Reasons for and Impacts of Kava Use by Tongan Men in Kava Clubs in Auckland and Tonga

Kava drinking in kava clubs has become an intrinsic part of Tongan Pasifika culture. Perceived effects and reasons for kava consumption are not fully understood. This study explored these issues using the culturally safe, Pasifika qualitative research approaches of Kakala and Talanga. Group interviews were held with a convenience sample of 104 Tongan men across 10 kava clubs in Tonga and New Zealand. A general inductive approach was used to analyse the interviews. Participants in both countries reported that kava use is socially sanctioned and easily accessible. Kava clubs provide an opportunity to learn about Tongan culture, socialise and are a safe way to relieve stress and boredom. However, kava consumption could reduce members’ productivity, contribute to ill-health and increase stress on family relationships. It is vital that kava use amongst Tongans is addressed in a way that deals with the negative impacts but protects its benefits. There is an opportunity to educate men about the health effects of kava. To enact this opportunity and solve this widespread issue, partnership between kava clubs, the church and the Tongan community is needed. A multi-agency engagement with kava club members and Tongan society may therefore be the best approach to minimize risks and optimize benefits of kava use.


Introduction
Known as the "intoxicating pepper", the roots of the kava plant (Piper methysticum) have been consumed for centuries as a traditional beverage across the Western Pacific region [1,2]. This national drink for Tongans has become an intrinsic part of social and cultural life, particularly in Tonga and Auckland, New Zealand. Kava drinking performs symbolic functions in promoting well-being and bringing people together to respect the divine, spirits and others. Almost exclusively, it is men who consume kava.
Almost two-thirds of Tongan men have tried kava at some stage of their life, and 41% of Tongan men report consuming it in the past 12 months [3]. The average frequency of kava consumption by Tongan men is between 2-3 times per week [4]. Tongans consume more kava than other Pacific peoples [4]. Kalapu Kava Tonga (Tongan kava clubs) is where most Tongans consume kava; whereas Fijians, Samoans and Tuvaluans consume kava mostly at their individual homes. A Tou'a, female server, oversees each faikava or kava session. Younger Tongan men are becoming more involved than previously in kava club [5][6][7][8]. The reasons for and perceived effects of kava use in the kava clubs are not yet fully understood. So this paper investigates these issues, being the first to do so across Tonga and Auckland.

Methods
A collaborative, qualitative, Pasifika research methodology was used. Specifically, "Kakala" and "Talanga" methodologies were employed to obtain and analyse interview narratives from Tongan men in 10 different kava clubs across Tonga and Auckland; where most Tongans live [9]. Ethics approval for this study was obtained from the University of Auckland Human Participants Ethics Committee (Reference number 011328).
The overall research design follows the Kakala or Tongan garland through the stages of "toli", data collection; "tui", analysis; and "luva", dissemination of findings. Kakala engages Tongans and other Pacific Islanders as people. It recognizes the researcher too as a person and assumes that the moral values and interests of all people warrant equal consideration. However, the Kakala emphasizes Pacific interests in the community, [10] and views the community as a person because it shares attributes of moral agents. Indeed the Kakala privileges the agency of the community from whom individual persons draw their moral standards. These standards include a group commitment to equality ahead of what appears true or useful.
This study focuses on kava clubs because their members have the most experience of kava use. A sample of 10 kava clubs was selected, comprising 5 in Tonga and 5 in Auckland (out of about 42 kava clubs in South Auckland alone). This was a convenience sample. The club leaders were all known by, the first author as an insider to the research and hence they were easily accessible and willing to participate. The club interviews took place between January and June 2017.
The first author approached each kava club through its president and secretary. He discussed the study, mata kihe mata, face to face, and the clubs agreeing to take part invited their members for a talanga, which is a Tongan word for "interactive talking with a purpose". However, the talanga is more than a focus group discussion because of its commitment to shared relationships in preserving cultural integrity. The talanga manages the tension that can arise between the interests of the researcher vis-à-vis participants by incorporating talanga fakamatapule, talking together with respect; talanga feveitokai'aki, reciprocity through bringing stories and wisdom to share; and talanga mafana, inspiration through talking together to inspire one another [11]. All members in each kava club were invited to participate in the talanga.
The talanga gathered information through the men in the kava club sessions speaking with each other and the interviewer about reasons for and impacts of kava consumption in the context of other social and cultural issues relevant to the well-being of Tongan people [12,13]. The questions posed and group dynamics were loosely structured but began with the broad open question, "what are your views of kava use and consumption by Tongan men?" The interviewer expressed his views last to minimize his influence on the discussion, while reducing the artificial distinction between the participants and himself as the researcher. To facilitate communication, he conducted the talanga in Tongan because Tongan was their shared native language.
The interviewer and Kalapu Kava Tonga members in Auckland and Tonga chose the time and location for each talanga. Each participating kava club from Auckland and Tonga was provided with a $50 gift voucher or a half kilogram of kava club worth NZ$50 as a gift for contributing to the research. The first author transcribed the interviews and conducted a thematic analysis from careful multiple readings of the transcripts.
This data analysis followed a standard, general inductive approach in order to develop meaningful thematic categories consistent with the research objectives [14]. Although participants were distributed across 10 kava clubs, the main unit of analysis of the interviews was members' country of residence as expressed in Tongan vis-à-vis Auckland, New Zealand kava clubs. Consistent with the communitarian culture of Pacific people, this approach was selected because we were less interested in identifying differences within these national groupings than between them.

Results
There were 104 participants in the study, 62 from Tonga and 42 from Auckland. Each kava club group ranged from 6 to 8 members. All participants were men. The age of participants ranged from 16-75 years. Most participants from Auckland were aged 36-55 years. Participants in Tonga were younger; most aged 15-35 years.
In Auckland and Tonga, the men consumed kava as a normal part of their lives and culture. Kava consumers fell into two categories. There were young and old men who are "regular kava consumers". They consumed high volumes of kava (Inu Kava Lahi 'aupito), attending the kava club 4-5 times a week or even every night including Sundays at a church hall. One group in Tonga described these men as "lazy and weak with red eyes in the morning but when the night approaches, they look strong with wide-open eyes to walk to the kava club". The other group used less kava and were "irregular kava consumers."

Reasons for Kava Use
Participants in both settings suggested that kava use is common for three main reasons: community endorsement, accessibility and psychosocial benefits.

Community Endorsement-Socially Sanctioned, Safe and for Health
Kava use was widely recognized as part of the Tongan culture and "it is regarded by Tongans as a national drink". The study participants also explained that in addition to its recreational consumption, kava is consumed for ceremonial purposes such as celebrating educational and social achievements, honouring weddings and birthdays, greeting and farewelling important guests. Kava is consumed at church, since the Church is sacred in Auckland and Tonga, parents trust it to provide kava to their sons.
"Koe lau pe eni ia 'ae tauhi fanau... Oku lelei ange ke alu hoku foha 'o inu kava pe 'I 'api siasi he 'oku 'ikai fai ha inu kava malohi ai... Ka tene ako ai e ulungaaga lelei mo taau kihe mo'ui", translated as, "I preferred my boys to go and drink kava at the church hall... I trust that this is the only safe place for them where no alcohol is available. It is a place where his life could be nurtured and mould to a better life by the elders." Two groups each from Tonga and New Zealand emphasized that, "many men have consumed kava in clubs for decades without evidence of apparent harm". Participants also described their use of kava as a traditional medicine.

Access
Kava was reported to be highly accessible to Tongan men in both settings. Although Auckland participants argued that men consume less kava in Tonga because in Auckland kava is more readily available, affordable and the sessions fit their working schedules. Moreover, participants pointed out that "no man is forced to pay anything for kava during a kava session." Payment is "voluntary" and based on the concept of "giving if you have."

Psycho-social Benefits Including Cultural Identity
Some men consumed a lot of kava to relieve boredom and stress. All groups in both sites stated in Tongan that, "neongo 'ae kona 'ae Kava, ka 'oku kei ifo pe he tafi ongosia," meaning that kava juice is so strong but it helps to release some stress. Kava enables them to achieve a care-free and euphoric escape from troubles like unemployment. Kava was also a social lubricant. In addition to entertainment, such as singing, provided by the clubs, friendship and bonding with men who shared their cultural values was important. "There is a Tongan concept called 'Ofa fai he feohi' (or Bonding Love) that explains the kind of relationship and reasons why men keep going back to their Kava sessions. Such relationship is more than a brother-sister relationship. It never ends and it is hard to break." The bonding helped typically unassuming men to develop self-confidence.
Attendance at the kava clubs also enabled the men, especially in Auckland, to learn about their cultural identity, and meet social obligations like fund-raising and remittances to support disadvantaged families and communities in Auckland and Tonga. All groups in New Zealand stated that, "this kind of experiential learning is a central feature of who we are as Tongans". Participants valued making their contribution in the spirit of fetokoni'aki, reciprocity, and 'ofa, love.

Concerns with Kava Use
Participants viewed the kava clubs as having complex, economic, social and cultural impacts including negative impacts such as reduced productivity, ill-health and family strain.

Productivity
Participants in Tonga pointed out that farmers in Tonga have experienced economic loss. They sold their kava cheaply for quick financial returns without realising that it takes four to five years to grow new kava plantations. Subsequently, local kava production has declined and kava has become expensive to buy in Auckland and Tonga. Participants from kava clubs in both countries further described how low motivation and laziness resulting from kava use adversely affected the ability to work. Key outcomes were being late for work, missing work, having no energy and commitment, and taking a lot of sick leave. Moreover, they slept during the day to recover, compromising their productivity at work.
These problems extended to some of the religious leaders who consumed a lot of kava. Groups, in Auckland and Tonga stated that, "these leaders sometimes arrived late to church, missed church services and were unprepared to deliver sermons". They delegate too many responsibilities so that the other church members do their jobs (like visiting the home of the poor, elders, the sick and disabled) and they just stay in the church and drink Kava.

Ill-health
Participants reported that some heavy kava drinkers have died suddenly of unknown causes in kava clubs. All groups stated that some deaths occurred during their kava sessions and "some slept at home after kava and died". They had also observed that kava can cause scaly skin rash, indigestion and can contribute to sexual problems such as erectile dysfunction. As one group in Tonga described, "men need help but they are shy to express the truth".
Club members combine kava use with other lifestyle behaviours that are unhealthy. For example, kava use often came with a cocktail with smoking, sugar and alcohol.
Smoking, sugary drinks and confectionary were used to balance the bitter taste of the kava. Alcohol enabled the "wash down/cleansing" of their system. Similarly, young men in Auckland talked about how, after a kava session, they usually ate enormous amounts of unhealthy food. "Loulou" is the common name for this practice of late eating in most kava clubs. The foods commonly consumed were salted, fatty meat; canned meat; and roasted pig head, lamb chops with taro, cassava or yams.
In Tonga the issue of driving under the influence of kava club was not considered significant because of the proximity of kava clubs to men's houses. However, in Auckland, minor driving accidents occurred among kava users. The accidents included missing the driveway or hitting the fence while parking the car.

Family Strain
Men from Auckland and Tonga also spoke about how regular attendance at kava clubs could reduce their time with family, increase family conflict and contribute to family breakdown and family violence. The role of the Tou'a could also upset the wives, for example because income set aside for family tasks or activities could be spent on the Tou'a. Moreover, some (especially married) men in both settings had established intimate relationships with Tou'a in kava sessions. As a consequence, many wives fought with Tou'a and their husbands. All groups shared the same Tongan slang, "koe kovi pe koe fu'u motu'a mali": the problem starts from the old man, not the Tou'a. Two kava clubs in Tonga reported that some Tou'a have been rushed to hospital with serious injuries.

Thoughts on Maximising Harms and Minimising Benefits
Despite the concerns raised, the study participants in Auckland and Tonga felt that due to social, identity and cultural benefits for Tongan men it is unrealistic to stop kava use altogether. Nevertheless members recognized a need to understand and minimise overuse of kava in Auckland and Tonga. Members in Auckland suggested that Kava Clubs themselves should take the lead in discussing the pros and cons of Kava consumption and then develop strategies to alleviate the harms in Tongan families and communities.

Discussion
Kava clubs were considered important for their role community cohesion, social support and cultural identity. Accessibility for Tongans to kava clubs was a priority particularly from one generation to the next. By partaking in kava, sons become part of the Church, which in Auckland is akin to the Tongan village [11]. Introduced to kava, they subsequently attend kava clubs [7,15]. Poor men are able to attend kava sessions regularly [16]. Commitments and community service opportunities via kava clubs have also been found to be important in other New Zealand work [17].
Participants in this study focussed on how the physiological outcomes of kava use had a negative effect on productivity and in Auckland, driving safety. Other studies have found that kava use reduced the ability to drive by weakening participants' concentration and inducing feelings of lethargy and sleepiness [18]. A survey in New Zealand found that kava use significantly impaired driving [19]. Productivity impacts, such as feeling tired and having headaches after a kava session, have been observed in other research [7,20].
Negative impacts of kava use on family life were another important theme emerging which is consistent with other research. Rychetnik & Madronio described a negative relationship with kava club use associated with impotence and loss of sexual drive [2]. Other studies [6,7,21] confirm this finding that over-consumption of kava contributes to marital conflict and divorce [2,7].
Association of kava use with health risk behaviour such as smoking, alcohol and excessive consumption of sugary and fatty foods was another theme arising that has been observed elsewhere. An Australian survey of 80 Tongan men found that 26% smoked and 15% drank alcohol during kava club sessions [20]. In addition, 73% drank cola and 60% of them consumed food with high fat or sugar content [20].
Participants noted deaths of other members at or shortly after kava sessions. Whilst, minimal evidence of adverse effects from moderate kava consumption were found in a recent safety review [22] there were clearly harmful, excessive consumption patterns observed by participants from Tonga and Auckland in this study.

Strengths
We have provided a comparison of kava use in clubs in Tonga and Auckland, New Zealand using integrated Western and Pacific approaches to qualitative research. Pacific methodologies of Kakala and Talanga contributed to cultural safety.
Kakala emphasizes communal values such as equality, which helped to mitigate unequal power both between the interviewer and participants and within the kava clubs [23]. Kakala also values participants using symbolism to communicate what words cannot always easily express. In turn, Talanga protected the authenticity of the stories shared because its commitment to respectful and purposeful dialogue enabled participants to speak freely without interruption. The depth of these interviews complemented the breadth afforded by the group meetings.
Tongan heritage of the first author, his fluency in the Tongan language and his familiarity with Tongan cultural processes and protocols enabled conduct of the research in a culturally appropriate manner. Further, his Tongan identity and his own use of kava in his youth enhanced his trustworthiness to the participants and enabled him to comprehend, from an emic or insider perspective, their experiences, including their cultural values and beliefs on kava club use. Since Tonga is a small place, he was able to draw on these relationships to enable the research in practice.

Limitations
This qualitative analysis is largely descriptive with a focus on meanings of interview content that are at the surface rather than hidden. Moreover, we chose not to explore differences between the kava clubs and individual members, within Auckland and within Tonga. This may have yielded a more nuances.
Other limitations of this study include the use of kava during the long Talanga sessions. However, unless consumed in very large amounts, kava does not interfere with mental sharpness and, in relaxing the participants, it facilitated their willingness to speak openly. Lastly, the insider perspective of the lead author could have limited his openness to recognize new patterns and themes. However the research team included Pālangi (white persons) experienced in qualitative research who provided critical peer review of the emergent themes.

Conclusion
Tongan men in kava clubs in both countries identified positive and negative impacts for kava users, their families and communities. Benefits of kava include community endorsement, increase accessibility and psycho-benefits including cultural identity. Whilst the negative consequences of kava drinking comprise of limited productivity, poor health and family strain. Kava drinkers acknowledge these concerns yet note the social and cultural benefits outweigh these. Kava club is part of the Tongan culture; therefore, it is unrealistic to try and ban it. Effort is needed to address the high consumption of kava in both places. Increasing the cost of kava may reduce kava use, however given accessibility is important, a better path forward is for government agencies to work with Tongan communities. A solution is needed to address kava use in ways that address negative impacts but protect its benefits. Kava clubs and the church need to be part of this partnership even though each has an interest in promoting kava use. Kava drinkers must be empowered to take lead in discussions of the problem and the development of strategies to combat concerns and maximise benefits. Thus, a multi-agency approach between kava drinkers and local Tongan society and abroad is imperative to address this predominant issue within the Pacific region.