Richard Edwards, Janet Hoek, Anaru Waa, George Thomson, Nick Wilson (author details*)
We congratulate the NZ Government on its proposed Action Plan for the Smokefree Aotearoa 2025 goal. Here we examine the evidence for three key ideas outlined in the plan: permitting tobacco products to be sold in only a small number of stores; reducing the nicotine in tobacco products to very low levels; and restricting the legal sale of tobacco products to people born before a certain fixed year (the “smokefree generation” idea).
Given sufficient political and public support, and effective implementation, New Zealand is poised to lead the world in tobacco control. The Government’s “Proposals for a Smokefree Aotearoa 2025 Action Plan: Discussion Document” represents a bold and innovative approach informed by sound logic and research findings from Aotearoa and internationally. If adopted and implemented in full, the Action Plan offers a realistic chance of realising the 2025 goal to achieve minimal smoking prevalence and eliminate smoking-related health disparities in Aotearoa.
Key measures proposed include:
- greatly reducing the availability of smoked tobacco products by only permitting these products to be sold in specialised stores or pharmacies;
- substantially decreasing the addictiveness of tobacco products by reducing the nicotine in these products to very low levels, and
- restricting the legal sale of tobacco products to people born before a designated year (the “smokefree generation” idea).
These measures sit alongside proposals to intensify and enhance established tobacco control interventions, such as mass media campaigns and smoking cessation support. Importantly, the action plan also includes a commitment to strengthening the tobacco control system, particularly for Māori. This important provision will ensure our diverse communities have a voice in the process, and it will promote uptake and compliance when these measures are implemented. The plan also commits to greater research, monitoring and evaluation, and enhanced compliance and enforcement.
The consultation process is open until 31 May (feedback can be submitted here); after analysing the feedback, the Ministry of Health will prepare a revised plan for Cabinet approval.
The Discussion Document includes many ideas for new interventions; we focus on three of these, outlining their rationale and evidence base, and extending the discussion set out in another recent blog.
1. Reducing retail availability: “Restrict sales of smoked tobacco products to a limited number of specific store types”
The Discussion Document includes measures to make smoked tobacco products less available and notes: “some commentators have suggested that tobacco products should be sold only in specialist R18 stores. Pharmacies have also been suggested as an option that could provide a strong link with smoking cessation advice.” (p 14).
This measure would redress a persistent anomaly, which has allowed a highly addictive and deadly product to be sold by almost every dairy, supermarket and service station. Allowing tobacco to be so widely available normalises the product, frames smoking as socially acceptable, and undermines smokefree initiatives. For example, quitters report that tobacco’s ubiquity triggers relapse and can undermine their journey to becoming smokefree.1 2 Reducing outlet numbers is likely to help reduce disparities in smoking as tobacco retailers are heavily concentrated in disadvantaged areas.3 NZ modelling studies suggest that greatly reducing the number of retail outlets would have a significant impact on reducing smoking prevalence.4-6 We therefore support reducing the number of retail outlets to around 5% of the current number (i.e., from around 6000 to 300).
Precedents for mandating marked reductions in the number of tobacco retail outlets exist. For example, in Europe, Hungary reduced tobacco outlet density by 83% in 2013 and now only allows tobacco sales at 7000 new government-operated stores.7 Phased reductions in availability were recently introduced in the Netherlands – with sales in supermarkets and gas stations due to be phased out by 2022.8 Licensing with fee increases has also achieved tobacco outlet reduction in South Australia.9
We also support options presented for managing tobacco supply, including limiting the outlets selling tobacco to either R18 specialist stores or pharmacies. Both options have particular advantages. Specialist R18 stores would facilitate enforcement of sales bans to minors and would provide flexibility to respond to changes in the minimal age for tobacco sales should NZ implement “T21” laws in the USA, or move to 25 years, as has been proposed.10 Tobacco outlets could have additional security to minimise the risk of robberies. Community pharmacies have similar advantages and could provide immediate smoking cessation advice to people who smoke. There is some evidence that pharmacists may be amenable to selling tobacco products (as a temporary measure as sales decrease).11 Nonetheless, more discussions with pharmacists and their organisations are required to assess the feasibility of this option. Both approaches will ensure that a ‘level playing field’ is maintained for the main existing retail outlets (dairies, convenience stores, service stations and supermarkets), none of which would be allowed to sell tobacco products.
To ensure this intervention promotes equity, the distribution of the stores selling tobacco products must align with population density and the over-concentration of stores among disadvantaged and high smoking prevalence communities must not continue.
2. Making smoked tobacco products less addictive and appealing: “Reduce nicotine in smoked tobacco products to very low levels”
The Discussion Document states that “Reducing nicotine content to minimal levels would likely decrease the number of young people trying smoking as they would not expect to get a hit from nicotine. It should also stop the progression to addiction among those who do experiment and prevent relapse in people who are trying to quit smoking.” (p 16)
This approach would address a major gap in NZ’s approach to tobacco control, which has failed to regulate the constituents and design of smoked tobacco products. This policy lacuna has enabled tobacco companies to maximise the addictiveness and palatability of cigarettes by ensuring high nicotine content,12 and by introducing appealing additives, flavours and product innovations like capsule cigarettes.13 These attributes make it difficult for people who smoke to quit and stay quit, and mean young people who experiment with smoking are more likely to progress rapidly to regular smoking and long-term addiction.
There is growing evidence14 and some modelling support,15 that mandating minimal or no nicotine in tobacco products is likely to markedly reduce uptake, increase quitting and greatly lower smoking prevalence. Despite concerns that people who smoke may smoke more frequently and more intensively, research shows very low nicotine content cigarettes (as proposed in the Government’s plan) elicit limited “compensatory” smoking, which typically lasts only for a few days, if it occurs at all. It is then followed by a reduction in the number of cigarettes smoked where people continue to smoke.16 Because even more intensive and frequent puffing cannot provide an effective dose of nicotine, people using very low nicotine cigarettes cease trying. This policy, like other measures, should be accompanied by an information campaign explaining the policy rationale, including outlining that removing nicotine reduces the addictiveness of smoked tobacco products. Messages should also advise that nicotine is not the primary toxic constituent of tobacco so people who smoke, and who cannot or do not want to quit, are not deterred from switching to reduced harm nicotine-delivery products such as e-cigarettes.
There is a strong international precedent for this measure from the USA where the FDA’s 2018 Advanced Notice of Proposed Rulemaking recommended developing a tobacco product standard for nicotine levels in cigarettes, which would mandate minimal or non-addictive nicotine levels.17 Removing flavourings like menthol, which may enhance the palatability and appeal of tobacco products, could accompany and support mandated minimisation of nicotine in tobacco products. There are many precedents for this latter measure, notably in the EU, UK and Canada, and emerging evidence of positive impacts.18
3. Reducing retail availability: “Introduce a Smokefree Generation Policy”
The Discussion Document states that: “a smokefree generation policy would prohibit the sale, and the supply in a public place, of smoked tobacco products to new cohorts from a specified date. For example, if legislation commenced on 1 January 2022, then people younger than 18 years at that time or those born after 1 January 2004 would never be able to lawfully be sold smoked tobacco products.” (p 15).
The smokefree generation measure could profoundly and permanently reduce smoking uptake among young people and hence protect them from the risk of lifelong addiction and future severe adverse health effects. Measures reducing uptake of smoking among young people are likely to have high public acceptability and strong political support. However, this intervention will have longer term impacts and will support maintenance of minimal smoking prevalence, once the goal has been attained.19 Because it will not have large immediate effects on smoking prevalence, which are required to achieve the Smokefree 2025 goal, this measure must be part of a comprehensive package that includes the measures discussed above. In addition, since uptake of smoking is rare after 25 years of age,20 there may be little gain from continuing the annual increases in legal age of purchase beyond 25 years.
NZ studies modelling the smokefree generation approach found it effective and highly pro-equity (i.e., even more favourable to Māori health vs non-Māori health, given the younger age-structure of the Māori population and the relatively high prevalence of smoking currently among young Māori).21 This strategy recognises that young people who start smoking rarely, if ever, make an informed choice,22 23 appreciates that regret among people who smoke is extremely high,24 and acknowledges that allowing tobacco sales to young people when there is a national smokefree goal is both illogical and unethical.
In summary, the NZ Government’s proposed Action Plan contains excellent potential new tobacco control measures that are truly world-leading. Each has a robust evidence base from intervention and modelling studies that illustrate local and international impact, and have substantial support from people who smoke as well as the general population.25 26 The plan demonstrates the government has listened to communities, in particular Māori, about the harm tobacco causes and respected solutions that Māori communities and leaders have proposed.27
Greatly reducing the supply of smoked tobacco products and removing the nicotine from the products will complement the recently introduced Vaping legislation.28 29 People unable or unwilling to stop using nicotine products will be more likely to switch to using harm-reduced products like e-cigarettes if these deliver nicotine effectively and people receive expert advice on switching at the point of purchase.
The Action Plan cannot compensate for a decade of minimal activity and lost opportunity that followed the Government’s adoption of the Smokefree Goal in 2011. However, it is comprehensive, bold and innovative, and offers the first realistic prospect of realising the Smokefree 2025 goal that was recommended by the Māori Affairs Select Committee in its 2010 report.27 We urge all individuals and groups who support eliminating the many harms smoking causes, and the inequitable burden of disease and premature death that follows, to express their support for the Action Plan via the consultation process.
*Author details: All authors part of ASPIRE2025 at the Department of Public Health, University of Otago, Wellington
- Chaiton M, Mercredy G, Cohen JE. Tobacco retail availability and risk of relapse among smokers who make a quit attempt: a population-based cohort study. Tob Control 2017;0(1-7)
- Hoek J, Gifford H, Pirikahu G, et al. How do tobacco retail displays affect cessation attempts? Findings from a qualitative study. Tob Control 2010;19(4):334.
- Marsh L, Doscher C, Robertson LA. Characteristics of tobacco retailers in New Zealand. Health Place 2013;23:165-70. doi: 10.1016/j.healthplace.2013.07.003
- Pearson AL, Cleghorn CL, van der Deen FS, et al. Tobacco retail outlet restrictions: health and cost impacts from multistate life-table modelling in a national population. Tob Control 2016;(E-publication 22 September) doi: 10.1136/tobaccocontrol-2015-052846 [published Online First: 2016/09/24]
- Pearson AL, van der Deen FS, Wilson N, et al. Theoretical impacts of a range of major tobacco retail outlet reduction interventions: modelling results in a country with a smoke-free nation goal. Tob Control 2015;24(e1):e32-8. doi: 10.1136/tobaccocontrol-2013-051362 [published Online First: 2014/07/20]
- Petrović-van der Deen FS, Blakely T, Kvizhinadze G, et al. Restricting tobacco sales to only pharmacies combined with cessation advice: a modelling study of the future smoking prevalence, health and cost impacts. Tob Control 2018;(E-publication 9 November) doi: 10.1136/tobaccocontrol-2018-054600 [published Online First: 2018/11/11]
- World Health Organization. Hungary – New regulation of tobacco sales introduced. 2013;(April). http://www.who.int/fctc/implementation/news/news_hung/en/.
- van Lier B, de kanter W. NETHERLANDS: Move to phase out tobacco sales in supermarkets and petrol stations. Tob Control 2020;29:247. https://tobaccocontrol.bmj.com/content/29/3/247.
- Bowden JA, Dono J, John DL, et al. What happens when the price of a tobacco retailer licence increases? Tob Control 2014;23(2):178-80. doi: 10.1136/tobaccocontrol-2012-050615 [published Online First: 2013/06/21]
- van der Eijk Y, Chen JI. Case for raising the minimum legal age of tobacco sale to 25. Tob Control 2021 doi: 10.1136/tobaccocontrol-2020-055964 [published Online First: 2021/01/09]
- Petrovic-van der Deen FS, Wilson N. Restricting tobacco sales to only pharmacies as an endgame strategy: are pharmacies likely to opt in? Aust N Z J Public Health 2018;42(2):219-20. doi: 10.1111/1753-6405.12764 [published Online First: 2018/02/15]
- Blakely T, Laugesen M, Symons R, et al. New Zealand cigarettes have a high nicotine content. N Z Public Health Report 1997;4(5):33-34.
- Hoek J, Gendall P, Eckert C, et al. Young adult susceptible non-smokers’ and smokers’ responses to capsule cigarettes. Tob Control 2019;28(5):498-505. doi: 10.1136/tobaccocontrol-2018-054470 [published Online First: 2018/10/05]
- Donny EC, Walker N, Hatsukami D, et al. Reducing the nicotine content of combusted tobacco products sold in New Zealand. Tob Control 2017;26(e1):e37-e42. doi: 10.1136/tobaccocontrol-2016-053186 [published Online First: 2016/09/28]
- Apelberg BJ, Feirman SP, Salazar E, et al. Potential Public Health Effects of Reducing Nicotine Levels in Cigarettes in the United States. N Engl J Med 2018;378(18):1725-33. doi: 10.1056/NEJMsr1714617 [published Online First: 2018/03/16]
- Benowitz NL, Donny EC, Edwards KC, et al. The Role of Compensation in Nicotine Reduction. Nicotine Tob Res 2019;21(Suppl 1):S16-S18. doi: 10.1093/ntr/ntz120 [published Online First: 2019/12/24]
- Food and Drug Administration. Tobacco Product Standard for Nicotine Level of Combusted Cigarettes 2018. Available at: https://www.federalregister.gov/documents/2018/03/16/2018-05345/tobacco-productstandard-for-nicotine-level-of-combusted-cigarettes.
- Chung-Hall J, Fong GT, Meng G, et al. Evaluating the impact of menthol cigarette bans on cessation and smoking behaviours in Canada: longitudinal findings from the Canadian arm of the 2016-2018 ITC Four Country Smoking and Vaping Surveys. Tob Control 2021 doi: 10.1136/tobaccocontrol-2020-056259 [published Online First: 2021/04/07]
- Gartner CE, Barendregt JJ, Hall WD. Predicting the future prevalence of cigarette smoking in Australia: how low can we go and by when? Tob Control 2009;18(3):183. doi: 10.1136/tc.2008.027615
- Edwards R, Peace J, Carter K, et al. An examination of smoking initiation rates by age: results from a large longitudinal study in New Zealand. Aust N Z J Public Health 2013;37(6):516-19.
- van der Deen FS, Wilson N, Cleghorn CL, et al. Impact of five tobacco endgame strategies on future smoking prevalence, population health and health system costs: two modelling studies to inform the tobacco endgame. Tob Control 2018;27(3):278-86. doi: 10.1136/tobaccocontrol-2016-053585 [published Online First: 2017/06/26]
- Gray RJ, Hoek J, Edwards R. A qualitative analysis of ‘informed choice’ among young adult smokers. Tob Control (ePub September 5, 2014) 2014 doi: 10.1136/tobaccocontrol-2014-051793
- Gifford H, Tautolo el S, Erick S, et al. A qualitative analysis of Maori and Pacific smokers’ views on informed choice and smoking. BMJ Open 2016;6(5):e011415. doi: 10.1136/bmjopen-2016-011415
- Wilson N, Edwards R, Weerasekera D. High levels of smoker regret by ethnicity and socioeconomic status: national survey data. N Z Med J 2009;122(1292):99-100. [published Online First: 2009/05/19]
- Gendall P, Hoek J, Maubach N, et al. Public support for more action on smoking N Z Med J 2013;126:85-94.
- ITC Project. Awareness and support for New Zealand’s Smokefree 2025 goal and key measures to achieve it. International Tobacco Control (ITC) New Zealand and ITC cross-country findings. Wellington: University of Otago and University of Waterloo, 2020.
- New Zealand Parliament. Inquiry into the tobacco industry in Aotearoa and the consequences of tobacco use for Māori. Report of the Māori Affairs Select Committee. Wellington: New Zealand Parliament 2010.
- Edwards R, Hoek J, Waa A. E-cigarettes, vaping and a Smokefree Aotearoa: where to next? N Z Med J 2020;133(1517):14-17.
- New Zealand Parliament. Smokefree Environments and Regulated Products (Vaping) Amendment Bill. Wellington: New Zealand Parliament 2020.