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‘The times are changing’: New Zealand smokers' perceptions of the tobacco endgame
  1. Ninya Maubach1,
  2. Janet A Hoek1,
  3. Richard Edwards2,
  4. Heather Gifford3,
  5. Stephanie Erick4,
  6. Rhiannon Newcombe5
  1. 1Department of Marketing, University of Otago, Dunedin, New Zealand
  2. 2Department of Public Health, University of Otago, Wellington, New Zealand
  3. 3Whakauae Research Services, Whanganui, New Zealand
  4. 4Tala Pasifika, Auckland, New Zealand
  5. 5Health Sponsorship Council, Wellington, New Zealand
  1. Correspondence to Dr Ninya Maubach, Department of Marketing, University of Otago, P O Box 7343, Wellington 6242, New Zealand; ninya.maubach{at}otago.ac.nz

Abstract

Background The New Zealand government's goal of achieving a smoke-free society by 2025 reflects growing interest in ‘endgame’ solutions to tobacco smoking. However, tobacco companies have framed ‘endgame’ strategies as contrary to individual freedoms and ‘choice’; these claims heighten politicians' sensitivity to ‘nanny state’ allegations and may undermine tobacco control policies. Public support for stronger policies could strengthen political will; however, little is known about how smokers perceive endgame scenarios or the factors underlying their support or opposition to these.

Methods The authors conducted 47 in-depth interviews with four priority groups: Māori, Pacific, young adults and pregnant women; all were smokers or very recent quitters. The authors used thematic analysis to interpret the transcripts.

Results Most participants strongly supported the 2025 smoke-free goal, recognised the broader social good that would result and accepted the personal inconvenience of quitting. Yet they wanted to retain control over when and how they would quit and asserted their ‘freedom’ to smoke. Participants identified interventions that would extend current policy and maintain the autonomy they valued; the authors classified these into four themes: restricting supply, diminishing visibility, decreasing availability and affordability, and increasing quit support.

Conclusions Politicians may have a stronger mandate to implement endgame policies than they appreciate. Participants' use of industry arguments when asserting their freedom to ‘choose’ to smoke and quit suggests a need for denormalisation strategies that challenge industry propaganda, demonstrate how endgame measures would empower smokers and re-iterate the community benefits a smoke-free society will deliver.

  • Tobacco endgame
  • priority populations
  • qualitative research
  • endgame
  • public policy
  • packaging and labelling
  • cessation
  • advertising and promotion
  • litigation
  • priority/special populations
  • primary healthcare
  • tobacco control in Africa
  • prevalence
  • environmental tobacco smoke
  • advocacy
  • smoking-caused disease

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A smoke-free 2025: the vision

Governments have shown increasing interest in measures that would limit tobacco supply, depress demand and lead to rapid reductions in smoking prevalence.1 Known as an ‘endgame’ scenario because it would bring about a near-zero smoking prevalence, this approach has also piqued the interest of New Zealand researchers and regulators.2 Yet while the New Zealand government has set a ‘longer term goal of making New Zealand essentially a smoke-free nation by 2025’,3 it has still to develop a strategy that will realise this goal. Tobacco industry interference has delayed policy progress,4 as has the lack of information about how smokers themselves perceive endgame strategies.

In New Zealand, smoking prevalence varies widely by ethnicity; it is nearly three times higher among the indigenous Māori population than among non-Māori and is also higher among Pacific peoples and non-Māori young adults.5 ,6 Achieving the 2025 goal will require significant increases in smoking cessation, decreases in lapsing among quitters and reduced smoking initiation among these groups and pregnant women, where smoking is especially harmful. While quantitative surveys show smokers and the wider public support further tobacco control measures,7 politicians may act more decisively if they better understand how smokers themselves perceive endgame goals and the measures that could realise these.

Since the smoke-free 2025 goal challenges addictive behaviours and directly confronts the tobacco industry, it is likely to elicit reactance. The tobacco industry has responded to this threat by rehearsing its usual litany of arguments, including claims that cigarettes are a legal consumer product (and so should be treated as any other legal product). This argument overlooks tobacco's uniquely harmful properties, recognised by recent measures such as the removal of tobacco retail displays and increases in excise tax. The industry also claims that smoking is a freely chosen behaviour, engaged in by those who understand and accept the risk it poses.8 ,9 However, this reasoning fails to recognise nicotine's addictiveness, which compromises smokers' ability to ‘choose’ and is inconsistent with evidence that a large majority of smokers would not smoke, if they could live their lives again.10

The industry's reasoning also presents smoking as a ‘right’, a position that sanctions marketing strategies that target disadvantaged people and presents smoking as a powerful symbol of emancipation. Framing smoking as a ‘right’ enables the industry to challenge measures restricting tobacco consumption, which they describe as authoritarian interference with individual liberties by an excessively paternalistic ‘nanny state’ whose approach will alienate an already marginalised group.11

Tobacco companies' self-depiction as ‘protector’ of personal freedoms presents policy makers with a serious challenge. While government endorsement of the 2025 goal suggests policy makers appreciate endgame logic, politicians remain sensitive to ‘nanny state’ allegations, which may lead them to refrain from implementing evidence-based measures.12 ,13 Given the industry's appeals to principles of individual choice, freedom and democracy, those working in tobacco control need to understand smokers' perceptions of the 2025 goal and the different interventions that may be required to realise a smoke-free society.14 ,15 Since the 2025 goal depends on substantial reductions in smoking among key priority groups, Māori, Pacific peoples, young adults and pregnant women, we explored how these groups interpreted the ‘endgame’ and understood its implications for themselves and other smokers.2

Methods

We conducted in-depth interviews with 47 people in August 2011. Participants were recruited from five New Zealand towns and cities, which were a mix of urban and provincial locations in the north and south islands. Table 1 explains the recruitment approaches used for each priority group.

Table 1

Recruitment strategies

Participants were either current daily (n=35) or social (intermittent) smokers (n=9) or had recently quit (n=3).Table 2 contains a summary of participants' characteristics; a supplementary file contains full details of participants' characteristics.

Table 2

Participants' characteristics

We used a semi-structured protocol to guide interviews, which lasted approximately 40–60 min; where possible, interviewers shared participants' ethnicity. Participants received a NZ$30 voucher to recognise their time (pregnant women received $40, in recognition of the greater effort required of them). The protocol began by exploring participants' perceptions of smoking and being a smoker, and their reactions to previous cessation campaigns, before probing their thoughts on the 2025 goal and how they believed the government should (and should not) pursue this goal. We analyse participants' thoughts on this latter question, which they spent 10 to 20 min discussing in each interview. To ensure participants had a common understanding of the goal, interviewers read the following statement: ‘New Zealand has a goal of being a smoke-free country by 2025; this means that, in about 15 years, only a very small proportion of people would smoke tobacco’. If necessary, interviewers explained that the government has no current plans to ban the sale or purchase of tobacco.

The interviews were audio recorded with permission, transcribed verbatim and then reviewed using a thematic analysis approach.16 Coders independently read and reviewed the transcripts, identified idea elements and then grouped these into specific themes. Finally, the coders compared the themes they had independently identified, adjusted and refined these, and re-checked the resulting themes against the transcripts.17 Table 3 outlines measures taken to promote data validity.

Table 3

Data validity assessment

An internal reviewer with delegated authority from the central university ethics committee reviewed and approved the research procedures; we also undertook consultation with an indigenous people's committee (the Ngāi Tahu Consultative Committee). Participants were informed of their rights and gave written consent prior to participating in the research.

Results

After analysing the interview transcripts, we grouped participants' comments according to their views on the 2025 goal and the four strategies to which they consistently referred: restricting supply, diminishing visibility, decreasing affordability and accessibility, and increasing quit support.

Responses to the 2025 goal

After outlining the 2025 goal, interviewers explored participants' thoughts on an environment where very few people smoked. A large majority from all groups supported the smoke-free 2025 vision, saw it as consistent with the smoke-free future they wanted for themselves and expressed few reservations: “If the Government are putting all these different legislations in place to make it uncomfortable for smokers then I'm gonna be one of the strongest advocates for that”(Māori, female, 36). “I think it's really appealing. I think 2025—you know to—to even make that—that year, you know, is—just makes you—you really look forward to it” (Pacific, male, 35).

However, although they did not disagree with the goal, a minority felt uncertain about its viability and saw it as highly desirable, but challenging for regulators to achieve: “I think it's a great idea, but if it's possible, I think is another one entirely…I wouldn't have any idea what the numbers are of smoking versus non-smoking, but to create an entire country that they're trying to claim is smokefree, it—it seems near impossible” (NZE, female, 18). “That's fine if they want to do it…how they are going to do it is a different story” (Māori, female, 45). Some could not envisage family members ever being smoke free because this change would conflict with deeply embedded social norms: “I know my family, I don't think they'd be able to quit, ever…They're just so—it's like normal, it's part of them. It's– I don't know. They're just so used to it” (Pregnant, Māori, 19).

A minority noted their ambivalence about the goal and resented attempts to dictate their behaviour but nevertheless recognised the benefits their communities would receive. “Again I get angry because it is that thing of you know, telling you what to do but then it's—it's the long term I think it's a good thing, you know if there— it is smokefree because again you've gotta think of it in terms of our people, Pasifika/Māori” (Pregnant, Pacific, 43). The tension between personal autonomy, potential inconvenience and a desire to achieve outcomes that would benefit others challenged participants, who saw the 2025 goal as simultaneously threatening yet highly desirable. “So it's just like, I will do what I like, thank you. And I don't like, yeah. But then, you know, it's in everybody's best interest, and, you know, for your health and everything, if it's, yeah, but for somebody who's addicted to smoking, they'll be very upset…it's absolutely terrifying to somebody who's a smoker. Like, it's really scary” (NZE, female, 24). Yet despite concerns over these personal costs, participants felt deeply attracted to the benefits their communities would receive and thought the 2025 goal would support smokers, who they believed wanted an environment that would help them become smoke free. “I think that'll be great for smokers. I reckon that that'll really push us to stop, and for those of us who don't wanna stop—you know I- I can't speak for them but ah—I can say confidently that I reckon about 70% of smokers deep down would be keen for that, and they'll look at it as another way of sort of—that that's a good push for them to stop” (Pacific, male, 25).

Two younger participants expressed immediate hostility to the goal: “That's ***! I think that is complete ***… It has to be New Zealand's choice” (Pregnant, NZE, 17), “In your *** dreams…I think that, sorry, try to make New Zealand smokefree, just try it. It's not going to happen” (NZE, male, 23). These participants firmly believed that the government had no business telling people how to live their lives and felt disempowered by the goal, even though both saw smoke-free futures for themselves. They framed their opposition by predicting dire social consequences, such as increased crime and social unrest, and mistakenly assumed the smoke-free goal would criminalise smoking. A small minority also foresaw potential unintended consequences if smokers were stressed; however, most supported the 2025 goal.

Participants balanced personal costs, which they saw as short-term, against long-term community-wide benefits. References to ‘our people’ and ‘our country’ suggest that the 2025 goal resonated deeply with participants and supported the innate desire most had for their community to become smoke free. Even those anticipating personal hardship felt the goal resolved their ambivalence and set out an aspiration with which they empathised: “I mean I like smoking but I don't like smoking…I enjoy doing it, but I don't like the actual habit. I think it's disgusting. I don't think anyone should start. I wish I'd never started. I love it, and then I'll be really pissed off when they make it smokefree and I can't buy cigarettes anymore. At least for like the first two weeks while it's getting out of my system and I'm grumpy as a mad man, but in the long run, I think smoking's something our country could do without” (NZE, female, 23).

After outlining their initial reactions to the 2025 goal, participants considered how they thought this goal might be realised.

Realising the vision: restricting supply

Many thought tighter controls on supply and distribution could ensure social and commercial environments aligned with the 2025 goal. They endorsed a tobacco-free vision, but believed tobacco's widespread availability undermined the smoke-free goal: “…you can't have that kind of goal when they're selling them in the shops. What's the point? You know what—seriously, what's the point? It's too readily available” (Pregnant, Pacific, 38). Some suggested removing tobacco from regular retail environments would denormalise smoking: “I reckon it's weird how they sell it with like food and stuff…it's just wrong for me…They should have like a R18 shop for them or something. That, I reckon that'd be good” (Pregnant, Māori, 17). The young man who initially vehemently opposed the goal later suggested that state supply controls could reduce initiation: “Um, I think that young people would take less and be much more sensible about their, their choices if it was run by the government. Or allowed by the government and monitored by the government but run through a third party” (NZE, male, 23).

A minority went further and suggested prohibiting smoking and banning tobacco products: “Um, I just think that it's [a tobacco free New Zealand] entirely appropriate and just a good idea…and I say that entirely as someone who has enjoyed smoking at various times and, I don't know, I just think that it would be great if it [smoking] was treated like, I don't know, it was just pro-, prohibited”(NZE, male, 22); “they should just take the smokes off the shelf” (Pregnant, Pacific, 28). Younger participants supported limiting the volume of tobacco smokers could purchase, and the ease with which they could access tobacco: ‘but just maybe you are limited to buy one pack or two packs and just make it harder for them to get…Just [have] only certain place or places where they're selling cigarettes. Some people don't want to travel far and they'll just say ‘I'm not going to smoke’” (Indian, male, 21). While prohibition went beyond most participants' suggestions, their support for supply restrictions directly challenges industry assertions that tobacco is legal (and, by implication, normal). These comments further highlight participants' willingness to endure some personal inconvenience if this will bring about a greater good and create an environment that supports them when they choose to quit.

However, some Māori and Pacific participants suggested restrictions could promote social supply and called for supply restrictions to occur first within the family: “cause there's still so many of them smoking, and still parents letting, you know, 12 year olds smoke. I think that if that was addressed a little bit more” (Māori, female, 29). Others suggested that home-grown tobacco would increase and noted that this supply route was much cheaper for smokers: “Unfortunately I—I want it [2025 goal] to happen, but just like drugs they're going to start growing their own soon. That's how bad it's getting…with the prices going up with cigarettes it's just gonna make them wanna buy—ah– make their own” (Māori, female, 27). Not all thought it would be worth the effort to grow or find homegrown: “I wouldn't mind if New Zealand was smokefree because then I'd just have to stop. I'm not going to grow my own tobacco plants and fork out like $60 a week for tobacco from some old man that lives in the whops [remote country area], like I wouldn't do that” (NZE, female, 19). However, some believed that home-grown tobacco was nicotine free and ‘better’ than retail tobacco cigarettes: “That's [the 2025 goal] a excellent idea, if they think they can do it…but otherwise, if they stop tobacco coming through—um—being imported into the country, I'm sure smokers will find a way in growing their own tobacco…And it's good to because if you grow your own there's no nicotine in as with the ones we buy off the shop there's a lot of rubbish inside” (Pregnant, Pacific, 43).

Despite these participants' enthusiasm for home-grown tobacco, recent evidence suggests that this source is likely to have only a small impact on consumption as it will be lower quality, less palatable, likely to be priced at similar levels to retail tobacco, if on-sold, and potentially difficult to access.18 Overall, this supply route is unlikely to disrupt progress to the 2025 goal. Rather than eliminating home-grown tobacco, it may be more important to disabuse smokers of the notion that ‘chop chop’ is less harmful than manufactured tobacco products.

Realising the vision: diminishing visibility

The second key theme highlighted reductions in the visibility of tobacco products and smoking. Participants endorsed recent policies removing tobacco retail displays and implementing smoke-free outdoor areas and suggested these could go further: “I mean the banning of cigarettes everywhere…like at the bar, at the airport um—our own family community centre we have to go outside the gate to have a cigarette, um—the school teachers that do smoke have to go outside the school grounds…Times are changing, um—it's changing for, you know, [the] better” (Pacific, female, 32). Despite the potential inconvenience, several participants believed restricting the areas where smoking could occur would reduce its perceived normality and acceptability: “I think there shouldn't also be smoking in CBD [central business district] areas…or at least designated parks or bench areas that are clearly marked for smoking…just to socially change people's mentality of having the right to smoke” (NZE, male, 29). These comments reinforce endgame objectives of recasting tobacco as noxious, not normal, and smoking as a perverse behaviour, not a socially accepted action. Furthermore, they explicitly challenge industry rhetoric casting smoking as a ‘right’ and instead reframe it as a behaviour that undermines community well-being.

Some participants supported plain packaging of tobacco products, which would reduce the visibility of tobacco brands but retain smokers' autonomy over when and how they decided to quit: “I think the brown paper bag or whatever size, style packaging, it's cool, it's a good idea, great idea. Um-.” [Interviewer: Why?] “Make it less glamorous. Without encroaching on people's civil liberties” (NZE, male, 23). This comment illustrates how plain packaging would erode the cachet branding confers on smoking, diminish individuals' experience of smoking and reduce the product's social standing.

Realising the vision: decreasing affordability and accessibility

Participants saw price as an important means of reducing demand for tobacco products but noted concerns that poorer smokers may be disproportionately affected by tax increases: “cause all that does is just hurt predominantly poor people who are already struggling to pay their bills” (NZE, male, 20). This implicit use of industry reasoning suggests a need to expose the logical corollary of industry claims: that less affluent smokers should have greater access to cancer, heart disease and respiratory illnesses.

Despite evidence that participants employed industry arguments about tax increases, several supported raising the price of tobacco products, which they believed would deter young people: “At least that stops it being something that's easily acquirable for young people, that's probably the best benefit of it for, of the price of cigarettes…Yeah it does, it takes it out of their sort of price range” (NZE, male, 23). Pacific participants were more likely to suggest steeper tax increases and felt anything less than a substantial increase would have little effect: “Keep putting the price up. None of this 50 cent/dollar sorta thing (laughs)…Put it up (laughs) by a lot, yeah. That's definitely one other thing” (Pacific, male, 28).

A minority favoured non-price measures, such as increasing the age at which people may purchase tobacco products: “as each year goes by they raise the age for smoking so that the smokers get older and eventually die, and then there's no more legalised smoking” (NZE, female, 25). This suggestion parallels endgame strategies from Singapore, where tobacco control advocates have proposed a smoke-free millennium generation that cannot access tobacco products.19

Realising the vision: increasing quitting support

To realise the 2025 goal, participants called for interventions to increase social and community cessation support. They offered several ideas, including personal incentives to quit and opportunities to share the quitting journey via online communities. Many supported community-oriented measures, whether these assisted individual quitters or contributed to a wider smoke-free culture: “If you talk to someone like face to face and give them advice that will be more effective…You just have like booths where you can meet people and talk with them and have a face to face conversation…They must be like, especially like ex-smokers: ‘I just quit smoking. Come and talk to me, and I have like that experience and I can give you way better advice rather than because I don't smoke’” (Indian, male, 21). These measures would enhance the visibility and credibility of quit support, prompt greater contact with quit services and reinforce smoke-free behaviour as a community norm.

Just as participants recommended reducing the supply, availability and visibility of tobacco, so they called for increases in quit support, including outreach that penetrated communities with high smoking prevalence. Improving the accessibility and visibility of cessation services could reach smokers at serendipitous moments when quitting might be top of mind: “They should—um—get more of those smokefree stores [Quit booths] out in the general public…shopping centres and stuff…if you're in a community, you know, populated with mostly Pacific Islanders and Māori then of course it'd be best to use non-smoking Pacific Island/Māoris to promote that…sorta like a brother and sister you can talk to, you know, to–to help you quit or stop” (Pacific, male, 25).

Participants often asserted smokers' need to make their own individual quit decision but also recognised the importance of community support that encouraged quitting, directly assisted quitters and provided opportunities for successful quitters to model their behaviour. Support for the smoke-free 2025 goal suggests that, despite the challenge of quitting, many wish to transition from the social groups that evolve around smoking to a society connected through its endorsement and support of smoke-free values.

Discussion

Although earlier surveys have documented support for endgame initiatives, we know little about smokers' perceptions of the 2025 goal and its realisation or how they balance the wider public good against the difficulties the goal might create for them. We explored these questions with participants from four priority groups for reducing smoking prevalence: Māori, Pacific peoples, young adults and women who smoke while pregnant.

Most participants strongly supported the 2025 goal and identified several measures they thought would help realise this goal. Their suggestions spanned the gamut of tobacco control measures, demonstrated an acceptance of both supply and demand initiatives,2 ,20 and hinted that smokers themselves endorse radical measures (such as restricting supply), which policy makers currently lack the confidence to implement, despite the international evidence supporting these interventions.21 ,22

Young adults, pregnant women and Pacific respondents expressed the strongest support for a tobacco endgame. Māori participants were more likely to note unintended outcomes and query the government's commitment to a smoke-free society and, while they called for a ‘radical’ approach, some doubted this would happen and feared the possible consequences if it did.

Participants' willingness to place wider social benefits ahead of their personal convenience reflects the internal conflict many feel about smoking: they need nicotine, yet resent this need; they wish to be smoke-free but do not want their decisions dictated. Underlying these competing attitudes, a majority from all groups supported the smoke-free goal because they believed this would bring about a ‘better’ society. Overall, participants saw smoking as ‘something our country could do without’ and were cognisant of the social, health and economic benefits Māori and Pacific communities would gain from a smoke-free society. Their views add a new dimension to survey data23 ,24 and foreground future work, which could estimate population support for alternative policies, explore the specific trade-offs smokers are willing to make and examine opportunities for greater community input into the design, implementation and management of endgame strategies.

This latter point is especially important as the findings reinforce the need for a community rather than individual focus. Endgame solutions concentrate debate on the tobacco industry's behaviour and the broader societal structures that support the industry's continuation; this approach explicitly rejects the industry's preference for increased education, which depicts smoking as a ‘choice’.9

However, while participants supported diverse policy measures, their reservations highlight the influence industry arguments have had. Many participants recited industry lines, declared their autonomy as a smoker and argued that they alone should make quitting choices. Yet not one recognised the industry's role in shaping their ideas or framing public debate. This finding questions whether tobacco control measures should focus more explicitly on industry denormalisation, a theme not widely used in New Zealand because of the industry's low profile. Exposing the industry's fallacious reasoning could help the public recognise its propaganda and reject arguments they might otherwise consider. To complement measures that confront industry claims, continuing public debate about the 2025 goal will help normalise tobacco control measures, demonstrate how these empower (rather than disenfranchise) smokers and expose tobacco industry claims as mendacious.14 ,15

What this paper adds

  • Although endgame strategies have gained political support, they remain at risk from tobacco industry allegations of ‘nanny state’ intervention. The paper augments survey evidence documenting smokers' support for specific interventions and explores their perceptions of smoke-free goals and how these should be achieved.

  • Smokers from the four priority groups interviewed supported the smoke-free 2025 goal and recognised the wider benefits it would bring. However, they disliked the thought they could be coerced to quit and favoured interventions such as decreased salience, visibility and affordability of tobacco, and enhanced quit outreach, that would still allow them to determine this decision.

  • The tobacco industry has successfully impeded policy progress by framing smoking as a question of individual freedoms. However, the smokers interviewed supported more progressive measures than policy makers have implemented, even though these would constrain their behaviour. Endgame strategies may need to confront industry arguments more directly so smokers and non-smokers recognise these as manipulative fallacies. Since smokers' own suggestions went well beyond current tobacco control measures, governments appear to have a strong mandate to introduce endgame policies.

Acknowledgments

We are grateful to the participants who agreed to be interviewed and whose detailed responses provided the basis of this article. The data were collected as part of a larger project exploring smoking cessation. We also appreciate the very helpful advice provided by Professor Ruth Malone and other reviewers.

References

View Abstract

Footnotes

  • All authors are members of the ASPIRE2025 collaboration (http://www.aspire2025.org.nz).

  • Funding This study was supported by New Zealand Ministry of Health.

  • Competing interests Although we do not consider it a competing interest, for the sake of full disclosure, we note that all authors have undertaken work for the New Zealand Ministry of Health; JAH, RE, HG and SE have also undertaken work for tobacco control NGOs and have received funding for tobacco control research from the Royal Society Marsden Fund and Health Research Council of New Zealand.

  • Ethics approval Ethics approval was provided by the University of Otago Human Ethics, Category B (Department of Marketing Ethics Administrator).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The qualitative data for this study were collected as part of a larger project for the New Zealand Ministry of Health. Additional unpublished data will be used in reporting to the ministry and may also be published in academic journals. Under the terms of informed consent signed by participants, only the immediate research team is granted permission to view the raw data.

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