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]]>As part of the consultation process to denicotinise cigarettes and reduce the number of stores selling tobacco, Associate Minister of Health Dr Ayesha Verrall has outlined proposals to strengthen vaping product regulation. Noting that: “youth vaping rates are too high and we need to strike a better balance”, she has requested feedback on three additional measures: proximity restrictions for specialist vape retailers, disallowing evocative flavour names, and introducing new requirements for disposable vapes, including a reduction in the maximum nicotine concentration permitted. These proposals will help protect young people from aggressive vape marketing, but do they go far enough? In this blog, we explore additional measures that could more comprehensively regulate vaping product design and packaging, pricing, availability and promotion.
We welcome the Government’s recognition that existing measures have not constrained rapidly rising youth vaping rates; the latest NZ Health Survey found daily vaping among 18 to 24 year olds had risen to 23% while current (at least monthly) vaping among this age group was 28% (data on vaping among 15 to 17 year olds was not reported). Among Y10 students (aged 14 to 15) daily vaping was 10% overall in 2022, but higher among Māori (22%) and Māori girls (25%). These data illustrate the importance of finding “a better balance” between supporting people who smoke to move to less harmful options, while protecting young people who have never smoked from vaping uptake.
However, will the three measures outlined go far enough to safeguard young people’s right to protection from highly addictive products?1 To address this question, we first explore the strategies vape marketers have used to target young people, before considering the proposed new measures and suggesting additional steps we believe are needed to bring rapid reductions in youth vaping prevalence.
Vape product marketing
Marketers develop strategies that address four domains, known colloquially as the “4Ps”;2 these include place (or availability); product design; promotion, and price. Distribution networks play a crucial role in fostering product trial and supporting on-going use; nearly 100 years ago, then Coca Cola chairman Robert Woodruff sought to bring his brand “within arm’s reach of desire”, knowing that easy availability would help Coca Cola become an internationally recognised lifestyle brand. NZ’s legislation, which allows vaping products to be sold as consumer items in non-specialist outlets such as dairies, service stations and supermarkets,3 has enabled wide distribution networks to evolve, thus ensuring vaping products are as ubiquitous as milk and other household essentials. Both generic and specialist vape store numbers have risen rapidly; for example, BAT’s Vuse website states the brand is available at more than 2500 outlets. Furthermore, many dairies have created spaces within or adjacent to their store; the current regulations allow these spaces to be registered as R18 specialist vape ‘stores’, which may sell a full flavour range.4 Dairies are often visited by young people, whose potentially high exposure and access to vaping products,5 may have helped normalise vaping as a common lifestyle practice within this age group.
Vaping products have evolved through several design phases that illustrate the shift from a market comprising people who smoke (targeted by a “cigalike” product, a visual analogue of a smoked cigarette)6 to a much broader market, including people who do not smoke, particularly young people. Products targeting this latter group include “pods”, aesthetically appealing and discreet devices reminiscent of the visually alluring imagery used to transform tobacco brands into “badge” products that communicated desirable attributes about users and appealed particularly to young people.7 Alongside changes in device design, the development of nicotine salts has enabled e-liquids to deliver higher nicotine concentrations without loss of palatability,8 thus increasing the addictiveness of vaping and the speed at which young people become addicted to nicotine.
Prior to the 2020 legislation, promotions directly targeted young people via influencers, event marketing, and lifestyle appeals.9 Post-legislation, promotions have continued as marketers make sophisticated use of social media to create personally targeted appeals, encourage user-content, and facilitate referrals among users’ social networks.10 Pricing strategies have enabled wide uptake of vaping products; many disposable vapes retail for less than $10, and are thus highly affordable, particularly to young people.
Collectively, these marketing strategies have expanded vaping’s market. No longer only an option offering a reduced harm alternative to adults unable to quit smoking using approved cessation treatments, vaping has become a lifestyle practice concentrated among young people and often unconnected to smoking status. The Government hopes to achieve a new “balance” that focuses on vaping’s role as a reduced harm alternative to smoking; however, it is not clear the three measures proposed will afford the protection young people deserve. We now explore those measures and outline additional policies that could help reduce vaping prevalence among young people.
Proposed place-related measures
The Government’s proposals suggest applying proximity restrictions to new specialist vape retailer applications by considering the store’s “location relative to the distance from schools and sports grounds or other considerations specific to certain communities”. Importantly, this step will help prevent growth of the “store-within-a-store” tactic practised by some dairies, if these are located near schools;4 however, it will not eliminate this practice. Nor will it require dairies to remove existing specialist vape stores developed within their store or reduce the many hundreds of generic vape stores already operating near schools.
More importantly, the measure addresses only proximity; it does not consider the wider problem of retailer density that in 2022 led Local Government NZ members to pass a remit calling for a reduction in vape store numbers. As well as considering the growth of specialist vape retailers, the Government needs to consider total vape store numbers and introduce measures that ensure vape products are no longer “within arm’s reach of desire”.
We suggest ending sales of vaping products in generic stores and restricting these products to stand-alone R18 specialist stores, where staff are more likely to be able to assist people who smoke and wish to switch to vaping. Removing vaping products from dairies, supermarkets and service stations would achieve several important benefits. First, this step would recognise vaping products are not low-involvement, low-risk consumer products, and acknowledge that purchasers need advice to identify an appropriate device, flavour(s), nicotine level(s), and practices to successfully transition from smoking to vaping.11 12 Research with dairy owners found they knew little about the products sold and sometimes gave incorrect advice.13 Given earlier work found few adults who smoke reported purchasing vaping products from dairies, removing these products from generic outlets may have little effect on how people who smoke access vapes or e-liquids. Second, this step would make vaping products less visible to young people, who often frequent dairies and are exposed to vaping power-walls or inadequately demarcated ‘stores within a store’; it would thus end the implicit framing of vaping products as everyday products. Third, this measure would encourage people who smoke to visit R18 specialist vape stores, where staff are typically more knowledgeable about the products sold. To enhance retailers’ knowledge, new regulations could also require all specialist retailers to have basic training in smoking cessation methods and knowledge of referral pathways (e.g., Stop Smoking Services or the Quitline).
Although reducing overall store numbers is crucial to controlling young people’s access to vaping products, the consultation document notes that restricting generic retail outlet numbers will require a legislative amendment. Omissions from the initial vaping Act and the most recent Act have limited the Government’s ability to manage overall store numbers. We strongly recommend on-going evaluation to assess how effectively the proposed measures reduce youth vaping. If levels do not decline or remain disproportionately high among some population groups, we urge the Government to introduce legislation that provides greater control over total vape store numbers.
Proposed product design measures
The Minister has proposed two product design restrictions: the first will limit vaping flavour names and thus end the egregious practice of labelling e-liquids flavours with names such as ‘unicorn milk’ and ‘gummy bear’. While important, this measure needs to be accompanied by plain packaging that removes the colourful designs that are also likely to appeal to young people, thus closing the loophole allowing marketers to recreate flavour connotations using on-pack imagery. Plain packaging in this context would be simple black and white packaging, not dissuasive packaging, which would remain reserved for combusted tobacco products.
The second product design measure would apply to single-use vaping products, also known as disposables (or ‘dispos’), and require these to have removable batteries, child safety mechanisms and container labelling. The Minister also proposes reducing the nicotine salts concentration to 35mg/ml, though the rationale for this reduction is not clear and the proposed level is higher than other jurisdictions, such as the 20mg/ml permitted in the EU. We support limiting nicotine concentration levels but believe the level set should be based on evidence that it is likely to be significantly less addictive to young people. This question also requires careful monitoring to ensure an appropriate balance between protecting young people while retaining a viable alternative for people wishing to transition from smoking to vaping.
Requiring removable batteries would eliminate many disposable vapes currently sold and potentially see the most inexpensive product options removed from the market. However, given the Minister noted that “86% of 14-17 years old from New South Wales had tried disposable vapes”, it is not clear why she did not disallow these products completely. Because people who smoke will need vaping devices that operate for weeks or months, disposable vapes that last for only days may be less useful in supporting a transition from smoking. As the Minister noted, disposables are an “easy gateway product to vaping” among young people; removing these products from the market would thus protect young people yet would be unlikely to deter switching among people who smoke.
Additional product restrictions could include removing lower content products (e.g., products containing 6ml or less e-liquid) from the market as these are the least expensive products (and thus appeal to young people while offering lower utility to people who smoke). This measure would parallel the decision to end sales of cigarettes in packs containing fewer than 20 sticks, which reduced the affordability of tobacco to young people.
Potential promotion measures
The proposed changes do not include measures to manage promotions occurring via social media10 or within stores. At present, all stores may feature vaping product displays and vaping power-walls have replaced the smoking power-walls associated with youth smoking experimentation.14 Young people walking within a CBD are exposed to alluring window displays that function as product advertisements.
Source: Janet Hoek, VAPO store window, George St, Dunedin
Social media promotions include free offers, lifestyle marketing that positions vaping as a social connector, and competitions (see Figures below), all visible to anyone willing to click the link indicating they are aged over 18 years:
Source: https://www.airscream.co.nz/
Source for above 2 images: Jude Ball, personal collection
We suggest the Government disallow in-store promotions such as point-of-sale displays in generic retail outlets (if these are permitted to continue selling vaping products), require that vaping products are not visible from the street, introduce and enforce robust age verification procedures for online and in-person sales, disallow sales promotions (e.g. ‘buy one get one free’ and referral promotions), and apply pre-vetting procedures to social media promotions to ensure these comply with the new regulations.15
Potential pricing measures
The proposals do not include measures to introduce minimum prices or an excise tax on vaping products shown to differentially appeal to young people. While it is important not to create barriers that could deter people who smoke from switching to vaping, the Government should consider minimum prices if youth vaping does not decline rapidly.
Monitoring and enforcement
We urge the Government to monitor the impact these new policies have on youth vaping prevalence. Detailed monitoring will require relevant surveillance information, including studies examining reasons why people use vaping products, their perceptions of these, usage practices (e.g., devices and flavours used), and sources. Given rapid rises in youth vaping prevalence, we strongly recommend that the Government set a date by which they will have evaluated and reported on these (and other) measures designed to reduce youth vaping. Evidence of underage sales and findings that more than 50% of young people reported buying vaping products from dairies indicate funding is needed to resource enforcement officers who can monitor compliance and undertake more frequent store surveillance operations. Stronger penalties for stores found to have sold to minors are also required; these could include restrictions on offenders’ ability to sell vaping products, including the possibility of long-term bans on selling for recidivist offenders. In tight financial times we recognise the challenge of allocating more funding and note that removing vaping products from generic stores would greatly reduce store numbers, thus enabling more detailed and cost-effective store surveillance.
In summary, we applaud the Minister’s recognition of youth vaping as a serious problem requiring urgent attention and her determination to find a “better balance” that protects young people from vaping uptake, and hope others will share their thoughts on where this balance should sit. We believe stronger measures are needed to control marketing strategies used to target vaping products at young people and call on the Government to implement more comprehensive proposals, including remedying omissions in earlier legislation. We encourage Minister Verrall to take a comprehensive rather than piecemeal approach; our rangatahi deserve no less.
* All authors are members of the Department of Public Health and ASPIRE Centre, University of Otago, Wellington. Contact author: Janet Hoek (janet.hoek@otago.ac.nz).
References
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The Draft NZ National Security Long-term Insights Briefing (LTIB) has recently been produced by the NZ Government. In this blog we discuss its merits and how the process could be further advanced. In particular there is a need to: (i) improve future iterations of the public survey (eg, the next one in February/March 2023); (ii) signal a move towards an integrated and comprehensive National Risks Assessment; and (iii) explicitly articulate the extreme tail risks of each major trend identified in the LTIB (ie, nuclear war, unaligned artificial intelligence, extreme climate change, and catastrophic pandemics).
Photo by 3DSculptor from iStock
The Draft NZ National Security Long-term Insights Briefing (LTIB) has been produced by the Department of Prime Minister and Cabinet in conjunction with nine agencies responsible for protecting NZ from national security threats. Media have summarised key features of the Briefing, which include discussion of four global trends (increasing geopolitical competition, technological change, climate change, and future pandemics), as well as three plausible global scenarios (continued decline, dramatic decline, and an optimistic scenario).
Previous academic research has noted that national risk reports can become politicised, so it is good to see that a public survey and feedback on the proposed theme of the LTIB informed its content and reinforces legitimacy. This content focuses on six security threats, namely: disinformation, hacking and cyberattacks, transnational organised crime, foreign interference, terrorism, and Pacific resilience.
The Briefing offers ‘Ten Features’ that could enhance national security. These features might be summarised as:
The Prime Minister stated that the LTIB will discuss ‘the most significant threats New Zealanders are concerned about for the next decade’. However, these may be different from the threats most likely to harm NZ citizens, and the briefing rightly notes that public expectations of investment might not reflect the increasing risks.
One concern we have is that not enough information about risks has yet been given to the public to appropriately support informed engagement. This should be addressed and any concerns about ‘scaring people’ need to be set aside so that high impact but rare scenarios can be discussed.
We note that all risks are made more likely or more consequential by disinformation and we applaud the authors of the draft LTIB for giving prominence to the risk of disinformation. Humans can only thrive if the information they have tracks actual states of affairs in the world. If there is a reality-information mismatch then people are at risk of exploitation or outright hostilities. They are also at risk of erroneous beliefs and decisions on national risks.
With respect to the media, we were impressed recently with the documentary miniseries Brave NZ World by Storymaker (available on Neon), which presents a wide range of views on the threats to NZ from nuclear war, climate change, engineered pandemics, and unaligned artificial intelligence. More reporting like this could be encouraged to help inform future NZ public surveys.
Additionally, two Cabinet papers proactively released in 2022 describe a potential approach to revamping the NZ National Security System that narrows the definition of security risks, and moves away from an ‘all-hazards’ approach. We think this will mean some of the major risks to NZ will not be captured by the new National Security System (however that looks) or by the National Emergency Management Agency (NEMA). We have articulated these concerns in another post here.
The advantage of having a single overarching National Risks Assessment (of which National Security is one module) is that this allows comparative assessment of risks as well as analysis of the interplay between natural hazards, threats that malicious agents pose, and growing risks of global catastrophe and even existential threats to humanity.
Comparative analysis allows resource prioritisation decisions to be made rationally to achieve maximal reduction in expected harm. For example this League Table allows comparison across NZ and Australia health sector interventions. When using similar methodology to analyse risk reduction activities, it is likely the case that interventions across various risks require very different levels of resources to achieve outcomes such as preventing a human death. Wide variation is probably not justified and mitigation resources should be shifted to where they are most cost-effective.
The same is almost certainly true for national risk mitigation investments and for low-probability but catastrophic scenarios which risk harm to very many NZ citizens and where there may be low-hanging fruit for which moderate investments reduce expected harm substantially.
We have advocated cost-effectiveness analyses across interventions aimed at mitigating risks of national significance but achieving this requires characterisation of all hazards, natural and agential, common and catastrophic. It also requires that the common consequences of diverse risks are understood, because building resilience to these consequences will have an amplified effect across multiple risk scenarios. We think this implies that low probability high-consequence threats should be explicitly listed in the draft LTIB, and at least one should be characterised in detail.
The public survey results discussed in the draft LTIB suggest that the public thinks the government is already capable of handling extreme natural hazards and disease epidemics, but that the threat of nuclear war, or major breakdown of national infrastructure has not yet been mitigated.
Nuclear war would be a good example of a representative global catastrophe, with severe cascading impacts for NZ, for analysis to provoke resilience thinking. Some risks like this are important because though ‘unlikely’ they would be unbearable, and even if unlikely means a one percent chance per annum, then such catastrophes would be almost inevitable sometime this century.
Recent international work by the UN maps a more integrated course for national risk assessments, moving away from a hazard-centric approach, to one which takes a resilience focus, attends to natural and human threats together, and which addresses global catastrophic and existential threats to humanity at the level of national action, and integrated global action. This approach has been advocated by the UNDRR Framework for Global Science, the UN Secretary General’s report Our Common Agenda, and through the mid-term review of the Sendai Framework for Disaster Risk Reduction.
Deliberation over such risks and whether they ought to be prioritised for mitigation, can only happen if they are included in an integrated national risk assessment, characterised, communicated to stakeholders, and put forward for engagement and resource prioritisation processes.
With an integrated national risk assessment there is likely less risk of overinvestment and infringement on liberty that is sometimes associated with over-securitisation of risk, but also there is the possibility to redirect resources away from diminishing gains at the margin on some natural hazards, and towards growing human-induced catastrophic risk (which may be neither natural hazards nor security threats).
Examples of integrated national risk assessments can be found in work by the UK, Switzerland, and the Netherlands. However, each approach has its drawbacks, and all can be improved upon. Transparency and consultation will be particularly important, but the full spectrum of risks, long-term intervention options, and resource efficiency across risk mitigation needs to be presented clearly.
National security risk assessments are known to be subject to groupthink, political subjectivity of value, and are sensitive to the scenarios developed. We advocate inclusion of a provocative, though plausible, catastrophic scenario in the LTIB to help broaden thinking in these areas.
Additionally, establishing oversight such as a Parliamentary Commissioner for Extreme National Risks could operationalise this integrated approach and facilitate a systematic assessment of the consequences in expectation from each threat (natural hazards, security threats, and other catastrophic risks), the marginal benefit of additional action, and the value of action across all national risks.
Overall, the draft national security LTIB is a good start, advocating the development of important features for national security, including engagement with people, partnerships, and leadership. The trick now is to develop structures that can implement this vision. Such mechanisms might include a Commissioner for National Risks, a two-way information platform to support public and expert engagement, refined surveys of the public, openness about risk information, and international cooperation. There also needs to be adequate resourcing for horizon scanning to monitor the four key trends identified, as well as analysis of emerging risks (eg, machine intelligence), unfamiliar risks (eg, major solar flares) and the extreme tail risks each trend implies (eg, nuclear war or an engineered pandemic). Any revisions to the NZ National Security System must not jeopardize this wider project.
*Author details: Dr Boyd is at Adapt Research Ltd, Dr Payne is a Research Associate with Massey University, Prof Wilson is with University of Otago, Wellington. All three authors are co-investigators on the Aotearoa NZ Catastrophe Resilience Project.
]]>New Zealand Health Survey (NZHS) data was released in late November. In this blog, we assess whether the substantial reductions in smoking prevalence and increase in e-cigarette (EC) use/vaping observed in last year’s survey have continued. Key findings included:
We explore implications for the Smokefree Aotearoa goal and legislative and regulatory frameworks for smoking and ECs.
Image by dragana991 from iStock
This is the fourth annual blog describing key findings about smoking and e-cigarette (EC) use/vaping from the NZ Health Survey (NZHS).
Previous analyses revealed a steady but unspectacular decrease in smoking prevalence from 2011/12 to 2019/20, though large inequities in smoking by ethnicity and socio-economic status (SES) persisted.
In last year’s blog we reported that the 2020/21 survey indicated substantial increases in quit rates and decreases in smoking prevalence, including among Māori and Pacific peoples and the most deprived population groups. These findings followed steady but unspectacular declines in smoking prevalence from 2011/12 to 2019/20. Nonetheless, large inequities in smoking prevalence persisted in the 2020/21 survey. We also reported that declines in smoking prevalence were concentrated among younger age groups, continuing a long-standing trend. The 2020/21 survey also revealed a large increase in daily and current (at least monthly) EC/vaping prevalence, particularly among young people aged <25 years.
We cautioned about reading too much into one year’s data particularly as the 2020/21 survey was adversely affected by COVID-19 (e.g., the sample size was reduced) and the extraordinary circumstances of the pandemic may have resulted in temporary behaviour changes affecting smoking and vaping. 1 2
This blog provides updated information on patterns and trends in smoking and vaping prevalence from the 2021/22 NZHS data and explores implications for the Smokefree Aotearoa goal and legislative and regulatory frameworks smoking and ECs.
The NZHS is a rolling nationally representative population survey conducted through face to face computer assisted personal interviews (CAPI) every year since 2011/12. The survey aims to sample around 14,000 adults aged 15 years and over, and usually averages around 13,500 participants. Response rates were around 80% up to 2011/12to 2018/19 before falling slightly to 75% in 2019/20 and 77% in 2020/21. However, data collection has been badly affected by COVID-19 and in 2020/21 the sample size was reduced to 9709 adults and in 2021/22 was only 4,434 adults. In 2021/22, largely due to reduced availability of interviewers, response rates fell to 56% and around a third of interviews were conducted by computer-assisted video interviews (CAVI) rather than face to face.
The smaller 2021/22 sample size reduced the precision of estimates reported and the ability to conduct meaningful sub-group analyses.
Full details of the methods and a methodology report are available on the Ministry of Health website. Data used in the blog are sourced from the NZHS data explorer.
1. Overall smoking prevalence and e-cigarette use trends
Figure 1 shows trends in current (at least monthly) and daily smoking and vaping/EC use prevalence among adults (≥15 years) between 2011/12 and 2021/22.
Daily smoking prevalence in 2021/22 was 8.0% (95%CI: 7.0-9.0%) with an estimated 331,000 New Zealanders smoking daily. Current (at least monthly) smoking prevalence was 9.2% (95%CI: 8.1-10.3%), representing around 380,000 people.
Current and daily smoking prevalence declined by about 0.6% per year in absolute terms from 2011/12 to 2019/20. In the two years since 2019/20, there has been a sustained acceleration of the decline in smoking with an absolute fall of 3.6% in daily and 4.5% in current smoking prevalence. This reduction represents an estimated 154,000 fewer people smoking daily and 179,000 fewer smoking monthly or more often, and is similar to the estimated reductions in numbers between 2011/12 and 2019/20 (188,000 and 182,000 respectively).
Use of ECs was first assessed in the 2015/16 NZHS; since then, the prevalence of current and daily EC use has steadily increased. The rate of increase in vaping accelerated between 2019/20 and 2021/22, with current use approximately doubling from 5.3% to 10.3% (95%CI 9.1-11.7%) and daily use increasing from 3.5% to 8.3% (95%CI 7.1-9.7%). These represent an estimated additional 202,000 daily vapers and 213,000 current vapers over the two year period.
The increase in daily and current EC use between 2019/20 and 2021/22 occurred concurrently with the large reduction observed in smoking prevalence (Figure 1), whereas the more gradual increase in EC use between 2015/16 and 2019/20 was not associated with a substantial change in the rate of decline in smoking prevalence. We note in the discussion the contrasting evidence in the NZHS figures about the association between increasing EC use and declines in smoking prevalence, and the need for a more detailed analysis to explore this issue further.
Figure 1 Trends in adult (≥15 years) current (≥ monthly) and daily smoking and e-cigarette use (NZHS 2011/12 to 2021/22)
2. Smoking and e-cigarette use by gender and age
Daily (8.6% men vs 7.3% women) and current (9.9% men vs 8.4% women) smoking prevalence in 2021/22 were slightly higher among men. Since 2019/20, absolute decreases in current and daily smoking prevalence have been similar among men and women. E-cigarette use was also similar among men and women in 2021/22, with current EC use 10.6% for men vs 10.1% for women and daily EC use 8.5% for men vs 8.1% for women.
Figure 2 shows current smoking prevalence by age group from 2019/20 to 2021/22. Due to small numbers, data for smoking among 15-17 year olds were not available in 2021/22 (prevalence in this age group was very low in 2020/21 at 1.4%). Current smoking prevalence in 2021/22 varied between 9.6% and 11.3% for 18-24 years, 25-34 years, 35-44 years and 55-64 years age groups, compared to 5.9% among 65-74 years and 3.3.% for ≥75 years. There were similar patterns in daily smoking prevalence.
Figure 2 Current (≥ monthly) smoking prevalence by age group (NZHS 2019/20-2021/22)
Figures for smoking among 15-17 year olds were not available in 2021/22 due to small sample numbers
Figure 2 suggests that reductions in smoking prevalence since 2019/20 have been greatest in younger age groups.
Figure 3 displays absolute changes in current smoking prevalence by age-group during three time periods since 2011/12. Reductions in smoking prevalence were greatest in absolute terms for the 15-24, 25-34 and 35-44 years age groups during the two periods up to 2019/20 and in age groups between 15-24 years and 45-54 years in the period since 2019/20. Changes in prevalence in age groups above 55 years have been modest during all time periods since 2011.
Figure 3 Changes in current (≥ monthly) smoking prevalence by age group and time period since 2011 (NZHS 2011/12-2021/22)
Figure 4 shows patterns of EC use by age from 2019/20 to 2021/22. Vaping has increased rapidly, particularly among younger age groups (although data is not available for 15-17 year olds in 2021/22). In 2021/22 EC use was most prevalent among 18-24 year olds (22.9% daily, 27.8% current) but progressively less prevalent among people aged 25-44 and 45-64 years, and relatively rare among people aged 65 or older.
Figure 4 Daily e-cigarette use by age group (NZHS 2019/20-2021/22)
Figures for EC use among 15-17 year olds were not available in 2021/22 due to small sample numbers
3. Smoking and e-cigarette use among adolescents and young adults
Figure 5 presents trends in current and daily smoking prevalence and EC use among 15-24 year olds since 2011/12.
Current and daily smoking prevalence among 15-24 year olds reduced steadily from 2011/12 to 2019/20 (current and daily smoking declined about 1.1% per annum on average during this period). EC use increased steadily from 2015/16 to 2019/20.
Between 2019/20 and 2020/21 there were very substantial declines in current and daily smoking prevalence, coinciding with a rapid increase in daily and current EC use. The decline in smoking did not continue between 2020/21 and 2021/22, but the rapid increase in EC use continued. EC use is now approximately three times more prevalent than smoking in this age group with almost a quarter (23.8%) of 15-24 year olds using ECs at least monthly and almost a fifth (18.6%) using them daily. Logically, a large proportion of 15-24 year old vapers will be non-smokers.
Data on smoking and EC use among young adults by ethnicity are not available in the NZHS data explorer.
Figure 5 Trends in current (≥ monthly) and daily smoking and e-cigarette use among 15-24 year olds (NZHS 2011/12-2021/21)
The data presented in Figure 5 suggest some substitution of smoking with EC use has occurred among 15-24 year olds. However, the absolute increase in prevalence of EC use since 2019/20 to 2021/22 was much larger than the reduction in the prevalence of smoking, and therefore the prevalence of use of any nicotine product (cigarettes or ECs) will have increased since 2019/20. For example, daily smoking declined by 4.2% in absolute terms during this period whilst daily EC use increased by 14.4%. This finding also suggests many EC users in this age group were people who would not have begun smoking.
However, it is difficult to quantify the increase in any nicotine product use and the proportion of current vapers who are non-smokers because the NZHS Explorer data does not identify the proportion of people who are dual users. For example, simply adding smoking and EC use prevalence without adjusting for dual use will over-estimate prevalence of any nicotine product use.
4. Smoking and e-cigarette use by ethnicity
Figures 6 and 7 show trends in current and daily smoking prevalence by ethnicity. The substantial decline in Māori current and daily smoking prevalence seen in 2020/21 continued in 2021/22, but the decline in Pacific smoking in 2021/22 was either much less spectacular (current smoking) or partially reversed (daily smoking). Substantial inequities persist, although absolute differences in prevalence narrowed in 2021/22, particularly for Māori compared to European/other.
There was a substantial decline in Māori current smoking prevalence from 31.2% in 2019/20 to 20.9% in 2021/22 (Figure 6). The absolute difference in current smoking prevalence between Māori and European/others narrowed from 19.4% in 2019/20 to 12.4% in 2021/22.
Similarly, Māori daily smoking prevalence declined from 28.6% in 2019/20 to 19.9% in 2021/22 (Figure 7). The absolute difference in daily smoking among Māori compared to European/others narrowed from 18.4% in 2019/20 to 12.7% in 2021/22.
Figure 6 Trends in current (≥ monthly) smoking prevalence by ethnicity (NZHS 2011/12-2020/21)
Figure 7 Trends in daily smoking prevalence by ethnicity (NZHS 2011/12-2020/21)
The decrease in smoking was greater among Māori women e.g., current smoking prevalence fell from 35.0% to 20.0% while men showed a smaller decline from 27.3% to 21.8%. This is the first time during the period since 2011/12 that daily and current smoking prevalence has been lower among Māori women than Māori men.
Since 2011/12, Māori smoking prevalence has almost halved with current smoking reducing from 40.3% to 20.9% in 2021/22. The absolute decreases in Māori current and daily smoking prevalence in the two years from 2019/20 to 2021/22 were similar in magnitude to those for the 8-year period from 2011/12 to 2019/20. However, relative differences in prevalence did not change appreciably and Māori remain almost three times more likely than non-Māori to be current smokers in 2021/22 (prevalence ratio: 2.88, 95%CI: 2.28 to 3.64, adjusted for age and gender).
By contrast with Māori, Pacific current smoking prevalence has only reduced by about a quarter from 2011/12 to 2021/22 – from 25.9% to 18.9%. The Pacific sample was relatively small in 2021/22 and changes in current and daily smoking prevalence between 2020/21 and 2021/22 were not statistically significant. However, the changes in Pacific smoking prevalence since 2019/20 were much less dramatic than for Māori. Current smoking prevalence decreased from 22.5% in 2019/20 to 18.9% in 2021/22, but daily smoking prevalence was essentially unchanged. Pacific people were over twice as likely to be current smokers that non-Pacific people in 2021/22 (prevalence ratio: 2.29, 95%CI: 1.55 to 3.39, adjusted for age and gender).
Smoking prevalence among Asian peoples has also declined since 2019/20 and reached 3.5% for current smoking and 2.6% for daily smoking in 2021/22.
There were also differences in EC use by ethnicity (Figure 8), with substantial increases particularly among Māori and Pacific peoples between 2019/20 and 2021/22. The increase in EC use among Māori and Pacific peoples was much greater among women in the 2021/22 survey. For Māori, daily EC use decreased from 15.2% to 13.8% for men but increased from 10.0% to 21.2% for women, while daily use among Pacific men increased from 11.7% to 16.9% and from 6.3% to 16.6% among Pacific women.
Figure 8 Daily e-cigarette use by ethnicity (NZHS 2019/20 – 2021/22)
5. Smoking prevalence and e-cigarette use by socio-economic status
Figure 9 shows there are very large disparities in smoking by SES (as measured by NZDep, an indicator of neighbourhood deprivation).
Figure 9 Trends in current (≥ monthly) smoking prevalence by socioeconomic status (NZDep, NZHS 2011/12-2021/22)
NZDep quintile 1 is the most affluent and quintile 5 the most deprived.
Substantial reductions occurred in current smoking (7.8% and 7.1% absolute reductions) since 2019/20 among the two most deprived quintiles, but much less so among the more affluent quintiles. There were similar patterns in the decline in daily smoking by deprivation level over this period. The reduction in current smoking prevalence in the most deprived quintile since 2019/20 was substantially higher than during the whole of the period from 2011/12 to 2019/20 (7.8% vs 1.8% absolute reduction).
However, although socioeconomic differences in smoking prevalence have narrowed, substantial inequities persist. For example, current smoking prevalence in 2021/22 was about three times higher (prevalence ratio: 2.98, 95%CI: 1.61 to 5.51, adjusted for age, gender and ethnicity) among the most deprived quintile of the population compared to the most affluent quintile. In quintile 5 current smoking prevalence was 18.1% (representing 147,000 people who smoke) compared to 6.8% in quintile 1 (56,000 people). Daily smoking was over four times higher (adjusted prevalence ratio: 4.31, 95%CI: 2.27 to 8.21) in the most deprived quintile, with daily smoking prevalence 17.4% (142,000 people) in quintile 5 compared to 4.8% (39,000 people) in quintile 1.
E-cigarette use also varied with SES (higher in more deprived groups), though less dramatically than for smoking. For example, daily use in 2021/22 was 6.0% (an increase from 2.2% in 2019/20) among NZDep quintile 1 compared with 10.4% in quintile 5 (up from 5.2% in 2019/20). After adjustment for age, gender and ethnic group, differences were minimal (prevalence ratio for quintile 5 vs quintile 1: 1.08 95% CI: 0.62, 1.91) and not statistically significant.
6. Quit rates for smoking
The NZHS estimates smoking quit rates for smoking from the number of people who reported they had quit smoking in the last year and had been quit for at least a month divided by the number of last year quitters plus the number of people who smoke daily. These figures will over-estimate long term quit rates as some recent quitters will subsequently relapse to smoking and self-reported figures may overestimate true quit rates. The quit rates are for quitting smoking, but not necessarily quitting all nicotine product use: some recent quitters will have switched to ECs. The proportion of quitters who have switched to ECs is not available from the data explorer.
Figure 10 shows that overall quit rates were fairly constant (lowest = 9.6% (2015/16), highest = 13.6% (2019/20)) during the period from 2011/12 and 2019/20, but increased markedly to 19.0% in 2020/21 and 20.2% in 2021/22. There were also large increases in quit rates for all ethnic groups after 2019/20; with particularly large increases among Māori (9.4% in 2019/20 vs 20.9% in 2021/22) and Pacific peoples (8.8% vs 27.1%). Quit rates were generally higher among European/other people than among Māori and Pacific peoples from 2011/12 onward, but this was no longer the case in 2021/22.
The high quit rates in 2021/22 among Pacific peoples appears inconsistent with the modest changes in smoking prevalence shown in Figures 6 and 7. However, the numbers of Pacific people and of Pacific people who smoke or have quit in the last year in the NZHS is small so these and previous figures for Pacific quit rates may be affected by chance fluctuations and should be viewed with caution.
Figure 10 Trends in quit rates by ethnicity # (NZHS 2011/12 to 2021/22)
Quit rates among Asian peoples are not reported in this graph as these fluctuated widely, likely reflecting chance variations due to the smaller numbers of participants identifying with Asian ethnicities.
Quit rates also varied substantially by SES (Figure 11) and age-group (Figure 12).
Figure 11 shows that there was a strong socio-economic gradient in quit rates in 2019/20 and 2020/21, but this was less clear cut in 2021/22 (partly because figures were not available for quintile 1 due to small sample size).
Figure 11 Quit rates by socioeconomic status (NZDep, NZHS 2019/20 – 2021/22)
NZDep quintile 1 is the most affluent and quintile 5 the most deprived. Quit rates were not available for quintile 1 in 2021/22 due to small numbers in the sample.
Figure 12 shows that quit rates decrease greatly with age. The age-related quitting gradient appears to have increased since 2019/20 due to larger increases in quit rates among age groups below 55 years.
Figure 12 Quit rates by age group (NZHS 2019/20-2021/22)
Key findings from the 2021/22 NZHS include the following:
Mostly, the smoking trends in the 2021/22 NZHS are very encouraging. The acceleration in the decline in smoking appears to have been maintained, including among Māori (particularly Māori women) and among the most deprived population groups. However, the lack of reduction in Pacific smoking prevalence is a major concern. Evidence that the accelerated decline in smoking prevalence seen in 2020/21 has generally continued means it is less likely that the accelerated decline in prevalence since 2019/20 is due to random fluctuations in year-to-year results. However, it will be reassuring if there are similar findings in future NZHS with full sample sizes that are not conducted in the shadow of a pandemic.
The NZHS is carried out each year using largely consistent methods. The most plausible threat from bias is that the COVID-19 pandemic resulted in a systematic change to the methods (e.g., to the sampling strategy, response rates or to the data collection methods) affecting particularly the 2020/21 and 2021/22 surveys.
In 2020/21, there were no major changes to the data collection methods other than a small number (n=31) of interviews were conducted by video rather than all being face-to-face (as in previous surveys). In 2021/22 about a third of interviews were conducted by video. However, the video interviews replicated the in-person interview as much as possible. The NZHS team (personal communication) also conducted a comparison of results for key indicators by interview type. This suggested that any biases due to change of data collection method were unlikely to be substantial.
There were substantial changes to response and coverage rates and the sample size in 2021/22. This may have introduced greater selection bias (e.g. the degree to which participants in the survey differ in smoking and EC use rates compared to the overall population) and will have reduced precision (increased the width of confidence intervals/margin of error for survey estimates). There is some evidence to suggest an increase in selection bias is unlikely to have greatly affected the findings, though it cannot be ruled out. For example, if the 2020/21 and 2021/22 NZHS participants were systematically different from previous surveys, then substantial changes might be expected in multiple measures included in the survey, particularly in other health-related risk behaviours (such as hazardous and heavy episodic drinking and illicit drug use). However, between 2019/20 and 2020/21, there were no substantial changes in these behaviours, and then small declines in prevalence (e.g. hazardous drinking fell from 19.9% to 18.8% among the adult population) between 2020/21 and 2021/22.
The most plausible explanations for the observed changes in smoking prevalence since 2019/20 are: (i) growing use of ECs is resulting in increased quitting smoking among people who smoke and/or reduced uptake if young people substitute vaping for smoking; (ii) the impact of tobacco control policies and interventions that have been implemented or proposed; (iii) an ongoing effect of the COVID-19 pandemic (e.g., increased quitting through various possible mechanisms).
We discussed the likelihood that the COVID-19 pandemic explained increased declines in smoking prevalence in last year’s blog and concluded these were unlikely to be the main drivers of the decreases observed.
Other tobacco control policies and interventions may have contributed to the observed smoking prevalence declines, but new polices or interventions are probably unlikely to be the main cause for these. New tobacco control policies since 2019/20 have been restricted to an above inflation tobacco excise increase on January 1 2020, some relatively modest changes to mass media campaigns on smoking, and the introduction of legislation prohibiting smoking in cars in November 2021.
However, previous policies could be having an ongoing or enhanced impact. For example, tobacco tax increases and reduced affordability of cigarettes and tobacco may have had an increased effect in the context of economic uncertainty and hardship caused by the pandemic. Supporting evidence comes from the ITC NZ/EASE survey (data collected October 2020 to February 2021) in which 90% of 692 people who smoke stated the price of cigarettes as a reason for wanting to quit (unpublished data) – the commonest reason given. It is also possible that the announcement of potential major new policies in the Smokefree Aotearoa Action Plan consultation document in April 2021 resulted in some anticipatory quitting among people who smoke, although this seems unlikely to have been a major influence.
Accelerated increases in EC use since 2019/20 coincided with more rapid declines in smoking prevalence and provides evidence to support the hypothesis that EC use contributed to recent reductions in smoking prevalence in New Zealand. A more detailed analysis (outside of the scope of this blog) of rates of EC use among recent quitters and of the degree to which smoking prevalence declines mirrored increases in EC use among different population sub-groups and exploration would help evaluate the likely impact of ECs. For example, evidence in support of the hypothesis is that some of the biggest increases in EC use and largest smoking prevalence declines have been among Māori women. However, against the hypothesis is that there have been similarly substantial increases in EC use among Pacific women, but little change in smoking prevalence. More detailed analyses are also required to assess whether EC use has displaced smoking among young people or attracted users who would not have smoked.
So what are the implications for future policy and practice and for the equitable achievement of the Smokefree Aotearoa 2025 goal?
First, the sustained reductions in smoking prevalence, including among Māori, suggest that the smokefree goal is attainable for all peoples in Aotearoa, particularly if the bold measures included in smokefree legislation before Parliament are introduced promptly (with mandated denicotinisation being the most pivotal). However, smoking continues to place a much higher burden on Māori and Pacific peoples. Given the continued inequities in smoking prevalence, ensuring Māori and Pacific governance over and engagement with the implementation of smokefree strategies and actions is essential, as is ongoing evaluation of new measures, particularly their impact on inequities.
Second, the findings of slower declines in smoking prevalence among Pacific peoples (and a possible increase in daily smoking prevalence) and older age groups suggests that greater attention is needed to implementing interventions that are effective among these groups and monitoring the impact of interventions on these populations as the Action Plan is rolled out.
Third, smoking prevalence among 18-24 year olds did not decrease significantly in the 2021/22 survey, despite very high prevalence of EC use in this age group. This underlines the importance of implementing the Smokefree Aotearoa Action Plan measures, which have the potential to greatly reduce smoking uptake smoking among young people.
Fourth, the findings are mostly consistent with the hypothesis that increasing EC use/vaping is contributing to falls in smoking prevalence and achievement of the Smokefree Aotearoa goal, and so are supportive of current legislation and regulations that ensure that people who smoke have ready access to these products. However, more detailed analysis should be undertaken to provide more definitive evidence.
Fifth, the continued rapid increase in EC use and increase in overall use of nicotine products (EC use and smoking prevalence combined) among young people aged < 25 years, many of whom would not have smoked, is worrying. It suggests that current legislation and regulations are failing to protect adolescents and young adults from the risk of starting to vape. Concerns include uncertainties about the long-term health effects of vaping and the risk of creating a new cohort of young people addicted to nicotine. The latter is at odds with the Tupeka Kore vision.
When submitting on the Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Bill, we called for a review of how vaping and other nicotine products are regulated. We continue to call for such a review, which should assess how regulations can best balance the interests of people who smoke and could benefit from switching to ECs and those of young people who do not smoke and will not benefit from commencing EC use. The findings of the 2021/22 NZHS underline the urgency and importance of carrying out that review.
* Author details: All authors are with ASPIRE2025 and the Department of Public Heath, University of Otago, Wellington
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Although tobacco harm reduction will likely support realisation of the Smokefree Aotearoa Goal, this approach is often narrowly conceptualised as supporting transitions from smoking to alternative nicotine products that are less harmful. In this blog, we outline an expanded definition that goes beyond supporting access to and uptake of alternative nicotine products like vaping and recognises other core harm reduction approaches. These include measures that decrease the harmfulness of smoked tobacco products to the user and to others, and interventions that reduce the appeal, availability and addictiveness of smoked tobacco products in absolute terms and relative to alternative nicotine products. We encourage further discussion of these ideas amongst the smokefree community as attention turns to how measures in the soon-to-be-enacted
Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Bill will be implemented.
Public health strategies have often used the term “harm reduction” to describe approaches that aim not to prevent an activity, but to reduce harmful health, economic, legal, cultural and social consequences of that activity. Harm reduction approaches commonly used in this way to mitigate harms of drug use include:
Harm reduction has also been applied to tobacco/nicotine use. Hatsukami and Carroll proposed a commonly applied conceptualisation of harm reduction in this context: “Tobacco harm reduction involves providing tobacco users who are unwilling or unable to quit using nicotine products with less harmful nicotine containing products for continued use.”2 They noted the potential benefit of nicotine harm reduction products (such as vaping products) and rising usage rates. New products that more closely mimic smoking practices may assist people unable to quit using traditional methods, such as nicotine replacement therapy (NRT), to transition away from smoking.3, 4 Nonetheless, the authors also recognised the potential risk these products pose when they commented: “others believe that we will be addicting another generation to tobacco products”. These comments reflect the careful balance required to ensure harm reduction measures bring overall population health benefits.
In Aotearoa NZ, recent data reporting on smoking and vaping show rapid declines in smoking,5 a finding that some have argued suggests vaping is displacing smoking. This reasoning is consistent with some population-level studies in the US,6 and would favour net health benefits according to NZ modelling work that found allowing access to vaping products could reduce harms to health.7 On the other hand, the marked increase in vaping amongst young people,8 evident also in the most recent NZ data5 (where current smoking decreased by 0.8% among 15-24 year olds [from 8.6% to 7.8%] while monthly vaping increased by 5.3% [from 18.5% to 23.8%]), supports concerns that current policy has given rise to a new generation of nicotine-dependent young people who have never smoked.
Although discussions of tobacco harm reduction tend to focus on providing alternatives to people who smoke such as vaping, we suggest there is a case for expanding conceptualisations of harm reduction as applied to tobacco smoking. So in this blog, we outline an expanded definition that goes beyond supporting access to, and uptake of, alternative nicotine products like vaping and recognises other core harm reduction approaches. This more expansive definition is compatible with more holistic approaches to health such as the WHO definition and those typically held by Indigenous peoples. These approaches consider harm not only to users and their health (including impacts on agency and self-determination), but also to families and communities, and to the natural environment.
An expanded definition of harm reduction relating to tobacco smoking
An expanded definition could include:
Categories 1a and 1b effectively describe risk proportionate regulation and acknowledge the potential synergies between smokefree policies introduced in settings where alternative nicotine products are available.9 On the basis of the above typology, we argue that smokefree policy and practice has often long deployed a harm reduction approach and, based on the final category, all effective smokefree policies and interventions could be considered harm reducing. However, although this final category is not generally considered a harm reduction approach, we suggest it fits logically within a harm reduction framework.
We outline examples of smokefree and vaping-related policy measures and interventions in the table below and describe which of the harm reduction categories noted above that they address. Even so, we have not included an example of category 2. This reflects the general failure to identify means by which smoked tobacco products can be made less harmful – though when addiction is conceptualised as a harm in itself, mandated denicotinisation of tobacco would fit in here.
Smokefree and vaping-related policy or intervention |
Promoting switching to/substitution by, lower risk products |
Reducing harm from smoking to others |
Reducing smoking by increasing quitting and/or reducing uptake of smoking |
Allowing ready access to vaping products for people who smoke or are dependent on nicotine (this is in place in NZ, albeit with concerns around increasing rangatahi/youth uptake8) [Category 1a] | Yes, this is a key potential benefit.
But note there may be increased harm through rangatahi/youth uptake of vaping among people other than those who would otherwise have smoked. |
Yes, exposure to vaping aerosol is probably less harmful than exposure to second-hand smoke (SHS), though the extent of harm reduction is still uncertain. | Yes, evidence from RCTs for increasing quit rates from smoked tobacco.10, 11 However, efficacy in promoting cessation outside of intervention study settings is still unclear. For example, a meta-analysis of observational studies found that e-cigarettes were not associated with increased smoking cessation in the adult population overall.12 Also dual users appear to be less likely to quit than people who only smoke tobacco.13 |
Smokefree areas including work places, public places, restaurants/bars, and vehicles with children. Many are currently mandated in NZ, albeit with scope for improvements.14, 15 [Category 3] | Unlikely to have a major impact. | Yes, very strong evidence of reduced exposure to SHS and reduced SHS harm to others.16 | Yes, strong evidence that smokefree areas improve quit rates17 and protecting adolescents and young people from smoking could reduce risk of them starting to smoke (eg, this NZ study: 18). |
Denicotinisation of tobacco. This is being considered by the NZ Parliament and is supported by NZ research.19-22 [Categories 1b, 4] | Yes, logic and emerging evidence,23 including self-reports from people who smoke in NZ (see here and here) suggests that a denicotinisation policy would promote switching to vaping. | Probably, logic suggests that denicotinisation will reduce SHS exposure to non-smokers (if people smoke less or quit). | Very probably, RCTs and other evidence suggest that denicotinisation promotes quitting (even in those not motivated to quit24). See also supportive NZ findings. |
Substantial reduction in retail outlet numbers (this is being proposed for NZ) [Categories 1b, 4]
|
Probably, as logic suggests that reducing availability relative to vaping products will promote switching. In the ITC NZ study 13% of people who smoke said they would switch to vaping if this policy was introduced. | Probably, logic suggests that reduced smoking and increased quitting will reduce SHS exposure to non-smokers. | Probably, though estimates of impact are largely based on modelling.22, 25-27 |
On the basis of our broader conceptualisation, past regulation for smokefree environments and Aotearoa NZ’s proposed pioneering legislation (relating to denicotinisation and retail reduction) employ harm reduction approaches. Nevertheless, we consider that greater acceptance of this broader conceptualisation could support policy synergies and more comprehensive strategies to address smoking and the harm it causes. A broader conceptualisation of harm reduction may also create opportunities for greater cohesion within the smokefree community. Tobacco companies have much to gain by creating divisions within our sector; critically reflecting on their narrow definition of harm reduction could expose their tactics and help us avoid fragmentations that will only benefit their ends.
While we plan to expand on this whole topic in future work (and detail other harm reduction examples, and the societal/community and equity dimensions of harm reduction), we now encourage comment on this conceptualisation, particularly its implications for progressing the Smokefree Aotearoa 2025 Goal and the kaupapa Tupeka Kore.
*Author details: The authors are with the Department of Public Health at the University of Otago Wellington.
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