Tobacco endgame intervention impacts on health gains and Māori:non-Māori health inequity: a simulation study of the Aotearoa/New Zealand Tobacco Action Plan
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  • Published on:
    Response to Clive Bates' critism of our article
    • Driss Ait Ouakrim, Senior Research Fellow University of Melbourne
    • Other Contributors:
      • Richard Edwards, Professor
      • Coral Gartner, Professor
      • Andrew Waa, Associate Professor
      • Raglan Maddox, Senior Research Fellow
      • Raymond Lovett, Professor
      • Tony Blakely, Professor


    Clive Bates’ commentary on our paper repeats claims we previously addressed [1]. Here, we address seven points, the first is contextual and the remaining are raised in his letter.

    1. We note the failure of the author to acknowledge Māori perspectives, in particular their support for endgame measures, concerns in relation to harm minimisation [2] as outlined in his “all in” strategy, and ethical publishing of research about Indigenous peoples. [3]

    2. We reject the assertion that the basis of our modelling is “weak”. While there is uncertainty around the potential effect of denicotinisation, as this policy hasn’t been implemented, there are strong grounds to believe that it will have a profound impact on reducing smoking prevalence. This is based on both theory and logic (i.e., nicotine is the main addictive component of cigarettes and why most people smoke), and the findings of multiple randomized controlled trials (RCTs) showing that smoking very low nicotine cigarettes (VLNCs) increases cessation rates for diverse populations of people who smoke [4-7].

    Our model’s estimated effect on smoking prevalence had wide uncertainty, namely a median of 85.9% reduction over 5 years with a 95% uncertainty interval of 67.1% to 96.3% that produced (appropriately) wide uncertainty in the health impacts. The derivation of this input parameter through expert knowledge elicitation (EKE) is described in the Appendix of our paper. Univariate se...

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    Conflict of Interest:
    None declared.
  • Published on:
    Multiple criticisms of this simulation


    I have published a summary critique of this modelling exercise on PubPeer. [1] This summarises concerns raised in post-publication reviews of this paper while it was in pre-print form by experts from New Zealand and Canada, and me. [2][3]

    By way of a brief summary:

    1. All the important modelled findings flow from a single assumption that denicotinisation will reduce smoking prevalence by 85% over five years. Yet the basis for this assumption is weak and disconnected from the reality of the market system being modelled.

    2. The central assumption is based partly on a smoking cessation trial that bears no relation to the market and regulatory intervention that is the subject of the simulation. Even so, the trial findings do not support the modelling assumption.

    3. The central assumption also draws on expert elicitation. Yet, there is no experience with this measure as it would be novel, and there is no relevant expertise in this sort of intervention. Where experts have been asked to assess the impacts, their views diverge widely, suggesting that their estimates are mainly arbitrary guesswork.

    4. The authors have only modelled benefits and have not included anything that might be a detriment or create a trade-off. The modelling takes no account of the black market or workarounds. These are inevitable consequences of such 'endgame' prohibitions, albeit of uncertain size. Though it may be challenging to mo...

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    Conflict of Interest:
    I have no financial or other conflicts of interest with respect to the tobacco, nicotine or pharmaceutical industries. However, I have supported harm reduction approaches to tobacco and in public health more generally for more than 25 years.