Addiction (1993) 88 (Supplement), 35S-41S

Interaction of public policy advocacy andresearch in the passage of New Zealand'sSmoke-free Environments Act 1990

MICHAEL CARR-GREGG

Social Biology Resources Centre, 139 Bouverie Street, Carlton, Victoria 3053, Australia

AbstractTTiis paper examines the public policy campaign that led up to the passage of New Zealand's Smoke-freeEnvironments Act 1990, arguably the toughest tobacco control legislation in the world, focusing on the criticalinteraction between advocacy and research. The paper argues that had it not been for the Toxic SubstancesBoard Report and the publicity it received, it is doubtful that the Smoke-free Environments Act would havebeen enacted. The tobacco industry catch cry that ad bans don't work, largely fell on deaf ears because of theToxic Substances Board Report's findings, and the public health advocate's ability to refer to an authoritativeDepartment of Health document.

IntroductionOn 28th August 1990, the New Zealand Parlia-ment enacted the Smoke-Free EnvironmentsAct, arguably one of the toughest pieces of anti-tobacco legislation ever enacted in the world.The law required all employers to draw up, inconsultation with employees a policy to protectthe rights of workers to a smoke-free environ-ment. Additionally, all direct advertising oftobacco products including point of sale adver-tising was banned and tobacco sponsorship ofsports, arts and cultural events was phased out.An alternative sponsorship mechanism, in theform of the Health Sponsorship Council wasestablished. The campaign, which culminated inthe new legislation, was initiated by the produc-tion of the Toxic Substances Board Report"Health or Tobacco" (1989)' containing awealth of scientific data culminating in strongpolicy recommendations.

This paper briefiy defines public policy advoc-acy, offers an overview of the New Zealandcampaign and demonstrates how the scientific

evidence was packaged by the policy makers andthen utilized by the public health advocates inthe campaign that produced the Smoke-FreeEnvironments Act 1990.

Public policy advocacyPublic policy advocacy may be defined as theattempt to infiuence what will, or will not be, amatter of public policy, the content of policies asthey are made, and the way in which they areimplemented, once agreed to by the government.In short public policy advocacy is important. Keyto an understanding of such advocacy is thereality of competition, in this case between thoseconcerned with the public health and those con-cerned with the continuing profits of the tobaccoindustry. The government itself is an arbitratorbetween competing interest groups.

Public policy advocacy is very different firomscientific investigation, as Gordis has noted, thepublic advocate has to know what to sell, towhom it can be sold and when the public is

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ready to move.̂ Advocates use the scientific liter-ature to convince, but tend to cite only the datasupporting their position, while ignoring or ac-tively disparaging contradictory evidence. Ingeneral, advocacy derives from personal valuesand self-interest and more latterly the findingsfrom science.' One of the great virtues of advo-cacy, however, is that it works, and that it makesthings happen.

It is clear that policies are adopted only in aclimate of public readiness. If the public is notready it is unlikely that Government will doanything revolutionary, as the principle is thatgovernment will not move far from the perceivedpublic opinion.* Lobby groups must compellegislators by demonstrating the weight of publicand professional opinion.

Background to the New Zealand campaignIn New Zealand, the current overall smokingrate is 22.8%. Even though this figure is thelowest of all OECD countries, yet 19% of alldeaths in New Zealand are attributable tocigarette smoking. This figure omits passivesmoking deaths and pipe smoking deaths. Thecost of excess hospital admissions due to smok-ing has been estimated to be $185.4 million andMaori females have one of the highest lung can-cer incidence rates in the world.'

Since 1984 the government has adopted anumber of preventive strategies which included:strong warnings, tar information on cigarettepackages, substantially raised tobacco prices,funding a smoke-free week and making tobaccosales to under 16's a criminal offence.

The Department of Health set a trend in1987, by providing a smoke free environment forits staff and in September 1988, the Departmentof Health released a discussion paper entitled"Creating smoke-free indoor environments—Options for Action." As a result, manygovernment and private sector work places arenow smoke-free. The Minister of Health an-nounced a half million dollar campaign toencourage people to stop smoking and in 1989the report of the Toxic Substances Board"Health or Tobacco" was released.

This report concluded that the elimination oftobacco promotions, when supported by othergovernmental measures such as tax hikes andcomprehensive education campaigns has broughtabout a decrease in teenage smoking rates as well

as bringing about a decrease in the consumptionof tobacco in adults.

The document summarized the weight ofmedical and social science research and sup-ported the arguments of those health groupssuch as the New Zealand Medical Association,the Cancer Society and Heart Foundation whohad for some years been calling for a ban ontobbaco promotions.

This Report coincided vtdth the appointmentof the Rt Hon Helen Clark, as Minister ofHealth and Deputy Prime Minister. For the firsttime the health lobby had a committed andinfiuential Minister, with the courage and politi-cal will to abolish the existing voluntaryagreement with the tobacco industry and pushthrough tough anti-tobacco legislation. TheMinister also enjoyed unprecedented support inthe bureaucracy who had acquired significantexpertise by conducting their own research andwere able to provide the Minister with the mostaccurate and up to date information on theeffects of tobacco advertising bans.

Although the Minister did not know it at thetime, public opinion polls conducted retrospec-tively, showed that there was significantgrassroots support favouring the legislative op-tion. Due to a marked decrease in the percentageof adult smokers, for the first time in NewZealand history, the public was ready for themeasures contained in the Bill. During the cam-paign the health group used the results of publicopinion polls in three ways; to generate mediacoverage, to provide ammunition to supportersin caucus when the issue was debated and tomonitor the success of the campaign messages. Apoll commissioned by the health groups, show-ing a dramatic decline in support for thelegislation, towards the end of the campaign,demonstrated a need to shift the focus of thecampaign. The decline in support followed afull-page advertising campaign by an industrycreated front group called "Sports People forFreedom in Sport", and featured elite NewZealand sportsmen and women alleging that theproposal would harm sport. As a result of thepoll, the health lobby intensified its efforts to winover the sports lobby and created its own group,called "Athletes For Tobacco-free Sport".

The circumstances, however, were not over-whelmingly in the Minister's favour, at thebeginning of 1989 there was no effective healthlobby and the opposition National party along

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with the newspaper publishers, hroadcasters andadvertisers had made it clear that they would notsupport the legislation.

In December 1989 the Minister of Healthadopted the first set of New Zealand HealthGoals and targets, and the control of the tobaccoepidemic was given the highest priority. Shortlyafterwards a decision was made to combine thesmoke-free workplaces component and bans ontobacco promotion into one Bill. The maintargets were: to reduce tobacco consumptionfrom 2068 g per person 15 years and over peryear, to 1500 g or less by the year 2000, and toreduce the prevalence of current smokers from27% in 1989 to 23% or less by the year 1995and 15% or less by the year 2000. Other specifictargets focused on smoking rates in children,Maori and pregnant women. On the 21st De-cember 1989, the Minister announced herintention to ban all tobacco advertising and pro-motion, and the Parliamentary Oppositionimmediately announced their intention to op-pose the proposal.

The New Zealand tobacco industry throughit's professional lobby group, the Tobacco Insti-tute of New Zealand had previously always beenable to discourage the introduction of such legis-lation, by constant reference to theindustry-inspired voluntary code of conduct.The history of this industry inspired voluntaryagreement was littered with flagrant violationsand example after example of non-enforcement.In essence, the agreement contained variouspromises by the industry not to market to child-ren and manifestly lacked both responsibility andcredibility, it's regulations being purposefully fullof loop holes, taken up with largely unenforce-able prescriptions and were virtually complaintproof. By comparison the medical organizationsand the health charities were politically inexperi-enced, devoid of clear goals, unco-ordinatedand, by and large, lacking in the skills, strengthand strategic know-how to mount an effectivecampaign. Their activities were dominatedlargely by research meetings and the use of themedical model, which focused on victims, ratherthan political strategies.

In the past the health community had sufferedfrom a combination of factors of varying impor-tance: the raw magnitude of the industry^ the NZS800 million of revenue collected by the Govern-ment from the sale of tobacco products, tobaccoindustry financial contributions to both political

parties; the strength and support of the advertis-ing industry, the dependence of the media andsporting bodies on the tobacco industry becauseof advertising and sponsorship revenues; andpolitical appraisal of public opinion.

In addition, the industry had always impliedthat any politician or party seeking to upset thestatus quo would be buying a confrontation thatwould be long, arduous and ultimately unre-warding. The tobacco issue was simply tootough, especially given the fact that at the timealmost a third of adults were smokers and NewZealand has a 3-year electoral cycle.

A further political dynamic that should not beunderemphasized was that the major party philo-sophically most predisposed to tobacco control,the Labour Party, historically drew its majorsupport from the blue-collar population—theheaviest smokers. In contrast, the Labour Gov-ernment was a reforming Government basing itsactions on philosophical precepts more than onpolitical exigencies.

The Canadian experienceThe passage of the Canadian Tobacco ProductsControl Act (Bill C51) and the Non Smokers'Health Act (Bill C-204) in 1989, showed thatwhen traditional health charities such as theCanadian Cancer Society, were willing to adoptpolitical strategies, work together in a coalitionwith other organizations, and mobilize their vol-unteers, they discovered that they could bringabout significant legislative changes.

The Canadian Coalition led by the NonSmokers Rights Association (NSRA) was com-posed of Canada's foremost health groups, all ofwhom were helped by the NSRA to identify thetobacco industry as the source of the tobaccoproblem, to recognize that smoking is a politicalproblem that needs a political solution. The NewZealand Cancer Society obtained a copy of areport on the Canadian campaign written byKen Kyle, the Director of Public Issues in theCanadian Cancer Society.*

Coalition strategyIn February 1989, the New Zealand CancerSociety and the National Heart Foundationformed the Coalition Against Tobacco Adver-tising and Promotion' (CATAP). This organ-ization employed the author as co-ordinator.

38S M. Carr-Gregg

and formed what became one of the largestcoalition of health and human service groups inthe history of New Zealand public health.

The challenge was to shift the anti-smokingactivities of the major health charities from theirfocus on individual smokers to a political per-spective. In the past, such groups were reluctantto participate in the public policy campaignsbecause of their conservative nature, their illness-orientated academic management and fear ofoffending corporate sponsors. The advocacy ap-proach of these groups was a shift fortraditionally conservative organizations. For along time, many felt that such charities shouldnot be involved in such activities. Given the factthat these charities were business backed, andsupported throughout the community, reljdngalmost exclusively on community donations fortheir operating expenses, such an attitude wasunderstandable. There was also a fear that theircharitable status could be repealed if they startedlobbying.

Action on Smoking and Health (NZ), a mem-ber of the Coalition, played a catalytic role indefining the most radical pole of the politicaloptions. By being both vociferous and radical,ASH allowed the other Coalition members(NZMA, Cancer, Heart, Asthma, Royal Collegesof Medicine, nurses associations, OTs, physio-therapists, etc.) to adopt what was for them,more aggressive stances, whilst at the same timeappearing to be moderate.

The Coalition was thus able to develop asubstantial network, allowing the health groupsto break out of their academic bureaucratic sub-culture. Through a letter of invitation signed bythe Medical Directors of the New Zealand Can-cer Society and National Heart Foundationmembership of all the major health groups in thecountry was quickly secured. A pamphlet, spon-sored by the Pharmacy Guild of New Zealand,summarizing the research evidence on tobaccorelated diseases, the effects of tobacco advertis-ing and promotion on the recruitment of youngNew Zealanders, especially young women wasproduced with the names of almost 50 nationalhealth and human service organizations. A care-fully staged media launch, which receivedsignificant and vital media coverage, served as afocal point for the campaign.

The pamphlet was aimed at groups not di-rectly involved in the smoking issue, but whowere keen to be identified as part of the main-

stream health lobby, were likely to besympathetic and would make valuable allies. Inorder to recruit allies, women's groups, (e.g.National Council of Women, Girl Guides) weresent summaries of the research on women andsmoking. Parent Centres, Scout groups weresent material on child smoking and the effects ofadvertising bans, whereas environmental groups(Royal Forest and Bird Society) were sent re-search data on deforestation, pesticides andair-pollution. The strategy was to tailor the issueto the concern of that group, so that the aspectof smoking that most concerned them was em-phasized. This customization was the glue thatenabled the Coalition to bind disparate partiestogether over the forthcoming turbulent period.

While the pamphlet, followed by personal rep-resentations by leading lights in the CancerSociety and Heart Foundation was a useful re-cruitment technique, ultimately the objective wasto infiuence legislators. Part of this involved get-ting as many prestigious groups as possible tomake media statements on this issue and agree totake part in delegations to meet politicians faceto face. The more high powered the delegation,the harder it became for politicians to dismiss theissue and ignore the campaign.

The researchThe cornerstone of the campaign was the inter-national scientific evidence on thehealth-damaging effects of tobacco. Beginningwith the reports of the Royal College of Physi-cians^ in 1962, and backed up by the landmarkUS Surgeon General's Report' of 1964, tobaccowas identified as a major preventable cause ofdeath and disease.

New Zealand reports, in particular producedby the National Heart Foundation, have regu-larly summarized the overseas evidence,particularly with regard to coronary heart dis-ease.'" Because the overseas evidence had beenaccepted, very few New Zealand aetiologicalstudies had been published." The pattern ofsmoking in New Zealand, particularly the highrates in Maori and young women was docu-mented by a series of reports that drew on datafrom the 1971 and 1976 national censuses.'^

Total tobacco consumption has been decliningsince 1953 and sales of machine-made cigarettessince 1975.'' Smoking rates in young womenhave declined gradually. Estimates based on

New Zealand's Smoke-free Environment Act 39S

New Zealand and international data have beenused to focus attention on the magnitude of thehealth problems caused by tobacco and havegiven credibility to the local campaign.'''

The US Surgeon General's Report in 1986 onpassive smoking further stimulated and mobi-lized the concern of non-smokers." This wascritical as smoking officially became everyone'sbusiness. The international data were used toextrapolate the number of deaths in NewZealand attributable to both smoking and pas-sive smoking.'*

The international scientific evidence providedjustification for the New Zealand public healthcampaign. In particular, the estimate of 4073"New Zealand deaths per annum attributable toactive smoking and the 273 deaths per annumattributable to passive smoking," both based onoverseas data, provided a simple means of indi-cating the extent of the problems caused bytobacco products in New Zealand. A centraltheme of the health campaign was to repeat asoften as possible two crucial statistics, that over4000 New Zealanders died each year from to-bacco-related diseases and that over 50 childrena day smoked their first cigarette. The use ofsuch creative epidemiology by advocates is usefulin focusing public debate. Within a few monthsthe figures were appearing in editorials and werefi-equently quoted by commentators on the elec-tronic media.

However, the key research that assisted thoseinvolved in public advocacy on this issue mostwas the study of the inter-relationship of tobaccoadvertising and tobacco consumption examinedin 33 countries in a study commissioned by theToxic Substances Board covering the year 1970to 1986. The study showed that:

• Government tobacco advertising bans andcontrol are accompanied by marked rates offall in tobacco consumption and in tobaccosmoking prevalence; in the absence of anysuch control, consumption increasesmarkedly.

• Total advertising bans for health reasons areon average accompanied by falls in tobaccoconsumption four times faster than in partialban countries.

• The annual rate by which tobacco consump-tion falls is graduated, with the maximum fallseen in total ban countries.

• Much slower declines in consumption are

seen in countries where tobbaco promotionhas been banned for political reasons or hasbeen permitted in some media.

• In countries where tobacco has been pro-moted virtually unrestricted in all media,consumption has markedly increased.

• In countries where advertising has been totallybanned or severely restricted, the percantageof young people who smoke has decreasedmore rapidly than in countries where tobaccopromotion has been less restricted.'

The industry responseThe TSB document helped dictate the groundson which this campaign was fought. Tradition-ally, the industry used several arguments—thatthe scientific evidence on the health effects ofsmoking is inconclusive, that ad bans are ineffec-tive and that ad bans are a violation of thefreeedom of commercial speech. The industryspent much valuable time, and energy on(specifically) attacking the TSB study of theinter-relationship of tobacco advertising and to-bacco consumption.

The Institute commissioned a 200 page 'Inde-pendent' Scientific Review of the ToxicSubstances Board Report which concluded that," . . . the report is full of untenable assumptions,misleading data, and faulty statistical methodol-ogy. Individually these various criticisminvalidate large sections of the report. Collec-tively, they indicate that its conclusions cannotbe regarded as a reasonable basis for publicdecision making."'^ Even to neutral observers,the effectiveness of the report could be gaugedby the ferocity with which the industry attackedit.

The TSB report played a significant role in thecampaign in several ways. Not only did it showthe Minister she had the support of the bureau-cracy, but it was also useful in assisting theMinister to win over her Cabinet and caucus.The Report also convinced the conservativemembers of the Cancer Society Council andNational Heart Foundation Executive and gavethem the impetus to form the Coalition. In addi-tion the document helped the Cancer Societyconvince the major health and human servicegroups, e.g. New Zealand Medical Associationto get involved in political advocacy." It was alsoreferred to in fact sheets distributed by the Can-cer Society to its list of donors and used by the

40S M. Carr-Gregg

Coalition in its formative stages when makingfund raising pitches to major organizations.

Once the Coalition was formed, the Reportgave the Coalition media managers an authorita-tive, local and prestigious document to cite infull page advocacy ads in the media. The authorused the Report to win over health reporters andleader writers, and secure the support of keynewspapers. An abridged version of the TSBReport was used in lobbying MPs, ministers anddistributed in health caucus meetings, thus en-suring their support and giving them theconfidence to take on the media and justify theirstand to industry representatives, disgruntledsports groups and their local electorate. Thisexecutive summary was used by the differentCoalition members as a reference documentwhen making media statements, in letters to theeditor, in speeches to other groups and in refut-ing tobacco industry arguments.

The fact that there was data in the documentrelating to Maori smoking rates assisted in effortsto recruit support from prominent Maori groups,e.g. Maori Women's Welfare League. The utilityof the abridged version was clearly illustrated bythe fact that it was referred to in many of the5000 oral and written submissions made to theparliamentary select committee considering theBill. In short, the executive summary of the TSBReport helped clarify a complex issue. It wascomprehensive, understandable and forceful,and therefore an important political tool.

ConclusionIt is the view of this author that researchers,especially those in receipt of pubUc money,should have the responsibility to the tax payersto ensure that what they do counts, in terms ofpublic health. There is little doubt that there isroom for closer co-operation between re-searchers and advocates.

From the public policy advocate's perspectivethere are a number of steps that could facilitatea closer working relationship. First, it would behelpful, if researchers put the public health im-plications of their investigations before the publicin a simplified and succinct matiner.

Secondly, that they communicate with publichealth advocates, and keep them abreast of theliterature and the public policy implications.Next, that they make themselves available totestify before Government committees and show

a willingness to state the policy implications oftheir findings. Lastly, that they help obtain fund-ing for public policy advocacy.

Scientific justification alone is rarely the onlyroute by which most policies come into being, ingeneral some combination of science and publicadvocacy come together to produce social poli-cies, with the role of science varying from policyto policy. In this instance, public understandingand public concern was the key element whichconverted the scientific findings into policy. Thisunderstanding was obtained by persistent intensepressure by informed groups who really wantedto see things change.

While most Governments have the desire tolead, they also have to sense the degree to whichthe public will follow. The information con-tained in the Toxic Substances Board Reportwas systematically sold first to the health groupsand then to the public so as to create a climate inwhich the politicians could take on powerfulvested interests knowing that there was informedpublic support.

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years of progress. A report of the Surgeon General, pp.157-158 (Rockville, Maryland, US Department ofHealth and Human Services).KAWACHI, I, PEARCE, N . E. & JACKSON, R. T .(1989) Deaths from Lung Cancer and IschaemicHeart Disease due to Passive Smoking in NewZealand, New Zealand Medical Journal, 102, pp.337-340.GRAY,AJ , REINKEN, J A. & LAUGESEN, M. (1988)The Cost of Cigarette Smoking in New Zealand,New Zealand Medical Journal, 101, pp. 270-274.TOBACCO INSTITUTE OF NEW ZEALAND (1989) In-dependent Scientific Review of the May 1989, ToxicSubstances Board Report (Auckland, Tobacco Insti-tute of New Zealand).CARR-GREGG, M. R. C. & GRAY, A, J. (1989) To-bacco Advertising—why the fuss? New ZealandMedical Journal, 102, pp. 405^06.