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When Smoke Gets In Your Eyes The Outcome Is Perversity

In 1959 The Platters, an early rock-and-roll era group, released the song Smoke gets in your eyes (first sung in a 1933 Broadway show: ‘Smoke gets in your eyes’.

The song is a sweetly romantic metaphoric song about falling in love and then breaking-up.

The unexpected announcement by Finance Minister Nicola Willis on Newshub Nation (24 November) was neither romantic nor sweet. Nor was it about falling in love. But it was about breaking up: Use tobacco tax income to fund tax cuts.

She proactively stated that the National-New Zealand First-Act government would repeal the Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Act 2022.

It came into force on 1 January this year but implementation is gradually. Its full provisions would take effect by January 2027.

Understanding the 2023 smokefree generation act

Few commentators have been as consistently critical of the Labour government’s handling of the health portfolio as I have. This criticism lies on a continuum between being terrible to being a shocker. There are two important exceptions to this, however.

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The first was its response to the Covid-19 pandemic, at least for the first 18 months. It was world-leading and saved thousands of lives at the time. The vaccine rollout in 2021 was also standout compared with other developed economies.

I discussed this in a BusinessDesk column (15 January 2022): New Zealand’s pandemic response performance

The second was its public (population) health measures. The importance of public health is not always appreciated because it doesn’t involve the treatment of individual patients.

But its prevention focus means that its measures do save many lives and prevent much harm (often quantifiable).

Overwhelmingly the political credit for this should go to infectious diseases specialist and former health minister Dr Ayesha Verrall.

Much of this was when associate health minister and, among other things, led to the adoption of this smokefree generation legislation.

The purpose of the legislation is to create a smokefree generation in Aotearoa New Zealand, something that would be world-leading. It recognises that smoking especially is not about choice; it’s about addiction.

The Act would greatly reduce the number of tobacco retailers, prohibit the sale of tobacco to people born on or after 1 January 2009 (thereby creating a smokefree generation), and provide for nicotine to be reduced to a non-addictive level in tobacco products.

There would also be strong restrictions to control the growing addiction of nicotine based vaping, including removing flavouring and reducing retailers.

However, this should not be confused with prohibition such as the infamous unsuccessful attempt with alcohol in the United States (1920-33).

There is no comparison. Instead it is about the creation over time of a smokefree generation by increasing annually the legal age to smoke by one year.

In other words, under the graduated implementation of the 2009 pivot, my children would not be part of a smokefree generation but my grandchildren would.

In September 2022 I discussed this substantial reform in the context of the bill that led to the act in both BusinessDesk and my health systems blog Otaihanga Second Opinion.

The respective links are: Grocery product that kills when used as intended (25 September) and What drives improved health outcomes (26 September).

The stark difference between the legislation currently in force and the decision to repeal it is that while the former is evidenced-based, the latter is not.

Publicly expressed alarm

Media coverage of this extraordinary situation has been immense. There has been a very strong reaction from health professionals (and their associations) and relevant non-government organisations such as the Asthma Foundation and those involved in Māori health.

Veteran NZ Herald political reporter Audrey Young provided an astute analysis of the politics of the decision (28 November): Smokefree delivers Prime Minister Chris Luxon’s first lesson in political accountability.

There have also been powerful critiques from those with a high level of health system experience. One example is Sir Collin Tukuitonga, a medical specialist and former deputy-director general of health.

As a leading Pasifika doctor he slammed the repeal decision in the NZ Herald: (28 November): Most vulnerable will suffer if smokefree law is repealed.

Stuff reported Māori health experts similarly condemning this decision (27 November): Most vulnerable to pay price for tax cuts cushioning the wealthiest.

On 1 December  Chris Bullen, Professor of General Practice and Primary Healthcare, had a firmly expressed paywalled column published by The PostGlobal reputation going up in smoke.

Unsurprisingly there was also the inevitable satire beginning with Tony Manhire in The Spinoff (30 November): Cigarettes rain on Luxon honeymoon. Seven days later Stuff provided its Donald Trump take-off: Make cancer great again.

International reaction

In fact, there has been extensive international coverage of the repeal decision, none of which does favours for the Government’s commitment to a smokefree New Zealand.

This began with The Guardian (27 November): New Zealand scraps world-first ‘generation ban’ to fund tax cuts.

The following day the NZ Herald usefully summarised some of the more prominent international reactions: Shock smokefree law repeal makes headlines all over the world

Then there was the British Medical Journal (28 November; paywalled): Profits before health. There is also an international petition being organised opposing repeal, which is also actively supported by the World Medical Association.

Now for the ‘heavy lifting’ analysis

New Zealand is fortunate to have the newly established Public Health Communication Centre (PHCC) hosted by the University of Otago Medical School including its Wellington and Christchurch clinical schools.

PHCC’s objective is to increase the reach and impact of public health research by making it more accessible to the public and decision-makers.

Its main publication, The Briefing, is commendably evidence-based and written for both lay and academic readerships. It is worthy of becoming a subscriber (at no charge).

On 30 November The Briefing explaining the evidence-based foundation of this world-leading smokefree legislation: Smokefree legislation is evidence-based; removing it is not.

After citing peer reviewed literature, the extent of benefit is identified. With 5,000 deaths every year from diseases caused by smoking it notes that:

Modelling suggests that the new legislation would save thousands of lives, particularly by reducing the heavy burden smoking places on Māori. Deaths from smoking are predicted to reduce by 1170 (463 among Māori) within 10 years and by 8150 (2811 among Māori) over 20 years (with 95% uncertainty for the 8150 value being: 6450 to 9890).

Over time, as smoking prevalence falls, the number of lives and health care costs saved, will increase greatly. However, repealing the legislation will cause more deaths, more preventable cancers and other serious diseases, more healthcare costs, and more suffering among families bereft of loved ones.

It responds to the Government’s two justifications for repealing this legislation, aside from funding tax cuts for better-off New Zealanders.

First, increased ram raids, which ironically are presently declining. No evidence is offered. However, reducing  the number of retail outlets and denicotinising cigarettes would make them less accessible and less appealing.

Second, fuelling a black market. This has been a common claim by the tobacco industry in response to earlier anti-smoking measures, such as increasing the tobacco tax and plain packaging.

But these claimed black markets never materialised. Evidence also suggests that smokers have little interest in illicit tobacco.

The Briefing also analysed the economic benefits of the legislation (and costs of repeal) in general terms. These are dealt with more specifically in the following issue (4 December): Major economic gains of threatened smokefree legislation.

Its analysis factors in the Smokefree Action Plan which was required to be established by the Act. This Plan is has been finalised and was supported by the National Party when in opposition.

On 6 December, The Briefing reported on the implications of an international survey of younger people (16-29 years) on being smokefree: Young New Zealanders want a tobacco-free future.

Overwhelmingly the 3,414 respondents supported it. Reducing tobacco outlets was supported by 78%; denicotinisation was supported by 68%; and 79% supporting having a smokefree generation.

Finally (to date), on 11 December, by drilling down beyond the soundbites, The Briefing contrasted the process for introducing the smokefree legislation (transparent and evidence-based) with the process for repealing it (untransparent and without evidence).

Consequently it convincingly argued that the Government has no mandate for repeal: Stubbing out democracy.

Enter British Medical Journal editorial

On 8 December the British Medical Journal published a paywalled editorial strongly critical of the move to repeal the smokefree generation act describing it as an “unconscionable blow to the health and wellbeing of all New Zealanders”: New Zealand reverses landmark tobacco controls.

There are two co-authors. The first is Martin McKee, Professor of European Public Health at the London School of Hygiene and Tropical Medicine and a director of the Brussels’ based European Observatory on Health Systems and Policies. He is also a past-president of the British Medical Association.

Professor McKee is familiar with New Zealand’s health system and has visited here several times. This  includes three times brought over by the Association of Salaried Medical Specialists when I was its executive director.

The second co-author is Nicholas Hopkinson, Professor of Respiratory Medicine at London’s Imperial College.

Among their astute observations are:

  • “Smoking is both uniquely lethal and a key driver of health inequality worldwide.”
  • “Much of the momentum for decisive action to eliminate tobacco came from Māori leaders….Tobacco was introduced by European colonists, so smoking and the tobacco industry are seen as manifestations of colonisation.”
  • “Most of the opposition to the legislation came from the tobacco industry, its front groups and allies.”
  • Increasing tobacco tax revenue to fund tax cuts “…ignores direct costs of smoking to societies through increased spending on healthcare and social care, as well as reduced productivity, which substantially exceed tax revenue.”
  • “The libertarian ideology beyond this decision also derives from a meagre view of freedom – one that ignores loss of the positive freedom for individuals to live a long life free from preventable disability….It also ignores the loss of freedom that comes from being subject to an addiction that typically starts in childhood.”

Where does this leave the health minister

Where this leaves the new health minister Dr Shane Reti, a general practitioner and Harvard graduate, is discussed in a paywalled article by Martin Johnston published in New Zealand Doctor (29 November): National’s bowing to partners and tax needs “appalling”.

Johnston reports that in August, as its then health spokesperson, Dr Reti told a Health Coalition Aotearoa political forum that National mostly agreed with the smokefree legislation.

The only change National would in government would be to prioritise denicotinisation, because that was where the “heavy lifting” of reducing smoking was expected to occur.

National did vote against the bill at its third reading but Dr Reti’s speech on this occasion was consistent with this position.

Dr Reti has defended the government’s repeal decision but it has come across as reluctant support. He was not part of National’s leadership team that negotiated the coalition agreement between the three parties.

However, it is has severely dented his credibility with the health system, especially health professionals.

Overwhelmingly health professionals are shocked and appalled with the repeal decision. There have even been calls for Dr Reti’s resignation, including by some doctors.

The unfortunate thing is that New Zealanders desperately needs the kind of political leadership that understands how the current protracted crisis that their health system has been thrust into. Without this leadership the crisis continues.

Of all the MPs in the new parliament, Dr Reti is the closest to having a practical understanding of what is required to provide this breakthrough.

Indications are that he grasps the critical issues of leadership culture, vertical centralisation and workforce shortages.

But the huge ‘dead rat’ he has been required to swallow makes this difficult task even more difficult. This is why it is imperative he should not resign.

Uneasy connections

At least Dr Reti now does not have to deal with the smokefree repeal issue. This has been delegated to first-time NZ First MP and associate minister Casey Costello.

But this raises other questions. Defending the repeal decision in Parliament on 7 December, without evidence, she claimed that the legislation’s provisions would have significant unintended consequences and are a “pseudo prohibition process”.

This was part of another paywalled Martin Johnston New Zealand Doctor article the following day which focused on alleged tobacco connections: Government questioned on tobacco industry influence.

Costello had been on the Board of the right-wing Taxpayers Union, including as acting chair, from 2021 to 2023. She denied any knowledge of the organisation receiving tobacco industry funding.

The uneasiness is not just that her defence of legislative repeal resembled a tobacco industry soundbite. 

On 24 January 2019 Newsroom investigative journalist Sam Sachdeva reported that the Taxpayer Union did receive funding from ‘Big Tobacco’: Taxpayers Union backed by tobacco giant.

This support led to ‘payback time’. In the journalist’s words:

The Taxpayers’ Union has repeatedly criticised annual rises to the tobacco excise tax, arguing smokers had become a “political punching bag” for tax hikes which did not reduce smoking rates.

Winners and losers

In many conflicts outcomes are achieved by finding an acceptable middle ground. No so in this case; just winners and losers, at least if the repeal of the smokefree generation legislation proceeds.

Winners

  • Tobacco companies.
  • NZ First (especially) and ACT.
  • Taxpayers Union.

Losers

  • Nicotine-generated cancer patients and their families.
  • Overworked health professionals struggling to treat and save lives.
  • Overstretched health system including public hospitals.
  • Shane Reti (his job to resolve the health crisis made much more difficult).

Perversity

Overwhelmingly for health professionals and their professional bodies consider the repeal decision to be an issue of perversity.

It is the perversity of reversing the opportunity to achieve a smokefree generation in Aotearoa. It is the perversity of reversing measures that would significantly reduce nicotine addiction, especially among those more vulnerable.

And it is the perversity of using fatal addiction largely of those on low incomes, disproportionately Māori,  to fund tax cuts benefiting most those on high incomes.

Smoke did get in the eyes of New Zealand’s new government and there has been a breaking up: that is, between it and the health system, especially the health professionals who hold it together.

This is highlighted by the resignation of Sir Collin Tukuitonga from the several government advisory boards as a vote of no confidence in the Government’s repeal decision: No confidence in government.

Given his high credibility this is a powerful message to both the health system and its political masters.  

This ‘smoky breakup’ makes the unenviable task of the new health minister providing the political leadership necessary for the health system out of its protracted and worsening crisis so much more difficult.

All the important for Shane Reti to prioritise and get on with it.

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