Tobacco Achievements Summary Report tabled in Parliament on 14 August 2014 by the Hon

Tariana Turia (docx, 200 KB)

Tobacco Achievements
Foreword

When I first entered parliament in 1996, one in four New Zealanders aged 15 and over, were
smoking daily. Secondary smoke exposure was part of our life; as was the loss of life to far
too many generations of New Zealanders who die prematurely from smoking.

Tobacco reform was therefore a key priority for me when I was appointed Associate Minister
of Health in 2008. I am so proud of the amazing achievements engineered by a highly
motivated workforce; a passionate community of advocates and a responsive health sector
in creating a pathway to a smokefree Aotearoa by 2025.

In a relatively short period of time we have been able to reduce tobacco consumption in all
types of tobacco products and across all population groups. The strategy has been a
comprehensive campaign in all spheres of influence health education, legislation, smoking
cessation, and tobacco taxation. The political will to reduce smoking prevalence and
consumption has been encouraging; the influence of the policy milestones negotiated in the
Relationship Accord with the Mori Party has also been significant.

There are still areas of significant challenge. As a nation we must continue to support
interventions which can support Mori, young adults and people with lower socio-economic
status to become smokefree. There is more that we can do in enacting the Smokefree
Environments Act. I have been impressed by the efforts of some local government bodies
to make public outdoor spaces smokefree. I have loved the efforts in Wainuiomata to
encourage their community to think about the children before they light up. All of us can
become wellbeing champions in our own homes, our marae, and our communities.

The Governments goal to be Smokefree by 2025 rests in all of our hands. It is a driven by
the vision that families are entitled to be well; to enjoy long life; to be free of chronic illness. I
commend this tobacco achievements report to all New Zealanders as a powerful message of
what we can achieve, when we work together in the common pursuit of a Smokefree
Aotearoa.

Mauri Ora!

Hon Tariana Turia

Associate Minister of Health

Minister Turia was awarded the World Health Organisation Western Pacific Region award for work on
tobacco control on 31 May 2014, World Smokefree Day

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Summary
Excellent progress has been made towards reducing harm caused by tobacco use. Tobacco
use results in between 4,500 and 5,000 deaths a year, is the single largest cause of
preventable death and chronic illness in this country, and is a major factor in health
inequality. The lifespan of those smokers who die prematurely from smoking is, on average,
reduced by 15 years. Both smoking prevalence and tobacco consumption, the two main
measures of progress in tobacco control, are falling rapidly.
The 2013 Census and the New Zealand Health Survey of 2012/13 reported daily smoking to
be 15%.1 and 15.5% respectively. As detailed below, this decline in smoking rates has
occurred in all ethnic groups, across all deprivation groups, among both genders, and
among most ages.
The decrease has not, however, been spread evenly across those groups. Smoking
prevalence and consumption are higher among Mori, young adults and people with lower
socio-economic status. Those communities bear a disproportionate burden of smoking-
related illness and death.
Tobacco consumption has plummeted. After falling gradually between 2000 and 2008
(generally hovering around the 1000 cigarette equivalents per year mark), tobacco
consumption has dropped from 961 cigarette equivalents per capita (adult over 15 years of
age) in 2009 to 683 per capita in 2013, a decrease of about 29 %. The sale of all types of
tobacco products - manufactured cigarettes, roll-your-own cigarettes, cigars and pipe
tobacco - is in decline.
What has brought about these dramatic changes? New Zealand has a comprehensive
tobacco control programme, which includes health education, legislation, smoking cessation
support and tobacco taxation. All are currently in use in New Zealand. They are most
effective when applied in combination.
Although it is difficult to untangle the contributions of each component, there can be no
doubt that raising the price of tobacco products through taxation increases has been
the most important single contributor, particularly to the drop in tobacco
consumption and the decline in youth smoking. In 2013, daily smoking among 14-15
year olds was down to 3.2 % and 75 % had not smoked a single cigarette. Smoking is
no longer normal in this age group and most will remain smokefree for life.
Price measures alone cannot achieve the Governments tobacco goal. Informing people of
the harm caused by tobacco use through media campaigns, health warnings on packets and
the like are crucial. The Mori Affairs Committees inquiry into the tobacco industry in
Aotearoa and the consequences of tobacco use for Mori gave tobacco issues a high public
profile and the Government adopted its main recommendation of an essentially smoke-free
Aotearoa by 2025.
Smoking cessation support services have been strengthened and cessation aids have
become more accessible. The Government health target requiring patients in secondary
hospital and primary care to be asked their smoking status and provided with brief advice
and support to quit has led to many thousands of smokers being encouraged and helped to
stop smoking.
The Smoke-free Environments Act 1990 has been amended. Work to further reduce
tobacco advertising by banning the display of tobacco products in retail outlets was passed
in July 2011 and the main provisions came into force a year later. Government
consideration of further measures to minimise tobacco advertising by introducing
standardised tobacco packaging and new larger health warnings, are well advanced. Legal
provisions to protect people from second-hand smoke have not changed, but surveys show
a gradual decline in exposure rates and many local authorities, encouraged by non-

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government organisations, have adopted, and in some cases extended, the smokefree
areas within their jurisdictions.
These developments have been magnificently supported by the non-government
organisations that support tobacco control and the tobacco research community has
provided high quality evidence to inform the development of policy and to promote innovative
ways to help smokers to quit.
As a result of these efforts promising progress has been made towards New Zealand
becoming an essentially smoke-free nation by 2025, but it is still an ambitious target. Much
remains to be done if the target is to be achieved. Hopefully the new Pathway to Smoke-
free New Zealand 2025 Innovation Fund will help us to reach those priority groups among
whom smoking rates remain far too high.

Reduced Smoking Prevalence and Consumption

1 Smoking Prevalence
Information on smoking prevalence has been obtained primarily from two sources, the New
Zealand Health Survey (NZHS) reports prepared by the Ministry of Healths Health and
Disability Intelligence Unit and data from the New Zealand Census which included two
questions on smoking in 1981, 1996, 2006 and 2013.
The 2013 Census showed that regular (daily) smoking for people aged 15+ years had fallen
from 20.9 % in 2006 to 15.1 % in 2013. The New Zealand Health Survey, using different
methodology, reported daily smoking to be 15.5 % in 2012/13.
While the Census reports regular smoking (essentially daily smoking), the New Zealand
Health Survey reports its findings primarily in terms of current smoking prevalence, that is,
those who smoke daily, weekly or monthly.
Detailed smoking prevalence data from the NZHS, both daily and current smoking rates
broken down by age, ethnicity and gender, are available at
http://www.health.govt.nz/publication/new-zealand-health-survey-annual-update-key-
findings-2012-13. Note that some of the NZHS data in this report is being prepared for
publication and is subject to change.
Smoking prevalence is declining in all ethnic groups, across all deprivation groups, among
both genders and amongst most ages. New Zealand has seen a significant decrease in
both current and daily smoking since 1996/97. In 1996/97, 25.2% of the adult population
(aged 15+ years) were daily smokers. By 2012/13, this rate had dropped to 15.5% which
equates to around 554,000 adult daily smokers.

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Daily smoking, 1996/97-2012/13 (age-standardised prevalence)

30

25

20
Percent

15

10

0
1996 2002 2006 2011 2012
Year

Data sources: 1996 = 1996/97 New Zealand Health Survey (NZHS); 2002 = 2002/03 NZHS; 2006 = 2006/07 NZHS; 2011 =
2011/12 NZHS; 2012 = 2012/13 NZHS

Census returns also showed a large decline in adult smoking prevalence, from 20.9 % in
2006 to 15.1 % in 2013 for the New Zealand population aged 15+ years - a remarkable
decline of 22.5 %.

Smoking Prevalence by age

According to the New Zealand Health Survey there has been a significant decrease in the
rate of current smoking in 15-19 year olds from 19.8% in 2006/07 to 12.7% in 2012/13.
Between 2006/07 and 2012/13, the largest decline in current smoking prevalence occurred
amongst 15-19 year olds (36%) followed closely by those aged 65-74 years (27%). The
third significant decline was recorded with smokers in the 25-34 year old age group (13%).
Those aged 75 years plus recorded a slight increase in smoking prevalence rates, although
this was not significant.

Time trend of current smoking prevalence by age group between 2006/07 and 2012/13
Relative percentage
Age group 2006/07 (%) 2012/13 (%)
change (%)
15-19 19.8 12.7 -36*
20-24 27.3 25.4 -7
25-34 28.3 24.5 -13*
35-44 22.3 20.5 -8
45-54 21.4 20.0 -7
55-64 15.0 14.8 -2
65-74 10.9 8.0 27*
75+ 4.0 4.4 9
Data sources: NZHS 2006/07 and NZHS 2012/13
*There is a statistically significant (p<0.05) difference between the prevalences in 2006/07 and 2012/13

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Although there was a significant decrease in young female smoking rates in the 1519 age
group between 2006/07 and 2012/13, there was no significant change for their male
counterparts.
For 15-17 year olds the current rate of smoking decreased from 15.7% in 2006/07 to 8.0% in
2012/13. The Action on Smoking and Health (ASH) Year 10 Survey also found large
decreases in smoking rates among 14 and 15 year old students.

Time trend of smoking prevalence among 14 and 15 year olds

Smoking
1999 2003 2006 2008 2009 2010 2011 2012 2013
status (%)

Daily 15.6 12.1 8.2 6.8 5.6 5.5 4.1 4.1 3.2

Weekly 6.7 4.3 3.3 2.6 2.7 2.4 2.0 1.8. 1.8

Monthly 6.3 4.3 2.8 2.5 2.6 2.1 2.1 1.8 1.8

Regular 28.6 20.7 14.2 11.9 10.9 10.0 8.2 7.7 6.8

Never
31.6 42.4 54.0 60.7 64.0 64.4 70.4 70.1 75.1
smoked

Data source: ASH year 10 snapshot survey 1999-2013

Similar to the NZHS, the 2013 census showed large decreases in smoking prevalence in all
age groups compared with the 2006 census, particularly in the younger age groups.

Time trend of regular (daily) smoking prevalence by age group between 2006 and 2013 Censuses
Age group 2006 (%) 2013 (%) Relative percentage
change (%)
15-19 19 10 -42
20-24 30 21 -30
25-34 27 20 -26
35-44 24 18 -25
45-54 22 18 -18
55-64 16 13 -19
65+ 8 7 -12
Data sources: NZ Census 2006 and 2013

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Smoking prevalence by ethnicity
The general decline in the overall prevalence of smoking in recent years has not occurred at
the same rate across all population groups, with some groups showing greater declines than
others.
As shown in the table below, between 2006/07 and 2012/13 the European/Other group
showed the largest decline (16%) amongst the ethnic groups.

Time trend of current smoking prevalence by ethnicity between 2006/07 and 2012/13
Ethnic group 2006/07 (%) 2012/13 (%) Relative percentage
change (%)
Mori 40.2 38.2 -5
Pacific 26.2 23.9 -9
Asian 10.6 10.3 -2
European/Other 20.3 17.0 -16*
Data sources: NZHS, 2006/07 NZHS; 2012/13
*There is a statistically significant (p<0.05) difference between the prevalences in 2006/07 and 2012/13

According to the 2013 ASH Year 10 smoking survey of 14 and 15 year olds, smoking among
Mori in Year 10 is also continuing to show a rapid decline. Daily smoking amongst Mori in
Year 10 has declined to 8.5% in 2013 compared to 26.9% in 2003 and 30.3% in 1999.
Regular smoking has also greatly reduced for Mori Year 10 students. For 2013, the figure
is 14.7% compared to 20.9% in 2010, 23.3% in 2009 and 42.8% in 1999.
Census returns showed large declines in smoking prevalence among all ethnic groups.

Time trend of regular (daily) smoking prevalence by ethnicity between 2006 and 2013
Ethnic group 2006 (%) 2013 (%) Relative percentage
change (%)
Mori 43 33 -23
Pacific 30 23 -23
Asian 11 8 -27
Middle Eastern, Latin
15 11 -27
American, African
European 19 14 -26
Total 20.9 15.1 -22.5
Data sources: NZ Census: 2006 and 2013

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Smoking prevalence by neighbourhood deprivation
Current smoking prevalence fell in all neighbourhood socioeconomic deprivation groups
between 2006/07 and 2012/13, but the declines were not even across all groups. Adults
living in the middle quintiles (2, 3 and 4) showed the biggest declines (22%, 17% and 17%
respectively). Nevertheless, in 2012/13 smoking prevalence remained lowest in quintile 1
and highest in quintile 5.

Time trend of current smoking prevalence by neighbourhood deprivation between 2006/07 and
2012/13
Neighbourhood Relative percentage
2006/07 (%) 2012/13 (%)
deprivation change (%)
Quintile 1 13.0 12.8 -11
Quintile 2 17.3 13.4 -22*
Quintile 3 20.1 16.7 -17*
Quintile 4 24.6 20.5 -17*
Quintile 5 33.1 31.3 -5
Data sources: NZHS; 2006/07, NZHS; 2012/13
*There is a statistically significant (p<0.05) difference between the prevalences in 2006/07 and 2012/13.

Smoking prevalence by gender

Current smoking prevalence fell significantly by a similar amount for both males and females
(11% and 13% respectively) between 2006/07 and 2012/13. The proportion of females
smoking in 2012/13 (17.6%) was significantly lower than the proportion of males smoking
(20.0%).

Time trend of current smoking prevalence by gender between 2006/07 and 2012/13
Gender 2006 (%) 2012 (%) Relative percentage
change (%)
Male 22.4 20.0 -11*
Female 20.3 17.6 -13*
Data sources: NZHS; 2006/07, NZHS; 2012/13
*There is a statistically significant (p<0.05) difference between the prevalences in 2006/07 and 2012/13.

The Census showed a larger downward trend for daily smokers.

Time trend of regular (daily) smoking prevalence by gender between 2006 and 2013
Gender 2006 (%) 2013 (%) Percentage change (%)
Male 22. 16 -27
Female 20. 14 -30
Source: NZ Census; 2006 and 2013

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2 Tobacco Consumption
More than any other measure, changes in tobacco consumption are related to the price of
tobacco. Some quit smoking in response to price increases but many more respond by
reducing their consumption or, in the case of many young people, not taking up smoking.
The tables below are from different sources and not strictly comparable. The data for 1999
2009 is from Statistics NZ and records tobacco products available for consumption -
essentially, product on which excise or duty has been paid. This series was discontinued in
2010 for reasons of confidentiality. The data for 2010-2013 is from the tobacco product
sales information provided annually by tobacco manufacturers and importers. The data are
is similar, but not identical.
After falling gradually between 2000 and 2008 (hovering around the 1000 cigarette
equivalents per year mark), tobacco consumption per adult aged 15+ has fallen dramatically
from 961 cigarette equivalents per capita in 2009 to 683 cigarettes per capita in 2013, a
decrease of about 7.2 % per year. The sale of all types of tobacco products - manufactured
cigarettes, roll-your-own cigarettes, cigars and pipe tobacco - is in decline.
Tobacco products released for consumption in New Zealand, 19992009
Number of cigarette equivalents released per adult
Tobacco products released
(15+ years)
Year Manufactured
Loose tobacco Loose tobacco per Manufactured
cigarettes Total per capita
(tonnes) 15+ cigarettes per capita
(millions)
1999 736 3119 251 1062 1312
2000 841 3152 281 1058 1352
2001 780 2608 262 875 1136
2002 810 2817 265 922 1187
2003 795 2367 255 759 1014
2004 841 2320 266 733 999
2005 889 2436 276 757 1033
2006 879 2439 269 747 1016
2007 904 2445 270 732 1002
2008 870 2550 257 755 1012
2009 856 2436 250 711 961
Source: Statistics New Zealand

Tobacco products sold in New Zealand, 2010-2013

Number of cigarette equivalents released per adult
Tobacco products released
(15+ years)
Year Manufactured
Loose tobacco Loose tobacco per Manufactured
cigarettes Total per capita
(tonnes) 15+ cigarettes per capita
(millions)
2010 771 2220 222 639 861
2011 631 2083 180 593 773
2012 593 2017 167 570 736
2013 564 1886 157 526 683
Source: Tobacco return sales data 2013 (Health New Zealand)
Notes for both tables:
1. One cigarette equivalent equals one manufactured cigarette or one gram of loose tobacco.
2. One tonne equals 1000 kg.

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3. It is assumed that one cigarette equals one gram of loose tobacco and one tonne of loose tobacco equals one million
manufactured cigarettes.
4. Calculations of cigarette equivalents are based on tobacco return data for manufactured cigarettes and loose tobacco
released for sale.
5. Per capita means for each individual (15+ years) in the population.

Achievements through Improved Tobacco Control

1 Tobacco Taxation
In October 2009, Cabinet agreed in principle to increase the excise on tobacco products. On
28 April 2010, tax on tobacco products was increased by 10% with an additional 14%
increase in the tax on loose tobacco. Increases of 10% on 1 January 2011 and 1 January
2012 were also provided for. The Mori Affairs Committee urged (Recommendation 32) the
Government to legislate for further incremental tax increases over and above the annual
adjustment for inflation. In October 2012, the Customs and Excise (Tobacco Products
Budget Measures) Amendment Act 2012 legislated for a further four tobacco tax increases
of 10% to come into effect on 1 January each year from 2013 to 2016.
The World Health Organization regards increasing the price of tobacco through higher taxes
as the single most effective way to decrease tobacco consumption and encourage smokers
to quit. Although, price rises do not work alone but they are instrumental in ensuring the
overall package of mutually-reinforcing measures (including Health Targets, smoking
cessation services and medication, retail controls, smoke-free environments, health
warnings, public education and media campaigns) works to maximum effect to reduce
smoking levels.
The biggest health gains from increasing tobacco taxes were expected to be among Mori
(particularly Mori women), Pacific, and low income communities, who are all significantly
over represented in smoking rates. There is also strong evidence that young people are
particularly price sensitive when making decisions about smoking uptake. The health
benefits of an excise increase are therefore likely to build over time.
Annual adjustments to the tobacco excise, based on movements in the Consumer Price
Index (CPI), occur every year, subject to Cabinet approval. In recent years this adjustment
has taken effect on 1 January. Increases in the tobacco excise over and above the inflation
adjustment have occurred from time to time, for example in 1998 and 2000 (a 14%
increase). However, the price of tobacco products is set by the tobacco companies and may
be more, less, or the same as the tobacco excise increase.
As noted, the first of the recent series of tobacco tax increases occurred on 28 April 2010.
The tax on all tobacco products was increased by 10% and there was an additional increase
of 14% on loose tobacco to align the excise tax on manufactured cigarettes with that on
loose tobacco based on the weight of tobacco. The tax on loose tobacco therefore
increased by about 25%.
The subsequent tobacco tax increases occurred as follows:
1 January 2011 10% increase on all tobacco products + CPI of 1.65%
1 January 2012 10% on all tobacco products + CPI of 4.492%
1 January 2013 10% on all tobacco products + CPI of 0.86%
1 January 2014 10% on all tobacco products+ CPI of 1.28%
In recommending the Bill that provided for four cumulative increases to the excise tax on
tobacco products of 10% from 2013 to 2016 to the House, by majority, the Finance and
Expenditure Committee also recommended that the Government:

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 monitor closely the progress made over the next few years toward the goal of a
smoke-free New Zealand by 2025, and implement further excise tax increases after
2016 if its achievement is in doubt.
As indicated, these increases in tobacco tax excise have contributed to significant decreases
in the amount of tobacco used by encouraging quitting, discouraging smoking uptake and
prompting smokers to smoke less. They have almost certainly contributed to the decline in
smoking prevalence, particularly to the decline in smoking rates among young people. Calls
to The Quitline, which spike with each tax increase, suggest this.

Inbound Calls to Quitline

9000
8000
7000
6000
5000
4000
3000
2000
1000
0
1/09/2010

1/05/2012

1/01/2014
1/01/2010
1/03/2010
1/05/2010
1/07/2010

1/11/2010
1/01/2011
1/03/2011
1/05/2011
1/07/2011
1/09/2011
1/11/2011
1/01/2012
1/03/2012

1/07/2012
1/09/2012
1/11/2012
1/01/2013
1/03/2013
1/05/2013
1/07/2013
1/09/2013
1/11/2013
Source: The Quit Group (Quitline)

Another consequence of the price increases is that those who have continued to smoke
have gravitated towards cheaper cigarettes. Lower priced cigarette brand variants have
been introduced and have been successful in gaining significant market share.
The chart below shows the changes in tobacco consumption for manufactured cigarettes
and loose tobacco in recent years, together with trend lines showing the relative increases in
tobacco excise for the two product classes, and the daily smoking prevalence as measured
by the NZ Health Survey (2006, 2011/12 and 2012/13).

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Duty-free and Gift Concessions
The current duty-free allowances allow for significantly cheaper avenues of smoking which
are out of step with the Governments broader measures particularly the tobacco excise
increases to make New Zealand effectively smoke-free by 2025.
However, from1 November 2014, the duty-free allowance will fall from 200 cigarettes to 50
cigarettes. The new limit will align New Zealand with the duty-free tobacco concession that
has been in place in Australia since 2012. In addition, and also from 1 November 2014,
tobacco products sent to New Zealand as a gift from abroad will no longer be eligible for the
$110 duty-free gift allowance. This means all gifts of tobacco products sent to New Zealand
will be subject to excise duty and GST.
These new rules will help to close these anomalies, thereby reducing the opportunities for
cheaper smoking.

2 Mori Affairs Select Committee Report

At its 23 September 2009 meeting, the Mori Affairs Committee resolved to conduct an
inquiry into the tobacco industry in Aotearoa and the consequences of tobacco use for
Mori. The committee called for public submissions on the inquiry. The closing date for
submissions was 29 January 2010. The committee received 260 submissions and many
supplementary submissions. It also received 1,715 form letters. It heard 96 of the
submissions orally at hearings of evidence at Wellington, Christchurch, Rotorua, and
Auckland. The committee reported to Parliament on 3 November 2010.
The purpose of the inquiry was to gain a comprehensive understanding of the actions of the
tobacco industry to promote tobacco use amongst Mori, and the impact of tobacco use on
the health of the Mori population, and the wider economic, social, cultural and
developmental impacts that arise from such health effects and tobacco use more generally.

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During the course of the inquiry tobacco issues were frequently prominent in the media.
People obtained a better understanding of the harm caused by tobacco. The process
contributed to the denormalising of smoking and to the development of a climate conducive
to advancing the tobacco control policies recommended.
The Government responded to the Committees 42 recommendations in March 2011.
Recommendation 1 from the Committee was that the Government aim for tobacco
consumption and smoking prevalence to be halved by 2015 across all demographics,
followed by a longer-term goal of making New Zealand a smoke-free nation by 2025.
In response, the Government agreed with a longer term aspirational goal of reducing
smoking prevalence and tobacco availability to minimal levels, thereby making New Zealand
essentially a smoke-free nation by 2025. This formal recognition of the need to address
tobacco issues urgently reinforced the momentum provided by the Committee process.
Public health proponents and tobacco control advocates have interpreted the Governments
goal of reducing smoking prevalence and tobacco availability to minimal levels to mean a
smoking rate of less than 5% of New Zealand adults, and that this should be achieved
across all major ethnic groups.
The Ministry of Health Statement of Intent 2013 to 2016 set mid-term goals. It included the
statement that To achieve the long-term smoke-free 2025 goal:
daily smoking prevalence falls to 10% in 2018
the Mori and Pacific rates halve from their 2011 levels.

3 The Pathway to Smoke-free New Zealand 2025 Innovation Fund

The Pathway to Smoke-free New Zealand 2025 Innovation Fund was established in 2012
and was one of the actions taken by the Government in response to the Mori Affairs
Committees inquiry into tobacco. The Innovation Fund was established to advance
progress towards the aspirational goal of making New Zealand an essentially smoke-free
nation by 2025. Specifically, the funds purpose is to support innovative approaches to
reduce the smoking prevalence among Mori, Pacific peoples, pregnant women and young
people across New Zealand. The fund distributes up to $5 million per annum.
Two funding rounds have been administered to date and 22 projects are receiving funding.
The first set of projects began in June 2013, and the second set began in June 2014.
Examples of projects funded include marae-based cessation support and education
sessions in Northland, a workplace cessation and wellbeing programme in Gisborne, a
mobile quit bus in Auckland, and a month-long stop smoking campaign whereby smokers
across the entire country will be targeted. Details of all projects are available at
http://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/pathway-
smokefree-new-zealand-2025-innovation-fund/smokefree-new-zealand-2025-innovation-
funding-successful-projects.
In 2013, a decision was made to ring-fence $250,000 from the Innovation Fund specifically
to provide grants to smaller, community-based projects. These projects focus on youth
(aged 1224 years), have an emphasis on Mori, Pacific peoples, and pregnant women of
any ethnicity.
The first six community projects began in April 2014, and were based in the selected areas
of Opotiki and Camberley. The second set of projects will be selected in August 2014 (to
commence in November 2014), and will be based in the selected areas of
Whanganui/Manawatu and Gisborne/East Coast. Details of all projects are available at:
http://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/pathway-

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smokefree-new-zealand-2025-innovation-fund/smokefree-new-zealand-2025-innovation-
fund-summary-round-one-projects
Going forward, the Ministrys intention is to share the outcomes of these initiatives to support
uptake of successful innovation:
continue to administer funding rounds as funding becomes available, selecting
innovative projects that are assessed as contributing to the Smoke-free New Zealand
2025 goal
extend the funding on existing projects where evaluations show they are contributing
to the Smoke-free New Zealand 2025 goal.

4 Health Target: Better help for smokers to quit

Better help for smokers to quit is a Government health target. The health target requires
that 95% of patients who smoke and are seen by a health practitioner in public hospitals,
and 90% of patients who smoke and are seen by a health practitioner in primary care will be
offered brief advice and support to quit smoking. Progress will be made towards 90% of
pregnant women who smoke being offered advice and support to quit.
Since the health target was introduced in 2009, incredible progress has been made. When
the Ministry first began reporting on the health target, only 17% of smokers that were
admitted to hospital were receiving brief advice and cessation support. Five years on, the
hospital component of the target has been achieved, meaning that over 95% of hospital
patients who smoke are now being given better help to quit smoking.
A number of initiatives have helped District Health Boards to achieve this massive change,
including providing accessible and relevant training and nominating smokefree champions
on each of the wards.
Advice and support to quit is being provided to over half of New Zealand's smokers through
the primary care component of the target. That result is currently at 71.6 % (a 14.7%
improvement from 2013) but is expected be over 75% by the end of 30 June 2014. This
means approximately 380,000 people who visited their general practitioner during the 2013-
14 financial year received brief advice and support to quit smoking. Two DHBs met the
primary care target and three more are achieving over 80%. All DHBs improved their
performance compared to the previous year.
Percentage of smokers who are offered help to quit, 2009/102012/13

Health Target Performance (Q1 2009/10 to Q3 2013/14)

100%
80%
60%
40%
Hospital target
20%
Primary care target
0%
2009/10 Q1
2009/10 Q2
2009/10 Q3
2009/10 Q4
2010/11 Q1
2010/11 Q2
2010/11 Q3
2010/11 Q4
2011/12 Q1
2011/12 Q2
2011/12 Q3
2011/12 Q4
2012/13 Q1
2012/13 Q2
2012/13 Q3
2012/13 Q4
2013/14 Q1
2013/14 Q2
2013/14 Q3

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This target is designed to prompt clinicians to routinely ask about smoking status as a
clinical vital sign, and then to offer brief advice and quit support to current smokers. There
is strong evidence that brief advice from clinicians is effective at prompting quit attempts and
long term quit success. The quit rate is further improved by the provision of effective
cessation therapies, including pharmaceuticals and face-to-face support.
As of the March quarter 2014, data from the Midwifery and Maternity Provider Organisation
and Lead Maternity Carer (LMC) Services (which represents around 80% of pregnant
women registered with a midwife) show that 86.9% of pregnant women (1497 out of 1723
smokers), who smoked and registered with a LMC, were offered advice and/or support to
quit during the quarter. The Ministry continues to look for a data source for the maternity
target that represents a greater proportion of the population.
Although health targets are supporting clinical practice change and helping to drive positive
results to reduce smoking, there are other initiatives as part of the wider tobacco control
programme that contribute to these outcomes.

New Zealand Guidelines for Helping People to Stop Smoking

The New Zealand Guidelines for Helping People to Stop Smoking provides guidance for
health care workers to use during their contact with smokers. An updated version was
published on 4 June 2014. The guidelines are structured around the ABC pathway for
stopping smoking, which requires health care workers to Ask about and document every
persons smoking status, give Brief advice to stop to every person who smokes, and to
strongly encourage every person who smokes to use Cessation support (a combination of
behavioural support and stop-smoking medicine) and offer to help them access it The new
Guidelines document is now only six pages in length and contains simple yet pragmatic
information for busy health care workers. The updated Guidelines and its supplementary
documents are available at: http://www.health.govt.nz/publication/new-zealand-guidelines-
helping-people-stop-smoking

ABC e-learning tool

The ABC pathway is a simple memory aid that incorporates the key steps for screening and
advising on tobacco use and its treatment.
The e-learning resource shows a variety of health professionals entering into the ABC
pathway conversation with their clients. It replaces an earlier training tool and has a modern
look and feel, with interactive text, holograms and continuous scrolling. Access is through
the LearnOnline platform and is hosted by Kineo. The new course includes an assessment,
and if a pass mark of more than 80% is obtained, the recipient can become a quit card
provider. CME points are also available. The resource is available at:
http://learnonline.health.nz/

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Improved access to licensed smoking cessation medications
In New Zealand all evidence based licensed smoking cessation medications are now fully
subsidised. These include:
Nicotine replacement therapy (NRT) - three forms are subsidised patch, gum and
lozenge.
Nortriptyline (Norpress) - available on prescription only
Bupropion (Zyban) - available on prescription only
Varenicline (Champix) - available on prescription only.
From February 2008, all medical practitioners who have the right to prescribe were able to
distribute Quit Cards without undertaking additional cessation training. Prior to this date, only
400 general practitioners were Quit Card providers and able to offer subsidized NRT to their
patient.
In June 2008, the Quit Groups Txt2Quit service was launched. This service used text
messages as a tool to support people attempting to quit smoking.
In July 2009, Bupropion (Zyban) was subsidised as a smoking cessation medication and in
September 2009 NRT became available on a prescription (as well as via a Quit Card) -
meaning that general practitioners did not have two systems for prescribing subsidised
medications.
In October 2010, Varenicline (Champix) was added to the subsidised list of medications with
a special authority requirement. The Special Authority means that a number of criteria have
to be met before a smoker becomes eligible for a subsidised course of Varenicline. These
include having previously tried quitting with the assistance of another subsidised smoking
cessation medication and not having had another subsidised course of Varenicline in the last
twelve months.
Use of subsidised smoking cessation medications is a highly cost-effective intervention.
Promoting the use of these products has long been a focus for the Ministry of Health as they
can double the chances of a person quitting successfully when compared to going cold turkey
that is, having no support. Adding extra behavioral support enhances the odds of success
even further.

5 Tobacco Display Ban

At its meeting on 26 October 2010, Cabinet agreed to a package of new and improved
controls on the retailing of tobacco products. The Health Committee considered the
proposed Bill and the Smoke-free Environments (Controls and Enforcement) Amendment
Act 2011 passed on 22 July 2011. It came into force on 23 July 2012. The Mori Affairs
Committee supported the proposal (Recommendation 11) that all retail displays of tobacco
products be prohibited.
The Amendment Act prohibited the display of tobacco products at any sales outlet. All
tobacco products for sale must now be out of sight and visible only to the extent necessary
for it to be delivered to the customer or store. The removal of power wall advertising will
discourage young people from taking up smoking and help people who have quit, or are
trying to quit, to remain smokefree.
The Amendment Act also gave effect to a number of the Mori Affairs Committees
recommendations by:
tightening controls on the display of trading names that include terms signifying the
availability or price of tobacco for sale; (Recommendation 17)

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 providing that any contract or other form of agreement which offers a sponsorship,
gift, rebate, prize or reward in exchange for the promotion or sale of tobacco products
is void to the extent to which it is inconsistent with the Smoke-free Environments Act
1990; (Recommendation 12)
providing powers to issue infringement notices for offences involving the sale of
tobacco products to people under 18 years of age; (Recommendation 15)
increasing the penalties for selling tobacco to minors; (Recommendation 13)
prohibited manufacturers, importers, distributors, and retailers of tobacco products
from sponsoring activities involving exclusive supply arrangements
(Recommendation 10).

6 Plain Packaging
The Mori Affairs Committee Inquiry into the tobacco industry in Aotearoa and the
consequences of tobacco use for Mori recommended in November 2010 that the tobacco
industry be required to provide tobacco products exclusively in plain packaging, harmonising
with the proposed requirement in Australia from 2012 (Recommendation 7). Government
agreed in principle with this recommendation in April 2012 and from July to October 2012 the
Ministry of Health conducted a consultation process on plain packaging.
As a result, Government decided in February 2013 to proceed with a legislative change.
Cabinet noted the need for enabling legislation to establish the plain packaging regime and
subsequent regulations to implement it. In August 2013, Cabinet approved the policy
recommendations for inclusion in the Bill, and agreed that the legislation needs to include
wide regulation - making powers of both a restrictive and a permissive nature to ensure that
every aspect of the appearance and all other designed features and sensory impacts of
tobacco products and tobacco product packaging can be controlled.
This Government Bill, in the name of Hon Tariana Turia, had its first reading on 11 February
2014 and was referred to the Health Committee for consideration.
The Bill proposes a plain packaging regime for tobacco products in New Zealand, similar to
that now in place in Australia since December 2012. The key provisions are designed to:
ensure that tobacco products can only be manufactured, packaged and sold if they
comply with plain packaging requirements
make the graphic warnings on the packs larger and more effective
enable regulations to be made to set out the detailed requirements for tobacco
product design, appearance, packaging and labelling (including the improved graphic
warnings)
allow a brand name and certain other manufacturer information to be printed on the
pack, but with tight controls (eg, over the type font, size, colour and position)
prohibit the use of tobacco company branding imagery and all other marketing
devices on tobacco product packaging, or on tobacco products themselves
create new offences with significant penalties to effectively deter and punish any non-
compliance, and also allowing lower penalties and an infringement notice scheme to
deal with any instances of small scale or low level offending
lift the maximum penalties for some existing and related tobacco advertising and
health warning offences to the same levels as the new offences, for consistency

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 widen the enabling powers for health warnings so that regulations might also require
positive images and messages designed to encourage people to quit smoking to be
displayed on some tobacco packages.
The Bill recognises that tobacco packaging serves to advertise and promote tobacco
products, which the Smoke-free Environments Act 1990 aims to prevent. Accordingly, the
Bill clarifies that a purpose of the Act is to regulate and control the appearance of tobacco
products and packages. In particular the Bill provides that tobacco products for retail sale
must: comply with plain packaging requirements in order to reduce the appeal, social
acceptance and approval of smoking and tobacco products; make warning messages more
noticeable; and reduce the likelihood of creating false perceptions about the safety of
tobacco products. As well as this, the Bill provides that required messages and information
on tobacco packs may be larger and broader in scope.
There is provision for tight controls over the way the brand name, tobacco company
branding imagery and other marketing devices and manufacturer information is printed on
the pack.
Detailed requirements for tobacco product design, appearance, packaging and labelling,
improved graphic warnings, and standardised pack quantities are to be set out in
subsequent regulations.
The Committee invited public submissions by 28 March 2014. The Ministry of Foreign
Affairs and Trade also notified the Bill to the WTO, and invited intergovernmental
submissions concerning international trade aspects of the Bill with a deadline of 18 April
2014. The Health Committee is to report back to Parliament by 11 August 2014.

7 Media campaigns
Numerous media campaigns have been conducted by the Health Sponsorship Council
(HSC), which merged into the Health Promotion Agency (HPA) on 1 July 2012, and the Quit
Group.
Examples of HSC/HPA campaigns are Smoking Not Our Future, Face the Facts, Smokefree
Homes and Cars. The HPA has also organised World Smokefree Days, and run the
Smokefree Rockquest, Smokefree Pacifica Beats and other events and programmes
targeted mainly at young people. Smokefree areas have also been promoted. The HPA has
recently launched a Tobacco Control Data Repository which is available at
www.tcdata.org.nz.
Smoking cessation media campaigns have included The New You Campaign, Did You Know
and The Moment I Knew. As well as providing smoking cessation services, the Quit Group
also helps to promote World Smokefree Day, Matariki as an opportunity to quit and other
events that encourage smoking cessation.
Recently media campaigns have been boosted to support the Smoke-free 2025 goal. A
smoke-free cars campaign and the new Stop Before You Start campaign are currently
showing.

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Increased Support for Tobacco Control Services
1 Stop Smoking Service Developments
The Ministry of Health directly funds Quitline as well as 42 face-to-face stop smoking services
(Aukati KaiPaipa and services for Pacific people and pregnant women). Some district health
boards also directly fund stop smoking services within their districts.
In 2012-13, 57,800 people enrolled on a Ministry-funded stop smoking programme. This
equates to 12.5% of adult smokers.
In July 2011, a new mandatory smoking cessation service specification was introduced. This
specification outlined a mandatory base set of requirements for all publicly-funded cessation
services.
In 2012-13, the Ministry of Health began to refocus the stop smoking services on quality of
practice, core competencies and clinical outcomes training. A series of eight regional
workshops resulted in significant improvements in performance across face-to-face smoking
cessation providers. The stop smoking services were refocused to deliver evidence-based
treatment and support including: (1) access to all options of subsidised nicotine replacement
therapy (NRT); (2) information about how to access and use all other approved stop smoking
medicines; and (3) behaviour support.
Since 2011, the proportion of clients achieving a successful quit attempt has steadily
increased following on-going workforce development. As at April 2014, the success rate for
face-to-face stop smoking service clients was 28% (i.e. 28% of people were validated as
being smokefree after 3 months following their quit date), an increase of 8% since 2011.
In July 2014, the new National Stop Smoking Practitioners Certificate and National Training
Service (NTS) were launched. The NTS was established to set a national standard for stop
smoking treatment and is committed to improving workforce service performance, clinical
excellence and quality. The first training product to be designed, developed and launched
by the NTS is the National Stop Smoking Practitioners Certificate. This certificate will be
compulsory for all Ministry of Health funded stop smoking practitioners as the first priority
and then opened to all other stop smoking practitioners. It will provide all stop smoking
practitioners with the core competencies for stop smoking treatment and the qualification is
inclusive of particular tangata whenua and Pasifika cultural competency elements which are
integral to achieving the qualification and applying it in practice. The certificate includes a
pedagogically sound approach to teach and assess a stop smoking practitioner the ability to
work within the New Zealand context with a focus on the needs of Mori, Pacific and
pregnant clients as priority population groups.

Quitline
The Quit Group (Quitline) provides national stop smoking services by way of phone, online
and text message. Established in 1999, Quitline has undergone significant changes since its
inception.
In 2012/13, Quitline supported 50,297 quit attempts. This equates to around 8% of the
smoking population. Mori clients made 10,748 quit attempts with Quitline, or 22% of total
quit attempts. Pacific clients made 2,716 quit attempts with Quitline, or 6% of total quit
attempts. Mori and Pacific peoples are two of Quitlines priority groups due to high rates of
smoking.
Since 2010, significant changes have occurred in the way people engage with Quitline.
These changes reflect the emerging trends in the use of information communication
technology.

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Quitline used changes in 2012/13 as an opportunity to further develop its service and
improve a clients experience via phone, online and text message. This work resulted in the
following key changes:
Clients who register with Quitline are now signed up to a 3 Month Quit Programme
Over the course of the 3 Month Quit Programme clients now receive a minimum of
four follow-up contacts
Tracking systems were created to assess clients quit status at four weeks and three
months
The support model underpinning Quitlines service was redeveloped to align with the
3 Month Quit Programme
The redeveloped Quitline support model was mapped across Quitlines three service
channelsphone, online and text
The channels now offer a single integrated smoking cessation support programme,
creating a seamless experience for clients
Client interaction and outcomes via each service channel are now recorded in a
single Customer Relationship Management System.
Quitline currently achieves a 24.2% quit rate at three months and 20.9% at 12 months.

Aukati KaiPaipa stop smoking service

Aukati KaiPaipa (AKP) is a kanohi ki te kanohi service that is delivered within most
communities. Each AKP provider is responsive to kaupapa Mori culture, whakapapa, reo,
tikanga and combines this with evidence based clinical treatment to overcome the addition to
the nicotine in tobacco to support Mori and their whnau to stop smoking.
The goal is to reduce the smoking prevalence amongst Mori. The programme also aims to
increase the positive attitudes towards supporting the smokefree kaupapa such as
smokefree environments, particularly for hap mama and their whnau and tamariki.
AKP was established in 1999 and now comprises 32 service providers throughout the
country. Under the programme 60.5 full time employees deliver face-to-face smoking
cessation services to individuals and whnau.

Pacific stop smoking services

Pacific stop smoking services provide face to face multiple support sessions for Pacific
people in individual, fnau and group settings. Pacific stop smoking services acknowledge
and are responsive to the cultural values, beliefs and the involvement of the family and the
community to ensure the effectiveness of services for Pacific people.
Pacific stop smoking services comprise six service providers throughout the country. Under
the programme around 14 full time employees deliver face-to-face smoking cessation
services to individuals and fnau.

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Services for pregnant women
There are six dedicated pregnancy stop smoking service providers funded directly by the
Ministry, all of which provide face to face, multi support sessions to pregnant women and their
whnau. In addition, all stop smoking services are required to prioritise pregnant women (as
well as Mori and Pacific) within their service, in recognition of the harm smoking has on the
health of the pregnancy, unborn baby and pregnant woman.
In 2012, the Ministry undertook the development of the Best practice framework for
dedicated pregnancy smoking cessation services. The framework sets out agreed principles
and parameters to support pregnant women to stop smoking, with sufficient flexibility to be
applicable to any stop smoking service. The dedicated pregnancy stop smoking services
were supported to take any steps necessary to meet the best practice framework and any
relevant recommendations to improve their performance.

2 Stop Smoking Practitioner Workforce Development

In 2011, the Ministry of Health contracted Te Ohu Rata o Aotearoa (Te ORA), the Mori
Medical Practitioners, to develop Te Ara Hiringa: A Strategic Plan for the National Mori
Tobacco Control Service 20112016. Te Ara Hiringa included a range of actions to
implement the Mori Affairs Select Committee recommendations including establishing a
national Mori tobacco control service (Te Ara H Ora was established in 2013) and
strengthening of the Mori tobacco control workforce (including development of specific
training programmes for the Mori workforce).
As noted, in July 2014 the Ministry launched the National Training Service and the National
Stop Smoking Practitioners Certificate. Both were established in response to the
recommendations of the Mori Affairs Select Committee relating to strengthening the Mori
tobacco control workforce as well as feedback and input from the tobacco control sector.
The national training service and the certificate also ensure tangata whenua and Pasifika
cultural competency in everyday practice for the non-Mori workforce.

3 Other Tobacco Control Services

Health Promotion and Advocacy

ASH New Zealand and the Smokefree Coalition are funded to provide smokefree
information, health promotion and advocacy services. ASH provides services to engage
communities in a democratic process around tobacco policy and undertakes intensive
community work to implement settings-based smokefree policies. ASH is also involved in
regional strategic forums for local smokefree polices and works with several DHBs on
regional Smoke-free 2025 strategies. The ASH Year 10 (1415 year olds) survey is part of
the New Zealand Youth Tobacco Monitor.
The Smokefree Coalition provides information dissemination and aims to strengthen
strategic alliances and collaboration between agencies involved in promoting tobacco control
in New Zealand.
The Heart Foundation provides ABC training to health care professionals and supports
activities in primary care to achieve the Better help to quit health target. The Heart
Foundation includes the Tala Pasifika service, which delivers Pacific leadership and health
promotion in relation to tobacco control awareness.

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Te Ara H Ora - the National Mori Tobacco Control Leadership Service
In July 2013, Hpai Te Hauora Tapui, Mori Public Health, in partnership with ASH, was
awarded the National Mori Tobacco Control Leadership Service Contract. The
establishment of this service was a direct response to Te Ara Hiringa and the Mori Affairs
Select Committee recommendations.
The purpose of Te Ara H Ora is to work to eliminate tobacco from Mori communities. To
achieve this goal, the service is working to grow local, regional and national leadership,
increase communication and enhance collaboration across the country. Te Ara H Ora is
dedicated to ensuring that Mori are strongly represented in local, regional and national
tobacco control initiatives, especially in regards to policy development.

National Training Programme for Midwives

In response to the recommendations of the Best practice framework for dedicated pregnancy
smoking cessation services that was developed in 2012, the Ministry sought to modify the
training that was provided to midwives to use ABC practice and support pregnant women to
quit smoking. This resulted in a new national training programme for midwives being
developed and implemented from July 2013.
The training aims to provide the midwifery workforce across New Zealand with the
confidence, knowledge and skills to safely and effectively encourage and support pregnant
women who smoke to take appropriate action to quit smoking. The training content focuses
on brief ABC interventions but takes account of the on-going relationship midwives have with
the women they provide care for during pregnancy.

District Health Board services

Since 2006, all DHBs have been funded to oversee and progress smokefree activities within
their districts, which includes provision of ABC by primary and secondary health services.
Some DHBs also directly fund cessation services.
All DHBs are achieving the Secondary Health Target and good progress is being made
towards achieving the Better help for smokers to quit Primary Care Health Target through
increased focus and collaboration with PHOs.
DHB public health units (PHUs) deliver smoke-free enforcement and compliance activities.
Recent changes have required PHU staff to undertake training with respect to the new retail
display and instant fine provisions. From July 2013 to June 2014, PHUs undertook 2018
tobacco retailer education visits and 77 controlled purchase operations involving 1204
retailers. These operations resulted in 78 sales to minors and resultant action taken against
those retailers.

Review of Tobacco Control Services

In 2013/14, in order to assist the Ministry of Health in taking the necessary steps to leading
the sector to achieving the Smoke-free Aotearoa 2025 goal, researchers from SHORE &
Whariki Research Centre, College of Health, Massey University, were selected to undertake
a review of tobacco control services funded by the Ministry of Health. The provisional overall
findings from the review suggest that the current tobacco control services are achieving
good results. Given no substantial issues were identified though the review, the Ministry
intends to continue refining services in partnership with relevant stakeholders.

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4 Emerging Issue - Electronic cigarettes
E-cigarettes (EC) are emerging products, which:
mimic traditional cigarettes, but do not produce smoke from combustion
deliver an aerosol vapour using an electronic system and a volatile chemical base
(typically propylene glycol)
may contain nicotine and/or other substances
vary from brand to brand
are not subject to tobacco excise tax
have an increasing advertising profile and market uptake
pose regulatory challenges, both in New Zealand and other countries, with respect to:
product safety and the risks of misuse
encouraging a possible role in helping smoking cessation and/or harm
reduction
possibly undermining other tobacco control policies
may have the potential, if well-regulated, to make a contribution to achieving New
Zealands Smoke-free 2025 goal
have increasingly received more national and international media attention.
There is a market for products providing smokers with nicotine, but that are less harmful than
smoking. Many recent nicotine containing products are marketed as an alternative to
tobacco and some make claims for harm reduction or smoking cessation. The rapid
evolution of this market and the lack of high quality data make it challenging for the health
sector to respond.
In New Zealand, EC have polarised the tobacco control sector. Some believe these devices
will contribute towards a Smoke-free New Zealand 2025 by assisting people either to quit or
to replace smoking. Others have concerns that EC may impact adversely on individual and
population health, perpetuating nicotine addiction, re-normalising smoking behaviour,
promoting dual use, and that they might be a gateway to smoking tobacco. Further to this,
the tobacco industry is purchasing companies producing these products.
The Ministry of Health acted on the World Health Organizations advice, recommending a
precautionary approach. New Zealand opted to apply its existing regulations to provide a
regulatory framework for EC: the Medicines Act 1981 and the Smoke-free Environments Act
1990 (SFEA). Subsequently, the Ministry has identified various concerns and is considering
a regulatory response.
Non-nicotine containing EC are widely available in New Zealand. No nicotine containing EC
have been licensed for sale so far: they should not be sold but people can import them for
personal use. Enforcement of illegal sales of EC is an emerging issue and the divergent
views of tobacco control experts present a challenge to informing policy decisions.
The tobacco control sector has been leading the way in New Zealand on how to effectively
and comprehensively address a major health issue and we have made good progress
towards Governments smoke-free goal. The sector is now at a critical point to decide
whether new nicotine products, such as EC, will help or hinder further progress. Ongoing,
constructive policy debate on nicotine products is needed so that valid concerns of both
sides can be addressed.

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5 Research and knowledge
The Ministry of Health, in partnership with the Health Research Council (HRC), directly funds
research into tobacco control carried out by the New Zealand Tobacco Control Research
Turanga. See the Tobacco Control Research Turanga for more information -
http://www.turanga.org.nz/ . High quality research on tobacco issues is also undertaken by
ASPIRE2025, the Health Promotion Agency, and other research groups.

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