The New Zealand government has decided to reorient its priorities in tobacco control. It has announced it will be pulling 73% of its previous funding support for tobacco control advocacy. The only money allocated for tobacco control to do the vital work of building and sustaining community and multi-party support for tobacco control will go to an Auckland-based Māori health agency Hāpai te Hauora.
Instead, New Zealand will be ploughing nearly all funding into “frontline cessation services with improved training to get better quit results”. Decoded, this means sinking money into efforts focused on smokers in clinical or small group settings and defunding efforts focused on advocacy for policies that will motivate smokers across the community to quit.
This policy shift risks stalling or even starting to reverse the decline in smoking prevalence that New Zealand has experienced. Here’s why.
Five assumptions have almost certainly driven this worrying shift in policy.
First, there is likely to be a myopic preoccupation with lifting smoking cessation success rates rather than a priority focus on increasing the number of people who quit. Advocates for encouraging what they amusingly call “evidence based” smoking cessation always highlight the generally better success rates obtained by smokers who use assistance compared to those who try to quit alone. From this they reason that the main game should therefore be convincing as many smokers as possible to use assistance.
But over 30 years of efforts in several nations to boost attendance at smoking cessation services have failed to lift attendance beyond fringe proportions of all smokers interested in quitting. Very few smokers are willing to seek anything more than brief assistance.
The number of people who quit is a function of the reach of a method and its rate of success. Consider this: in a million smokers, if 3% quit and stay quit unaided in a year, 30,000 ex-smokers result. But if 15% of 10,000 smokers convinced to attend professional smoking cessation services quit – five times the success rate – the yield is only 1,500 ex-smokers. Clearly, a lower success rate in a much larger number of people should always trump a much higher success rate in a much smaller number.
So the second problem is that intensive smoking cessation services usually requiring repeated contact have always failed to attract anything but tiny proportions of smokers.
In New Zealand, some 88% of smokers appear uninterested in even communicating via the quitline, by far the least demanding of all “interventions”. The number who would be willing to attend or engage with multiple session professional support services would be far, far less.
If you want to get smoking down across a whole population, there is no substitute for policies and campaigns that have mass reach potential, reaching nearly all smokers. Tobacco tax, mass reach motivational media campaigns, smoke-free policies, and packaging controls all tick that box. Intensive smoking cessation services don’t.
Third, the cessation method that has delivered by far the most number of ex-smokers (unassisted cessation or cold turkey) is routinely neglected and often openly denigrated by smoking cessation specialists.
The conversation stopper here is that if you ask 100 ex-smokers how they stopped smoking, volumes of studies stretching back more than 40 years have shown that between two-thirds and three-quarters of ex-smokers used no pharmacological or professional assistance on their final successful quit attempt. Before the availability of nicotine replacement therapy, hundreds of millions of smokers globally quit smoking unassisted, including many heavily addicted smokers. So often denigrated by cessation specialists whose interests lie in providing assistance, the evidence shows unassisted cessation has the population cessation runs on the board.
The lesson from this is that ongoing, hard-hitting campaigns and evidence-based policies like tobacco tax to encourage quit attempts are of vital importance.
Fourth, those making the decisions are likely to have been mesmerised by clinical trial results, rather than real world data on how various smoking cessation strategies perform. Nicotine-replacement therapy (NRT) used with on-going support has better success than unassisted cessation. But again, we need to ask how many New Zealand smokers will realistically be interested in receiving that sort of support. Most will collect their subsidised NRT and not participate further.
New Zealand reportedly spends $NZ61m on tobacco control, with the great majority of this going to subsidised NRT. There is increasing evidence that handing out NRT to smokers away from ongoing professional support and over-the-counter use is all but useless. Evidence from England shows that the use of NRT bought over the counter is associated with a lower rate of abstinence than quitting unassisted.
Fifth, the seductive power of the so-called “hardening” hypothesis is likely to have tightened its grip on New Zealand policymakers. This hypothesis proposes that as smoking prevalence falls in a country, the proportion of “hard core” smokers rises.
True believers in this hypothesis then argue that the suite of comprehensive policies and campaigns that has caused smoking to fall over the past decades has seen nearly all the low-hanging fruit quit smoking and is now producing diminishing returns. Calls are then made to focus efforts on the burgeoning hard core smokers by labour and pharmacologically intensive cessation methods.
The problem with all this is that it is simply not true. New Zealand research just published found “no statistically significant changes in indicators of hardening including the proportion of smokers who were unmotivated or unable to quit despite repeat attempts” between 2008-2014. Similar findings have been reported in other studies internationally.
New Zealand could do with more commitment to the sort of large scale tough, motivating mass media campaigns that have contributed so much to motivating Australian smokers to quit and children not to start. Funding boosts to campaigns such as Stop before you start are likely to reach and influence far more people than giving extra support to low-demand services.
Advocacy groups have provided invaluable assistance to New Zealand governments over the years by making and defending the case for policies such as tobacco tax and plain packaging that can make a difference to the whole population of current and potential smokers. Former Australian health minister Nicola Roxon, the political architect of plain packaging (which is now spreading globally), told me that the call to legislate for plain packaging and very large tax increases was made politically and popularly palatable by the years of policy advocacy undertaken by NGOs and advocates for tough policy.
By all but removing advocacy funding in New Zealand, and filling the vacuum with funding for strategies simply incapable of reaching large numbers of smokers, the government is likely to be doing something it will regret.
New Zealand has some of the world’s most mature, astute and advanced strategic policy researchers. Together, they have punched well above their national weight in stimulating original thinking about pathways toward an endgame for tobacco use. The government would do well to provide support to harness their expertise to bring their analytic and research skills together rather than putting so many eggs in the individualistic smoking cessation basket.
Authors: Simon Chapman, Emeritus Professor in Public Health, University of Sydney