The New Zealand Government adopted the “Smokefree 2025” policy in March 2011. The aim of the policy is to bring smoking rates to below five percent of all population groups by December 2025. Arguably, the main measure for achieving this goal is the attempt to make tobacco products less affordable. Since 2011 the government has imposed an additional 10 percent excise tax, plus inflation, on tobacco products annually. Whilst it may be a noble goal, is this the least harmful way to reduce the harm that tobacco causes?

Marewa Glover is Associate Professor in Public Health for the School of Health Sciences at Massey University. Her research addresses major public health threats for Maori and has worked in Tobacco Control for 23 years across policy, health promotion, advocacy, and research. Glover is also author of Māori Smoking: An epic saga of love and abuse and co-author of An Online Survey of New Zealand Vapers. Reuben McLaren spoke with Glover.

 

Reuben McLaren: To start off with, we’ll talk about the two population groups with the highest smoking rates in New Zealand, Maori and Pacifica. Have the tobacco tax hikes had any real impact on smoking cessation for them?

Marewa Glover: [Some] people do quit; they are prompted to try and quit by the rising prices. So we always see a burst of activity at the beginning of the year when the price goes up. But in the lower socioeconomic groups with financial strain it is very difficult to maintain that cessation. The financial strain prompts people — well, it triggers people — to relapse often.

RM: There is the idea that at first the tax hikes were effective, but now we’re stuck with what might be called “hardcore smokers”. And maybe it’s having less impact on them. What do you think about that.

MG: I don’t like to think of the people as being “hardcore smokers”; I always think that it’s more about our policies not being designed to be effective for some groups. They work for particular sections: higher socially ranked groups respond to the tax increases. There is a lot of research that claims that lower economic people are particularly sensitive to price increases, and you would think that is logical. Of course, they would be; but financial strain causes a lot of stress — and all the other problems that go along with low income and crowded housing and unemployment will cause stress. Stress is a major trigger for smoking and a major function of smoking is to relieve stress. What we may have been doing all along is increasing the strain and stress for some groups, the groups who have the lowest income and a lot of stress already, so we compound that and that becomes a trigger to smoke. In some ways we might be driving some people to smoke while others are being driven to quit. So you get a balancing out. With what is happening now, the analysts might go, “Well, on balance more people are quitting than smoking. We’re going to get health gain for more people, so it’s okay”. But, on the other hand, we’re worsening the situation for some people.

RM: So what do you think needs to change or what other actions need to be taken by the government?

MG: If you look at Pacific Island smoking rates, for instance, their rates haven’t changed over the last ten years, and that was almost the case for Maori smoking rates as well, except in the tenth year the decline reached significance. So for nine years there was no statistically significant difference. And then in the tenth year, it was, and we finally have a reduction, but the rate of reduction is very slow. So it’s about understanding that some policies work for different groups, and the socioeconomic status is a major factor in terms of what effect the policy is going to have.

Given that we’re down to about fifteen percent of New Zealand smoking and, if you have a look at the demographic[s], [those are] the people who are overrepresented — they’re of lower socioeconomic groups, Maori, Pacific, people with mental health illnesses, drug and alcohol issues — and we need to review the whole comprehensive program and look at what will work for those groups. I think that the ones who can quit will quit, the ones who have resources will quit. There [are] plenty of resource[s] now for them to access. We’re seeing an enormous shift to vaping and, again, we’ll see that first among those that have resources to access those products and the information they need to successfully do that. So… we need to review the whole thing.

We need to stop the tax rises, particularly. What I say is we just need to hold on, because it’s a bit scary for the government to go, “Oh no, we need that money. No, we can’t stop that”. But, at the moment, we just need to pause it. [We need to look at] the unintended negative effects of the tobacco tax now — and I mean New Zealand has… the highest price of tobacco in the world relative to income, and I think we’ve passed the tipping point. We’re now seeing the robberies, the injury to shopkeepers, the number of people being incarcerated for robbery-related crimes.

The black market is growing in tobacco, but it isn’t just that. People, especially under financial strain already, can’t quit smoking and are using the money that they need for food to buy tobacco. It’s not that they don’t buy food, it’s just the food that they buy is going to be more obesogenic, so it doesn’t help with the rising obesity rates. So there [are] a lot of unintended negative effects that we haven’t been looking at, and I’m glad to hear that the Ministry of Health is now going to review that. They’re going to be looking at the unintended negative effects. They’re going to be reviewing the tobacco tax rises to see if this is still the way to go. And I believe it isn’t, I think it time to pause that and try other measures.

RM: Previously you talked about smoking rates over a ten-year period. Is that ten years from now? So 2008?

MG: From 2006-7 to 2016-17, that is the New Zealand health survey data which is on the Ministry web site. So yes, going back ten years.

RM: You mentioned the unintended consequences of these tax hikes. A lot of people argue against outlawing tobacco because of them. We’ll get a prohibition era, where we’ll have an increase in black markets and there will be more crime. But are we already seeing a kind of soft prohibition era on tobacco?

MG: Yes, I think we are. I’m often asked this: “Why doesn’t the government just ban it?” The main reason is that there are several trade and investment laws that the government has entered into over many years and those laws prevent a total ban. You can’t expect foreign investors to come invest in your country and bring their business and then turn around and prohibit their products, so those trade and investment laws are there for other economic reasons that they’re under the control of other ministries, and so that option isn’t there at the moment. It would take a lot of effort and a long time — a lot of political wrangling, lobbying, and discussion — to actually revisit that, because it would put all of our trade and investment at risk. Other industries would go, “Well, where are you going to stop and are you going to stop us?” We would [not] become a safer place to invest. So it’s huge. We need to look at what we can do within the current laws across the board.

Soft prohibition, you said: I think that is a good way to put it. I think that prohibition is exactly what is being proposed now by some people lobbying the government to reduce smoking and to achieve Smokefree 2025. They are pushing a prohibitionist agenda. Why that concerns me is because we never actually agreed even on the five percent figure, it’s kind of random. So Smokefree 2025, the goal is to get to five percent or below by 2025. It was not to get to zero percent. I don’t believe that zero percent is realistic — even two percent of doctors still smoke. In 2006, I think, three percent of doctors smoked. So we need to be realistic, there are going to be people who can’t quit and there are going to be a small percentage of people who don’t want to quit. I think that what we need to look at is about being realistic. And one of the unintended negative effects of what we’re doing now — and there [are] many — is the stigmatisation of smokers, the discrimination that they’re beginning to feel. The New Zealand Defence Force last year… passed a smoke free policy. They’re going to go smoke free, nobody will smoke. Nobody who is employed by New Zealand Defence will smoke. Well, hang on a minute, thirty-three percent of Māori men smoke, does that mean they can’t go into the Defence Force, housing corps, or [The Department of Conservation]? The Department of Conservation are being lobbied to make all the land under their control smoke free. We really need to stop and go, “Hang on a minute, where are we going with this?”

There is no evidence for banning smoking in outside areas, it doesn’t harm anybody except for the person who [are] smoking themselves. But evidence doesn’t seem to count anymore. People are just going, “Wow, let’s ban it everywhere, ban the sale of it and don’t let people smoke anywhere”. Well those people who aren’t going to quit or can’t quit, where are they going to be, where will they be left to smoke? I’ve just seen some results come out of a global poll of thirteen countries and New Zealand was one of them. They asked people across the thirteen countries, “What are the three top things that trigger your smoking?” So the first one is obviously waking up in the morning, everybody’s nicotine levels are low and so they’re going to smoke. That was fairly consistent across the thirteen countries. Some countries had “when their drinking coffee” and “when they’re out with friends”. New Zealand had “when they’re drinking alcohol” as one of the reasons and it made me think. Yes, actually, we have banned smoking in so many areas that one of the areas where people smoke now is when they’re out at the pub. Although outside – you must be outside – but still, we may have strengthened the association between smoking and drinking alcohol.

So what we’ve been doing is a really silo-ed approach. We’re not looking at like, “If we do this, will we actually worsen another social problem or a public health problem?” For example, will we worsen alcohol consumption, or will we worsen obesity? What now needs to happen is a real thorough look at the unintended negative effects of what we’ve been doing, of our approach to date, especially now that these other effects are starting to show up so clearly.

RM: You bring up an interesting point on the stigmatisation of smokers. I would sometimes jest that smokers are a persecuted minority. But, regarding the information you just shared, it doesn’t seem like a joke anymore.

MG: No, it’s not a joke. This has been a deliberate strategy. It’s part of what tobacco control call “de-normalisation”. It’s a strategy being used across the world to de-normalise smoking and part of this includes campaigns — like the one we ran back in the early 2000s — where we called smokers losers. So there has been a very deliberate stigmatisation of smokers trying to break down their identity as a smoker; to tarnish it, to taint it. So why would anyone want to identify as a smoker when you are an outcast, basically? The very powerful psychology of it is to threaten people with social exclusion, and so smokers are feeling marginalised. If a pregnant woman — who is obviously pregnant — is out in public smoking, it’s not uncommon that people will openly abuse her for having a cigarette. So it’s really gone to the extreme, and I think they are now a persecuted minority.

There was a recent article in The Herald… about a guy down in Hawke’s Bay. He put a camera on his porch because someone was coming in the middle of the night. He caught a middle-aged woman, and you can clearly see she is coming onto his porch in the middle of the night stealing cigarette butts out of an ashtray. He went to the papers with it and they made this really horrible story about her. He said things like, “If I quit [smoking], what are they going to do? Are they going to break into my house? And they’re going to hurt my children?” I felt only compassion and sadness and it made me cry. But she is being driven to this, to go on to her neighbour’s porch — and he said she was doing it to someone else as well — to steal cigarettes. You call that stealing? I mean it’s rubbish, but to take cigarette butts out of the ashtray?

RM: I just found the article, you’re right. It’s heart-breaking.

MG: It’s heart-breaking, it’s disgusting. And he was just so horrible about her, only painting her like she’s a criminal, and he tried to get the police to charge her. This is what we’ve come to in New Zealand. We’ve also got people like dairy owners — one guy has lost his eye, two more in Hamilton, one has just suffered a skull fracture. Nobody cares about them. I [asked] somebody in tobacco control who was going to a hui [committee] about crime…  to do something — talk about what is happening to the dairy owners, for instance. And he said he has no sympathy for anyone who sells tobacco. So I think that what is happening is a threat to the nature of Kiwis, the way we are and our culture. Dairies and convenience stores are going to turn into a little cage, when you go you’ll enter a little cage and you say, “Can I please have?” Similar to going to the petrol station at night… you can’t go in anymore, you have to go up to the window, and they will be behind a cage, and you’ll say, “Can I please have a litre of milk or a bit of sugar or something?” We really need to, as a society, seriously address where we are going with these kinds of public health measures that stigmatise people and de-humanise some to that extent you see in that video. I don’t think that is us.

RM: Regarding burglaries for cigarettes, RNZ reported that dairy and convenience store owners are demanding that the government funds cigarette vending machines to discourage robberies and the violent nature of them.

MG: New Zealand’s quite unique in this sense, there is a black market wherever tobacco taxes have been applied and applied to such high levels around the world — Australia and the U.K., for example. The difference for New Zealand is that we are an island state, so tobacco can’t just be brought across the border. People can’t just go across the border and buy cheaper tobacco. And the other thing is… we reduced the duty-free allowance. It was 2015 when that came in, and after New Year’s 2016 the price went up, and that is when the robberies of dairies began to skyrocket. I’m not saying it was just a reduction in the duty-free allowance — which dropped it from 200 to 50 cigarettes — but definitely, that has contributed to the spike. So where is the black-market tobacco, the cheaper tobacco, going to come from? You can’t bring it in over the border, you can’t now bring it when you travel, you are only allowed to bring 50 cigarettes which are for your own use only. So they must get it internally. They’re going to rob dairies, they’re going to rob petrol stations. How are we going to solve it? I don’t agree with necessarily the tougher measures. I don’t agree with the prohibition agenda. We need to address what we’ve done, we need to review the price of tobacco, it has definitely passed the tipping point and too much harm is now being done to too many people — [with] the robberies etc. It’s not just the dairy owner, usually a car is stolen as well, so it just goes on.

RM: And regarding alternative measures such as vaping and e-cigarettes, do you think there should be more government backing on it or at least a legalisation of the nicotine “e-liquid”?

MG: Yeah. So that is interesting. I don’t believe we’ve heard what [has] happened to that. The previous government announced that it was going to pass legislation this year regarding regulations on cigarettes and vaping products, that the nicotine e-liquid would be legal to import and sell in New Zealand. Now the Labour Government seems to have put it on a back burner and they’re not saying, in fact, certainly Minister Jenny Salesa even said, “Oh, Labour hasn’t got a position on that yet, we’re not sure what they’re going to do”. Well that is kind of horrifying, because people are switching to these products and now after National said that the law is going to change, pretty much all the vape shops started selling nicotine e-liquid and many people have switched to vaping and are continuing to switch to vaping. That is fantastic. It means they’re not smoking, or they are at least transitioning towards not smoking. It absolutely is the new and alternative strategy. So that is the first thing to do. The second thing is that there is a whole range of other harm reducing products that, if we’re going to allow vaping, why wouldn’t we allow those as well or some of those? Because vaping might not work for everybody. So the heat-not-burn product is another example and the Ministry [of Health] just took [Phillip Morris] to court over the ICOS product. They’ve clearly signalled that it is not to be imported for sale in New Zealand. Though, if you look at Japan — which doesn’t have e-cigarettes because they banned them — the ICOS has taken twenty-two percent of the tobacco smoking market very rapidly, more rapid than any other kind of product change. So that is another disruptive technology that maybe would work for some people. There is also Swedish snus, which End Smoking NZ lobbied for over ten years ago, but we couldn’t get anybody to agree to allow it to come into New Zealand. There is now over twenty years of data showing that it is harm reduced. And Sweden and Norway are leading the world and reduced smoking rates and reduced cancer, cardiovascular disease, etcetera.

RM: Do you think this comes down to a lack of political will? Maybe it’s almost as though the government policies on changing the culture around smoking have worked so well that they can no longer sell these harm reducing policies to their constituents.

MG: I believe that it is really the academics that drive this. They advise and lobby their ministers, so it’s academics and it’s the NGO health organisations. For example, when the government changed, the Asthma and Respiratory Foundation of New Zealand began to lobby very hard against e-cigarettes. It is organisations like that, that are lobbying Jenny Salesa; trying to get her to reverse the previous government’s promise to bring in the e-cigarette regulation, which would legalise the nicotine e-liquid. The whole soft prohibition, as you called it, all of those policies are driven by public health academics and they also lobby very hard to have what they want brought in. So at some point politicians may make up their own mind about what they want done, and the Ministry of Health will, of course, play an important role in advising the ministers as well. So there is a whole lot of players, but particularly tobacco control has been driven very hard by academics and those health organisations, like ASH and End Smoking NZ, which I’m chair of. We’ve lobbied for ten years for harm reduction, but there is a lot of fighting going on between all of those groups.