1. Snuffing out cigarette sales in our lifetime - a New Zealand perspective Murray Laugesen* Public Health Physician, Health New Zealand Ltd www.healthnz.co.nz Chair, SmokeLess New Zealand www.smokeless.org.nzwww.smokeless.org.nz Honorary Senior Research Fellow Auckland Tobacco Control Research Centre; School of Population Health, University of Auckland Lecture, Harvard School of Public Health, 5 October 2006 *no financial connection to the tobacco or nicotine industry

2. (c) www.healthnz.co.nz2 Aim of this presentation To show how cigarette sales in NZ can be snuffed out in about 10 years based on New concepts that make it feasible Public opinion running ahead of health groups Research now beginning.

3. (c) www.healthnz.co.nz3 New Zealand 23% of adults smoked cigarettes daily in 2004 A fifth of European, half of Maori and a third of Pacific Islanders smoke cigarettes daily. Hand-rolled smoking tobacco is popular. Oral tobacco sales are banned. NRT is subsidised and sold in supermarkets. Tobacco consumption is around 1000 g/adult per year; 13 cigs/smoker/day. Cigarettes costly. No tobacco promotion, no smoking indoors at work

4. (c) www.healthnz.co.nz4 Tobacco control scale scoring policies and programmes, 2005 Based on Joossens and Raw Tobacco Control June 2006 - Based on Joossens & Raw Tobacco Control Score, Tob.Control Jun 2006

5. (c) www.healthnz.co.nz5 Abstract: Stubbing out cigarette sales Since 1990, New Zealand reducing smoking prevalence slowly Smokers are reluctant to quit and stay quit. Four approaches are suggested for accelerated smoking cessation: 1. Increase government resourcing of the current programme, especially of research and 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. R&D OF THE BEST PRODUCTS. 3. Make cigarettes less attractive. Raise cigarette taxes higher than taxes on the alternatives. Gradually reduce nicotine in cigarettes: once nicotine content falls to 15% of current values, sales will fall sharply. R&D NEEDED 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 would be achieved 15 years after the sales ban. R&D NEEDED

6. (c) www.healthnz.co.nz6 New concepts used in this paper 1) Cigarette nicotine can be lowered, and safely without causing compensatory smoking (Benowitz, Dixon), or toxicant absorption (Benowitz) 2) Cigarettes will remain too dangerous to defend. 3) The continued legality of cigarette sales is challenged. The onus of proof should shift to the industry to show cause why cigarettes should continue to be sold. 4) Relative risk of smokeless tobacco is much less than for cigarettes. (Bjartveit 2005, Levy 2004) underlining the case for tobacco tax proportional to death risk of the product. www.smokeless.org.nz www.smokeless.org.nz 5) Snus in Swedish men, a natural experiment, provides proof of concept that Addictive Nicotine Replacement can replace smoking, and reduce mortality. (Foulds, www.tobaccocontrol.com ) www.tobaccocontrol.com 6) A new generation of fast acting pure nicotine products by Fagerstrom et al could put pure Addictive Nicotine Replacement on sale within 2 years. www.niconovum.comwww.niconovum.com 7) Parliamentary and social reforms –MMP, Private Member’s Bills, Select Committees’ increased powers –Maori health and political renaissance.

7. (c) www.healthnz.co.nz7 Fig. 1. New thinking: Compensatory smoking avoidable Most commercial cigarettes reduce nicotine + tar. But if nicotine is reduced but tar unchanged, fewer cigarettes are smoked per day Benowitz SRNT 2004

8. (c) www.healthnz.co.nz8 Confirmed: Even reduced-risk cigarettes will remain too dangerous to smoke Age 35+ : 1 in 2 smokers die early Marlboro UltraSmooth can clean 200 ml of smoke (whereas usual puff vol. =600ml). Even if risks can be halved, a 1 in 4 dying early is unacceptable.

9. (c) www.healthnz.co.nz9 New thinking: Inhaled cigarette smoke much more dangerous than tobacco not inhaled

10. (c) www.healthnz.co.nz10 Male lung cancer rate lowest in Sweden

11. (c) www.healthnz.co.nz11 Encouraging the switch from smoke nicotine to nicotine without smoke Strengthen the current programme New policies needed $$$ to maintain quit advertising Need timely monitoring, forecasting Make cigarettes less attractive Increase cigarette excise Decrease the nicotine Make the alternatives more attractive Eventually, end cigarette sales Availability Adjust excise to product’s death risk Regulate for lowest risk Graphic health warnings

12. (c) www.healthnz.co.nz12 The case against cigarette smoking Since 1950, cigarette smoking has killed 15 mln in the USA and 21 mln in Europe, 200,000 in NZ. Logically, such a dangerous product should be phased out. Health agencies have to state whether they believe continued cigarette sales are defensible, and if so for how long; and if not, when they should be phased out, and how.

13. (c) www.healthnz.co.nz13 Time for a Lucky Strike against Cigarettes If smoking can be banned from bars a ban on cigarette sales is do-able. Leadership from health groups (a clear goal, clear plan) to end smoking will enable society to confront the issue, and move forwards. First step is to reduce prevalence further, before ending cigarette sales, to protect children but not penalise smokers for smoking Legislators will end cigarette sales if we ensure smokers can buy a regular nicotine fix instead of cigarettes.

14. (c) www.healthnz.co.nz14 NZ smoking tobacco consumption now below Sweden’s

15. (c) www.healthnz.co.nz15 Decreased national consumption per adult does not equate to programme success unless smoking prevalence is also declines. The cigarette offers huge untapped capacity for more intensive smoking, with less tobacco going to waste in sidestream smoke. This suits smokers who wish to smoke fewer cigarettes per day Only 21 seconds spent puffing (8 % of time smoking) A total of 5 minutes spend smoking a manufactured cigarette A burning cigarette smoulders for 92% (4 mins 40 seconds) of the avg. burning time, creating side stream smoke - Observations on 8 NZ smokers and 13 cigarettes. – Health NZ data Conclusion: Fewer cigarettes smoked due to price increases, may merely mean those fewer cigarettes now smoked more intensively.

16. (c) www.healthnz.co.nz16 RYO in NZ, snuff in Sweden, taking market share from manufactured cigarettes

17. (c) www.healthnz.co.nz17 Inter-country comparison of trends in smoking prevalence - the % of adults who smoke Method- compare the slope of the trend over time Inter-country comparison of average rates of annual decrease, (to eliminate inter-country differences in survey methods.)

18. (c) www.healthnz.co.nz18 Adult smoking prevalence, 1990-2 to 2002-4: Rate of reduction p.a.

19. (c) www.healthnz.co.nz19 Male smoking prevalence 1990-2 to 2002-4: Rate of reduction p.a.

20. (c) www.healthnz.co.nz20 Female smoking prevalence 1990-2 to 2002-4: Rate of reduction p.a.

21. (c) www.healthnz.co.nz21 Smoking prevalence in Canada 1990-2004 and graphic health warnings, December 2000

22. (c) www.healthnz.co.nz22 Forecasts of adult smoking prevalence, if post- 1990 and post-2000 trends persisted: NZ 5% of doctors smoking,1996 Maori Total population

23. (c) www.healthnz.co.nz23 Need for re-appraisal: Moral distaste for tobacco clashing with data on health consequences Cigarettes Oral snuff _______________________________________ Ratio of excess mortality risks : 20 : 1 (Levy 2004) ____________________________________ Health No plan yet to end Largely want it banned Groups’ sales to adults or discouraged Attitudes Don’t like it but Because it’s tobacco so far, acquiescent most disapprove _____________________________________________________

24. (c) www.healthnz.co.nz24 Nicotine options without the smoke Nasal (tobacco) snuff Legal to import and sell: Price ?? 2/3 x cigarettes Addictive +++ Fast acting < 5 minutes Finely ground powder Risk ? 5% x cigarettes Fast nicotine R&D needed Would be legal to sell in NZ Price ?? 2/3 x cigarettes Addictive ? +++ Fast acting < 5 mins Lozenge/spray/pouch Risks virtually zero Oral (tobacco) snuff Mail-order import only for own use 2/3 price of cigarettes Addictive +++ Acts in 5-15 mins Risk ? 5% of cigarettes (Pure) nicotine gum (medicinal) Sold in pharmacies, supermarkets Price: 5% x cigarettes, if subsidised Addictive + /- 15 mins to act. Risks virtually zero

25. (c) www.healthnz.co.nz25 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

26. (c) www.healthnz.co.nz26 This product (nasal snuff) is addictive, may cause disease, but is much less harmful than cigarettes. Nasal snuff is finely ground tobacco which is 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

27. (c) www.healthnz.co.nz27 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 associated with the lowest male smoking and lung cancer and lowest male mouth cancer mortality rates.

28. (c) www.healthnz.co.nz28 The effect of smokers using snuff: 92% quit smoking 54%-56% of male smokers quit both smoking and tobacco. Those using snuff accounted for an extra 38% quitting smoking; only 8% of the snuffers remained smokers: a 92% quit rate - Ramstrom and Foulds Tobacco Control June 2006

29. (c) www.healthnz.co.nz29 Snuff a gateway away from smoking: of primary snuffers only 5% became smokers Smoking prevalence across all primary snuffers here is 5%, as opposed to 35% for primary smokers, a 1 to 7 ratio. - Ramstrom & Foulds Tob Control 2006 Whether started as a snuffer or a smoker: tobacco use when surveyed If young people ignored the under-18 sales ban and used snuff, it would reduce their risk of becoming a smoker.

30. (c) www.healthnz.co.nz30 Policies to make cigarettes less attractive Increase tax relative to affordability Decrease nicotine content Gradual but flexible: 2-8 years Do it in 7 step-downs at least four months apart Increase the excise rate Tax proportional to death risk Major effect from 6 th stepdown Increase tax relative to alternatives Ban RYO cigarettes-or tax them much more

31. (c) www.healthnz.co.nz31 The tax rate (flat line) vs. the relative risk of each product (columns), NZ, 2006

32. (c) www.healthnz.co.nz32 Nicotine content per cigarette, versus threshold (minimum) required daily to sustain addiction 2-3 cigarettes a day provide enough nicotine to maintain addiction

33. (c) www.healthnz.co.nz33 A ban on hand-rolled cigarettes From pipe to cigarette and the much greater risks of inhaled smoke 1800s 1900s Broughton J 1996 Puffing up a storm With the shift from traditional pipe smoking in the 1800s, to cigarettes in the 1900s, smoking mortality among Maori and all New Zealanders increased greatly.

34. (c) www.healthnz.co.nz34 For and against a ban on cigarette sales Justification of sales ban –Harmful to smokers’ health killing 1 in 6 NZ adults 13 y early –Health Protection Banning sale to adults will protect children from taking up cigarette smoking. –Harmful to Wealth costs 1.7% of NZ GDP. –Smokers will be able to buy a nicotine fix without smoking Arguments against Liberty limitations - but most smokers regret starting Nanny state. Everyone who smokes knows the risks (though most regret ever starting) Black market (dampened by access to smokeless nicotine, and no ban on growing of one’s own) Ma and Pa corner stores (dairies) will lose profit (though they may sell nicotine or snuff instead). Ban the product not the smoker. Smokers not to be penalised

35. (c) www.healthnz.co.nz35 Policy choices and prevalence reduction estimates for New Zealand males, 2006 - 2016

36. (c) www.healthnz.co.nz36 Policy choices and prevalence reduction estimates for New Zealand, 2006-16

37. (c) www.healthnz.co.nz37 Preconditions and predictions for making smoking history in NZ within 10 years Graphic packet warnings……………….. Research results on fast NRT v gum Fast NRT sold and 1.5x as effective Fast NRT will be subsidised ++ --------------------------------------------------- MoH doubles promotion of quitting…… < 15% of adults smoke…………………. Health groups ask for cig. sales ban _______________________________ Law to lower cigarette nicotine………… Law to end cigarette sales……………. YES, 2008. YES, 2007, 2008 YES, 2008; snus is 2x gum effect YES, NRT subsidised since 2000. __________________ YES, once fast NRT delivers results YES, after 5 years of fast NRT YES, once < 15% smoke. ___________________________ YES, once sales ban law agreed to. YES, if Greens + Maori + Labour all want it.

38. (c) www.healthnz.co.nz38 Research to reduce smoking and snuff out cigarette sales Clinical trial units: RCTs for better NRT. Health outcomes research: Snus risks. Policy makers Need applied policy research (on black markets, price, behavioural economics labs, cigarette nicotine, projections of smoking mortality and policy scenarios. Providers of stop smoking services – provide them with research support. Advocates: Track opinions of smokers, nonsmokers, health groups, legislators.

39. (c) www.healthnz.co.nz39 Do you support a ban on the sale of all tobacco products in New Zealand? N =1000, age 18+, March 2006. TNS for TV3, telephone survey N =750, age 18+, May 2000, UMR for NBR, telephone survey Do you support or oppose a complete ban on smoking in pubs?