Stakeholder Appraisal of Selected Tobacco
Endgame Policy Options in New Zealand
Jude Ball, MA, DPH
Richard Edwards, MB BChir, MD, MPH
Andrew Waa, BSocSc, MPH
El-Shadan Tautolo, PhD
Objectives: We explored the perceived strengths and weaknesses of selected endgame policy
options in the context of New Zealand, a country with a smoke-free goal, and identified generalizable insights about progressing the next generation of tobacco control measures. Methods:
We identified key 5 potential ‘endgame’ policies – dramatic tax increases, substantial reduction
of availability through comprehensive retail restrictions, annual increase in the legal age of
purchase, denicotinization, and restriction of additives. We interviewed 19 Māori, Pacific, and
European key informants including politicians, senior public servants, and tobacco control advocates, and sought their views on each policy’s likely effectiveness, impact on ethnic inequalities, unintended effects, political feasibility, technical feasibility, and acceptability. Results: Key
informants viewed dramatic tax increases as the most promising of the 5 options. Opinions on
the other policies were mixed. Perceived barriers to moving the policies forward included lack of
political will, limited evidence of effectiveness, and that New Zealand’s smoke-free goal focuses
on reducing prevalence rather than eliminating the availability of tobacco products. Conclusions: The findings provide insights about barriers to progressing novel tobacco control interventions and how these might be overcome, for example by building and communicating the
evidence base, and building public support for endgame options.
Key words: endgame; tobacco; public policy; tobacco control; indigenous; policy appraisal
Tob Regul Sci.™ 2017;3(1):56-67
DOI: https://doi.org/10.18001/TRS.3.1.6
A
ccording to the World Health Organization
(WHO), tobacco kills around 6 million
people annually,1 making it the most deadly
substance legally sold to consumers worldwide.
Given the unacceptable human cost of tobacco
consumption, advocates and academics have increasingly called for a tobacco-free future. Over the
past 12 years a number of ‘endgame’ policy proposals have been put forward,2 designed ‘to change/
eliminate permanently the structural, political and
social dynamics that sustain the tobacco epidemic,
in order to end it within a specific time’.3
A growing number of countries are committing
to tobacco-free visions of the future, but New Zealand is one of few with a specific governmental
endgame target. Māori (indigenous) advocates and
politicians led work that culminated in 2011 in
the New Zealand government setting a goal of becoming an essentially smoke-free nation by 2025.
New Zealand had relatively strong tobacco control measures in place prior to 2011, including all
MPOWER policies recommended by the WHO,4
but policy progress has been modest in the 5 years
since the smoke-free goal was set.5-7 Overall tobacco use is declining in New Zealand, but modeling
shows that ‘business as usual’ will not achieve the
smoke-free 2025 goal.8,9 Marked disparities in tobacco use persist and smoking prevalence remains
high for Māori and New Zealand Pacific populations, at 38% and 25% respectively.10 These pat-
Jude Ball, Research Fellow, Department of Public Health, University of Otago, Wellington, New Zealand. Richard Edwards, Professor, Department
of Public Health, University of Otago, Wellington, New Zealand. Andrew Waa, Research Fellow, Department of Public Health, University of Otago,
Wellington, New Zealand. El-Shadan Tautolo, Senior Research Fellow, Centre for Pacific Health, Auckland University of Technology, New Zealand.
Correspondence Ms Ball; [email protected]
56
Ball et al
terns and trends suggest that radical new ‘endgame’
policies may be necessary to achieve the goal for all
population groups in New Zealand.
Research in many developed countries has demonstrated relatively strong public support for tobacco endgame strategies, even among smokers.12-15
However, to our knowledge, only one previous
study has examined policy experts’ and decision
makers’ views. That study,16 entitled ‘Daring to
Dream,’ was conducted in New Zealand nearly 10
years ago, and explored perceptions of the endgame
concept itself and broad structural strategies rather
than specific policy options for achieving it. The
current study builds on that earlier work.
Leading tobacco control thinkers worldwide
agree on the need for new approaches to reduce tobacco consumption and related harm dramatically,
but the sector is far from consensus on which ‘new
generation’ strategies should be pursued.11Warner
argues that, to move the debate forward, it is necessary to evaluate each strategy’s potential outcomes,
good and undesirable, and the political, legal, ethical, economic, regulatory and social opportunities
and barriers to implementation.2 The current study
presents just such an appraisal of 5 selected endgame options based on interviews with New Zealand stakeholders:
• dramatic (eg, 40%) tax increases on tobacco
products;
• substantial reduction of tobacco availability
through comprehensive retail restrictions;
• denicotinization (mandated very low nicotine tobacco products);
• restriction of additives to tobacco products to
reduce palatability and toxicity; and
• creating a ‘tobacco-free generation’ through
annual increases in the legal age of purchase.
Our aims in this paper are 2-fold: (1) to inform
debate by exploring perceived strengths and weaknesses of selected policy options in the New Zealand context; and (2) to identify any generalizable
insights about progressing the next generation of
tobacco control measures.
METHODS
We identified policies with potential to contribute to the tobacco endgame that were actively being considered in the tobacco control sector in New
Tob Regul Sci.™ 2017;3(1):56-67
Zealand in mid-2015. Included policies fulfilled 2 or
more of the following criteria; (1) were included in
the 2015-2018 Action Plan of the National Smokefree Working Group, New Zealand’s peak body for
tobacco control advocacy;17 (2) were recommended
to Government by the Māori Affairs Select Committee in 2010, alongside the recommendation to
set a goal of becoming a smoke-free nation;18 (3)
have been discussed by Ministry of Health tobacco
control officials as being promising options; and (4)
have been the subject of discussion in tobacco control sector seminars or symposia in New Zealand.
Measures already in the process of being introduced
(eg, plain packaging) were excluded.
The research team developed a policy appraisal
framework adapted from Morestin,19 focusing on
the (1) effectiveness, (2) impact on ethnic inequalities, (3) unintended effects, (4) political feasibility,
(5) technical feasibility, and (6) acceptability of
each policy. The acceptability dimension included
the extent of support amongst Māori and Pacific
leaders and communities. Key informants were
purposively selected and comprised:
• Politicians from a range of political parties
(N = 5)
• Leading tobacco control advocates and researchers (N = 5)
• Chairs, managers and senior staff of smoking
cessation and tobacco control services (N =
6)
• Senior public servants (not limited to tobacco control specialists) (N = 2)
• Policy and regulatory consultants with expertise in tobacco control (N = 1)
The knowledge and networks of the research
team were used to identify and select potential
key informants. Māori (N = 7) and Pacific (N =
6) participants were selected based on their current or potential role in achieving smoke-free 2025
and their leadership role within Māori and Pacific
communities and organisations. We selected other
key informants based on their seniority and relevant policy, regulatory and technical expertise. We
sought broad representation and prioritised inclusion of those with the greatest political and sector
understanding. The composition of the groups of
key informants differed, with the Māori and Pacific groups including more individuals in local
roles and with close community links, whereas
DOI: https://doi.org/10.18001/TRS.3.1.6
57
Stakeholder Appraisal of Selected Tobacco Endgame Policy Options in New Zealand
Table 1
Outline of Policy Options Appraised, as Described to Key Informants
Policy Option
Dramatic tax
increases
Substantial
reduction
of availability
through
comprehensive
retail restrictions
Tobacco-free
generation
Denicotinization of
tobacco products
Restriction of
additives to
tobacco products
Description
The New Zealand government has implemented regular above inflation tobacco tax increases from
2011-2015 and there will be a further annual 10% increase in 2016. More dramatic tax increases have
been proposed. For example, the Smokefree Aotearoa 2025 Next Steps Action Plan 2013-2015 called
for a tax increase of 40% followed by 20% per annum. For the purposes of this project ‘dramatic tax
increases’ are defined as one or more one-off tax increase of at least 40% and regular large increases of
at least 20% per annum.
Reducing the supply of tobacco products is another approach to reducing smoking in New Zealand.
There are over 6000 outlets that sell tobacco products, mostly dairies, convenience stores, garages,
and supermarkets. For this project, a ‘substantial reduction in availability’ is defined as a 90% or more
reduction in the number of retailers selling tobacco (to less than 600), plus a ban in mail order retailing
of tobacco products. One possible approach to achieving this goal is mandatory retail licensing with a
‘sinking lid’ on the number of licenses available. For example, there could be a 50% reduction in the
number of retailers selling tobacco followed by an additional 5% per year decrease until at least 90%
reduction is achieved. Another option is the phased elimination of tobacco sales from outlets within 1
km or 2 km of all schools. This would leave 641 and 260 remaining outlets respectively. A third option
is restricting tobacco sales to a small number (600 max) of licensed specialist retailers.
The Tobacco-free generation idea proposes that the age of individuals to whom cigarettes can be legally
sold is increased each year (from the current 18 years), possibly starting with the generation born in year
2000. This will mean that for people born in 2000 (and all people born after that date), they will never
legally be able to buy tobacco products in New Zealand, and by 2025 the legal age for purchase will
have reached 27 years.
Regulation of the composition of tobacco products may also help reduce smoking. Nicotine is believed
to be the primary addictive component of tobacco products. Although it is present in tobacco, it is
technically possible to remove the majority of the nicotine content (just as coffee can be decaffeinated).
That would have the effect of making tobacco products much less addictive. It is thought that removal of
most of the nicotine is sufficient to make cigarettes minimally addictive, and we propose that the
nicotine content could be mandated to be less than 2 mg per cigarette for all cigarettes sold in New
Zealand.
In New Zealand there are over 350 known additives in cigarettes. These include agents to retain
moisture and preservatives to increase shelf-life, and flavorings and other chemicals that modify the
properties of tobacco or enhance the experience of smoking. Some additives (eg, ammonia) make
nicotine more ‘available’ to the smoker, and thus, increase the addictiveness of tobacco products.
International attention has focused on additives that make tobacco products more ‘attractive’, eg,
flavorings and vitamins. For this project, we propose comprehensive restrictions to ban all additives
that plausibly have the effect of: (1) increasing addictiveness; (2) increasing toxicity; (3) increasing
attractiveness (particularly to young people); and (4) increasing palatability of tobacco products. As
with the recent Psychoactive Substances legislation, the onus of proof would be on the industry to show
that additives were safe, non-addictive, and did not increase attractiveness or palatability.
the New Zealand European/other (NZEO) group
comprised mainly those with national-level policy
or political roles.
Prior to each interview, participants were given
written information about the project, the appraisal framework, and the 5 policy options to be discussed. Table 1 outlines the policy options, as they
were presented to participants. The research team
developed a semi-structured interview schedule,
with questions based on the appraisal framework.
We also asked participants to rank the 5 options
based on the criteria in the appraisal framework,
58
and included questions about participants’ perceptions of the 2025 goal and its alignment with Māori
and Pacific aspirations. Interviews were conducted
in July, August and November 2015. They were
digitally recorded and professionally transcribed.
We analyzed data using thematic analysis, following an approach proposed by Braun and Clarke.20
After reviewing the transcripts, the research team
discussed and agreed the broad themes and coding frame. The data were then coded and analyzed
by one researcher (JB), with each ethnic group
analyzed separately. We then synthesized findings
Ball et al
across all 3 groups and examined differences among
ethnic groups. Quotes are labeled according to the
ethnic group of the participant.
RESULTS
Key Informant Appraisal of Policy Options
Most participants in all 3 groups viewed dramatic tax increases as the option most likely to be
both effective and politically and technically feasible. Opinions on the other 4 options were mixed.
Table 2 summarizes key findings, which are presented in detail below. A cross-cutting theme was
the perceived need for a comprehensive package of
tobacco control policies to achieve New Zealand’s
endgame goal, and participants pointed out the
synergistic effects that policies could have if introduced in combination.
Dramatic tax increases. Dramatically increasing
excise tax on tobacco was seen as an evidence-based
option that would be effective in reducing tobacco
consumption and uptake, but several participants
also noted it could have significant adverse effects
on low income households.
In those poor families where the addicted parents can’t stop, it means kids will get less access to
food… it’ll mean those children will come under
more pressure for daring to whine about not getting more kai [food] and ‘how come you’re still
smoking dad?’ and somebody’s gonna get a thwack
[beating]. (Māori)
Despite these concerns, the majority in all 3 ethnic groups believed that, with appropriate cessation
support and complementary policies and services
in place, the health benefits would outweigh any
negative impacts. However one participant noted
that providing financial or in-kind support (eg,
food parcels) to mitigate adverse effects on lowincome families was likely to undermine the effectiveness of this policy, because it is largely financial
pressure at the household level that forces smokers
to quit or cut down their smoking.
Participants commented there is a body of evidence showing tax increases are effective, and most
believed this policy would reduce ethnic disparities, because Māori and Pacific are overrepresented
in highly price-sensitive low-income groups. A
Tob Regul Sci.™ 2017;3(1):56-67
minority view was that Māori and Pacific smokers
were less likely than the general population to quit
in response to tax increases, in part, due to lower
health literacy and self-efficacy.
Most saw dramatic tax increases as technically
easy to implement, and relatively politically feasible
because excise tax is an established tobacco control
measure in New Zealand that is revenue-producing
for the government. However, a few argued that
the suffering imposed on low-income families (in
particular concerns about food security, stress and
family violence) would limit the public acceptability and political feasibility of this option. Security
risk to retailers, home grown tobacco and illicit
trade were also seen as potential unintended effects.
Substantial reduction of availability through
comprehensive retail restrictions. Most Māori
and Pacific participants were supportive of this
option and believed comprehensive retail restrictions would be effective in reducing uptake, reducing consumption, helping people to quit,
denormalizing tobacco and sending a clear message
that the government is serious about the smokefree goal. This policy option was also well aligned
with Māori aspirations of removing tobacco from
communities. Several argued that tobacco-outlet
density, underage sales, and single cigarettes sales
were higher in low-income communities, and this
unfairly disadvantaged Māori and Pacific people,
and led to higher smoking rates in these groups.
Therefore, retail restrictions were seen as justified,
and an important equity measure. Māori and Pacific participants also highlighted other advantages
of having a smaller number of licensed retailers, for
example, making monitoring and enforcing retail
compliance easier, and providing a platform for local action.
It’s obvious that there’s more cigarettes in [high
deprivation] areas. And pokies [slot machines] as
well, and alcohol. [But] at least with alcohol and
gambling we have platforms to change that [via
the licensing system], and we desperately need that
for tobacco. (Māori)
Whereas some NZEO participants agreed, saying
this was a logical public health measure, consistent
with restrictions on other harmful products, others
felt that that reducing retail availability would have
DOI: https://doi.org/10.18001/TRS.3.1.6
59
Stakeholder Appraisal of Selected Tobacco Endgame Policy Options in New Zealand
Table 2
Summary of Key Informant Views on Endgame Policy Options
Perceived
Effectiveness
Perceived Adverse
Effects
Perceived Impact On
Equity
Perceived Political and
Technical Feasibility, and
Acceptability
High
Strong evidence base.
Moderate/high
Significant concern
about impacts on
families of low income
smokers – eg, child
abuse, hunger.
Positive
Likely to reduce ethnic
disparities in smoking
rates.
Moderate
Existing mechanisms, established
policy measure, quick and easy
to implement, revenue producing.
However 40% rise seen as ‘a step
too far’.
Dramatic tax
increases
Possible growth in
illicit trade and home
grown tobacco.
With complementary
measures, benefits may
outweigh adverse
consequences on low
income families.
Retailer security
concerns.
Substantial reduction
of availability through
comprehensive retail
restrictions
Mixed
Perceived effectiveness
higher among Māori
and Pacific key
informants.
Low/uncertain
Uncertain impact on
retail sector. If a ‘level
playing field’
maintained, may be
minimal.
Possible increase in
illicit trade.
Tobacco-free
generation
Denicotinization
of tobacco products
Restriction of
additives to
tobacco products
Low
Strong opposition expected from
retail sector.
High implementation and political
costs for government.
Moderate
Effectiveness
(especially for Māori,
Pacific) compromised
by social supply, and
retail non-compliance.
Low
Possible growth in
illicit trade.
Negative
May widen ethnic
disparities in tobacco use.
Low/uncertain
Public opinion and political
feasibility may be limited by
perceived age discrimination;
inconsistency with other age-based
laws.
Possible public support if framed
appropriately.
Mixed
Impact on behavior
uncertain.
Limited (awareness of)
evidence base.
High
Significant concern
about possible
compensatory
smoking; doping
with liquid nicotine;
perverse message that
smoking now ‘safer’.
Possible growth in
illicit trade.
Neutral
Low/uncertain
Strong opposition expected from
tobacco industry.
Policy rationale may not be easily
understood by the public.
Mixed
Impact on behavior
uncertain.
Limited (awareness of)
evidence base.
Low
Could make tobacco
products appear less
harmful and
discourage quitting/
encourage uptake.
Possible growth in
illicit trade.
Neutral
Moderate/uncertain
Strong opposition expected from
tobacco industry.
Possible public support if framed
appropriately.
little effect on existing smokers, who would simply
travel farther to buy tobacco. Several participants
described this option as politically ‘impossible’ under the current right-of-center government due to
its philosophical opposition to interference in the
market.
There was wide agreement in all 3 ethnic groups
60
Positive
Will address current
inequity caused by higher
retail availability and
underage sales in Māori,
Pacific and low income
communities.
that opposition from the retail sector would affect
the political feasibility of retail restrictions under
any government.
Politically [it’s] a lot harder [than tax] because,
as long as it remains socially acceptable to poison
your customer, the grocers’ lobby is probably the
Ball et al
second most powerful lobby in New Zealand after
the dairy industry. (Māori)
However, the actual impact on the retail sector
was questioned by some who said the policy would
not be significantly detrimental to retailers so long
as a ‘level playing field’ was maintained, because
tobacco is a low-margin product.
Participants noted that the mechanism for gradual reduction from 6000 to 600 retail outlets was
not obvious and would need to be fair and transparent. An additional impediment noted was that
the implementation and enforcement of this option would have cost implications for government.
Tobacco-free generation. The majority of participants found the idea of annual increases in
the legal age of purchase appealing. They felt that
creating a generation that would never be able to
purchase tobacco products legally would help to
protect young people from smoking, particularly if
implemented alongside a range of complementary
interventions such as tax increases and restrictions
on retail availability. However, there was considerable uncertainty about how effective it would be in
practice, and whether it would receive public and
political support.
Participants agreed there would be enforcement
challenges, noting that most young people start
smoking before the age they can legally buy tobacco. Some participants thought the tobacco-free
generation policy would be less effective for Māori
and Pacific than the general population, because
social supply to minors and retail non-compliance
were seen as particularly prevalent in Māori and Pacific communities and neighborhoods. Thus, some
were concerned this policy could widen existing
disparities.
Many participants felt uncertain about how the
public would react to the tobacco-free generation
idea. On one hand, the potential positive framing of the policy as protecting the next generation
was seen as appealing. For example, one politician
thought that, done well, it could be framed as a
policy to support young people:
I think if you could say that this is what young
people want, and particularly if you had opinion
poll data [it could get political support]. (NZEO)
Tob Regul Sci.™ 2017;3(1):56-67
On the other hand, many participants envisaged
arguments against the policy that also would have
public appeal, for example ‘nanny state’ arguments,
inconsistency with other age-based legislation (eg,
for alcohol sales), and the perceived unfairness of
an arbitrary cut-off date. For example, some saw it
as a law that would be imposed on young adults,
raising concerns about age discrimination:
You’re either an adult or you’re not. This product’s
either legal or it’s not. And, if it’s legal and you’re
an adult then you should have access to it. And to
then just isolate a particular group is effectively
discrimination. (NZEO)
Pacific participants were the most optimistic
about this policy receiving community support,
from both parents and community leaders. On balance, however, the majority were pessimistic about
the political feasibility and acceptability of this policy, despite their personal support for it.
Denicotinization. Participants had somewhat
polarized views on compulsory mandating of very
low nicotine tobacco products. Proponents argued
that dramatically reducing the nicotine content
of tobacco products would make them less addictive, and therefore, young people would not
become addicted and current smokers would find
it easier to quit. However others questioned how
effective denicotinization would be, saying that
people smoke for social and psychological reasons,
and may continue to smoke even if the physically
addictive elements in tobacco are removed. Some
also questioned whether nicotine is the only addictive component in tobacco smoke, and wondered
whether tobacco companies might introduce other
addictive additives in response. Several participants
also speculated about whether people could add
liquid nicotine (available for use in e-cigarettes) to
denicotinized tobacco, thereby undermining the
effectiveness of the policy.
As well as queries about effectiveness, there was
also widespread concern about the possibility of
‘compensatory smoking’ – people smoking more
cigarettes or inhaling more intensely to try to get the
same nicotine ‘hit’. Participants argued this policy
could harm rather than protect health if compensatory smoking occurred, and therefore, caution
(and solid evidence) was needed. Another concern
DOI: https://doi.org/10.18001/TRS.3.1.6
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Stakeholder Appraisal of Selected Tobacco Endgame Policy Options in New Zealand
was that this intervention could paradoxically give
the message that smoking was ‘safer’ despite the
fact that denicotinized products would remain as
health-damaging as regular tobacco products.
You take out the sweeteners and all of that sort of
stuff and people who smoke, they’ll go ‘holy ****
this tastes like ****’, you know, and if that can
help to turn them off tobacco, great.” (Māori)
When the government regulates something, particularly what’s going into a product, there’s an
inferred message, often, that ‘oh, it must be safer
now… The government’s made this product ‘safe’.
(NZEO)
However, others argued this policy would not
change behavior significantly because it would
not address the root causes of smoking such as addiction or the desire to rebel or appear cool. One
participant was concerned that banning additives
would make tobacco products more attractive to
consumers, because they would be perceived as less
toxic.
There were also mixed views about how easy the
policy would be to introduce and enforce. Several
participants noted that existing models (eg food
safety regulations) could be replicated, putting the
onus of proof on manufacturers. A minority view
was that developing and enforcing such restrictions
would be both complex and costly for the government, because there are a large number of additives
to be regulated and monitored.
Participants also had differing perspectives on the
acceptability and political feasibility of this option.
On one hand, some participants said it would be
strongly opposed by the tobacco industry on intellectual property grounds, and that the threat of
legal action would likely dampen any political support for such regulation.
Participants agreed this policy was likely to be
strongly opposed by the tobacco industry, and
many felt that the threat of legal action would
limit political support. However, supporters of this
policy argued that denicotinization was likely to be
more politically palatable than an outright ban on
sales or use of tobacco products, and, because it
is a technical matter, politicians may be willing to
be guided by advice from scientific experts. Several
participants commented that the general public
(Pacific communities in particular), would have
little interest in or understanding of this policy.
Yeah at the moment their understanding – you
know, you’re still trying to tell our community,
‘look, smoking kills for these particular reasons.’…
We’re a long way away from understanding the
makeup of a cigarette and that denicotinization
might help. (Pacific)
Some saw this as a strength because it meant
regulations could be introduced quietly without
public outcry. Others argued that politicians were
unlikely to act without public pressure, and that
this policy was unlikely to generate grassroots community support.
Restriction of additives to tobacco products.
Key informants had mixed views about the likely
effectiveness of a comprehensive ban on additives
to tobacco products, and the primary rationale
behind it did not always appear to be well understood (ie, to make tobacco products less palatable,
appealing and addictive and thereby reduce uptake
and encourage quitting.) Some felt restriction of
permitted additives would be effective, because removing additives would make cigarettes very unpleasant to smoke.
62
I think of all the interventions, this is the one
where probably you’d face the biggest challenge
from the industry – the whole intellectual property thing. They’d argue that you’re destroying their
brand. (NZEO)
On the other hand, some argued that this policy
might receive strong public support, because there
is a general public perception that additives are
undesirable and should be minimized. It was felt
that the rationale for the policy, whether framed
as protecting the public from toxic additives or
making tobacco less appealing to young people,
would appeal to people’s values, and would be difficult to argue against. For these reasons some participants thought that this policy might be more
politically palatable than some of the other options discussed.
Ball et al
Barriers to Progressing the Next Generation of
Tobacco Control Measures
Analysis revealed a number of broader inter-related themes about moving novel tobacco control
measures forward in the context of a developed
country with an endgame goal, which may be generalizable to other similar jurisdictions.
Political will. Most key informants saw New
Zealand’s smoke-free 2025 goal as achievable, but
only if bold steps were taken. The goal did not appear to be, in itself, a strong motivator for government action, and participants expressed frustration
at the lack of strategic and policy action since it was
adopted in 2011. Lack of political will was seen as
the main barrier to progress:
Apparently, they [government] don’t seem to want
to do anything, not even plain packaging (Māori);
It’s just been more of the same…They need to be
thinking about bold interventions. (NZEO)
Evidence. Participants, particularly those in
policy and political roles, saw limited evidence of
effectiveness as a key barrier to progressing and
prioritising ‘next generation’ policy options. With
the exception of tax increases, the evidence base
was perceived as weak for the proposed endgame
interventions:
We know about taxation; do we know about
these? (NZEO)
Without detailed knowledge about how policies
would impact on behaviour, participants admitted
they were somewhat relying on ‘hunches’ and ‘gut
feeling’ to appraise the policy options, and this was
seen as problematic.
To decide if you want to proceed with them, you
actually need to know a bit more about effectiveness…Guessing isn’t good enough. (NZEO)
A key theme was that government (particularly
one that is ideologically committed to ‘small government’ and the free market) is unlikely to act unless pressured to do so. The urgent need for bold
and innovative action expressed by most participants was in stark contrast to the view of a government politician:
Several participants who were sceptical or negative about an option said they would happily revise
their opinions if new evidence came to light.
Participants also noted that evidence of effectiveness was key to the political feasibility of any
option, making untested options politically risky.
One participant stated that gaining political support for an option:
If there’s a big popular public push, then politicians generally have to react. But I think there’s a
sense that we’re doing the right things already…
and therefore, a dramatic step is not needed.
(NZEO)
…comes down to good political advocacy, good
evidence base. For a politician, you’re trying to
quell any anxiety around you know, the possibility that they could be out on their ear. (Māori)
Participants noted that, in this context, advocates
should focus on building public support for policy
action and for the endgame goal itself. Communicating the purpose of any new policy to communities was seen as important, along with supporting
community leaders to be advocates for the policy.
Get some advocates, some allies, who can speak
to some of the issues. So work out what the values
issues are in here and get people to speak to those.
(NZEO)
Tob Regul Sci.™ 2017;3(1):56-67
The political risk of introducing a policy that
fails or has unintended consequences was also
highlighted by a politician commenting about
denicotinization.
Politically I wouldn’t push it until I’m clear on the
evidence, and if I saw evidence that showed that
a reduction in nicotine doesn’t have the adverse
effect of pushing up consumption, then it would
be something I’d be prepared to look at. (NZEO)
Definition of the endgame goal. Almost all par-
DOI: https://doi.org/10.18001/TRS.3.1.6
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Stakeholder Appraisal of Selected Tobacco Endgame Policy Options in New Zealand
ticipants described New Zealand’s endgame goal in
terms of dramatically reduced prevalence of tobacco smoking, with a figure of ‘less than 5%’ widely
accepted as the goal. Many Māori participants felt
there was a lack of alignment between what they
perceived to be the government’s smoke-free 2025
goal (ie, reduced prevalence) and the aspirations of
Māori leaders and communities (ie, to ‘get rid of
tobacco’).
It’s about reclaiming what we once were. You
know, tobacco’s not, I think, traditionally part of
our culture, so for us it’s reclaiming that space.
And that doesn’t mean this whole 5% goal, it’s
actually bigger than that, and it’s ensuring that
tobacco’s not present in Aotearoa [NZ]. (Māori)
These participants said defining the endgame in
terms of prevalence reduction (rather than elimination of tobacco availability) had practical and
policy implications.
It lifts the attention off actually the tobacco industry and puts it firmly - the blame firmly on [cessation] services…or individuals who fail. It’s like it’s
their problem and not the tobacco industry’s and
not our government’s. (Māori)
Defining the endgame in terms of prevalence reduction was seen as absolving the government
and the tobacco industry of responsibility, and deflecting policy attention away from ‘next generation’ measures that address the product itself or its
widespread availability. Thus, the way the endgame
vision is defined and framed may, paradoxically, reinforce ‘business as usual’ approaches rather than
paving the way for more radical interventions.
DISCUSSION
This study is one of few worldwide that has explored key stakeholder views on tobacco endgame
policy options. Although stakeholders’ perceptions
and views may or may not be supported by evidence, the views of politicians, policymakers, and
tobacco control advocates are likely to be influential in framing tobacco control issues and setting
the policy agenda, and therefore, are important to
explore. Such research is intended to stimulate and
64
inform debate, and contribute to the policy development process.
Several of the themes we identified echoed the
results of Daring to Dream16 in which policymakers, journalists, and public health physicians were
interviewed about the tobacco endgame, and legal
and structural strategies for achieving it. Both studies found strong support for the endgame vision
but highlighted perceived political barriers to its
achievement. Both found strongly divergent views
on the feasibility and likely effectiveness of the options discussed, with little consensus about the preferred approach.
Our findings highlight the difficulty of achieving
consensus about the merits of novel policies with a
limited (and/or little known) evidence base. There
was relatively strong agreement among participants
on the tobacco tax proposal – a widely researched
and implemented policy, (albeit at lower rates than
proposed here). In contrast, there was much less
certainty, and therefore, less agreement, about the
likely impacts of the more novel policy proposals.
This lack of certainty resulted in these novel policies being seen as more politically risky and therefore less politically feasible than increased taxation.
These findings also reveal commonly held misperceptions about the endgame policies appraised,
suggesting existing evidence (limited as it is) has
not yet been well communicated to stakeholders.
For example, there was widespread concern that
denicotinization of tobacco products would lead to
compensatory smoking, but emerging research suggests there may be little or no compensation effect
when switching from regular cigarettes to very low
nicotine cigarettes.21-24 Concerns that tax increases
may widen existing ethnic and socio-economic status (SES) disparities in smoking rates also appear
to be misplaced. Most studies show that increasing tobacco tax reduces SES disparities in smoking
rates.25,26 There were also gaps in the knowledge of
participants about information relevant to assessing the feasibility of some of the options discussed.
For example, few were aware that there is an existing power (never used to date) under the 1990
New Zealand Smokefree Environment Act (section
39) to introduce regulations to prohibit harmful
constituents from tobacco products.27
The limited nature of the evidence base suggests
that conducting policy research and evaluation,
Ball et al
and disseminating the findings, are key priorities.
Strengthening and communicating the evidence
base will not only help the sector to prioritise those
endgame policy proposals worth pursuing, but may
also reduce the perceived political risks and uncertainty highlighted by this study that perhaps present the most significant impediment to endgame
progress.28,29 Examples of pre-implementation research that could be used to build the evidence base
include experimental and simulation research using
methods such as ‘experimental marketplace’,30 discrete choice,31 naturalistic studies32,33 and modeling
studies.34 Thorough evaluation of impact, feasibility, and acceptability where innovative policies are
implemented also will be important to inform both
domestic policy review and debate within jurisdictions where such policies are under consideration.
Such pre- and post-intervention policy research
may help speed the implementation of effective
new responses, and could be carried out alongside
any progressive policy change that can be actioned
in the current political environment.
Another implication is that endgame proposals
that extend, adapt, or intensify ‘proven’ policies may
be more politically palatable than completely novel
initiatives, because they are likely to be perceived as
less risky. Therefore, the current study adds weight
to Rabe’s comment that “careful review of all existing policies’ could be beneficial, as new permutations might present significant opportunities.”29
The current study also highlights an issue raised
by Malone in 2013 – the lack of consensus on the
envisioned endpoint of the tobacco endgame.35
There appears to be a lack of alignment in New
Zealand between the dominant understanding of
what New Zealand’s 2025 goal means, and the
original vision of the indigenous leaders who led
the ‘tupeka kore’ (tobacco-free) movement. Almost
all of the participants described the government’s
2025 endgame goal in terms of dramatically reduced smoking prevalence (to less than 5%). This
definition contrasts with Māori aspirations (to ‘get
rid of tobacco’), and also with the actual wording
of the government’s goal that includes “minimal
availability of tobacco by 2025,” as well as “minimal smoking levels.”36
It is not clear why the ‘minimal availability’ aspect
of the goal appears to have dropped out of mainstream discourse in New Zealand, but this shift has
consequences for how the policy problem is framed
and addressed. As Māori participants argued, the
focus on prevalence reduction tends to frame individual behavior as the problem, and de-emphasizes
the product and the industry. Certainly, there has
been little progress on – or even debate about –
supply side measures since New Zealand’s endgame
goal was set in 2011.5,37,38 This lack of supply-side
policy action may have both influenced and been
influenced by the dominance of the ‘prevalence reduction’ definition of the endgame. Ironically, the
current framing of the endgame may be reinforcing the status quo and providing a barrier to serious
consideration of novel policy measures that address
the product itself and its availability.
A limitation of the current research is that the
generalizability of the findings to other groups of
people or to other jurisdictions is uncertain. However, the findings align with previous New Zealand
stakeholder research, and echo key points from
international endgame commentary, which does
suggest that this research can make a useful contribution to the global endgame agenda. Firestone’s
concept of case-to-case transferability is a useful model of generalizability for such exploratory
qualitative research, whereby it is readers and users
who evaluate the extent to which insights might
apply to their own situation, based on the degree
to which the study context matches their own.39,40
Lack of focus on the possible role of e-cigarettes in
endgame strategies also may be considered a limitation of this research, given the increasing interest in
this area.41,42 However, we chose to focus on those
strategies that were most actively being considered
in New Zealand at the time the study was developed, and policy surrounding e-cigarettes did not
meet our criteria for inclusion at that time.
The strengths of the study include a diverse range
of key informants, including some of New Zealand’s most influential opinion-leaders on health
issues, and a particular focus on the viewpoints of
Māori and New Zealand Pacific leaders. In prioritizing and appraising possible policy options, the
perspectives of the population groups most affected
by the tobacco epidemic are important to explore;
yet, research in this area has been limited to date.
Our findings suggest that the endgame vision and
preferred interventions of indigenous and ethnic
minority policy experts may differ from those of
Tob Regul Sci.™ 2017;3(1):56-67
DOI: https://doi.org/10.18001/TRS.3.1.6
65
Stakeholder Appraisal of Selected Tobacco Endgame Policy Options in New Zealand
the dominant culture. Both the process and the
findings of this study may inform research and policy development in other jurisdictions with stark
ethnic disparities in tobacco use.
IMPLICATIONS FOR TOBACCO
REGULATION
This study provides important information for
tobacco control researchers and regulators developing ‘next generation’ interventions in an endgame
context. The findings, though specific in time and
place, provide potentially generalizable insights
about barriers to progressing novel interventions,
and how these might be overcome. For example,
the findings highlight the political risks associated
with novel policies, and suggest that adaptation or
intensification of established policies (eg, taxation)
may be more immediately acceptable and politically feasible than completely novel proposals. The
findings also suggest that evidence and communication gaps must be addressed if the appeal of
endgame policy proposals to decision makers is to
be increased. A stronger evidence base will decrease
perceived political risk, but evidence alone in the
absence of political pressure is unlikely to achieve
change. Vocal champions who can build public
pressure for stronger policy measures by speaking
powerfully to the values issues inherent in tobacco
control may be vital to the progress of ‘next generation’ policies. Furthermore, endgame visions,
if framed in terms of freeing society from tobacco
rather than merely reducing smoking, may help to
pave the way for ‘next generation’ interventions.
Human Subjects Statement
Ethical approval was received from a delegated
authority of the University of Otago Ethics Committee on May 8, 2015.
Conflict of Interest Statement
All authors of this article declare they have no
conflicts of interest.
Acknowledgments
This work was supported by New Zealand’s Tobacco Control Research Tūranga, a program of
innovative research to halve smoking prevalence
in Aotearoa/New Zealand within a decade. The
66
Tūranga is supported through funding from the
Reducing Tobacco-related Harm Research Partnership co-funded by the Health Research Council of New Zealand and the Ministry of Health of
New Zealand (HRC Grant 11/818). This project
was funded by the Tūranga’s Emerging Issues Fund
and led by the University of Otago, in partnership
with Auckland University of Technology. The authors wish thank the key informants who generously shared their expertise and opinions with us.
A preliminary report on the findings of this study
entitled ‘Future directions to achieve smoke-free
2025?’ was circulated to participants, the New Zealand tobacco control sector, and key members of
parliament in March 2016. The report can be found
at: https://aspire2025.org.nz/2016/04/05/reportfuture-directions-to-achieve-smokefree-2025/.
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