Similarly to countries like Canada, Iceland and Norway, New Zealand has made significant progress in reducing smoking prevalence since the 1980s.1 In this issue of the Journal,2 Laugesen and Grace show how major shifts in risky health behaviours, such as tobacco smoking, but also saturated fat consumption, are likely to have positively contributed towards increased life expectancy in most Organisation for Economic Cooperation and Development (OECD) countries, but particularly so for males in New Zealand. Out of 22 OECD countries included in their analysis, New Zealand showed the largest decline in per adult tobacco consumption among males (41%), as well as the largest increase in their life expectancy (3.2 years), with the latter two strongly associated. Yet, while New Zealand has come a long way in curbing the tobacco epidemic, in part likely due to measures such as tobacco tax, health warnings, mass media campaigns and the Smoke-free Environments Act, research suggests that a continuation of current policies is unlikely to achieve the Government-supported Smokefree goal for 2025.3 In addition, unacceptably large ethnic inequalities in smoking prevalence remain.Adequate progress will most likely require ‘something bold, something new’ to accelerate progress in reducing the prevalence of tobacco smoking, or what is often defined as the ‘tobacco endgame’.4 An increasing number of tobacco endgame strategies have been proposed in recent years.5
With an emerging body of research suggesting that easy access to tobacco retail outlets may facilitate smoking uptake in youth, increase smoking and reduce (the success of) smoking cessation in adults, one proposed endgame measure is restricting the tobacco retail environment.6 Specific measures include restricting outlets within a certain distance of locations frequented by children and youth, restricting sales to certain outlet types only, or a sinking lid on the number of tobacco retail licences over time. While jurisdictions overseas are making progress in putting measures in place to restrict the tobacco retail environment,7 there is still little (if any) progress in New Zealand on this front. Documenting the views of tobacco control experts on what retail policy options may contribute towards achieving the 2025 goal, could help re-direct and guide advocacy efforts in this area. As such, Robertson and colleagues in this issue of the Journal8 explored the views of 25 tobacco control experts in New Zealand on tobacco retail outlet restrictions. Implementing a tobacco retail outlet licensing scheme that would regulate who can sell tobacco was seen as a crucial short-term step towards New Zealand’s Smokefree goal by the vast majority of experts. It was, however, also envisaged that tighter restrictions on who can hold a tobacco retail licence would be needed as 2025 approached, such as restricting tobacco sales to pharmacies or adult-only (‘R18’) outlets (eg, liquor stores). While modelling studies suggest that tobacco retail outlet restrictions are likely to accelerate progress towards New Zealand’s Smokefree 2025 goal, and result in population health gains and cost-savings to the health system, additional measures are most likely required if the goal is to be achieved.9–11
Another category of endgame measures proposes more strict regulations on the design and contents of tobacco products. One particular proposal involves a reduction in the level of nicotine in tobacco products, ultimately aiming to reduce the likelihood of new smokers becoming addicted to tobacco and making it easier for smokers to quit.12 There is emerging evidence for such a strategy from clinical trials that have found that the consumption of very low nicotine cigarettes (VLNCs) reduces smoker’s dependence on tobacco and their daily tobacco consumption.13 In addition, there is some evidence that smokers who used VLNCs were more likely to start thinking about quitting, as well as actually making a quit attempt. A modelling study furthermore suggests that such a strategy may result in substantive population health gains, even if this measure would result in the rise of a black market of high nicotine products or result in over-compensatory smoking behaviours (increased intensity of smoking to boost nicotine intake).14 It is therefore perhaps not surprising that this strategy has received support from a number of public health experts to form the backbone of New Zealand’s tobacco endgame strategy.13 Yet, little has been known about New Zealand key stakeholders’ or smokers’ perspectives of a nicotine reduction strategy, which may be an important indicator of political acceptability of implementing such a measure.
The qualitative study by Fraser and Kira in this issue of the Journal15 helps address this knowledge gap. They report results of 17 semi-structured interviews with key stakeholders on VLNCs, as well as focus groups with 21 smokers who were given the opportunity to use VLNCs. Findings of the stakeholder interviews suggest that there was not much support for a population-level measure that would involve a reduction in the level of nicotine in cigarettes. Lack of real-life evidence, potential to still cause harm to health and political difficulty to implement such a measure were mentioned as reasons. While initially being interested in VLNCs, after using them, smokers mentioned they did not like the taste and smell of these products. They also voiced concerns about the hazardous components that would remain in cigarettes. Yet, some stakeholders and smokers did believe there was a place for VLNCs in the market, alongside high-nicotine cigarettes, and saw potential in smokers taking up these products if they would be offered at lower prices than high-nicotine tobacco cigarettes. Yet, the effectiveness of such a strategy where both products co-exist is potentially more questionable now that the Government has recently decided to make retail access to nicotine-containing electronic cigarettes (e-cigarettes) legal in New Zealand. While there are still many uncertainties about the long-term health impacts of e-cigarettes, there is increasing consensus that the latter products are less harmful to health if smokers make the full transition from smoking to using e-cigarettes (vaping).16 VLNCs, in comparison, would apart from a lower level of nicotine, still contain all the hazardous components that regular tobacco cigarettes have.
Other major tobacco endgame measures that have been proposed in recent years include a sinking lid on the supply of tobacco, major tax increases and a tobacco-free generation (TFG).5 The first strategy would involve annual reductions in import quotas of tobacco, resulting in reduced commercial availability of tobacco products each year until a final year wherein sales become illegal.17 Such a strategy, if implemented carefully and monitored closely, may have a relatively high likelihood of achieving the Smokefree 2025 goal, and would result in substantial health gains and cost-savings to the health system in the next two to three decades.11 The legal availability of nicotine-containing e-cigarettes would furthermore offer a potential alternative nicotine source for smokers that would find it difficult to quit smoking. Yet, it seems desirable for the New Zealand Government to restrict the sale of the latter products to pharmacies or specialist vape stores where smokers can be supported with professional tobacco cessation advice (and ideally nicotine cessation advice eventually also).Further increases in tobacco tax (beyond the increases scheduled to 2020) are also likely to accelerate progress towards the Smokefree 2025 goal, but may still not be sufficient.11 Another proposed strategy, the TFG strategy, would entirely prevent future generations from taking up smoking. The TFG strategy could achieve fast reductions in future smoking prevalence if effectively enforced, particularly so for Māori who have nearly double the smoking rate among young people compared to non-Māori.11
Achieving the Smokefree 2025 goal would result in substantive population health gains and cost-savings to the New Zealand health system, and would reduce the ethnic gap in tobacco-related health inequalities.11,18 Yet, benefits of achieving this goal may span much wider. Reduced tobacco use would also decrease tobacco waste, an important problem considered in this issue of the Journal by Metcalfe and colleagues.19 Their proposed approaches are well worthy of further consideration for two reasons. Firstly, if New Zealand (unfortunately) avoids bold initiatives and ends up taking a slower and more incremental approach to ending the tobacco epidemic, then it will need a wide range of other initiatives, including making smokers and the tobacco industry deal with the tobacco waste problem more appropriately. Secondly, for dealing with tobacco waste from international visitors who continue to smoke in coming decades (ie, once New Zealand has achieved its Smokefree goal for its own population).
Tobacco endgame measures will enhance New Zealand’s likelihood of achieving the Smokefree 2025 goal, but New Zealand policy-makers undoubtedly give consideration to other factors such as political and public acceptability and feasibility. Nevertheless, it appears unethical to us for a government that stated its commitment to a Smokefree 2025 goal (and which specifically stipulated that it would reduce both smoking prevalence and the availability of tobacco to minimal levels by 2025), to not seriously consider further substantial advances in tobacco control and the implementation of major endgame measures.