Opinion

Innovative measures to achieve smokefree vision

New Zealand led the world with its Smokefree 2025 goal, but bold and fundamental changes are needed, now. The co-directors of Otago's ASPIRE 2025 research centre outline the measures they believe are crucial to make this goal a reality.

New Zealand's 2020 response to the COVID-19 pandemic showed we could lead the world with bold, innovative and evidence-based measures. While the delta variant has brought new challenges, our initial decisive measures to protect population health meant we enjoyed freedoms seen in few other countries.

Yet, despite this evidence of our ability to act quickly when faced with a serious infectious disease, we have been much slower to respond to other sustained threats to health, such as the smoking pandemic, which still kills nearly 5,000 New Zealanders every year.

New Zealand led the world in announcing a Smokefree 2025 goal, which Māori leaders proposed, to reduce the unacceptably large disparities in smoking prevalence between Māori and Pacific peoples and non-Māori/non-Pacific. Sadly, successive governments have failed to develop a bold strategy and action plan to achieve the goal: our largely business-as-usual approach has seen smoking prevalence decline slowly while disparities remain unaddressed.

However, change looks likely. Associate Minister of Health Hon Dr Ayesha Verrall's recent Smokefree 2025 Action Plan discussion document sets out bold measures that could see New Zealand providing global leadership in dealing with an insidious non-communicable disease. So, what are the key measures that will help us achieve this transformational goal and bring smoking prevalence in every population group down below five per cent (and as close to zero per cent as possible)?

“For decades, we have allowed tobacco to be sold at any store, just like milk and bread. Yet, smoked tobacco products are inherently unsafe and would never meet product safety standards if they were introduced today.”

We believe the solution lies in changing our approach to focus on supply-side measures that will reduce tobacco's availability and addictiveness. Hon Dr Verrall's discussion document proposes ideas that could bring about fundamental changes needed to achieve the Smokefree 2025 goal. What do we see as crucial?

Tobacco products are highly addictive and widely available through comprehensive distribution networks. We need to restructure the market place by changing the composition of tobacco products and making them much less available.

Because the design of smoked tobacco products is largely unregulated, tobacco companies have created extremely addictive products and added ingredients to reduce the harsh sensations of smoking. Cigarettes and rolling tobacco are engineered to make it very difficult for people who smoke to quit and stay quit. This same design means young people who experiment with smoking quickly become dependent on nicotine.

If tobacco products were no longer addictive, the incentive to keep using them would disappear. Studies conducted in Aotearoa and internationally report that people using very low nicotine cigarettes (VLNCs), which have had nearly all nicotine removed from them, often reduce the number of cigarettes they smoke, make more quit attempts and are more likely to successfully quit.

A large New Zealand trial that investigated adding VLNCs to Quitline cessation support found no difference in quitting between Māori and non-Māori participants. A Health Research Council-funded study led by the University of Otago (the Te Ara Auahi Kore project) surveyed Māori who smoke and found over half said they would quit smoking or switch to e-cigarettes, if VLNCs were the only smoked tobacco product available. Introducing VLNCs could help reduce sustained disparities in smoking prevalence and the health inequities that follow.

Although it may seem intuitive that reducing the nicotine in cigarettes would lead people to smoke more, research has found compensatory smoking is not sustained, probably because there is not enough nicotine in VLNCs to make even greatly increased smoking worthwhile. Several studies found participants provided with VLNCs who continued smoking realised they could not access the same dose, quickly lost interest in smoking and consumed fewer cigarettes.

Surveys and in-depth interviews conducted by ASPIRE 2025 have found the VLNC policy has strong support from people who smoke, most of whom have tried many times to quit and greatly regret ever having started to smoke. Removing nicotine, which is the major barrier to quitting, will help people achieve their goal of becoming smokefree.

As well as changing the addictiveness of smoked tobacco, we also need to reduce the availability of these products, which anyone aged 18 years or over may buy from virtually every dairy, convenience store, petrol station and supermarket in the country. For decades, we have allowed tobacco to be sold at any store, just like milk and bread. Yet, smoked tobacco products are inherently unsafe and would never meet product safety standards if they were introduced today.

Restricting tobacco sales to a limited number of specific outlets, such as specialist R18 (“adult only”) stores or pharmacies, would signal tobacco is not a normal product and could bring considerable health benefits. If young people had less exposure to outlets selling tobacco, smoking uptake would decrease. In addition, removing tobacco products from many retail outlets could help people making a quit attempt to avoid cues that trigger impulse purchases and relapse.

Changing our perspective also means recognising Māori were originally a tupeka kore (tobacco free) society, and viewing smoking as one of many harms caused by colonisation. Because Māori led the Smokefree 2025 goal proposal to eliminate smoking disparities and return to the hauora they enjoyed before tobacco was introduced, supporting Māori governance to develop, implement and oversee new measures is essential.

Other measures could support supply-side initiatives. Developing more social marketing campaigns, explaining the goal and measures being introduced, creating a smokefree generation, removing filters (a consumer fraud that does not reduce the risk of smoking), and developing more targeted support for people quitting, could underpin more fundamental changes.

Predictably, tobacco companies and the groups they fund oppose supply-side measures, just as they have fought against every proportionate and evidence-based policy that would reduce their profits. Claims that illicit trade would increase gain traction only from reports tobacco companies have commissioned and spokespeople they fund. New Zealand's strong border controls and surveillance, and relative geographical isolation, make it unlikely that smuggled tobacco will be a major problem. Nor do arguments that small retailers would go out of business withstand close scrutiny. Robust studies undertaken by ASPIRE members show tobacco is a low profit product that tends to be a single-item purchase.

Reducing the nicotine in cigarettes to non-addictive levels and greatly reducing the outlets selling tobacco would change the design, appeal and availability of this toxic product. National and international evidence shows these measures could accelerate progress towards the 2025 goal. Drawing on the same courage shown in response to the COVID-19 pandemic, could see New Zealand lead the world in eliminating smoking and the terrible health disparities it causes.

Professor Janet Hoek, Professor Richard Edwards, Andrew Waa
Co-directors, ASPIRE 2025 research centre