2nd June 2017, Volume 130 Number 1456

Lindsay Robertson, Louise Marsh, Janet Hoek, Rob McGee

New Zealand tobacco control advocates have consistently called for reductions in tobacco retail availability.1–5 Higher tobacco retailer density promotes youth smoking6 and reduces the odds of smoking cessation7 by making cigarettes more accessible and available, and by increasing environmental cues to smoke.6 Tobacco’s widespread retail distribution—one of the few remaining forms of tobacco promotion in New Zealand—also presents a challenge for enforcing restrictions on sales to minors, since there is no accurate list of tobacco retail outlets in New Zealand.8 Thus, fewer tobacco outlets could reduce smoking initiation among young people who are susceptible to smoking, and help quitters remain abstinent after a cessation attempt.

The Government’s smokefree goal includes a commitment to “reducing smoking prevalence and tobacco availability to minimal levels by 2025”.9 Despite this, the Ministry of Health has described interventions to reduce tobacco availability and supply as a ‘low priority’.10 Previous research has identified different approaches to reducing tobacco retail availability, several of which have been implemented internationally.8,11 Examples include registration of tobacco retailers, or licensing with conditions imposed on licensees (eg, no licences granted within a certain distance of a school; a maximum limit on licences for a given area; no tobacco sales at alcohol-licensed premises). More far-reaching options include tobacco sales only at limited adult-only (“R18”) outlets, government-controlled outlets or pharmacy-only sales.8 The National Smokefree Working Group (NSFWG) recognises that tobacco retailer licensing may restrict tobacco supply, but has called for examination of a wider range of policy options.4 No New Zealand studies have yet examined experts’ views on different policies that could reduce tobacco retail availability. Identifying experts’ preferred policies may support and refine advocacy efforts in this area.

We conducted an in-depth analysis of New Zealand tobacco control experts’ views on policies that would reduce tobacco retail supply. We explored experts’ views as we wanted to achieve an in-depth understanding about possible policy options from a public health perspective. Tobacco control experts were chosen because of their ability to offer detailed and articulate insights regarding the societal relevance of the interview topic and the public policy process.12 The research questions were: i) how important do New Zealand tobacco control experts consider tobacco retail policies to be in achieving the 2025 goal; ii) which retail policies do they consider most likely to achieve the 2025 goal and why; and iii) what barriers may impede policy adoption?

Methods

Sample

A purposeful sampling strategy was used to select individuals who would be “information-rich” about tobacco retail regulation.13 A list of possible participants, judged by the research team to have been influential in the tobacco sector for a minimum of one year, or whose organisation was actively involved in the tobacco control sector, were identified. Snowball sampling was also used when participants made suggestions about further individuals to contact. Thirty-eight individuals were invited to take part in the study, including representatives from non-governmental organisations (NGOs), smoking cessation services, Māori and Pacific health organisations, the Health Promotion Agency, Ministry of Health, district health boards (DHBs) and public health units (PHUs), former politicians, individuals working in clinical or academic roles and Smokefree Enforcement Officers (SEOs).

Qualitative approach

We used qualitative description, a pragmatic research method that emphasises practical application and providing “a rich, straight description” (p.2) of the data.14 Qualitative description uses generic methods, such as interviews, reflection on the interviews and coding data into themes.15 We used a semi-structured interview, whereby discussion topics were specified in advance, though flexibility in wording and sequencing of questions was retained to ensure the interview remained conversational.13 Introductory questions probed participants’ perceptions of the 2025 goal and priority interventions to reach the goal. We then asked participants to identify the changes they would make to the way that tobacco is sold in New Zealand (aside from a total ban on tobacco), their likely impact and potential barriers. The interview explored participants’ views on the registration or licensing of tobacco retailers, since these interventions have been topical within the sector3,4 and could potentially be mechanisms to reduce tobacco retail outlet density. Interviews also explored how participants viewed restrictions on the number, outlet type or location of tobacco retailers.

Procedure

LR contacted participants by telephone to explain the study, and subsequently emailed them the information sheet. Once participants had agreed to participate, interviews took place by telephone and were audio recorded and later transcribed. Data collection was conducted between May and December 2014 by LR. Interviews continued until the point of saturation, when no new themes emerged.

Analysis

Qualitative content analysis (QCA) was undertaken using transcripts as the data source. The focus of QCA is on summarising the informational content of the data (as opposed to theory development).16 Data were predominantly analysed in a deductive manner using the interview guide as a framework, although inductive analysis was also used as additional patterns were identified.13 After coding transcripts, data were sorted to identify themes using NVivo software. Commonalities and differences were identified for further consideration. A second author (LM) coded three randomly selected interviews; LR and LM then compared the themes identified before finalising themes through discussion.

Results

Participants

Of the 38 individuals invited, 25 (66%) participated in the research. To maintain anonymity, specific characteristics of each participant are not presented. Half of the participants were aged 45 years or younger (n=12) and the remainder were 46 years or above. Four identified as Māori, two as Pacific and the remainder as New Zealand European/ European. Participants had a median of 4.5 years’ experience in tobacco control. Roles comprised: executive and clinical directors (n=4); team leader/strategic advisor/managers (n=5); research professors (n=2); Smokefree Coordinator/health promotion advisor (n=2), and Smokefree Enforcement Officers (n=12). Nine were male; 16 were female. All were smokefree, and eight identified as former smokers. Interviews lasted a mean duration of 29 minutes (range 15–70 minutes; one interview lasted only 15 minutes due to the time constraints for the participant).

Of those individuals who did not take part: no contact was achieved with two former politicians, two managers working for government organisations were unable to take part due to role constraints (ie, having to maintain political neutrality), eight individuals from government organisations (one team leader and seven SEOs) did not respond to attempts to contact them and one NGO representative (director) agreed to take part although it was not possible to set up an interview within the data collection period.

Interview themes

The first section of results reports participants’ perceptions about the interventions required to achieve 2025 and the importance of tobacco retail policies. Subsequent sections summarise views towards registration and licensing of tobacco retailers, strategies for reducing outlet density and perceived barriers to policy adoption.

Importance of tobacco retail interventions in achieving 2025

A comprehensive programme of interventions comprising taxation, plain packaging, smoking cessation initiatives, mass media campaigns and extending smokefree environments was seen as necessary to achieve the 2025 goal. The vast majority of participants considered tobacco retail interventions a priority within this policy programme, and cited the lack of tobacco retailing regulation as a key concern:

“I think it’s really important to make selling and distributing tobacco across the nation as inconvenient as possible. That is priority number one.” (Executive Director, Health Organisation)

“… It’s absolutely nonsensical that anyone can sell tobacco in New Zealand with absolutely no restriction at all other than the ban on selling cigarettes to under 18s.” (Clinical Director, Health NGO)

A countervailing view expressed by one participant was that advocating for retail interventions as a priority could undermine other policy campaigns, such as plain packaging:

“… it is important, but it’s not top of the agenda for me … it could be a bit of a distraction and we should put all of our efforts at the present time into standardising packaging … I don’t doubt the importance of a retail licence, but it’s going to take energy, commitment and work from the NGO sector and also the Ministry of Health and that will detract, in my view, from other key issues.” (Research Professor, University 1)

Registration of tobacco retailers

A short-term intervention, whether licensing or registration of tobacco retailers, was seen by the vast majority of participants as the crucial next step in tobacco retail regulation. Some understood registration as a scheme that would provide more accurate information about tobacco retailers, thus enhancing enforcement efforts:

“I visit every single lunch bar, every single premise that I can think of to find out if they do sell tobacco. So having a register of people who sell would be a lot easier for me.” (Smokefree Coordinator, DHB)

Another potential benefit of registration was that it could deter some retailers from selling tobacco:

“It’s just another step that people would have to go through in order to sell tobacco and … if a retailer doesn’t have the patience to go through the registration process, then that would probably be somewhere where tobacco wouldn’t be sold.” (Programme Manager, Health NGO)

Others did not consider a registration system to be an effective way of enhancing enforcement:

“…a simple registration that would just provide us information with who was selling tobacco? The public health units already hold that information. As part of our contract with the Ministry of Health, we are supposed to have an up-to-date list of tobacco retailers … all that will do is tell us what we already know.” (Team Leader, PHU)

Overall, participants tended to see that there would be some benefits to registration of tobacco retailers, yet did not feel that this should be a sole focus of advocacy efforts.

Licensing of tobacco retailers

Unlike registration, licensing was seen as providing a means to introduce restrictions on tobacco sales:

“A register is just a list. A licence, I guess, will have a difference. Technically, there must be some conditions for a licence.” (Research Professor, University 1)

One of the main advantages of licensing over registration was the means to revoke a retailer’s ability to sell tobacco:

 “… when they’re found to be breaching the legislation, [rather] than being fined or simply warned you’d have the mechanism to suspend or completely revoke someone’s licence to sell tobacco. I think that would be a really powerful tool for enforcing the age limit legislation.” (Clinical Director, Health NGO)

Participants suggested a mandatory fee as a key component, and thought this could be set at a level that deterred retailers from selling tobacco, with the revenue used to fund tobacco control. Some additional requirements that could be incorporated into a licensing scheme were identified, for example, restrictions on the age of people selling tobacco, and retail staff training on smokefree legislation:

“… giving people the opportunity to know exactly what’s legal and what’s not would be an important element of a licensing regime. So they might have to pass a little test …” (Research Professor, University 2)

As with registration, licensing was also seen as a way to enhance communication between government agencies and tobacco retailers, which could help counter the industry’s influence on retailers. Overall, participants agreed on the need for a regulatory system for tobacco retailers; most preferred licensing over registration, citing several benefits specific to licensing.

Retailer reduction policies

The interviews explored various potential restrictions that could be introduced as part of licensing. A ‘sinking-lid’ policy was identified as a means of reducing tobacco outlet density, though this approach was conceptualised in different ways. One conceptualisation was based on a licensing fee initially set according to outlet sales volume; the fee would increase progressively so as to decrease the number of retailers choosing to sell tobacco. Alternatively, a sinking-lid model could mandate that licences are not transferred if a retailer ceased selling tobacco, moved or closed down. This would gradually decrease the number of tobacco retailers over time and represent a more acceptable outcome for existing retailers; the idea of imposing an immediate maximum quota of retailer licences was considered potentially unacceptable by one participant:

“… to arbitrarily go into the community and say that in this particular area there are currently 500 retail outlets, we think there should only be 400 or 250, therefore we’re going to revoke licences for half of them … seems quite capricious and arbitrary … whereas a sinking-lid policy would say, ‘well look, if a service station on the corner closes down, goes out of business for whatever reason, then that registration or that licence—whatever you want to call it—is not then issued to another retailer in that area’. We’re not arbitrarily just taking it away from any retailer.” (Clinical Director, Health NGO)

Another description of a sinking-lid policy involved banning tobacco sales at certain types of outlets, gradually extending the outlets prohibited from selling tobacco:

“Let’s stop all of the corner dairies to start with. And then … whether it’s six months or a year down the track … then let’s stop it in licensed premises … your supermarkets probably would be next, and then your petrol stations.” (Smokefree Coordinator, DHB)

In particular, SEOs suggested removing the sale of tobacco from dairies, as they reported that dairy owners and employees were the usual perpetrators of sales to minors. However, a contrasting view suggested this approach would be seen as unfair and unacceptable by stakeholders, and one that could potentially attract legal action by the tobacco industry:

“… they [the Government] open themselves up to litigation by the tobacco industry whenever they discriminate against a specific business type. It’s against international trade laws to do that … I wouldn’t advise that.” (Executive Director, Health Organisation)

Prohibiting the sale of tobacco at alcohol-licensed premises elicited mixed views. Some did not support the idea, which they thought could distract from higher priority interventions and may not be very effective. Others saw a need to break the association between alcohol and smoking:

“I don’t think licensed premises should be able to sell smokes, because smoking and alcohol go hand in hand.” (Smokefree Coordinator, DHB)

All participants considered it important to protect children from exposure to tobacco outlets. Creating zones around schools where tobacco sales were not permitted was viewed as a very worthwhile policy by all participants, and such zones could be extended to disallow tobacco sales at a broader range of locations where children tended to be present:

“… you could have some restriction around location, in regards to say, schools … then you could look at phase two where you could consider … community centres, libraries, youth centres, that kind of thing ...” (Research Professor, University 2)

An alternative possibility was only allowing tobacco sales at stores children could not access. Such outlets were identified as “specialised” or “R18” stores, or tobacconists:

 “I’ve heard of a retailer somewhere in New Zealand that only sells tobacco and they were advocating for that, ‘cos… you can’t have kids in a tobacco store.” (Chief Executive Officer, Health Service Provider)

Other restricted sales options included pharmacy-only sales, either via normal retailing or by prescription:

“… ultimately, I would like us to move towards the non-retail selling of tobacco… where you end up providing tobacco through some other mechanism, either through potentially pharmacies or doctors …” (Team Leader, PHU)

The long-term scenario envisaged for New Zealand included only allowing tobacco sales from a very small number of outlets, whether pharmacies, or specialised outlets where children could not enter. A progressive reduction in outlet density, brought about by a sinking-lid policy, was seen as a possible way to realise that long-term scenario.

Risks and barriers to policy adoption

Participants’ views highlighted some uncertainty about the number of tobacco control interventions that might feasibly be introduced within a relatively short space of time:

“If you kind’ve go for plain packaging, do you want to get their backs up if you tried to push this idea through at the same time? It might be the straw that breaks the camel’s back politically and lose public support or something.” (Research Professor, University 2)

There was also discussion around the preferred short-term intervention: registration or licensing. Registration was considered more politically acceptable, though ultimately less effective than a licensing scheme:

“Is it a registration system we’re asking for or do we just go for the licensing system? Governments don’t favour the licensing kōrero and the registration kōrero is much more palatable … do you go in for what you really want or do you start with something simple?” (Manager, Health NGO)

Some viewed registration as a first step which, once in place, could be strengthened to include conditions on who could sell tobacco:

“…I would focus very much on the early stages at least on just getting the concept of a register acceptable to people … then once it’s established then you can make further legislation …” (Clinical Director, Health NGO)

However, a contrasting viewpoint was that if registration was legislated, there was no guarantee that further conditions on retailers would ever be implemented:

“… I don’t really like that idea of pussy-footing around and putting energy into a registration system that’s gonna do what? I’d rather go for a licensing system straight away …” (Manager, Health NGO)

Participants expressed pessimism about the likelihood of achieving the 2025 goal, due to a perceived lack of government leadership in the area and the loss of Dame Turia as the main political champion. While several participants believed tobacco retailers might view certain tobacco retail reduction measures as unfair, regulating the retail environment tended to be seen as crucial to public health goals:

“My view is if dairy owners are only going to be able to sustain their business by selling tobacco, alcohol and lotto tickets, then they do need to go out of business. And as a society we have to be tough-minded about that ... they shouldn’t be in business if all you can sell is stuff that’s bad for people.” (Chief Executive Officer, Professional Association)

Despite the varied perceived barriers, we identified two themes that expressed participants’ views on policy changes. The first was the need to promote awareness of the 2025 goal to generate public support. The second was the need for stronger government leadership to introduce new policies that would achieve the goal:

 “… if we’re ever going to have any hope of reaching the goal it just really needs a lot more oomph behind it … the oomph needs to come from everybody but it needs to come from the Government particularly because it is their goal.” (Smokefree Coordinator, DHB)

Discussion

Summary of findings

New Zealand’s smokefree sector has long been influential in shaping New Zealand tobacco control policies.17 Our participants’ views reflect measures set out in the NSFWG’s action plan and roadmap,4 and align with international discourse about the role of supply-side policies in the tobacco endgame.18–22 Participants considered that substantially reducing the number of tobacco outlets could reduce tobacco consumption, improve enforcement, prevent sales to minors, support tobacco denormalisation and assist realisation of the 2025 goal.

There is limited research to which our findings can be compared. A recent New Zealand study examined how key informants (politicians, managers of smoking cessation and tobacco-related organisations, researchers and advocates) viewed a reduction in tobacco availability of 90% or more, among other endgame policy ideas.23 Most participants supported a large reduction in tobacco retail availability, yet tended not to see this outcome as politically feasible. However, that study did not examine the range of different policies that could reduce tobacco outlet density; without doing so, it is unsurprising that that study identified concerns regarding feasibility.

Policy implications

Despite the strong similarity in our participants’ views, we identified some divergences. As with most tobacco control interventions, there is a trade-off between policy effectiveness and acceptability. Our study demonstrated some tension between licensing (seen as the option that would bring about the greatest benefits) versus registration (considered more acceptable but less effective). Further, the incremental approach to reducing tobacco availability advocated by most participants would see very gradual changes in outlet density over time, and does not align with calls for “radical” and “game-changer” policies to achieve 2025.23 Research from the US suggests an amortisation approach could offer a compromise by providing retailers with a set period of time (eg, up to five years) to recoup their investment and adjust to new tobacco retail restrictions.21 Future research could explore whether similar legal mechanisms could be used in New Zealand. Policy tools such as amortisation would require existing tobacco retailers to transition out of selling tobacco within a relatively short timeframe, thus contributing to the 2025 goal to a greater extent than a sinking-lid or zoning policy.

Despite participants’ strong support for tobacco retailer licensing as a measure to achieve the 2025 goal, jurisdictions that have introduced tobacco retailer licensing without complementary policies have seen only relatively modest declines in tobacco retail availability. For example, the introduction of a licensing scheme in Finland is believed to have reduced the number of outlets selling tobacco, yet this reduction has occurred mostly at restaurants where tobacco retail was minor in the first place.7 In South Australia, after the cost of a tobacco retail licence fee increased from $12 (in 2006) to around $200AUD (from 1 January 2007), the number of tobacco retail licences decreased by 24% over the subsequent two years.24 However, this decline was seen almost entirely at on-licensed venues (ie, venues where alcohol is available for consumption on the premises), and the tobacco licence fee increase had little impact on reducing licences in other retail outlet types.24 It is also important to note that five of Australia’s eight states and territories have implemented mandatory tobacco retailer licensing schemes, yet none of these have been amended to restrict the number, type or location of tobacco licensing schemes since their introduction.25 The risk, therefore, is that if licensing was introduced as a short-term measure, there is no guarantee that the Government would ever proceed beyond this intervention alone.

Recent New Zealand modelling studies suggest that drastically reducing the number of tobacco outlets in New Zealand could reduce smoking prevalence, achieve health gains (as measured by quality-adjusted life years) and reduce health system expenditure.11,26 Although the estimated effects were modest in size, the analyses undertaken were based on assumptions that may have resulted in conservative estimates. In reality, the positive effects of a substantial reduction in tobacco outlet density could be much larger, with the realisation of ‘spill-over effects’ such as tobacco denormalisation.26

Strengths and limitations

To our knowledge, this study is the first to explore how New Zealand tobacco control experts view future tobacco retail policies. Identifying where consensus exists could help to inform future advocacy and ensure that limited advocacy resources are used efficiently. Some limitations should be noted. The findings in the study represent a ‘snapshot’ of participants’ views, which may change over time and are likely affected by the current political context. At the time of data collection, the Smokefree Environments (Tobacco Plain Packaging) Amendment Bill27 had undergone its first parliamentary reading but had been put on hold pending the outcome of litigation in Australia.28 Participants may have been more cautious about advocating for tobacco retail regulation, which they feared may distract political attention from plain packaging. We did not explore equity outcomes directly and most participants identified as New Zealand European ethnicity. Examining the impact of tobacco control policies on smoking among Māori, Pacific and people from more deprived communities is important, given that substantial reductions in smoking prevalence among these groups needs to occur for the 2025 goal to be realised. Furthermore, certain subgroups of New Zealand‘s tobacco control sector were not represented. Specifically, our attempts to recruit politicians and representatives from certain government agencies were not successful. Participants’ views concerning the political feasibility of tobacco retail regulation may have differed had we successfully recruited from these subgroups. A limitation with all qualitative research is that the views and beliefs of the researchers invariably influence the study process, from conceptualisation, interaction with participants and data interpretation.29 We attempted to minimise this possibility through using a post-interview reflective journal to encourage awareness of the factors (eg, our position) that may have influenced the research. Further, the views of participants are inherently subjective, though nonetheless reflect their expertise and experience. The relatively large and representative sample, comprising a wide range of participants from academia, health NGOs and government agencies is a strength of the study.

Conclusion

Overall, reducing tobacco retail availability was seen as one important part of the programme of interventions needed to achieve the 2025 goal. While this outcome was viewed as feasible, a perceived lack of government commitment meant that policies resulting in gradual decreases in outlet density were seen as more realistic than those that would have a more immediate effect on existing tobacco retailers. To achieve its goal of reducing tobacco availability to minimal levels by 2025, the Government must explore policy options that could affect substantial changes to the tobacco retail environment in the coming years.

Summary

We undertook a qualitative research study, which involved in-depth interviews with 25 smokefree experts throughout New Zealand, to explore their views about the importance of reducing tobacco retail supply, on different policy options, and barriers to policy adoption. In the long-term, participants envisaged tobacco only being available at a small number of specialised outlets, either pharmacies or adult-only/R18 stores. To achieve that long-term scenario, participants suggested a sinking-lid policy on licences or a zoning approach could be adopted to gradually reduce outlet density. Policies banning sales at only certain types of outlet were not considered feasible.

Abstract

Aim

Higher tobacco retailer density promotes smoking by making cigarettes more accessible and available, and by increasing environmental cues to smoke. We aimed to examine tobacco control experts’ views on policies that could reduce tobacco retail availability.

Method

Telephone interviews with 25 individuals drawn from academia, non-governmental organisations, Māori and Pacific health, smoking cessation services, district health boards and other public health-related organisations. We used a semi-structured interview guide to explore the perceived importance of reducing tobacco retail supply, views on different policy options and barriers to policy adoption. Qualitative content analysis was conducted using transcripts as the data source.

Results

Participants believed tobacco retailer licensing was an important short-term step towards the 2025 goal. In the long-term, participants envisaged tobacco only being available at a small number of specialised outlets, either pharmacies or adult-only stores. To achieve that long-term scenario, participants suggested a sinking-lid policy on licences or a zoning approach could be adopted to gradually reduce outlet density. Policies banning sales at certain types of outlet were not considered feasible.

Conclusion

There is tension between the tobacco retail reduction policies seen as more likely to be politically acceptable, and the need to make substantial changes to the tobacco retail environment by 2025. Future research could investigate possible legal mechanisms for requiring existing tobacco retailers to transition out of selling tobacco.

Author Information

Lindsay Robertson, Cancer Society Social & Behavioural Research Unit, Department of Preventive and Social Medicine, University of Otago, Dunedin; Louise Marsh, Cancer Society Social & Behavioural Research Unit, Department of Preventive and Social Medicine, University of Otago, Dunedin; Janet Hoek, Department of Marketing, University of Otago, Dunedin; Rob McGee, Cancer Society Social & Behavioural Research Unit, Department of Preventive and Social Medicine, University of Otago, Dunedin.

Acknowledgements

We wish to extend a sincere thank you to the individuals who took the time to participate in an interview. Funding for this study was provided by New Zealand Lottery Health and the New Zealand Asthma Foundation. LM, RM and LR are supported by the Cancer Society of New Zealand.

Correspondence

Miss Lindsay Robertson, Cancer Society Social & Behavioural Research Unit, Department of Preventive and Social Medicine, University of Otago, PO Box 56, Dunedin 9054.

Correspondence Email

l.robertson@otago.ac.nz

Competing Interests

Dr Robertson reports that NZ Asthma Foundation provided project funding, and her PhD stipend was provided by NZ Lottery Health. Dr Robertson is based in The Cancer Society Social and Behavioural Research Unit. Dr Marsh is supported by The Cancer Society of New Zealand. Professor Rob McGee is based in the Cancer Society Social and Behavioural Research Unit and is supported by the Cancer Society of New Zealand.

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