Smokefree Aotearoa – world-leading developments with profound public health implications

Smoking is the single biggest risk factor for preventable disease and premature death in Aotearoa. ¹ It is responsible for almost 10% of all health loss (measured in DALYs). There are large inequities in smoking prevalence by ethnicity and socio-economic status. For example, current (at least monthly) smoking prevalence in 2021/22 was 20.9% among Māori, 18.9% among Pacific peoples and 8.5% among people with European/other ethnicity.  Smoking-related ill health is also highly inequitable with smoking causing almost a quarter of deaths among Māori. ²  Smoking also impacts negatively on the economic, social and cultural wellbeing of Māori, ³ constraining their development aspirations and opportunities.

In response to a recommendation from the Māori Affairs Select Committee of the New Zealand (NZ) Parliament, the NZ Government committed to the Smokefree 2025 goal in 2011. Adoption of the goal followed sustained advocacy by Māori leaders for the ‘Tupeka Kore’ goal and elimination of tobacco products, which were introduced to Māori by colonisation. Māori leaders also emphasised that the tobacco industry should be held to account as the main driver of the smoking epidemic.  

The Smokefree goal was defined as achieving minimal prevalence (commonly interpreted as <5%) of smoking and minimal availability of tobacco products. The Government set an interim target for reducing smoking prevalence and addressed equity by through specific prevalence reduction targets for Māori and Pacific peoples.

The Māori Affairs Select Committee report recommended the Government develop a strategy for achieving the Smokefree 2025 goal. Despite this, and sustained advocacy from the smokefree and public health sectors, successive governments failed to do so. Instead, they introduced important, yet piecemeal, smokefree policy interventions. These included implementing annual above inflation increases in tobacco excise duty (2011-2021), removal of point-of-sale tobacco displays in retail settings (2012), plain packaging and enhanced pictorial pack warning labels (2018), and smokefree prisons (2011) and cars (2021).

These policy measures left the nature of tobacco products and their availability largely unregulated. As a result, cigarettes remained highly addictive and continued to be sold in almost every dairy, supermarket and petrol station as if they were a normal consumer product.

During this period there was a slow decline in smoking prevalence (see figure): from 2011/12-2019/20 current smoking prevalence fell from 18.4% to 13.7% and daily smoking from 16.4% to 11.9%. Large inequities in smoking prevalence persisted and the mid-term targets for Māori and Pacific peoples were missed by a large margin.

However, the rate of decline in smoking prevalence accelerated from 2019/20 to 2021/22 In 2021/22 current smoking prevalence was 9.2% and daily smoking prevalence was 8.0%, representing an estimated 380,000 and 331,000 people respectively. There were more substantial falls in prevalence among Māori (particularly among Māori women whose prevalence fell from 35% to 20% and was less than Māori men for the first time), see figure), but inequities remained with current smoking prevalence in 2021/22 20.9% among Māori, 18.9% among Pacific peoples and 18.1% among people living in the most deprived localities (NZ Dep quintile 5, data not shown).

New Zealand Health Survey (NZHS) data shows Increasing vaping prevalence since 2015, suggesting that growing numbers of people who smoke are vaping as an alternative to smoking. This may have contributed to falls in smoking prevalence, particularly since 2019/20.

However, vaping among young people, including adolescents, has greatly increased in recent years, particularly among Māori. This will include a large number of people who have never smoked. As a result, restrictions on marketing, sales to minors and on products available in non-specialist stores were introduced through the 2020 Smokefree Environments and Regulated Products (Vaping) Amendment Act. Despite these changes, the most recent Year 10 snapshot and NZHS data indicate vaping prevalence remains extremely high among young people and the Government has proposed additional measures to try to address this.

The Smokefree Aotearoa Action Plan and Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Act

In 2021 the new Associate Minister Dr Ayesha Verrall published a discussion document for an action plan to achieve the Smokefree Aotearoa goal. ⁴  This document signalled an end to the piecemeal approach to reducing smoking. The final action plan published in December 2021 ⁵ and the subsequent Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Act were landmarks in smokefree and public health actions in Aotearoa, catapulting New Zealand to the vanguard of international action to end the global smoking epidemic.

Key features of the action plan and the SERPA Act that make them stand out as pivotal smokefree and public health measures include the following (additional detail of the key actions and their current status are summarised in the appendix).

First, there is a clear focus on addressing smoking-related inequities and recognising Te Tiriti o Waitangi, and a commitment to engaging with Māori. The smokefree sector in Aotearoa has emphasised that the smokefree goal of minimal smoking prevalence must be achieved equitably for all peoples. ⁶ The first stated outcome of the action plan aims to eliminate inequities in smoking rates and smoking-related illnesses. In addition, the first of the action plan’s six ‘focus areas’ recognises the requirement for Māori leadership and decision-making at all levels. The rationale for the focus on Māori equity and governance has been discussed elsewhere. A Māori-led Smokefree Aotearoa taskforce has been established to advise on whether the action plan is achieving the smokefree goal for Māori. A Pacific taskforce (The Pacific Assurance Group) has also been established.

Second, the action plan and SERPA Act address previously unregulated structural factors that create and maintain the smoking epidemic. These include the high palatability, addictiveness, and easy availability of smoked tobacco products.  Ground-breaking ‘endgame’ measures in the action plan that address these factors include: mandating removal of virtually all nicotine from smoked tobacco products, so these become non-addictive; greatly reducing the retail availability of smoked tobacco products (decreasing the number of stores able to sell these products by about 90% to 600 outlets);  and introducing a ‘smoke-free generation’ policy, where it will be illegal to sell tobacco products to people born after a specified date. Estimates from a recent modelling study suggest these interventions, particularly mandated denicotinisation, will have profound and equitable impacts in rapidly reducing smoking prevalence. ⁷

Third, the action plan includes comprehensive supporting measures such as enhanced smoking cessation services for priority populations, increased funding for mass media campaigns, and support for community mobilisation and community-based interventions to help achieve the smokefree goal. The action plan also proposes restricting design features that enhance the appeal and addictiveness of smoked tobacco products, including investigating how to best ‘restrict’ filters to minimise their impact on health and the environment.

Finally, the action plan commits to a risk-proportionate regulation framework for nicotine products that introduces stronger policies and regulations for smoked tobacco products than for vaping products. The action plan acknowledges vaping as a lower cost and less physically harmful alternative to smoking that could contribute to achieving the Smokefree 2025 goal (e.g., via people who smoke switching completely to vaping). However, the plan also recognises that preventing vaping uptake among youth and young adults is crucial, and acknowledges the need for an appropriate regulatory balance.

Wider public health implications

The action plan and SERPA Act have several key potential implications outside of Aotearoa.

First, implementation of the three ‘endgame’ measures that have not previously been introduced at national level anywhere in the world should provide crucial evidence about their feasibility, effectiveness and impact on equity. This could greatly influence whether other countries and jurisdictions introduce similar measures. However, this assumes that the comprehensive and robust evaluation set out in the action plan is carried out, and emphasises how important it is that this occurs.

Second, the action plan represents the most comprehensive strategy proposed worldwide for achieving the elimination of smoking. If successful, it is a possible exemplar of how to end the health loss, inequity and economic burden caused by the tobacco epidemic, and provides a possible blueprint other countries could adopt or adapt when developing strategies to end their own tobacco-related epidemics.

Thirdly, the action plan’s comprehensive approach with a focus on equity, rights and addressing structural determinants of tobacco use is a potential framework which could inform strategies to address other major public health issues such as unhealthy diets, obesity and excessive alcohol use.

Finally, the actions of the tobacco industry in Aotearoa # in response to the action plan measures will provide crucial intelligence for governments considering introducing similar approaches. The experience in Aotearoa will provide an indication about tactics and arguments that the tobacco industry may use to oppose these interventions, as well as evidence for the effectiveness of these tactics and pointers for how the public health and smokefree sector should best respond. It will also provide evidence about whether tobacco industry claims that they have ‘transformed’ to support public health goals have any substance. ⁸ Recent industry actions in Aotearoa such as opposing key measures included in the action plan and PMI’s launch of a new smoked tobacco product strongly suggest they do not.

Current status and potential threats

The status of key measures included in the plan is summarised in the appendix table. There is a current consultation (closes March 15 2023) over the regulatory regime and implementation of the key legislative measures included in the SERPA Act.

There are at least three major challenges or threats to the action plan proposals.

First, introducing unprecedented measures like greatly reducing retail availability and mandating denicotinisation of smoked tobacco products may be complex and challenging. It will require careful attention to implementation and a clear communication strategy to explain the new measures and their rationale.

Second, the tobacco industry and their allies will almost certainly strongly oppose key action plan measures. The industry will be aware of the threat the action plan poses to their profits in Aotearoa, and potentially much more widely if it acts as a precedent for effective action globally to end the tobacco epidemic. Opposition is also likely from other groups, such as retailers, who believe they will be adversely affected by the action plan. The smokefree and public health sectors should be prepared to counter this opposition and the arguments that are advanced such as exaggerated concerns about an increase illicit trade and economic impact on small retailers.

Third, 2023 is an election year and Aotearoa has a new Prime Minister. Political change and uncertainty creates opportunities, but also threats. Implementation of the action plan appears to be proceeding as intended, but that may not continue as election campaigning gets underway or in the event of a change of government (although the National Party has thus far strongly supported the key measure of mandated denicotinisation).

Priorities and next steps for smokefree and public health practitioners, advocates and researchers

The greatest priority is to support Associate Minister Verrall and the Ministry of Health team to effectively and comprehensively implement the action plan measures.

The smokefree community need to continue to communicate the urgency and importance of achieving the smokefree goal, advocate for the action plan and its key measures, and counter the arguments and oppositional tactics of the tobacco industry and its allies.

The public health sector should support implementation of the action plan fully, equitably, in alignment with the evidence and best practice, and with appropriate engagement with Māori and Pacific communities and leaders. An initial task is to contribute to the current consultation on the proposals for implementation of the key measures in the SERPA Act.

Another important priority, for the research community particularly, is to advocate for robust and comprehensive monitoring and evaluation of the action plan and its key measures and to ensure that findings are widely and effectively communicated both locally and internationally.

The smokefree and public health communities need to consider what more needs to be done.  For example, some proposed measures (e.g. protecting the environment by prohibiting cigarette filters) and suggestions for strengthening the action plan and SERPA legislation in previous consultations have not been actioned and may require ongoing advocacy.

In response to the very high levels of vaping among youth and young adults, the government has published proposals to strengthen regulation of vaping products and retailers, but whether these will be sufficient is questionable. Further strengthening of the regulation of vaping products to minimise youth uptake may be required.

Finally, the smokefree community needs to debate what should happen after the smokefree goal has been achieved. Is achieving the smokefree goal sufficient or should it be replaced now or in the future by a nicotine-free goal as the original proponents of the Tupeka Kore vision proposed?