End Smoking NZ (ESNZ) is proposing two new methods for controlling smoking – first to reduce imports of cigarettes at the border, and secondly by reducing the nicotine per cigarette. Both methods have been researched, but neither has been used in any country. Both would require legislation, we suggest it be called the End Smoking Act 2021. The methods are put forward by Dr George Laking, chair of ESNZ, an organisation with 35 years of uninterrupted experience in research and advocacy on tobacco control. Associate Minister of Health Dr Ayesha Verrall seeks proposals to shape the government’s plan for tobacco control. These ideas will be included in our submission to the Ministry of Health this month.
1: Reducing imports of cigarettes by 20 percent from each company’s imports the previous year, continuing on a yearly basis.
Cigarette sales would decrease by nearly 60 percent over 4 years. We first proposed this policy to progressively reduce tobacco imports by statute in the NZ Medical Journal in 2010. No-one else has adopted the same policy overseas to our knowledge. Geographical isolation and a capable border service make our country favourable for this approach. The policy embraces the idea that the first duty of a health service is to detoxify the patient and remove the poison, that is, cigarettes for smoking, which kill 10 New Zealanders per day. Moreover the best point for a concentrated strike against disease is the vector, in this case the import of tobacco into our country. Restrictions on imports would work in support of New Zealand’s retail tobacco price regime. This measure would start before and continue alongside the reduction in nicotine per cigarette described below. ESNZ has documented that current policies are already resulting in collapse in tobacco imports by 8 percent annually in recent years. All that is needed is legislation to formalise and strengthen this process. Legislation would be needed in 2021 before import restrictions could be applied. The effects would be seen from 2022 onward.
2: Reduction of nicotine per cigarette from present industry-determined levels of 9 mg to a new legislated maximum of 0.4 mg nicotine.
This is a 96 percent reduction, to create a very low nicotine cigarette, the VLNC. Cigarette consumption would decrease by a further 22 percent. Although regulation under the prevailing law could offer a convenient pathway to mandate VLNCs, we recommend enactment within a new law. This sends a more durable message of Parliamentary support for the change. When these very low nicotine cigarettes come in, old style cigarettes will no longer be stocked. Instead smokers will be encouraged to persist with VLNCs, or quit, or take up vaping. This policy has been researched since 1994 in the United States, and since 2010 by End Smoking NZ members in their paper “Four Policies to end sales of cigarettes and smoking tobacco in New Zealand by 2020”. The policy is backed by many researchers in New Zealand and other countries. One of our group has researched the weights of the cigarettes and the nicotine in each brand. This policy could be legislated in 2021, with introduction of VLNCs beginning one to two years thereafter. Delay may be due to objections from tobacco companies losing their rights to sell non-VLNC combustibles. The beginning of VLNC would mark the end of the sale of non-VLNC combustible cigarettes, with smokers either smoking VLNCs or quitting or taking up vaping.
New Zealand smokers are rejecting tobacco faster than at any time before, according to Dr George Laking, Chair of End Smoking NZ (ESNZ). Tobacco company sales fell in 2019 to 2132 million cigarettes. This is an 8.1 percent annual rate of decline across 2017 to 2019. It is more than three times the rate of decline seen across the first six years of the Government’s Smokefree 2025 project, starting in 2011 (see Table, Decline in NZ Tobacco Sales 2011 to 2019).
On a per-population basis, cigarette consumption amongst New Zealanders aged 15 and over fell from 670 to 543 per annum across 2017 to 2019. This is an annual decline of 9.5 percent, almost three times the rate of 3.5 percent, seen across 2011 to 2017. Dr Murray Laugesen, an ESNZ trustee long involved in tobacco control, analysed company returns published on the Ministry of Health website. It is 30 years this Friday since the Smokefree Environments Act first required manufacturers to report cigarettes sold. The data was priceless he said, in that it told us exactly how many cigarettes were sold.
Two main things could account for the accelerating decline in tobacco sales, according to Dr Laking. These are the appeal of tobacco, and the availability of alternative products. In March 2011 smokers were paying only $16.39 for a pack of 25 cigarettes. In March 2020 they are paying $41.89. Dr Laking said these prices are meant to reduce the appeal of tobacco smoking, which kills four thousand New Zealanders each year. They are the result of eleven successive 10 percent increases in tobacco excise since 2011, via the Excise and Excise-equivalent Duties Table (Tobacco Products) Amendment Act 2010, and the Customs and Excise (Tobacco Products—Budget Measures) Amendment Acts 2012 and 2016.
Meantime the widespread availability of vaping e-cigarettes and heat-not-burn devices may help smokers quit sooner. In 2018 the Health Promotion Agency found that 23 percent of recent quit attempters had used an e-cigarette in the previous two weeks.
In 2011 the Government committed to the Smokefree 2025 goal, of a less than 5 percent prevalence of smokers by the year 2025. Continuation of a 9.5 percent annual per-capita decline in tobacco use, suggests the goal will still not be met until at least 2029, four years overdue.
End Smoking New Zealand urges the incoming New Zealand government to prioritise the Smokefree 2025 campaign, and to support innovative measures in tobacco control, so we can meet the goal of 5 percent smoking prevalence in the year 2025. Success in the goal would imply further reductions of tobacco imports by 5–6 percent per year from 2021 onwards.
Population age 15 and over, millions
Cigarettes per person
Based on calculations from returns of manufacturers, and population age 15 and over, annually up to June 2019. One roll-your-own cigarette = 1.43 factory made cigarettes, based on tobacco content and excise. Deleted: cigars, cigarillos, blunts, hookah tobacco, heat not burn, and duty-free tobacco.
Dad was a smoker when I grew up in the 1970s, his parents too. Mum’s side of the family didn’t. Mum told me of her experiences nursing people with respiratory illness, including a younger person who was killed by asthma. Dad’s father smoked the occasional cigar, I used to like the aroma around their house.
You can still buy “cigarette stink loads”. In 1978 I bought some from the local toyshop and fixed up one of Dad’s cigarettes. The prank made its presence known in the lounge but he just threw the cigarette away and started another one. Some scarily severe asthma attacks around 1982 convinced Dad to finally quit. Instead he took up distance running. He went on to a marathon PB of 3:03 at Christchurch in 1988.
As kids we used to go into the woods and make forts and puff on bits of straw and cigarettes we’d buy from the old fella at the corner store. A store-owner who sold tobacco to primary students! He seemed ancient to us, but probably hit his teens in the Depression years. It was a different world. Anyhow, those first smokes made no great impression on me, because I had no idea about inhaling. We did learn to cover our tracks with peppermints.
I first inhaled tobacco smoke in a woolshed in Whiteman’s Valley, Upper Hutt, in 1985. Oh boy! Head spins! It is one of life’s great misfortunes to enjoy a cigarette. Blessed are those who smoke and feel sick. They usually don’t repeat it.
Smoking never really worked for me because I was physically active, running or cycling. I could tell that smoking and sport were incompatible. I might enjoy a cigarette, usually with a drink, in the evening. The next day I would feel even worse. I still carry some nostalgia. Is that a curse? Indonesian clove cigarettes, with the sugar on the filter. The pop and crackle of burning clove oil at night. The stars spinning above me!
I studied medicine and was influenced by a surgeon from Australia who had amputated too many smokers’ limbs. He urged us to become active against tobacco. He said it would be the most effective thing we could do in our career. As a medical student I wrote a submission in support of Helen Clark’s 1990 Smokefree Environments Bill. More comical was to recently find a second submission, the one I didn’t send in, that argued the reverse on some points. I usually tried to understand a topic from different directions.
I spent the 1990s training for a career in medical oncology, with a focus on lung cancer. In 2010 I made a submission to the NZ Maori Affairs Select Committee inquiry into the tobacco industry in Aotearoa and consequences of tobacco use for Māori. It supported taxation, cessation services, protection of tamariki, and tikanga approaches to removing tobacco from Māori environments. In the 2010s I continued tobacco control work with Te Hotu Manawa Māori and the Smokefree Coalition. Since 2014 I have been with End Smoking New Zealand.
At the start of the decade I was optimistic about nicotine replacement (NRT) with patches and gum to help people quit, realising that some would need quite high doses. Alas NRT adds only 6–8% to the chance of a sustained quit at 6 months. Even with intensive behavioural support, the 6 month quit was not more than 23.2% in the 2018 Cochrane Review.
During the last decade I have seen tobacco control split over the issue of electronic cigarettes (e-cigarettes). It has often been said that tobacco is an addictive poison. Nicotine brings the addiction and tar brings the poison. Although not totally true, this statement is true in ways that matter.
My colleague Dr Penny Truman from End Smoking New Zealand is doing valuable work on the euphoriant properties of non-nicotine components of smoke. It does not surprise me that nicotine would not be the only euphoriant in smoke. Humans are likely to find smoke appealing, because it means food and warmth. This is in contrast to most animals, that will run away from smoke. Probable exceptions are rats and domestic animals that seek out humans. Penny suspects the combination of nicotine with other euphoriants gives tobacco smoke a double-whammy for addiction.
The marvel of e-cigarettes has been to separate the addiction from the poison in tobacco smoke. We found the same separation in tobacco control. It turns out tobacco control was an alliance between some who were more opposed to the poison of tobacco, and others who were more opposed to the addiction. This alliance was revealed, and strained or broken, by the arrival of e-cigarettes.
A subset of people, strongly opposed to the addictive potential of nicotine, have been trying very hard to find poison in e-cigarettes. In actual fact there is poison everywhere. It is 500 years since Paracelsus taught “everything is a poison – only the dose matters”. So there is an expanding literature reporting toxins in e-cigarette liquids, and effects of e-cigarette aerosols principally in animals, with a small number of studies in people.
There is still no literature to confirm actual physical harm, at a population level, to users of nicotine-containing e-cigarettes. A paper claiming that “some‐day and every‐day e‐cigarette use are associated with increased risk of having had a myocardial infarction” has been retracted.
Of course there must be controls on the ingredients of e-liquids. You probably wouldn’t want to try bitter almond flavour, for example. The main reason we can be confident that e-cigarettes are much safer than smoked tobacco is temperature. An e-cigarette atomises e-liquids at around 240 Celsius. A combustible cigarette burns tobacco leaf at around 900 Celsius. The higher temperature, and complex biological substrate, greatly increase the toxicity of tobacco smoke.
With more than 10 years but less than a lifetime’s experience, it remains possible that an adverse effect of e-cigarettes on population health will emerge. But if it did, that would be a surprise. Whereas we know for a fact that smoking combustible tobacco is highly harmful to health. Some people, motivated by their opposition to addiction, are trying hard to find physical harm in nicotine-containing e-cigarettes. For some people, e-cigarettes are scarily effective nicotine replacement.
Addiction is a harm. It takes away the person’s freedom to choose, and puts them at the mercy of others. In the case of tobacco, those others were an industry focused on profit, that twisted science to deny the harm of its products. There is still a reckoning to be had with the tobacco industry over its historical actions. It remains to be seen whether the tobacco industry can reinvent itself, now there are finally safer nicotine products available.
I’ve tried a cartridge-based, nicotine salt e-cigarette. It popped and crackled like the clove cigarettes of my youth. That was pleasant enough, but fortunately for me I have not felt the need to go back to it. As a society, we tend to ascribe a power to addictive euphoriants that is near magical. “One puff and you will be hooked”. I have not forgotten my first puff in a woolshed in 1985. But there have been other things in my life that prevented me from returning.
As a society, we should ask what is driving our young people into the arms of tobacco. In 2002 my son chased me around the garden at a lunchtime barbecue, outraged that I was puffing on a cigar. He was right! Even at primary age, many young people are aware that smoking is harmful to health. In 2016 my son as a young adult took up smoking, while working at a restaurant. Fortunately he has since switched to vaping. I can’t deny I would prefer it if he stopped.
It is not always easy to be young, with doubt as to what the future holds for work, housing, and the world at large. Human beings have long turned to chemical relief for stress and anxiety. We should grow a kinder society. Until then, for those who turn to chemicals, they should at least have a safer option.
There is indeed a gateway between vaping and smoking, but the direction of travel is set by policy. Good policy pushes to vaping. Poor policy pushes to smoking. When I say “push”, I don’t mean “shove” or even the trendy “nudge”. I just mean that good policy helps people move in a better direction. There are many other gateways in the continuum from harm to health. Good policy helps people move towards health. To achieve good policy takes courage (to venture where others didn’t), faith (that policy will succeed), and commitment (to accept that good is not perfect, and keep improving).
Briefly, smoking prevalence in China is 26.6%, 50.5% in males and 2.1% in females. Farsalinos searched PubMed on 1 April (truly). From 432 studies, they identified 13 that reported smoking status of hospitalized COVID-19 patients. The pooled prevalence of current smoking was 6.5%. In other words it looked as though Chinese people who smoke were less likely to be in hospital with COVID-19.
Likewise in the USA, where adult smoking prevalence in 2018 was 13.7%, the CDC reported on 31 March that only 1.3% of those in hospital with COVID-19 were current smokers.
Both these reports are cross-sectional in design, i.e., they offer a snapshot of the data at a single point in time. Cross-sectional designs are the weakest form of observational study in epidemiology. Taken on their own, these data cannot prove that smoking protects against COVID-19 hospitalisation.
A significant weakness of the reports is that they are not accompanied by a statement of reliability of the data on current smoking. The reliability of hospital inpatient smoking surveys is poorly reported in the literature as a whole. Twenty one years ago a study from Australia found that about two-thirds of smokers could be correctly identified at admission. One can’t assume that such a figure holds true for China or the USA in the context of a pandemic crisis. In the absence of reliability data, “current smoking status”, a primary endpoint for these analyses, has to be viewed as unvalidated.
For example in the case of the Chinese data, male gender in that country is known to be strongly associated with smoking. Chinese COVID-19 hospitalisations by gender reveal a 23% excess for male (3286) versus female (2673). Gender is a robust classifier. It is much more likely to be accurately and thoroughly recorded, than is self-reported smoking status at admission. If smoking were truly protective against hospitalisation, one would expect to see more Chinese women than men admitted with COVID-19. The reverse is true.
Another thing to undermine inference from smoking status to COVID-19 hospitalisation would be any difference in structure of the reported populations from the national average. For example it is possible the studied populations might have lower smoking prevalence in relation to factors such as age, ethnicity, or economic status. Such information is not available in the reports.
In general it is understood that smoking increases the risk of hospitalisation with respiratory disease. For example, in 2019 Han and colleagues found that current smoking increased the odds of influenza hospitalisation by 50% (odds ratio of 1.5, 95% confidence interval 1.3–1.9). This work was based on a pooled analysis from 12 studies, some using the more reliable case-control designs.
Farsalinos et al hypothesise that nicotine might be protective against SARS-CoV-2. There is a prior literature about nicotine’s effects on expression of angiotensin converting enzyme 2 (ACE2) receptors, that the virus uses for cell entry. This is an hypothesis worthy of study. But obviously smoking involves many exposures, of which nicotine is only a part. There could be any number of mechanisms at work.
My view as of 6 April is that it is still not possible to define a strong link between smoking and COVID-19 hospitalisation, in either direction. The virus strikes smokers and non-smokers alike. It is likely to be a different story when it comes to morbidity and survival however. Based on what we know about outcomes for the critically ill who smoke, we have to expect these will be worse.
New Zealand is in pressing need of a regulated environment for electronic and alternative nicotine delivery devices. As noted in the Bill’s introduction, such legislation has to strike a balance between helping smokers stop smoking, and reducing uptake of nicotine consumption by young people. An absence of legislation not only jeopardises the Smokefree Aotearoa 2025 goal, but also exposes New Zealanders to products of unacceptably low quality.
ESNZ recommends the Act’s Statement of Purpose acknowledge that vaping and smokeless tobacco products are less harmful than smoking, and that they may help people to quit smoking.
We support allowing vaping indoors, within workplaces, at the discretion of the individual business.
People should have freedom to share information about vaping and other harm reduction technologies.
Health warnings should be proportionate to risk, since disproportionate statements of risk may impede smokers’ transition to lower harm technologies.
The best way to deal with youth uptake of vaping is by age restrictions on purchase. ESNZ is concerned that flavour restrictions will unbalance the Bill’s aims.
ESNZ recommends increasing the scope of Schedule 2 Part 2 to encompass a more complete list of banned ingredients, not just flavours.
ESNZ recommends regulatory flexibility in relation to snus and related products.
End Smoking New Zealand is mindful of the intense disruption, concern, and distress imposed on our country by the COVID-19 pandemic. New Zealand entered national Alert Level 4 at midnight on Thursday 26 March. ESNZ supports the NZ Government’s measures, and the efforts of all New Zealanders, to eliminate the virus. For official information on COVID-19 we recommend the Ministry of Health website. For further information and resources specifically for Māori, we recommend the website of Te Rōpū Whakapaupapa Urutā, National Māori Pandemic Group.
Although there is now an unavoidable focus on COVID-19, especially for our clinician members, ESNZ is continuing its work in support of tobacco harm reduction.
ESNZ is fundraising in support of its scientific activities. A “tobacco endgame” is taking shape, but not as was predicted a decade ago. Electronic cigarettes are disrupting the old plan of tax increases, social denormalisation, and supply reduction. The indicators are there to be studied, in terms of tobacco sales, smoking rates, and health and cultural trends. Can New Zealand achieve its Smokefree goal? Can we do it by 2025? What will a Smokefree New Zealand look like, in terms of policy and practice? ESNZ offers an independent eye on these questions, but we need capacity. If these topics interest you, and you would wish to partner with ESNZ, please contact us by email, firstname.lastname@example.org. * We can’t accept funds from the tobacco industry.
Happy New Year from End Smoking New Zealand. What better way to start 2020 than to order a copy of Murray Laugesen (our founder)’s autobiography, My Life in Public Health. Starting his career as a surgeon, Murray worked in India in the 1960s and 70s, where he became involved in public health. He returned to New Zealand where he pioneered tobacco control in the 1980s and 90s. In the new millennium, Murray has had the foresight to see the potential of tobacco harm reduction technologies. Murray has written more about his work at his website, Health New Zealand. This post goes out at sunrise in Christchurch on New Year’s Day 2020.
End Smoking NZ has co-signed this open letter to Hon Jenny Salesa, Associate Minister Health, urging her to table the Smokefree Environments Amendment (Vaping) Bill for first reading in Parliament. There is an urgent need to fill the current regulatory vacuum.