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Getting there together: highlights, challenges and opportunities for tobacco control in the Oceania region
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  1. Heather Gifford1,
  2. El-Shadan Tautolo2,
  3. Judith P McCool3,
  4. Coral E Gartner4,5,
  5. Richard Edwards6,
  6. Raglan Maddox7
  1. 1 Whakauae Research, Whakauae Research for Maori Health and Development, Whanganui, Manawatu-Whanganui, New Zealand
  2. 2 Centre for Pacific Health and Development, Auckland University of Technology, Auckland, New Zealand
  3. 3 School of Population Health, University of Auckland, Auckland, New Zealand
  4. 4 School of Public Health, University of Queensland, Herston, Queensland, Australia
  5. 5 Queensland Alliance for Environmental Health Sciences, University of Queensland Faculty of Health and Behavioural Sciences, Woolloongabba, Queensland, Australia
  6. 6 Department of Public Health, University of Otago, Wellington, New Zealand
  7. 7 Aboriginal and Torres Strait Islander Health Program, National Centre for Epidemiology and Public Health, Australian National University, Acton, Australian Capital Territory, Australia
  1. Correspondence to Dr Heather Gifford, Whakauae Research, Whakauae Maori Health Research and Development, Wanganui 4500, Manawatu-Wanganui, New Zealand; heather{at}whakauae.co.nz

Abstract

Background The paper focuses on the geographical region of Oceania. We highlight the tobacco control leadership demonstrated in this region and describe the challenges and opportunities to achieving country-specific smoke-free goals.

Results Significant achievements include smoke-free nation goals, world-leading initiatives such as plain packaging, and a bold plan by New Zealand to reduce the retail availability of smoked tobacco products and remove virtually all the nicotine from cigarettes and rolling tobacco. There are significant challenges and opportunities before reaching smoke-free status including implementation pathways requiring strong governance and leadership and compliance monitoring and enforcement.

Conclusions We conclude that achieving a smoke-free Oceania is possible through already existing bold country and regional smoke-free goals, excellent tobacco control leadership, experience and resources, and an understanding of how to work collectively. However, a commitment to focus tobacco control efforts regionally is required to achieve a smoke-free Oceania together.

  • endgame
  • disparities
  • public policy
  • global health

https://doi.org/10.1136/tobaccocontrol-2021-056542

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    Context for tobacco control in Oceania

    Oceania includes Australasia (Australia and New Zealand), and 22 Pacific Island Countries and Territories (PICTs) across Melanesia, Micronesia, and Polynesia (figure 1). Most of Oceania’s population of over 41 million live in Australia (25.4 million), Papua New Guinea (8.8 million) and New Zealand (4.9 million).

    Figure 1
    Figure 1

    Map of Oceania region.

    Although the Oceania region has been a leader in tobacco control policy, these gains have not been universal or equitable. The region has one of the highest burdens of preventable non-communicable disease (NCD), a significant proportion of which can be attributed to tobacco use. Examples of stellar success are offset by an active tobacco industry and glaring disparities across the region.

    Oceania has been shaped by colonisers who settled and established governance over the Indigenous peoples. The PICTs, where the Indigenous peoples remain the majority population, have retained distinct economic, political and parliamentary systems. In Australia and New Zealand, non-Indigenous peoples (predominantly Europeans) became the majority and established political, economic, and cultural dominance. Colonisation disrupted social structures, community resources, and altered cultures, practices and values to differing degrees across Oceania.1 This included the introduction, commercialisation and trade of tobacco throughout the region; trading commercial tobacco as a profitable, but harmful commodity.2 Reducing the harm caused by the tobacco epidemic is reflected in biennial Oceania Tobacco Control Conferences which bring together tobacco control researchers, advocates, policymakers and administrators from across the region. This collaboration underpins the spirit of the WHO Framework Convention on Tobacco Control (FCTC)3 and acknowledges ‘the high levels of smoking and other forms of tobacco consumption by Indigenous people’.

    Australia and New Zealand have strong historical partnerships, and a major influence on PICTs. Objectives of Australian and New Zealand foreign policy with PICTs are primarily focused on trade and capital flows, migration and labour force needs and strategic considerations such as sovereignty, stability, security, and prosperity for the region.4 5 Both countries play a significant role in development assistance to the Pacific via bilateral and multilateral intermediaries. Significant numbers of Pacific Island peoples live in New Zealand6 and Australia7 facilitated through various constitutional acts (eg, Cook Islands Constitution Act 1964 and Niue 1972) which articulate rights to citizenship and through the Trans-Tasman Travel Arrangement.8

    Prevalence

    Smoking prevalence varies among PICTs from 17.7% in Niue to 62.4% in Federated States of Micronesia (FSM) (adults, both sexes) (table 1). Smoking prevalence was higher among male (range: 24.6% in Niue; 69.1% in FSM) than female (range: 4% in Vanuatu; 63% in Tokelau) in all countries except Tokelau. Smoking prevalence in PICTs was mostly considerably higher than in Australia and New Zealand. The only notable exception was Niue, a New Zealand Realm9 country with a fluctuating population of around 1619 residents. It is tempting to attribute lower smoking prevalence in Niue to its ‘free association’ (Realm country status). However, Tokelau, also a Realm country, has among the highest smoking prevalence in the region.

    View this table:
    Table 1

    Prevalence of current tobacco smoking among adults in Oceania*

    Smoking prevalence in New Zealand and Australia has decreased at similar rates over the last three decades to around 11%–13% currently.10–12 Smoking rates among Indigenous populations and those living in the most deprived communities13 remain comparatively high.10–12 For instance, Māori women have the highest daily smoking prevalence (33%) in New Zealand.10 Smoking prevalence among Pacific peoples living in New Zealand remains persistently high, with only a small reduction in the last 10 years.10 14 People living in the most deprived areas are over five times more likely to smoke than those living in the least deprived areas.10 14 Similar patterns are evident in Australia.15 Despite significant declines in daily smoking prevalence among Aboriginal and Torres Strait Islander peoples, down to 40.2% in 2018/2019 from 50.0% in 2004–2005, smoking remains much higher than in the non-Indigenous population and is a major contributor to preventable mortality and morbidity.16 17

    Tobacco control achievements

    Tobacco control achievements in the region have primarily benefited Australia and New Zealand. The decrease in age-standardised smoking prevalence in Oceania (1990–2019) was 16.1% for the PICTs, compared with 47.5% for Australia and 40.2% for New Zealand.18

    What accounts for such striking differences?

    Aotearoa New Zealand

    Strong Māori tobacco control advocacy in Aotearoa New Zealand pioneered discussion of endgame options, such as a private members’ bill to end tobacco sales,19 and development of the Tupeka Kore (‘no tobacco’) concept for Aotearoa New Zealand.20 In 2010, recommendations from a Māori Affairs Select Committee enquiry21 culminated in the commitment to achieving an essentially smoke-free Aotearoa by 2025. New Zealand has been instrumental in gathering evidence and advocating for endgame options.22–24 The most recent and potentially boldest action is the New Zealand government’s draft plan for achieving the Smokefree 2025 goal released in April 2021.25 This sets out a comprehensive plan including world-leading measures26 such as greatly reducing the retail availability of smoked tobacco products, phasing out sales through a ‘smoke-free generation’ policy, and removing virtually all the nicotine from cigarettes and rolling tobacco.

    Pacific Island Countries and Territories

    At a strategic level, Pacific leaders are committed to tobacco control27 with 14 PICT Parties to the FCTC, and all 22 PICTs supporting the Tobacco Free Pacific 2025 goal launched in 2014.28 In 2018, the Monitoring Alliance for NCD Action Dashboard29 was endorsed at the Pacific Health Ministers Meeting. The Dashboard maps country-level progress against specific NCD policies, prioritising actions and accountably and against specified tobacco control measures, including taxation, smoke-free environments, tobacco warnings, advertising and promotion, tobacco licensing, smoking cessation and tobacco industry interference.30

    A WHO FCTC31 report provides evidence of innovation and incremental progress in tobacco control in many PICTs. Most PICTs are implementing FCTC measures, with several being exemplars. These include the Cook Islands which has implemented annual tax increases since 2014, smoke-free environment laws, primary care-delivered cessation support and has trialled SMS-delivered cessation support intervention. Fiji ratified the Protocol to Eliminate Illicit Trade in Tobacco Products (Protocol) and implemented strong taxation, smoke-free environment, packaging and promotion measures. Palau prohibits duty-free tobacco sales, enforces underage sales laws, and hypothecates tobacco tax to NCD prevention and other tobacco control measures including the innovative ‘Palau Pledge’, which requires visitors to respect smoke-free places and not litter butts. Samoa’s 2019 Tobacco Control Amendment32 established a multisector tobacco control committee to develop the work plan to promote, among other measures, the Protocol, introduction of tobacco retail licensing, ban tobacco sales by people aged <15 years and regulate e-cigarettes. Samoa is a member of the WHO FCTC 2030 project, a prestigious opportunity which provides support to scale up implementation. Papua New Guinea’s 2015 policy responses33 included a comprehensive package of strategies to reduce the demand for tobacco products, to reduce the cultivation and supply of tobacco and to strengthen international collaboration in tobacco control; providing a basis for the review of legislation to control advertising, sales, promotion, graphic pack health warnings, and enforce pricing and taxation measures.

    Australia

    Australia is a world leader in tobacco control mass media campaigns, taxation and smoke-free environments. In 2012, Australia implemented the world’s first tobacco plain packaging laws, which prohibited branding and promotional text on tobacco packaging and required packs to be ‘drab olive-green’ with large text and graphic health warnings.34 Australia successfully defended these laws against industry challenges and countries acting in the interest of the industry. This success has led to the policy being adopted by 20 other countries35 so far, including New Zealand.

    There has also been a concerted effort to address smoking among Aboriginal and Torres Strait Islander populations through the Tackling Indigenous Smoking Program,36 formerly the Regional Tackling Indigenous Smoking and Healthy Lifestyle Program established in 2010. This was the first significantly resourced, long-term commitment to address Indigenous smoking in Australia with evidence of impact through sizeable reductions in smoking prevalence.37

    Challenges and opportunities for achieving smoke-free status

    Similar tobacco control challenges are faced throughout Oceania, including ongoing tobacco industry interference, as well as distinct country and territory needs and opportunities; reflective of their broader social, environmental, and economic positions and their respective tobacco control journeys.

    Aotearoa New Zealand

    New Zealand has an opportunity to lead the world by implementing an innovative Smokefree 2025 Action Plan.26 However, fully implementing the proposed policy measures will require ongoing government commitment in the face of anticipated efforts to dilute, delay and derail by the tobacco industry and its allies. Comprehensive tobacco control infrastructure urgently needs to be strengthened including, but not limited to, enhanced mass media and cessation support, and strengthened governance and leadership (especially Māori governance and leadership), compliance monitoring and enforcement, and evaluation and research.

    Australia

    Australia has often had bipartisan political support for strong tobacco control measures, but new tobacco control policies in the last decade have been mainly limited to annual tax increases. To offset political complacency, investment is still needed in tobacco control including national mass media campaigns, whole of government, and targeted approaches to address inequities and bolder policy and legislative reform.38 39 Reaching the Draft National Preventive Health Strategy’s proposed target of less than 5% smoking prevalence by 203040 will require a range of measures such as those outlined in the draft strategy and those being considered in New Zealand. Reducing tobacco supply and availability and regulating the contents of tobacco products have been flagged for implementation over the next 10 years.38 39 The Australian tobacco control community must unite and advocate strongly for such measures. However, progress in Australia risks being stalled by a preoccupation with the vaping debate,41 which while important, can divert attention from taking the necessary strong evidence-based action on combustible tobacco products.

    Pacific Island Countries and Territories

    Tobacco use is a major driver of the burgeoning NCD crisis in the PICTs.42 Tobacco control implementation is highly variable in and between countries, with gaps in core FCTC measures and challenges to policy implementation due to under-resourced legislative capacity. Competing priorities, such as COVID-19, climate change, re-emerging infectious diseases and a climate of economic volatility, divert attention from tobacco control. Tobacco industry interference is also widespread43 44 with evidence indicating more sophisticated approaches being undertaken by the industry.31 Building and retaining a public sector workforce with the technical skills of tobacco control (especially Article 5.3) required to gather and maintain momentum towards full FCTC implementation, especially given competing priorities, remains a widespread challenge.

    Discussion

    We have described a number of successes across Oceania; however, few countries have comprehensive tobacco control strategies and there are numerous gaps in FCTC implementation particularly in PICTs. In the mid to long term, the COVID-19 pandemic response (surveillance and cooperation) could bolster tobacco control efforts via clear leadership, reinvigorated bilateral and multilateral arrangements (eg, the Polynesian Health Corridors45), strengthening the healthcare system and improved public health capacity. Progress in tobacco control is closely aligned with growing Pacific leadership, within and outside government, to continue to invest in a strategic, evidence-based, regional approach to tobacco control.

    This work has started with the Oceania Tobacco Control Conferences, the establishment of the Oceania Chapter of SRNT, and more recently a significant effort by Indigenous tobacco control researchers within the Oceania region to reinvigorate the global Indigenous Tobacco Control Network.46 However, much of this effort is carried out by the tobacco control sector with limited resources; more can and should be done by governments, particularly the Australian and New Zealand governments, through regional investment to support tobacco control in PICTs. Further, to avoid colonising attitudes to tobacco control development, the focus for this support should be on sustainable capacity and capability building with local leadership and decision-making a priority to reduce tobacco use and improve health outcomes.

    Conclusion

    Achieving a smoke-free Oceania will have an enormous impact on improving health and well-being. This paper identifies the somewhat sporadic and incremental progress in tobacco control, and the challenge of an active and well-resourced tobacco industry, alongside other impediments to effective tobacco control implementation. To achieve equitable health outcomes across Oceania and full implementation of the FCTC, we need to harness our strengths; bold country and regional smoke-free goals, excellent tobacco control leadership, experience and resources. The collective resources of the region are essential to bolster cross-sector technical support that grows and retains country capacity. As depicted in this Māori whakatauki (proverb), everyone has something to offer and by working together we can all flourish. Nāu te rourou, nāku te rourou, ka ora ai te iwi.

    What this paper adds

    • This report collates tobacco control data and information across the Oceania region.

    • This paper identifies the somewhat sporadic and incremental progress in tobacco control, and the challenge of an active and well-resourced tobacco industry, alongside other impediments to effective tobacco control implementation.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This paper was commissioned and reports on high-level strategic public policy.

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    Footnotes

    • Twitter @Jude.McCool, @CoralGartner, @RaglanMaddox

    • Contributors The lead author HG was invited to submit the article. E-ST, CEG, JPM, RE and RM contributed to all aspects of the article development including original content and revisions. HG submitted the article.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Map disclaimer The inclusion of any map (including the depiction of any boundaries therein), or of any geographic or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.

    • Competing interests None declared.

    • Provenance and peer review Commissioned; externally peer reviewed.