Recently we asked a group of Christchurch medical students to estimate how much money Christchurch Hospital’s surgical unit alone would spend on pharmaceutical aids to facilitate smoking cessation. Medical students have a good understanding of the role of smoking in many medical illnesses such as ischaemic heart disease, peripheral vascular disease, respiratory diseases, and many others.

We gave background information that in year 2006 the surgical unit identified 2320 patients as being current tobacco users (this is probably an underestimate of the real number of current smokers as only 59–83% are identified as smokers in the medical notes). Effective pharmaceuticals for the treatment of tobacco dependence are available—nicotine replacement therapies [NRTs] bupropion, nortriptyline, varenicline—and most are priced at a cost of approximately a ‘packet of cigarettes’ a day (NZ$7–$10/day).1

“One million dollars!” was the first estimate. This was corrected by other students with estimates between $500,000 and $800,000.

In fact, $759.60c is the total amount of money that surgical services spent on pharmacological treatments, in particular nicotine patches, during the financial year of 2005/06. The pharmacological expenditure during the same time period was $648,320.33c for the surgical service alone. We do point out, however, that the medical services didn’t perform much better: 2916 patients were identified as smokers in internal medicine, and only $5,075.68c was spent on NRT. Indeed, hospital services are spending nowhere near enough money to meet the smoking cessation needs of their patients.

How does New Zealand compare to other countries in measures of tobacco control? New Zealand can take pride in being mentioned positively by the World Health Organization (WHO) as having legislation ensuring a smoke-free workplace in public bars, clubs, restaurants, and school grounds:2

Also leading is the Ministry of Health initiative Clearing the Smoke – A five-year plan for tobacco control in New Zealand (2004–2009):

Although the prevalence of smoking in New Zealand is lower than in England, Germany, and most European countries, the prevalence of smokers in New Zealand is higher than in Sweden, California, and Australia. This may improve over the next few years, however, with the announcement of further injections in total $43.6 million in addition to the $27 million spent yearly on tobacco control. The New Zealand Government is earning approximately $900 million per annum from tobacco tax.

This issue of the Journal contains some excellent articles on New Zealand initiatives addressing issues of tobacco control. The article of Judy Li and Michele Grigg reports on the smoking cessation success rate of the New Zealand Quitline users between 2001 and 2005.4

Quitline is a government-funded initiative, with an excellent international reputation. In November 2000 it become a world-first in providing heavily subsidised NRT in the form of patches and gum as an adjunct to its telephone smoking cessation service. This is an example of an excellent world-leading government-funded anti-smoking initiative which should be celebrated by all New Zealanders.

The proportion of Māori callers remained at status quo, at approximately 20% of all new callers. This Quitline data complements the Ministry of Health data,5 which shows:

The figure for the entire 15–19 years age group in New Zealand is 26.8% while the figure for Asian 15–19 year olds is only 6.2%.

Also in this issue of the Journal, Stephanie Erik-Peleti and colleagues from the Pacific Islands Families (PIF) Study interviewed the mothers of a cohort of 1180 Pacific infants born in Middlemore Hospital, South Auckland at 6 weeks and 12 months post-partum.6 They found that 24% of all mothers at 6 weeks smoke and at 12 months 29% of mothers smoked. They found that while 4.4% had managed to stop smoking, 9.6% of mothers resumed smoking during this time period.

They also found that 45% of all patients who continued to smoke lived in a household with another smoker. Building on the experience of the PIF study and from sexual health planning, the non-smoking message may need to be tailored specifically to this section of the New Zealand population, who have the highest smoking prevalence. This will be best achieved in partnership with Māori/Pacific health providers.

This issue of the Journal also contains a passionate viewpoint article by Murray Laugesen of the Smokeless New Zealand Trust who came up with the innovative idea to consider the use of nasal snuff as a method of reducing nicotine craving and thereby cigarette smoking.7

Laugesen’s article quotes experience from Scandinavian countries, where cigarette consumption has reduced by continuing to feed smokers’ nicotine addiction with snuff, without killing people through cigarette smoke. There still may be different views on this issue, in particular seeing the potential societal impact and the unresolved position of nicotine itself as a carcinogen.

Family practitioners and hospital doctors at all levels need to continue to embrace the smoking cessation message. Imagine in today’s setting that significantly elevated blood pressure was discovered in the cohort of 1180 Pacific women described in the PIF Study. (Untreated hypertension may lead to premature ischaemic heart disease and premature strokes.) Every medical officer would have had a strategy to address the hypertension urgently while patients were being admitted to hospital. Indeed, guidelines for blood pressure control are easily available.

At this stage the same urgency is not felt for the smoking cessation message and the management of individuals with nicotine addiction. Guidelines are readily available, but there is not the same urgency to familiarise one’s self with these. Nicotine addiction should be viewed as a chronic condition that requires appropriate intervention. Would a doctor abandon treatment for hypertension, if a patient’s blood pressure remained elevated after introducing one antihypertensive agent? Why abandon smoking cessation intervention after one attempt, when it is well known that smokers need on average five to six attempts before quitting smoking?

Management of the acute nicotine craving of patients admitted to hospital differs from a quit attempt. One may have to acknowledge that NRT must be offered regardless of the individual patient’s commitment (or “readiness”) to a quit attempt. It is not good practice to have hypoxic patients in need of oxygen treatment being taken outside of hospital grounds in a wheelchair to smoke, because one did not consider it to be “worth” providing NRT without the patient having signalled such a commitment. Many smokers are probably under-treated with NRT (if they are fortunate enough to be offered that intervention)—an offence worsened when ongoing craving is interpreted as nicotine overdose.

We appeal to all doctors to make it part of their clinical practice to not only check for blood pressure control, warfarinisation for atrial fibrillation, or cholesterol management, but also to address smoking cessation in patients under a doctor’s care.

The issue of smoking cessation also has a significant political dimension. It is very concerning to know that from one of New Zealand’s major migrant populations we 9% of young Pacific mothers resumed smoking within a year after the birth of a child. Furthermore, it should concern New Zealand policymakers that the smoking cessation message is not meeting the needs of New Zealand’s indigenous Māori population. By addressing these issues, in partnership with Māori health providers, New Zealand has the potential to regain its leading position in the world on prioritising indigenous health.

In the meantime, all health professionals must show a commitment to the issue of smoking cessation initiatives and tobacco control by acquiring the relevant knowledge and skills; and by influencing hospital managers, district health board CEOs, and policymakers to continue to make further gains across the entire health sector.

Author information: Lutz Beckert, Roland Meyer; Respiratory Physicians; Respiratory Medicine, Christchurch Hospital, Christchurch

Correspondence: Lutz Beckert, Respiratory Physician, Christchurch Hospital, PO Box 4345, Christchurch 8011. Fax: (03) 364 0193; email: Lutz.Beckert@cdhb.govt.nz