The Smokefree Generation: Perspectives from young people

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Janet Hoek, Lani Teddy, Elizabeth Fenton, Jude Ball, Richard Edwards, Ell Lee*

Aotearoa New Zealand’s Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Bill proposes introducing a Smokefree Generation (SFG) policy; over time, this policy would end sales of smoked tobacco products. Although supported by health researchers, we know little about how young people – those targeted by the SFG policy – perceive it. In this blog, we briefly explain the policy rationale before discussing findings from our recent paper that addressed this knowledge gap.

Image by Tumisu from Pixabay

The Aotearoa New Zealand (NZ) Parliament is currently progressing the Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Bill; this legislation proposes three core measures: denicotinisation, a large reduction in the availability of smoked tobacco products, and the introduction of a smokefree generation policy (SFG).1 Implementing an SFG disallows the sale of smoked tobacco products to anyone born on or after a specified date, which is proposed as 01 January 2009.2

Rationale for an SFG policy

While age restriction policies have helped reduce youth smoking, they have not eliminated inequities or provided sustained protection. For example, the latest (2021) Year 10 Snapshot Survey conducted by ASH NZ found 9.3% of 14-15 year old Māori students reported regular (i.e., at least monthly) smoking, compared with only 2.7% of their NZ European peers.3 Furthermore, evidence that smoking prevalence rises rapidly among 18-24 year olds suggests age restrictions only delay recruitment of ‘replacement smokers’ and do not close the pipeline altogether.4

Increased age restrictions offer one response to this evidence and the US Food and Drug Administration has introduced a T21 policy that does not allow tobacco sales to anyone aged under 21.5 However, the T21 policy is not a full solution as it continues to imply that smoking is ‘safe’ or ‘acceptable’ beyond a certain age.2 The SFG addresses this problem, thus extending the protection provided by age restriction policies.

The SFG reinforces smoking as a socially unacceptable practice by removing its status as a “rite of passage”.6 For many decades, tobacco companies framed smoking as a symbol of maturity and associated it with connotations of rebellion, sophistication and adulthood.7 8 Despite restrictions on the rampant marketing that fostered this positioning, these connotations linger and help smoking maintain a residual appeal among some young people. The SFG will help extinguish these lingering connotations, thus reducing the pipeline of ‘replacement smokers’ that helps tobacco companies remain financially viable.

Supporting evidence for SFG policy and implementation

The SFG has strong empirical support. A modelling study estimated that introducing an SFG policy could halve smoking prevalence within 14 years among people aged 45 and under; it also predicted strong pro-equity benefits, with the SFG delivering around 5.6 times the health gain per capita to Māori relative to non-Māori, due largely to the youthful population structure of the Māori population.9 Studies show strong public support for the SFG among both adult and young adult populations,10 and among people who do and do not smoke.11 12

Brookline (in the state of Massachusetts, USA), has recently successfully defended its SFG policy against action taken by retailers who argued the measure was pre-empted by earlier legislation and violated equal protection guarantees in the Massachusetts Declaration of Rights. The Court rejected the pre-emption arguments and held the SFG policy complemented rather than conflicted with earlier legislation. Further, the Court held that there was “no plausible set of facts” that could be used to show Brookline’s by-law “was not rationally related to the furtherance of a legitimate state interest”.13 The recent UK Khan report proposes a smokefree generation policy while Malaysia and Denmark have announced plans to introduce nicotine free policies that end sale of nicotine products to anyone born after 2005 and 2010, respectively.14-16

Flawed opposition arguments

Opponents of SFG policies have erroneously claimed the SFG amounts to prohibition; British American Tobacco stated the SFG removed young people’s “personal freedoms, [and] their right to autonomy in their private lives”.17 Yet logically, prohibition arguments apply only when young people are denied a behaviour they have freely chosen. Evidence that very few, if any, young people make truly informed choices to smoke or understand addiction; evidence of high regret and a strong desire to quit, alongside the difficulty of quitting once addicted, and the severe health consequences of life-long smoking, seriously undermine prohibition arguments.18-20 More fundamentally, these arguments suggest regulation reducing smoking initiation removes rather than protects freedoms.21 Bioethicists have advocated an alternative perspective where regulation promotes freedom by preventing addiction that compromises young people’s autonomy and ability to make free choices.22

Young people’s perspectives

To explore how young people perceive the SFG proposal, we undertook in-depth interviews with 20 youth aged 17 or 18 living in Dunedin, a medium sized city in Aotearoa New Zealand.23 We explained the policy to ensure participants understood its implications and asked them to assume the SFG applied to those aged 17 but not to those aged 18. Despite tobacco industry arguments that the SFG would deprive young people of “personal freedoms [and] their right to autonomy in their private lives”,17 most of our participants (and particularly those identifying as Māori) supported the SFG.

These young people placed a higher priority on measures that would protect their well-being and help keep ensure future generations free from addiction to tobacco than on the “right” to purchase tobacco. They took a long-term perspective and demonstrated a keen ability to differentiate between freedoms that mattered and those that offered nothing. One participant explained: “I don’t really think that’s a really important freedom at all [to buy tobacco], because, I mean, okay, it is important, but banning, I feel like banning smoking has many more benefits, rather than saying, ‘Oh, it’s freedom, so we should have it, we should keep it’.” Some believed the SFG would bring increasing benefits across generations “it [the SFG] would change the world in a few years… if you stop… the young, the next generation will stop. They when they’re the leaders of their generation, or generations below them… it will just get better and better and better, the younger they go”.

Only a small minority saw retaining the personal choice to buy cigarettes and tobacco as more important than the long-term societal benefits others associated with the SFG. Some among this minority supported what they thought would be less restrictive measures to reduce smoking uptake while others outlined “personal responsibility” arguments and argued “you shouldn’t be protected from your environment”.

Implications

The young people we interviewed drew strongly on freedom and choice metaphors, and most expressed a “positive freedom” view that recognised policy restrictions could help preserve freedoms. Most explicitly rejected tobacco companies’ claims that the SFG would limit their freedoms and curtail personal rights, and instead recognised the longer-term, societal benefits the SFG could deliver.

Participants’ deep reflections on the interview questions highlight the value of incorporating young people’s views in policy development and implementation. In particular, their comments suggest framing the SFG as a measure that enables, rather than removes, freedoms could stimulate reflection and elicit strong support for a policy that safeguards the well-being of future generations.

*Authors: Janet Hoek, Lani Teddy, Jude Ball, Richard Edwards are members of the Department of Public Health, University of Otago, Wellington. Elizabeth Fenton is a member of the Bioethics Centre, University of Otago, Dunedin, Ell Lee is a medical student, University of Otago, Wellington.

Funding: This research was funded by the Health Research Council of New Zealand (programme grant (19/641).

A story commenting on these findings is now available on the Conversation:

https://theconversation.com/forget-tobacco-industry-arguments-about-choice-heres-what-young-people-think-about-nzs-smokefree-generation-policy-193529

Earlier blogs on the SFG may be found here:

https://blogs.otago.ac.nz/pubhealthexpert/the-smokefree-generation-a-core-measure-in-new-zealands-endgame-strategy/

https://blogs.otago.ac.nz/pubhealthexpert/phasing-out-smoking-the-tobacco-free-generation-policy/

https://theconversation.com/new-zealand-is-introducing-law-to-create-a-smokefree-generation-here-are-6-reasons-to-support-this-policy-186283

To access our new paper, please use this link:

https://tobaccocontrol.bmj.com/content/early/2022/10/25/tc-2022-057658

References

  1. New Zealand Government. Smokefree Aotearoa 2025 Action Plan Wellington: Ministry of Health,; 2021 [Available from: https://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/smokefree-aotearoa-2025-action-plan accessed 09 December 2021.
  2. Berrick A. The tobacco-free generation proposal. Tobacco Control 2013;22(suppl 1):i22-i26.
  3. ASH New Zealand. Year 10 Snapshot Survey 2021: Regular Smoking and Regular Vaping, 2022.
  4. Ministry of Health. Annual Update of Key Results 2020/21: New Zealand Health Survey Wellington: Ministry of Health; 2021 [Available from: https://www.health.govt.nz/publication/annual-update-key-results-2020-21-new-zealand-health-survey accessed 07 December 2021.
  5. Food and Drug Administration. Newly Signed Legislation Raises Federal Minimum Age of Sale of Tobacco Products to 21 Maryland: Food and Drug Administration,; 2020 [Available from: https://www.fda.gov/tobacco-products/ctp-newsroom/newly-signed-legislation-raises-federal-minimum-age-sale-tobacco-products-21.
  6. Berrick J. Drawing on adolescent psychology to achieve tobacco-free generations. Public Health Reviews 2022:27.
  7. Teague C. Research planning memorandum on some thoughts about new brands of cigarettes for the youth market. RJR Tobacco Company 1973:BATES No. 505101981-1992.
  8. Ling PM, Glantz SA. Why and how the tobacco industry sells cigarettes to young adults: evidence from industry documents. American Journal of Public Health 2002;92(6):908-16.
  9. 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. Tobacco Control 2018;27(3):278-86. doi: 10.1136/tobaccocontrol-2016-053585
  10. Trainer E, Gall S, Smith A, et al. Public perceptions of the tobacco-free generation in Tasmania: adults and adolescents. Tobacco Control 2017;26(4):458-60.
  11. Khoo D, Chiam Y, Ng P, et al. Phasing-out tobacco: proposal to deny access to tobacco for those born from 2000. Tobacco Control 2010;19(5):355-60.
  12. Edwards R, Johnson E, Stanley J, et al. Support for New Zealand’s Smokefree 2025 goal and key measures to achieve it: Findings from the ITC New Zealand Survey. Australian and New Zealand Journal of Public Health 2021;45(6):554-61.
  13. US A. Cour dismisses lawsuit challening Brookline, Massachusetts’ tobacco-free generation law: ASH US; 2022 [Available from: https://ash.org/court-dismisses-lawsuit-challenging-brookline-massachusetts-tobacco-free-generation-law/2022.
  14. Alfiq F. Malaysia will ban the sale of tobacco products to individuals born after 2005 2022 [Available from: https://mothership.sg/2022/01/malaysia-ban-smoking-2005/ accessed 05 April 2022.
  15. Khan J. Making smoking obsolete: UK Government,, 2022.
  16. Unknown. Denmark considers ban on cigarette sales to anyone born after 2010 2022 [accessed 03 November 2022].
  17. British Amercian Tobacco (New Zealand) Limited. Proposed Smokefree Aotearoa 2025 Action Plan Submission 2021.
  18. Gifford H, Tautolo D, Erick S, et al. A qualitative analysis of Māori and Pacific smokers’ views on informed choice and smoking BMJ Open 2016 doi: bmjopen-2016-011415
  19. Gray R, Hoek J, Edwards R. A qualitative analysis of ‘informed choice’ among young adult smokers. Tobacco Control 2016;25(1):46-51. doi: 10.1136/tobaccocontrol-2014-051793
  20. Hoek J, Ball J, Gray R, et al. Smoking as an ‘informed choice’: implications for endgame strategies. Tobacco Control 2017;26(6):669-73. doi: 10.1136/tobaccocontrol-2016-053267
  21. Schmidt AT. Freedom of choice and the tobacco endgame. Bioethics 2022;36(1):77-84.
  22. Griffiths PE, West C. A balanced intervention ladder: promoting autonomy through public health action. Public Health 2015;129(8):1092-98. doi: https://doi.org/10.1016/j.puhe.2015.08.007
  23. Hoek J, Lee E, Teddy L, et al. How do New Zealand youth perceive the smoke-free generation policy? A qualitative analysis. Tobacco Control 2022:tc-2022-057658. doi: 10.1136/tc-2022-057658

 

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