We congratulate the authors of the new smoking cessation guidelines for New Zealand, which are summarised in this issue of the Journal by McRobbie and colleagues (http://www.nzma.org.nz/journal/121-1276/3117).

It is heartening to see guidelines developed through a rigorous, evidence-based approach; and which provide practical advice clearly and succinctly for all those engaged in smoking cessation support in New Zealand.

But, and there is always a but, the publication of the guidelines also underlines the need for public health decision-makers to adopt a determined, similarly rigorous, and evidence-based approach to the development and implementation of population-based tobacco control policies. The publication should also focus the minds of all organisations with an interest in health and social justice to support and participate in advocacy for effective tobacco control policies. This should, of course, include organisations which represent the medical profession and specialities.

We need to keep in mind the extent of the public health problem that tobacco represents for the people of New Zealand. In 2006, over 50 years after it became clear that tobacco smoking is a deadly carcinogen, almost a quarter (23.5%1) of the New Zealand population were still regular smokers, and over 4000 New Zealanders died from smoking-related diseases.

The rate of decline in the proportion of adults smoking regularly in the last two decades in this country has been very low, although evidence from the 2006/7 New Zealand Health Survey was more promising.2 Other countries such as Canada and Sweden have achieved much greater reductions in prevalence.3 Furthermore, the continuing very high prevalence of smoking and the resulting harm from tobacco to the health of Māori and Pacific peoples’, and its contribution to health inequalities in New Zealand is a particular concern.4

Fortunately there has been some recent progress. There has been a successful new smokefree environments law 5 (Smoke-free Environments Amendment Act 2003), continuing development of the Quitline, and some innovative mass media campaigns. The introduction of graphic health warnings on tobacco products is underway. But the slow reduction in adult smoking prevalence suggests that much more is needed to make substantial progress.

First, health service policy needs to ensure that the new smoking cessation guidelines are fully implemented at every level of the health system. This requires planning, allocation of resources, training of staff, and appropriate performance monitoring or incentives.

It is not good enough that many patients with smoking-related diseases continue to be admitted to hospital, patched up, and then sent out until it happens again; without receiving evidence-based smoking cessation interventions which are some of the most cost-effective medical interventions known. A particular priority is to ensure that all pregnant women smokers and the caregivers of any child with respiratory or ENT problems are identified and given maximal encouragement and support to quit.

But improving individually-focused cessation support is far from sufficient. Most smokers who quit do so in the community beyond the reach of the new smoking cessation guidelines, and without the benefit of structured cessation support or use of nicotine replacement therapy (NRT) or other cessation aids.

Quitting often occurs after multiple unsuccessful attempts. Many quit attempts are unplanned and spontaneous, frequently in response to motivational trigger events like price increases, new restrictions on smoking, and mass media campaigns.6 Increasing the frequency of quit attempts within populations has been shown to have the greatest impact on increasing population quit rates.7

We therefore must aim to increase the total number of quit attempts by providing regular and intensive triggers to prompt quitting. We must also continue to implement policy measures to reduce the proportion of young people starting to smoke. Both will require addressing upstream factors, and crucially, rigorous implementation of evidence-based population orientated interventions.

Evidence-based reviews 8 stress the importance of the following interventions to reduce population smoking prevalence: increases in price of tobacco products; increases in the coverage of smoke-free environments; comprehensive bans on tobacco marketing; strong counter-marketing through mass media campaigns; and comprehensive smoking cessation support.

For each of these interventions much more could be done in New Zealand. For example: point-of-sale marketing could be banned and plain packaging introduced; smokefree laws could be extended to cover cars with child occupants; mass media campaigns could be much more extensive, more sustained, and far better resourced; and population level smoking cessation support (e.g. the Quitline) could be even more comprehensive and better funded. Additional effort could be made to ensure interventions are effectively targeted at and developed in partnership with priority groups such as Māori smokers.

Funding for tobacco control, while increased over the last 10 years, is still woefully inadequate in relation to the scale of the problem. For example, in relation to the number of premature deaths caused, national tobacco control health promotion campaigns are funded at a fiftieth or less of the rate for road safety campaigns.9

The record is least impressive recently for increasing the price of tobacco products. The current New Zealand Tobacco Control Strategy notes that tobacco taxation: “...is probably the most important single intervention to reduce smoking initiation” and “Strong scientific evidence supports the effectiveness of increasing the unit price for tobacco products”10. Yet, there has been no real increase in the level of tobacco taxation since 2001.

We need a tobacco tax strategy, with regular significant price rises, which are clearly presented and justified as a public health measure, and are accompanied by integrated media campaigns and increased cessation support to maximise their impact.11

Only a small fraction of tobacco tax revenue is allocated for tobacco control. Tobacco control spending, at under $45 million a year, is less than 5% of the tobacco tax revenue. Dedicating much of the additional revenue from price increases to tobacco control will increase support for the increase and ensure a robust funding stream.

As well as doing more of what we know works, and doing it better, we should also investigate more fundamental long-term solutions. One option is to introduce an autonomous Tobacco Control Authority.12 Another is to revise the regulatory framework for nicotine delivery devices so that the level of regulation is in proportion to the hazard of the product. This would ensure that cigarettes are far more stringently regulated compared with less harmful products such as some oral tobacco products and NRT.13 14

Other proposals include progressively decreasing the allowable nicotine content of cigarettes and regularly decreasing tobacco product volume quotas for manufacturers and importers.15 Finally, some commentators have gone further. They suggest that the ultimate vector for the tobacco epidemic is a profit-driven tobacco industry; and that whilst that remains the case, effective tobacco control policy will continue to be contested, delayed, diluted, or even destroyed. Solutions advocated include introducing a not-for-profit tobacco industry, or tobacco product distribution and retail network.16 17

This is election year in New Zealand. One goal that every health organisation can achieve is to actively support every political party having an evidence-based policy for tobacco control in its manifesto. Achieving commitments to improved tobacco control will do far more for public health than the usual election year focus on tweaking surgical waiting lists and health sector organisational issues.

Acknowledgements: Various strands of the authors’ ongoing work in tobacco control are supported by the Health Research Council and the Marsden Fund.

Correspondence: Dr Richard Edwards, Department of Public Health, University of Otago, Wellington, PO Box 7343, Wellington, New Zealand. Email: richard.edwards@otago.ac.nz