Tobacco Achievements

Foreword

When I first entered parliament in 1996, one in four New Zealanders aged 15 and over, were smoking daily.   Secondary smoke exposure was part of our life; as was the loss of life to far too many generations of New Zealanders who die prematurely from smoking.

Tobacco reform was therefore a key priority for me when I was appointed Associate Minister of Health in 2008.   I am so proud of the amazing achievements engineered by a highly motivated workforce; a passionate community of advocates and a responsive health sector in creating a pathway to a smokefree Aotearoa by 2025.

In a relatively short period of time we have been able to reduce tobacco consumption in all types of tobacco products and across all population groups.   The strategy has been a comprehensive campaign in all spheres of influence – health education, legislation, smoking cessation, and tobacco taxation.  The political will to reduce smoking prevalence and consumption has been encouraging; the influence of the policy milestones negotiated in the Relationship Accord with the Māori Party has also been significant.

There are still areas of significant challenge.  As a nation we must continue to support interventions which can support Māori, young adults and people with lower socio-economic status to become smokefree.   There is more that we can do in enacting the Smokefree Environments Act.   I have been impressed by the efforts of some local government bodies to make public outdoor spaces smokefree.  I have loved the efforts in Wainuiomata to encourage their community to think about the children before they light up. All of us can become wellbeing champions in our own homes, our marae, and our communities.

The Government’s goal to be Smokefree by 2025 rests in all of our hands.   It is a driven by the vision that families are entitled to be well; to enjoy long life; to be free of chronic illness.  I commend this tobacco achievements report to all New Zealanders as a powerful message of what we can achieve, when we work together in the common pursuit of a Smokefree Aotearoa.

Mauri Ora!

Hon Tariana TuriaAssociate Minister of Health

Minister Turia was awarded the World Health Organisation Western Pacific Region award for work on tobacco control on 31 May 2014, World Smokefree Day

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Summary

Excellent progress has been made towards reducing harm caused by tobacco use. Tobacco use results in between 4,500 and 5,000 deaths a year, is the single largest cause of preventable death and chronic illness in this country, and is a major factor in health inequality. The lifespan of those smokers who die prematurely from smoking is, on average, reduced by 15 years. Both smoking prevalence and tobacco consumption, the two main measures of progress in tobacco control, are falling rapidly.

The 2013 Census and the New Zealand Health Survey of 2012/13 reported daily smoking to be 15%.1 and 15.5% respectively. As detailed below, this decline in smoking rates has occurred in all ethnic groups, across all deprivation groups, among both genders, and among most ages.

The decrease has not, however, been spread evenly across those groups. Smoking prevalence and consumption are higher among Māori, young adults and people with lower socio-economic status. Those communities bear a disproportionate burden of smoking-related illness and death.

Tobacco consumption has plummeted. After falling gradually between 2000 and 2008 (generally hovering around the 1000 cigarette equivalents per year mark), tobacco consumption has dropped from 961 cigarette equivalents per capita (adult over 15 years of age) in 2009 to 683 per capita in 2013, a decrease of about 29 %. The sale of all types of tobacco products - manufactured cigarettes, roll-your-own cigarettes, cigars and pipe tobacco - is in decline.

What has brought about these dramatic changes? New Zealand has a comprehensive tobacco control programme, which includes health education, legislation, smoking cessation support and tobacco taxation. All are currently in use in New Zealand. They are most effective when applied in combination.

Although it is difficult to untangle the contributions of each component, there can be no doubt that raising the price of tobacco products through taxation increases has been the most important single contributor, particularly to the drop in tobacco consumption and the decline in youth smoking. In 2013, daily smoking among 14-15 year olds was down to 3.2 % and 75 % had not smoked a single cigarette. Smoking is no longer normal in this age group and most will remain smokefree for life.

Price measures alone cannot achieve the Government’s tobacco goal. Informing people of the harm caused by tobacco use through media campaigns, health warnings on packets and the like are crucial. The Māori Affairs Committee’s inquiry into the tobacco industry in Aotearoa and the consequences of tobacco use for Māori gave tobacco issues a high public profile and the Government adopted its main recommendation of an essentially smoke-free Aotearoa by 2025.

Smoking cessation support services have been strengthened and cessation aids have become more accessible. The Government health target requiring patients in secondary hospital and primary care to be asked their smoking status and provided with brief advice and support to quit has led to many thousands of smokers being encouraged and helped to stop smoking.

The Smoke-free Environments Act 1990 has been amended. Work to further reduce tobacco advertising by banning the display of tobacco products in retail outlets was passed in July 2011 and the main provisions came into force a year later. Government consideration of further measures to minimise tobacco advertising by introducing standardised tobacco packaging and new larger health warnings, are well advanced. Legal provisions to protect people from second-hand smoke have not changed, but surveys show

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a gradual decline in exposure rates and many local authorities, encouraged by non-government organisations, have adopted, and in some cases extended, the smokefree areas within their jurisdictions.

These developments have been magnificently supported by the non-government organisations that support tobacco control and the tobacco research community has provided high quality evidence to inform the development of policy and to promote innovative ways to help smokers to quit.

As a result of these efforts promising progress has been made towards New Zealand becoming an essentially smoke-free nation by 2025, but it is still an ambitious target. Much remains to be done if the target is to be achieved. Hopefully the new Pathway to Smoke-free New Zealand 2025 Innovation Fund will help us to reach those priority groups among whom smoking rates remain far too high.

Reduced Smoking Prevalence and Consumption

1 Smoking Prevalence

Information on smoking prevalence has been obtained primarily from two sources, the New Zealand Health Survey (NZHS) reports prepared by the Ministry of Health’s Health and Disability Intelligence Unit and data from the New Zealand Census which included two questions on smoking in 1981, 1996, 2006 and 2013.

The 2013 Census showed that regular (daily) smoking for people aged 15+ years had fallen from 20.9 % in 2006 to 15.1 % in 2013. The New Zealand Health Survey, using different methodology, reported daily smoking to be 15.5 % in 2012/13.

While the Census reports “regular” smoking (essentially daily smoking), the New Zealand Health Survey reports its findings primarily in terms of “current” smoking prevalence, that is, those who smoke daily, weekly or monthly.

Detailed smoking prevalence data from the NZHS, both daily and current smoking rates broken down by age, ethnicity and gender, are available at http://www.health.govt.nz/publication/new-zealand-health-survey-annual-update-key-findings-2012-13. Note that some of the NZHS data in this report is being prepared for publication and is subject to change.

Smoking prevalence is declining in all ethnic groups, across all deprivation groups, among both genders and amongst most ages. New Zealand has seen a significant decrease in both current and daily smoking since 1996/97. In 1996/97, 25.2% of the adult population (aged 15+ years) were daily smokers. By 2012/13, this rate had dropped to 15.5% which equates to around 554,000 adult daily smokers.

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Daily smoking, 1996/97-2012/13 (age-standardised prevalence)

1996 2002 2006 2011 20120

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Data sources: 1996 = 1996/97 New Zealand Health Survey (NZHS); 2002 = 2002/03 NZHS; 2006 = 2006/07 NZHS; 2011 = 2011/12 NZHS; 2012 = 2012/13 NZHS

Census returns also showed a large decline in adult smoking prevalence, from 20.9 % in 2006 to 15.1 % in 2013 for the New Zealand population aged 15+ years - a remarkable decline of 22.5 %.

Smoking Prevalence by age

According to the New Zealand Health Survey there has been a significant decrease in the rate of current smoking in 15-19 year olds from 19.8% in 2006/07 to 12.7% in 2012/13.

Between 2006/07 and 2012/13, the largest decline in current smoking prevalence occurred amongst 15-19 year olds (36%) followed closely by those aged 65-74 years (27%). The third significant decline was recorded with smokers in the 25-34 year old age group (13%). Those aged 75 years plus recorded a slight increase in smoking prevalence rates, although this was not significant.

Time trend of current smoking prevalence by age group between 2006/07 and 2012/13

Age group 2006/07 (%) 2012/13 (%) Relative percentage change (%)

15-19 19.8 12.7 -36*20-24 27.3 25.4 -725-34 28.3 24.5 -13*35-44 22.3 20.5 -845-54 21.4 20.0 -755-64 15.0 14.8 -265-74 10.9 8.0 27*75+ 4.0 4.4 9

Data sources: NZHS 2006/07 and NZHS 2012/13

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*There is a statistically significant (p<0.05) difference between the prevalences in 2006/07 and 2012/13

Although there was a significant decrease in young female smoking rates in the 15–19 age group between 2006/07 and 2012/13, there was no significant change for their male counterparts.

For 15-17 year olds the current rate of smoking decreased from 15.7% in 2006/07 to 8.0% in 2012/13. The Action on Smoking and Health (ASH) Year 10 Survey also found large decreases in smoking rates among 14 and 15 year old students.

Time trend of smoking prevalence among 14 and 15 year olds

Smoking status (%) 1999 2003 2006 2008 2009 2010 2011 2012 2013

Daily 15.6 12.1 8.2 6.8 5.6 5.5 4.1 4.1 3.2

Weekly 6.7 4.3 3.3 2.6 2.7 2.4 2.0 1.8. 1.8

Monthly 6.3 4.3 2.8 2.5 2.6 2.1 2.1 1.8 1.8

Regular 28.6 20.7 14.2 11.9 10.9 10.0 8.2 7.7 6.8

Never smoked 31.6 42.4 54.0 60.7 64.0 64.4 70.4 70.1 75.1

Data source: ASH year 10 snapshot survey 1999-2013

Similar to the NZHS, the 2013 census showed large decreases in smoking prevalence in all age groups compared with the 2006 census, particularly in the younger age groups.

Time trend of regular (daily) smoking prevalence by age group between 2006 and 2013 CensusesAge group 2006 (%) 2013 (%) Relative percentage

change (%)15-19 19 10 -4220-24 30 21 -3025-34 27 20 -2635-44 24 18 -2545-54 22 18 -1855-64 16 13 -1965+ 8 7 -12

Data sources: NZ Census 2006 and 2013

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Smoking prevalence by ethnicity

The general decline in the overall prevalence of smoking in recent years has not occurred at the same rate across all population groups, with some groups showing greater declines than others.

As shown in the table below, between 2006/07 and 2012/13 the European/Other group showed the largest decline (16%) amongst the ethnic groups.

Time trend of current smoking prevalence by ethnicity between 2006/07 and 2012/13Ethnic group 2006/07 (%) 2012/13 (%) Relative percentage

change (%)Māori 40.2 38.2 -5Pacific 26.2 23.9 -9Asian 10.6 10.3 -2

European/Other 20.3 17.0 -16*

Data sources: NZHS, 2006/07 NZHS; 2012/13*There is a statistically significant (p<0.05) difference between the prevalences in 2006/07 and 2012/13

According to the 2013 ASH Year 10 smoking survey of 14 and 15 year olds, smoking among Māori in Year 10 is also continuing to show a rapid decline. Daily smoking amongst Māori in Year 10 has declined to 8.5% in 2013 compared to 26.9% in 2003 and 30.3% in 1999. Regular smoking has also greatly reduced for Māori Year 10 students. For 2013, the figure is 14.7% compared to 20.9% in 2010, 23.3% in 2009 and 42.8% in 1999.

Census returns showed large declines in smoking prevalence among all ethnic groups.

Time trend of regular (daily) smoking prevalence by ethnicity between 2006 and 2013

Ethnic group 2006 (%) 2013 (%) Relative percentage change (%)

Māori 43 33 -23Pacific 30 23 -23Asian 11 8 -27

Middle Eastern, Latin American, African 15 11 -27

European 19 14 -26Total 20.9 15.1 -22.5

Data sources: NZ Census: 2006 and 2013

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Smoking prevalence by neighbourhood deprivation

Current smoking prevalence fell in all neighbourhood socioeconomic deprivation groups between 2006/07 and 2012/13, but the declines were not even across all groups. Adults living in the middle quintiles (2, 3 and 4) showed the biggest declines (22%, 17% and 17% respectively). Nevertheless, in 2012/13 smoking prevalence remained lowest in quintile 1 and highest in quintile 5.

Time trend of current smoking prevalence by neighbourhood deprivation between 2006/07 and 2012/13

Neighbourhood deprivation 2006/07 (%) 2012/13 (%) Relative percentage

change (%)Quintile 1 13.0 12.8 -11Quintile 2 17.3 13.4 -22*Quintile 3 20.1 16.7 -17*Quintile 4 24.6 20.5 -17*Quintile 5 33.1 31.3 -5

Data sources: NZHS; 2006/07, NZHS; 2012/13 *There is a statistically significant (p<0.05) difference between the prevalences in 2006/07 and 2012/13.

Smoking prevalence by gender

Current smoking prevalence fell significantly by a similar amount for both males and females (11% and 13% respectively) between 2006/07 and 2012/13. The proportion of females smoking in 2012/13 (17.6%) was significantly lower than the proportion of males smoking (20.0%).

Time trend of current smoking prevalence by gender between 2006/07 and 2012/13

Gender 2006 (%) 2012 (%) Relative percentage change (%)

Male 22.4 20.0 -11*Female 20.3 17.6 -13*

Data sources: NZHS; 2006/07, NZHS; 2012/13 *There is a statistically significant (p<0.05) difference between the prevalences in 2006/07 and 2012/13.

The Census showed a larger downward trend for daily smokers.

Time trend of regular (daily) smoking prevalence by gender between 2006 and 2013

Gender 2006 (%) 2013 (%) Percentage change (%)Male 22. 16 -27

Female 20. 14 -30

Source: NZ Census; 2006 and 2013

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2 Tobacco Consumption

More than any other measure, changes in tobacco consumption are related to the price of tobacco. Some quit smoking in response to price increases but many more respond by reducing their consumption or, in the case of many young people, not taking up smoking.

The tables below are from different sources and not strictly comparable. The data for 1999–2009 is from Statistics NZ and records tobacco products available for consumption - essentially, product on which excise or duty has been paid. This series was discontinued in 2010 for reasons of confidentiality. The data for 2010-2013 is from the tobacco product sales information provided annually by tobacco manufacturers and importers. The data are is similar, but not identical.

After falling gradually between 2000 and 2008 (hovering around the 1000 cigarette equivalents per year mark), tobacco consumption per adult aged 15+ has fallen dramatically from 961 cigarette equivalents per capita in 2009 to 683 cigarettes per capita in 2013, a decrease of about 7.2 % per year. The sale of all types of tobacco products - manufactured cigarettes, roll-your-own cigarettes, cigars and pipe tobacco - is in decline.

Tobacco products released for consumption in New Zealand, 1999–2009

Year

Tobacco products released Number of cigarette equivalents released per adult (15+ years)

Loose tobacco (tonnes)

Manufactured cigarettes (millions)

Loose tobacco per 15+

Manufactured cigarettes per capita Total per capita

1999 736 3119 251 1062 13122000 841 3152 281 1058 13522001 780 2608 262 875 11362002 810 2817 265 922 11872003 795 2367 255 759 10142004 841 2320 266 733 9992005 889 2436 276 757 10332006 879 2439 269 747 10162007 904 2445 270 732 10022008 870 2550 257 755 10122009 856 2436 250 711 961

Source: Statistics New Zealand

Tobacco products sold in New Zealand, 2010-2013

Year

Tobacco products released Number of cigarette equivalents released per adult (15+ years)

Loose tobacco (tonnes)

Manufactured cigarettes (millions)

Loose tobacco per 15+

Manufactured cigarettes per capita Total per capita

2010 771 2220 222 639 8612011 631 2083 180 593 7732012 593 2017 167 570 7362013 564 1886 157 526 683

Source: Tobacco return sales data 2013 (Health New Zealand)

Notes for both tables:1. One cigarette equivalent equals one manufactured cigarette or one gram of loose tobacco.

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2. One tonne equals 1000 kg.3. It is assumed that one cigarette equals one gram of loose tobacco and one tonne of loose tobacco equals one million

manufactured cigarettes.4. Calculations of cigarette equivalents are based on tobacco return data for manufactured cigarettes and loose tobacco

released for sale.5. ‘Per capita’ means for each individual (15+ years) in the population.

Achievements through Improved Tobacco Control

1 Tobacco Taxation

In October 2009, Cabinet agreed in principle to increase the excise on tobacco products. On 28 April 2010, tax on tobacco products was increased by 10% with an additional 14% increase in the tax on loose tobacco. Increases of 10% on 1 January 2011 and 1 January 2012 were also provided for. The Māori Affairs Committee urged (Recommendation 32) the Government to legislate for further incremental tax increases over and above the annual adjustment for inflation. In October 2012, the Customs and Excise (Tobacco Products—Budget Measures) Amendment Act 2012 legislated for a further four tobacco tax increases of 10% to come into effect on 1 January each year from 2013 to 2016.

The World Health Organization regards increasing the price of tobacco through higher taxes as the single most effective way to decrease tobacco consumption and encourage smokers to quit. Although, price rises do not work alone but they are instrumental in ensuring the overall package of mutually-reinforcing measures (including Health Targets, smoking cessation services and medication, retail controls, smoke-free environments, health warnings, public education and media campaigns) works to maximum effect to reduce smoking levels.

The biggest health gains from increasing tobacco taxes were expected to be among Māori (particularly Māori women), Pacific, and low income communities, who are all significantly over represented in smoking rates. There is also strong evidence that young people are particularly price sensitive when making decisions about smoking uptake. The health benefits of an excise increase are therefore likely to build over time.

Annual adjustments to the tobacco excise, based on movements in the Consumer Price Index (CPI), occur every year, subject to Cabinet approval. In recent years this adjustment has taken effect on 1 January. Increases in the tobacco excise over and above the inflation adjustment have occurred from time to time, for example in 1998 and 2000 (a 14% increase). However, the price of tobacco products is set by the tobacco companies and may be more, less, or the same as the tobacco excise increase.

As noted, the first of the recent series of tobacco tax increases occurred on 28 April 2010. The tax on all tobacco products was increased by 10% and there was an additional increase of 14% on loose tobacco to align the excise tax on manufactured cigarettes with that on loose tobacco based on the weight of tobacco. The tax on loose tobacco therefore increased by about 25%.

The subsequent tobacco tax increases occurred as follows:

1 January 2011 10% increase on all tobacco products + CPI of 1.65% 1 January 2012 10% on all tobacco products + CPI of 4.492% 1 January 2013 10% on all tobacco products + CPI of 0.86% 1 January 2014 10% on all tobacco products+ CPI of 1.28%

In recommending the Bill that provided for four cumulative increases to the excise tax on tobacco products of 10% from 2013 to 2016 to the House, by majority, the Finance and Expenditure Committee also recommended that the Government:

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monitor closely the progress made over the next few years toward the goal of a smoke-free New Zealand by 2025, and implement further excise tax increases after 2016 if its achievement is in doubt.

As indicated, these increases in tobacco tax excise have contributed to significant decreases in the amount of tobacco used by encouraging quitting, discouraging smoking uptake and prompting smokers to smoke less. They have almost certainly contributed to the decline in smoking prevalence, particularly to the decline in smoking rates among young people. Calls to The Quitline, which spike with each tax increase, suggest this.

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Inbound Calls to Quitline

Source: The Quit Group (Quitline)

Another consequence of the price increases is that those who have continued to smoke have gravitated towards cheaper cigarettes. Lower priced cigarette brand variants have been introduced and have been successful in gaining significant market share.

The chart below shows the changes in tobacco consumption for manufactured cigarettes and loose tobacco in recent years, together with trend lines showing the relative increases in tobacco excise for the two product classes, and the daily smoking prevalence as measured by the NZ Health Survey (2006, 2011/12 and 2012/13).

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Duty-free and Gift Concessions

The current duty-free allowances allow for significantly cheaper avenues of smoking which are out of step with the Government’s broader measures particularly the tobacco excise increases to make New Zealand effectively smoke-free by 2025.

However, from1 November 2014, the duty-free allowance will fall from 200 cigarettes to 50 cigarettes. The new limit will align New Zealand with the duty-free tobacco concession that has been in place in Australia since 2012. In addition, and also from 1 November 2014, tobacco products sent to New Zealand as a gift from abroad will no longer be eligible for the $110 duty-free gift allowance. This means all gifts of tobacco products sent to New Zealand will be subject to excise duty and GST.

These new rules will help to close these anomalies, thereby reducing the opportunities for cheaper smoking.

2 Māori Affairs Select Committee Report

At its 23 September 2009 meeting, the Māori Affairs Committee resolved to conduct an inquiry into the tobacco industry in Aotearoa and the consequences of tobacco use for Māori. The committee called for public submissions on the inquiry. The closing date for submissions was 29 January 2010. The committee received 260 submissions and many supplementary submissions. It also received 1,715 form letters. It heard 96 of the submissions orally at hearings of evidence at Wellington, Christchurch, Rotorua, and Auckland. The committee reported to Parliament on 3 November 2010.

The purpose of the inquiry was to gain a comprehensive understanding of the actions of the tobacco industry to promote tobacco use amongst Māori, and the impact of tobacco use on the health of the Māori population, and the wider economic, social, cultural and developmental impacts that arise from such health effects and tobacco use more generally.

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During the course of the inquiry tobacco issues were frequently prominent in the media. People obtained a better understanding of the harm caused by tobacco. The process contributed to the denormalising of smoking and to the development of a climate conducive to advancing the tobacco control policies recommended.

The Government responded to the Committee’s 42 recommendations in March 2011. Recommendation 1 from the Committee was “that the Government aim for tobacco consumption and smoking prevalence to be halved by 2015 across all demographics, followed by a longer-term goal of making New Zealand a smoke-free nation by 2025”.

In response, the Government agreed with a longer term aspirational goal of reducing smoking prevalence and tobacco availability to minimal levels, thereby making New Zealand essentially a smoke-free nation by 2025. This formal recognition of the need to address tobacco issues urgently reinforced the momentum provided by the Committee process.

Public health proponents and tobacco control advocates have interpreted the Government’s goal of reducing smoking prevalence and tobacco availability to minimal levels to mean a smoking rate of less than 5% of New Zealand adults, and that this should be achieved across all major ethnic groups.

The Ministry of Health Statement of Intent 2013 to 2016 set mid-term goals. It included the statement that “To achieve the long-term smoke-free 2025 goal:

daily smoking prevalence falls to 10% in 2018

the Māori and Pacific rates halve from their 2011 levels.”

3 The Pathway to Smoke-free New Zealand 2025 Innovation Fund

The Pathway to Smoke-free New Zealand 2025 Innovation Fund was established in 2012 and was one of the actions taken by the Government in response to the Māori Affairs Committee’s inquiry into tobacco. The Innovation Fund was established to advance progress towards the aspirational goal of making New Zealand an essentially smoke-free nation by 2025. Specifically, the fund’s purpose is to support innovative approaches to reduce the smoking prevalence among Māori, Pacific peoples, pregnant women and young people across New Zealand. The fund distributes up to $5 million per annum.

Two funding rounds have been administered to date and 22 projects are receiving funding. The first set of projects began in June 2013, and the second set began in June 2014. Examples of projects funded include marae-based cessation support and education sessions in Northland, a workplace cessation and wellbeing programme in Gisborne, a mobile quit bus in Auckland, and a month-long stop smoking campaign whereby smokers across the entire country will be targeted. Details of all projects are available at http://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/pathway-smokefree-new-zealand-2025-innovation-fund/smokefree-new-zealand-2025-innovation-funding-successful-projects.

In 2013, a decision was made to ring-fence $250,000 from the Innovation Fund specifically to provide grants to smaller, community-based projects. These projects focus on youth (aged 12–24 years), have an emphasis on Māori, Pacific peoples, and pregnant women of any ethnicity.

The first six community projects began in April 2014, and were based in the selected areas of Opotiki and Camberley. The second set of projects will be selected in August 2014 (to commence in November 2014), and will be based in the selected areas of Whanganui/Manawatu and Gisborne/East Coast. Details of all projects are available at: http://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/pathway-

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smokefree-new-zealand-2025-innovation-fund/smokefree-new-zealand-2025-innovation-fund-summary-round-one-projects

Going forward, the Ministry’s intention is to share the outcomes of these initiatives to support uptake of successful innovation:

continue to administer funding rounds as funding becomes available, selecting innovative projects that are assessed as contributing to the Smoke-free New Zealand 2025 goal

extend the funding on existing projects where evaluations show they are contributing to the Smoke-free New Zealand 2025 goal.

4 Health Target: Better help for smokers to quit

‘Better help for smokers to quit’ is a Government health target. The health target requires that 95% of patients who smoke and are seen by a health practitioner in public hospitals, and 90% of patients who smoke and are seen by a health practitioner in primary care will be offered brief advice and support to quit smoking. Progress will be made towards 90% of pregnant women who smoke being offered advice and support to quit.

Since the health target was introduced in 2009, incredible progress has been made.  When the Ministry first began reporting on the health target, only 17% of smokers that were admitted to hospital were receiving brief advice and cessation support. Five years on, the hospital component of the target has been achieved, meaning that over 95% of hospital patients who smoke are now being given better help to quit smoking.

A number of initiatives have helped District Health Boards to achieve this massive change, including providing accessible and relevant training and nominating smokefree champions on each of the wards.

Advice and support to quit is being provided to over half of New Zealand's smokers through the primary care component of the target. That result is currently at 71.6 % (a 14.7% improvement from 2013) but is expected be over 75% by the end of 30 June 2014. This means approximately 380,000 people who visited their general practitioner during the 2013-14 financial year received brief advice and support to quit smoking.  Two DHBs met the primary care target and three more are achieving over 80%. All DHBs improved their performance compared to the previous year.

Percentage of smokers who are offered help to quit, 2009/10–2012/13

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2009/10 Q3

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Health Target Performance (Q1 2009/10 to Q3 2013/14)

Hospital targetPrimary care target

This target is designed to prompt clinicians to routinely ask about smoking status as a clinical ‘vital sign’, and then to offer brief advice and quit support to current smokers. There

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is strong evidence that brief advice from clinicians is effective at prompting quit attempts and long term quit success. The quit rate is further improved by the provision of effective cessation therapies, including pharmaceuticals and face-to-face support.

As of the March quarter 2014, data from the Midwifery and Maternity Provider Organisation and Lead Maternity Carer (LMC) Services (which represents around 80% of pregnant women registered with a midwife) show that 86.9% of pregnant women (1497 out of 1723 smokers), who smoked and registered with a LMC, were offered advice and/or support to quit during the quarter. The Ministry continues to look for a data source for the maternity target that represents a greater proportion of the population.

Although health targets are supporting clinical practice change and helping to drive positive results to reduce smoking, there are other initiatives as part of the wider tobacco control programme that contribute to these outcomes.

New Zealand Guidelines for Helping People to Stop Smoking

The New Zealand Guidelines for Helping People to Stop Smoking provides guidance for health care workers to use during their contact with smokers. An updated version was published on 4 June 2014. The guidelines are structured around the ABC pathway for stopping smoking, which requires health care workers to “Ask about and document every person’s smoking status, give Brief advice to stop to every person who smokes, and to strongly encourage every person who smokes to use Cessation support (a combination of behavioural support and stop-smoking medicine) and offer to help them access it” The new Guidelines document is now only six pages in length and contains simple yet pragmatic information for busy health care workers. The updated Guidelines and its supplementary documents are available at: http://www.health.govt.nz/publication/new-zealand-guidelines-helping-people-stop-smoking

ABC e-learning tool

The ABC pathway is a simple memory aid that incorporates the key steps for screening and advising on tobacco use and its treatment.

The e-learning resource shows a variety of health professionals entering into the ABC pathway conversation with their clients. It replaces an earlier training tool and has a modern look and feel, with interactive text, holograms and continuous scrolling. Access is through the LearnOnline platform and is hosted by Kineo. The new course includes an assessment, and if a pass mark of more than 80% is obtained, the recipient can become a quit card provider. CME points are also available. The resource is available at: http://learnonline.health.nz/

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Improved access to licensed smoking cessation medications

In New Zealand all evidence based licensed smoking cessation medications are now fully subsidised. These include:

Nicotine replacement therapy (NRT) - three forms are subsidised patch, gum and lozenge.

Nortriptyline (Norpress) - available on prescription only

Bupropion (Zyban) - available on prescription only

Varenicline (Champix) - available on prescription only.

From February 2008, all medical practitioners who have the right to prescribe were able to distribute Quit Cards without undertaking additional cessation training. Prior to this date, only 400 general practitioners were Quit Card providers and able to offer subsidized NRT to their patient.

In June 2008, the Quit Group’s Txt2Quit service was launched. This service used text messages as a tool to support people attempting to quit smoking.

In July 2009, Bupropion (Zyban) was subsidised as a smoking cessation medication and in September 2009 NRT became available on a prescription (as well as via a Quit Card) - meaning that general practitioners did not have two systems for prescribing subsidised medications.

In October 2010, Varenicline (Champix) was added to the subsidised list of medications with a ‘special authority’ requirement. The ‘Special Authority’ means that a number of criteria have to be met before a smoker becomes eligible for a subsidised course of Varenicline. These include having previously tried quitting with the assistance of another subsidised smoking cessation medication and not having had another subsidised course of Varenicline in the last twelve months.

Use of subsidised smoking cessation medications is a highly cost-effective intervention. Promoting the use of these products has long been a focus for the Ministry of Health as they can double the chances of a person quitting successfully when compared to going ‘cold turkey’ that is, having no support. Adding extra behavioral support enhances the odds of success even further.

5 Tobacco Display Ban

At its meeting on 26 October 2010, Cabinet agreed to a package of new and improved controls on the retailing of tobacco products. The Health Committee considered the proposed Bill and the Smoke-free Environments (Controls and Enforcement) Amendment Act 2011 passed on 22 July 2011. It came into force on 23 July 2012. The Māori Affairs Committee supported the proposal (Recommendation 11) that all retail displays of tobacco products be prohibited.

The Amendment Act prohibited the display of tobacco products at any sales outlet. All tobacco products for sale must now be out of sight and visible only to the extent necessary for it to be delivered to the customer or store. The removal of “power wall” advertising will discourage young people from taking up smoking and help people who have quit, or are trying to quit, to remain smokefree.

The Amendment Act also gave effect to a number of the Māori Affairs Committee’s recommendations by:

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tightening controls on the display of trading names that include terms signifying the availability or price of tobacco for sale; (Recommendation 17)

providing that any contract or other form of agreement which offers a sponsorship, gift, rebate, prize or reward in exchange for the promotion or sale of tobacco products is void to the extent to which it is inconsistent with the Smoke-free Environments Act 1990; (Recommendation 12)

providing powers to issue infringement notices for offences involving the sale of tobacco products to people under 18 years of age; (Recommendation 15)

increasing the penalties for selling tobacco to minors; (Recommendation 13)

prohibited manufacturers, importers, distributors, and retailers of tobacco products from sponsoring activities involving exclusive supply arrangements (Recommendation 10).

6 Plain Packaging

The Māori Affairs Committee Inquiry into the tobacco industry in Aotearoa and the consequences of tobacco use for Māori recommended in November 2010 that “the tobacco industry be required to provide tobacco products exclusively in plain packaging, harmonising with the proposed requirement in Australia from 2012” (Recommendation 7). Government agreed in principle with this recommendation in April 2012 and from July to October 2012 the Ministry of Health conducted a consultation process on plain packaging.

As a result, Government decided in February 2013 to proceed with a legislative change. Cabinet noted the need for enabling legislation to establish the plain packaging regime and subsequent regulations to implement it. In August 2013, Cabinet approved the policy recommendations for inclusion in the Bill, and agreed that the legislation needs to include wide regulation - making powers of both a restrictive and a permissive nature to ensure that every aspect of the appearance and all other designed features and sensory impacts of tobacco products and tobacco product packaging can be controlled.

This Government Bill, in the name of Hon Tariana Turia, had its first reading on 11 February 2014 and was referred to the Health Committee for consideration.

The Bill proposes a plain packaging regime for tobacco products in New Zealand, similar to that now in place in Australia since December 2012. The key provisions are designed to:

ensure that tobacco products can only be manufactured, packaged and sold if they comply with plain packaging requirements

make the graphic warnings on the packs larger and more effective

enable regulations to be made to set out the detailed requirements for tobacco product design, appearance, packaging and labelling (including the improved graphic warnings)

allow a brand name and certain other manufacturer information to be printed on the pack, but with tight controls (eg, over the type font, size, colour and position)

prohibit the use of tobacco company branding imagery and all other marketing devices on tobacco product packaging, or on tobacco products themselves

create new offences with significant penalties to effectively deter and punish any non-compliance, and also allowing lower penalties and an infringement notice scheme to deal with any instances of small scale or low level offending

lift the maximum penalties for some existing and related tobacco advertising and health warning offences to the same levels as the new offences, for consistency

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widen the enabling powers for health warnings so that regulations might also require positive images and messages designed to encourage people to quit smoking to be displayed on some tobacco packages.

The Bill recognises that tobacco packaging serves to advertise and promote tobacco products, which the Smoke-free Environments Act 1990 aims to prevent. Accordingly, the Bill clarifies that a purpose of the Act is to regulate and control the appearance of tobacco products and packages. In particular the Bill provides that tobacco products for retail sale must: comply with plain packaging requirements in order to reduce the appeal, social acceptance and approval of smoking and tobacco products; make warning messages more noticeable; and reduce the likelihood of creating false perceptions about the safety of tobacco products. As well as this, the Bill provides that required messages and information on tobacco packs may be larger and broader in scope.

There is provision for tight controls over the way the brand name, tobacco company branding imagery and other marketing devices and manufacturer information is printed on the pack.

Detailed requirements for tobacco product design, appearance, packaging and labelling, improved graphic warnings, and standardised pack quantities are to be set out in subsequent regulations.

The Committee invited public submissions by 28 March 2014. The Ministry of Foreign Affairs and Trade also notified the Bill to the WTO, and invited intergovernmental submissions concerning international trade aspects of the Bill with a deadline of 18 April 2014. The Health Committee is to report back to Parliament by 11 August 2014.

7 Media campaigns

Numerous media campaigns have been conducted by the Health Sponsorship Council (HSC), which merged into the Health Promotion Agency (HPA) on 1 July 2012, and the Quit Group.

Examples of HSC/HPA campaigns are Smoking Not Our Future, Face the Facts, Smokefree Homes and Cars. The HPA has also organised World Smokefree Days, and run the Smokefree Rockquest, Smokefree Pacifica Beats and other events and programmes targeted mainly at young people. Smokefree areas have also been promoted. The HPA has recently launched a Tobacco Control Data Repository which is available at www.tcdata.org.nz.

Smoking cessation media campaigns have included The New You Campaign, Did You Know and The Moment I Knew. As well as providing smoking cessation services, the Quit Group also helps to promote World Smokefree Day, Matariki as an opportunity to quit and other events that encourage smoking cessation.

Recently media campaigns have been boosted to support the Smoke-free 2025 goal. A smoke-free cars campaign and the new Stop Before You Start campaign are currently showing.

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Increased Support for Tobacco Control Services

1 Stop Smoking Service Developments

The Ministry of Health directly funds Quitline as well as 42 face-to-face stop smoking services (Aukati KaiPaipa and services for Pacific people and pregnant women). Some district health boards also directly fund stop smoking services within their districts.

In 2012-13, 57,800 people enrolled on a Ministry-funded stop smoking programme. This equates to 12.5% of adult smokers.

In July 2011, a new mandatory smoking cessation service specification was introduced. This specification outlined a mandatory base set of requirements for all publicly-funded cessation services.

In 2012-13, the Ministry of Health began to refocus the stop smoking services on quality of practice, core competencies and clinical outcomes training. A series of eight regional workshops resulted in significant improvements in performance across face-to-face smoking cessation providers. The stop smoking services were refocused to deliver evidence-based treatment and support including: (1) access to all options of subsidised nicotine replacement therapy (NRT); (2) information about how to access and use all other approved stop smoking medicines; and (3) behaviour support.

Since 2011, the proportion of clients achieving a successful quit attempt has steadily increased following on-going workforce development. As at April 2014, the success rate for face-to-face stop smoking service clients was 28% (i.e. 28% of people were validated as being smokefree after 3 months following their quit date), an increase of 8% since 2011.

In July 2014, the new National Stop Smoking Practitioners Certificate and National Training Service (NTS) were launched. The NTS was established to set a national standard for stop smoking treatment and is committed to improving workforce service performance, clinical excellence and quality. The first training product to be designed, developed and launched by the NTS is the National Stop Smoking Practitioners’ Certificate. This certificate will be compulsory for all Ministry of Health funded stop smoking practitioners as the first priority and then opened to all other stop smoking practitioners. It will provide all stop smoking practitioners with the core competencies for stop smoking treatment and the qualification is inclusive of particular tangata whenua and Pasifika cultural competency elements which are integral to achieving the qualification and applying it in practice. The certificate includes a pedagogically sound approach to teach and assess a stop smoking practitioner the ability to work within the New Zealand context with a focus on the needs of Māori, Pacific and pregnant clients as priority population groups.

Quitline

The Quit Group (Quitline) provides national stop smoking services by way of phone, online and text message. Established in 1999, Quitline has undergone significant changes since its inception.

In 2012/13, Quitline supported 50,297 quit attempts. This equates to around 8% of the smoking population. Māori clients made 10,748 quit attempts with Quitline, or 22% of total quit attempts. Pacific clients made 2,716 quit attempts with Quitline, or 6% of total quit attempts. Māori and Pacific peoples are two of Quitline’s priority groups due to high rates of smoking.

Since 2010, significant changes have occurred in the way people engage with Quitline. These changes reflect the emerging trends in the use of information communication technology.

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Quitline used changes in 2012/13 as an opportunity to further develop its service and improve a client’s experience via phone, online and text message. This work resulted in the following key changes:

Clients who register with Quitline are now signed up to a 3 Month Quit Programme

Over the course of the 3 Month Quit Programme clients now receive a minimum of four follow-up contacts

Tracking systems were created to assess clients’ quit status at four weeks and three months

The support model underpinning Quitline’s service was redeveloped to align with the 3 Month Quit Programme

The redeveloped Quitline support model was mapped across Quitline’s three service channels—phone, online and text

The channels now offer a single integrated smoking cessation support programme, creating a seamless experience for clients

Client interaction and outcomes via each service channel are now recorded in a single Customer Relationship Management System.

Quitline currently achieves a 24.2% quit rate at three months and 20.9% at 12 months.

Aukati KaiPaipa stop smoking service

Aukati KaiPaipa (AKP) is a kanohi ki te kanohi service that is delivered within most communities. Each AKP provider is responsive to kaupapa Māori culture, whakapapa, reo, tikanga and combines this with evidence based clinical treatment to overcome the addition to the nicotine in tobacco to support Māori and their whānau to stop smoking.

The goal is to reduce the smoking prevalence amongst Māori. The programme also aims to increase the positive attitudes towards supporting the smokefree kaupapa such as smokefree environments, particularly for hapū mama and their whānau and tamariki.

AKP was established in 1999 and now comprises 32 service providers throughout the country. Under the programme 60.5 full time employees deliver face-to-face smoking cessation services to individuals and whānau.

Pacific stop smoking services

Pacific stop smoking services provide face to face multiple support sessions for Pacific people in individual, fānau and group settings. Pacific stop smoking services acknowledge and are responsive to the cultural values, beliefs and the involvement of the family and the community to ensure the effectiveness of services for Pacific people.

Pacific stop smoking services comprise six service providers throughout the country. Under the programme around 14 full time employees deliver face-to-face smoking cessation services to individuals and fānau.

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Services for pregnant women

There are six dedicated pregnancy stop smoking service providers funded directly by the Ministry, all of which provide face to face, multi support sessions to pregnant women and their whānau. In addition, all stop smoking services are required to prioritise pregnant women (as well as Māori and Pacific) within their service, in recognition of the harm smoking has on the health of the pregnancy, unborn baby and pregnant woman.

In 2012, the Ministry undertook the development of the Best practice framework for dedicated pregnancy smoking cessation services. The framework sets out agreed principles and parameters to support pregnant women to stop smoking, with sufficient flexibility to be applicable to any stop smoking service. The dedicated pregnancy stop smoking services were supported to take any steps necessary to meet the best practice framework and any relevant recommendations to improve their performance.

2 Stop Smoking Practitioner Workforce Development

In 2011, the Ministry of Health contracted Te Ohu Rata o Aotearoa (“Te ORA”), the Māori Medical Practitioners, to develop Te Ara Hiringa: A Strategic Plan for the National Māori Tobacco Control Service 2011–2016. Te Ara Hiringa included a range of actions to implement the Māori Affairs Select Committee recommendations including establishing a national Māori tobacco control service (Te Ara Hā Ora was established in 2013) and strengthening of the Māori tobacco control workforce (including development of specific training programmes for the Māori workforce).

As noted, in July 2014 the Ministry launched the National Training Service and the National Stop Smoking Practitioners’ Certificate. Both were established in response to the recommendations of the Māori Affairs Select Committee relating to strengthening the Māori tobacco control workforce as well as feedback and input from the tobacco control sector. The national training service and the certificate also ensure tangata whenua and Pasifika cultural competency in everyday practice for the non-Māori workforce.

3 Other Tobacco Control Services

Health Promotion and Advocacy

ASH New Zealand and the Smokefree Coalition are funded to provide smokefree information, health promotion and advocacy services. ASH provides services to engage communities in a democratic process around tobacco policy and undertakes intensive community work to implement settings-based smokefree policies. ASH is also involved in regional strategic forums for local smokefree polices and works with several DHBs on regional Smoke-free 2025 strategies. The ASH Year 10 (14–15 year olds) survey is part of the New Zealand Youth Tobacco Monitor.

The Smokefree Coalition provides information dissemination and aims to strengthen strategic alliances and collaboration between agencies involved in promoting tobacco control in New Zealand.

The Heart Foundation provides ABC training to health care professionals and supports activities in primary care to achieve the Better help to quit health target. The Heart Foundation includes the Tala Pasifika service, which delivers Pacific leadership and health promotion in relation to tobacco control awareness.

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Te Ara Hā Ora - the National Māori Tobacco Control Leadership Service

In July 2013, Hāpai Te Hauora Tapui, Māori Public Health, in partnership with ASH, was awarded the National Māori Tobacco Control Leadership Service Contract. The establishment of this service was a direct response to Te Ara Hiringa and the Māori Affairs Select Committee recommendations.

The purpose of Te Ara Hā Ora is to work to eliminate tobacco from Māori communities. To achieve this goal, the service is working to grow local, regional and national leadership, increase communication and enhance collaboration across the country. Te Ara Hā Ora is dedicated to ensuring that Māori are strongly represented in local, regional and national tobacco control initiatives, especially in regards to policy development.

National Training Programme for Midwives

In response to the recommendations of the Best practice framework for dedicated pregnancy smoking cessation services that was developed in 2012, the Ministry sought to modify the training that was provided to midwives to use ABC practice and support pregnant women to quit smoking. This resulted in a new national training programme for midwives being developed and implemented from July 2013.

The training aims to provide the midwifery workforce across New Zealand with the confidence, knowledge and skills to safely and effectively encourage and support pregnant women who smoke to take appropriate action to quit smoking. The training content focuses on brief ABC interventions but takes account of the on-going relationship midwives have with the women they provide care for during pregnancy.

District Health Board services

Since 2006, all DHBs have been funded to oversee and progress smokefree activities within their districts, which includes provision of ABC by primary and secondary health services. Some DHBs also directly fund cessation services.

All DHBs are achieving the Secondary Health Target and good progress is being made towards achieving the Better help for smokers to quit Primary Care Health Target through increased focus and collaboration with PHOs.

DHB public health units (PHUs) deliver smoke-free enforcement and compliance activities. Recent changes have required PHU staff to undertake training with respect to the new retail display and instant fine provisions. From July 2013 to June 2014, PHUs undertook 2018 tobacco retailer education visits and 77 controlled purchase operations involving 1204 retailers. These operations resulted in 78 sales to minors and resultant action taken against those retailers.

Review of Tobacco Control Services

In 2013/14, in order to assist the Ministry of Health in taking the necessary steps to leading the sector to achieving the Smoke-free Aotearoa 2025 goal, researchers from SHORE & Whariki Research Centre, College of Health, Massey University, were selected to undertake a review of tobacco control services funded by the Ministry of Health. The provisional overall findings from the review suggest that the current tobacco control services are achieving good results. Given no substantial issues were identified though the review, the Ministry intends to continue refining services in partnership with relevant stakeholders.

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4 Emerging Issue - Electronic cigarettes

E-cigarettes (EC) are emerging products, which:

mimic traditional cigarettes, but do not produce smoke from combustion

deliver an aerosol vapour using an electronic system and a volatile chemical base (typically propylene glycol)

may contain nicotine and/or other substances

vary from brand to brand

are not subject to tobacco excise tax

have an increasing advertising profile and market uptake

pose regulatory challenges, both in New Zealand and other countries, with respect to:

product safety and the risks of misuse

encouraging a possible role in helping smoking cessation and/or harm reduction

possibly undermining other tobacco control policies

may have the potential, if well-regulated, to make a contribution to achieving New Zealand’s Smoke-free 2025 goal

have increasingly received more national and international media attention.

There is a market for products providing smokers with nicotine, but that are less harmful than smoking. Many recent nicotine containing products are marketed as an alternative to tobacco and some make claims for harm reduction or smoking cessation. The rapid evolution of this market and the lack of high quality data make it challenging for the health sector to respond.

In New Zealand, EC have polarised the tobacco control sector. Some believe these devices will contribute towards a Smoke-free New Zealand 2025 by assisting people either to quit or to replace smoking. Others have concerns that EC may impact adversely on individual and population health, perpetuating nicotine addiction, re-normalising smoking behaviour, promoting dual use, and that they might be a gateway to smoking tobacco. Further to this, the tobacco industry is purchasing companies producing these products.

The Ministry of Health acted on the World Health Organization’s advice, recommending a precautionary approach. New Zealand opted to apply its existing regulations to provide a regulatory framework for EC: the Medicines Act 1981 and the Smoke-free Environments Act 1990 (SFEA). Subsequently, the Ministry has identified various concerns and is considering a regulatory response.

Non-nicotine containing EC are widely available in New Zealand. No nicotine containing EC have been licensed for sale so far: they should not be sold but people can import them for personal use. Enforcement of illegal sales of EC is an emerging issue and the divergent views of tobacco control experts present a challenge to informing policy decisions.

The tobacco control sector has been leading the way in New Zealand on how to effectively and comprehensively address a major health issue and we have made good progress towards Government’s smoke-free goal. The sector is now at a critical point to decide whether new nicotine products, such as EC, will help or hinder further progress. Ongoing, constructive policy debate on nicotine products is needed so that valid concerns of both sides can be addressed.

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5 Research and knowledge

The Ministry of Health, in partnership with the Health Research Council (HRC), directly funds research into tobacco control carried out by the New Zealand Tobacco Control Research Turanga. See the Tobacco Control Research Turanga for more information - http://www.turanga.org.nz/ . High quality research on tobacco issues is also undertaken by ASPIRE2025, the Health Promotion Agency, and other research groups.

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