Government struggling with evidence: HTPs, addiction levels, and Smokefree 2025

Earlier this year, the Coalition Government repealed tobacco endgame measures that would have substantially reduced tobacco’s addictiveness and availability. Associate Health Minister Casey Costello justified this decision by proposing to target people she described as “hardcore smokers”. The Government also recently reduced the excise tax on heated tobacco products (HTPs), despite advice from the Ministry of Health and Treasury. Instead, it accepted the Associate Health Minister’s recommendation, which drew on arguments from a mystery document¹ and “independent advice” that did not in fact support the decision.

These actions raise important questions. First, claims about “hardcore smokers” assume smoking has become more entrenched and thus requires a targeted approach. While it may seem commonsense that hardening occurs as smoking prevalence reduces, this assumption does not reflect the dynamic population profile of people who smoke. For example, less heavily addicted people who quit may be replaced by less heavily addicted younger people who join the population, and older more addicted people may be more likely to die. Furthermore, policies’ on-going effects will likely increase motivation to quit. Many recent studies have questioned the logic and evidence for “hardening”,^2-4 with a recent systematic review concluding that smoking is instead “softening”.⁵

Second, while important to offer evidence-based cessation tools to people trying to quit, the Government has acted against advice from the Health Ministry and Treasury, against WHO recommendations, and against the conclusions of a Cochrane Review (regarded as “gold standard” evidence) by halving excise tax on HTPs. The ’independent advice’ the Associate Health Minister drew on comprises dated and mostly irrelevant papers.

In this Briefing, we review whether evidence from Aotearoa supports “hardening” claims and consider the Government’s decisions on HTPs.

Figure 1 shows the average number of cigarettes smoked per day among people who smoke daily. Hardening suggests this number would increase over time as people who smoke less frequently, and are less dependent on nicotine, quit. However, the data show a significant decline in cigarettes smoked per day over the last ten years. Second, if hardening was occurring, the proportion of daily smokers who are “heavy smokers” (defined as people smoking more than 21 cigarettes per day) should increase as people who smoke fewer cigarettes (i.e., who have lower nicotine dependency) quit. Again, the data show a significant decline in “heavy smokers” from 2011/12 to 2022/23. Third, if people had become less motivated to quit, we would expect the quit rate to decline over time; however, the data show significant increases in quitting. All three measures from the NZ Health Survey suggest smoking in Aotearoa is “softening” rather than “hardening”.

Figure 1. Trends in markers of heavy smoking over time

The Associate Health Minister argued that reducing the excise tax on heated tobacco products would assist “hardcore smokers”. Costello commented that “about 285,000 New Zealanders are daily smokers” and asserted these people need “alternatives to cigarettes that may not be tobacco-free themselves but serve as a means-to-an-end to transition away from tobacco use entirely”. As her Ministry officials had earlier advised, there is no evidence that HTPs support smoking cessation.

The independent modelling informing her decision suggests HTPs will do very little to achieve the Smokefree 2025 goal (smoking prevalence of under 5%). Costello asserted “Preliminary modelling from the Ministry of Health suggests that around 7200 smokers over the next two years could switch to HTPs”; that implies 3600 people are predicted to stop smoking by switching to HTPs per year. That is just a small fraction (4.5%) of the 80,505 required to meet the SmokeFree 2025 goal (based on the 2023 adult population). This calculation does not account for inequities in smoking prevalence and the Associate Health Minister has acknowledged the Smokefree goal must be reached among all population groups.

The “trial” of HTPs that the Prime Minister and Associate Health Minister explained is no longer feasible, given nearly all HTP products have been removed from sale (for failing to meet new safety regulations). Costello and the Prime Minister have repeatedly stated their commitment to achieving the Smokefree2025 goal. However, their actions do not align with that commitment. Instead, they have replaced evidence-based measures that leading experts believed would greatly reduce smoking prevalence with a price discount for an unproven alternative product now no longer available.

It is time this Government took the evidence-based approach to decision-making outlined in their Coalition agreement. What options do they have, given time is limited and smoking prevalence among Māori is more than three times the five percent threshold? We suggest heeding advice from the Ministry of Health and public health community would be a helpful starting point.

Associate Health Minister Costello rightly states that most people who smoke want to quit and noted she would like to follow a process by “consent rather than coercion”. The high regret among people who smoke⁶ and their strong support for denicotinising tobacco suggests the Government has a powerful mandate to introduce this policy as soon as possible. In 2022, Health Minister, Dr Shane Reti’s introduced a Supplementary Order paper to accelerate the introduction of denicotinisation and supported this measure (see here and here), which would reduce smoking prevalence quickly and equitably.⁷ The Government should favour Dr Reti’s earlier proposal over advice that appears to arise from a mystery document, which has brought on-going embarrassment for the Associate Health Minister and Prime Minister. It would also do far more to support the people they profess to want to help.