The Pros and Cons of a Smokefree Aotearoa 2025 Goal: The Case is Overwhelmingly Pro for NZ

In this blog we review the case for the Smokefree Aotearoa 2025 Goal. We find that this is an ideal health goal given the large health gains, impact on reducing health inequalities, and savings in health costs that will follow from achieving it. Arguments against having such a goal are also considered.

 

Smokefree Aotearoa 2025 has been described as “a world-leading, bold ‘endgame’ goal” [1]. The goal arose from a recommendation by the 2010 Māori Affairs Select Committee and in 2011, the Government of the day adopted it as a national target to achieve minimal smoking prevalence and availability by 2025 [2]. A number of other high-income country governments have also adopted smokefree goals eg, Canada, Scotland, Ireland, Sweden and Finland.

Two of us recently participated in a public debate on the Smokefree 2025 Goal at a Law and Economics Association of NZ (LEANZ) event (copies of our presentations are here). This experience stimulated wider reflection among the ASPIRE 2025 and BODE³ research groups on the pros and cons of NZ having such a goal.

Do goals work?

There is no doubt that at the international level goals to achieve bold and ambitious health and societal outcomes can be successful. The eradication of smallpox within two decades of the goal being set in a World Health Assembly resolution is one of the best examples. Similarly, for the successful global eradication of rinderpest, a cattle disease that caused famines in Africa. Furthermore, we are not too far away with achieving the global eradication of polio (just two countries left).

NZ has already successfully achieved several health goals, including the elimination of polio, hydatids, and brucellosis (see this previous blog on successful NZ endgames, and these publications: [3, 4]). NZ also successfully achieved goals to eradicate a mosquito species (the southern saltmarsh mosquito) and mammalian pests from numerous off-shore islands and in mainland island sanctuaries. NZ has also achieved goals around banning leaded petrol, banning DDT, ending the importation of asbestos, and prohibiting nuclear-armed ships from visiting.

Specific benefits of setting goals

Setting goals brings several important potential benefits:

1. Enabling and encouraging sustained commitment by governments (over multiple electoral cycles), the public and civil society. This commitment typically includes long-term planning and resourcing.
2. Stimulating the building of supportive infrastructure, such as establishing surveillance and monitoring systems (especially relevant for disease eradication goals).
3. Spurring investment in research and development, for example, as appears to be occurring with NZ’s predator-free goal, with new methods and technologies being developed.
4. Strengthening national identity and generating a collective purpose amongst New Zealanders, eg, the popular and iconic nuclear-free goal.

Why a Smokefree Aotearoa Goal is a top priority goal

The Smokefree Goal could bring at least five important benefits to NZ:

1) Very large health gains possible. An intervention that approximates the Smokefree Aotearoa goal of minimal smoking prevalence is a sinking lid on tobacco sales (with all sales ending in 2025). A modelling study estimates that this would generate at least an extra 1.2 billion quality-adjusted life-years (QALYs) in the current NZ population over their remaining lifetimes [5], with additional substantial gains for future populations. Since QALYs are somewhat abstract as a health gain measure, this figure is equivalent (in numbers terms) of around two extra years of healthy life among 600,000 people. Due to differences in susceptibility to smoking-related diseases, benefits to smokers who quit would vary: from those who gain decades of extra life (eg, if death from cancer in their 40s is prevented) to those who gained minimal or no health benefits. There would also be substantial benefits of deaths and morbidity averted among future generations who never start to smoke, but would have done so if the Smokefree Goal had not been achieved. It is plausible that similar sized health gains could be achieved by other interventions in the NZ setting, such as markedly reducing the obesogenic environment, but we suspect that achieving these goals are not as feasible as the Smokefree Goal.

2) Impact on benefiting Māori health and reducing health inequalities. Smoking is currently a major cause of health inequalities in NZ by socio-economic position and especially between Māori and non-Māori. As such it can be considered a Treaty of Waitangi issue. One model for the elimination of smoked tobacco use estimated that it would close the life expectancy gap between Māori and non-Māori by 2 years (from a projected 3.8 years down to 1.8 years) [6]. Furthermore, various modelling studies show around at least a three-fold higher per capita health gain for Māori relative to Māori from tobacco control measures (see [7] for results from 6 interventions). Also, by removing the financial burden tobacco purchasing imposes (along with some out-of-pocket health costs from tobacco-related diseases), lower-income New Zealanders will realise substantial health and economic benefits.

3) Impact on lowering health costs and wider economic benefits. Achieving the Smokefree Goal would realise large net health cost savings to the NZ health system – even when considering the extra health costs associated with longer lives. Our estimate (again using the sinking lid intervention as per above) suggests savings of $17.1 billion over the remaining lifetime of the current NZ population [5]. These savings would release resources that could be spent on providing other public services and achieving other social goods. There would also be economic gains for the country from improved worker productivity eg, using productivity loss estimates from an Australian study [8], the lifetime loss for all NZ’s 581,000 smokers can currently be estimated at NZ$30.1 billion.

4) The achievement of the goal could allow for shifting of tax revenue sources to more ethical and sustainable areas. Even though tobacco taxation is a valuable strategy in helping to achieve the smokefree goal, using a dangerous addictive product to generate tax revenue poses ethical problems [9]. Achieving the goal would therefore provide an incentive to government to move taxation to areas where ethical and sustainability gains would be provided (eg, higher taxes on pollutants such as carbon).

5) Other co-benefits. There are numerous co-benefits of achieving a smokefree nation, including:

• Reduced environmental impacts of tobacco, which include those from: “tobacco growing and curing; product manufacturing and distribution; product consumption; and post-consumption waste” [10]. Tobacco butts and packaging are the most prevalent litter item in NZ [11-13], and have major adverse impacts on the environment. Tobacco use even contributes to climate change via greenhouse gases from forest destruction for tobacco growing [14].
• Elimination of smoking-related house fires and forest fires.
• Elimination of vehicle crashes and industrial accidents that are currently associated impaired smoker performance and distraction.
• Reduced child exploitation on tobacco farms in some low-income countries where tobacco is grown [15].
• Elimination of nuisance impacts where non-smokers are exposed to secondhand smoke in homes, cars and in public places eg, in NZ transportation settings [16].

Support for, and feasibility of, the Smokefree Aotearoa Goal

New Zealanders want to see the goal realised. Survey data indicate that 74% of New Zealanders support the Smokefree Goal, when they understand what it means [17]. There is also support even among smokers, at 58% and 50% in two waves of the ITC Survey in NZ (unpublished ITC Survey data). In addition, NZ data shows that most smokers regret starting smoking (at 83%) [18] and a majority make annual quit attempts, averaging 1.5 attempts per year [19]. At an organisational level, the goal has wide political support (it arose during a National-led Coalition Government) and has persisted during a Labour-led Coalition Government. It’s supported by key Māori leaders (eg, Hon Dame Tariana Turia who helped create it) and by all the civil society organisations in the health sector that we are aware of.

The goal is potentially achievable with available interventions. A detailed action plan setting out how the goal could be achieved – “Achieving Smokefree Aotearoa by 2025” – has been published [1]. This plan advances key existing measures that have a strong evidence base (taxation, reducing appeal, reducing access, media campaigns etc) and that could all be intensified, given sufficient political will. In addition, it includes non-business-as-usual interventions to reduce the supply of smoked tobacco products and regulate the product to reduce its appeal and addictiveness. These include substantially reducing retail outlets selling smoked tobacco products (see these modelling studies [5, 20, 21]), removing flavours and additives, and introducing a mandated nicotine reduction policy to restrict the sale of tobacco to very-low-nicotine content tobacco products. Collectively, these measures would also be likely to facilitate the transition of smokers who cannot or do not want to quit the use of nicotine to alternative vaping products, which are likely to be less harmful.

 What might be the downsides of having a Smokefree Goal?

1) Opportunity costs. The biggest disadvantage of having such a goal is the potential opportunity costs, ie, if it diverts attention and resources away from a goal or other activities that are, or become, even more important for NZ society. For example, if an extremely strong societal response to climate change became even more critical – then also having a Smokefree Goal might impose opportunity costs. However, we believe that governments should be able to address several goals at once – and indeed, they typically sign up to multiple ones (eg, in NZ: the goal of a lower-carbon future, reducing child poverty, the Smokefree Goal, and the Predator-free 2050 Goal etc).

Furthermore, there are often some synergies eg, a healthier and more economically productive population (arising from the Smokefree Goal) will potentially help achieve aspects of the low-carbon goal (eg, making it easier for people to walk/cycle as a transport option). The cost of smoking to the health system is also so high (see above) that this could also liberate resources for addressing the low-carbon goal.

2) Concern around negative impacts on smokers whilst trying to achieve the goal. Some critics may argue that achieving the Smokefree Goal imposes excessive fiscal burdens on low-income smokers due to tobacco tax increases. Yet as some of us detailed recently in another blog – there are far more New Zealanders who potentially benefit from increasing tobacco taxes. The government can also minimise this potential financial burden by adjustments in the benefit system and doing far more to help smokers to quit – including potentially subsidising e-cigarettes for low-income smokers. Even without any such subsidies, e-cigarettes are now a widely available cheaper source of nicotine (ie, around 8 to 12 times cheaper based on this NZ cost calculator).

Summary

Goals set internationally and within NZ have achieved impressive results – particularly with infectious disease eradication. Setting goals supports achieving outcomes that may span multiple electoral cycles and need sustained resourcing. The Smokefree Aotearoa 2025 Goal is a particularly high priority health goal, given the size of the potential health gain, the impact on reducing health inequalities and the savings in health costs.

References

1. Thornley L, Edwards R, Waa A, Thomson G: Achieving Smokefree Aotearoa by 2025. University of Otago, ASPIRE 2025, Quitline, Hapai Te Hauora, 2017. https://aspire2025.files.wordpress.com/2017/08/asap-main-report-for-web2.pdf
2. New Zealand Government: Government Response to the Report of the Māori Affairs Committee on its Inquiry into the tobacco industry in Aotearoa and the consequences of tobacco use for Māori (Final Response). Wellington: New Zealand (NZ) Parliament, 2011. http://www.parliament.nz/en-nz/pb/presented/papers/49DBHOH_PAP21175_1/government-final-response-to-report-of-the-m%c4%81ori-affairs
3. Wilson N, Baker MG. Celebrating 50 years of polio elimination in New Zealand: but inadequate progress in eliminating other vaccine-preventable diseases. N Z Med J. 2012;125(1365):67-74.
4. Gemmell MA. Australasian contributions to an understanding of the epidemiology and control of hydatid disease caused by Echinococcus granulosus–past, present and future. Int J Parasitol. 1990;20(4):431-456.
5. van der Deen FS, Wilson N, Cleghorn CL, Kvizhinadze G, Cobiac LJ, Nghiem N, Blakely T. Impact of five tobacco endgame strategies on future smoking prevalence, population health and health system costs: two modelling studies to inform the tobacco endgame. Tob Control. 2018;27(3):278-286.
6. Blakely T, Carter K, Wilson N, Edwards R, Woodward A, Thomson G, Sarfati D. If nobody smoked tobacco in New Zealand from 2020 onwards, what effect would this have on ethnic inequalities in life expectancy? N Z Med J. 2010;123(1320):26-36.
7. Nghiem N, Cleghorn CL, Leung W, Nair N, van der Deen FS, Blakely T, Wilson N. A national quitline service and its promotion in the mass media: modelling the health gain, health equity and cost-utility. Tob Control. 2018;27:434–441.
8. Owen AJ, Maulida SB, Zomer E, Liew D. Productivity burden of smoking in Australia: a life table modelling study. Tob Control. 2019;28(3):297-304.
9. Wilson N, Thomson G. Tobacco taxation and public health: ethical problems, policy responses. Soc Sci Med. 2005;61(3):649-659.
10. Novotny TE, Bialous SA, Burt L, Curtis C, da Costa VL, Iqtidar SU, Liu Y, Pujari S, Tursan d’Espaignet E. The environmental and health impacts of tobacco agriculture, cigarette manufacture and consumption. Bull World Health Organ. 2015;93(12):877-880.
11. Hoek J, Gendall P, Blank ML, Robertson L, Marsh L. Butting out: an analysis of support for measures to address tobacco product waste. Tob Control. 2019.
12. Patel V, Thomson GW, Wilson N. Cigarette butt littering in city streets: a new methodology for studying and results. Tob Control. 2013;22(1):59-62.
13. Wilson N, Oliver J, Thomson G. Smoking close to others and butt littering at bus stops: pilot observational study. PeerJ. 2014;2:e272.
14. Geist HJ. Global assessment of deforestation related to tobacco farming. Tob Control. 1999;8(1):18-28.
15. Otanez MG, Muggli ME, Hurt RD, Glantz SA. Eliminating child labour in Malawi: a British American Tobacco corporate responsibility project to sidestep tobacco labour exploitation. Tob Control. 2006;15(3):224-230.
16. Russell M, Wilson N, Thomson G. Health and nuisance impacts from outdoor smoking on public transport users: data from Auckland and Wellington. N Z Med J. 2012;125(1360):88-91.
17. Gendall P, Hoek J, Edwards R. What does the 2025 Smokefree Goal mean to the New Zealand public? N Z Med J. 2014;127(1406):101-103.
18. Wilson N, Edwards R, Weerasekera D. High levels of smoker regret by ethnicity and socioeconomic status: national survey data. N Z Med J. 2009;122(1292):99-100.
19. Li J, Newcombe R. Past 12-month quit attempts and the use of cessation aids. [In Fact]. Wellington: Health Promotion Agency Research and Evaluation Unit. 2013.
20. Pearson AL, van der Deen FS, Wilson N, Cobiac L, Blakely T. Theoretical impacts of a range of major tobacco retail outlet reduction interventions: modelling results in a country with a smoke-free nation goal. Tob Control. 2015;24(e1):e32-38.
21. Pearson AL, Cleghorn CL, van der Deen FS, Cobiac LJ, Kvizhinadze G, Nghiem N, Blakely T, Wilson N. Tobacco retail outlet restrictions: health and cost impacts from multistate life-table modelling in a national population. Tob Control. 2016;(E-publication 22 September).