New Zealand has long been a leader in ‘best practice’ tobacco control, adopting a mix of policies to discourage people from smoking by legislating for smoke-free indoor workplaces, schools, cafes, bars and cars. Laws prohibit the advertising of tobacco products and require standardised packaging with graphic warnings on cigarette packets. Support for smokers to quit smoking is very accessible. Annual increases in taxation have led to the price of tobacco being among the highest in the world.
But continuation of this current tobacco control approach is unlikely to achieve the 2025 goal, especially the equity commitment. Without a dramatic decline in smoking, Māori New Zealanders are not on track to reach the goal until 2061. Māori leaders have pointed out that would be a breach of the government’s obligations to Māori under the Treaty of Waitangi.
In December 2022, New Zealand passed the ‘Smokefree Environments and Regulated Products’ Amendment Act into law. This paves the way for a comprehensive package of additional new tobacco control measures. The Act significantly limits the number of retailers able to sell smoked tobacco products and aims to make smoked tobacco products less appealing and addictive. It is possible that this could rapidly and dramatically reduce smoking and inequities in smoking to 5 per cent by 2025.
New Zealand does not currently place restrictions on where tobacco can be sold. Reducing the availability of tobacco products in retail outlets will reduce the number of people who start smoking, encourage smokers to quit and support ex-smokers to stay off smoking. But to have a large impact, the number of retail outlets would need to be significantly reduced.
The second policy involves reducing the nicotine content of tobacco to very low levels, below which addiction will occur. Among smokers who are not considering quitting, using very low-nicotine cigarettes reduces the number of cigarettes they smoke and increases their interest in quitting, as well as their chances of succeeding attempts to quit. While it has a solid research base, this policy has never been implemented and there are technical challenges to manufacturing very low nicotine tobacco products at scale. But modelling studies have shown this could be the strategy with immediate and dramatic benefits.
Measures to protect young people from the risk of starting to smoke are essential as most smokers start in adolescence or early adulthood. It is already illegal to sell tobacco to anyone under the age of 18 but minimum-age laws can send the wrong message that there is a safe age for smoking and make smoking a kind of rite of passage. The Smoke-free Generation policy looks to ultimately end the sale of tobacco altogether, by making it illegal to sell or supply tobacco to people born in or after 2009.
In effect, there will be an increase in the age of purchase restrictions by one year, every year. This policy would turn off the tap of ‘replacement smokers’ flowing into the current pool of smokers. Smoking prevalence would stay at low levels beyond 2025. With no new customers, legal sales of smoked tobacco products would gradually peter out. Modelling studies suggest that the policy would halve smoking rates within 10–15 years and lead to health benefits five times larger for Māori than for non-Māori New Zealanders. The policy would also help further denormalise tobacco use in New Zealand.
Over a century ago, opium smoking was one of the leading health concerns in many Asian countries. The problem was tackled in Taiwan in 1900 and Sri Lanka in 1910 with analogous ‘opium-free generation’ policies. Within 35 years, opium use had been eradicated from both countries.
In 2016, the city of Balanga in the Philippines introduced a Tobacco Free Generation Ordinance, with widespread public support. Balanga’s Tobacco Free Generation Ordinance banned the sale of tobacco products to citizens born after the year 2000. Predictably, the tobacco industry mounted legal challenges. But despite industry pushback, the impact of the ordinance triggered a sharp decline in both youth and adult smoking.
Some argue that the Smoke-free Generation policy involves a denial of choice and is discriminatory. But there are many precedents where restrictions are made to consumer choice, such as seatbelt wearing and wearing crash helmets for motorcyclists. We accept other forms of age-cohort discrimination, such as compulsory education and immunisation and, in some countries, military conscription. Freedom of choice arguments don’t stand up to scrutiny because tobacco smoking is driven by nicotine addiction.
Critical to the success of the New Zealand Smoke-free Generation and other new policies will be investment in communication initiatives to explain the policy and the benefits that will accrue to future generations. Additional investments will also be needed in retailer compliance monitoring and enforcement. Retailer licensing and the reduction in the number of retailers will help make this commitment less onerous.
One major concern with New Zealand’s legislation is that it could increase the illicit trade in normal-strength tobacco and lead to an increase in organised crime. To counter this threat, the government has provided additional resources to the Customs Service to strengthen the detection of smuggled tobacco products and has established a monitoring programme to track illicit use as the new policies take effect.
New Zealand’s many initiatives may be just what is needed to change the game rapidly and make the Smokefree goal a reality. The lessons learned will hopefully trigger a ripple effect and embolden other countries to take similarly innovative actions.
Chris Bullen is Professor of Public Health at the University of Auckland.