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BackgroundTo survey the smoke-free status of airports in New Zealand (NZ), a country with a smoke-free goal for 2025, and where public indoor areas are required to be smoke-free.MethodsA cross-sectional survey of a convenience sample of airports with data collection on smoke-free signage, observed smoking behaviour, cigarette butt litter and designated smoking areas.ResultsA total of 23 airports were surveyed, including all those for the 10 most populous urban areas in NZ (82% of all airports with scheduled flights on the main islands). There were no smoke-free signs found at entrances/exits to the terminal building in 26% of airports, with a mean of 1.7 such signs per entrance/exit. Only one airport had any signage stating that all the grounds were smoke-free. Qualitatively, the signage was often small in size (ConclusionsDespite this country having a smoke-free goal, it has largely deficient smoke-free policies at its airports. There is a case to make airport grounds entirely smoke-free as part of an upgrade of the national smoke-free law.

BackgroundTo prioritise tobacco control interventions, simulating their health impacts is valuable. We undertook a systematic review of tobacco intervention simulation models to assess model structure and input variations that may render model outputs non-comparable.MethodsWe applied a Medline search with keywords intersecting modelling and tobacco. Papers were limited to those modelling health outputs (eg, mortality, health-adjusted life years), and at least two of cancer, cardiovascular and respiratory diseases. Data were extracted for each simulation model with ≥3 arising papers, including: model type, untimed or with time steps and trends in business-as-usual (BAU) tobacco prevalence and epidemiology.ResultsOf 1911 papers, 186 met the inclusion criteria, including 13 eligible simulation models. The SimSmoke model had the largest number of publications (n=46), followed by Benefits of Smoking Cessation on Outcomes (n=12) and Tobacco Policy Model (n=10). Two of 13 models only estimated deaths averted, 1 had no time steps, 5 had no future trends in BAU tobacco prevalence, 9 had no future trends in BAU disease epidemiology and 7 had no time lags from quitting tobacco to reversal of health harm.ConclusionsConsiderable heterogeneity exists in simulation models, making outputs substantively non-comparable between models. Ranking of interventions by one model may be valid. However, this may not be true if, for example, interventions that differentially affect age groups (eg, a tobacco-free generation policy vs increased cessation among adults) do not account for plausible future trends. Greater standardisation of model structures and outputs will allow comparison across models and countries, and for comparisons of the impact of tobacco control interventions with other preventive interventions.

BackgroundBetween 2010 and 2020, the New Zealand (NZ) Government increased tobacco excise tax by inflation plus 10% each year. We reviewed market structure changes and examined whether NZ tobacco companies shifted excise tax increases to maintain the affordability of lower priced cigarette brands.MethodsWe cluster-analysed market data that tobacco companies supply to the NZ Ministry of Health, created four price partitions and examined the size and share of these over time. For each partition, we analysed cigarette brand numbers and market share, calculated the volume-weighted real stick price for each year and compared this price across different price partitions. We calculated the net real retail price (price before tax) for each price partition and compared these prices before and after plain packaging took effect.ResultsThe number and market share of Super Value and Budget brands increased, while those of Everyday and Premium brands decreased. Differences between the price of Premium and Super Value brands increased, as did the net retail price difference for these partitions. Following plain packaging’s implementation, Super Value brand numbers more than doubled; contrary to industry predictions, the price difference between these and higher priced brands did not narrow.ConclusionsBetween 2010 and 2020, NZ tobacco companies introduced more Super Value cigarette brands and shifted excise tax increases to reduce the impact these had on low-priced brands. Setting a minimum retail price for cigarettes could curtail tobacco companies’ ability to undermine tobacco taxation policies designed to reduce smoking.

BackgroundMass media campaigns and quitlines are both important distinct components of tobacco control programmes around the world. But when used as an integrated package, the effectiveness and cost-effectiveness are not well described. We therefore aimed to estimate the health gain, health equity impacts and cost–utility of the package of a national quitline service and its promotion in the mass media.MethodsWe adapted an established Markov and multistate life-table macro-simulation model. The population was all New Zealand adults in 2011. Effect sizes and intervention costs were based on past New Zealand quitline data. Health system costs were from a national data set linking individual health events to costs.ResultsThe 1-year operation of the existing intervention package of mass media promotion and quitline service was found to be net cost saving to the health sector for all age groups, sexes and ethnic groups (saving $NZ84 million; 95%uncertainty interval 60–115 million in the base-case model). It also produced greater per capita health gains for Māori (indigenous) than non-Māori (2.2 vs 0.73 quality-adjusted life-years (QALYs) per 1000 population, respectively). The net cost saving of the intervention was maintained in all sensitivity and scenario analyses for example at a discount rate of 6% and when the intervention effect size was quartered (given the possibility of residual confounding in our estimates of smoking cessation). Running the intervention for 20 years would generate an estimated 54 000 QALYs and $NZ1.10 billion (US$0.74 billion) in cost savings.ConclusionsThe package of a quitline service and its promotion in the mass media appears to be an effective means to generate health gain, address health inequalities and save health system costs. Nevertheless, the role of this intervention needs to be compared with other tobacco control and health sector interventions, some of which may be even more cost saving.

ObjectiveThere is growing international interest in advancing ‘the tobacco endgame’. We use New Zealand (Smokefree goal for 2025) as a case study to model the impacts on smoking prevalence (SP), health gains (quality-adjusted life-years (QALYs)) and cost savings of (1) 10% annual tobacco tax increases, (2) a tobacco-free generation (TFG), (3) a substantial outlet reduction strategy, (4) a sinking lid on tobacco supply and (5) a combination of 1, 2 and 3.MethodsTwo models were used: (1) a dynamic population forecasting model for SP and (2) a closed cohort (population alive in 2011) multistate life table model (including 16 tobacco-related diseases) for health gains and costs.ResultsAll selected tobacco endgame strategies were associated with reductions in SP by 2025, down from 34.7%/14.1% for Māori (indigenous population)/non-Māori in 2011 to 16.0%/6.8% for tax increases; 11.2%/5.6% for the TFG; 17.8%/7.3% for the outlet reduction; 0% for the sinking lid; and 9.3%/4.8% for the combined strategy. Major health gains accrued over the remainder of the 2011 population’s lives ranging from 28 900 QALYs (95% Uncertainty Interval (UI)): 16 500 to 48 200; outlet reduction) to 282 000 QALYs (95%UI: 189 000 to 405 000; sinking lid) compared with business-as-usual (3% discounting). The timing of health gain and cost savings greatly differed for the various strategies (with accumulated health gain peaking in 2040 for the sinking lid and 2070 for the TFG).ConclusionsImplementing endgame strategies is needed to achieve tobacco endgame targets and reduce inequalities in smoking. Given such strategies are new, modelling studies provide provisional information on what approaches may be best.

As Verguet et al note,1 taxing tobacco products has been consistently shown to reduce smoking prevalence by stimulating cessation, deterring uptake and reducing consumption among people who continue to smoke.2–6 Health benefits attributable to tobacco excise tax increases include increased life expectancy and reduced hospitalisations.7 8 Tobacco excise taxes can potentially bring large health benefits at a population level,9 particularly for young people and people with fewer financial resources.3 10 Yet tobacco taxation in most countries is low; in 2014 experts estimated that 200 million deaths could be averted by 2025 if the price of cigarettes was doubled globally, which ‘in many low and middle-income countries’ could be achieved by tripling the tax on tobacco.11 This evidence has led many countries, including the UK, Ireland, France and Canada, to implement regular tobacco excise tax increases. Australia and New Zealand have taken this policy further than other countries; sustained increases in tobacco excise taxes mean a pack of 20 cigarettes now costs around $35 (approximately USD20) in New Zealand and will soon reach $40 per pack (around USD25) in Australia. The people most likely …

Background Since there is some evidence that the density and distribution of tobacco retail outlets may influence smoking behaviours, we aimed to estimate the impacts of 4 tobacco outlet reduction interventions in a country with a smoke-free goal: New Zealand (NZ). Methods A multistate life-table model of 16 tobacco-related diseases, using national data by sex, age and ethnicity, was used to estimate quality-adjusted life years (QALYs) gained and net costs over the remainder of the 2011 NZ population9s lifetime. The outlet reduction interventions assumed that increased travel costs can be operationalised as equivalent to price increases in tobacco. Results All 4 modelled interventions led to reductions of >89% of current tobacco outlets after the 10-year phase-in process. The most effective intervention limited sales to half of liquor stores (and nowhere else) at 129 000 QALYs gained over the lifetime of the population (95% UI: 74 100 to 212 000, undiscounted). The per capita QALY gains were up to 5 times greater for Māori (indigenous population) compared to non-Māori. All interventions were cost-saving to the health system, with the largest saving for the liquor store only intervention: US$1.23 billion (95% UI: $0.70 to $2.00 billion, undiscounted). Conclusions These tobacco outlet reductions reduced smoking prevalence, achieved health gains and saved health system costs. Effects would be larger if outlet reductions have additional spill-over effects (eg, smoking denormalisation). While these interventions were not as effective as tobacco tax increases (using the same model), these and other strategies could be combined to maximise health gain and to maximise cost-savings to the health system.

ObjectiveRestricting tobacco sales to pharmacies only, including the provision of cessation advice, has been suggested as a potential measure to hasten progress towards the tobacco endgame. We aimed to quantify the impacts of this hypothetical intervention package on future smoking prevalence, population health and health system costs for a country with an endgame goal: New Zealand (NZ).MethodsWe used two peer-reviewed simulation models: 1) a dynamic population forecasting model for smoking prevalence and 2) a closed cohort multi-state life-table model for future health gains and costs by sex, age and ethnicity. Greater costs due to increased travel distances to purchase tobacco were treated as an increase in the price of tobacco. Annual cessation rates were multiplied with the effect size for brief opportunistic cessation advice on sustained smoking abstinence.ResultsThe intervention package was associated with a reduction in future smoking prevalence, such that by 2025 prevalence was 17.3%/6.8% for Māori (Indigenous)/non-Māori compared to 20.5%/8.1% projected under no intervention. The measure was furthermore estimated to accrue 41 700 discounted quality-adjusted life-years (QALYs) (95% uncertainty interval (UI): 33 500 to 51 600) over the remainder of the 2011 NZ population’s lives. Of these QALYs gained, 74% were due to the provision of cessation advice over and above the limiting of sales to pharmacies.ConclusionsThis work provides modelling-level evidence that the package of restricting tobacco sales to only pharmacies combined with cessation advice in these settings can accelerate progress towards the tobacco endgame, and achieve large population health benefits and cost-savings.

Objective To review the published survey data on public support for smoke-free outdoor regulations in the USA and Canada (two countries at the forefront of such policies). Data sources and study selection We searched for English language articles and reports using Medline, Google Scholar and Google for the period to December 2014. We retained population-based surveys of the adult general population in jurisdictions in the USA and Canada, with a minimum survey sample of 500. Data extraction The analysis focused on assessing levels and trends in public support for different types of places and also explored how support varied between population groups. Results Relevant data were found from 89 cross-sectional surveys between 1993 and 2014. Support for smoke-free regulations in outdoor places tended to be highest for smoke-free school grounds (range: 57–95%) playgrounds (89–91%), and building entrances (45–89%) and lowest for smoke-free outdoor workplaces (12–46%) and sidewalks (31–49%). Support was lower among smokers, though for some types of places there was majority smoker support (eg, school grounds with at least 77% support in US state surveys after 2004). Trend data involving the same questions and the same surveyed populations suggested increased general public and smoker support for smoke-free regulations over time (eg, from 67% to 78% during 2002–2008 for smoke-free school grounds in the USA). Higher support was typically seen from women and some ethnic groups (eg, African-Americans). Conclusions Outdoor smoke-free regulations can achieve majority public support, including from smokers.

ObjectiveThe health gains and cost savings from tobacco tax increase peak many decades into the future. Policy-makers may take a shorter-term perspective and be particularly interested in the health of working-age adults (given their role in economic productivity). Therefore, we estimated the impact of tobacco taxes in this population within a 10-year horizon.MethodsAs per previous modelling work, we used a multistate life table model with 16 tobacco-related diseases in parallel, parameterised with rich national data by sex, age and ethnicity. The intervention modelled was 10% annual increases in tobacco tax from 2011 to 2020 in the New Zealand population (n=4.4 million in 2011). The perspective was that of the health system, and the discount rate used was 3%.ResultsFor this 10-year time horizon, the total health gain from the tobacco tax in discounted quality-adjusted life years (QALYs) in the 20–65 year age group (age at QALY accrual) was 180 QALYs or 1.6% of the lifetime QALYs gained in this age group (11 300 QALYs). Nevertheless, for this short time horizon: (1) cost savings in this group amounted to NZ$10.6 million (equivalent to US$7.1 million; 95% uncertainty interval: NZ$6.0 million to NZ$17.7 million); and (2) around two-thirds of the QALY gains for all ages occurred in the 20–65 year age group. Focusing on just the preretirement and postretirement ages, the QALY gains in each of the 60–64 and 65–69 year olds were 11.5% and 10.6%, respectively, of the 268 total QALYs gained for all age groups in 2011–2020.ConclusionsThe majority of the health benefit over a 10-year horizon from increasing tobacco taxes is accrued in the working-age population (20–65 years). There remains a need for more work on the associated productivity benefits of such health gains.

We aimed to examine smoking-related content in all 24 James Bond movies in the Eon Productions series from 1962 to 2015. There were favourable downward trends for any smoking by James Bond (p=0.015 for trend), and for tobacco-related spy-gadgetry (p=0.009). Around 20% of Bond's 60 sexual partners smoked in each decade, and most recently in 2012. There were regular mentions of smoking risks to health (starting from 1967) and product placement of branded packs was present in two movies. Overall, the persisting smoking content remains problematic from a public health perspective, especially given the popularity of this movie series.

OBJECTIVE: We examine the potential role for taxation in the tobacco endgame in New Zealand, where the goal is to become 'smokefree' (less than 5% smoking prevalence) by 2025. DESIGN: Modelling study using a dynamic population model. SETTING AND PARTICIPANTS: New Zealand, Māori and non-Māori men and women. INTERVENTIONS: Annual increases in tobacco excise tax of 5%, 10%, 15% and 20% (with 10% reflecting the annual increase recently legislated by the New Zealand Government to 2016). RESULTS: With a continued commitment to annual 10% increases in tobacco excise tax, in addition to on-going Quitline and cessation support, New Zealand's smoking prevalence is projected to fall from 15.1% in 2013 to 8.7% (95% uncertainty interval 8.6% to 8.9%) by 2025. This is compared to 9.9% without any further tax rises. With annual tax increases of 20%, the prevalence is projected to fall to 7.6% (7.5% to 7.7%) by 2025. The potential reductions in smoking prevalence are substantial for both Māori and non-Māori populations, although annual tax increases as high as 20% will still only see Māori smoking prevalence in 2025 approaching the non-Māori smoking levels for 2013. Scenario analyses did not suggest that growth of the illicit tobacco market would substantively undermine the impact of tobacco tax rises. Nevertheless, unknown factors such as the gradual denormalisation of smoking and changes to the 'nicotine market' may influence sensitivity to changes in tobacco prices in the future. CONCLUSIONS: Regular increases in tobacco taxation could play an important role in helping to achieve tobacco endgames. However, this modelling in New Zealand suggests that a wider range of tobacco endgame strategies will be needed to achieve a smoke-free goal of less than 5% prevalence for all social groups-a conclusion that could also apply in other countries.

Objective To inform endgame strategies in tobacco control, this study aimed to estimate the impact of interventions that markedly reduced availability of tobacco retail outlets. The setting was New Zealand, a developed nation where the government has a smokefree nation goal in 2025. Methods Various legally mandated reductions in outlets that were phased in over 10 years were modelled. Geographic analyses using the road network were used to estimate the distance and time travelled from centres of small areas to the reduced number of tobacco outlets, and from there to calculate increased travel costs for each intervention. Age-specific price elasticities of demand were used to estimate future smoking prevalence. Results With a law that required a 95% reduction in outlets, the cost of a pack of 20 cigarettes (including travel costs) increased by 20% in rural areas and 10% elsewhere and yielded a smoking prevalence of 9.6% by 2025 (compared with 9.9% with no intervention). The intervention that permitted tobacco sales at only 50% of liquor stores resulted in the largest cost increase (∼$60/ pack in rural areas) and the lowest prevalence (9.1%) by 2025. Elimination of outlets within 2 km of schools produced a smoking prevalence of 9.3%. Conclusions This modelling merges geographic, economic and epidemiological methodologies in a novel way, but the results should be interpreted cautiously and further research is desirable. Nevertheless, the results still suggest that tobacco outlet reduction interventions could modestly contribute to an endgame goal.

In 2003, the New Zealand Parliament passed a smokefree law that included the prohibition of smoking inside restaurants and bars/pubs (the Smoke-free Environments Amendment Act 2003). A key purpose of the act was ‘to prevent the detrimental effect of other people’s smoking on the health of people in workplaces, or in certain public enclosed areas…’. But despite this purpose, the law still allowed for smoking in so-called ‘open areas’ at hospitality venues. These open areas are often surrounded by walls and partial roofing, and are typically inside the actual architectural footprint of the building (eg, see elsewhere for an example photograph of this problem).1 When smoking occurs in these areas, high levels of air pollution from fine particulates (PM2.5) has been detected.2 This poses risks to non-smoking patrons in these areas, but also the associated air pollution can drift into adjacent indoor areas via open windows and doors.3 4 The …

Background New Zealand has a goal of becoming a smokefree nation by the year 2025. Smoking prevalence in 2012 was 17%, but is over 40% for Maori (indigenous New Zealanders). We forecast the prevalence in 2025 under a business-as-usual (BAU) scenario, and determined what the initiation and cessation rates would have to be to achieve a

Background There is evidence that smoking is associated with poorer mental health. However, the underlying mechanisms for this remain unclear. We used longitudinal data to assess whether smoking uptake, or failed quit attempts, are associated with increased psychological distress. Methods Data were used from Waves 3 (2004/05), 5 (2006/07) and 7 (2008/09) of the longitudinal New Zealand Survey of Family, Income and Employment. Fixed-effects linear regression analyses were performed to model the impact of changes in smoking status and quit status (exposure variables) on changes in psychological distress (Kessler 10 (K10)). Results After adjusting for time-varying demographic and socioeconomic covariates, smoking uptake was associated with an increase in psychological distress (K10: 0.22, 95% CI 0.01 to 0.43). The associations around quitting and distress were in the expected directions, but were not statistically significant. That is, smokers who successfully quit between waves had no meaningful change in psychological distress (K10: −0.05, 95% CI −0.34 to 0.23), whereas those who tried but failed to quit, experienced an increase in psychological distress (K10: 0.18, 95% CI −0.05 to 0.40). Conclusions The findings provide some support for a modest association between smoking uptake and a subsequent increase in psychological distress, but more research is needed before such information is considered for inclusion in public health messages.

Objectives The objectives of the present work were to (a) develop a relatively simple single-observer method for data collection on cigarette butt discarding; and (b) quantify cigarette butt discarding behaviour in city streets. Methods A method was developed, piloted and refined (with interobserver assessment). Cigarette butt discarding was systematically observed by a single data collector while walking a continuous circuit of busy downtown streets in a capital city (Wellington, New Zealand). Results The final method appeared feasible in this setting and seemed efficient (at 5.5 discarding events observed per hour). A clear majority (76.7%; 95% CI 70.8 to 82.0%) of the 219 smokers observed littered their cigarette butts. Butt littering was more common for those who did not extinguish their cigarette (94.4% vs 4.5%, p=0.003). Butt littering was more common in the evening versus lunchtime periods of observation (85.8% vs 68.1%, p=0.002, logistic regression analysis). Overall, most smokers (73.5%) did not extinguish their butts and some placed lit butts in bins (constituting a risk of bin fires). The context for this littering was a high density of rubbish bins on this circuit with a mean of 3.5 bins being in view and with a bin every 24 m on average. Conclusions Butt littering behaviour appears to be the norm among smokers in this urban setting, even though rubbish bins were ubiquitous. One solution is stronger enforcement of littering laws. Nevertheless, in a society with a national smokefree goal (by year 2025 for New Zealand), it would probably be more logical and cost effective to move to smokefree policies for major city streets, which are used in a number of jurisdictions internationally.

Google Street View (GSV) is an increasingly used data collection method for objectively measuring observable features of the environment as detailed in a recent review.1 But as its overall potential for studying tobacco control-related issues to date has never been considered, we aimed to perform a brief review of this potential. Searches were conducted using PubMed for articles using the term ‘Google Street View’ (to January 2017). From these articles, additional ones involving GSV were identified in bibliographies. Articles were excluded from further analysis if they focused on the non-human environment (n=3 excluded, ie, bird nests, insects with silk nests and invasive plants) or if they did not cover any of the following: signage/advertising, retail outlets/stores or bars/pubs, or tobacco content (n=15 excluded). We identified 23 relevant Medline-indexed studies relating to GSV and one review. A total of four tobacco-related issues were specifically covered in this …

Objectives The objective is to (a) refine and use methods to measure the point prevalence of smoking and of secondhand smoke exposure in moving vehicles and (b) compare these prevalences (1) between two areas of contrasting socioeconomic status and (2) over time. Methods The authors developed and tested a singleobserver method and observed the point prevalence of smoking in vehicles in Wellington, New Zealand. The two observation sites represented high and low areas of socioeconomic deprivation (based on a small area deprivation index). Results A total of 149886 vehicles were observed. The mean point prevalence of smoking in vehicles at both sites combined was 3.2% (95% CI 3.1% to 3.3%). Of those vehicles with smoking, 4.1% had children present. Smoking point prevalence in vehicles was 3.9 times higher in the area of high deprivation than in the area of low deprivation (95% CI 3.6 to 4.2). The same pattern was seen for vehicles with only the driver at 3.6 times (95% CI 3.4 to 4.0), in vehicles with other adults at 4.0 times (95% CI 3.4 to 4.7) and in vehicles with children at 10.9 times (95% CI 6.8 to 21.3), with all results adjusted for vehicle occupancy. Conclusions Observing smoking in vehicles using a single-observer method provides a feasible and objective indicator of the different smoking behaviours, especially around children, within an area. This study further supports the evidence from this country and internationally that adults and children from highdeprivation areas are much more likely to be exposed to secondhand smoke.

Background The internet is an ideal forum for tobacco marketing, as it is largely unregulated and there is no global governing body for controlling content. Nevertheless, tobacco companies deny advertising on the internet. Objective To assess the extent and nature of English language videos available on the Web 2.0 domain ‘YouTube’ that contain tobacco brand images or words. Methods The authors conducted a YouTube search using five leading non-Chinese cigarette brands worldwide. The themes and content of up to 40 of the most viewed videos returned for each search were analysed: a total of 163 videos. Results A majority of the 163 tobacco brand-related videos analysed (71.2%, 95% CI 63.9 to 77.7) had pro-tobacco content, versus a small minority (3.7%) having anti-tobacco content (95% CI 1.4 to 7.8). Most of these videos contained tobacco brand content (70.6%), the brand name in the title (71.2%) or smoking imagery content (50.9%). One pro-smoking music video had been viewed over 2 million times. The four most prominent themes of the videos were celebrity/movies, sports, music and ‘archive’, the first three of which represent themes of interest to a youth audience. Conclusions Pro-tobacco videos have a significant presence on YouTube, consistent with indirect marketing activity by tobacco companies or their proxies. Since content may be removed from YouTube if it is found to breach copyright or if it contains offensive material, there is scope for the public and health organisations to request the removal of pro-tobacco content containing copyright or offensive material. Governments should also consider implementing Framework Convention on Tobacco Control requirements on the internet, to further reduce such pro-tobacco content.

Objectives: To examine the impact of health warnings on smokers by comparing the short-term impact of new graphic (2006) Australian warnings with: (i) earlier (2003) United Kingdom larger text-based warnings; (ii) and Canadian graphic warnings (late 2000); and also to extend our understanding of warning wear-out. Methods: The International Tobacco Control Policy Evaluation Survey (ITC Project) follows prospective cohorts (with replenishment) of adult smokers annually (five waves: 2002-2006), in Canada, United States, UK and Australia (around 2000 per country per wave; total n = 17 773). Measures were of pack warning salience (reading and noticing); cognitive responses (thoughts of harm and quitting); and two behavioural responses: forgoing cigarettes and avoiding the warnings. Results: All four indicators of impact increased markedly among Australian smokers following the introduction of graphic warnings. Controlling for date of introduction, they stimulated more cognitive responses than the UK (text-only) changes, and were avoided more, did not significantly increase forgoing cigarettes, but were read and noticed less. The findings also extend previous work showing partial wear-out of both graphic and text-only warnings, but the Canadian warnings have more sustained effects than UK ones. Conclusions: Australia's new health warnings increased reactions that are prospectively predictive of cessation activity. Warning size increases warning effectiveness and graphic warnings may be superior to text-based warnings. While there is partial wear-out in the initial impact associated with all warnings, stronger warnings tend to sustain their effects for longer. These findings support arguments for governments to exceed minimum FCTC requirements on warnings.

As smoke-free car policy is a frontier domain for tobacco control, attitudes to smoke-free private car laws are briefly reviewed. Medline and Google Scholar searches for the period up to mid-November 2008, from English language sources, were undertaken. Studies were included that contained data from national and subnational populations (eg, in states and provinces), but not for smaller administrative units, eg, cities or councils. Jurisdiction, sample size and survey questions were assessed. One reviewer conducted the data extraction and both authors conducted assessments. A total of 15 relevant studies (from 1988) were identified, set in North America, the UK and Australasia. The available data indicates that, for the jurisdictions with data, there is majority public support for laws requiring cars that contain children to be smoke free. There appears to be an increase over time in this support. In five surveys in 2005 or since (in California, New Zealand and Australia), the support from smokers was 77% or more. The high levels of public (and smoker) support for smoke-free car laws found in the studies to date suggest that this can be a relatively non-controversial tobacco control intervention. Survey series on attitudes to such laws are needed, and surveys in jurisdictions where the issue has not been investigated to date.

Objective: To examine the role of tobacco use in creating financial hardship for New Zealand (NZ) low income households with children. Data: The 1996 NZ census (smoking prevalence by household types), Statistics NZ (household spending surveys 1988-98), and NZ Customs (tobacco released from bond 1988-98). Main outcome measures: Proportion of children in households with smokers and ≤$NZ15 000 gross income per adult. Proportion of spending on tobacco of second lowest equivalised household disposable income decile and of solo parent households. Results: In ≤$NZ15 000 gross income per adult households with both children and smokers, there were over 90 000 children, or 11% of the total population aged less than 15 years. Enabling second lowest income decile households with smokers to be smoker-free would on average allow an estimated 14% of the non-housing budgets of those households to be reallocated. Conclusions: The children in low income households with smokers need to be protected from the financial hardship caused by tobacco use. This protection could take the form of more comprehensive government support for such households and stronger tobacco control programmes. A reliance on tobacco price policy alone to deter smokers is likely to have mixed outcomes—for example, increased hardship among some of these households. The challenge for tobacco control is to move from a sole focus on "doing good" towards incorporating the principle of "doing no harm".

Aim: To clarify the extent of use of foreign (including duty free, foreign normal retail and smuggled) tobacco, and to estimate missed government tax revenue in a geographically isolated country. Methods: Discarded cigarette packs were collected on the streets of four cities and six New Zealand towns/rural locations between November 2008 and January 2009. Results: Out of a total of 1310 packs collected, 42 foreign packs were identified (3.2%, 95% CI 2.4% to 4.3%). Overall, the distribution of packs by country and company was not suggestive of any clustering that might indicate smuggling. At 3.2% of packs being “foreign”, the New Zealand government is losing around $36 million per year in tobacco-related tax relative to if all this tobacco was purchased in New Zealand. For various reasons (including that it was not possible to identify packs bought duty free within New Zealand, and other New Zealand survey data indicating duty free product use at 3.8% of packs), the figure reached is probably an underestimate of the true level. Conclusion: The New Zealand government is missing out on revenue that could be used for improving the funding of tobacco control, and smokers are being exposed to cheaper tobacco thus increasing their risk of continuing to smoke. This government and other governments can and should act at the international and national levels to end the sales of duty free tobacco.

To extend the limited international evidence on youth in-vehicle second-hand smoke (SHS) exposure by examining trends in New Zealand, a country with a national smoke-free goal and indoors smoke-free environment legislation.We tracked exposure rates and explored the associations between in-vehicle SHS exposure and smoking behaviours. In-home exposure was also examined for comparative purposes. Data were collected in annual surveys of over 25 000 year 10 school students (14-15-year olds) for a 7-year period (2006-2012). Questions covered smoking behaviour, exposure to smoking and demographics.Youth SHS exposure rates in-vehicle and in-home trended down slightly over time (p0.0001 for both) with 23% exposed in-vehicle in the previous week in 2012. However, marked inequalities in exposure between ethnic groups, and by school-based socioeconomic position, persisted. The strongest association with SHS exposure was parental smoking (eg, for both parents versus neither smoking in 2012: in-vehicle SHS exposure adjusted OR: 7.4; 95% CI: 6.5 to 8.4). After adjusting for seven other factors associated with initiation, logistic regression analyses revealed statistically significant associations of in-vehicle SHS exposure with susceptibility to initiation and smoking.The slow decline in SHS exposure in vehicles and the lack of progress in reducing relative inequalities is problematic. To accelerate progress, the New Zealand Government could follow the example of other jurisdictions and prohibit smoking in cars carrying children. Other major policy interventions, beside enhanced smoke-free environments, will also likely be required if New Zealand is to achieve its 2025 smoke-free nation goal.

To examine time trends in the portrayal of smoking in a national collection of portraiture and to compare this with the similar trends for television and film.A compact disc produced by the National Portrait Gallery in London, UK, was systematically searched for artworks produced in the years 1950 to 1999. A "smoking portrayal" in an artwork was defined as having a cigarette, cigar or pipe in the mouth or hand of a named individual.Out of 1063 artworks included in the analysis, 53 portrayed smoking by identifiable individuals (5.0%). The rate of portrayal was highest in the 1950s (10%) and 1960s (11%) and then declined sharply thereafter (p value for trend0.00001). Smoking virtually disappeared from portraiture in the 1990s (at 0.6%). The median age of the smokers portrayed was significantly higher in the 1970 to 1999 period when compared to the 1950 to 1969 period.The decline of smoking in this collection of portraiture is consistent with the decline in smoking in the UK over these decades, but contrasts with trends for increasing smoking portrayal described elsewhere for film and television.

The objectives of the present work were to (a) develop a relatively simple single-observer method for data collection on cigarette butt discarding; and (b) quantify cigarette butt discarding behaviour in city streets.A method was developed, piloted and refined (with interobserver assessment). Cigarette butt discarding was systematically observed by a single data collector while walking a continuous circuit of busy downtown streets in a capital city (Wellington, New Zealand).The final method appeared feasible in this setting and seemed efficient (at 5.5 discarding events observed per hour). A clear majority (76.7%; 95% CI 70.8 to 82.0%) of the 219 smokers observed littered their cigarette butts. Butt littering was more common for those who did not extinguish their cigarette (94.4% vs 4.5%, p=0.003). Butt littering was more common in the evening versus lunchtime periods of observation (85.8% vs 68.1%, p=0.002, logistic regression analysis). Overall, most smokers (73.5%) did not extinguish their butts and some placed lit butts in bins (constituting a risk of bin fires). The context for this littering was a high density of rubbish bins on this circuit with a mean of 3.5 bins being in view and with a bin every 24 m on average.Butt littering behaviour appears to be the norm among smokers in this urban setting, even though rubbish bins were ubiquitous. One solution is stronger enforcement of littering laws. Nevertheless, in a society with a national smokefree goal (by year 2025 for New Zealand), it would probably be more logical and cost effective to move to smokefree policies for major city streets, which are used in a number of jurisdictions internationally.

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 Māori 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 Māori, 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.

The available literature on tobacco endgames tends to be limited to discussing means, targets and difficulties. This article offers additional ideas on the key elements of endgame strategies and the circumstances in which these are likely to be adopted and implemented. We suggest such strategies will include explicit plans, will define the nature of `the end of tobacco use/sale' and have target dates within 20 years. The likely circumstances for endgame strategy development include low (probably under 15% adult smoking) prevalence and/or rapid prevalence reductions, wide support and strong political leadership. Even with some or all these circumstances, opposition from business, internal government forces and international factors may influence results.

We discuss some of the practical and ethical questions that may arise for a jurisdiction where a sinking lid endgame strategy for tobacco supply is implemented. Such a strategy would involve regular required reductions in the amount of tobacco released to the market for sale, sufficient to achieve the desired level of commercial sales by a target date. Tobacco manufacturers would periodically bid to the government for a residual quota. Prices would increase as supply reduced. The price level would be influenced by demand, which in turn would reflect the impact of other interventions to reduce demand and the changing normality of smoking. Higher priced tobacco could result in increased smuggling, theft, illegal sales and short-to-medium-term aggravation of some social inequalities. We suggest that the strategy be introduced in conjunction with a range of complementary interventions that would help reduce demand, and thus help ensure that the possible adverse effects are minimised. These complementary interventions include: providing comprehensive best practice smoking cessation support, better information to smokers and the public, strengthened regulation of tobacco retailing and supply, further controlling the pack and product design, measures to restrict supplies that bypass the increases in product price, strengthened enforcement and combating industry attacks. General prerequisites for a sinking lid strategy include public support for the goal of a tobacco-free society, and strong political leadership. The likely context for initial success in jurisdictions includes geographical isolation and/or strong border controls, absence of significant tobacco production and/or manufacturing and low government corruption.

Background: The New Zealand 2003 Smoke-free Environments Amendment Act (SEAA) extended existing restrictions on smoking in office and retail workplaces by introducing smoking bans in bars, casinos, members’ clubs, restaurants and nearly all other workplaces from 10 December 2004. Objective: To evaluate the implementation and outcomes of aspects of the SEAA relating to smoke-free indoor workplaces and public places, excluding schools and early learning centres. Methods: Data were gathered on public and stakeholder attitudes and support for smoke-free policies; dissemination of information, enforcement activities and compliance; exposure to secondhand smoke (SHS) in the workplace; changes in health outcomes linked to SHS exposure; exposure to SHS in homes; smoking prevalence and smoking related behaviours; and economic impacts. Results: Surveys suggested growing majority support for the SEAA and its underlying principles among the public and bar managers. There was evidence of high compliance in bars and pubs, where most enforcement problems were expected. Self reported data suggested that SHS exposure in the workplace, the primary objective of the SEAA, decreased significantly from around 20% in 2003, to 8% in 2006. Air quality improved greatly in hospitality venues. Reported SHS exposure in homes also reduced significantly. There was no clear evidence of a short term effect on health or on adult smoking prevalence, although calls to the smoking cessation quitline increased despite reduced expenditure on smoking cessation advertising. Available data suggested a broadly neutral economic impact, including in the tourist and hospitality sectors. Conclusion: The effects of the legislation change were favourable from a public health perspective. Areas for further investigation and possible regulation were identified such as SHS related pollution in semi-enclosed outdoor areas. The study adds to a growing body of literature documenting the positive impact of comprehensive smoke-free legislation. The scientific and public health case for introducing comprehensive smoke-free legislation that covers all indoor public places and workplaces is now overwhelming, and should be a public health priority for legislators across the world as part of the globalisation of effective public health policy to control the tobacco epidemic.

It is now over 10 years since a New Zealand law1 requiring all preschools and schools to become completely smoke-free (including all grounds) became operational in 2004. Previously, indoor school areas had been required to be largely smoke-free, but there was ‘variable compliance’.2 ,3 As there is limited literature on the international long-term experience (outside of California4) with laws covering outdoor areas such as school grounds, we briefly reviewed the experience with this New Zealand law. Literature searches using PubMed, MEDLINE and Google Scholar were performed for the period 1 January 2004 to 17 June 2014. These were all focused on the New Zealand setting (preschools, schools and smoking). There was some evidence that the implementation of the law went relatively well. A survey published …

The call rate to New Zealand’s national Quitline service1 appears to be influenced by mass media campaigns,2 media publicity on the risks of smoking,3 and even international events.4 We examined the usage of this Quitline before and after the time that new smoke-free environments legislation became operational in New Zealand on 10 December 2004. This legislation extended previous legislation so as to completely ban smoking in bars, restaurants, and nearly all indoor workplaces. It appears that this new law has been well accepted by smokers.5 We analysed routinely collected data on smokers who registered with the Quitline to undertake a quit attempt, comparing the period from 1 December 2004 to 31 January …

Increasing the price of tobacco products through tobacco taxation is one of the most effective tobacco control interventions.1 An additional benefit is that a “dedicated tobacco tax” (where some or all of the revenue raised is earmarked for specific spending or programmes) can generate revenue for funding other tobacco control and health programmes.2 3 Should dedicated tobacco taxes be introduced, it will be useful for decision makers to know whether there is support from all sociodemographic categories of smokers. Accordingly, we aimed to examine smoker support for tobacco taxes by an individual level measure of deprivation. As part of the New Zealand arm of an international study (the International Tobacco Control (ITC) project),4 5 we surveyed a national sample of 1376 New Zealand adult (18+ years) smokers (between March 2007 and February 2008). We …

New Zealand has a national (free) telephone Quitline service that is promoted through regular mass media campaigns. Data are routinely collected on the over 100 callers per day. We used this data source to investigate the impact of the 11 September 2001 terrorist attacks in the USA on calls to this service. On Wednesday 12 September (11 September in New York was 12 September in New Zealand) there was a sudden decline in the number of new callers to the Quitline (only 137 callers relative to 237 on the previous day—a 42% reduction). Similarly, relative …