NEW ZEALAND HEALTH STRATEGY

DHB TOOLKIT Tobacco Control

To reduce smoking (and harm from second-hand smoke)

2001

Edition 1: October 2001

Contents

Executive summary ...... 3 Introduction...... 4 Development of the toolkit ...... 4 Key documents ...... 4 Linkages...... 6 Policy context...... 7 The rationale for tobacco control in New Zealand ...... 7 Who smokes in New Zealand? ...... 9 Regional prevalence data ...... 9 Tobacco control efforts in New Zealand ...... 13 Roles and responsibilities for tobacco control ...... 14 The Ministry of Health...... 14 District Health Boards ...... 14 Other providers ...... 14 Best evidence on interventions...... 16 Effective interventions across the whole population...... 16 Interventions for Maori ...... 16 Interventions for Pacific peoples...... 17 Interventions for low-income New Zealanders...... 17 Interventions for older people ...... 17 Interventions for people with existing chronic illness...... 17 Interventions for young people ...... 18 Recommended key interventions ...... 18 Research strategy...... 19 Appendix 1: Recommended key interventions: tobacco control...... 20 Appendix 2: Draft indicators for District Health Boards and other regional providers ....25 Data and information requirements ...... 26 Appendix 3: Tobacco-related websites...... 27 New Zealand...... 27 Australia ...... 27 International ...... 27 Endnotes...... 29

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 2

Executive summary

This toolkit is designed to assist District Health Boards (DHBs) to implement the New Zealand Health Strategy priority population health objective of: ‘reducing smoking (and the harm from second-hand smoke)’. This is one of 13 priority areas identified in the New Zealand Health Strategy. The toolkit’s development has been led by the Public Health Directorate of the Ministry of Health, with expert advice from an advisory group of tobacco control experts drawn from the wider health sector. This toolkit has linkages to toolkits in several other priority areas of the New Zealand Health Strategy. Tobacco policy operates within a context of significant tobacco-related death and illness, associated costs to the public health services and to the wider costs to society, and an emphasis on Maori health and wellbeing. Approximately 4,700 New Zealand smokers die from smoking- related illnesses each year. It is estimated that a further 400 people die each year from exposure to second-hand smoke. Those smokers who die from a tobacco-related cause lose, on average, 14 years of life compared with non-smokers. New Zealand’s tobacco control strategy has seen tobacco consumption fall by almost 50 percent from 1990 to 2000. However, the percentage of people smoking, although continuing a downward trend, fell by only about 2–3 percent over that period. The section on Policy Context covers these issues. The challenge is to reduce smoking prevalence by assisting those who wish to quit smoking and, better still, discouraging people from taking up the habit in the first place. The benefits of quitting are considerable in terms of both people’s health and quality of life and the cost savings to the health services and society. For example, within two years of quitting, a former smoker’s risk of heart disease or stroke is similar to that of a non-smoker. The New Zealand Health Strategy emphasises the need for health policy to reduce inequalities for those population groups with the poorest health status, and particularly Maori and Pacific peoples. The section entitled Best Evidence on Intervention points to those interventions for the prevention and cessation of smoking for which strong evidence is available. Research also indicates benefits are forthcoming from interventions that target or adapt services to specific population groups. This section also identifies recommended key interventions, a subject Appendix 1 develops in more detail. In some areas, more research is required to develop a greater understanding of effective interventions and this issue is discussed under the section on Research Strategy. Appendix 3 points to useful tobacco control websites and the Endnotes to the toolkit include references noted in the toolkit text and in the interventions template. Key reference documents, upon which the toolkit relies heavily, are identified at the front of the toolkit.

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 3

Introduction

Objective: To reduce smoking (and harm from second-hand smoke)

The New Zealand Health Strategy has identified 13 priority areas for population health. District Health Boards (DHBs) will be required to report annually on progress towards each of these priority areas. The Minister of Health will then report to Parliament on overall progress in these areas (New Zealand Public Health and Disability Act 2000, section 8(4)). This toolkit addresses the priority of reducing smoking and harm from second-hand smoke. This toolkit: • outlines the burden to health and society resulting from active tobacco use and people’s exposure to second-hand smoke • provides evidence on the best ways to achieve health gain for tobacco users and those exposed to second-hand smoke • identifies priorities for further research on tobacco control • proposes indicators so that progress towards identified targets can be monitored • provides baseline data for indicators.

Development of the toolkit This toolkit was developed by the Ministry of Health Public Health Directorate (National Drug Policy Team), in conjunction with an expert advisory group of tobacco control experts from the wider health sector. It was developed with reference to a considerable amount of research on tobacco control issues. Given that Ministry of Health personnel have regular contact with a broad range of tobacco control agencies in New Zealand and internationally (eg, the World Health Organization), this toolkit includes elements of international best practice. This document is, however, still a preliminary toolkit. A more comprehensive version will be available in future years on the Ministry of Health website. This toolkit should be read in conjunction with the Public Health Services Handbook,1 which sets out the tobacco control services that public health services are to provide.

Key documents In particular, the toolkit relies heavily on the following documents: WHO-WPRO. 1999. Regional Action Plan on Tobacco or Health 2000–2004. Manila: World Health Organization (Western Pacific Regional Office). Ministry of Health. 1998. National Drug Policy Part 1: Tobacco and Other Drugs Part 2: Illicit and Other Drugs. 1998. Wellington: Ministry of Health. [Online] available at http://www.ndp.govt.nz/policy/ndppolicy.html) Health Funding Authority & Ministry of Health. 2000. Public Health Services Handbook 2000–2001. Wellington: Health Funding Authority and Ministry of Health. Health Funding Authority. 1999. Toward a Tobacco-Free New Zealand: A Five-Year Plan for HFA Funding for Tobacco Control (1999–2003). Wellington: Health Funding Authority, [Online] available at http://www.ndp.govt.nz/tobacco/tobaccofreenz.html)

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 4

Health Funding Authority. 1999. Toward a Tobacco-Free Aotearoa: A Five-Year Plan for HFA Funding of Tobacco Control for Maori (1999-2003). Wellington: Health Funding Authority, [Online] available at http://www.ndp.govt.nz/tobacco/tobaccofreeMaori.html). Health Funding Authority. 1998. Evidence for Tobacco Control Activities Available to the Health Funding Authority. HFA Special Report 3. Wellington: Health Funding Authority Central Office. (This report evaluates a range of tobacco control interventions in place in, or available to, New Zealand. This document can be inter-loaned from the Ministry of Health Library through your local public library.) Health Funding Authority. 1998. Spatial Analysis of Smoking in New Zealand as a Tool for Targeting Tobacco Control Interventions. HFA Special Report 1. Wellington: Health Funding Authority Central Office. (The aim of this report is to examine the spatial distribution of smoking prevalence in New Zealand and to explore its role in the targeting of tobacco control interventions. This document can be inter-loaned from the Ministry of Health Library through your local public library). Public Health Commission. 1994. Tobacco Products The Public Health Commission’s Advice to the Minister of Health 1993–1994. Wellington: Public Health Commission. (This report outlines the health effects and social consequences of tobacco use in New Zealand, and includes recommendations to the Minister of Health in 1994 on outcome targets and policy, programmes, research, and information initiatives to achieve the outcomes. A copy of this document is held in the Ministry of Health library and can be inter-loaned through your local public library). One of the key themes in the New Zealand Health Strategy is that of reducing inequalities in health and this runs throughout this Toolkit. Further information on Ministry of Health work on reducing inequalities in health is also available. The reader is referred to these documents as an evidence base for future tobacco control efforts. In particular, the Health Funding Authority documents, which refer to the evidence for tobacco control interventions and recommended future services, were developed after extensive consultation with the health sector.

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 5

Linkages This toolkit has clear overlaps with the other New Zealand Health Strategy objectives.2 Table 1 outlines the main linkages.

Table 1: Main linkages between this and other priority health areas in the New Zealand Health Strategy

Objective Details To improve nutrition Smoking harms micronutrient status due to its toxic effects and adverse impacts on appetite. Among low-income groups, expenditure on tobacco reduces economic resources available for spending on nutritious foods (eg, fresh fruit and vegetables). To reduce obesity Concern about putting on weight is related to continued smoking in some populations.3 As detailed below, smoking can reduce physical activity levels and hence it may further complicate the management of obesity. To increase the level of Smoking reduces physical activity levels as smokers have higher rates of physical activity respiratory infections and chronic lung disease, along with poorer exercise capacity. There is also evidence that smokers have higher injury rates4 – which itself may impede involvement in physical activity. To reduce the rate of There is a growing body of evidence that smoking is an independent risk suicides and suicide factor for suicide.5 attempts To minimise harm caused by As detailed elsewhere in this document, tobacco is a major cause of early alcohol and illicit and other death and illness in New Zealand – among smokers and non-smokers. drug use to both individuals Tobacco control may be linked to alcohol control in that there is some and the community evidence that increases in alcohol tax can reduce smoking6 (presumably by reducing discretionary expenditure available for tobacco and as alcohol consumption is likely to be associated with smoking). To reduce the incidence and Smoking is the major cause of lung cancer in New Zealand and it causes a impact of cancer range of other cancers (eg, oropharynx, larynx, oesophagus, stomach, bladder). Exposure to second-hand smoke also causes lung cancer in non- smokers. To reduce the incidence and Smoking is a major contributor to both heart attacks and strokes. There is now impact of cardiovascular good evidence that exposure to second-hand smoke also causes heart disease attacks and strokes in non-smokers. To reduce the incidence and Smoking is a major risk factor for adverse health outcomes among people impact of diabetes with diabetes (particularly in terms of cardiovascular disease7 and eye disease8). To improve oral health There is substantial evidence that smoking is an important risk factor for periodontal disease.9

In addition to this toolkit, and documents referenced within it, information on specific population groups will be available within: • the Maori Health Strategy • the Pacific Health and Disability Action Plan • the Health of Older People Strategy • the Youth Health Strategy.

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 6

Policy context

The rationale for tobacco control in New Zealand Reasons for tobacco control are considered here under four main categories: • its contribution to improving public health • economic benefits • its contribution to improving Maori health and wellbeing • ethical justifications.

Improving public health Tobacco use, and more specifically dependence on nicotine, is probably the most readily preventable cause of premature death in New Zealand. While social inequalities might be a more important cause of poor health in this country, proven interventions to reduce the health impact of inequality are probably less readily available. Among the major adverse impacts of tobacco use on health are the following. Mortality: Tobacco smoking kills an estimated 4,700 New Zealanders per year (excluding deaths from passive smoking).10 Those that die early as a result of a smoking-related illness lose an average of 14 years of life compared with non-smokers.11 In the next 20 years, it is expected that among smokers already smoking there will be 80,000 deaths in New Zealand, including 8,000 deaths among Maori (ie, an average of 400 deaths per year among Maori), unless these smokers quit.12 Acute and chronic illness: Tobacco causes or exacerbates around 40 different medical conditions13 – but particularly respiratory and cardiovascular diseases. Some conditions such as severe emphysema or heart failure can be extremely debilitating. Burden of suffering imposed on those exposed to the smoke of others: Proven adverse effects of second-hand smoke (SHS) include asthma, glue ear, and respiratory infections in infants and children.14 There is also growing evidence that behavioural problems in children are related to maternal smoking in pregnancy.15 Adults exposed to SHS are at greater risk of asthma exacerbations, heart disease16 and stroke,17 as well as lung cancer.18 A recent report commissioned by the Ministry of Health has estimated that around 388 deaths are attributable to exposure to SHS in New Zealand each year.19 This total includes cot deaths attributable to smoking. In terms of illness from SHS exposure, it has been estimated that each year in New Zealand there are: • over 500 hospitalisations of children under two years of age • almost 15,000 episodes of childhood asthma • more than 27,000 consultations with general practitioners for asthma and other respiratory problems in childhood • 1,500 hospital operations to treat glue ear • approximately 50 cases of meningococcal disease • approximately 1,200 hospitalisations to hospital for ischaemic heart disease • almost 500 hospitalisations for persons suffering from strokes.20 The burden of death and illness from exposure to SHS is highest among lower socioeconomic groups as these groups have higher levels of SHS exposure in New Zealand.21

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 7

Economic benefits of tobacco control Tobacco control has the potential to reduce health sector costs within the short and long term. Costly chronic diseases and complications that would be prevented by reducing smoking include heart disease, respiratory disease, cancer and delayed wound healing.22 For hospitalised patients, quitting tobacco use reduces general medical costs in the short term but also reduces the number of future hospitalisations.23 Short-term savings are also realised if smoking in pregnancy is reduced (due to the lower costs from fewer low-weight newborns and perinatal deaths24). Smoking cessation also brings economic benefits to society through reducing premature deaths (especially among workers) and absenteeism from tobacco-related illness, lowering insurance costs, preventing tobacco-related fire damage, and reducing requirements for air conditioning and cleaning. The Public Health Commission conservatively estimated the cost to society of tobacco use (excluding passive smoking costs or costs such as grief and suffering or the cost of fires) at around $1.9 billion per annum in 1992 dollars.25 Taking into account the theoretical benefits of smoking (to a minority of smokers) as well as all the costs, another study puts the overall social cost of smoking in New Zealand at 3.2 percent of total human capital and 1.7 percent of GDP.26 Based on a value of a human life at $2 million, the costs totalled $22.5 billion for the 1990 year (relative to a scenario of no smoking) with tangible costs being $1.2 billion. Although there is some debate over what monetary value such analyses should put on human life, this analysis used the value with the strongest official recognition, that is, the value based on work by the Land Transport Safety Authority. The economic benefits of tobacco control are discussed in more detail in a recent World Bank report.27

Improving Maori health and wellbeing Tobacco control is a major issue for Maori in terms of health, equity, economic status and cultural identity. Health status: Tobacco use has a particularly adverse impact on Maori health. An estimated 31 percent of Maori deaths are attributable to tobacco use.28 Further, an estimated 14–15 percent more Maori would survive middle age if no Maori smoked after age 35 years. Also, tobacco use is likely to be important in the higher Maori rates of lung cancer, heart disease, sudden infant death syndrome, respiratory infections, otitis media (glue ear) and the adverse outcomes of diabetes (for comparisons of rates see the Ministry of Health’s annual reports29). Exposure to SHS may also play a role in the higher rates of meningococcal disease among Maori and contribute to the possibly higher rates of asthma among Maori compared to non-Maori. The health impact of tobacco use is the reason why, under the Treaty of Waitangi, the New Zealand Government and its health agencies have an obligation to address the impact of smoking on Maori. Also, given the high value that Maori society places in kaumatua, the impact of premature death from tobacco may be an outcome of high concern to Maori. Economic status: The cost burden – from purchasing tobacco and tobacco-related absenteeism, premature death and illness – is likely to be particularly severe for Maori. Part of the reason is that Maori are already disadvantaged by lower than average incomes. Also the harm of smoking interacts synergistically with other risk factors such as poor diet (for the risk of heart disease) and poor housing (for the risk of respiratory disease). Furthermore, the economic independence of Maori is impeded by expenditure on tobacco.

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 8

Cultural identity: Tobacco use is not a traditional part of Maori culture.30 Indeed it appears that traditional Maori society did not use any psychotropic substances and certainly no addictive substances.

Ethical justification for further expenditure on tobacco control Expenditure on tobacco control is still only a very small proportion of the total revenue collected annually in tobacco taxes from New Zealand smokers (over $800 million). Given this imbalance, there is an ethical argument for both government and the health sector to put additional resources into tobacco control. (This particular issue has also been raised in the Australian setting31). The adverse effects of smoking are particularly marked for Maori and low-income groups due to their greater exposure to tobacco.32 A recent study found evidence to support the view that effective activities for tobacco control should address ethnic differences in smoking behaviour as well as socioeconomic deprivation.33 Therefore equity considerations suggest that enhanced tobacco control is one approach available to reduce the gaps in health status in our society. Indeed, tobacco control is actually a Treaty of Waitangi issue as detailed above. Enhanced tobacco control can also be justified in terms of intergenerational justice. Tobacco use behaviours are to some extent transmitted from parents to children.34 Moreover, foetuses, infants and children are directly harmed by second-hand smoke.

Who smokes in New Zealand? Recent data indicate that 25 percent of New Zealand adults still smoke.35 For Maori and Pacific peoples the smoking prevalence is 49 percent and 33 percent respectively. Nevertheless, indications are that the amount smoked has declined by at least 10 percent during the year 2000 – which is likely to be partly attributable to the 14 percent tobacco tax increase in May 2000.36 During the 1990s there was evidence of increased smoking by youth.37 Recent surveys by Action on Smoking and Health indicate that around 23 percent of 14- to 15-year-old girls, and 19 percent of 14- to 15-year-old boys, were daily or weekly smokers in 1999.38 As discussed above, smoking rates are relatively high among low-income groups. Census data provide more detailed information on the demographics of smoking in New Zealand.39 A spatial analysis of smoking in New Zealand40 has been supplemented by further work by the Ministry of Health in Tobacco Facts.41 (See Tobacco Facts 2001 on the NDP website http://www.ndp.govt.nz/tobacco/tobaccofacts2001.html)

Regional prevalence data ACNielsen (NZ) Ltd is contracted by the Ministry of Health to undertake surveys of smoking prevalence in New Zealand. ACNielsen conducted approximately 11,000 face-to-face interviews during 2000, with different consumers interviewed each quarter. Those interviewed are provided with a show-card that itemises: ready-made cigarettes, roll-your- own tobacco, cigars/cigarillos, pipe or none of these. They are asked: ‘Which of these products, if any, do you ever smoke?’ People who ever smoke ready-made cigarettes are then asked: ‘On average how many ready-made cigarettes do you smoke on an average day?’ Those who indicate they ever smoke roll-your-own cigarettes are then asked: ‘On average, how many roll-your-own cigarettes do you smoke on an average day?’ Cigarette smokers are defined as those who ever smoke any ready-made cigarettes or roll-your- own tobacco cigarettes. The prevalence of cigarette smoking for 1998–2000 are presented in Table 2, broken down by DHB region.

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 9

In 2000 the interviews were completed in 48.6 percent of the occupied dwellings approached. (Contact was made in 85.1 percent of the total number of occupied dwellings approached. Interviews were completed in 57.1 percent of occupied dwellings where contact was made.) The data obtained from the survey are weighted to reflect the age, sex and household size characteristics of the 1996 Census population. Weighted values are used in the analysis of this report.

Table 2: Prevalence1 of cigarette smoking (indirectly standardised) by DHB region,2 1998–2000

DHB region Male Female % male High/low % female High/low Northland 29 34 H Waitemata 24 22 L Auckland 22 L 17 L Counties Manukau 26 24 Waikato 29 25 Bay of Plenty 28 28 Lakes 30 32 H Tairawhiti 38 H 39 H Taranaki 32 H 27 Whanganui 30 32 H MidCentral 26 26 Hawkes Bay 33 H 28 Wairarapa 35 32 Hutt 28 29 Capital and Coast 22 L 22 L Nelson Marlborough 26 25 West Coast 32 38 H Canterbury 23 L 24 South Canterbury 29 29 Otago 28 25 Southland 28 26

National Average 25.9 24.9

Source: ACNielsen (NZ) Ltd Notes: 1. Prevalence was calculated by multiplying crude New Zealand gender-specific rates (male 26%, female 25%) by the indirectly age-standardised DHB region rate ratio. 2. The matching from TLAs to DHB regions is approximate only.

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 10

Map 1: Prevalence1 of male cigarette smoking (indirectly standardised) by DHB region,2 1998–2000

Source: ACNielsen (NZ) Ltd Notes: 1. Prevalence was calculated by multiplying crude New Zealand gender-specific rates (male 26%, female 25%) by the indirectly age-standardised DHB region rate ratio. 2. The matching from TLAs to DHB regions is approximate only. 3. Darkly shaded and lighter shaded areas represent indirectly age-standardised cigarette smoking prevalence, which are statistically significantly different from the male or female New Zealand rate. For example, although there were more smokers surveyed than expected in the Wairarapa region, the number of people interviewed was not large enough to be sure that this finding was statistically significant.

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 11

Map 2: Prevalence1 of female cigarette smoking (indirectly standardised) by DHB region,2 1998–2000

Source: ACNielsen (NZ) Ltd Notes: 1. Prevalence was calculated by multiplying crude New Zealand gender-specific rates (male 26%, female 25%) by the indirectly age-standardised DHB region rate ratio. 2. The matching from TLAs to DHB regions is approximate only. 3. Darkly shaded and lighter shaded areas represent indirectly age-standardised cigarette smoking prevalence, which are statistically significantly different from the male or female New Zealand rate. For example, although there were more smokers surveyed than expected in the Wairarapa region, the number of people interviewed was not large enough to be sure that this finding was statistically significant.

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 12

Tobacco control efforts in New Zealand The New Zealand Health Strategy states: ‘The reduction of tobacco smoking will be achieved by the implementation of a comprehensive mix of initiatives under the National Drug Policy (NDP) in each of the following areas: smoking cessation services; health promotion; tobacco taxation; and legislative development and implementation’ (p14). The National Drug Policy (available on the NDP website http://www.ndp.govt.nz/policy/ndppolicy.html) provides the framework for reducing harm in the community resulting from the use of tobacco.42 Under this framework, New Zealand has implemented a tobacco control programme, incorporating strategies under each of the following key areas for action: • legislation and enforcement (eg, restricting the advertising, sale and use of tobacco products) • taxation (increasing the price of tobacco products) • health promotion (encouraging changes in attitude and behaviour) • cessation services (helping smokers to quit). Two of the five priorities for action under the NDP relate to tobacco: • Priority One: To enable New Zealanders to increase control over and improve their health by limiting the harms and hazards of tobacco and alcohol use • Priority Two: To reduce the prevalence of tobacco smoking and exposure to second-hand smoke. In addition, under tobacco control, the Public Health Services Handbook identifies the following goal: ‘To promote a social and physical environment which improves and protects the public health/whanau public health by reducing the harm from tobacco use and exposure to environmental tobacco smoke (second-hand smoke).’ Internationally there is agreement that a comprehensive approach to tobacco control is the ideal. The World Health Organization strongly recommends a mix of tobacco control strategies. It has congratulated New Zealand for its considerable success in reducing both smoking rates and the amount of tobacco smoked in New Zealand. The Government released its Tobacco Action Plan in December 2000. The Tobacco Action Plan on reducing smoking outlines initiatives designed to reduce the number of New Zealanders who die or suffer ill health as a result of smoking tobacco. Initiatives include work on policy and legislative development; assessment, advice and treatment services; health promotion; law enforcement; information, research and evaluation. (For a copy of the work programme, see the NDP website http://www.ndp.govt.nz/policy/ndptobacco.html) More detailed discussions of New Zealand’s tobacco control programme in the last decade have been published.43

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 13

Roles and responsibilities for tobacco control

The Ministry of Health The Ministry of Health is in the best position to work on interventions involving tobacco taxation, smokefree environments legislation and other regulatory controls (eg, limiting promotion, controlling product constituents, improving access to smoking cessation products such as nicotine replacement therapy, (NRT)). It may also be in the best position to purchase certain national level programmes (such as the Quitline, the subsidised nicotine patches and gum programme and mass media campaigns that use nationwide television advertising). In terms of surveillance, monitoring and evaluation, the Ministry of Health regularly purchases national survey data (ie, from ACNielson). It has also been a purchaser of national youth smoking surveys. This information is reported in Tobacco Facts 2001 (which you can download from the NDP website http://www.ndp.govt.nz/tobacco/tobaccofacts2001.html) and state of the public health reports. The Ministry of Health is purchasing evaluation work relating to the Quitline, the Quit / Me Mutu Campaign and the subsidised nicotine patches and gum programme. The Ministry has also purchased ad hoc studies to assist with policy development.

District Health Boards DHBs are well positioned to actively promote and fund local approaches to reducing tobacco use. Public health units, for example, are currently: • promoting the adoption of smokefree policies in workplaces and in other settings (eg, schools, clubs) • enforcing and providing information about the Smoke-free Environments Act 1990 • mobilising the community to reduce the uptake of smoking and encourage smokers to quit • mobilising the health sector and other providers to reduce the uptake of smoking, encourage smokers to quit and promote tobacco control (eg, mobilising other agencies regarding the provision of training for cessation providers) • monitoring and assessing the effectiveness of tobacco control programmes through surveillance and evaluation • strengthening strategic alliances and interagency networks to optimise the impact of smokefree initiatives. DHB staff who are based in hospitals are also increasingly involved in smoking cessation activities (eg, via the provision of brief counselling and via a national programme using NRT).

Other providers A number of other local providers, including Maori service providers, have been funded in whole or in part from Vote: Health to undertake similar activities to those undertaken by public health units (excepting the enforcement role). In addition, they have been funded for activities such as: • advocacy (eg, on the value of tobacco taxation, smokefree environments, mass media campaigns and smoking cessation support) • provision of smoking cessation services (eg, marae-based programmes, programmes for pregnant women) • smokefree (and other drug) education programmes • community development programmes that include a tobacco control component • smokefree sponsorship of events and activities.

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 14

Furthermore a number of agencies are funded, wholly or in part, at a national level to provide tobacco control services. These agencies include: Action on Smoking and Health, the Smokefree Coalition, Aparangi Tautoko Auahi Kore (Maori Smokefree Coalition), the National Heart Foundation, Te Hotu Manawa Maori, the Quit Group (Quitline, Quit media campaign and cessation services) and the Health Sponsorship Council (healthy lifestyle promotion, sponsorship activities). A number of local and national agencies that do not receive Vote: Health funding (eg, the Cancer Society) work in partnership with government-funded agencies locally, regionally and nationally. It is crucial that future planning for the delivery of tobacco control services be undertaken in partnership with all relevant agencies. By this means, tobacco control activities will be co- ordinated, supported by the community and thus able to deliver their full potential.

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 15

Best evidence on interventions

This section sets out the evidence for the effectiveness of a broad range of tobacco control interventions that are available for implementation locally or regionally. It identifies the population groups that interventions should target. The information is complemented by the table in Appendix 1, which summarises the key approaches that should be taken and the initiatives for which there is good evidence as to effectiveness. This table is a broad summary of recent key documents.44

Effective interventions across the whole population The Health Funding Authority’s Toward a Tobacco-Free New Zealand: a Five-Year Plan for HFA Funding for Tobacco Control (1999–2003) states: ‘Substantial reductions in the prevalence of smoking and tobacco use are most likely to be achieved by interventions affecting the whole smoking population such as taxation, legislation for smokefree environments and mass media campaigns (especially if these are combined).’ This report highlights the effectiveness of increasing tobacco taxation in reducing tobacco consumption. After fiscal and legislative change, it identifies mass media campaigns as probably the next most cost-effective intervention. In addition, community-based contests for smoking cessation have been successful internationally, and brief advice from health professionals is of proven effectiveness, as is the use of nicotine replacement therapy and antenatal counselling for cessation. Support for non-government organisations (NGOs), advocacy work, publicity and media advocacy on the health risks of smoking and similar activities are also considered to have a beneficial impact. See the full version of Toward a Tobacco-Free New Zealand: a Five-Year Plan for HFA Funding for Tobacco Control (1999–2003) http://www.ndp.govt.nz/tobacco/tobaccofreenz.html

Interventions for Maori Few studies have evaluated the effectiveness of interventions specifically for Maori. It is clear that Maori have benefited from mainstream tobacco control programmes (taxation increases, smokefree environments and mass media campaigns), but generally not to the extent that non- Maori have. Some of the current tobacco control interventions, particularly smoking cessation initiatives, have a strong focus on Maori. For example, the national freephone Quitline, although not a Maori initiative, has Maori as a priority group, uses Maori Quit advisers and advertises with a focus on Maori (eg, iwi radio). In March–April 2001 it received over 1,500 calls from Maori per month (18 percent of all calls). A national smoking cessation programme for Maori women and their whanau – Aukati Kai Paipa – has (by April 2000) involved 2,900 Maori.45 Preliminary results from the Quitline and the Aukati Kai Paipa programme have shown some promising quit rates for Maori. Favourable results have also been obtained from a Noho Marae Stop Smoking Programme.46 These initiatives suggest that programmes with a Maori focus (particularly those run by Maori for Maori) are effective in reaching Maori. The document Toward a Tobacco-Free Aotearoa: a Five- Year Plan for HFA Funding of Tobacco Control for Maori (1999–2003) sets out recommended interventions. (See the full document on the NDP website http://www.ndp.govt.nz/tobacco/tobaccofreeMaori.html).

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 16

Interventions for Pacific peoples Pacific peoples are likely to have benefited from mainstream tobacco control programmes (tobacco taxation, smokefree environments, mass media campaigns). The Quitline has had some success in attracting Pacific peoples (568 callers between October 2000 and April 2001). Nevertheless, it is important that further consideration be given to targeted interventions that involve Pacific peoples at all of the stages of programme development, implementation and delivery.

Interventions for low-income New Zealanders Tax increases are particularly effective in reducing smoking in low-income populations. Indeed, the World Bank reports that tobacco tax increases are not regressive since they favour quitting by low-income smokers relative to high-income smokers.47 Ideally, however, further tobacco taxation increases should be accompanied by further improvements in access to interventions and services for smoking cessation. At present the free Quitline service and the subsidised nicotine patches and gum programme are available to facilitate quitting by low-income New Zealanders. The current Quit / Me Mutu mass media campaign also has design elements to reach this population group. There is international evidence that ‘quit and win’ contests have particular success in attracting involvement from low- income smokers.48

Interventions for older people There is a case for prioritising older people for access to smoking cessation services above younger populations, for two main reasons. First, it is far more cost-effective to support quitting in older people than younger people in terms of cost per year of life saved.49 The greater cost-effectiveness arises because the gains in life expectancy are realised sooner with older smokers who quit (assuming some level of discounting of health benefits as is the most common health economic practice). Furthermore there is international evidence that smoking cessation is more successful in older smokers.50 Secondly, the health sector is more likely to save health expenditure in the short and medium term as older smokers are more likely to need to be hospitalised or to consult a doctor than younger smokers (since the prevalence of nearly all tobacco-associated disease increases with age). In the United States it has been calculated that creating a new non-smoker reduces anticipated medical costs associated with acute myocardial infarction and stroke by US$47 in the first year and by US$853 during the next seven years (discounting at 2.5 percent per year).51 The exception to this higher economic benefit for quitting by older smokers is quitting by pregnant women smokers, which also produces substantial economic benefits.52 Thus it may be relevant to prioritise access for older people to programmes providing intensive smoking cessation counselling or subsidised pharmacotherapy (eg, nicotine replacement therapy, bupropion).

Interventions for people with existing chronic illness Some populations with existing chronic diseases are at relatively higher risk of smoking-related hospitalisations and premature death. These include people with diabetes, cardiovascular disease, asthma and other chronic respiratory diseases (eg, chronic obstructive respiratory disease). As with providing a subsidised influenza vaccine to these populations (which is current Ministry of Health policy), there is a reasonable case for prioritising these populations for access to smoking cessation interventions. Such prioritisation would be relevant to programmes providing intensive counselling or subsidised pharmacotherapy (eg, nicotine replacement therapy).

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 17

Interventions for young people Young people are relatively price sensitive so New Zealand’s relatively high level of tobacco taxation is probably the key intervention to prevent youth smoking. In addition, there is some evidence that mass media campaigns aimed at adolescents provide favourable results if these campaigns are very well resourced.53 Currently there is a strong focus on smokefree promotion for young people (eg, the Smokefree, Auahi Kore and Lungfish brands). Reducing young people’s access to tobacco is emphasised by enforcement of the legislation banning sales of tobacco to minors and advertising and promotion of tobacco products. There is some evidence that the latter is reducing sales to young people in New Zealand.54

Recommended key interventions The table in Appendix 1 summarises the objectives set out in the Health Funding Authority’s two Five-Year plans for the funding of tobacco control activities in New Zealand.55 The table also lists some effective interventions that are currently being applied locally (by public health services and other providers), and others that could be applied in the future, to achieve the objectives in these two plans. DHBs are encouraged to continue and enhance current efforts in these areas. The HFA undertook a review of a wide range of current and potential tobacco control interventions.56 Although some of this review is outdated it still provides a reasonable guide to the evidence for particular tobacco control interventions. For the most up-to-date evidence, see: systematic reviews in the Cochrane Collaboration (tobacco section) – abstracts are available online http://www.cochrane.org/cochrane/revabstr/g160index.htm review articles in the journal Tobacco Control – most of which is available online (and all of it will be by 2002) http://tc.bmjjournals.com the US Public Health Service’s Smoking Cessation Guidelines, available online http://www.ahrq.gov. All government-funded DHB activities for tobacco control should be consistent with the Public Health Services Handbook.57

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 18

Research strategy

A national alcohol and drug research strategy is under development. Tobacco-related research will be considered under this strategy in future. The provisional lists below illustrate the sorts of key research questions requiring further work.

Prevention • How can further tobacco taxation increases best be balanced by improving access to smoking cessation services for low-income New Zealanders? • What information is required to best assist in strengthening smokefree environments legislation (eg, on workers and patrons in various venues)? • What are worthwhile regulatory controls on tobacco product constituents in the New Zealand setting (eg, setting maximum levels of nicotine and tar)? • What are worthwhile and feasible additional restrictions on tobacco sales in the New Zealand setting (eg, the idea of making tobacco products pharmacy-only drugs so their distribution is better controlled and smoking cessation advice can be delivered at the point of sale)? • What are the most effective themes for mass media campaigns in the New Zealand setting both for prevention and to stimulate quitting (eg, smoking cessation themes, health impact themes, and SHS themes)? • How can mass media campaigns be designed to best support smoking cessation by Maori and low-income New Zealanders?

Smoking cessation • What are the best ways to build on the success to date of the Quitline (eg, integration of the Quitline with ‘quit and win’ contests or annual mail-outs to previous Quitline users who have still not quit)?

Surveillance and research strategies • What are the optimal arrangements for conducting surveillance, monitoring and evaluation for tobacco control (ie, building on a recent review paper commissioned by the Health Funding Authority58)? • What is an appropriate long-term research strategy for supporting tobacco control in New Zealand (including the appropriate organisational arrangements and capacity)?

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 19

APPENDIX 1: Recommended key interventions: tobacco control

Note: those interventions marked with an asterisk (*) are listed in the Public Health Services Handbook as being required services provided by public health unit services and non-government organisations.

Template

Action / intervention Services / resources Partners Evidence Population Specific actions that can be More descriptive examples of actual programmes and resources that are available Those agencies References and The population undertaken under the These include published material, Internet resources or specific staff resources that are important brief summaries of group or groups for broad heading of the toolkit to the achievement the evidence that whom this action / Note: of the specific this particular intervention is action or action / intervention particularly relevant # The bolded statements intervention. These is effective (if appropriate) in this column are may be inside or objectives from the HFA’s outside the health Five-Year funding plans sector (mainstream and Maori) Note: Non-bolded statements are service areas from the Agencies indicated Public Health Services refer to the action/ Handbook for 2000–2001 intervention as a whole

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 20

Action / intervention# Services / resources Partners Evidence Population Prevent the uptake of Refer to HFA Five-Year plans, available at Include: See HFA Five-Year Young people smoking http://www.ndp.govt.nz/tobacco/tobaccofreenz.html and Public health units plans (With some http://www.ndp.govt.nz/tobacco/tobaccofreeMaori.html Strengthen and increase NGOs implications for the the level of community Examples of initiatives include: health of infants of Schools action to reduce the uptake • tobacco taxation – promoting tobacco taxation as the key strategy to prevent the teenage mothers)

of smoking uptake of smoking by youth Promote smokefree • health promotion – sponsorship activities*, media campaigns, support for World environments, including Smokefree Day activities*, school-based interventions*, community-based school environments efforts*, promotion of physical activities, health education resources* Facilitate the enforcement • tobacco advertising – enforce restrictions* of the Smoke-free • enforce legislation on sales of tobacco to minors – undertake Controlled Environments Act Purchase Operations in a minimum of 10 percent of retailers (see Public Health Maintain the capacity to Services Handbook)* deal with incidents that • education of retailers regarding sales to minors* contravene the Smoke-free Environments Act • advice on the legislation* • vending machines – enforce controls on location of vending machines* • promote totally smokefree school environments* • promote a ban on toy and confectionery cigarettes • other interventions – eg, publicity on health risks of smoking*, improving school performance

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 21

Action / intervention# Services / resources Partners Evidence Population Encourage and facilitate Refer to HFA Five-Year plans. Include: See HFA Five-Year All smokers smoking cessation Examples of initiatives include: Public health units plans Low-income Facilitate the • legislation and taxation – advocacy for national-level changes in legislation and Cessation smokers implementation of the taxation on tobacco providers Maori Smoke-free Environments • NRT subsidisation programme – encouraging smokers to use this national Primary health Pacific peoples Act 1990 programme* providers (With implications Strengthen and increase • National Quitline – encouraging smokers to use this national programme* Quit Group for those exposed the level of community to SHS) action to encourage • cessation services for Maori* – promoting the development of culturally NGOs smokers to quit appropriate providers, training of providers* Maori health and Strengthen skills and • mass media campaign – supporting national mass media campaigns at the local other groups knowledge of the health level (eg, local efforts to highlight the health risks of smoking and benefits of sector and other change quitting*) agents to promote tobacco • cessation counselling for health professionals – circulation of national smoking control cessation guidelines for health professionals*, training of professionals*, provide information to primary health care providers* • smoking cessation contests* – if further work indicates that these are more appropriate at the local rather than the national level • health education resources* – appropriate distribution of existing resources and potentially the development of new resources when no appropriate national resources exist (see the website for national health education resources) • other cessation services – support and strengthen primary care and hospital- based smoking cessation interventions • other interventions – eg, promotion of smokefree workplaces and public places including bars, cafes, casinos, nightclubs and restaurants, training of health workers, community-based actions*, support World Smokefree Day*

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 22

Action / intervention# Services / resources Partners Evidence Population Prevent harm to the Refer to HFA Five-Year plans. Include: See HFA Five-Year Pregnant women foetus, children and adult Examples of initiatives include: Primary health plans Caretakers of non-smokers • smoking cessation services for pregnant women – supporting and developing providers children Promote smokefree antenatal and other counselling services Maori health and All workers environments including • advice on and enforcement of the Smoke-free Environments Act 1990* – other groups exposed to SHS at smokefree school restrictions on smoking in workplaces and public places NGOs work environments • media campaigns and publicity around the health effects of second hand smoke Cessation The public exposed Promote the adoption of (use of media, publicity, fact sheets etc) providers to SHS in indoor smokefree policies environments • health education resources – eg, second-hand smoke, smoking in the home Maternity providers Facilitate the (restaurants, pubs, implementation of the • promotion of smokefree environments beyond the minimum legislative Public health units clubs etc) Smoke-free Environments requirements – work and public places, home* (with a leadership role in the Act 1990 community eg, work for a totally smokefree property or campus) Maintain the capacity to • smokefree grants programmes – to support schools and communities* deal with incidents that • advocacy via NGOs and other agencies for smokefree environments legislation* contravene the Smoke-free Environments Act

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 23

Action / intervention# Services / resources Partners Evidence Population Support the monitoring, Possible initiatives include: Include: Necessary for All groups surveillance and • local tobacco control needs assessments Action on Smoking informed decision- evaluation of tobacco making and • identifying key groups for efforts locally and Health (ASH), control activities Cancer Society, targeting of efforts • youth smoking rates – eg, use of data from the national youth smoking Monitor and assess the Health Sponsorship surveys effectiveness of tobacco Council and other control programmes • establish/maintain a database of tobacco retailers* agencies with a through surveillance and • evaluate tobacco control programmes for effectiveness* (where this past involvement in evaluation, and provide appropriate, given that some evaluations are best done at a national youth smoking information to the public level) surveys • use information from surveillance and evaluation in unpaid media Public health units publicity to advance tobacco control • monitor the observance of the Smoke-free Environments Act and Regulations in regard to smokefree public and work areas • maintain a database of public and work areas where people are exposed to SHS (predominantly food and beverage service outlets and non-office based workplaces) • monitor the level of public knowledge of the risks of smoking and SHS at the DHB regional level

Assist in the co- Refer to HFA Five-Year plans. Examples of initiatives include: All agencies with Necessary to All groups ordination of tobacco • co-ordination regionally and nationally to avoid duplication and ensure a interest in tobacco maximise potential control activities comprehensive approach to tobacco control control synergies (eg, between local and Strengthen strategic • information exchanges and joint projects with other agencies alliances and interagency national • support the Health Sponsorship Council’s promotion of the smokefree ‘brand’* networks to optimise components of a impact of smokefree • promote the national Quit / Me Mutu campaign* mass media initiatives campaign)

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 24

APPENDIX 2: Draft indicators for District Health Boards and other regional providers

The Ministry of Health has negotiated accountability agreements with District Health Boards which contain indicators related to NZHS priority areas. Indicators directly related to Tobacco have not been included in this years accountability agreements and will not be included until funding for public health is devolved to DHBs. Some work has been done on looking at possible indicators and the following are draft indicators and targets for tobacco-related ‘desired outcomes’ under Priority Two of the National Drug Policy: to reduce the prevalence of tobacco smoking and expose to (environmental tobacco smoke) second-hand smoke. Further development of some of these indicators is desirable.

Outcome Baseline data Indicator Target Smoking in Data collected • Cigarette equivalents • To reduce tobacco products sold to the adult annually consumed per adult 1,000 cigarette equivalents or less population Indicators and targets (15 years and over) per adult (15 years and over) by the set in 1994 as part of • Proportion of all adults year 2005 annual report series (15 years and over) • To reduce the percentage of adults on the State of Public smoking cigarettes (15 years and over) smoking any Health type of cigarette to 20 percent or less by the year 2005 Smoking Data collected • Proportion of Maori • To reduce the percentage of Maori and Maori annually adults (15 years and adults (15 years and over) smoking Indicators and targets over) smoking any type of cigarette to 40 percent set in 1994 as part of cigarettes or less by the year 2005 annual report series on the State of Public Health Under-18 Date collected • Proportion of all N/A smokers annually persons aged between 15 and 17 years smoking cigarettes Smoking Baseline data, last • Proportion of all women Targets set in 1994 have been partially and collected in 1996 smoking cigarettes met. pregnant Indicators and targets during pregnancy • To reduce the percentage of women set in 1994 as part of • Proportion of Maori pregnant women smoking any type annual report series women smoking of cigarette to 20 percent or less by on the State of Public cigarettes during the year 2000. Health pregnancy • To reduce the percentage of (Conditional on additional pregnant Maori women smoking any baseline data being type of cigarette to 50 percent or secured within the term of less by the year 2000 the NDP) Target revision required

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 25

Additional areas

Outcome Baseline data Indicator Target Reduction in Create a database of Reduction in the numbers To be advised exposure to public areas where of licensed premises, second-hand people are exposed workplaces and homes smoke to SHS where people are exposed Implement the to SHS Smokefree Environments Act 1990 and any amendments Workforce development

Data and information requirements Within the parameters set out in this toolkit and the Public Health Services Handbook, DHBs will need to identify tobacco control needs for their districts. Such needs analysis should consider the needs of individual population groups, as well as the general population. At a national level there is a lack of information in the following areas: • smoking during pregnancy • exposure to SHS in the workplace. The Ministry of Health, through the Inter-Agency Committee on Drugs, is looking at ways in which these gaps in information can be filled. Findings from future research will be shared with DHBs.

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 26

APPENDIX 3: Tobacco-related websites

New Zealand Action on Smoking & Health (ASH) http://www.ash.org.nz Asthma & Respiratory Foundation http://www.asthmanz.co.nz Cancer Society of New Zealand http://www.cancernz.org.nz Foundation for Alcohol and Drug Education http://www.fade.org.nz Health Sponsorship Council (HSC) was established in 1990, under the Smoke-free Environments Act (1990) to promote health and encourage New Zealanders to enjoy healthy lifestyles, and to replace tobacco sponsorship with positive health messages. The HSC's current health brands are Smokefree, Auahi Kore, SunSmart, Bike Wise, and Quit/Me Mutu. Relevant websites are: • http://www.healthsponsorship.co.nz, the corporate site for the HSC, from which all brand sites of the HSC can be accessed, including those listed below • http://www.smokefree.co.nz, the general site pertaining to the smokefree brand promoted by HSC • http://www.auahikore.co.nz, the Maori-specific site pertaining to smokefree • http://www.quit.co.nz, the tobacco cessation site. Quit / Me Mutu is a brand promoted by the Quit Group Charitable Trust. It is managed by HSC, Cancer Society and Te Hotu Manawa Maori http://www.quit.co.nz Health Education Resources http://www.healthed.govt.nz Urge / Whakamanawa Youth http://www.urge.co.nz http://www.whakamanawa.co.nz

Australia National Tobacco Campaign http://www.quitnow.info.au Quit Victoria http://www.quit.org.au Tobacco Control Supersite http://www.health.usyd.edu.au/tobacco Reachout Youth Website http://www.reachout.asn.au

International The World Health Organization's website http://www.who.org contains a page dedicated to its Tobacco Free Initiative http://tobacco.who.int/index.html World Health Organization (Western Pacific Regional Office) Tobacco Free Initiative http://www.wpro.who.int/themes_focuses/theme2/special/tobacco.htm

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 27

Cochrane Collaboration (tobacco section) http://www.cochrane.org/cochrane/revabstr/g160index.htm Tobacco Control Online http://tc.bmjjournals.com US Public Health Services Smoking Cessation Guidelines http://www.ahrq.gov Virtual Clearinghouse on Alcohol, Tobacco and Other Drugs http://www.atod.org/

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 28

Endnotes

1 HFA and Ministry of Health. 2000. Public Health Services Handbook 2000–2001. Wellington: Health Funding Authority and Ministry of Health. 2 King A. 2000. The New Zealand Health Strategy: discussion document. Wellington: Ministry of Health. 3 Fiore MC, Bailey WC, Cohen SJ et al. 2000. Treating Tobacco Use and Dependence: clinical practice guideline. Rockville, MD: US Department of Health and Human Services, [Online] available at http: //www.ahrq.gov 4 Kaufman KR, Brodine S, Shaffer R. 2000. Military training-related injuries: surveillance, research, and prevention. American Journal of Preventive Medicine 18(3 Suppl): 54–63. Jones BH, Cowan DN, Knapik JJ. 1994. Exercise, training and injuries. Sports Medicine 18: 202–14. 5 Miller M, Hemenway D, Bell NS et al. 2000. Cigarette smoking and suicide: a prospective study of 300,000 male active-duty army soldiers. American Journal of Epidemiology 151: 1060–3. Miller M, Hemenway D, Rimm E. 2000. Cigarettes and suicide: a prospective study of 50,000 men. American Journal of Public Health 90: 768–73. Tanskanen A, Tuomilehto J, Viinamaki H et al. 2000. Smoking and the risk of suicide. Acta Psychiatrica Scandinavica 101: 243–5. 6 Jimenez S, Labeaga JM. 1994. Is it possible to reduce tobacco consumption via alcohol taxation? Health Economics 3: 231–41. 7 Brown WV. 2000. Risk factors for vascular disease in patients with diabetes. Diabetes, Obesity and Metabolism 2 (Suppl 2): S11–8. 8 Congdon NG. 2001. Prevention strategies for age related cataract: present limitations and future possibilities. British Journal of Ophthalmology 85: 516–20. 9 Kinane DF, Chestnutt IG. 2000. Smoking and periodontal disease [Medline abstract]. Critical Reviews in Oral Biology and Medicine 11: 356–65. 10 Ministry of Health. 1999. Our Health, Our Future: the health of New Zealanders 1999. Wellington: Ministry of Health. 11 Peto R, Lopez A. 1994. Mortality from Smoking in Developed Countries 1950–2000: indirect estimates from national vital statistics. New York: Oxford University Press. 12 Laugesen M, Clements M. 1998. Cigarette Smoking Mortality among Maori. Wellington: Ministry of Maori Development. 13 Doll R. 1998. Uncovering the effects of smoking: historical perspective. Statistical Methods in Medical Research 7: 87–117. 14 DiFranza JR, Lew RA. 1996. Morbidity and mortality in children associated with the use of tobacco products by other people. Pediatrics 97: 560–8. Li JSM, Peat JK, Xuan W, Berry G. 1999. Meta-analysis on the association between environmental tobacco smoke (ETS) and the prevalence of lower respiratory tract infection in early childhood. Pediatric Pulmonology 27: 5–13.

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 29

15 Williams GM, O'Callaghan M, Najman JM et al. 1998. Maternal cigarette smoking and child psychiatric morbidity: a longitudinal study. Pediatrics 102: e11. Fergusson DM, Woodward LJ, Horwood LJ. 1998. Maternal smoking during pregnancy and psychiatric adjustment in late adolescence. Archives of General Psychiatry 55: 721–7. Orlebeke JF, Knol DL, Verhulst FC. 1997. Increase in child behaviour problems resulting from maternal smoking during pregnancy. Archives of Environmental Health 52: 317–21. 16 He J, Vupputuri S, Allen K et al. 1999. Passive smoking and the risk of coronary heart disease: a meta-analysis of epidemiologic studies. New England Journal of Medicine 340: 920–6. Law MR, Morris JK, Wald NJ. 1997. Environmental tobacco smoke exposure and ischaemic heart disease: an evaluation of the evidence. British Journal of Medicine 315: 973–80. 17 Bonita R, Duncan J, Truelsen T, Jackson RT, Beaglehole R. 1999. Passive smoking as well as active smoking increases the risk of acute stroke. Tobacco Control 8: 156–60. 18 Hackshaw AK, Law MR, Wald NJ. 1997. The accumulated evidence on lung cancer and environmental tobacco smoke. British Journal of Medicine 315: 980–8. 19 Woodward A, Laugesen M. 2000. Deaths in New Zealand Attributable to Second-hand Cigarette Smoke: a report to the New Zealand Ministry of Health, [Online] available at: http://www.moh.govt.nz 20 Woodward A, Laugesen M. 2001. Morbidity Attributable to Second-hand Cigarette Smoke in New Zealand. Report to the Ministry of Health, [Online] available at: Woodward A, Laugesen M. 2001. Morbidity Attributable to Second-hand Cigarette Smoke in New Zealand. Report to the Ministry of Health, [Online] available at: http://www.moh.govt.nz 21 Whitlock G, MacMahon S, Van der Hoorn S et al. 1998. Association of environmental tobacco smoke exposure with socioeconomic status in a population of 7725 New Zealanders. Tobacco Control 7: 276–80. 22 Fiore MC, Bailey WC, Cohen SJ et al. 2000. Treating Tobacco Use and Dependence: clinical practice guideline. Rockville, MD: US Department of Health and Human Services, [Online] available at http://www.ahrq.gov 23 Lightwood JM, Glantz SA. 1997. Short-term economic and health benefits of smoking cessation: myocardial infarction and stroke. Circulation 96: 1089–96. 24 Lightwood JM, Phibbs CS, Glantz SA. 1999. Short-term health and economic benefits of smoking cessation: low birth weight. Pediatrics 104: 1312–20. 25 PHC. 1994. Tobacco Products: the Public Health Commission’s advice to the Minister of Health 1993–1994. Wellington: Public Health Commission. 26 Easton B. 1997. The Social Costs of Tobacco Use and Alcohol Misuse. Wellington: Department of Public Health, Wellington School of Medicine. 27 World Bank. 1999. Curbing the Epidemic: government and the economics of tobacco control. Washington DC: World Bank. 28 Laugesen M, Clements M. 1998. Cigarette Smoking Mortality among Maori. Wellington: Ministry of Maori Development. 29 Ministry of Health. 1997. Progress on Health Outcome Targets 1997. Wellington: Ministry of Health.

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 30

30 Reid P, Pouwhare R. 1991. Te-Taonga-mai-Tawhiti (the gift from a distant place). Auckland: Niho Taniwha. Broughton J. 1996. Puffing Up a Storm, Vol 1 ‘Kapai te torori’. Dunedin: University of Otago. 31 Doran CM, Sanson-Fisher RW, Gordon M. 1996. A cost–benefit analysis of the average smoker: a government perspective. Australian and New Zealand Journal of Public Health 20: 607–11. 32 Whitlock G, MacMahon S, Vander-Hoorn S et al. 1997. Socioeconomic distribution of smoking in a population of 10,529 New Zealanders. New Zealand Medical Journal 110: 327– 30. Pearce NE, Davis PB, Smith AH, Foster FH. 1985. Social class, ethnic group, and male mortality in New Zealand, 1974–8. Journal of Epidemiology and Community Health 39: 9– 14. Jackson R, Beaglehole R, Yee RL et al. 1990. Trends in cardiovascular risk factors in Auckland, 1982 to 1987. New Zealand Medical Journal 103: 363–5. Kawachi I, Marshall S, Pearce N. 1991. Social class inequalities in the decline of coronary heart disease among New Zealand men, 1975–1977 to 1985–1987. International Journal of Epidemiology 20: 393–8. Pearce N, Bethwaite P. 1997. Social class and male cancer mortality in New Zealand, 1984– 7. New Zealand Medical Journal 110: 200–2. Whitlock G, MacMahon S, Hoorn SV et al. 1998. Association of environmental tobacco smoke exposure with socioeconomic status in a population of 7725 New Zealanders. Tobacco Control 7: 276–80. Ministry of Health. 1999. Taking the Pulse: the 1996/97 New Zealand Health Survey. Wellington: Ministry of Health. 33 Crampton P, Salmond C, Woodward A, Reid P. 2000. Socioeconomic deprivation and ethnicity are both important for anti-tobacco health promotion. Health Education and Behavior 27: 317–27. 34 Conrad KM, Flay BR, Hill D. 1992. Why children start smoking cigarettes: predictors of onset. British Journal of Addiction 87: 1711–24. 35 Ministry of Health. 2001. Tobacco Facts 2001. Wellington: Ministry of Health, [Online] available at http://www.moh.govt.nz 36 Laugesen M, Clements C. 1998. Cigarette Smoking Mortality Among Maori 1954–2028. Wellington: Te Puni Kokiri (Ministry of Maori Development). 37 Laugesen M, Scragg R. 1999. Trends in cigarette smoking in fourth-form students in New Zealand, 1992–1997. New Zealand Medical Journal 112: 308–11. 38 Scragg R, Laugesen M. In press. Cigarette Smoking by 4th Form Students (1992, 1997– 1999). NZ Public Health Report. 39 Borman B, Wilson N, Maling C. 1999. Socio-demographic characteristics of New Zealand smokers: results from the 1996 census. New Zealand Medical Journal 112: 460–3. 40 HFA. 1998. Spatial Analysis of Smoking in New Zealand as a Tool for Targeting Tobacco Control Interventions. HFA Special Report 1. Wellington: Health Funding Authority Central Office. 41 Ministry of Health. 2001. Tobacco Facts 2001. Wellington: Ministry of Health, [Online] available at http://www.ndp.govt.nz/tobacco/tobaccofacts2001.html

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 31

42 Ministry of Health. 1998. National Drug Policy Part 1: Tobacco and Other Drugs Part 2: Illicit and Other Drugs. Wellington: Ministry of Health, [Online] available at http://www.ndp.govt.nz/policy/ndppolicy.html 43 Laugesen M, Swinburn B. 2000. New Zealand's tobacco control programme 1985–1998. Tobacco Control 9: 155–62. Laugesen M, Scollo M, Sweanor D et al. 2000. World's best practice in tobacco control. Tobacco Control 9: 228–36. Thomson GW, Wilson NA. 2000. Lost in the smoke: tobacco control in New Zealand during the 1990s. New Zealand Medical Journal 113: 122–4. Thomson G, Wilson N. 2001. Tobacco control policy during 1984–1998. In: P Davis, T Ashton (eds). Health Policy in New Zealand. Oxford: Oxford University Press. 44 HFA. 1998. Evidence for Tobacco Control Activities Available to the Health Funding Authority. HFA Special Report 3. Wellington: Health Funding Authority Central Office. HFA. 1999. Toward a Tobacco-Free New Zealand: a Five-Year plan for HFA funding for tobacco control (1999–2003). Wellington: Health Funding Authority. HFA. 1999. Toward a Tobacco-Free New Zealand: a Five-Year plan for HFA funding for tobacco control (1999–2003). Wellington: Health Funding Authority. 45 BRC. 2001. Autaki Kai Paipa 2000 Evaluation Report (April 2001). Unpublished report for the Ministry of Health. Wellington: BRC. 46 Glover M. 1999. Comparison of Maori Smokers Undertaking a Noho Marae Stop Smoking Programme with a Group of Unaided Maori quitters: preliminary findings. Paper presented at the PHA Conference, Wellington. 47 World Bank. 1999. Curbing the Epidemic: government and the economics of tobacco control. Washington DC: World Bank. 48 HFA. 1998. Evidence for Tobacco Control Activities Available to the Health Funding Authority. HFA Special Report 3. Wellington: Health Funding Authority Central Office. 49 Ministry of Health. 2001. Unpublished analysis. 50 Hymowitz N, Cummings KM, Hyland A et al. 1997. Predictors of smoking cessation in a cohort of adult smokers followed for five years. Tobacco Control 6 (Suppl 2): S57–62. Osler M, Prescott E. 1998. Psychosocial, behavioural, and health determinants of successful smoking cessation: a longitudinal study of Danish adults. Tobacco Control 7: 262–7. Monsó E, Campbell J, Tønnesen P et al. 2001. Sociodemographic predictors of success in smoking intervention Tobacco Control 10: 165–9. 51 Lightwood JM, Glantz SA. 1997. Short-term economic and health benefits of smoking cessation: myocardial infarction and stroke. Circulation 96: 1089–96. 52 Marks JS, Koplan JP, Hogue CJ, Dalmat ME. 1990. A cost-benefit/cost-effectiveness analysis of smoking cessation for pregnant women. American Journal of Preventive Medicine 6: 282– 9. Dolan-Mullen P, Ramirez G, Groff JY. 1994. A meta-analysis of randomized trials of prenatal smoking cessation interventions. American Journal of Obstetrics and Gynecology 171: 1328–34. [The Cochrane Library 1997: DARE-920007] Warner KE. 1997. Cost effectiveness of smoking-cessation therapies. Pharmacoeconomics 11: 538–49.

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 32

53 Sly DF, Heald GR, Ray S. 2001. The Florida ‘truth’ anti-tobacco media evaluation: design, first year results, and implications for planning future state media evaluations. Tobacco Control 10: 9–15. 54 Laugesen M, Scragg R. 1999.Changes in cigarette purchasing by fourth form students in New Zealand 1992–1997. New Zealand Medical Journal 112: 379–83. 55 HFA. 1999. Toward a Tobacco-Free New Zealand: a Five-Year plan for HFA Funding for Tobacco Control (1999–2003). Wellington: Health Funding Authority. HFA. 1999. Toward a Tobacco-Free New Zealand: a Five-Year plan for HFA Funding for Tobacco Control (1999–2003). Wellington: Health Funding Authority. 56. HFA. 1998. Evidence for Tobacco Control Activities Available to the Health Funding Authority. HFA Special Report 3. Wellington: Health Funding Authority Central Office. 57 HFA and Ministry of Health. 2000. Public Health Services Handbook 2000–2001. Wellington: Health Funding Authority and Ministry of Health. 58 Laugesen M, McClellan V. 2000. Monitoring, Surveillance and Evaluation of Tobacco Control Activities in New Zealand: an options paper. Report for the Health Funding Authority. Auckland: Health New Zealand & Research and Evaluation Services.

New Zealand Health Strategy • DHB Toolkit: Tobacco Control • Edition 1 33