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A decade has passed since the then National-led government accepted the Māori Affairs Select Committee (MASC) Inquiry recommendation that New Zealand set a “longer-term goal of reducing smoking prevalence and tobacco availability to minimal levels, thereby [becoming] essentially a smokefree nation by 2025.”[[1]] Three years after the goal’s announcement, a survey found widespread misunderstanding of the 2025 goal, particularly among people who smoke daily; once the goal was explained, support increased, a finding that led to calls for an urgent and comprehensive communications campaign.[[2]] However, the Government did not implement measures to increase understanding of the goal; indeed, investment in smokefree communications decreased and, with some notable exceptions, politicians responsible for realising the goal did little to communicate it.[[3,4]]

Given the lack of investment in communication, evidence that the 2025 goal will not be realised for key population groups,[[5]] and the fact 2025 is fast approaching, it is timely to revisit how people who smoke interpret the goal. Smoking prevalence peaks among people living in neighbourhoods that experience high material deprivation;[[6]] these people are less likely to quit smoking successfully,[[7]] even though their desire to quit is similar to that of people living in more affluent areas.[[8]] Because attaining the Smokefree 2025 goal will have potentially profound effects on people from these communities, it is crucial to probe how they interpret and respond to the goal.

To address this question, we undertook in-depth interviews with 20 people aged between 21 and 53 who smoked daily. Eligible participants earned less than the median income (NZ$33,900) and had marginal or inadequate income sufficiency (ie, those who answered “Only just enough” or “Not enough” to the question: “Do you have enough money to meet every day needs?”).[[9]] Among other topics, we explored participants’ unprompted and prompted perceptions of the Smokefree 2025 goal and their views on its implications. A delegated authority from the University of Otago’s Human Ethics Committee reviewed and approved the project (reference D20/383). Participants received a $40 gift voucher (not redeemable for tobacco) to recognise any costs they incurred by participating in the study.

Interviews took place between November and December 2020 and lasted between 42 and 66 minutes; interviewing ceased when data saturation had been reached (defined as no new idea elements identified in two consecutive interviews). We dual coded the data, interpreted these using a ‘codebook thematic analysis’ approach[[10]] and described key themes using participants’ words (all participants have been assigned pseudonyms).

We first probed participants’ unprompted interpretation of the goal. Most felt unclear what the goal meant, though many mistakenly believed sales of tobacco products would end in 2025. Alan commented: “I think they’re going to stop cigarettes in New Zealand. That's what I think... you won't be able to get them anywhere... but I'm not too sure what actually, what it means” (Alan). Quinn reiterated this point: “I’m guessing by then [2025] they’re planning on making it [tobacco] like illegal, or something, yeah? Um, maybe do it so that, you know, retail places, that they can’t sell them anymore” (Quinn). As well as stopping tobacco sales, others thought smokefree spaces would expand and greatly limit where smoking could occur: “There’s some place overseas... you’re not allowed to smoke within like two and a half metres of like a business door... it basically means that the only place you could smoke would be right in the centre of a busy road... I’ve heard of other places like whole cities just being smokefree... I don’t mind if I’ve just gotta smoke at home [but] I don’t know how that would work if I’m out and about” (Ian). Bans featured strongly in participants’ interpretations and a minority thought the goal aimed to eradicate smoking: “they want to wipe out smoking altogether; that's what I’ve heard” (Olivia), and “they want smokers... don’t exist in 2025... That’s what I believe they want. Um, I believe they might even make cigarettes illegal” (Gavin). Katie drew these perspectives together in her interpretation of the goal: “I think the Government wants to not have any cigarettes whatsoever or tobacco to be able to be accessed in New Zealand whatsoever. And that people will not be smoking in 2025” (Katie).

Most participants had strong negative reactions to these scenarios; they envisaged angry and violent responses: “There are gonna be riots, there gonna be... Yeah, that’s gonna be crazy” (Gavin). They anticipated people would circumvent the bans they assumed would be introduced: “people are going to find a way to get it. Whether it’s growing your own or whatever. Um, I don’t see the government preventing people from getting it. I don’t see that stopping it. People are too clever for that” (Fran). Several predicted black markets would develop, which could potentially increase crime and social tensions and lead people desperate for tobacco into dangerous situations: “I know that there’s a massive black market for it... Like, I’ve heard that you can get counterfeit smokes... but I’ve never actually come across any of that yet. But I can see that there being another way that the gangs will make their money... I don't wanna associate with the gangs, but if I want a cigarette, I will” (Ian).

We explained the goal’s commonly accepted definition as reducing smoking prevalence to 5% or below alongside large reductions in tobacco supply. Many participants viewed this definition positively: “I think that them having this goal is great, because that’s what we need to do. Like, we need to look at people’s health and the pollution and stuff as well” (Quinn). Despite information reframing the goal as a large reduction in smoking prevalence and availability, several participants nonetheless supported banning tobacco sales. For some, their support recognised the limitations of earlier measures. Tom noted that, despite restrictions on tobacco retail displays, tobacco’s easy availability compromised quit attempts: “It would make it so much easier to quit. I wouldn’t have, yeah... I know they’ve got the cabinets behind them now and you can’t see what’s in them. But you know what’s in there... And you walk into a shop and they’re always right behind the counter. Like they’re right there as soon as you walk in the door... It’s like, ‘Oh, fuck. I need a pack of smokes’” (Tom).

Even if they thought people would circumvent measures to continue smoking, several participants still supported the goal. Thus, while Holly thought that “if they get rid of smoking, then people will still find a way to grow tobacco, smoke, whatever, you know,” she supported banning sales of tobacco products, which she thought would help her quit: “I’d be stoked. (laughs) ‘Cause it would help… it would just mean, boom. It’s done. I can’t smoke any more. So, yeah, it wouldn’t really bother me. It’d be quite a bit good thing I reckon” (Holly). Others also thought banning tobacco sales would support them to become smokefree: “…‘cause it would make me stop... If it wasn’t available, I wouldn’t… I wouldn’t be doing it. Pretty much” (Nick), and “I wouldn’t mind, because like I say, I don’t want to smoke forever, and obviously that would probably be the best motivator” (Samantha).

The minority who did not anticipate quitting felt relieved to learn the goal aimed to reduce smoking prevalence and tobacco supply rather than ban either smoking or tobacco sales. Megan noted: “It puts me more at ease. Yeah. The last thing we need is more volatile people in the world. (laughs) But yeah, that’s... you know, tobacco can still be bought. Yeah, make things a lot easier” (Megan). Others felt more secure and saw themselves among the 5% who would continue smoking: “See, when I see that I get a bit happy and I see hope and I think, ‘Yes, I'll be in the 5%.’ (laughs) ‘Cause I will be” (Katie).

However, when reflecting on what continuing to smoke would mean when few people smoked, some saw new tensions. Charlotte explained: “...If it was less than 5%, you’d just feel like such a, I don't know, a weirdo smoking, really, being such a small group of the population and you were still doing it, (laughs) and you know?... Yeah. That, the less and less it gets the worse and worse you feel, like, yeah” (Charlotte). Nonetheless, others dismissed the likely impact: “I don’t think it would impact my smoking at all... I’m quite happy to be part of that 5%, if need be... I just don’t think that’s going to affect me... I mean, you’d still feel a little bit shitty about yourself. But I, I don’t view myself under those stereotypes, so I still don’t think it would touch me really” (Laura).

In summary, even ten years after the Smokefree 2025 goal was set, our study highlights some sustained misperceptions associated with negative responses to the goal. These findings raise questions about what might have been achieved had successive governments made the goal a political priority. Even today, improving understanding of the goal remains urgent, given confusion may lead to resistance and opposition.

We suggest three priorities to address misunderstandings about the goal and negative reactions that follow.

First, develop a communications plan to ensure people, particularly people who smoke, understand the goal, its rationale and its benefits, and are encouraged to quit. Addressing the confusion we and others have detected, and that earlier studies have reported, may decrease negative reactions towards the goal and reduce opportunities for tobacco companies to create doubt and concern. New Zealand’s response to COVID-19 included a comprehensive media strategy that showed the power of government communications to support health priorities. Second, use revenue from tobacco excise tax to fund high-quality cessation support that people who smoke find authentic, accessible and helpful. Finally, respond to participants’ comments about the likely positive impacts of reducing tobacco products’ availability and visibility, and to the many studies documenting associations between tobacco availability and smoking prevalence[[11,12]] by developing and swiftly implementing a plan to reduce the number of tobacco retail outlets as part of a comprehensive strategy to achieve the Smokefree 2025 goal.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Janet Hoek: Professor, Department of Public Health, University of Otago, Wellington. Ivana Barbalich: Otago Medical School, University of Otago, Dunedin. Richard Edwards: Professor, Department of Public Health, University of Otago, Wellington. Coral Gartner: Associate Professor, School of Public Health, University of Queensland, Australia.

Acknowledgements

We thank the Health Research Council of New Zealand for funding this research (programme grant 19/641). We thank our participants who shared their time, thoughts and experiences with us.

Correspondence

Janet Hoek, Professor, Department of Public Health, University of Otago, Wellington, PO Box 7343, +64 34797692

Correspondence Email

janet.hoek@otago.ac.nz

Competing Interests

Janet Hoek, Richard Edwards and Ivana Barbalich declare support from the Health Research Council of New Zealand paid to the University of Otago since the initial planning of this research. Richard Edwards also declares a project grant (HRC 15/072) paid to the University of Otago; an honoraria received personally as Deputy Editor of the journal Nicotine & Tobacco Research; payments received personally for expenses to travel to expert advisory groups (eg, Hāpai te Hauora Tobacco Advisory Group) and conferences (eg, Oceania Tobacco Control Conference and Australasian and New Zealand Thoracic Society conferences); and being a member of Project Sunset Oceania and the Global Project Sunset, all during the past 36 months. Janet Hoek also declares a project grant (19/327) and a Cancer Society Research Collaboration programme grant paid to the University of Otago; personally receiving travel funding to attend Health Promotion Agency advisory group meetings; and being a member of Project Sunset Oceania and the Global Project Sunset, all during the past 36 months. Coral Gartner declares support from the National Health and Medical Research Council (GNT1198301) paid to the Centre of Research Excellence on Achieving the Tobacco Endgame since the initial planning of this research and, during the past 36 months, being a member of Project Sunset Oceania, a member of the Global Project Sunset and Secretary and Treasurer of the Society for Research on Nicotine and Tobacco Oceania Chapter.

1. New Zealand Government. Government Final Response to Report of the Māori Affairs Committee on Inquiry into the tobacco industry in Aotearoa and the consequences of tobacco use for Māori, presented to the House of Representatives in accordance with Standing Order 248 (J.1). In: New Zealand Government, ed. Wellington, 2011.

2. Gendall P, Hoek J, Edwards R. What does the 2025 Smokefree Goal mean to the New Zealand public. NZ Med J 2014;127(1406):101-03.

3. Edwards R, Hoek J, Thomson G. Smokefree 2025: patterns and trends in references to the smokefree goal in political speeches and press releases. NZ Med J 2014;127(1398):122-25.

4. Edwards R, Hoek J, van der Deen F. Smokefree 2025 – use of mass media in New Zealand lacks alignment with evidence and needs. Australian and New Zealand Journal of Public Health 2014:n/a-n/a. doi: 10.1111/1753-6405.12246

5. van der Deen F, Ikeda T, Cobiac L, et al. Projecting future smoking prevalence to 2025 and beyond in New Zealand using smoking prevalence data from the 2013 Census. NZ Med J 2014;127 (1406) [published Online First: 28th November 2014]

6. Atkinson J, Salmond C, Crampton P. NZDep2018 Index of Deprivation, Final Research Report,. Wellington: University of Otago, 2020.

7. Hiscock R, Bauld L, Amos A, et al. Smoking and socioeconomic status in England: the rise of the never smoker and the disadvantaged smoker. Journal of Public Health 2012;34(3):390-96. doi: 10.1093/pubmed/fds012

8. Kotz D, West R. Explaining the social gradient in smoking cessation: it’s not in the trying, but in the succeeding. Tobacco control 2009;18(1):43-46.

9. Statistics New Zealand. Wellbeing statistics: 2018 Wellington: Statistics NZ; 2019. Available from: https://www.stats.govt.nz/information-releases/wellbeing-statistics-2018 accessed 15 November 2020.

10. Braun V, Clarke V, Hayfield N, et al. Thematic Analysis. In: Liamputtong P, ed. Handbook of Research Methods in Health Social Sciences. Singapore: Springer Singapore 2019:843-60.

11. Robertson L, McGee R, Marsh L, et al. A systematic review on the impact of point-of-sale tobacco promotion on smoking. Nicotine Tob Res 2015;17(1):2-17. doi: 10.1093/ntr/ntu168

12. Robertson L, Cameron C, McGee R, et al. Point-of-sale tobacco promotion and youth smoking: a meta-analysis. Tobacco Control 2016;25:tobaccocontrol-2015-052586. doi: 10.1136/tobaccocontrol-2015-052586

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

A decade has passed since the then National-led government accepted the Māori Affairs Select Committee (MASC) Inquiry recommendation that New Zealand set a “longer-term goal of reducing smoking prevalence and tobacco availability to minimal levels, thereby [becoming] essentially a smokefree nation by 2025.”[[1]] Three years after the goal’s announcement, a survey found widespread misunderstanding of the 2025 goal, particularly among people who smoke daily; once the goal was explained, support increased, a finding that led to calls for an urgent and comprehensive communications campaign.[[2]] However, the Government did not implement measures to increase understanding of the goal; indeed, investment in smokefree communications decreased and, with some notable exceptions, politicians responsible for realising the goal did little to communicate it.[[3,4]]

Given the lack of investment in communication, evidence that the 2025 goal will not be realised for key population groups,[[5]] and the fact 2025 is fast approaching, it is timely to revisit how people who smoke interpret the goal. Smoking prevalence peaks among people living in neighbourhoods that experience high material deprivation;[[6]] these people are less likely to quit smoking successfully,[[7]] even though their desire to quit is similar to that of people living in more affluent areas.[[8]] Because attaining the Smokefree 2025 goal will have potentially profound effects on people from these communities, it is crucial to probe how they interpret and respond to the goal.

To address this question, we undertook in-depth interviews with 20 people aged between 21 and 53 who smoked daily. Eligible participants earned less than the median income (NZ$33,900) and had marginal or inadequate income sufficiency (ie, those who answered “Only just enough” or “Not enough” to the question: “Do you have enough money to meet every day needs?”).[[9]] Among other topics, we explored participants’ unprompted and prompted perceptions of the Smokefree 2025 goal and their views on its implications. A delegated authority from the University of Otago’s Human Ethics Committee reviewed and approved the project (reference D20/383). Participants received a $40 gift voucher (not redeemable for tobacco) to recognise any costs they incurred by participating in the study.

Interviews took place between November and December 2020 and lasted between 42 and 66 minutes; interviewing ceased when data saturation had been reached (defined as no new idea elements identified in two consecutive interviews). We dual coded the data, interpreted these using a ‘codebook thematic analysis’ approach[[10]] and described key themes using participants’ words (all participants have been assigned pseudonyms).

We first probed participants’ unprompted interpretation of the goal. Most felt unclear what the goal meant, though many mistakenly believed sales of tobacco products would end in 2025. Alan commented: “I think they’re going to stop cigarettes in New Zealand. That's what I think... you won't be able to get them anywhere... but I'm not too sure what actually, what it means” (Alan). Quinn reiterated this point: “I’m guessing by then [2025] they’re planning on making it [tobacco] like illegal, or something, yeah? Um, maybe do it so that, you know, retail places, that they can’t sell them anymore” (Quinn). As well as stopping tobacco sales, others thought smokefree spaces would expand and greatly limit where smoking could occur: “There’s some place overseas... you’re not allowed to smoke within like two and a half metres of like a business door... it basically means that the only place you could smoke would be right in the centre of a busy road... I’ve heard of other places like whole cities just being smokefree... I don’t mind if I’ve just gotta smoke at home [but] I don’t know how that would work if I’m out and about” (Ian). Bans featured strongly in participants’ interpretations and a minority thought the goal aimed to eradicate smoking: “they want to wipe out smoking altogether; that's what I’ve heard” (Olivia), and “they want smokers... don’t exist in 2025... That’s what I believe they want. Um, I believe they might even make cigarettes illegal” (Gavin). Katie drew these perspectives together in her interpretation of the goal: “I think the Government wants to not have any cigarettes whatsoever or tobacco to be able to be accessed in New Zealand whatsoever. And that people will not be smoking in 2025” (Katie).

Most participants had strong negative reactions to these scenarios; they envisaged angry and violent responses: “There are gonna be riots, there gonna be... Yeah, that’s gonna be crazy” (Gavin). They anticipated people would circumvent the bans they assumed would be introduced: “people are going to find a way to get it. Whether it’s growing your own or whatever. Um, I don’t see the government preventing people from getting it. I don’t see that stopping it. People are too clever for that” (Fran). Several predicted black markets would develop, which could potentially increase crime and social tensions and lead people desperate for tobacco into dangerous situations: “I know that there’s a massive black market for it... Like, I’ve heard that you can get counterfeit smokes... but I’ve never actually come across any of that yet. But I can see that there being another way that the gangs will make their money... I don't wanna associate with the gangs, but if I want a cigarette, I will” (Ian).

We explained the goal’s commonly accepted definition as reducing smoking prevalence to 5% or below alongside large reductions in tobacco supply. Many participants viewed this definition positively: “I think that them having this goal is great, because that’s what we need to do. Like, we need to look at people’s health and the pollution and stuff as well” (Quinn). Despite information reframing the goal as a large reduction in smoking prevalence and availability, several participants nonetheless supported banning tobacco sales. For some, their support recognised the limitations of earlier measures. Tom noted that, despite restrictions on tobacco retail displays, tobacco’s easy availability compromised quit attempts: “It would make it so much easier to quit. I wouldn’t have, yeah... I know they’ve got the cabinets behind them now and you can’t see what’s in them. But you know what’s in there... And you walk into a shop and they’re always right behind the counter. Like they’re right there as soon as you walk in the door... It’s like, ‘Oh, fuck. I need a pack of smokes’” (Tom).

Even if they thought people would circumvent measures to continue smoking, several participants still supported the goal. Thus, while Holly thought that “if they get rid of smoking, then people will still find a way to grow tobacco, smoke, whatever, you know,” she supported banning sales of tobacco products, which she thought would help her quit: “I’d be stoked. (laughs) ‘Cause it would help… it would just mean, boom. It’s done. I can’t smoke any more. So, yeah, it wouldn’t really bother me. It’d be quite a bit good thing I reckon” (Holly). Others also thought banning tobacco sales would support them to become smokefree: “…‘cause it would make me stop... If it wasn’t available, I wouldn’t… I wouldn’t be doing it. Pretty much” (Nick), and “I wouldn’t mind, because like I say, I don’t want to smoke forever, and obviously that would probably be the best motivator” (Samantha).

The minority who did not anticipate quitting felt relieved to learn the goal aimed to reduce smoking prevalence and tobacco supply rather than ban either smoking or tobacco sales. Megan noted: “It puts me more at ease. Yeah. The last thing we need is more volatile people in the world. (laughs) But yeah, that’s... you know, tobacco can still be bought. Yeah, make things a lot easier” (Megan). Others felt more secure and saw themselves among the 5% who would continue smoking: “See, when I see that I get a bit happy and I see hope and I think, ‘Yes, I'll be in the 5%.’ (laughs) ‘Cause I will be” (Katie).

However, when reflecting on what continuing to smoke would mean when few people smoked, some saw new tensions. Charlotte explained: “...If it was less than 5%, you’d just feel like such a, I don't know, a weirdo smoking, really, being such a small group of the population and you were still doing it, (laughs) and you know?... Yeah. That, the less and less it gets the worse and worse you feel, like, yeah” (Charlotte). Nonetheless, others dismissed the likely impact: “I don’t think it would impact my smoking at all... I’m quite happy to be part of that 5%, if need be... I just don’t think that’s going to affect me... I mean, you’d still feel a little bit shitty about yourself. But I, I don’t view myself under those stereotypes, so I still don’t think it would touch me really” (Laura).

In summary, even ten years after the Smokefree 2025 goal was set, our study highlights some sustained misperceptions associated with negative responses to the goal. These findings raise questions about what might have been achieved had successive governments made the goal a political priority. Even today, improving understanding of the goal remains urgent, given confusion may lead to resistance and opposition.

We suggest three priorities to address misunderstandings about the goal and negative reactions that follow.

First, develop a communications plan to ensure people, particularly people who smoke, understand the goal, its rationale and its benefits, and are encouraged to quit. Addressing the confusion we and others have detected, and that earlier studies have reported, may decrease negative reactions towards the goal and reduce opportunities for tobacco companies to create doubt and concern. New Zealand’s response to COVID-19 included a comprehensive media strategy that showed the power of government communications to support health priorities. Second, use revenue from tobacco excise tax to fund high-quality cessation support that people who smoke find authentic, accessible and helpful. Finally, respond to participants’ comments about the likely positive impacts of reducing tobacco products’ availability and visibility, and to the many studies documenting associations between tobacco availability and smoking prevalence[[11,12]] by developing and swiftly implementing a plan to reduce the number of tobacco retail outlets as part of a comprehensive strategy to achieve the Smokefree 2025 goal.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Janet Hoek: Professor, Department of Public Health, University of Otago, Wellington. Ivana Barbalich: Otago Medical School, University of Otago, Dunedin. Richard Edwards: Professor, Department of Public Health, University of Otago, Wellington. Coral Gartner: Associate Professor, School of Public Health, University of Queensland, Australia.

Acknowledgements

We thank the Health Research Council of New Zealand for funding this research (programme grant 19/641). We thank our participants who shared their time, thoughts and experiences with us.

Correspondence

Janet Hoek, Professor, Department of Public Health, University of Otago, Wellington, PO Box 7343, +64 34797692

Correspondence Email

janet.hoek@otago.ac.nz

Competing Interests

Janet Hoek, Richard Edwards and Ivana Barbalich declare support from the Health Research Council of New Zealand paid to the University of Otago since the initial planning of this research. Richard Edwards also declares a project grant (HRC 15/072) paid to the University of Otago; an honoraria received personally as Deputy Editor of the journal Nicotine & Tobacco Research; payments received personally for expenses to travel to expert advisory groups (eg, Hāpai te Hauora Tobacco Advisory Group) and conferences (eg, Oceania Tobacco Control Conference and Australasian and New Zealand Thoracic Society conferences); and being a member of Project Sunset Oceania and the Global Project Sunset, all during the past 36 months. Janet Hoek also declares a project grant (19/327) and a Cancer Society Research Collaboration programme grant paid to the University of Otago; personally receiving travel funding to attend Health Promotion Agency advisory group meetings; and being a member of Project Sunset Oceania and the Global Project Sunset, all during the past 36 months. Coral Gartner declares support from the National Health and Medical Research Council (GNT1198301) paid to the Centre of Research Excellence on Achieving the Tobacco Endgame since the initial planning of this research and, during the past 36 months, being a member of Project Sunset Oceania, a member of the Global Project Sunset and Secretary and Treasurer of the Society for Research on Nicotine and Tobacco Oceania Chapter.

1. New Zealand Government. Government Final Response to Report of the Māori Affairs Committee on Inquiry into the tobacco industry in Aotearoa and the consequences of tobacco use for Māori, presented to the House of Representatives in accordance with Standing Order 248 (J.1). In: New Zealand Government, ed. Wellington, 2011.

2. Gendall P, Hoek J, Edwards R. What does the 2025 Smokefree Goal mean to the New Zealand public. NZ Med J 2014;127(1406):101-03.

3. Edwards R, Hoek J, Thomson G. Smokefree 2025: patterns and trends in references to the smokefree goal in political speeches and press releases. NZ Med J 2014;127(1398):122-25.

4. Edwards R, Hoek J, van der Deen F. Smokefree 2025 – use of mass media in New Zealand lacks alignment with evidence and needs. Australian and New Zealand Journal of Public Health 2014:n/a-n/a. doi: 10.1111/1753-6405.12246

5. van der Deen F, Ikeda T, Cobiac L, et al. Projecting future smoking prevalence to 2025 and beyond in New Zealand using smoking prevalence data from the 2013 Census. NZ Med J 2014;127 (1406) [published Online First: 28th November 2014]

6. Atkinson J, Salmond C, Crampton P. NZDep2018 Index of Deprivation, Final Research Report,. Wellington: University of Otago, 2020.

7. Hiscock R, Bauld L, Amos A, et al. Smoking and socioeconomic status in England: the rise of the never smoker and the disadvantaged smoker. Journal of Public Health 2012;34(3):390-96. doi: 10.1093/pubmed/fds012

8. Kotz D, West R. Explaining the social gradient in smoking cessation: it’s not in the trying, but in the succeeding. Tobacco control 2009;18(1):43-46.

9. Statistics New Zealand. Wellbeing statistics: 2018 Wellington: Statistics NZ; 2019. Available from: https://www.stats.govt.nz/information-releases/wellbeing-statistics-2018 accessed 15 November 2020.

10. Braun V, Clarke V, Hayfield N, et al. Thematic Analysis. In: Liamputtong P, ed. Handbook of Research Methods in Health Social Sciences. Singapore: Springer Singapore 2019:843-60.

11. Robertson L, McGee R, Marsh L, et al. A systematic review on the impact of point-of-sale tobacco promotion on smoking. Nicotine Tob Res 2015;17(1):2-17. doi: 10.1093/ntr/ntu168

12. Robertson L, Cameron C, McGee R, et al. Point-of-sale tobacco promotion and youth smoking: a meta-analysis. Tobacco Control 2016;25:tobaccocontrol-2015-052586. doi: 10.1136/tobaccocontrol-2015-052586

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

A decade has passed since the then National-led government accepted the Māori Affairs Select Committee (MASC) Inquiry recommendation that New Zealand set a “longer-term goal of reducing smoking prevalence and tobacco availability to minimal levels, thereby [becoming] essentially a smokefree nation by 2025.”[[1]] Three years after the goal’s announcement, a survey found widespread misunderstanding of the 2025 goal, particularly among people who smoke daily; once the goal was explained, support increased, a finding that led to calls for an urgent and comprehensive communications campaign.[[2]] However, the Government did not implement measures to increase understanding of the goal; indeed, investment in smokefree communications decreased and, with some notable exceptions, politicians responsible for realising the goal did little to communicate it.[[3,4]]

Given the lack of investment in communication, evidence that the 2025 goal will not be realised for key population groups,[[5]] and the fact 2025 is fast approaching, it is timely to revisit how people who smoke interpret the goal. Smoking prevalence peaks among people living in neighbourhoods that experience high material deprivation;[[6]] these people are less likely to quit smoking successfully,[[7]] even though their desire to quit is similar to that of people living in more affluent areas.[[8]] Because attaining the Smokefree 2025 goal will have potentially profound effects on people from these communities, it is crucial to probe how they interpret and respond to the goal.

To address this question, we undertook in-depth interviews with 20 people aged between 21 and 53 who smoked daily. Eligible participants earned less than the median income (NZ$33,900) and had marginal or inadequate income sufficiency (ie, those who answered “Only just enough” or “Not enough” to the question: “Do you have enough money to meet every day needs?”).[[9]] Among other topics, we explored participants’ unprompted and prompted perceptions of the Smokefree 2025 goal and their views on its implications. A delegated authority from the University of Otago’s Human Ethics Committee reviewed and approved the project (reference D20/383). Participants received a $40 gift voucher (not redeemable for tobacco) to recognise any costs they incurred by participating in the study.

Interviews took place between November and December 2020 and lasted between 42 and 66 minutes; interviewing ceased when data saturation had been reached (defined as no new idea elements identified in two consecutive interviews). We dual coded the data, interpreted these using a ‘codebook thematic analysis’ approach[[10]] and described key themes using participants’ words (all participants have been assigned pseudonyms).

We first probed participants’ unprompted interpretation of the goal. Most felt unclear what the goal meant, though many mistakenly believed sales of tobacco products would end in 2025. Alan commented: “I think they’re going to stop cigarettes in New Zealand. That's what I think... you won't be able to get them anywhere... but I'm not too sure what actually, what it means” (Alan). Quinn reiterated this point: “I’m guessing by then [2025] they’re planning on making it [tobacco] like illegal, or something, yeah? Um, maybe do it so that, you know, retail places, that they can’t sell them anymore” (Quinn). As well as stopping tobacco sales, others thought smokefree spaces would expand and greatly limit where smoking could occur: “There’s some place overseas... you’re not allowed to smoke within like two and a half metres of like a business door... it basically means that the only place you could smoke would be right in the centre of a busy road... I’ve heard of other places like whole cities just being smokefree... I don’t mind if I’ve just gotta smoke at home [but] I don’t know how that would work if I’m out and about” (Ian). Bans featured strongly in participants’ interpretations and a minority thought the goal aimed to eradicate smoking: “they want to wipe out smoking altogether; that's what I’ve heard” (Olivia), and “they want smokers... don’t exist in 2025... That’s what I believe they want. Um, I believe they might even make cigarettes illegal” (Gavin). Katie drew these perspectives together in her interpretation of the goal: “I think the Government wants to not have any cigarettes whatsoever or tobacco to be able to be accessed in New Zealand whatsoever. And that people will not be smoking in 2025” (Katie).

Most participants had strong negative reactions to these scenarios; they envisaged angry and violent responses: “There are gonna be riots, there gonna be... Yeah, that’s gonna be crazy” (Gavin). They anticipated people would circumvent the bans they assumed would be introduced: “people are going to find a way to get it. Whether it’s growing your own or whatever. Um, I don’t see the government preventing people from getting it. I don’t see that stopping it. People are too clever for that” (Fran). Several predicted black markets would develop, which could potentially increase crime and social tensions and lead people desperate for tobacco into dangerous situations: “I know that there’s a massive black market for it... Like, I’ve heard that you can get counterfeit smokes... but I’ve never actually come across any of that yet. But I can see that there being another way that the gangs will make their money... I don't wanna associate with the gangs, but if I want a cigarette, I will” (Ian).

We explained the goal’s commonly accepted definition as reducing smoking prevalence to 5% or below alongside large reductions in tobacco supply. Many participants viewed this definition positively: “I think that them having this goal is great, because that’s what we need to do. Like, we need to look at people’s health and the pollution and stuff as well” (Quinn). Despite information reframing the goal as a large reduction in smoking prevalence and availability, several participants nonetheless supported banning tobacco sales. For some, their support recognised the limitations of earlier measures. Tom noted that, despite restrictions on tobacco retail displays, tobacco’s easy availability compromised quit attempts: “It would make it so much easier to quit. I wouldn’t have, yeah... I know they’ve got the cabinets behind them now and you can’t see what’s in them. But you know what’s in there... And you walk into a shop and they’re always right behind the counter. Like they’re right there as soon as you walk in the door... It’s like, ‘Oh, fuck. I need a pack of smokes’” (Tom).

Even if they thought people would circumvent measures to continue smoking, several participants still supported the goal. Thus, while Holly thought that “if they get rid of smoking, then people will still find a way to grow tobacco, smoke, whatever, you know,” she supported banning sales of tobacco products, which she thought would help her quit: “I’d be stoked. (laughs) ‘Cause it would help… it would just mean, boom. It’s done. I can’t smoke any more. So, yeah, it wouldn’t really bother me. It’d be quite a bit good thing I reckon” (Holly). Others also thought banning tobacco sales would support them to become smokefree: “…‘cause it would make me stop... If it wasn’t available, I wouldn’t… I wouldn’t be doing it. Pretty much” (Nick), and “I wouldn’t mind, because like I say, I don’t want to smoke forever, and obviously that would probably be the best motivator” (Samantha).

The minority who did not anticipate quitting felt relieved to learn the goal aimed to reduce smoking prevalence and tobacco supply rather than ban either smoking or tobacco sales. Megan noted: “It puts me more at ease. Yeah. The last thing we need is more volatile people in the world. (laughs) But yeah, that’s... you know, tobacco can still be bought. Yeah, make things a lot easier” (Megan). Others felt more secure and saw themselves among the 5% who would continue smoking: “See, when I see that I get a bit happy and I see hope and I think, ‘Yes, I'll be in the 5%.’ (laughs) ‘Cause I will be” (Katie).

However, when reflecting on what continuing to smoke would mean when few people smoked, some saw new tensions. Charlotte explained: “...If it was less than 5%, you’d just feel like such a, I don't know, a weirdo smoking, really, being such a small group of the population and you were still doing it, (laughs) and you know?... Yeah. That, the less and less it gets the worse and worse you feel, like, yeah” (Charlotte). Nonetheless, others dismissed the likely impact: “I don’t think it would impact my smoking at all... I’m quite happy to be part of that 5%, if need be... I just don’t think that’s going to affect me... I mean, you’d still feel a little bit shitty about yourself. But I, I don’t view myself under those stereotypes, so I still don’t think it would touch me really” (Laura).

In summary, even ten years after the Smokefree 2025 goal was set, our study highlights some sustained misperceptions associated with negative responses to the goal. These findings raise questions about what might have been achieved had successive governments made the goal a political priority. Even today, improving understanding of the goal remains urgent, given confusion may lead to resistance and opposition.

We suggest three priorities to address misunderstandings about the goal and negative reactions that follow.

First, develop a communications plan to ensure people, particularly people who smoke, understand the goal, its rationale and its benefits, and are encouraged to quit. Addressing the confusion we and others have detected, and that earlier studies have reported, may decrease negative reactions towards the goal and reduce opportunities for tobacco companies to create doubt and concern. New Zealand’s response to COVID-19 included a comprehensive media strategy that showed the power of government communications to support health priorities. Second, use revenue from tobacco excise tax to fund high-quality cessation support that people who smoke find authentic, accessible and helpful. Finally, respond to participants’ comments about the likely positive impacts of reducing tobacco products’ availability and visibility, and to the many studies documenting associations between tobacco availability and smoking prevalence[[11,12]] by developing and swiftly implementing a plan to reduce the number of tobacco retail outlets as part of a comprehensive strategy to achieve the Smokefree 2025 goal.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Janet Hoek: Professor, Department of Public Health, University of Otago, Wellington. Ivana Barbalich: Otago Medical School, University of Otago, Dunedin. Richard Edwards: Professor, Department of Public Health, University of Otago, Wellington. Coral Gartner: Associate Professor, School of Public Health, University of Queensland, Australia.

Acknowledgements

We thank the Health Research Council of New Zealand for funding this research (programme grant 19/641). We thank our participants who shared their time, thoughts and experiences with us.

Correspondence

Janet Hoek, Professor, Department of Public Health, University of Otago, Wellington, PO Box 7343, +64 34797692

Correspondence Email

janet.hoek@otago.ac.nz

Competing Interests

Janet Hoek, Richard Edwards and Ivana Barbalich declare support from the Health Research Council of New Zealand paid to the University of Otago since the initial planning of this research. Richard Edwards also declares a project grant (HRC 15/072) paid to the University of Otago; an honoraria received personally as Deputy Editor of the journal Nicotine & Tobacco Research; payments received personally for expenses to travel to expert advisory groups (eg, Hāpai te Hauora Tobacco Advisory Group) and conferences (eg, Oceania Tobacco Control Conference and Australasian and New Zealand Thoracic Society conferences); and being a member of Project Sunset Oceania and the Global Project Sunset, all during the past 36 months. Janet Hoek also declares a project grant (19/327) and a Cancer Society Research Collaboration programme grant paid to the University of Otago; personally receiving travel funding to attend Health Promotion Agency advisory group meetings; and being a member of Project Sunset Oceania and the Global Project Sunset, all during the past 36 months. Coral Gartner declares support from the National Health and Medical Research Council (GNT1198301) paid to the Centre of Research Excellence on Achieving the Tobacco Endgame since the initial planning of this research and, during the past 36 months, being a member of Project Sunset Oceania, a member of the Global Project Sunset and Secretary and Treasurer of the Society for Research on Nicotine and Tobacco Oceania Chapter.

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