Tobacco Control 2000;9:155–162 155
New Zealand’s tobacco control programme Tob Control: first published as 10.1136/tc.9.2.155 on 1 June 2000. Downloaded from 1985-1998
Murray Laugesen, Boyd Swinburn
Abstract This paper reviews New Zealand’s national Objective—To review the impact of New tobacco control programme (TCP), asking Zealand’s tobacco control programme whether it has: (1) fulfilled its original aims and from 1985 to 1998 on smoking prevalence targets in reducing smoking; (2) achieved and tobacco consumption, and to estimate reductions in smoking among youth, Maori, the scope for further reduction. and lower income groups; (3) reduced Design—Country case study; interven- exposure to second hand smoke; (4) reduced tions, with outcomes ranked internation- cigarette mortality; and (5) made favourable ally across time. progress compared to other OECD (Organisa- Setting—New Zealand 1985-98; for 1985- tion for Economic Cooperation and Develop- 95, 23 OECD countries. ment) countries. Interventions—Between 1985 and 1998, This review begins in 1985, when the Minis- New Zealand eliminated tobacco advertis- ter of Health publicised a “comprehensive ing, halved the aVordability of cigarettes, policy to promote non-smoking” from his and reduced smoke exposure in work time advisory committee on smoking and health, by 39%. which asked the government to commit itself Main outcome measure—Reduction in to its TCP plan. The plan included public adult smoking prevalence and in tobacco involvement and health education, quit clinics products consumption per adult. for adults, restricted adolescent access to Results—Changes in prevalence 1985-98: tobacco products, regulation of tar yields, in adults (aged 15+ years), −17% (from increased taxation, smokefree environments, 30% to 25%) but short of the 20% target for health warnings, and a ban on advertising tobacco products and on tobacco brand name
2000; in youth (aged 15–24 years), −20% http://tobaccocontrol.bmj.com/ sponsorships.1 (from 35% to 28%); and in Maori adults At the 1996 census, the overall smoking (aged 15+ years), −17% (from 56% in 1981 prevalence for adults (aged 15+ years) was to 46% in 1996). Changes in consumption 23.7%. For Europeans the prevalence was 1985-98: tobacco products per adult aged 23%, for Pacific people 32%, and for Maori 15+ years, −45% (2493 to 1377 cigarette 46%. Maori, who are the indigenous people of equivalents); cigarettes smoked per New Zealand, comprised 11.7% of the total smoker, −34% (22.7 to 15.0 per day). adult population but 22% of the adult smoking Between 1985 and 1995 New Zealand population. reduced tobacco products consumption In this review we have attempted to assess per adult more rapidly than any other the impact of the total TCP because, apart OECD country, and reduced youth preva- from sharp increases in tobacco tax, a single
lence more rapidly than most. The component usually cannot be studied in isola- on September 24, 2021 by guest. Protected copyright. acceleration of the decline in cigarette tion from the total programme. We also attributable mortality rates in men and in assessed the scope for the TCP to achieve fur- women age 35–69 years averted an ther reductions in smoking and mortality. additional 1400 deaths between 1985 and 1996. Between 1981 and 1996 smoking prevalence among blue collar workers Methods decreased only marginally, and in 14–15 POPULATIONS AGED 15 YEARS AND OVER year olds, rose by one third between 1992 (1) New Zealand mean resident total and 1997. population 1985-98 (supplied by Statistics Conclusion—In 13 years, New Zealand’s New Zealand 1999). tobacco control programme has been suc- (2) Maori in New Zealand 1981-96, adjusting Health New Zealand, cessful in almost halving tobacco products for the changed census definitions of and Heart Foundation, consumption, particularly by lowering Maori.2 Auckland consumption per smoker. With strong (3) The 23 OECD countries as at January M Laugesen B Swinburn political support for quit campaigns, 1995, after deleting Mexico because of increased taxation, and the elimination of lack of data, were: Australia, Austria, Correspondence to: displays of tobacco products on sale, the Belgium, Canada, Denmark, Finland, Dr Murray Laugesen, Health New Zealand, PO Box 360 consumption could theoretically be halved France, Germany, Greece, Iceland, Waiheke, New Zealand; again in as little as 3–6 years. Ireland, Italy, Japan, Netherlands, New [email protected] (Tobacco Control 2000;9:155–162) Zealand, Norway, Portugal, Spain, Received 23 July 1999 and in Keywords: New Zealand, tobacco control policy; Sweden, Switzerland, Turkey, UK, USA, revised form October 18, 1999. Accepted Organisation for Economic Cooperation and excluding Luxembourg. Federal Republic 9 November 1999 Development of Germany data were used for Germany 156 Laugesen, Swinburn
pre-1990. Population data were from (iv) Cigarettes per day (cpd)—This was Tob Control: first published as 10.1136/tc.9.2.155 on 1 June 2000. Downloaded from published WHO/OECD/UN midyear calculated from the formula cpd = ((i) above)/ estimates. [((iii) above) × 365]. This avoids the under (4) Comparisons of mortality: OECD coun- reporting inherent in self reported cpd data. tries were compared on 1990 mortality. (v) Addiction—This was measured as the time Iceland and Turkey were deleted because from waking to first cigarette. of lack of data, and Luxembourg (vi) Costliness and its inverse, aVordability— included.3 Maori mortality was based on Within New Zealand, costliness was estimated 1989-93.2 from the time taken to earn 20 cigarettes at the (5) Prevalence and cigarettes per day (cpd): average hourly ordinary time earnings before data were obtained from 21 OECD coun- income tax. For international comparisons, tries (table 1). costliness was defined as the percentage of per (6) For the existence of smokefree legislation: capita gross domestic product (GDP) required 1996 data.4 to buy 20 cigarettes every day. DATA SOURCES CALCULATION OF AVERTED MORTALITY For total population and Maori, the census Cigarette smoking attributable mortality ignored gave smoking prevalence data for 1976, 1981, deaths: Under the age of 35 years (for example, and 1996. For the total population, a continu- from sudden infant death syndrome), from ous doorstep survey of 10 000 persons gave smoking only pipes or cigars, and from passive prevalence since 1982.5 OECD data for smoking in never smokers. It was calculated by 1985-95 were obtained from the Health New Peto’s indirect method, from the second Zealand database.6 The data are based on sta- American Cancer Society study (ACS-II) tistical yearbooks, oYcial reports, and web cohort study. He attributed lung cancer to sites. smoking according to the diVerence between the national rate and the ACS-II non-smokers’ rate. He then calibrated the severity of the epi- MEASUREMENTS demic in each country and year against the (i) Consumption of tobacco products per adult per ACS lung cancer rate benchmark.3 For other year (hereafter called consumption)—This is a diseases he conservatively attributed to summary measure of smoking and was smoking only half the smokers’ excess mortal- calculated as the annual volume sales of ity. The seven, five year age specific rates were tobacco products (derived from tobacco taxes averaged to give the 35–69 years age standard- paid) per adult aged 15+ years, measured in ised rate. cigarettes, or in the case of roll your own The rate decreases in age standardised, ciga-
(RYO) tobacco, in grams. The traditional rette attributable mortality between its 1975 http://tobaccocontrol.bmj.com/ approximation of 1 g of tobacco being equiva- peak in men, or its 1985 peak in women, and lent to one cigarette was used in the absence of the respective 1996 rate, were applied to the data on the weight of tobacco per 1995 population to estimate the number of manufactured cigarette by country and year. cigarette deaths of each sex averted in 1996. (ii) Weight of tobacco in tobacco products—This The TCP’s eVect was calculated from the allows for the fact that tobacco weight per acceleration in those rate decreases after 1985 manufactured cigarette was less than 1 g and in the 35–79 year old population. varied by year. For other tobacco products, tobacco weight was calculated as equalling the ASSUMPTIONS FOR FURTHER REDUCTION IN product weight. CONSUMPTION WITHIN 3-6 YEARS (iii) Smoking prevalence—In New Zealand, this Policy 1—An Australian style quit campaign was defined as the percentage of adults aged 15 could be expected to reduce tobacco products on September 24, 2021 by guest. Protected copyright. years and over who smoked manufactured or consumption per adult by at least 10% if hand rolled cigarettes. In other countries, sustained for 3–6 years, based on the fact that smoking prevalence definitions varied, and in only six months, the 1997 Australian their inclusion of cigar and pipe smoking may campaign reduced prevalence and consump- have given New Zealand an artificially lower tion per adult by 4–5%, by inducing quitting.7 prevalence than a few other countries, but In addition, a media campaign was expected, would not have aVected comparisons based on while it lasted, to double smokers’ reported the rate of prevalence reduction. temporary quit episodes, from 2 to 4 weeks per
Table 1 New Zealand trends in tobacco and tobacco products consumption and adult and youth smoking prevalence, with OECD rankings for 1995 values and rate of change 1985-95
1995 OECD rank 1985-95 % OECD rank for rate of 1985 1990 1995 (1st = lowest) change change 1985-95 Tobacco products/adult, consumption, cigarettes or grams 2493 1959 1472 2nd of 23 −41% 1st of 23* countries† RYO per adult per year Cigarettes or grams RYO/ smoker/ day 23 20 15 2nd of 21 −34% 1st of 21‡ Adult smoking prevalence age 15+ years (%) 30 27 26 8th of 21 −12% 9th of 21‡ Youth smoking prevalence 15–24 years (%) 35 32 29 10th of 19 −18% 3rd of 17‡
*1st = largest reduction achieved of any country in group. †Data on tobacco products consumption per adult: 23 OECD countries compared (see Method). ‡Data on smoking prevalences and consumption per smoker, 1995: not obtained for Switzerland; Turkey; for youth prevalence not for Belgium, Denmark, Greece, Japan, Switzerland, Turkey. Netherlands data were for ages 15–19 years. In a few years, prevalences were estimated from adjacent year values. Source: Health New Zealand database 1999,6 based on national statistical publications, US Department of Agriculture,46 UN commodity production and trade data, and OECD mid year populations, including cigarettes by number, cigars, and manufactured tobacco (including RYO and pipe) by weight, calculated as: 1 manufactured cigarette = 1 g tobacco. Smokeless tobacco was not included. RYO, roll your own. Tobacco control in New Zealand 157
year, and thus depress consumption by a packets, and paid advertising campaigns. News Tob Control: first published as 10.1136/tc.9.2.155 on 1 June 2000. Downloaded from further 4%.8 items in newspapers on smoking issues Policy 2—A tax increase of 50 cents per pack of averaged 4000 annually from 1986-91, but fell 20 in May 1998 increased cigarette prices 13% to between 2000 and 2900 annually during and decreased consumption by 10.2% over the 1992-98. Estimated from newspapers’ own following 12 months.9 Similarly, a 50 cents per files, and from purchased news items,13 the pack tax increase in 1991 increased the price peak years (5000 items) were 1986 (Smokefree by 17% and decreased sales by 15%. We Week) and 1990 (legislation). The number of estimate that if the tax was increased weekly news items was associated with lower suYciently to cause a 50% increase in price cigarette sales.14 The public debate of the issues from the current (year to June 1999) average of created informed support for the policies NZ$6.50 (US$3.40) to NZ$9.75 ($US5.10), needed to reduce smoking. The media were it would lower cpd and consumption per adult supplied with views from a variety of organisa- by 44% below the 1998 level. Such a fall would tions, in particular: the Tobacco Institute of be permanent because the tobacco tax rate per New Zealand from 1980; ASH (Action on gram of tobacco is adjusted regularly for infla- Smoking and Health) from 1983; the tion, and is uniform across tobacco products. Department of Health (subsequently the Min- Policy 3—The eVect of not permitting display istry of Health) from 1985 which reported to of tobacco products for sale is diYcult to esti- the public from its monitoring mate, but according to a cigarette company programme9 15–17; the Coalition to End Tobacco marketing manager, display is essential for Advertising during 1989-1993; the Smokefree maximising sales.10 Making advertising bans Coalition from 1995; the crown public health total but permitting display has been estimated units from 1996; and the Maori smokefree to lower consumption 6%.11 The eVectiveness coalition (ATAK) from 1998. of bans increase as they become more 6 complete. If the bans were extended to ban ADULT ORIENTED PROGRAMMES display of tobacco products, we estimated a Paid advertising campaigns lasted only a few further one step decrease of 1–2% with perma- weeks each because of the costs involved. nent eVect. About $1.5 million (1995 NZ$) was spent on Policies (1) to (3) above, assuming they the Smokefree Week (1986) and “Kick it in the acted without overlap or synergy, could Butt” (1988-90). After that (1991-98) there together lower consumption 50%. Given suY- was no major campaign or public service cient political will, 3–6 years may still be announcements targeting adult smoking. needed to increase the tax in stages. Three health groups began a quit campaign in
ESTIMATION OF THE EFFECT OF REDUCED one region in late 1998 (using Australian http://tobaccocontrol.bmj.com/ SMOKING ON MORTALITY. advertisements “Every cigarette is doing you We focused only on the three policy eVects damage”). Pharmaceutical companies adver- above. The estimated fractional reductions, tised nicotine replacement therapy in the when multiplied together, would halve the 1990s. Quit clinics were not seen as cost 1998 consumption per adult. A number of eVective.18 In 1998 not one quit clinic was in assumptions and calculations were used in operation. deriving these estimates. We ignored averted deaths in those under 35 or over 70 years of YOUTH ORIENTED PROGRAMMES age. The 1996 population aged 35–69 years Despite in-class education, half of 14–15 year was projected 16.5 years using life table meth- olds in 1993 said they had received no ods, based on 1995 mortality rates by age and information from school about smoking in the 19
sex. The 1995 non-cigarette attributable past year. The government ran media on September 24, 2021 by guest. Protected copyright. mortality rates by age and sex were calculated campaigns discouraging adolescent smoking in by Peto’s method3 and applied to the 1996 1979, 1984, and latterly, at NZ$1 million census never-smoker population by age and annually, in 1996-99 (“Why Start?”). The sex to estimate survival and mortality risk Smoke-free Environments (SFE) Act 1990 within the next 16.5 years. The total mortality established a Health Sponsorship Council, risks within 16.5 years for never, heavy (21+ funded from the health budget, to promote cpd), light (1–20 cpd), and ex-smokers by age health through sponsorship and to replace and sex were obtained from the ACSII study,12 tobacco sponsorship advertising of arts, and calibrated according to the New Zealand culture, and sports for a 2–3 year period after never smoker population mortality risk. Based the end of tobacco sponsorships. It also used its on the 1981-96 decreases (tobacco products discretionary funds to promote its main brand, consumption −48%, prevalence −26%, and “Smokefree”’, paying particular attention to cpd −30%9), we calculated the deaths averted sponsoring school based events, minor sports, if 26% of smokers quit (reducing prevalence and sports favoured by high smoking from 25% in 19989 to 18.5%) and if continuing prevalence groups. Government separately smokers reduced cpd by 30%, from 15 cpd allocated half a million dollars a year for (recorded in 19989) to 10.5 cpd. smokefree schools programmes from 1996. In 1986 an amendment to the Toxic Interventions Substances Act 1979 banned trade in oral PUBLIC INVOLVEMENT THROUGH INFORMATION tobacco, (smokeless tobacco) and another in AND EDUCATION April 1988 banned tobacco product sales to Public education was mainly through news under 16 year olds. The SFE Act incorporated items, mandated health warnings on tobacco these bans, and also banned the giving of 158 Laugesen, Swinburn
tobacco product samples by the tobacco trade. cents (11% of the price). In 1985, New Tob Control: first published as 10.1136/tc.9.2.155 on 1 June 2000. Downloaded from From July 1997 the minimum age at which Zealand was ranked 10th among OECD coun- people could be sold tobacco products was tries for the costliness of cigarettes but by 1990 raised to 18 years and more responsibility was it was second and in 1995 it was third. The placed on the retailer. From February 1998, 1995 price of 20 cpd (every day)26 equalled 9% cigarette packs of less than 20 cigarettes and of per capita gross domestic product (GDP) in tobacco packs of less than 30 g were banned. Ireland, 8% in the UK, 7% in New Zealand, From 1996 to 1999 the Ministry of Health and less in other OECD countries. was allocated nearly NZ$1 million annually for enforcement, mainly to stop underage sales, as RESTRICTIONS ON SMOKING detected by under age volunteers.20 In 1996-97 The 1985 TCP aimed to promote smokefree volunteers aged on average 14.5 years were enclosed public and workplaces. The SFE Act sold cigarettes on 15% of shop visits; in 1997- 1990 banned smoking on most public 98, and again in 1998-99, on 5% of visits. transport, in half of restaurant seating, in From 1996-99, an average 10% of retailers shared oYces, in the public parts of workplaces were visited annually, and some 4% of all including shops and banks, and in most visited were successfully prosecuted for selling enclosed public places. In 1997, the amended to under age persons.21 Surveys of 14–15 year Act required 25% of casino gaming floors to be old smokers found that personal buying of smokefree. Other authorities such as airports cigarettes decreased from 60% in 1992 to 38% and shopping malls and many schools have in 1997; someone else buying for them since enforced their own extended smokefree increased from 14% in 1992 to 46% in 1997; zones. The Act did not protect factory workers, and supply from family increased from 14% to nightclub, bar, and casino workers from second 25%. In 1992, 25% reported being refused sale hand smoke. Public support ensured because of their age, with 62% reporting compliance in oYce workplaces but restaurant refusal in 1997. In 1992, 7% reported diYculty smokefree zones were often ignored; by 1998 buying cigarettes compared to 28% in 1997.22 only one case had come to court.
REGULATION OF PRODUCT CONTENT REQUIREMENTS FOR WARNINGS The SFE Act required manufacturers to report Government and manufacturers agreed on annually to the Ministry of Health the tar and weak cigarette packet warnings—“Smoking nicotine yields in the smoke of all may damage your health” (1974-80), then manufactured cigarette brands sold, as well as “Smoking can endanger your health” the amount of tobacco, additives, and price. (1980-88). From mid-1988, under regulatory
The Act provides the Director General of threat, stronger warnings appeared on all http://tobaccocontrol.bmj.com/ Health with the powers to require manufactur- tobacco packets except cigars. Regulations ers to pay for additional independent testing. under the SFE Act 1990 required cigarettes The Ministry of Health adopted a harm reduc- and cigarette tobacco to carry these warnings: tion approach for tobacco products,23 and in “Smoking causes lung cancer”, “Smoking 1997 Parliament amended the SFE Act to causes heart disease”, “Smoking causes fatal enable tighter regulation of harmful constitu- diseases”, “Smoking damages your lungs”; it ents, but to date, such regulations have not also required pipe tobacco and cigars to carry been prepared. In 1998, many cigarette brands the message “Smoking causes lung cancer”. had higher smoke yields of tar24 than would Stronger warnings were sought by the govern- have been permitted in the European Union. ment in 1994 but tobacco industry objections In 1998, RYO and non-filter cigarettes, which successfully slowed the passage of regulations,
have higher tar yields, comprised over 20% of delaying the stronger warnings until 2000. on September 24, 2021 by guest. Protected copyright. all tobacco smoked. TOBACCO ADVERTISING RESTRICTIONS TAXATION Broadcast authorities stopped tobacco adver- The 1985 TCP aimed to “adopt a taxation tising on television and radio in 1963. Govern- policy that encourages non-smoking”.1 From ment and manufacturers in 1973 agreed to ban 1986 to 1992 the economic recession provided tobacco advertising on cinema screens and an important incentive to maximise tobacco outdoor billboards. Tobacco advertising other- tax revenue and this coincided with health wise continued with minimal restrictions, objectives. The aVordability of cigarettes under government industry agreements signed halved between 1985 and 1998, with the in 1973, 1979, 1985, and 1987. number of minutes needed to earn 20 The 1985 TCP forecast was “1990: as pub- cigarettes25 increasing from 12 (1985), to 22 lic support builds up, amend (the) law to ban (1995), and to 24 minutes (late 1998). Tax advertising and sports sponsorship.”1 The Act rates were significantly raised in real terms in banned new tobacco advertising from Decem- 1986, 1988, 1989, 1991, and 1998. From 1990 ber 1990 by print media and shops signs, and onwards tobacco tax was adjusted for inflation banned new sponsorships. However, manufac- at least annually. Tax rates per 1000 cigarettes turers used a legislative loophole to display or per kilogram of tobacco were equalised in-shop “price notices” resembling advertise- across tobacco product types based on their ments. During the 1995-98 period, manufac- tobacco weight (1995). In December 1998, the turers agreed to limit price notices to one tobacco excise was 19.3 cents (10 cents US) square metre per shop. The SFE Act, amended per cigarette (59% of the average price) and in 1997, made the ban total, restricting price the goods and services tax was another 3.6 notices to business card size from December Tobacco control in New Zealand 159
1998. Product displays were permitted. Only Socioeconomic status (SES) prevalence Tob Control: first published as 10.1136/tc.9.2.155 on 1 June 2000. Downloaded from Norway, Tasmania, and perhaps one or two The medical profession reduced its smoking other jurisdictions have such extensive prevalence early, from 35% (1963) to 20% advertising bans. (1976) to 15% (1981) to 5% (1996).33 This The 1990 “World Cup cricket amendment” two thirds reduction in smoking prevalence gave the Minister of Health power to grant among doctors between 1981 and 1996 was exemptions to the sponsorship ban, but few high compared to other occupational classes. were granted, and none after 1996. A proposed Professionals in total reduced their prevalence 1991 amendment would have repealed the by one third (from 23% to 16%), and technical tobacco sponsorship ban, but all parties agreed and other professionals class reduced in 1993 to postpone the commencement of the prevalence by 29% (from 41% to 29%). Only ban from 1993 to July 1995. The “Winfield minor prevalence changes (between −6% and amendment” permitted tobacco sponsored +0.8%) were recorded for the managerial class rugby league until December 1995. (29% to 27%), clerks (30% to 28%), service Advertising of tobacco brand names on and sales workers (36% to 35%), trades work- other goods was also banned by the SFE Act ers (35% to 36%), and labourers (49% to (1990), with qualified exceptions for goods 49%).34 In 1992-93, those of below average that had been on sale before the Act, such as socioeconomic status consumed three quarters Dunhill watches. Selling tobacco brand named of all tobacco (products).35 items such as clothing or coVee became illegal. CONSUMPTION PER ADULT OUTCOMES Main outcome measures Trends and targets The 1985 TCP paper set a target of reducing From 1975 to 1985, consumption (tobacco smoking prevalence in adults to 20%,1 without products consumption per adult) decreased specifying a time limit. From 1994 the Public 23%, accelerating to a 41% decrease in Health Commission27 and then the Ministry of 1985-95 under the TCP. The compound Health adopted this target for completion by annual rate of decrease in consumption 2000, and a consumption target of 1000 averaged −4.7% between 1985 and 1990, cigarettes per adult by 2000. −5.6% between 1990 and 1995, −0.8% between 1995 and 1998, then accelerating after the May 1998 tobacco tax increase. Results Over this review period between 1985 and SMOKING PREVALENCE OUTCOMES 1998, consumption decreased by 45%, from Adult prevalence 2493 to 1377 cigarettes per adult per year in The population reduced its smoking preva- 1998—75% of the distance to the 1000 target http://tobaccocontrol.bmj.com/ lence from 36% in 1976 to 32% in 1981, then set for the year 2000. Tobacco weight to 24% in 1996 (using census data); and (using consumed per adult—a measure not specified annual survey data) from 30% in 1985 when 9 in the targets—decreased 48% from 2149 g in the TCP began, to 25% in 1998 —halfway 1985 to 1118 g in 1998. towards the target of 20% prevalence by 2000. Adult smoking prevalence in 1995 was eighth Rate of reduction lowest among 21 countries. On tobacco products consumption per adult, New Zealand had the most rapid reduction of Youth and teenage prevalence smoking of any OECD country between 1985 Smoking prevalence in youth (aged 15–24 and 1995 (table 1). Between 1981 and 1996, years) decreased 20% (from 35% in 1985 to consumption fell 48% in New Zealand as a 9
28% in 1998). Of 17 countries, New Zealand whole, 41% in Canada, 40% in Australia, and on September 24, 2021 by guest. Protected copyright. had the third most rapid reduction of youth 38% among Maori in New Zealand.2 Twenty smoking prevalence between 1985 and 1995 OECD countries experienced lower percent- (table 1). Daily prevalence at age 15–19 years age decreases than Maori. fell 39% (from 31% in 1985 to 19% in 1998.5) Daily prevalence at age 14–15 years rose 37% 28 Consumption level (from 11.6% in 1992 to 15.5% in 1997). In 1995, New Zealand’s tobacco products con- sumption was second lowest of the OECD Maori prevalence countries, with only Sweden’s consumption Maori prevalence between 1981 and 1996 being lower (table 1). The 1998 level at 1371 decreased by 18% (from 56% to 46%) using cigarettes per adult was the lowest since the 1981 definition of Maori.2 In terms of per- records began in 1920. In comparison with the centage points, this 10 point reduction US states, New Zealand in 1995 appeared to compares with an 8 point reduction for the rank among the lowest four states for total population over the same period.29 In consumption, after allowing for RYO tobacco.4 1996, Maori had twice the smoking prevalence 30 of the total population, starting smoking CONSUMPTION PER SMOKER OUTCOMES earlier30 and continuing longer.30 Among ever In 1998, 78% of tobacco used was in manufac- smokers, 29% of Maori had quit, as against tured cigarettes, 21% in RYO, and 1% in pipe 48% in the total population.29 Interestingly, and cigar tobacco.24 Between 1985 and 1998, Maori had similar attitudes to smokefree cpd per smoker decreased by 34% (22.7 to issues,31 similar addiction and quit attempt 15.0 cpd). Between 1981 and 1996, cpd for rates,8 and were equally frequent users of the Maori decreased 25% (23.0 to 17.3 cpd) as Quitline32 compared to the total population. against a 28% fall (24.8 to 17.4 cpd) in the 160 Laugesen, Swinburn
total population.2 In 1995, Norway had a lower about 1666 to 1200 deaths (3.67 to 2.31 per Tob Control: first published as 10.1136/tc.9.2.155 on 1 June 2000. Downloaded from cpd but New Zealand’s rate of reduction in cpd 1000 per year). The cigarette attributable was the most rapid of 21 countries (table 1). deaths and mortality rate for middle aged women peaked around 1985 at 663 deaths. SMOKEFREE LIFESTYLE OUTCOMES The rate fell 10% from 1.35 per 1000 in 1985 At work to 1.21 per 1000 in 1996 (626 deaths). In 1989, 31% of workers were exposed to sec- 8 ond hand smoke while working (as opposed to Acceleration in the decline in cigarette mortality tea breaks), decreasing after the SFE Act to rate 21% in 1991, and to 19% in 1996.8 California, 36 37 Cigarette deaths averted per year in middle Norway, and Sweden banned smoking at aged men rose from 650 in 1985 to 938 in work, along with various US and Canadian cit- 1996, totalling 9600 averted deaths in middle ies. aged men from 1985 to 1996. The annual rate of decline in the cigarette attributable death Eating out rate accelerated 21% between 1975-85 and In 1998, 50% of restaurant seating was 1985-96. mandated smokefree, but bars carried no restriction. In 1998, California banned smoking in both restaurants and stand alone Lung cancer rate trends bars, while Utah,5 Norway,36 Western Mortality rates in New Zealand men (aged Australia, South Australia, and the Australian 35–69 years) decreased from 1975 (1.16 per capital territory had 100% smokefree dining 1000, 491 deaths) onwards. Lung cancer has laws. begun to decrease among women born after 1940. Among New Zealand women aged 35–54 years, lung cancer mortality rates At home decreased from 12 per 100 000 (67 deaths) in Of 14–15 year olds, 39% were exposed to sec- 40 38 1991 to 7 per 100 000 (46 deaths) in 1995. ond hand smoke in 1989, 33% in 1991, and In women overall, the lung cancer rate increased 38% and 39% in 1997, of whom one third were 9 exposed to two parents’ smoke.39 little from 1990-96. Lung cancer killed Maori at three to four times the rate of the total population.2 Cigarette attributable cancer rates CIGARETTE MORTALITY OUTCOMES In 1995, 4800 deaths (17% of all deaths) were in middle age decreased in Maori men between 1984-88 and 1989-93, but continued to attributed to cigarettes. In 1989-93 Maori 2 deaths comprised nearly 10% of these, increase in Maori women. 2 accounting for 31% of all Maori deaths. http://tobaccocontrol.bmj.com/ Lung cancer rate comparisons Deaths averted Lung cancer mortality rates in middle aged The estimated deaths from smoking at age New Zealand men ranked sixth lowest of 22 35–79, which were averted between 1985 and countries whereas middle aged women ranked 1996 because of the declines in smoking since fifth highest.3 Middle aged women in New 1975, were about 12 000 for men and about Zealand had a 51% higher lung cancer mortal- 200 for women, whose mortality rates have ity rate than in Australia in 1995,41 42 despite only decreased recently. In the absence of fur- almost identical female smoking prevalence ther declines in smoking from 1985, the smok- rates since 1976.43 In 1989-93, the lung cancer ing attributable deaths for 35–79 year old men mortality rates for middle aged Maori men and in 1996 would have been about 3500 instead of women2 were respectively higher than in either
the 2200 they actually were. For women aged sex of 22 OECD countries in 1990, except for on September 24, 2021 by guest. Protected copyright. 35–79 years, if 1985 smoking attributable mor- Belgian males.3 tality rates had applied in 1996, smoking attributable deaths would have been 1300, as CAPACITY TO REDUCE SMOKING FURTHER against 1200 estimated. Three quarters of the We estimate the potential reductions in male averted and 60% of the female averted consumption achievable within 3–6 years if deaths were age 35–69 years, each such middle there is suYciently strong political support for aged death on average averting 22 years of life the following three policies: (1) mass media otherwise lost.3 quit campaigns modelled on the Australian campaign and sustained for three years should Cigarette attributable mortality trends induce long term quitting (tobacco products Middle aged (35–69 years) cigarette attribut- consumption −10%) and increase short term able male mortality peaked around 1975 at quitting (−4%) across all SES groups; (2) step- 1917 deaths (table 2). The rate fell rapidly wise tobacco tax increases can achieve a 50% (37% decline) between 1985 and 1996 from increase in the price of cigarettes (estimated
Table 2 Mortality, whether cigarette smoking attributable or not, in New Zealand in middle age (age 35–69 years), 1975 to 1996, annual rates per 1000 persons, age standardised
Death rates per 1000 (mean of seven age specific rates, age 35–69 years) 1975 1985 1990 1995 1996 1985-96 % change Male, cigarette smoking attributable 4.57 3.67 2.89 2.41 2.31 −37% Male, all other mortality 9.48 8.21 7.16 6.57 6.53 −21% Female, cigarette attributable 1.01 1.35 1.33 1.28 1.21 −10% Female, all other mortality 6.50 5.42 5.01 4.45 4.34 −20%
Source: Peto et al3 for 1975-90; 1995-96 data calculated by same method. Tobacco control in New Zealand 161
44% reduction in tobacco products consump- and clearly warrant more attention. Adult Tob Control: first published as 10.1136/tc.9.2.155 on 1 June 2000. Downloaded from tion); (3) non-display of tobacco products in smoking prevalence has not decreased as shops (estimated 1–2% decrease in consump- rapidly as in other countries, consistent with tion). the more recent lack of political will for the The multiplied eVect of these policies TCP and the absence until recently of a media (assuming no overlap or synergy) would be to led quit campaign. California has decreased its reduce consumption by about 50%. Once con- prevalence to 18% through a range of strong sumption halves, we estimate that over 2000 tobacco control policies and, similarly, the deaths can be prevented before age 70, during Australian prevalence has now fallen to 22%.7 the first 16 years. As prevalence decreases, it is possible that the remaining smokers are the more heavily Discussion addicted ones and this might make further This review of New Zealand’s TCP shows that, reductions in prevalence diYcult.45 European despite not attaining its original prevalence tar- and white collar smokers, however, with half get, the TCP has fulfilled many of its original the prevalence rates of Maori and blue collar aims and has successfully reduced smoking workers, had similar addiction levels.8 While since 1985. Smoking rates in adolescents, not discounting the hypothesis completely, it Maori, and those of low socioeconomic status, does suggest that the prevalence rates could be while remaining high, have also reduced over reduced substantially without encountering this time period. Exposure to second hand any great increase in nicotine induced smoke at work has also reduced. Cigarette resistance to quitting. attributable mortality has declined significantly Smoking in several groups, particularly for males including Maori, and is declining in lower SES groups, has decreased little if at all women under 70 years in the total population, and therefore strategies which are particularly though not for Maori. eVective in lower income groups need to be The level of TCP activity has been highly used preferentially. Tax increases and media dependent on the prevailing political will and led quit campaigns are good examples of strat- was closely correlated to changes in smoking egies which should reach lower SES groups prevalence. Activity was highest in 1984-90, eVectively, if not preferentially. The continued culminating in the SFE Act. A new high smoking rates among Maori is of major government in 1990 wanted initially to repeal concern and interventions to reduce these rates the tobacco sponsorship ban; and did not fund need to be kept a high priority. Cigarette any media quit campaign from 1991-98, but attributed cancer is still rising in Maori women instead began a campaign in 1996 to prevent of middle age, and the higher rate of lung can-
adolescents from starting to smoke. Adult cer in New Zealand women compared to Aus- http://tobaccocontrol.bmj.com/ prevalence fell from 27% in 1990 to 26% in tralian women of middle age is consistent with 1991 (owing to a tax increase), rose to 27% high female smoking prevalence from a young during 1991-94,4 a period of little political age. commitment to TCP, fell to 26% during 1995- 98, and fell again to 25% in 1998 following a Conclusion tax increase.32 New Zealand’s TCP has been successful by The medical profession led the reduction in OECD standards in reducing smoking rates. smoking by example in the 1960s, but little The TCP, however, needs to be broadened in happened in the wider population until the scope and better resourced to lower smoking 1980s when major health groups funded ASH and smoking attributable morbidity and to publicise and politicise the issue. The new mortality further. The key to achieving this is
government welcomed the 1985 TCP political will. Government commitment is on September 24, 2021 by guest. Protected copyright. initiative. Health groups formed coalitions at needed to strengthen the taxation, legislation, critical periods. The committed health and regulation strategies as well as to provide bureaucracy, and the absence of a large adequate resources for quit campaigns to assist tobacco growing and manufacturing industry, Maori and low SES smokers in particular. The also assisted. A single legislature, a slow rate of comprehensive tobacco control policy now GDP growth to fuel demand for consumer needs updating for 2000 to 2005. Given products such as cigarettes, and a government suYcient political commitment to the above often needing taxation revenue, also helped. strategies, it appears possible that tobacco con- The reductions in smoking compare favour- sumption could be halved over the next 3–6 ably with other OECD countries, and by most years. measures New Zealand appears to have achieved the greatest percentage reduction in The authors acknowledge financial assistance from the Ministry of Health in researching this paper, but the views expressed are tobacco products consumption over the entirely those of the authors. 1985-95 decade. New Zealand’s tobacco taxa- tion policies increased government revenue 1 Advisory Committee on Smoking and Health. Comprehen- sive policy for the promotion of non-smoking in New Zealand. and reduced consumption. Decreased aVord- Wellington: Department of Health, 1985. ability could also help explain the relatively 2 Laugesen M, Clements M. Cigarette smoking mortality among Maori 1954–2028. Wellington: Te Puni Kokiri (Ministry of rapid reduction of youth smoking prevalence as Maori Development), 1998. 44 the decision to smoke can be price sensitive. 3 Peto R, Lopez AD, Boreham J, Thun M, Jr CH. Mortality from smoking in developed countries 1950–2000. Oxford: Despite these gains, major concerns still Oxford University Press, 1994. remain about New Zealand’s TCP. Smoking 4OYce of Smoking and Health. CDC’s tobacco information—state and national tobacco control high- prevalence among 14–15 year olds recently lights, California. Atlanta: Centers for Disease Control. increased. The causes of this are not apparent www.cdc.gov/nccdphp/osh/statehi/, 1999. 162 Laugesen, Swinburn Tob Control: first published as 10.1136/tc.9.2.155 on 1 June 2000. Downloaded from 5 AC Nielsen (formerly OTR Spectrum Research). Cigarette 27 Public Health Commission. Tobacco products. Wellington: smoking surveys. Wellington: Ministry of Health, 1982– Public Health Commission, 1994. 1999. 28 Laugesen M, Scragg R. Trends in cigarette smoking in 6SaVer H, Chaloupka F. Tobacco advertising: economic fourth-form students in New Zealand, 1992–1997. NZ theory and international evidence. Working paper 6958. Med J 1999;112:308–11. Cambridge, Massachusetts: National Bureau of Economic 29 Anon. Census of population and dwellings, smoking prevalence Research, 1999.
25 Laugesen M. Tobacco statistics 1996. Wellington: Cancer 45 Fagerstrom KO, Kunze M, Schoberberger R, et al. Nicotine http://tobaccocontrol.bmj.com/ Society of New Zealand and Ministry of Health, 1996. dependence versus smoking prevalence: comparisons 26 Non-Smokers’ Rights Association. Average retail selling among countries and categories of smokers. Tobacco price and total tax incidence for a pack of 20 cigarettes in Control 1996;5:52–6. various countries as of March 22, 1995. Ottawa: 46 US Department of Agriculture.