Robert Beaglehole: Smokefree by 2025 - fairly and simply

Emeritus Professor and chairperson of ASH, Robert Beaglehole, writes about the introduction to Parliament of legislation to get Aotearoa/New Zealand to the Smokefree 2025 goal.

The oped is published on NZ Herald Premuim.


Last week marked an important milestone in tobacco control – the introduction to Parliament of legislation to get Aotearoa/New Zealand to the Smokefree 2025 goal.

The ambitious legislation, introduced by Associate Health Minister Ayesha Verrall, takes tobacco control into new territory. Its success, however, will depend on the strict cigarette controls being compassionate and supportive towards the 380,000 New Zealanders who still smoke.

With just three and a half years to go, the Smokefree 2025 goal of less than 5 per cent of New Zealanders smoking is in sight. There have been enormous successes in smoke-free policy, for example, the significant declines in youth smoking and wealthier groups in our society who are already at the goal.

The Government's strong support for reducing the harm of cigarettes by promoting vaping has contributed to the unprecedented reduction in smoking rates over the last year. Vaping is the most effective and cheapest available cessation tool; the Ministry of Health provides very helpful vaping information. The increased funding by this Government for mass marketing, supporting community-led initiatives, and controlling the illicit trade is also important.

But there is still more to do.

Policy over the past 30 years has worked for the privileged in our society, but it has failed people most at risk. Smoking has become entrenched among poor non-white people, contributing at least two years to the seven-year life expectancy gap between Māori and Pakeha. The urgent challenge in reaching the Smokefree 2025 goal remains the much higher smoking rates in poor, Māori and Pacific adult populations.

Three proposals are central to the legislation. Firstly, progressively raising the age for buying cigarettes to create a "smokefree generation"; people born from January 1, 2009 will never be able to buy cigarettes legally. Secondly, drastically cutting the number of places that can sell cigarettes. Lastly, limiting the nicotine content of cigarettes to prevent people, especially youth, from being dependent on cigarettes.

These proposals seem exciting and ground-breaking. On closer examination, however, there are problems ahead. Will the legislation help the most at-risk adults who smoke cigarettes? Can we build on past successes while avoiding potential pitfalls? And most importantly, will the legislation help achieve the 2025 goal?

The good news is that creating a smoke-free generation is now obsolete. Recent data from ASH and the New Zealand Health Survey shows that youth are already almost smoke-free; the most at-risk group is now their (smoking) parents.

Reducing the sales outlets for cigarettes, and making cigarettes less available than vaping, could be helpful. However, this will only work if the demand for cigarettes responds to the reduced supply. Given the high dependence of smokers on nicotine, we can't count on a rational response, as shown by attempts to control illicit drugs, alcohol consumption and problem gambling. Policymakers must ensure that a rapid reduction in supply does not worsen inequalities and punish dependent smokers.

Reducing the nicotine content of cigarettes to levels where they are no longer addictive or satisfy cravings is, in effect, prohibition and could negatively impact the mental well-being of dependent smokers. There are no real-world experiences with this policy, and its community-wide impact on quitting is unknown.

An inevitable consequence of all three "game-changing" policy proposals is an increase in the illicit trade in cigarettes, which is already substantial.

In the three and a half years left to reach the Smokefree goal, we need to reduce smoking rates by up to three-quarters for Māori and the poorest New Zealanders – more than half of whom will likely still die as a result of smoking.

The main proposals of the legislation will not help us reach the 2025 goal. A "smoke-free generation" will not affect death rates for at least 20 years. Reducing the number of outlets selling cigarettes will take time to come into effect and may be delayed further by legal challenges. The low nicotine policy will come into effect in three years.

As ground-breaking as these policies may be, they will not dramatically reduce smoking rates by 2025.

So how can we reach the Smokefree 2025 goal quickly and fairly?

We can do it by building on recent successes which have dramatically increased the use of e-cigarettes by adult smokers.

Four actions are required. Firstly, more sustained and targeted mass and social media campaigns, such as QuitStrong and Vape to Quitstrong, to trigger and maintain quit smoking attempts. Secondly, ongoing campaigns to support people who want to switch. Thirdly, more community-led initiatives for Māori, Pasifika and low-income smokers to encourage vaping for people unable to quit outright. Finally, we need to track smoking trends to ensure we are reversing the unfairness of past tobacco control measures.

If the Government accelerates and adequately resources these simpler and fairer policies, all groups will reach the Smokefree goal by the end of 2025. The more complex "game-changing" policies may then not even be needed.

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