L8 Public Health Smokefree 2025

Overview

This lecture traces the Smokefree 2025 goal in Aotearoa New Zealand: why smoking is such a large and inequitably distributed harm, what evidence-based tobacco control measures exist (cessation support, nicotine replacement, retail and marketing controls), the “tobacco endgame” policies designed to reach near-zero prevalence (denicotinisation, retail outlet reduction, the smokefree generation law), the 2023-2024 repeal of that legislation and the tobacco industry lobbying behind it, and what role doctors can play as advocates.

The scale and perception of harm

• Cigarette smoke contains 4000+ chemicals, 50+ of them carcinogens; smoking also causes many non-fatal diseases (e.g. amputation, disfigurement, laryngectomy), not just fatal ones.
• In a large Australian cohort, smokers reach any given cumulative mortality risk roughly 9-10 years earlier than non-smokers (by age 75, men: ~44.0% cumulative death risk in smokers vs ~13.9% in non-smokers; women: ~33.0% vs ~12.2%).
• Smokers substantially underestimate their own risk: actual relative risk of lung cancer rises steeply with cigarettes/day (from ~9 up to ~21.5), but perceived relative risk stays flat and low (~5-6.5) regardless of how much someone smokes.
• Smokers are unrealistically optimistic about their own ability to quit: across surveys, people rate quitting as much easier for themselves than for others, and much less likely to be “almost impossible” for themselves (e.g. Robert Wood Johnson youth survey: rated “easy” for oneself 43% vs only 2% for others).
• Global toll: an estimated 100 million tobacco deaths in the 20th century, projected to reach 1 billion this century if trends continue.

Current status of smoking in New Zealand

• NZ population daily smoking rate is 6.9%, having gradually declined over the past decade (after a period of increase, now plateauing).
• Ethnic inequities persist despite the overall decline (NZHS 2011/12-2023/24): Māori prevalence fell from ~37.7% to ~17.3% (still highest), Pacific from ~22-23% to ~14.7%, European/Other and Asian from ~14.7%/~7% down to ~3-9%.
• Deaths attributable to smoking (2013-2015): 22.6% of Māori deaths (2,199 of 9,717), 13.8% of Pacific peoples’ deaths, 12.3% of non-Māori/Pacific deaths.
• Smoking odds rise steeply, roughly exponentially, with deprivation: odds ratio for smoking climbs from ~1.0 in the least deprived decile to ~5.5-5.8 in the most deprived decile.
• Quit attempts (2008-2020 survey) show no clear trend over time; “no quit attempts in the past 12 months” remains the largest category each year (~43-52%).
• NZ ITC data (2020): high regret (~82% regret starting) and intention to quit (~70% planning to quit) but much lower actual recent quit attempts (~45% attempted in the last year, ~35% planned within 6 months) - a gap between intention and action.

Individual smoking cessation

• Methods: pharmacological aids and behavioural support.
• Success rates: about 2% of people who smoke quit per year unaided; ~4% with simple advice from a health professional; about 20% long-term quitting is achievable with structured smoking cessation interventions. Multiple quit attempts are usually needed before success (mean probably >10).
• NRT (nicotine replacement therapy) approximately doubles success rates.
• Nicotine delivery speed drives addictiveness: cigarettes deliver nicotine fastest and to the highest peak plasma level (peaking ~25-26 mg/ml within 5-10 minutes); nasal spray peaks quickly but lower (~15 mg/ml); gum/inhaler/tablet rise gradually to a lower plateau (~7-8 mg/ml by 30 min); patches stay very low and flat throughout. Electronic cigarettes generally deliver lower and/or slower plasma nicotine than combustible cigarettes, though variable-power tank devices come closer to combustible levels than cig-a-likes or fixed-power tanks.
• Trial evidence (Hajek et al. 2019): comparing ENDS vs NRT, both with behavioural support, 1-year abstinence was higher with ENDS (18.0%) than NRT (9.9%; RR 1.83, 95% CI 1.30-2.58, P<0.001). In real-world use, behavioural support is not typically offered alongside ENDS, which are usually bought over the counter with limited advice.
• Smoking is more than a nicotine-delivery habit: it is a social practice embedded in other practices (alcohol use, mealtimes, coffee) and is associated with perceived benefits (comfort, stress/anxiety relief, friendship) - these must be addressed alongside pharmacological substitution.

Electronic nicotine delivery systems (ENDS/vaping) and new nicotine products

• Framed as either a disruptive innovation that could end the smoking epidemic (harm-reduction view, focused on adult smokers) or a “Trojan horse” recruiting new generations to nicotine dependence (youth-protection view); evidence on population-level impact is mixed, contested and muddled by tobacco industry involvement.
• ENDS have helped some individuals quit smoking, but overall population impact is unclear. Transitioning fully from smoking to vaping (or to abstinence) is a complex journey: a different physical experience (hand/mouth, inhalation), nostalgia for smoking’s attributes, and disruption of social connections built around smoking. There is little emphasis on vaping cessation itself, and continued tobacco industry presence in the space is not conducive to health outcomes.
• Youth trends: among Year 10 (14-15 year olds), daily smoking fell steadily from ~15.5% (1999) to ~1.2% (2024), while daily vaping (appearing from ~2015) rose sharply to a peak of ~10% around 2021-2022 before declining slightly to 8.7% by 2024 - daily vaping has substantially overtaken daily smoking in this age group.
• Among 15-24 year olds, total daily nicotine-product use has risen overall, driven by growth in vaping-only use, while daily-smoking-only has shrunk.
• Among Year 10 students who vape daily, the proportion who have never smoked has risen sharply (from ~10.7% in 2019 to ~40.4% in 2023), i.e. an increasing share of daily vapers are vaping without ever having smoked.
• Competing explanations for the smoking-vaping relationship in young people: (1) gateway - vaping is an entry practice that progresses to smoking; (2) common liability - these young people would have smoked anyway, so vaping instead is preferable; (3) “move on, nothing to see” - vaping mostly occurs among youth who already smoke. The rising share of never-smokers among daily vapers is presented as evidence consistent with gateway concerns.
• Continuing monitoring is called crucial, particularly around decisions to make heated tobacco products (HTPs) cheaper and to introduce oral nicotine products (pouches).
• Manatū Hauora (Ministry of Health) evidence review found no compelling evidence of benefit from HTPs or from snus/nicotine pouches as smoking cessation tools (studies lacked population-level data, limited exposure/health-effect information, no empirical studies of complete transition from smoking). Some evidence of harm was identified for both product types: increased dependency/addiction risk, toxicant exposure, cardiovascular impacts, chronic respiratory disease, and developmental impacts; because both product types are relatively new, more health outcomes are likely to emerge over time.

Tobacco control framework and measures adopted

• The Framework Convention on Tobacco Control (FCTC) is a global treaty for comprehensive tobacco control policy; NZ ratified it in 2004. Key articles include price/tax measures (Art. 6), protection from smoke exposure (Art. 8), regulation of product contents (Art. 9) and disclosures (Art. 10), packaging/labelling (Art. 11), public education (Art. 12), advertising/promotion/sponsorship bans (Art. 13), and demand-reduction/cessation measures (Art. 14).
• NZ has adopted many FCTC measures: gradually controlling marketing (removing advertising and sponsorship, removing tobacco “powerwalls” and the “silent salesperson” display in shops) and normalising smokefree spaces (ending smoking in bars, ending smoking and vaping in cars).
• Despite these measures, change has been too slow: the ethnicity gap in smoking prevalence (Māori and Pacific peoples consistently higher than European/Other and Asian) has persisted.

Origins of Smokefree 2025 and the tobacco endgame

• Smoking imposes a disproportionate burden on Māori. Māori leaders proposed the tobacco endgame vision and launched the first “denormalisation” campaigns.
• The 2010 Māori Affairs Select Committee inquiry into the tobacco industry and its consequences for Māori led to a government response agreeing to the goal of reducing smoking prevalence and tobacco availability to minimal levels, making New Zealand essentially a smokefree nation by 2025.
• Tobacco endgame = an explicit government intention and plan to reach close to zero tobacco use prevalence, rejecting the status quo of gradual, incremental decline in favour of innovative solutions applied quickly.
• The Smokefree Aotearoa 2025 Action Plan’s six focus areas: (1) ensure Māori leadership and decision-making at all levels; (2) increase health promotion and community mobilisation; (3) increase evidence-based stop-smoking services; (4) reduce the addictiveness and appeal of smoked tobacco products; (5) reduce the availability of smoked tobacco products; (6) ensure manufacturers, importers and retailers meet their legal obligations.
• Core Aotearoa endgame policies: denicotinisation (very low nicotine cigarettes), a large reduction in the number of retail outlets selling tobacco, and a “smokefree generation” law.

Denicotinisation (very low nicotine cigarettes, VLNCs)

• Under the plan, denicotinisation would have applied to all smoked tobacco products, which would have required approval to be sold in NZ, with manufacturers subject to annual testing to demonstrate compliance.
• A 1959 internal British American Tobacco document already recognised the threat: lowering nicotine too much “might end up destroying the nicotine habit in a large number of consumers and prevent it from ever being acquired by new smokers.” The logic: if tobacco is no longer addictive, there is no craving to smoke and no reward for smoking.
• Strong empirical (RCT) support: people supplied with VLNCs found them less satisfying and less able to relieve cravings, and as a result smoked less, were exposed to fewer toxins, were more likely to try to quit, and were more likely to succeed in quit attempts.
• Modelling (Ait Oukrim et al. 2023) projects that a low-nicotine policy would produce a much faster and larger decline in smoking prevalence than business-as-usual out to 2060, for both Māori and non-Māori, converging to very low levels (near 0-5%) by around 2030 under the low-nicotine scenario versus a much slower decline (staying at ~15-20% for Māori by 2060) under business-as-usual.

Retail outlet reduction

• NZ currently has no licensing scheme or register for tobacco retailers; an estimated 6000-8000 retailers sell tobacco, concentrated in high-deprivation neighbourhoods (tobacco outlet numbers rise with deprivation decile, peaking around deciles 8-9).
• The plan aimed to reduce outlet numbers by ~95%, to around 600 outlets, by allowing only authorised retailers to sell tobacco, cutting numbers significantly, and ensuring supply was not concentrated in more deprived areas.
• Rationale: widespread availability is illogical given known harms (a historical anachronism); reframing tobacco as “not normal” is overdue and could reduce youth uptake; existing high retailer density entrenches health inequities; and removing temptation supports cessation and reduces relapse risk.
• Strong industry and small-retailer opposition argued the measure would reduce financial viability (“rips the guts out of an important source of footfall”), a particularly potent argument in the post-Covid era.
• This “footfall” argument is not supported by NZ and US studies: most convenience-store purchases do not involve tobacco at all - only around 15% of transactions involved tobacco, and of those, two-thirds were tobacco-only purchases; just 5% of all transactions combined tobacco and non-tobacco items.
• Industry-linked campaigning included a “Save Our Stores” Facebook page (revealed to be backed by British American Tobacco NZ) running sponsored ads with anti-prohibition messaging, warnings that new laws would “hand more power to gangs,” and arguments that tobacco tax revenue funds 35,000 police officers.

Smokefree generation (SFG)

• Modelling (Van der Deen et al. 2018) estimates an SFG policy would decrease smoking prevalence overall and could halve prevalence within 14 years among people aged 45 and under, with the effect described as greater for Māori and Pacific peoples (pro-equity), including 5.6 times the health gain per capita for Māori compared to non-Māori.
• Projected prevalence trajectories show the SFG strategy declining much faster than business-as-usual for both Māori and non-Māori, with the largest absolute prevalence gap for Māori.

Repeal, key challenges and industry influence

• Illicit trade was raised as a “bogeyman” threat (reduced government revenue, gang power, product-standard concerns); NZ’s proposed response was greater monitoring of illicit supply, though the fundamental point made is that reducing smoking prevalence itself means little or no illicit market to begin with.
• The endgame measures were framed by opponents as an attack on freedom: British American Tobacco NZ argued the SFG restricted “personal freedoms” and young people’s “right to autonomy,” amounting to “age discrimination”; dairy owners and small retailers called it “another arrogant hand-wringing response from people who want to tell others how they ought to live.”
• The “prohibition” framing is argued to be fundamentally illogical, since nicotine itself remains available (e.g. via vaping) and most cigarettes are consumed by dependent smokers who regret their use and want to quit, not by recreational users. This is described as an industry “zombie argument” - a last resort used when there is no empirical or logical opposition available.
• The smokefree legislation (denicotinisation, retail reduction, smokefree generation) was subsequently repealed, which the lecture presents alongside evidence of tobacco industry lobbying.
• The lobbying material shown includes a Manatū Hauora briefing to the Associate Minister of Health, Hon Casey Costello (“Getting to Smokefree 2025: reform of vaping, smokeless tobacco and consumer nicotine product regulation”, IN CONFIDENCE, due 31 January 2024), presented next to what appears to be a leaked internal memo with sections struck through and marked “DELETED”. That memo reportedly argued nicotine is “as harmful as caffeine” and that its association with smoking has seen the poorest punished by huge taxes, since the poorest make up 64% of all daily smokers, used to justify moving smokers onto vaping. Its smoking bullet points reportedly proposed or referenced repealing the Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Act 2022 and Regulations 2023, zero-rating excise where nicotine content is below 0.8 mg/gram, and freezing excise rates on smoked tobacco for three years from 31 December 2023. These are reported leaked-memo contents rather than confirmed enacted policy.

The transcript flags the small print on this leaked-memo excerpt as partly obscured and overlapping, so it could not be read in full.

• Evidence of political-industry connections: NZ First Minister Shane Jones was reported to have taken tobacco-policy advice from a PMI (Philip Morris International) lobbyist (“We took soundings from a whole range of people”), and, asked about compliance with the FCTC, was reported to have said he would give “not one iota of attention” to the matter.

Transcript ambiguous here: the two caption boxes on this slide overlap, so both the exact wording of the Shane Jones quote and what it referred to (the Treaty or the FCTC) are uncertain, and were transcribed only as a best-effort composite.

• Analysis of released documents found the Associate Health Minister’s tobacco policy recommendations conflicted with official Ministry advice but aligned with tobacco industry lobbying talking points (“Mind the gap”).
• “#JUULGATE” (Hoek, Cochran, Ball, 2025) highlighted leaked nicotine-industry documents (including a “political-economic landscape for nicotine vapor” strategy document) as evidence for the need for greater transparency in public health policymaking.
• Implications drawn: public health should challenge industry discourse and influence, expose the hypocrisy of trying to “unsmoke the world” while continuing to sell smoked tobacco, reframe “right to autonomy” as freedom from addiction, and take opportunities for political accountability.

Role of doctors

• Doctors and public health practitioners have historically been framed as natural advocates for affected communities (Sigerist): they see the social causes of illness as clearly as the physical ones and are well placed to speak out.
• Following the repeal of smokefree legislation, the medical profession publicly opposed the change (reported in RNZ, BBC and other media), including calls for select-committee scrutiny and expressions of disappointment from physicians.
• What doctors can/should do:
  • Follow best-practice cessation care (with training if needed): identify people who smoke and provide high-quality individual smoking cessation support.
  • Set an example by being smoke-free themselves.
  • Support and advocate for systematic cessation support being available.
  • Support and advocate for broader tobacco control measures and the Smokefree 2025 goal.
  • Hold politicians to account.

Self-test

1. Describe how the cumulative mortality risk of smokers compares with non-smokers over the lifespan, and by roughly how many years smokers reach a given risk level earlier.
2. Explain the mismatch between actual and perceived relative risk of lung cancer as cigarette consumption increases.
3. Describe the optimism bias smokers show about their own ability to quit compared with how they view others’ ability to quit.
4. Describe the current pattern of smoking prevalence inequity in New Zealand by ethnicity and by deprivation.
5. List the methods of individual smoking cessation intervention and give their approximate success rates, with and without support.
6. Explain why cigarettes are more addictive than approved nicotine replacement products in terms of nicotine delivery kinetics.
7. What did the Hajek et al. trial find when comparing ENDS and NRT (both with behavioural support), and what caveat limits generalising this to real-world ENDS use?
8. Distinguish the “gateway,” “common liability,” and “move on, nothing to see” explanations for the association between youth vaping and smoking.
9. What did the Manatū Hauora evidence review conclude about heated tobacco products and nicotine pouches as smoking cessation tools?
10. List the three core policies of the Aotearoa tobacco endgame.
11. Describe the mechanism and expected outcomes of denicotinisation (very low nicotine cigarettes) based on RCT evidence.
12. Explain the rationale for reducing the number of tobacco retail outlets, and describe the evidence against the retailer “footfall” argument.
13. What does modelling predict a smokefree generation (SFG) policy would achieve, and what does it say about its equity impact?
14. Describe how tobacco industry and small-retailer opposition framed the endgame measures, and explain why the “prohibition” framing is considered illogical.
15. A patient tells you they “want to quit but it’s basically impossible for someone like me.” Using the concepts from this lecture, how does their view compare with the usual pattern of smokers’ beliefs about quitting, and what would you offer them?
16. List at least four actions doctors can take to support progress toward Smokefree 2025.

Answers

Reveal answers

1. In a large Australian cohort, smokers reach any given cumulative mortality risk (by age 75) roughly 9-10 years earlier than non-smokers; by 75, cumulative death risk was about 44.0% in male smokers vs 13.9% in male non-smokers, and about 33.0% vs 12.2% in women.
2. Actual relative risk of lung cancer rises steeply with cigarettes/day (from about 9 up to about 21.5), but smokers’ perceived relative risk stays flat and low (about 5-6.5) across all consumption levels - smokers substantially underestimate how much heavier smoking increases their risk.
3. Across surveys, smokers rate quitting as much easier for themselves than for other smokers, and rate it as much less likely to be “almost impossible” for themselves than for others - an unrealistic optimism about their own capacity to quit compared with how they judge others.
4. NZ daily smoking prevalence overall is 6.9% and gradually declining, but Māori (~17.3%) and Pacific peoples (~14.7%) remain markedly higher than European/Other and Asian groups (~3-9%); smoking odds also rise roughly exponentially with deprivation, from about 1.0 in the least deprived decile to about 5.5-5.8 in the most deprived decile.
5. Methods are pharmacological aids and behavioural support. Unaided quitting succeeds in about 2% of smokers per year; simple health-professional advice raises this to about 4%; structured cessation interventions can achieve about 20% long-term quitting; NRT roughly doubles success rates versus no support.
6. Cigarettes deliver nicotine fastest and to the highest peak plasma level (peaking around 25-26 mg/ml within 5-10 minutes), producing a stronger, quicker reward that reinforces addiction; approved NRT products (spray, gum/inhaler/tablet, patch) deliver nicotine more slowly and to a much lower peak, so they are far less addictive.
7. The trial found 1-year abstinence was higher with ENDS (18.0%) than NRT (9.9%), a statistically significant difference. The caveat is that this trial provided behavioural support alongside ENDS, which is not typically offered in real-world ENDS use, where products are usually bought over the counter with limited advice - so the trial result may not generalise to typical use.
8. Gateway: vaping is an entry practice that leads young people on to smoking. Common liability: these young people would have ended up smoking regardless, so vaping is a comparatively safer substitute. “Move on, nothing to see”: vaping mostly occurs among young people who already smoke, so it isn’t recruiting new nicotine users.
9. The review found no compelling evidence of benefit from HTPs or snus/nicotine pouches as smoking cessation tools (studies lacked population-level data and full-transition evidence), but did find some evidence of harm from both product types, including increased dependency/addiction risk, toxicant exposure, cardiovascular impacts, and chronic respiratory disease, with more health outcomes likely to emerge over time given their relative newness.
10. Denicotinisation (very low nicotine cigarettes), a large reduction in the number of outlets selling tobacco, and a smokefree generation policy.
11. VLNCs (very low nicotine cigarettes) are less satisfying and less able to relieve cravings, so RCT evidence shows people supplied with them smoke less, are exposed to fewer toxins, are more likely to attempt to quit, and are more likely to succeed. Modelling projects this policy produces a much faster decline in prevalence than business-as-usual for both Māori and non-Māori, converging to very low levels by around 2030 rather than remaining substantially higher out to 2060.
12. Widespread tobacco retail availability is illogical given known harms, entrenches inequity (outlets are concentrated in high-deprivation areas), and removing easy access supports cessation and reduces relapse. Against the retailer “footfall” argument, NZ and US studies found only about 15% of convenience-store transactions involved tobacco at all, two-thirds of those were tobacco-only purchases, and just 5% of all transactions combined tobacco with other goods - so tobacco sales drive little of a store’s overall business.
13. Modelling predicts an SFG policy would decrease smoking prevalence overall and could roughly halve prevalence within 14 years among people aged 45 and under. Its effect is described as greater for Māori and Pacific peoples, that is, pro-equity, with 5.6 times the health gain per capita for Māori compared with non-Māori. [slide does not elaborate on the reason for this difference]
14. Industry and retailer opposition framed the measures as an attack on personal freedom and autonomy (even “age discrimination”) and as economically damaging to small businesses. The “prohibition” framing is considered illogical because nicotine itself would remain legally available (e.g. via vaping), and because most cigarettes are consumed by dependent smokers who already regret smoking and want to quit, not by recreational users choosing to start - so removing supply targets dependence, not recreational “choice.”
15. This patient’s pessimism runs opposite to the usual survey pattern: smokers typically show optimism bias, rating quitting as much easier for themselves than for other smokers (for example 43% rated it “easy” for oneself vs 2% for others), so they underestimate rather than overestimate how difficult quitting will be for them. Either way, explain that most people need multiple attempts (mean probably >10) before succeeding, which is normal rather than a sign of failure. Offer pharmacological aids (NRT roughly doubles success rates) plus behavioural support, since structured cessation intervention achieves around 20% long-term quitting versus roughly 2% unaided, and address the social and emotional roles smoking plays (comfort, stress relief, friendship, its embedding in drinking, coffee and mealtimes) rather than only its pharmacology.
16. Follow best-practice cessation care and get training if needed; identify people who smoke and provide high-quality individual cessation support; set an example by being smoke-free themselves; support and advocate for systematic cessation support availability; support and advocate for broader tobacco control measures and the Smokefree 2025 goal; and hold politicians to account.