I have been pleased to collaborate with ASH (New Zealand) – Action for Smokefree 2025 – on a report on how vaping and other low-risk technologies could help get New Zealand back on track to meet its high profile target to have less than 5% smoking by 2025. The report is called: A Surge Strategy for Smokefree Aotearoa 2025.
…and these are all available here on the ASH Zealand web site.
Key features of wider interest include a focus on: (1) inequities (Māori smoking rates are over 30% and tax-driven policies add a further inequitable burden of harm to marginalised groups); (2) the concept of ‘risk-proportionate regulation’ as a framework to exploit the major opportunity while containing the relatively minor risks.
I include below the main report executive summary (more detailed than the two-page summary above):
In New Zealand, smoking is the leading cause of premature mortality for cancer, cardiovascular and respiratory disease. Smoking is also a leading contributor to ethnic and socioeconomic inequities in health and welfare, while imposing financial burdens on the poorest people. Progress in meeting the ambitious Smokefree Aotearoa 2025 goal to reduce adult smoking prevalence to below five percent by 2025 is now significantly off-track.
To get back on track, we advocate a surge strategy based on driving down smoking by facilitating smokers to switch to smokefree alternatives such as vaping products, heated tobacco and smokeless tobacco products. These smokefree alternatives present much lower health risks compared to cigarettes and with the right tax structure can ease financial pressures on smoking households, mitigating both health and economic inequities.
The concept of a public health surge is drawn from management of disasters and emergencies where a rapid increase in capability is essential to meet immediate demands. We argue that the concept can be applied to long-running chronic emergencies where a rapid change relative to business-as-usual is necessary – in this case to meet a target that will otherwise be missed.
We outline the proposed surge strategy in more detail below and expand in the body of this report.Smoking remains a major public health challenge that causes 5000 deaths every year. In New Zealand, around one in seven adults (13.1%) or about 512,000 persons continue to smoke daily despite sustained tobacco control efforts over several decades. For Maori adults, the daily smoking prevalence is one in three (31.2%), and for Pacific adults, one in five (20.0%). Smoking is a significant cause of health inequity between ethnic groups and by socio-economic status. The health inequities are compounded by the financial burdens of purchasing tax-paid cigarettes, which attract one of the highest tax rates in the world and fall disproportionately on the poorest groups. The Smokefree 2025 goal can be achieved by accelerating the trend towards switching from high-risk smoked products such as cigarettes to low-risk smokefree products such as e-cigarettes, heated tobacco products, and smokeless tobacco. This approach is known as tobacco harm reduction, and is based on the idea that people smoke for the nicotine but die from the tar. It works because almost all of the disease risk attributable to smoking arises from the smoke: the particles of tar and toxic gases that are inhaled from burning tobacco. Nicotine creates dependence, which keeps people smoking. The smoke contains thousands of toxic agents, many of which are formed in reactions during combustion. If smokers can find satisfactory alternatives to cigarettes that do not involve combustion but do provide nicotine, then they would avoid almost all of the disease risk. This harm reduction concept is endorsed in Article 1 of the World Health Organization Framework Convention on Tobacco Control (FCTC) and is supported by many scientists and policy experts world-wide. It is a complement, not an alternative to established tobacco control approaches and works by giving smokers additional and more appealing options to quit smoking. E-cigarette use or vaping has emerged as a popular new technology and phenomenon. The devices deliver nicotine via an aerosol (liquid mist) with added flavours. They are popular with many former smokers because they replace many aspects of smoking, not just nicotine. This includes hand-to-mouth habits and behavioural rituals, while also providing a pleasurable sensory experience and flavours that aid in switching. They are largely marketed as comnsumer alternatives to smoking and are intended to be pleasurable. That is an important contrast with nicotine replacement therapy or smoking cessation medicines. This consumer appeal may be the reason why vaping attracts smokers in greater numbers and faster than established smoking cessation approaches. There is also a new generation of tobacco products that heat rather than burn tobacco. These smokefree products also create a flavoured vapour aerosol but do not create products of combustion. In three years following introduction of heated tobacco products in Japan, cigarettes sales volumes fell by 33 percent, an unprecedented decline. There has been renewed interest in smokeless tobacco as the experience of snus, a form of smokeless tobacco, in Scandinavia has become more widely recognised. For example, in Sweden where snus use has been displacing smoking, adult daily smoking prevalence has already fallen to five percent – compared to a European Union average of 26 percent. Like many new and disruptive innovations, there are also potential risks. Concerns have been raised about abuse, youth uptake and unknown longterm health effects. However, there is much existing evidence to provide reassurance. Regulators therefore must try to exploit the opportunities but also to mitigate the risks of adverse effects through effective regulation. Effective regulation involves striking a balance between measures that are so weak they do not have the intended effect and measures that are so excessive that they cause unintended harm. For example, by obstructing smokers switching from smoking by making smokefree alternatives more expensive, less appealing, or more difficult to access. The way to strike this balance is to adopt risk-proportionate regulation. This imposes regulatory burdens and controls in proportion to the risk posed by the product, but also taking account of the opportunities it offers. The New Zealand government is currently revisiting the regulatory framework for consumer nicotine products. It has the opportunity to introduce world best-practice by developing a framework for risk-proportionate regulation for smokefree alternative nicotine products. Key features of such a framework would include the following: Differentiation between smoked and smokefree products. A comprehensive framework would cover all forms of consumer nicotine product. The key differentiator for policy purposes is whether the product is for smoking. Combustion is far more important than the distinction between tobacco and non-tobacco products. Smokefree tobacco and nicotine products can displace smoking and greatly reduce health burdens. It follows that they should be treated differently to smoked products – reflecting opportunity as well as risk. A nuanced approach to youth use of smokefree products. Measures introduced to protect youth should focus primarily on responsible marketing and not on modifying or limiting the appeal of the product itself to adults. Youth use may be beneficial for some young people who are smokers or would-be smokers – it is important, therefore, to recognise that some young people could be potentially harmed by measures aimed to protect youth. Recognising that flavours play an important role. Flavours are integral to the appeal of smokefree alternatives and an essential part of the proposition to smokers to try switching and remain smokefree. They also raise concerns about attracting non-smoking youth. We recommend focussing controls on marketing, branding, and flavour descriptors rather than on banning particular flavour chemicals or categories (except where there are safety concerns). Controls on advertising, not an outright ban. Advertising allows new smokefree products and innovation to reach smokers and encourage switching. It is, in essence, anti-smoking advertising. Controls on themes, placement, timing and media are appropriate, but not a ban. It is important to recognise that a ban on advertising of smokefree alternatives has the effect of protecting the dominant cigarette trade and discouraging smoking cessation. The policy for use of smokefree products in public spaces should be a matter for owners or managers. In the absence of evidence of a plausible material risk to bystanders arising from vaping or heated tobacco products, the government should not mandate wide-ranging bans; nor should it treat smokefree vapour products as though they are smoked products. The same reasoning applies to limitations by local authorities on vaping in outdoor places, e.g., central business districts, beaches, and parks. The government’s role should be to provide information to assist decision-making by owners and managers of properties. Warning and packaging labels should convey accurate information including messages that explain relative risk. Warnings should not be misused to scare users out of trying products that could be life-saving for them. They should be focussed on helping smokers make better-informed decisions by communicating relevant risk information, including risks relative to smoking, ideally using a range of statements authorised by health officials. Smokefree products should have access to the market via a notification regime. There should be no requirement for pre-market authorisation, but post-market surveillance and a system for product stewardship that allows improvements and innovations to assist in mitigating safety risks or emerging problems. Products should meet specific safety standards for devices, liquids and ingredients. Such standards for chemical, thermal, mechanical and electrical safety are emerging internationally, and New Zealand is well placed to take advantage of these. For heated tobacco, standards should provide assurance that there is no combustion. There are established and recommended standards for smokeless tobacco to draw on. Plain-packaging should be mandatory for smoked products only. The rationale for standardised plain packaging does not apply to smokefree alternatives, which both impose low risks and offer substantial benefits to smokers who switch. Different packaging would also help convey to consumers the different risk profile of these products in a clear and intuitive manner. The fiscal regime should create a strong incentive to switch from smoking to smokefree products. Most smokefree products should attract only standard sales taxes and zero excise duties. If excise duty is applied, it should leave the highest-taxed smokefree product with a much lower tax burden than the lowest-taxed smoked product to support switching. Public health agencies should provide well-crafted communications to help smokers make informed choices. Public health communicators should engage all relevant stakeholders in communicating risk and the case to switch from smoking to smokefree products.
Comments, criticisms and suggestions welcome.
See David Sweanor discuss the report on NZ TV Expert looks to vaping to get NZ back on track for Smokefree 2025 (7 Oct 2019)