The tobacco endgame and correction of socioeconomic health inequity

Ait Ouakrim et al., 2023. Tobacco endgame intervention impacts on health gains and Māori:non-Māori health inequity: a simulation study of the Aotearoa/New Zealand tobacco action plan. Tobacco Control doi:10.1136/tc-2022-057655

British Prime Minister Rishi Sunak received a lot of attention recently when he proposed raising the age at which people could purchase tobacco products by one year every year, but the idea is hardly new. The ‘tobacco-free generations’ concept was first described in 2010, as a way to curb the uptake of smoking.

In Australia, more than three out of four adult males who currently smoke started before they turned 18. Not only does this show the ineffectiveness of current laws aimed at restricting access to tobacco products to adults, but it also highlights the link between starting smoking at a young age and becoming a long-term smoker. Hence, “preventing youth initiation may be the key to ending the tobacco epidemic”.

Existing laws that ban the sale of tobacco products to people over 18 create a ‘rite-of-passage’ effect and send a mixed health message. The tobacco-free generations approach, which restricts the sale of tobacco products only to people born before a specific year, addresses these problems and phases out tobacco supply. Smoking ceases being something associated with ‘coming of age’ and, over time, increasingly becomes identified with the poor health effects that manifest after years of smoking. 

The importance of preventing the uptake of smoking in young people

We often think of lung disease when considering the harms caused by tobacco products. The adage that ‘people smoke for the nicotine but are killed by the tar’ overlooks the potentially damaging effects of nicotine beyond its addictive properties, and this is especially relevant for adolescents.

There is “substantial evidence for long-term negative impact of adolescent nicotine exposure on brain and behaviour”, although most is from studies of experimental animals that may not be directly relevant to humans. However, for example, analysis of data from the United States National Youth Tobacco Survey found that the odds of self-reported “serious difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition” were substantially higher in middle- and high-school students who smoked cigarettes and/or used vapes than in students who did not (the effect of vaping was greater in males than females). 

A new approach to smoking prevention

Protecting the physical and mental wellbeing of young people by implementing the tobacco-free generations approach is part of the New Zealand/Aotearoa strategy to become ‘smoke free’  by 2025, but their approach goes further. The country’s action plan to achieve their goal also includes the restriction of the availability of tobacco products and the de-nicotinisation of tobacco (for example, so that the available amount of nicotine in a cigarette was below an addictive level). These measures target the initiation of smoking and tobacco products themselves, rather than focus on people who smoke (with measures related to advertising, packaging, taxation, smoking restrictions, and services to support cessation).

The Smokefree Aotearoa 2025 Action Plan explicitly targets socioeconomic inequities in smoking rates and harm from smoking. In doing so, it addresses the health disadvantage of Māori people, which stems from their access to social determinants of health and the legacy of colonisation.

How the smoking endgame can improve health inequity

A recent article describes modelling of the effect of the New Zealand/Aotearoa policy on smoking rates and health-adjusted life year (HALY) gains for the country, estimating the relative contributions of each of the three measures (i.e., tobacco-free generations, de-nicotinisation and retail restrictions) compared to a ‘business as usual’ scenario. It shows that the combined measures could reduce smoking rates from around 32% to just over 7% for Māori, and from around 12% to under 3% in non-Māori, in three years. Māori males would achieve the <5% target within four years, and Māori females (the population group with the highest current smoking prevalence), within five years.

Reductions in smoking rates and consequent gains in HALYs are greatest for Māori because of their existing high rates of smoking. And since the burden of disease from smoking is so high in Māori, the benefits of the proposed reforms result in a considerable reduction in the health gap between Māori and non-Māori groups aged 45 years and older: by almost 23% for females and almost 10% for males.

The relative contributions of the three measures in the Smokefree Aotearoa 2025 Action Plan, on smoking rates and HALYs, are quite different. For example, de-nicotinisation has a large and rapid effect on smoking rates, but the tobacco-free generations measure takes years to have a substantial effect. The tobacco-free generations measure alone achieves 13% of the HALY gains, retail restrictions alone achieve 18%, and de-nicotinisation alone achieves 97%, but the majority of the HALY gains are not realised for decades.

The fact that smoking prevalence and harm are tied to socioeconomic factors such as income, location and indigeneity, suggests that tobacco endgame strategies may substantially reduce health inequities while benefiting the health of all population groups. This possibility cannot be realised, though, simply by preventing our children from ever buying cigarettes.