snuffing out cigarette sales in our lifetime - a new zealand perspective murray laugesen* public...

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.nz

Honorary Senior Research FellowAuckland 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

http://www.healthnz.co.nz/

http://www.smokeless.org.nz/

(c) www.healthnz.co.nz 2

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.


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


Tobacco control scale scoringpolicies and programmes, 2005

Based on Joossens and Raw Tobacco Control June 2006

0

20

40

60

80

100

Sco

re

Price Bans Treatment Expenditure including public information

- Based on Joossens & Raw Tobacco Control Score, Tob.Control Jun 2006


Abstract: Stubbing out cigarette salesSince 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


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

• 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 )

• 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.com

• 7) Parliamentary and social reforms – MMP, Private Member’s Bills, Select Committees’ increased powers – Maori health and political renaissance.

http://www.smokeless.org.nz/

http://www.tobaccocontrol.com/

http://www.niconovum.com/


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

0

5

10

15

20

25

2 3 4 5 6 7 8

weeks

mg

or c

igs

per

day

0

0.2

0.4

0.6

0.8

1

Smok

e ni

cotin

e m

g

Nicotine content

Tar yield in smoke

Cigarettes per day

Smoke nicotineyield

Benowitz SRNT 2004


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.


New thinking: Inhaled cigarette smoke much more dangerous

than tobacco not inhaled3.7

3.43.1

2.82.5

2.0

1.6

1.2 1.17 1.141.0 1.0

0

1

2

3

425

+ ci

gts

/day

20-2

4 ci

gts

Cig

ar, i

nh

ales

15-1

9 ci

gts

10-1

4 ci

gts

5-9

cig

ts

1-4

cig

ts

SH

Sm

oke

Sn

uff

on

ly

Cig

ar, n

on

-in

hal

er

Nic

oti

ne

gu

m

No

to

bac

co o

rn

ico

tin

e

Ris

k fo

r nev

er-s

mok

ers

=1.0

Male inhalers

Female inhalers


Male lung cancer rate lowest in Sweden Male lung cancer mortality rate in 2000, age standardised per 100 000

32

0

20

40

60

80

100

120

Bel Net Gre Lux Ita US Spa Den Can Fra Ger UK Ire Aut Fin Swi Asl NZ Nor Port Ice Swe

deat

hs /1

00 0

00 /y

ear


Encouraging the switch from smoke nicotine to nicotine without smoke

Strengthen the current programme

New policiesneeded

$$$ to maintain quit advertising

Need timely monitoring, forecasting

Make cigarettes less attractive

Increase cigarette excise

Decrease the nicotine

Make the alternativesmore attractive

Eventually, end cigarette sales

Availability

Adjust excise to product’s death risk

Regulate for lowest risk

Graphic health warnings


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.


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.


NZ smoking tobacco consumption now below Sweden’s

0

500

1000

1500g

/ ad

ult

NZ drysmokingtobacco

Sweden drysmokingtobacco

Sweden,tobacco,dry, in snuff


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.


RYO in NZ, snuff in Sweden, taking market share from manufactured cigarettes

0%

20%

40%

60%

% o

f all s

mo

kin

g t

ob

acco

Sweden: Snuffas % of drysmokingtobacco

NZ RYO as %of dry smokingtobacco

Sweden: RYOas % of drysmokingtobacco

Sweden -snuff

ryo NZ

ryo Sweden


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.)


Adult smoking prevalence, 1990-2 to 2002-4: Rate of reduction p.a.

-0.83

-0.70

-0.54

-0.30

-0.29

-0.21

-1.00 -0.80 -0.60 -0.40 -0.20 0.00

Canada

Sweden

Australia

NZ Maori

California

NZ

average change p.a.(in % points)


Male smoking prevalence 1990-2 to 2002-4: Rate of reduction p.a.

-0.83

-0.76

-0.65

-0.17

-0.17

-1.00 -0.80 -0.60 -0.40 -0.20 0.00

Sweden

Canada

Australia

California

NZ

average change p.a. (in % points)


Female smoking prevalence 1990-2 to 2002-4: Rate of reduction p.a.

-0.95

-0.56

-0.42

-0.41

-0.25

-1.00 -0.80 -0.60 -0.40 -0.20 0.00

Canada

Sweden

Australia

California

NZ

Average change p.a. ( % points)


Smoking prevalence in Canada 1990-2004 and graphic health warnings, December 2000

0

10

20

30

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

% w

ho

smok

e

graphic health warnings on packets Dec 2000

in 3 years before warnings: -1.6% per annum in 3 years after warnings: -1.0% per annum


Forecasts of adult smoking prevalence, if post-1990 and post-2000 trends persisted: NZ

0

10

20

30

40

50

60

1990 2000 2010 2020 2030 2040 2050 2060

% a

du

lts

sm

ok

ing

1990-2005 total population rate of decrease2000-05 total population rate of decrease1990-2004 Maori rate of decrease2000-2004 Maori rate of decrease

actual

projected

5% of doctors smoking,1996

Maori

Total population


Need for re-appraisal: Moral distaste for tobacco clashing with data on health consequences

Cigarettes Oral snuff_______________________________________Ratio of excessmortality risks: 20 : 1 (Levy 2004)

____________________________________Health No plan yet to end Largely want it banned Groups’ sales to adults or discouragedAttitudes Don’t like it but Because it’s tobacco so far, acquiescent most disapprove

_____________________________________________________


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


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


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


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.


The effect of smokers using snuff: 92% quit smoking

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

54 56

380

844

0%

50%

100%

Primary smokers,then used snus

Primary smokers,never used snus

Quit smoking; no tobacco use Snuffing not smoking

Now smokers

- Ramstrom and Foulds Tobacco Control June 2006


Snuff a gateway away from smoking:of primary snuffers only 5% became smokers

22

48

73 17

5

35

0%

50%

100%

Primary snuffer Primary smoker

Smoking

Snuff ing

No tobacco use

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.


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 6th stepdown

Increase tax relative to alternatives

Ban RYO cigarettes-or tax them much more


The tax rate (flat line) vs. the relative risk of each product (columns), NZ, 2006

237

137115 112 100

340$349

0

100

200

300

400

cigarettes cigarsinhaled

all cigarsmokers

cigars notinhaled

oral snuff never auser

% r

isk

of

dy

ing

ea

rly

% risk of early death if never user's risk =100

excise, $ / Kg of tobacco


Nicotine content per cigarette, versus threshold

(minimum) required daily to sustain addiction 13.0

11.6

2.71.9

0

5

10

15

Content, regularbrand

Content, lownicotine brand

Absorbed permedium-

nicotine contentcigarette

Absorbed perlow-nicotine

contentcigaretteper cigarette

nic

oti

ne

mg

addiction threshold 5mg /day

2-3 cigarettes a day provide enough nicotine to maintain addiction


A ban on hand-rolled cigarettesFrom 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.


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


Policy choices and prevalence reduction estimates for New Zealand males, 2006 - 2016

0

5

10

15

20

25

30

% w

ho

sm

ok

e

trend 1991-03

snus onsale, USA

snus onsale,SwedenNicotinereduced

0

5

10

15

20

25

30

% w

ho s

mok

e

trend 1991-03

snus onsale, USA

snus onsale,SwedenNicotinereduced


Policy choices and prevalence reduction estimates for New Zealand, 2006-16

0

5

10

15

20

25

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

% w

ho s

mok

e

NZ 1990-04 trend - carrying on as before

Canada 1990-04 representing the fastest reduction seen using conventionalpoliciesAssumes NZ trend + cigarette nicotine reduced + smokeless nicotine onsale + cigarette sales ban 2014

Most of final decrease in smoking is due to steady reduction in cigarette nicotine, locked in with cigarette sales ban

Smokers Choices Bill creates options for smokers

Canada

NZ


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.


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.


Do you support a ban on the sale of all tobacco products in New Zealand?

6%

43%

52%

0% 100%

Not sure

No

Yes

N =1000, age 18+, March 2006. TNS for TV3, telephone survey

8%

64%

28%

0% 100%

Not sure

No

Yes

N =750, age 18+, May 2000, UMR for NBR, telephone survey

Do you support or oppose a complete ban on smoking in pubs?

snuffing out cigarette sales in our lifetime - a new zealand perspective murray laugesen* public...

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