1	Stubbing out cigarette sales in New Zealand Murray Laugesen Public Health Physician, Health New Zealand Ltd and Honorary Senior Research Fellow Auckland Tobacco Control Research Centre School of Population Health, University of Auckland ATCRC & CTRU Tobacco Control Symposium 24 March 2006 “Towards a Smokeless New Zealand”
2	Funding and Financial Interest statement Funding received – None. Financially independent of the smoking tobacco, smokeless tobacco, nicotine, pharmaceutical industries.
3	Abstract: Stubbing out cigarette sales Since 1990, New Zealand and New Zealand Maori are reducing smoking prevalence much more slowly than Australia, Canada, California, or Sweden. In all jurisdictions the smoker is setting the current pace of smoking reduction. Smokers need empowering to more rapidly forsake cigarettes. Four approaches are suggested, and their effects modelled: 1. Increase government resourcing of the current programme, especially of media campaigns to quit smoking; and adopt graphic warnings on cigarette packets. 2. Put more effective low-risk alternative products on sale. Let smokers buy a regular nicotine fix - without the financial and health costs of smoking. Fast-acting pure nicotine is still in development. Acceptability and effectiveness to test these products as quitting aids is needed. Sale of lowest-risk Swedish oral snuff has been illegal since 1987, and this same law impedes its research. 3. Make cigarettes less attractive. Raise cigarette taxes higher than taxes on the alternatives. Gradually reduce nicotine in cigarettes. Smoking will be largely unaffected until nicotine content falls to 15% of current values. This requires a private member's bill. 4. Finally, stub out cigarettes sales altogether (“I just wish I couldn’t buy them”), without penalising smokers. Five percent may remain smokers. The full reduction in lives saved (4000 per year) would be achieved 15 years after the sales ban.
4	New concepts used in this paper 1) Cigarette nicotine can be lowered, and safely. 2) Snus in Sweden, a natural experiment, provides proof of concept that Addictive Nicotine Replacement reduces mortality 3) A new generation of fast acting pure nicotine products 4) Smoked tobacco products are far more dangerous 5) Parliamentary and social reforms
5	Route map for this paper
6	The case against Cigarettes Cigarette smoking has killed 20 million in Europe, and 200,000 in New Zealand since 1950. Cigarettes kill cause one third of all Maori deaths. Logically, such a dangerous product should be phased out. Health agencies have to state whether they believe cigarettes should be phased out, can be phased out; and if so, then how, and when.
7	Major disconnect Cigarettes Smokeless _________________________________ Ratio of excess risks 20 to 1 _________________________________ Health No plan to end Largely approve Groups’ sales to adults continued sales bans Attitudes Acquiescent Disapproving of change _____________________________________________________
8	Time for a Lucky Strike against Cigarettes Leadership from health groups (a clear goal, clear plan) To protect children, a cigarette sales ban Individual smokers: regular nicotine fix Population level: Providing for smokers’ addiction is a pre-condition for effective legislation
9	NZ: Tobacco products, consumption, per adult 1990-2004 Tax paid products consumption per adult age 15 and over 1990-2 avg v. 2002-4 avg, = 3.3% average annual rate of reduction
10	NZ smoking tobacco consumption now below Sweden’s
11	Proportion of the burn time actually spent puffing
12	RYO in NZ, snuff in Sweden, taking market share from manufactured cigarettes
13	Adult smoking prevalence, 1990-2 to 2002-4: Rate of reduction p.a.
14	Male smoking prevalence 1990-2 to 2002-4: Rate of reduction p.a.
15	Female smoking prevalence 1990-2 to 2002-4: Rate of reduction p.a.
16	Trend in smoking prevalence 1994-5 to 2003-4. Annual reduction as a % of 1994-5 prevalence
17	Smoking prevalence trend in Canada 1990-2004 and graphic health warnings, December 2000
18	Daily smoking prevalence, men, 1990-04
19	Daily smoking prevalence, women, 1990-04
20	Forecasts of adult smoking prevalence, if post-1990 and post-2000 trends persisted: NZ
21	The continuum of risk from using tobacco and nicotine. Relative mortality risk from smoking cigarettes, cigars, snuffing, chewing nicotine gum or abstaining from tobacco
22	Major disconnect ___________________________ Cigarettes Oral snuff _______________________________________ Ratio of excess mortality risks: 20 : 1 (Levy 2004) ____________________________________ Health No plan yet to end Largely approve Groups’ sales to adults continued sales bans Attitudes Don’t like it, but If a tobacco product, so far, acquiescent most disapprove _____________________________________________________
23	Nicotine options for smokers
24	Nicotine is addictive. It does not carry the other risks of cigarette smoking Safe. Fast-acting nicotine products under development: Probably addictive Lozenge Mouth spray Pouch / teabag. Pure nicotine in micro-cellulose carrier www.niconovum.com
25	This product (nasal snuff) is addictive, may cause disease, but is much less harmful than cigarettes. Nasal snuff is finely ground tobacco which is sniffed or snorted up the nose. It can give a nicotine hit within 2 minutes. Not sold, but legal to sell. Can substitute for a cigarette. Addictive +++
26	This product (moist oral snuff) is addictive, may cause disease, but is much less harmful than cigarettes. Tobacco in the form of moist snuff (snus) Sale banned: can be imported for personal use. As addictive as cigarettes. 20 times less risky than cigarette smoking** Snus allows smokers to quit smoking’s risks without giving up nicotine or tobacco. Users few – university students from Scandinavia. Outside Sweden is important as “proof of concept” that tobacco harm reduction is popular and associated with the lowest male smoking and lung cancer and lowest male mouth cancer mortality rates.
27	Policies to make cigarettes less attractive
28	The tax rate (flat line) versus the relative risk of each product (columns), NZ, 2006
29	A ban on hand-rolled cigarettes
30	Type of cigarette smoked as a proportion of all smokers, 2002 The case for banning the sale of RYOs: Over half of cigarettes smoked by Maori are RYOs. RYOs probably kill one in six Maori
31	Nicotine content per cigarette, versus threshold (minimum) required daily to sustain addiction
32	Policy choices and prevalence reduction estimates for New Zealand males, 2006 - 2016
33	Ban on manufactured cigarette sales (assuming RYO already banned) Justification of sales ban 200,000 cigarette deaths Protect children Lock in gains achieved so far. Many smokers would welcome it. Against a sales ban Smokers’ rights Retailers’ livelihood Black market and fear of gangs Prohibition didn’t work (alcohol) Marijuana law doesn’t work (but no ban proposed on possession, smoking or growing for personal use)
34	Policy choices and prevalence reduction estimates for New Zealand, 2006-16
35	Smoking can be made history within 10 years