Support for a tobacco endgame and increased regulation of the tobacco industry among New Zealand smokers: results from a National Survey.

AIM: To examine the prevalence of smoker support for a ban on cigarette sales in 10 years time and increased regulation of the tobacco industry and to investigate the independent associations of support for these measures. METHODS: The authors surveyed opinions among adult smokers in two survey waves (N=1376 and N=923) from the New Zealand arm of the International Tobacco Control Policy Evaluation Survey during 2007-2009. The authors report prevalence of support stratified by age, gender and ethnicity. The authors carried out multivariate analyses to identify significant associations among potential determinants (demographics, socioeconomic status, mental health and smoking-related beliefs and behaviours) of support. RESULTS: Most New Zealand smokers supported greater regulation of the tobacco industry (65%) and more government action on tobacco (59%). Around half (46%) supported banning sales of cigarettes in 10 years time, provided effective nicotine substitutes were available. In a fully adjusted model, significant associations with support for greater tobacco company regulation included Maori ethnicity, experience of financial stress and greater awareness about the harms of smoking. Significant associations with support for a ban on tobacco sales in 10 years time included increasing area-based deprivation level, increasing intention to quit and greater concern about the health effects of smoking. CONCLUSIONS: The findings suggest that most smokers will support stronger government action to control the tobacco industry and that many support radical 'endgame' approaches. Greater support among Maori, more deprived and possibly Pacific smokers, is an important finding, which could inform the design and implementation of new policies given the very high smoking prevalence among these groups and hence high priority for targeted tobacco control interventions. Perceived difficulties in gaining public support should not impede the introduction of rigorous tobacco control measures needed to achieve a tobacco-free New Zealand.

An examination of smoking initiation rates by age: results from a large longitudinal study in New Zealand.

OBJECTIVE: Investigations of smoking initiation often focus on the experiences of children and youth. However, prevalence data from the Tobacco Use Surveys (TUS) and the New Zealand (NZ) census suggest substantial uptake of smoking occurs after 15 years of age, including among young adults aged 18-24 years. Identifying initiation rates is difficult using cross-sectional prevalence data, particularly among older age groups, which are subject to cohort effects and where quitting and premature mortality reduce prevalence. We aimed to identify initiation rates using a prospective study design. METHODS: The SoFIE-Health longitudinal survey included 15,095 subjects aged 15 years or older who responded in the three years that include the health module: 2004/05, 2006/07 and 2008/09. We calculated the proportion of 'never smokers' who became regular smokers (initiation) by age at baseline. RESULTS: Initiation between 2004/05 and 2008/09 was 14.2% for 15-17 year olds, 7.0% for 18-19 years, 3.1% for 20-24 years and 1.4% for 25-34 years, with low levels of initiation (<1.0%) among older age groups. CONCLUSIONS: There were strong age-related gradients in smoking initiation. Substantial initiation occurs among older youth and young adults, but is rare after age 24. IMPLICATIONS: Efforts to prevent initiation of smoking should focus not only on adolescents but also on older youth and young adults.

Qualitative exploration of public and smoker understanding of, and reactions to, an endgame solution to the tobacco epidemic.

BACKGROUND: There is increasing interest in ending the tobacco epidemic and in applying 'endgame' solutions to achieve that goal at national levels. We explored the understanding of, and reactions to, a tobacco-free vision and an endgame approach to tobacco control among New Zealand smokers and non-smokers. METHODS: We recruited participants in four focus groups held in June 2009: Maori (indigenous people) smokers (n=7); non-Maori smokers (n=6); Maori non-smokers (n=7); and non-Maori non-smokers (n=4). Participants were from the city of Whanganui, New Zealand. We introduced to them the vision of a tobacco-free New Zealand and the concept of a semi-autonomous agency (Tobacco-Free Commission [TFC]) that would control the tobacco market as part of an endgame approach. RESULTS: There was mostly strong support for the tobacco-free New Zealand vision among all groups of participants. The reason most commonly given for supporting the vision was to protect children from tobacco. Most participants stated that they understood the TFC concept and reacted positively to it. Nevertheless, rather than focusing on organisational or structural arrangements, participants tended to focus on supporting the specific measures which a future TFC might facilitate such as plain packaging of tobacco products. Various concerns were also raised around the TFC, particularly around the feasibility of its establishment. CONCLUSIONS: We were able to successfully communicate a complex and novel supply-side focused tobacco control policy intervention to smokers and non-smokers. The findings add to the evidence from national surveys that there is public support, including from smokers, for achieving a tobacco-free vision and using regulatory and policy measures to achieve it. Support for such measures may be enhanced if they are clearly communicated and explained with a rationale which stresses protecting children and future generations from tobacco smoking.

Setting a good example? Changes in smoking prevalence among key occupational groups in New Zealand: evidence from the 1981 and 2006 censuses.

INTRODUCTION: Role modeling by smokers may influence smoking among children and young adults. Most work on smoking by occupation has focused on health workers. A unique opportunity to explore smoking by occupation is presented in New Zealand (NZ) due to inclusion of a smoking status question in most national censuses since 1976. Our aim was to assess trends in smoking prevalence among potential role model occupational groups in NZ. METHODS: Adult smoking status by occupation was obtained from the 1981 census (N = 1,321,323) and 2006 census (N = 1,744,479). Subjects were aggregated into 5 broad groups of potential role-model occupations: teachers, uniformed services, health-related occupations, public figures, and sportspeople/entertainers. Age and sex-standardized current smoking prevalences were calculated using the 2006 NZ employed population as the reference standard. RESULTS: Standardized smoking prevalence among the employed population was 34.5% in 1981 and had declined 37% in relative terms and 12.8% in absolute terms to 21.7% in 2006. Relative declines in smoking prevalence between 1981 and 2006 ranged from 35% to 60% among the role model occupational groups and absolute declines from 8.3% to 19.9%. Maori had higher smoking prevalence and lower relative declines in prevalence in each occupational group from 1981 to 2006, compared with non-Maori. Specific occupations mostly had low smoking prevalences--particularly doctors and teachers. But some role model occupations had high crude smoking prevalences in 2006 (up to 47%). CONCLUSIONS: Persisting high smoking prevalence among some occupational groups suggest that additional targeted smoking cessation support for role model occupational groups may be justified.

Parental behaviours, but not parental smoking, influence current smoking and smoking susceptibility among 14 and 15 year-old children.

OBJECTIVE: To explore whether parental behaviours related to smoking socialisation and parenting are associated with smoking susceptibility and current smoking in 14-15 year old students. METHOD: Data were sourced from the New Zealand 2006 Year 10 In-depth Survey, a school-based survey of 3,189 students. Outcome measures were susceptibility to smoking and current smoking. Potential determinants were second-hand smoke exposure in the home, parental smoking, parental anti-smoking expectations, anti-smoking rules, pocket money, monitoring of pocket money expenditure, general rule setting and monitoring, and concern about education. Analysis used logistic regression to adjust for potential confounding factors. RESULTS: Exposure to second-hand smoke and lack of parental anti-smoking expectations were independently associated with smoking susceptibility and current smoking. Parental smoking was not independently associated with current smoking or susceptibility. Receiving pocket money and an absence of monitoring of expenditure were associated with smoking susceptibility and current smoking. Lack of parental rule setting was associated with smoking susceptibility. Findings were similar whether or not one or more parents were smokers. CONCLUSIONS: Not allowing smoking in the home, communicating non-smoking expectations to children, monitoring pocket money, and setting rules to guide behaviour are strategies which are likely to reduce risk of smoking uptake. IMPLICATIONS: The study provides evidence to inform the development of parent-focused interventions to reduce the risk of smoking initiation by children.

Smokers have varying misperceptions about the harmfulness of menthol cigarettes: national survey data.

OBJECTIVE: To describe the prevalence of menthol use and perceptions of relative harmfulness among smokers in an ethnically diverse population where tobacco marketing is relatively constrained (New Zealand). METHODS: The New Zealand (NZ) arm of the International Tobacco Control Policy Evaluation Survey (ITC Project) utilises the NZ Health Survey (a national sample). From this sample we surveyed adult smokers, with Wave 2 (n=923) covering beliefs around menthol cigarettes. RESULTS: Agreement with the statement that "menthol cigarettes are less harmful than regular cigarettes" was higher in smokers who were: older, Maori, Pacific, Asian, financially stressed and had higher levels of individual deprivation. Most of these associations were statistically significant in at least some of the logistic regression models (adjusting for socio-economic and smoking beliefs and behaviour). In the fully-adjusted model this belief was particularly elevated in Pacific smokers (adjusted odds ratio [aOR] = 7.36, 95% CI = 1.92 - 28.27) and also in menthol smokers (aOR = 4.58, 95% CI = 1.94-10.78). Most smokers in this study (56%), and especially menthol smokers (73%), believed that menthols are "smoother on your throat and chest". CONCLUSION: Various groups of smokers in this national sample had misperceptions around the relative harmfulness of menthols, which is consistent with most previous studies. IMPLICATIONS: This evidence, along with a precautionary approach, supports arguments for enhanced regulation of tobacco marketing and tobacco ingredients such as menthol.

Survey of descriptors on cigarette packs: still misleading consumers?

AIM: In September 2008, the New Zealand (NZ) Commerce Commission issued a warning to the major tobacco companies to remove "light" and "mild" descriptors from cigarette packaging. Despite published evidence that suggested tobacco companies had started colour-coding their packs in anticipation of the Commission's decision, the investigation did not consider more general misleading packaging. This study explored changes in tobacco packaging that had been introduced to the New Zealand market, by surveying descriptors used on cigarette packs after the Commerce Commission's warning. METHOD: A convenience sample of discarded cigarette packs were collected in four cities and six towns/rural areas between November 2008 and January 2009. The majority of packs (93%) were collected in the capital city (Wellington). Information on the descriptors and pack colours was analysed. RESULTS: Four percent of the 1208 packs collected still included the terms "light" and "mild". Almost half the packs (42%) used a colour word (e.g. red, blue, gold) as a descriptor to indicate mildness or strength. A further 18% used other words that suggested mildness/strength (e.g. "subtle", "mellow"). A quarter of packs used a descriptor that did not connote either mildness or strength; however, the majority of these packs still appeared to be colour-coded. CONCLUSION: Although the words "light" and "mild" have been largely removed from tobacco packaging in the New Zealand market, these words have been replaced with associated colours or other words that may continue to communicate "reduced harm" messages to consumers. Further research to test how smokers interpret the new words and colours, and how these influence their behaviour, is desirable. However, government-mandated generic (plain) packaging would remove the opportunity to communicate misleading claims and so would afford the highest level of consumer protection.

Distribution of new graphic warning labels: Are tobacco companies following regulations?

OBJECTIVE: To test the hypothesis that tobacco companies would not follow a regulation that required seven new graphic health warnings (GHWs) to be evenly distributed on cigarette packs and that they would distribute fewer packs featuring warnings regarded by smokers as being more disturbing. METHODS: Cross-sectional survey of purchased packs (n = 168) and street-collected discarded packs (convenience sample of New Zealand cities and towns, n = 1208 packs) with statistical analysis of seven types of new GHWs. A priori warning impact was judged using three criteria, which were tested against data from depth interviews with retailers. RESULTS: The GHWs on the purchased packs and street-collected packs both showed a distribution pattern that was generally consistent with the hypothesis ie, there were disproportionately more packs featuring images judged as "least disturbing" and disproportionately fewer of those with warnings judged "more disturbing". The overall patterns were statistically significant, suggesting an unequal frequency of the different warnings for both purchased (p < 0.0001) and street-collected packs (p = 0.035). One of the least disturbing images (of a "corpse with toe-tag") dominated the distribution in both samples. Further analysis of the street-collected packs revealed that this image appeared disproportionately more frequently on manufactured cigarettes made by each of the three largest New Zealand tobacco companies. Although stock clustering could explain the purchase pack result, there were no obvious reasons why the same uneven warning distribution was also evident among the street-collected packs. CONCLUSION: These results suggest that tobacco companies are not following the regulations, which requires even distribution of the seven different GHWs on cigarette packs; further monitoring is required to estimate the extent of this non-compliance. As an immediate measure, governments should strictly enforce all regulations applying to health warnings, particularly given that these are an effective tobacco control intervention that cost tax payers nothing.

Misperceptions of "light" cigarettes abound: national survey data.

BACKGROUND: Many smokers believe that "light" cigarettes are less harmful than regular cigarettes, which is at variance with the scientific evidence. The Framework Convention on Tobacco Control (FCTC) aims to address this problem in Article 11 which deals with misleading labelling of tobacco products. In this study we aimed to determine smokers' use and beliefs concerning "light" and "mild" cigarettes ("lights"), including in relation to ethnicity, deprivation and other socio-demographic characteristics. METHODS: The New Zealand (NZ) arm of the International Tobacco Control Policy Evaluation Survey (ITC Project) uses as its sampling frame the NZ Health Survey. This is a national sample with boosted sampling of Maori, Pacific peoples and Asians. From this sample we surveyed adult smokers (n = 1376) about use and beliefs relating to "light" cigarettes. We assessed the associations with smoking "lights" after adjusting for socio-demographic variables, and smoking-related behaviours and beliefs. RESULTS: Many smokers of "lights" believed that smoking "lights" made it easier to quit smoking (25%), that "lights" are less harmful (42%), and that smokers of "lights" take in less tar (43%). Overall most "lights" smokers (60%) had at least one of these three beliefs, a proportion significantly higher than for smokers of "regular" cigarettes at 45% (adjusted odds ratio (aOR) = 1.96, 95% CI = 1.29 - 2.96). While "lights" smokers had significantly lower tobacco consumption and were more aware of smoking harms, they were no more likely to be intending to quit or have made a previous quit attempt. By ethnicity, both Maori and Pacific people were less likely to smoke "lights" than Europeans (aOR = 0.53, 95% CI = 0.35 - 0.80 and aOR = 0.14, 95% CI = 0.05 - 0.40 respectively). In contrast there was no significant difference by level of deprivation. Roll-your-own (RYO) tobacco smokers were less likely to smoke "light" forms of RYO tobacco while both older and women smokers were more likely to smoke "lights". CONCLUSION: Most "lights" smokers have one or more misperceptions about the product they use, and were no more likely to intend to quit or to have made a quit attempt. In response to such misperceptions, governments could act further to eliminate all misleading tobacco marketing. Ideally, they could not only adopt FCTC requirements, but go further by requiring plain packaging for all tobacco products.