Today is World Smokefree Day, and we’re presenting two views on the future of tobacco and nicotine use. Here the co-directors Otago University’s tobacco-control research group ASPIRE 2025 explain how we can build on existing success to make New Zealand almost entirely smokefree by 2025.
New Zealand has a world-leading goal to reduce smoking to minimal levels by 2025. World Smokefree Day is a good time to reflect on progress and review what is needed to realise that goal. Happily, this year, it seems that actions that could make World Smokefree Day irrelevant by 2025 may be imminent.
So what is the status of Smokefree Aotearoa? Most people working to reduce the epidemic of deaths caused by smoking in New Zealand would agree that progress is far too slow. Seven years from 2025, over a third of Māori and a quarter of Pasifika adults smoke, compared to about 16% of all adults.
That said, smoking is decreasing, and recent data suggest the decline accelerated modestly among Māori and young people between 2011/12 and 2016/17. Smoking among adolescents has reduced greatly over the same period, with daily smoking now at 2% among Year 10 students, and 5% among Māori adolescents.
These reductions in smoking have occurred even though many of the actions recommended in the Māori Affairs Select Committee report that first proposed the Smokefree 2025 goal have not been addressed. This suggests that more robust measures could rapidly accelerate progress.
So what are the grounds for optimism that necessary measures will be introduced? First, Minister Jennie Salesa recently announced the Government is committed to developing an action plan setting out measures to achieve Smokefree 2025. The previous Government failed to take this step, even though it was a key recommendation in the Māori Affairs Select Committee report. A plan developed by the tobacco control sector last year could form the basis of a comprehensive and multi-faceted approach to reach the 2025 goal.
Second, the Ministry of Health recently announced it will introduce ‘risk-proportionate’ regulation for tobacco and vaping products. What does this mean? Commentators with links to the tobacco industry have focused on its possible application to vaping products (like e-cigarettes) and new ‘heat-not-burn’ tobacco products – unsurprisingly arguing for minimal regulation. However, this misses a crucial detail from the Ministry’s announcement that risk-proportionate regulation applies to ‘all tobacco and vaping products’. This must include smoked tobacco for the new regulatory approach to be credible, as these products cause the vast majority of death and disease due to vaping and tobacco products and are greatly under-regulated in relation to the harm they cause.
The new regulatory approach should aim to minimise use of smoked tobacco products and accelerate progress towards the Smokefree 2025 goal. It should create an environment that promotes quitting and supports smokers trying to quit, or helps them switch to lower-harm alternative products if they are unable or unwilling to quit. Crucially, it should also minimise the risk that young people and adult non-smokers experiment with or become addicted to any nicotine-delivery products.
To achieve this, regulations should ensure that the least harmful products are the most affordable, accessible and appealing to smokers, while making the most harmful smoked tobacco products the least affordable, accessible and appealing to smokers and young people. For vaping products, the regulations should balance: making these products easily available for smokers who want to use them to quit or to transition away from smoking; and ensuring they are not available or appealing to children and adolescents, thus minimising nicotine addiction among future generations.
What would risk-proportionate regulation look in practice? This is illustrated here for three key areas of regulation: tax, allowed places of sale, and marketing and product appeal.
Tobacco tax increases should continue, as these prompt quitting and reduce uptake of smoking by children and young adults. Many smokers support this measure provided more of the tax revenue is used to help smokers to quit. In contrast, for vaping products no additional taxes should be applied, unless needed to deter youth initiation. This strategy would ensure e-cigarettes are much cheaper than smoked tobacco, thus encouraging smokers who cannot quit to switch.
Currently more than 6000 retailers sell smoked tobacco products, including almost every dairy, convenience store, supermarket and petrol station. The availability of such a harmful and addictive product on every street corner, often in shops positioned next to schools is unjustifiable. The number of retail outlets selling tobacco should be reduced so that within a few years there is only a single store for each locality or community. Ultimately, sales could be restricted to R18 stores to minimise children’s access.
Vaping products should be more widely available to smokers than cigarettes, but some restrictions may be required to prevent access by children. Another consideration is that vaping devices can be quite complex to use, and getting the right advice could be the difference between a smoker trying vaping and giving up, or persisting and successfully quitting or transitioning away from smoking. One approach is to make vaping products available only from specialist stores and pharmacies where there are staff available trained to offer advice on using e-cigarettes and e-liquids effectively, and to inform smokers where they can get help to quit.
Existing comprehensive restrictions on advertising of smoked tobacco products, including plain packaging, must continue. Possible additional measures to reduce the appeal of smoked tobacco products to young people and smokers include banning flavours like menthol which increase the palatability of cigarettes for new smokers, reducing nicotine content to very low levels to reduce the addictiveness of smoking, and outlawing product design innovations such as the recently introduced ‘capsule’ cigarettes which may enhance product appeal but do nothing to reduce harm.
Surveys suggest that e-cigarette awareness and use among New Zealand smokers is very high, so advertising of vaping products could be restricted to in-store product displays in R18 stores. This would prevent advertising prompting experimentation by children and young people. If necessary, public education campaigns could be used to provide information about vaping products and correct misperceptions such as exaggerated beliefs about the harmfulness of nicotine.
Many smokers and quitters find e-liquid flavours important, but so too do young people. While we need to encourage transition to vaping products among smokers, we should avoid recruiting new users. Some flavours, particularly when combined with child-friendly names and packaging (e.g. ‘Gummy bear’, ‘Banana Split’), may encourage use by young people. Little is known about the safety of flavourings when inhaled, which provides further grounds for caution. We suggest establishing an ongoing process for reviewing evidence of toxicity and impact of flavours on use among young people, and for implementing, where necessary, regulations to ban high risk flavourings, and flavours and packaging that appeal preferentially to children.
There are many other potential regulatory issues including product quality and safety standards, decisions about legal age of sale or purchase for different products, and determining where vaping and smoked tobacco products may be used in public. These will require careful consideration prior to regulation or policy development.
We have not addressed regulation of the new ‘heat-not-burn’ products like ‘IQOS’, where tobacco is heated, but not burnt, to release nicotine-containing vapour. Evidence is still emerging about the relative harmfulness of these products, their appeal to young people and role in helping smokers to quit. This suggest stronger regulations are required compared to vaping products, pending further evidence. This could include additional restrictions on place of sale and packaging or higher levels of excise/taxation. Other new products will require careful evaluation to assess where they fit on the risk continuum and to determine appropriate regulations.
The new action plan for Smokefree 2025 and risk-proportionate regulation are opportunities to greatly strengthen the regulation of smoked tobacco products and intensify policy measures to encourage smokers to quit and discourage children, adolescents and young adults from starting to smoke. Meanwhile, carefully designed regulations should also ensure that e-cigarettes and other lower-harm alternative products are relatively more affordable, accessible and appealing to smokers, enhancing their impact on reducing the harm due to smoking, whilst minimising the use of these products by children and adolescents. Such an approach would greatly accelerate progress towards Smokefree 2025 and by doing so soon make World Smokefree day gloriously irrelevant, at least in New Zealand.
Richard Edwards, Janet Hoek and Anaru Waa are the co-directors of ASPIRE 2025, Otago University, Wellington.