a lot of things that report hazardous drinking compared to you don’t talk about… so I think non-Pacific ethnicities. There have been people would sign up for this because promising declines in Pacific youth alcohol it seems like something you can do consumption and binge drinking. Gender personally that you don’t have to differences in alcohol use, particularly by tell people about. So you don’t have women, have featured in research on Pacific to talk about it… I think getting the ethnicities and alcohol use from 2009 to 2017. texts would be helpful cause then it wold be like a way for you to However, there are still some gaps to be kind of like reflect and then like cut addressed: down.” (Female, Samoan inpatient, What is the role of prejudices and hazardous drinker)36 oppression due to gender, racism, coloni- If youth remain consistently engaged with sation and different sexual orientation or support services after their initial contact, gender identity (eg, LBGT and fa’afine (or there is a high probability of resolving fakaleiti)) in both the uptake of harmful their alcohol- and drug-abuse problems.38 alcohol consumption and access to support Research has been done to inves- services? tigate factors associated with successful What are the specific attributes of New engagement. One of these studies—a retro- Zealand Pacific men’s alcohol consumption, spective study of engagement of youth such as the link between masculinity, sport with an outpatient service in Auckland, and consumption? New Zealand, for reducing alcohol and What are the inherent protective factors, drug harm—found that, once connected particularly those that can be drawn from with the service, Pacific Island youth were pre-colonial Pacific and spiritual culture, more likely than European youth to remain that had no place for alcohol? Such factors engaged in the service. For Pacific youth, can include, but are not limited to, family remaining connected with family (eg, living dynamics and obligations and cultural at home), especially for older youth (16–19- and religious practices, such as church year-old age range), also predicted longer attendance. engagement with the service.38 Finally, a critical examination is needed Limitations of health system services, the accessibility The search was limited to literature of alcohol and alcohol and drug services for that was published since 2009. This was a Pacific peoples from specific Pacific ethnic- scoping review and not a critical review of ities, genders and generational perspectives the studies conducted. (eg, New Zealand born versus Pacific born).

Competing interests: Nil. Acknowledgements: We would like to thank the Health Promotion Authority for reviewing early drafts of this article. Author information: Vili Nosa: Associate Professor, Pacific Health, University of Auckland, Auckland, New Zealand. Gemma Malungahu: Pacific Health, University of Auckland, Auckland, New Zealand. Janine Paynter: General Practice & Primary Healthcare, University of Auckland, Auckland, New Zealand. Dudley Gentles: Pacific Health, University of Auckland, Auckland, New Zealand. David Newcombe: Associate Professor, Social and Community Health, University of Auckland, Auckland, New Zealand. Corresponding author: Associate Professor Vili Nosa, PMB 92019, University of Auckland, Auckland, 1142 [email protected] URL: www.nzma.org.nz/journal-articles/pacific-peoples-and-alcohol-a-review-of-the-literature

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