The final puff? New Zealand’s plan for country smoke-free
New Zeland: Smoking kills. Ayesha Verrall has seen it up close. As a young resident physician in New Zealand’s public hospitals in the 2000s, Verrall watched smokers come into the emergency ward every night, struggling to breathe with their damaged lungs. Later, as an infectious disease specialist, she saw how smoking exacerbated illness in individuals diagnosed with tuberculosis and HIV/AIDS. She would tell them: “The best thing you can do to promote your health, other than take the pills, is to quit smoking.”
Verrall is still urging citizens to give up cigarettes—no longer just one by one, but by the thousands. As New Zealand’s associate minister for health, she has led the development of the Smokefree Aotearoa 2025 Action Plan, which could make New Zealand the first country in the world to achieve smoke-free status—typically defined as an adult smoking rate of no more than 5%. (Aotearoa, loosely “Land of the Long White Cloud,” is a traditional Māori name for the country.) New Zealand’s Parliament is about to vote on the plan, which Chris Bostic, Washington, D.C.–based policy director at Action on Smoking & Health (ASH), calls “a huge deal. This will be the most comprehensive antitobacco policy in history.”
Unveiled in December 2021, the plan features three radical interventions. One, called the smoke-free generation strategy, will make it illegal to ever sell combustible tobacco products to those born in 2009 or later. The goal is to create an ever-growing cohort that never picks up the smoking habit. A second provision calls for reducing the number of tobacco retailers by as much as 95%, to make cigarettes harder to get. The boldest proposal in the eyes of experts is reducing cigarettes’ nicotine content to below addictive levels. This “cuts right at the heart of why people smoke in the first place,” says Geoffrey Fong, head of the International Tobacco Control Policy Evaluation Project at the University of Waterloo. It’s potentially a “true game changer in the battle against smoking.”
Verrall emphasizes the importance of all three measures. “It’s not a matter of one magic bullet that will fix our tobacco control,” she says. But all, she says, are buttressed by science. “The effectiveness of denicotinization is well proven in clinical trials,” she says. Research has also shown that reversing the current clustering of tobacco retailers in poor neighborhoods will reduce smoking among young people and make it easier for smokers to quit. Verrall believes those two strategies will get New Zealand to the smoke-free goal, and preventing young people from purchasing cigarettes will keep it there.
Skeptics warn that the measures will fuel an underground market. The plan is “likely to fail as a result of numerous unintended consequences, including illicit markets and a poor understanding of how it will work in practice,” says Clive Bates, a tobacco control expert at London-based Counterfactual Consulting. Critics also say it will criminalize smokers, although only retailers who sell and individuals who give tobacco products to those of the smoke-free generation will face penalties.
New Zealand’s House of Representatives is expected to vote on the proposed law next week. If passed, it will take effect in January 2023. Advocates, which include Māori leaders, are confident the bill will pass.
From low to zero
New Zealand is already a leader in controlling tobacco, which kills 8 million worldwide annually. It was among the first countries to ban smoking in indoor workplaces, in 1990, and in bars and restaurants, in 2004. Taxes on cigarettes have risen 165% since 2010. In Auckland, a pack of Marlboros costs the equivalent of $21 (35 New Zealand dollars); in New York City, $14. Gruesome pictures of diseased lungs and hearts and dire warnings plaster cigarette packages. There is extensive support for quitting and tolerance of vaping as an alternative nicotine source. These efforts have given New Zealand one of the lowest smoking rates among industrialized nations: 10.9% of adults. (In the United States the rate was about 12.5% in 2020.) Yet tobacco use is still New Zealand’s leading cause of preventable death and disease; smoking-related cancer, stroke, and heart disease claims 5000 lives annually in a country of 5.1 million.
The health burden falls disproportionally on the Māori, 22.3% of whom smoke. The gap in smoking leads to stark health inequities. Māori life expectancy is 73.4 years for men and 77.1 years for women; for Kiwis of European descent, the numbers are 81 and 84.5, respectively. Tobacco was introduced to the islands by Europeans in the late 1700s, and the lingering impacts of colonialism and racism mean Māori still have fewer of the social, institutional, and economic resources available to help citizens trying to quit smoking, says Andrew Waa, a public health specialist at the University of Otago, Wellington.
New Zealand’s path to ending tobacco use
Increasingly strict restrictions on smoking and bans on tobacco advertising have driven New Zealand’s smoking prevalence down to 10.9%. Now the Smokefree Aotearoa 2025 Action Plan, unveiled in December 2021, and pending legislation could make New Zealand the first country in the world to become smoke-free.
In the mid-2000s, Māori leaders came to believe “the solution to addressing these inequities was to get rid of tobacco altogether,” says Waa, a Māori who belongs to the Ngāti Hine tribe. Their concerns led to an earlier antismoking effort, launched in 2011. Like the new plan, it aimed to reduce smoking prevalence to below 5%, relying on higher taxes, public education, and support for those trying to give up smoking through a toll-free Quitline that offers expert advice and access to nicotine substitutes. Smoking rates trailed downward, but it was evident more had to be done.
It’s the nicotine, stupid!
The seductive power of cigarettes and other tobacco products comes from nicotine—a compound as addictive as cocaine and heroin. Smokers get hooked on the rush of pleasure they feel when a drag from a cigarette sends nicotine through their bloodstream to the brain, where it triggers the release of dopamine. Other cues can also trigger that dopamine rush. “There are behavioral aspects of smoking—opening the packet, the crinkling of the wrapper, the smell of the tobacco, all those hand-to-mouth things can be very strong for some people,” says Natalie Walker, a public health scientist at the University of Auckland. Oddly, nicotine itself has little, if any, role in causing cancer. “It is the 4000-plus chemicals in tobacco smoke that cause these horrendous diseases,” Walker says.
That’s not to say nicotine isn’t injurious: It raises the pulse rate and blood pressure and hardens blood vessels, increasing the long-term risk of hypertension and heart disease. But the most harmful thing about nicotine in cigarettes is that it makes it hard for smokers to give up the habit. Quitting cold turkey leaves people restless and grouchy, unable to concentrate, anxious, or depressed.
Scientists have suggested since the 1990s that limiting nicotine in cigarettes to a level that would be nonaddictive might discourage smoking. “The assumption is that if you reduce dependence and addiction, people will choose not to use [tobacco],” says Eric Donny, a tobacco expert at Wake Forest University.
In the United States, related research got a boost in 2009, when Congress gave the Food and Drug Administration (FDA) authority to regulate the nicotine in tobacco products, provided it not be reduced to zero. Needing scientific evidence to guide regulatory decisions, the agency provided funding for studies, and its National Institute on Drug Abuse started to make cigarettes with varying levels of nicotine for research use. (Nicotine in tobacco can be reduced by treating the leaves with solvents, steam, microbes, or gases in a process akin to decaffeinating coffee beans; or by genetically modifying the plant.)
Donny took advantage of the opportunity with a 6-week, double-blind trial that randomized smokers to receive cigarettes with standard nicotine levels, about 15.8 milligrams per gram of tobacco, or cigarettes with four different nicotine levels ranging from 5.2 to 0.4 mg of nicotine per gram. The cigarettes were free; so initially all 780 participants were lighting up more than usual. But 6 weeks later, those given standard cigarettes were smoking even more, 21 or 22 times a day; whereas groups puffing cigarettes with nicotine concentrations of 2.4 mg or less had cut their daily habit to 15 to 16. One month later, one-third of those who smoked the lowest nicotine cigarettes were trying to quit, even though they had not previously intended to do so; only 17% of those who smoked standard cigarettes were making the attempt. “Reducing nicotine content in cigarettes could lead to less smoking, less nicotine dependence and improved public health,” Donny and colleagues wrote in The New England Journal of Medicine in October 2015.
Donny and other researchers have considered the possibility that people might just smoke more low-nicotine cigarettes to get their fix. But the evidence from his studies and others lays that concern to rest, he says. “The clinical data don’t bear that out.”
Some research also supports another pillar of New Zealand’s antismoking plan. Research had shown those living near retail tobacco outlets smoked more, more easily picked up the habit, and found it more difficult to quit. Frederieke Petrović-van der Deen, a public health scientist at Otago, built on those data with a modeling study based on New Zealand’s demographics that found cutting the number of tobacco retailers by 90% over 10 years and limiting their locations would drive smoking prevalence down.
Hopes for the third strategy, the ban on tobacco sales to a new generation, rest on evidence that more than 80% of smokers start by age 18, and virtually all by 26, and most later regret it. Parents approve of the idea. “If you ask even the most hardened smoker, ‘When would you like your kids to start smoking?’ the answer is invariably ‘Never!’” says Marita Hefler, a tobacco control specialist at Charles Darwin University. Also, “It’s politically palatable, because it doesn’t take anything away from adults who are addicted to nicotine,” Bostic says.
By the late 2010s, New Zealand researchers could “put forward a case to the government saying this is the evidence we have about what sort of policies would make a difference,” Walker says. And Verrall, a first-term parliamentarian, stepped up to craft a plan.
A straight-talking doc
From her early years as a student, Verrall showed a knack for leadership. She was elected president of the Otago students’ association as an undergrad and while in medical school led a group that founded the New Zealand Medical Student Journal. After joining the Otago faculty, she also worked as an infectious disease physician for the Wellington regional public health service and was elected to the service’s board in 2019.
She gained national attention by criticizing the government’s early handling of the COVID-19 outbreak. “Our contact tracing capacity is a fire extinguisher, we need a fire engine,” she tweeted in April 2020. The government acted on Verrall’s advice, dramatically expanding and speeding up contact tracing and testing as part of its successful effort to keep case numbers near zero during the early phase of the pandemic. “She was the perfect person to directly engage the politicians at that time, as she understood both (the scientific and political) worlds,” says Philip Hill, an international health specialist at Otago who had been Verrall’s thesis adviser.
Subsequently, Verrall made the rounds of TV news shows and gave newspaper interviews explaining the importance of contact tracing. Audiences recognized that “she is empathetic and cares about making a difference to the health of New Zealanders,” Walker says. Capitalizing on her popularity, the Labour Party nominated Verrall for a seat in the House of Representatives in the October 2020 election.
She won and was made minister of COVID-19 response as well as research, science, and innovation. Verrall asked Prime Minister Jacinda Ardern to put her in charge of realizing the smoke-free goal. Among Labour’s public health commitments, “[It] was the most bold and inspiring one and I really wanted to take it forward,” she says.
After a year of reviewing strategies, issuing proposals, and soliciting public feedback, the action plan was unveiled in December 2021. Verrall’s “amazing” effort is “why this bundle of policies has come through,” Walker says.
New Zealand may be the perfect test bed for the plan Verrall is rolling out. Smoking rates are already low. Surveys indicate 74% of the public supports the 2025 smoke-free goal and more than 70% of smokers and recent quitters favor denicotinization and the restrictions on tobacco retailers.
Not everyone is happy, though. The measures are expected to be particularly hard on small mom-and-pop convenience stores called “dairies.” Giving oral comments to the parliamentary committee considering the bill in September, an unnamed representative of the Dairy and Business Owners Group begged the lawmakers to “avoid ‘dairygeddon’” by delaying implementing the plan until 2025 to allow “time to re-engineer dairies.”
Others have argued the low-nicotine cigarette policy will backfire. It will fuel “a ‘booming’ black market” in normal cigarettes, British American Tobacco New Zealand warned in a submission to the committee. A May 2020 report by the consulting firm KPMG for Imperial Tobacco estimated that illicit tobacco already accounts for 11.5% of total New Zealand consumption in 2019. And some critics point to the experience of Bhutan, a tiny Himalayan kingdom that banned the sale of tobacco products in 2004. But aside from a limited antitobacco media campaign, Bhutan did not offer cessation support or address adolescent tobacco use. A 2014 survey found more than 20% of Bhutanese teens and adults were still smoking and using snuff, relying on “robust” smuggling, says Michael Givel, a political scientist and Bhutan scholar at University of Oklahoma, Norman. In 2021, Bhutan gave up and allowed tobacco imports again. The government is now running antitobacco public education campaigns and offering cessation support.
Tobacco interests exaggerate the black market problem “to scare off policymakers,” says Nick Wilson, a public health scientist at Otago. To check smuggled cigarette prevalence, Wilson and 10 colleagues picked up nearly 1600 littered tobacco packs around the country and counted how many were foreign. (Wilson, self-conscious over people thinking he might be scavenging discarded cigarettes, says he “pretended to be doing up a shoelace—while also discreetly picking up packs.”) Just 5.4% of the packs were foreign, mostly from China and South Korea. Most of the contraband enters the country in shipping containers, which suggests more targeted inspections could further dent the illicit trade, Wilson says.
Control advocates believe history is on their side. Once, Hefler says, “Smoke-free public places were considered impossible.” Yet California, despite fierce opposition, made workplaces and restaurants smoke-free in 1995; other states have followed. Ireland became the first country with a national ban on smoking in indoor public spaces—including its iconic pubs—in 2004. In 2021, the World Health Organization (WHO) reported that 67 countries had made public indoor spaces completely smoke-free. A similar pattern has been seen with pictorial health warnings, plain packaging, and stiff taxation. Again and again, one country has led the way, and “all of these innovations were followed by other countries,” Hefler says.
They helped. The number of cigarettes smoked in the European and American WHO regions decreased by 33% and 44%, respectively, between 1980 and 2016, according to U.K. ASH. (Cigarette consumption increased by more than 50% in WHO regions covering mainly low-income countries.) For advanced nations, the New Zealand plan “seems like the next logical step,” Hefler says.
So far, the United States is the only other country considering regulating nicotine. FDA in June announced it plans to set a maximum nicotine level for cigarettes; the move will be opened for public comment in May 2023.
Bostic worries the tobacco industry’s influence will delay any substantive action in the United States. He is more optimistic about progress at the local level. Beverly Hills and Manhattan Beach, both in California, halted all tobacco sales in January 2021; and Brookline, Massachusetts, in November 2020 approved a law that bans sales to those born after 1 January 2000. However, Bostic points out, smokers can just go to neighboring towns to make a purchase.
Internationally, at least a half-dozen countries are studying tobacco-free generation policies. And the once fringe idea of a tobacco endgame—explicitly aiming to permanently end, rather than simply minimize, tobacco use—“is being taken very seriously,” Bostic says.
New Zealand is setting the pace. “We will be very happy to share our experience as we go,” Verrall says.
Source: Science
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