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Tobacco affordability in New ZealandThe affordability of tobacco products is a major determinant of smoking prevalence in New Zealand,1-3 as it is elsewhere in the world.4,5Tobacco affordability reflects a combination of tobacco product prices and levels of consumer disposable incomes.6 Affordability is particularly important for children and youththe cheaper the price of tobacco, the more likely children and youth are likely to start smoking.7,8 It is also important for those on low incomes, with tobacco price increases reducing both smoking prevalence and tobacco consumption far more for those on low incomes compared to those on medium and high incomes.9,10In New Zealand, tobacco product prices are largely determined by the level of tobacco taxation (about 70% of the price is tobacco tax or GST).11 However, tobacco companies and retailers can also affect the price. For example, in July 2009, British American Tobacco and Imperial Tobacco reduced the prices for several of their brands in New Zealand.12 Public health and other organisations in New Zealand and elsewhere have argued that tobacco taxes should be increased, in order to reduce smoking prevalence and tobacco consumption.13,14The Framework Convention on Tobacco Control Treaty, which New Zealand has ratified, states that countries: ...should take account of its national health objectives concerning tobacco control and adopt or maintain, as appropriate, measures which may include: (a) implementing tax policies and, where appropriate, price policies, on tobacco products so as to contribute to the health objectives aimed at reducing tobacco consumption.15 Trends in tobacco consumption and real cigarette prices To inform discussions around appropriate tobacco tax levels, we examined the rates of per capita (15 years plus) tobacco consumption and the real cigarette prices, from 1975 to 2008. For detail on the data sources for real tobacco prices and consumption, see pp.25-6 of our 2007 report,11 and Table A.2 of the report Volume 2. In this work consumption is measured by the manufactured cigarettes and loose tobacco released by tobacco companies from bond. For cigarette consumption, one gram of loose tobacco is counted as one cigarette. There can be some year to year trend variations, if there are fluctuations in tobacco product releases close to the start or end of a data year. Figure 1 shows the change in the real price (adjusted for inflation) of cigarettes against per capita consumption of manufactured and roll-your-own (RYO) cigarettes. The results indicate two key points. The first is that from 1975 to 1984, while the real price was very stable, there was a considerable decline in per capita consumption, from 3168 to 2724 cigarettes a year. This decline occurred before most established evidence-based tobacco control interventions were implemented in New Zealand, and suggests that during that period other factors, such as increasing information about health risks in the mass media, were sufficiently compelling for some groups to prompt quitting and reductions in the amount smoked. The second key point is the reciprocity of price and consumption since 1984. When the real price rose, consumption fell markedly. For example, between 1988 and 2001 the real price of cigarettes more than doubled, and per capita consumption approximately halved. However, when the price was stable, per capita consumption was also fairly stable; see for example the periods between 1992-1997 and 2002-2008. The real price of tobacco products in New Zealand has changed little since the last tobacco tax rise (beyond inflation), in 2000. Furthermore, because of rising average real incomes, the affordability of tobacco products has effectively been increasing over this time period, despite the annual inflation adjustment in the tobacco tax rate.11pp.45-46 Figure 1. Real cigarette prices and per capita tobacco consumption, 1975-2008* *Consumption is from tobacco released from bond data, and includes both RYO and factory made cigarettes. Scale is the same for both series. Real cigarette prices are expressed relative to all groups consumer price index (June 1999 = 1000). Measuring the effects of tobacco control Besides tobacco consumption, a more widely used measure of smoking at the population level is adult smoking prevalence. Some survey (self-reported) data indicate that daily smoking rates fell 5% in absolute terms between 2003 and 2007.16 However, this may be misleading, and may reflect that as smoking becomes less normalised, smokers are increasingly giving socially desirable responses to survey questions and stating that they are non-smokers. This can result in an increasing underestimate of true smoking prevalence over time.17 The lack of decline in per capita consumption during this period supports this explanation. There are also some potential problems with the use of annual consumption measures. For example, these could be distorted by higher or lower releases at the beginning or end of the measurement year, or prior to implementation of interventions like tax and duty changes; or due to changes in stock ordering and invoicing procedures. However, these are unlikely to result in systematic bias over long periods of time, and so should not distort observed trends. Hence, for multi-year periods, per capita consumption, measured through cigarettes and tobacco released to the market, may be a more robust measure of overall levels of smoking in the New Zealand population. The consequences of stable tobacco prices The stability of capita tobacco consumption (and possibly adult smoking prevalence) since 2002 suggests that tobacco control activities in New Zealand have been undercut by increased tobacco affordability, due to the failure to increase real cigarette prices. It further suggests that all the other tobacco control interventions introduced during this period in New Zealand besides tax (e.g., graphic health warnings, extension of the smokefree indoor workplaces legislation, mass media campaigns, and enhanced smoking cessation assistance) have been needed just to keep per capita tobacco consumption stable. The tobacco control spending and efforts appear to be running hard just to maintain the status quo. Do smokers and non-smoking New Zealanders want tobacco taxes to stay unchanged in real terms? There is public (combined smoker and non-smoker) support for a tobacco tax increase, provided the extra revenue raised is used to help smokers. For example, in a 2008 national survey of over 1600 people, 64% agreed with the statement Tax on cigarettes and tobacco should be increased and all the extra money used to help smokers wanting to quit.18 The data about smokers views is more mixed. In the same survey, only 30% of current smokers agreed with this statement (46% of those who had made two or more quit attempts).18 However, in another national survey of over 1300 smokers and recent quitters in 2007-8, almost 60% supported an increase in tobacco tax, if all the extra revenue was used to promote healthy lifestyles, including helping smokers wanting to quit.19 The need for government action on tobacco affordability The possibility of raising alcohol taxation levels has currently been raised by the Law Commission.20 The government could take this opportunity to also review tobacco taxation, and to put in place an effective health-driven tobacco price strategy that extends beyond episodic and ad-hoc revenue raising decisions. Besides the overall tobacco tax rates, there is the urgent need to consider the relative cheapness of RYO tobacco, because smoking thinner RYO cigarettes is cheaper and provides an alternative to quitting.21 Over 80% of New Zealand RYO smokers give lower cost as a reason for their RYO preference, with this being the most common reason given.22 RYO cigarettes are also more likely to be used by young smokers, due to the lower cost,23 with 69% of smokers aged 15-19 smoking RYO.24 In 2008, 12% of New Zealand year 10 students were regular smokers (and 31% of M ori girls).25 Of these regular smoking students, 57% (68% of M ori) usually smoked RYO.26 New Zealand smokers regret starting smoking and want to quit,27,28 with over 60% attempting to quit over a five year period.24 They need far more help. For instance, the Quitline and its associated media work, (the most prominent cessation intervention by government) results in less than 10% of smokers contacting the Quitline annually.29 Less than 5% of tobacco tax revenue in New Zealand is used for preventing the tobacco problem. There are strong practical arguments for a much greater proportion of the revenue being used for prevention.30 Extra tobacco tax revenue could help pay for more prime-time mass media campaigns and greater Quitline capacity.31 Furthermore, there are strong ethical grounds for all tobacco tax revenue to be used to help smokers quit.32 Decisions about tobacco tax rates should be informed by the evidence that tobacco smoking is highly addictive.33,34 The addiction causes a huge burden of avoidable disease, disability, premature death,23,35 and economic costs.36 Tobacco use is a major contributor to health inequalities in New Zealand, with M ori and those on low incomes particularly affected.37-39 In terms of life lost, the harm to populations on low incomes from tobacco tax rises, due to increased economic hardship among continuing smokers, is far less than the gains from quitting and reducing smoking.40 Households where smokers quit as a result of a tax increase experience considerable financial gains (in 2007 calculated as about $2200 per year on average).11 Real increases in tobacco product prices are a highly effective public health measure to reduce smoking uptake and consumption, and to increase smoking cessation.4,7 The revenue raised by tobacco tax increases represents an opportunity to fund support for smokers to quit, and other interventions to reduce smoking. Successive governments have refused to institute a long term tobacco tax plan, with regular above inflation tax increases.11 This represents a failure to implement evidence-based policy, which has resulted in repeated missed opportunities to reduce smoking and save lives. This failure also means that tax-payers are not getting full value-for-money from government expenditure on tobacco control. These failures have contributed to the continuing high death toll from the tobacco epidemic, the persistence of youth smoking, and result in a continuing tobacco epidemic which kills over 4000 New Zealanders every year,23 and causes and exacerbates health inequalities.37

Summary

Abstract

Tobacco affordability, prices and tobacco tax rates have considerable effects on smoking uptake, consumption, and quitting. We examined the trends in New Zealand per capita tobacco consumption and real cigarette prices from 1975-2008. Since 1984, there has been a close inverse relationship between real price and per capita tobacco consumption. Thus price increases drive consumption falls. However, in the periods of 1992-1997 and 2002-2008, both price and consumption were largely stable. The stability since 2002 means other tobacco control interventions have been undercut by increased tobacco affordability (due to increased average real incomes). Furthermore, the lack of tobacco tax increases (to be used to fund better tobacco control) is against majority surveyed New Zealand public opinion, and may be contrary to even smokers views. The great majority of smokers, who want to quit, could be assisted by more extensive programmes funded by the extra revenue from tobacco tax increases. These could include more prime-time mass media campaigns and greater Quitline capacity. Tobacco tax increases are a highly evidence-based policy that could help reduce harm to the health of New Zealanders and reduce health inequalities.

Aim

Method

Results

Conclusion

Author Information

George Thomson, Des ODea, Nick Wilson, Richard Edwards; Public Health Researchers; Department of Public Health, University of Otago, Wellington

Acknowledgements

This work had funding support from the Health Research Council of New Zealand (the Smokefree Kids Policy Project and the ITC Project (NZ arm)).

Correspondence

George Thomson, Department of Public Health, University of Otago, Box 7343 Wellington, New Zealand

Correspondence Email

george.thomson@otago.ac.nz

Competing Interests

Although we do not consider it a competing interest, for the sake of full transparency we note that all of the authors have undertaken work for health sector agencies working in tobacco control.

Wilson N, Thomson G. Tobacco tax as a health protecting policy: a brief review of the New Zealand evidence. N Z Med J. 2005;118;1213:U1403.Wilson N, Thomson G, Edwards R. Use of four major tobacco control interventions in New Zealand: a review. N Z Med J. 2008;121;1276:71-86.Wilson N, Thomson G, Edwards R. What's new in tobacco tax research for New Zealand and is it time for a tax hike now? N Z Med J. 2009;122;1293:89-92.Jha P, Chaloupka FJ, Corrao M, Jacob B. Reducing the burden of smoking world-wide: effectiveness of interventions and their coverage. Drug Alcohol Rev. 2006;25:597-609.Ranson MK, Jha P, Chaloupka FJ, Nguyen SN. Global and regional estimates of the effectiveness and cost-effectiveness of price increases and other tobacco control policies. Nicotine Tob Res. 2002;4:311-9.Blecher E, van Walbeek C. Cigarette affordability trends: an update and some methodological comments. Tob Control. 2009;18:167-75.Liang L, Chaloupka F, Nichter M, Clayton R. Prices, policies and youth smoking, May 2001. Addiction. 2003;98 Suppl 1105-22.Ding A. Curbing adolescent smoking: a review of the effectiveness of various policies. Yale J Biol Med. 2005;78:37-44.Gallet CA, List JA. Cigarette demand: a meta-analysis of elasticities. Health Econ. 2003;12:821-35.Siahpush M, Wakefield MA, Spittal MJ, et al. Taxation reduces social disparities in adult smoking prevalence. Am J Prev Med. 2009;36;4:285-91.ODea D, Thomson G, Edwards R, Gifford H. Tobacco Taxation in New Zealand. Wellington: Smokefree Coalition and ASH NZ; November 2007 http://www.uow.otago.ac.nz/academic/dph/research/heppru/research/TobTaxVolOneNovemberUnTracked%2011-07.doc.Hotton M. Tobacco giant says price cuts legal. Southland Times 4 July 2009.Jha P, Chaloupka F. Curbing the epidemic: governments and the economics of tobacco control. Washington DC: World Bank; 1999.Smokefree Coalition. Smokefree Coalition submission to the Finance and Expenditure Committee on the Budget Policy Statement 2007. Wellington: Smokefree Coalition; January 2007. Accessed 5 August 2009: http://www.sfc.org.nz/pdfs/sfcbudgetsub2007.pdfWorld Health Organization. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003. Accessed 5 August, 2009: http://www.who.int/tobacco/framework/WHO_FCTC_english.pdfMinistry of Health. A portrait of health: Key results of the 2006/07 New Zealand Health Survey: Appendix 6. Wellington: Ministry of Health; June 2008. Accessed September 8, 2008: http://www.moh.govt.nz/moh.nsf/pagesmh/7690/$File/a6-ch2-adult.xlsLaugesen M. Has smoking prevalence markedly decreased despite more cigarettes released for sale? N Z Med J. 2009;122;1290:76-82.National Research Bureau. Health Sponsorship Council 2008 health and lifestyles survey: Tables of results. Auckland: National Research Bureau; June 2008.Wilson N, Edwards R, Weerasekera D, Thomson G. Most Smokers Support a Dedicated Tobacco Tax Increase (ITC Project: New Zealand). [POS1-3]. Joint Conference of SRNT and SRNT-Europe, Dublin, Ireland; 27-30 April 2009.http://www.wnmeds.ac.nz/academic/dph/research/HIRP/Tobacco/posters/Wilson%20et%20al%202009%20SRNT%20Tax%20poster.pdfNew Zealand Law Commission. Alcohol In Our Lives. Wellington: New Zealand Law Commission; 30 July 2009. Accessed August 3, 2009: http://www.lawcom.govt.nz/ProjectIssuesPaper.aspx?ProjectID=154Laugesen M, Epton M, Frampton C, et al. Hand-rolled cigarette smoking patterns compared with factory-made cigarette smoking in New Zealand men. BMC Public Health. 2009;18:194.Wilson N, Young D, Weerasekera D, et al. The importance of tobacco prices to roll-your-own (RYO) smokers (national survey data): higher tax needed on RYO. N Z Med J. 2009;122;1305:92-6.Ministry of Health. Tobacco Trends 2008: A brief update of tobacco use in New Zealand. Wellington: Ministry of Health; June 2009.http://www.moh.govt.nz/moh.nsf/pagesmh/9081/$File/tobacco-trends-2008.pdfMinistry of Health. New Zealand Tobacco Use Survey 2006. Wellington: Ministry of Health; June 2007.Paynter J. National Year 10 ASH Snapshot Survey, 1999-2008: Trends in tobacco use by students aged 14-15 years [Report for the Ministry of Health, Health Sponsorship Council and Action on Smoking and Health]. Auckland: ASH New Zealand; 2009.Health Sponsorship Council. 2008 HSC Year 10 In-depth Survey Report. Wellington: Health Sponsorship Council; July 2009.Bullen C, Wilson N, Edwards R, et al. Quitting Intentions and Behaviour of Smokers by Ethnicity, Deprivation and Financial Stress. [Poster POS3-54]. Joint Conference of SRNT and SRNT-Europe, Dublin, Ireland; 27-30 April 2009.http://www.wnmeds.ac.nz/academic/dph/research/HIRP/Tobacco/posters/Bullen%20et%20al%20Quitting_Intentions%20-%20Final.pdfWilson N, Edwards R, Weerasekera D. High levels of smoker regret by ethnicity and socioeconomic status: national survey data. N Z Med J. 2009;122;1292:99-100.Quit Group. The Quit Group Quit Service Client Analysis Report: January-December 2008. Wellington: Quit Group; 2009. Accessed 5 August 2009: http://www.quit.org.nz/file/research/Yearly%20Callers%20Report%20200801-200812.pdfThomson G. Dedicated tobacco taxes - experiences and arguments [Report for Smokefree Coalition and ASH NZ]. Wellington: Smokefree Coalition and ASH NZ; November 2007.http://www.uow.otago.ac.nz/academic/dph/research/heppru/research/DedicatedTaxNovember%2007.docBala M, Strzeszynski L, Cahill K. Mass media interventions for smoking cessation in adults. Cochrane Database of Systematic Reviews. 2008;1:CD004704.Wilson N, Thomson G. Tobacco Taxation and Public Health: Ethical Problems, Policy Responses. Soc Sci Med. 2005;61:649-59.Hatsukami DK, Stead LF, Gupta PC. Tobacco addiction. Lancet. 2008;371:2027-38.Benowitz NL. Neurobiology of nicotine addiction: implications for smoking cessation treatment. Am J Med. 2008;121, Suppl 1:S3-10.Bullen C. Impact of tobacco smoking and smoking cessation on cardiovascular risk and disease. Expert Rev Cardiovasc Ther. 2008;6:883-95.Max W. The financial impact of smoking on health-related costs: a review of the literature. Am J Health Promot. 2001;15:321-31.Blakely T, Fawcett J, Hunt D, Wilson N. What is the contribution of smoking and socioeconomic position to ethnic inequalities in mortality in New Zealand? Lancet. 2006;368:44-52.Blakely T, Wilson N. The contribution of smoking to inequalities in mortality by education varies over time and by sex: two national cohort studies, 1981-84 and 1996-99. Int J Epidemiol. 2005;34:1054-62.Ponniah S, Bloomfield A. Sociodemographic characteristics of New Zealand adult smokers, ex-smokers, and non-smokers: results from the 2006 Census. N Z Med J. 2008;121;1284:34-42.Wilson N, Thomson G, Tobias M, Blakely A. How Much Downside?: Quantifying the Relative Harm from Tobacco Taxation. J Epidemiol Community Health. 2004;58:451-4.

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Tobacco affordability in New ZealandThe affordability of tobacco products is a major determinant of smoking prevalence in New Zealand,1-3 as it is elsewhere in the world.4,5Tobacco affordability reflects a combination of tobacco product prices and levels of consumer disposable incomes.6 Affordability is particularly important for children and youththe cheaper the price of tobacco, the more likely children and youth are likely to start smoking.7,8 It is also important for those on low incomes, with tobacco price increases reducing both smoking prevalence and tobacco consumption far more for those on low incomes compared to those on medium and high incomes.9,10In New Zealand, tobacco product prices are largely determined by the level of tobacco taxation (about 70% of the price is tobacco tax or GST).11 However, tobacco companies and retailers can also affect the price. For example, in July 2009, British American Tobacco and Imperial Tobacco reduced the prices for several of their brands in New Zealand.12 Public health and other organisations in New Zealand and elsewhere have argued that tobacco taxes should be increased, in order to reduce smoking prevalence and tobacco consumption.13,14The Framework Convention on Tobacco Control Treaty, which New Zealand has ratified, states that countries: ...should take account of its national health objectives concerning tobacco control and adopt or maintain, as appropriate, measures which may include: (a) implementing tax policies and, where appropriate, price policies, on tobacco products so as to contribute to the health objectives aimed at reducing tobacco consumption.15 Trends in tobacco consumption and real cigarette prices To inform discussions around appropriate tobacco tax levels, we examined the rates of per capita (15 years plus) tobacco consumption and the real cigarette prices, from 1975 to 2008. For detail on the data sources for real tobacco prices and consumption, see pp.25-6 of our 2007 report,11 and Table A.2 of the report Volume 2. In this work consumption is measured by the manufactured cigarettes and loose tobacco released by tobacco companies from bond. For cigarette consumption, one gram of loose tobacco is counted as one cigarette. There can be some year to year trend variations, if there are fluctuations in tobacco product releases close to the start or end of a data year. Figure 1 shows the change in the real price (adjusted for inflation) of cigarettes against per capita consumption of manufactured and roll-your-own (RYO) cigarettes. The results indicate two key points. The first is that from 1975 to 1984, while the real price was very stable, there was a considerable decline in per capita consumption, from 3168 to 2724 cigarettes a year. This decline occurred before most established evidence-based tobacco control interventions were implemented in New Zealand, and suggests that during that period other factors, such as increasing information about health risks in the mass media, were sufficiently compelling for some groups to prompt quitting and reductions in the amount smoked. The second key point is the reciprocity of price and consumption since 1984. When the real price rose, consumption fell markedly. For example, between 1988 and 2001 the real price of cigarettes more than doubled, and per capita consumption approximately halved. However, when the price was stable, per capita consumption was also fairly stable; see for example the periods between 1992-1997 and 2002-2008. The real price of tobacco products in New Zealand has changed little since the last tobacco tax rise (beyond inflation), in 2000. Furthermore, because of rising average real incomes, the affordability of tobacco products has effectively been increasing over this time period, despite the annual inflation adjustment in the tobacco tax rate.11pp.45-46 Figure 1. Real cigarette prices and per capita tobacco consumption, 1975-2008* *Consumption is from tobacco released from bond data, and includes both RYO and factory made cigarettes. Scale is the same for both series. Real cigarette prices are expressed relative to all groups consumer price index (June 1999 = 1000). Measuring the effects of tobacco control Besides tobacco consumption, a more widely used measure of smoking at the population level is adult smoking prevalence. Some survey (self-reported) data indicate that daily smoking rates fell 5% in absolute terms between 2003 and 2007.16 However, this may be misleading, and may reflect that as smoking becomes less normalised, smokers are increasingly giving socially desirable responses to survey questions and stating that they are non-smokers. This can result in an increasing underestimate of true smoking prevalence over time.17 The lack of decline in per capita consumption during this period supports this explanation. There are also some potential problems with the use of annual consumption measures. For example, these could be distorted by higher or lower releases at the beginning or end of the measurement year, or prior to implementation of interventions like tax and duty changes; or due to changes in stock ordering and invoicing procedures. However, these are unlikely to result in systematic bias over long periods of time, and so should not distort observed trends. Hence, for multi-year periods, per capita consumption, measured through cigarettes and tobacco released to the market, may be a more robust measure of overall levels of smoking in the New Zealand population. The consequences of stable tobacco prices The stability of capita tobacco consumption (and possibly adult smoking prevalence) since 2002 suggests that tobacco control activities in New Zealand have been undercut by increased tobacco affordability, due to the failure to increase real cigarette prices. It further suggests that all the other tobacco control interventions introduced during this period in New Zealand besides tax (e.g., graphic health warnings, extension of the smokefree indoor workplaces legislation, mass media campaigns, and enhanced smoking cessation assistance) have been needed just to keep per capita tobacco consumption stable. The tobacco control spending and efforts appear to be running hard just to maintain the status quo. Do smokers and non-smoking New Zealanders want tobacco taxes to stay unchanged in real terms? There is public (combined smoker and non-smoker) support for a tobacco tax increase, provided the extra revenue raised is used to help smokers. For example, in a 2008 national survey of over 1600 people, 64% agreed with the statement Tax on cigarettes and tobacco should be increased and all the extra money used to help smokers wanting to quit.18 The data about smokers views is more mixed. In the same survey, only 30% of current smokers agreed with this statement (46% of those who had made two or more quit attempts).18 However, in another national survey of over 1300 smokers and recent quitters in 2007-8, almost 60% supported an increase in tobacco tax, if all the extra revenue was used to promote healthy lifestyles, including helping smokers wanting to quit.19 The need for government action on tobacco affordability The possibility of raising alcohol taxation levels has currently been raised by the Law Commission.20 The government could take this opportunity to also review tobacco taxation, and to put in place an effective health-driven tobacco price strategy that extends beyond episodic and ad-hoc revenue raising decisions. Besides the overall tobacco tax rates, there is the urgent need to consider the relative cheapness of RYO tobacco, because smoking thinner RYO cigarettes is cheaper and provides an alternative to quitting.21 Over 80% of New Zealand RYO smokers give lower cost as a reason for their RYO preference, with this being the most common reason given.22 RYO cigarettes are also more likely to be used by young smokers, due to the lower cost,23 with 69% of smokers aged 15-19 smoking RYO.24 In 2008, 12% of New Zealand year 10 students were regular smokers (and 31% of M ori girls).25 Of these regular smoking students, 57% (68% of M ori) usually smoked RYO.26 New Zealand smokers regret starting smoking and want to quit,27,28 with over 60% attempting to quit over a five year period.24 They need far more help. For instance, the Quitline and its associated media work, (the most prominent cessation intervention by government) results in less than 10% of smokers contacting the Quitline annually.29 Less than 5% of tobacco tax revenue in New Zealand is used for preventing the tobacco problem. There are strong practical arguments for a much greater proportion of the revenue being used for prevention.30 Extra tobacco tax revenue could help pay for more prime-time mass media campaigns and greater Quitline capacity.31 Furthermore, there are strong ethical grounds for all tobacco tax revenue to be used to help smokers quit.32 Decisions about tobacco tax rates should be informed by the evidence that tobacco smoking is highly addictive.33,34 The addiction causes a huge burden of avoidable disease, disability, premature death,23,35 and economic costs.36 Tobacco use is a major contributor to health inequalities in New Zealand, with M ori and those on low incomes particularly affected.37-39 In terms of life lost, the harm to populations on low incomes from tobacco tax rises, due to increased economic hardship among continuing smokers, is far less than the gains from quitting and reducing smoking.40 Households where smokers quit as a result of a tax increase experience considerable financial gains (in 2007 calculated as about $2200 per year on average).11 Real increases in tobacco product prices are a highly effective public health measure to reduce smoking uptake and consumption, and to increase smoking cessation.4,7 The revenue raised by tobacco tax increases represents an opportunity to fund support for smokers to quit, and other interventions to reduce smoking. Successive governments have refused to institute a long term tobacco tax plan, with regular above inflation tax increases.11 This represents a failure to implement evidence-based policy, which has resulted in repeated missed opportunities to reduce smoking and save lives. This failure also means that tax-payers are not getting full value-for-money from government expenditure on tobacco control. These failures have contributed to the continuing high death toll from the tobacco epidemic, the persistence of youth smoking, and result in a continuing tobacco epidemic which kills over 4000 New Zealanders every year,23 and causes and exacerbates health inequalities.37

Summary

Abstract

Tobacco affordability, prices and tobacco tax rates have considerable effects on smoking uptake, consumption, and quitting. We examined the trends in New Zealand per capita tobacco consumption and real cigarette prices from 1975-2008. Since 1984, there has been a close inverse relationship between real price and per capita tobacco consumption. Thus price increases drive consumption falls. However, in the periods of 1992-1997 and 2002-2008, both price and consumption were largely stable. The stability since 2002 means other tobacco control interventions have been undercut by increased tobacco affordability (due to increased average real incomes). Furthermore, the lack of tobacco tax increases (to be used to fund better tobacco control) is against majority surveyed New Zealand public opinion, and may be contrary to even smokers views. The great majority of smokers, who want to quit, could be assisted by more extensive programmes funded by the extra revenue from tobacco tax increases. These could include more prime-time mass media campaigns and greater Quitline capacity. Tobacco tax increases are a highly evidence-based policy that could help reduce harm to the health of New Zealanders and reduce health inequalities.

Aim

Method

Results

Conclusion

Author Information

George Thomson, Des ODea, Nick Wilson, Richard Edwards; Public Health Researchers; Department of Public Health, University of Otago, Wellington

Acknowledgements

This work had funding support from the Health Research Council of New Zealand (the Smokefree Kids Policy Project and the ITC Project (NZ arm)).

Correspondence

George Thomson, Department of Public Health, University of Otago, Box 7343 Wellington, New Zealand

Correspondence Email

george.thomson@otago.ac.nz

Competing Interests

Although we do not consider it a competing interest, for the sake of full transparency we note that all of the authors have undertaken work for health sector agencies working in tobacco control.

Wilson N, Thomson G. Tobacco tax as a health protecting policy: a brief review of the New Zealand evidence. N Z Med J. 2005;118;1213:U1403.Wilson N, Thomson G, Edwards R. Use of four major tobacco control interventions in New Zealand: a review. N Z Med J. 2008;121;1276:71-86.Wilson N, Thomson G, Edwards R. What's new in tobacco tax research for New Zealand and is it time for a tax hike now? N Z Med J. 2009;122;1293:89-92.Jha P, Chaloupka FJ, Corrao M, Jacob B. Reducing the burden of smoking world-wide: effectiveness of interventions and their coverage. Drug Alcohol Rev. 2006;25:597-609.Ranson MK, Jha P, Chaloupka FJ, Nguyen SN. Global and regional estimates of the effectiveness and cost-effectiveness of price increases and other tobacco control policies. Nicotine Tob Res. 2002;4:311-9.Blecher E, van Walbeek C. Cigarette affordability trends: an update and some methodological comments. Tob Control. 2009;18:167-75.Liang L, Chaloupka F, Nichter M, Clayton R. Prices, policies and youth smoking, May 2001. Addiction. 2003;98 Suppl 1105-22.Ding A. Curbing adolescent smoking: a review of the effectiveness of various policies. Yale J Biol Med. 2005;78:37-44.Gallet CA, List JA. Cigarette demand: a meta-analysis of elasticities. Health Econ. 2003;12:821-35.Siahpush M, Wakefield MA, Spittal MJ, et al. Taxation reduces social disparities in adult smoking prevalence. Am J Prev Med. 2009;36;4:285-91.ODea D, Thomson G, Edwards R, Gifford H. Tobacco Taxation in New Zealand. Wellington: Smokefree Coalition and ASH NZ; November 2007 http://www.uow.otago.ac.nz/academic/dph/research/heppru/research/TobTaxVolOneNovemberUnTracked%2011-07.doc.Hotton M. Tobacco giant says price cuts legal. Southland Times 4 July 2009.Jha P, Chaloupka F. Curbing the epidemic: governments and the economics of tobacco control. Washington DC: World Bank; 1999.Smokefree Coalition. Smokefree Coalition submission to the Finance and Expenditure Committee on the Budget Policy Statement 2007. Wellington: Smokefree Coalition; January 2007. Accessed 5 August 2009: http://www.sfc.org.nz/pdfs/sfcbudgetsub2007.pdfWorld Health Organization. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003. Accessed 5 August, 2009: http://www.who.int/tobacco/framework/WHO_FCTC_english.pdfMinistry of Health. A portrait of health: Key results of the 2006/07 New Zealand Health Survey: Appendix 6. Wellington: Ministry of Health; June 2008. Accessed September 8, 2008: http://www.moh.govt.nz/moh.nsf/pagesmh/7690/$File/a6-ch2-adult.xlsLaugesen M. Has smoking prevalence markedly decreased despite more cigarettes released for sale? N Z Med J. 2009;122;1290:76-82.National Research Bureau. Health Sponsorship Council 2008 health and lifestyles survey: Tables of results. Auckland: National Research Bureau; June 2008.Wilson N, Edwards R, Weerasekera D, Thomson G. Most Smokers Support a Dedicated Tobacco Tax Increase (ITC Project: New Zealand). [POS1-3]. Joint Conference of SRNT and SRNT-Europe, Dublin, Ireland; 27-30 April 2009.http://www.wnmeds.ac.nz/academic/dph/research/HIRP/Tobacco/posters/Wilson%20et%20al%202009%20SRNT%20Tax%20poster.pdfNew Zealand Law Commission. Alcohol In Our Lives. Wellington: New Zealand Law Commission; 30 July 2009. Accessed August 3, 2009: http://www.lawcom.govt.nz/ProjectIssuesPaper.aspx?ProjectID=154Laugesen M, Epton M, Frampton C, et al. Hand-rolled cigarette smoking patterns compared with factory-made cigarette smoking in New Zealand men. BMC Public Health. 2009;18:194.Wilson N, Young D, Weerasekera D, et al. The importance of tobacco prices to roll-your-own (RYO) smokers (national survey data): higher tax needed on RYO. N Z Med J. 2009;122;1305:92-6.Ministry of Health. Tobacco Trends 2008: A brief update of tobacco use in New Zealand. Wellington: Ministry of Health; June 2009.http://www.moh.govt.nz/moh.nsf/pagesmh/9081/$File/tobacco-trends-2008.pdfMinistry of Health. New Zealand Tobacco Use Survey 2006. Wellington: Ministry of Health; June 2007.Paynter J. National Year 10 ASH Snapshot Survey, 1999-2008: Trends in tobacco use by students aged 14-15 years [Report for the Ministry of Health, Health Sponsorship Council and Action on Smoking and Health]. Auckland: ASH New Zealand; 2009.Health Sponsorship Council. 2008 HSC Year 10 In-depth Survey Report. Wellington: Health Sponsorship Council; July 2009.Bullen C, Wilson N, Edwards R, et al. Quitting Intentions and Behaviour of Smokers by Ethnicity, Deprivation and Financial Stress. [Poster POS3-54]. Joint Conference of SRNT and SRNT-Europe, Dublin, Ireland; 27-30 April 2009.http://www.wnmeds.ac.nz/academic/dph/research/HIRP/Tobacco/posters/Bullen%20et%20al%20Quitting_Intentions%20-%20Final.pdfWilson N, Edwards R, Weerasekera D. High levels of smoker regret by ethnicity and socioeconomic status: national survey data. N Z Med J. 2009;122;1292:99-100.Quit Group. The Quit Group Quit Service Client Analysis Report: January-December 2008. Wellington: Quit Group; 2009. Accessed 5 August 2009: http://www.quit.org.nz/file/research/Yearly%20Callers%20Report%20200801-200812.pdfThomson G. Dedicated tobacco taxes - experiences and arguments [Report for Smokefree Coalition and ASH NZ]. Wellington: Smokefree Coalition and ASH NZ; November 2007.http://www.uow.otago.ac.nz/academic/dph/research/heppru/research/DedicatedTaxNovember%2007.docBala M, Strzeszynski L, Cahill K. Mass media interventions for smoking cessation in adults. Cochrane Database of Systematic Reviews. 2008;1:CD004704.Wilson N, Thomson G. Tobacco Taxation and Public Health: Ethical Problems, Policy Responses. Soc Sci Med. 2005;61:649-59.Hatsukami DK, Stead LF, Gupta PC. Tobacco addiction. Lancet. 2008;371:2027-38.Benowitz NL. Neurobiology of nicotine addiction: implications for smoking cessation treatment. Am J Med. 2008;121, Suppl 1:S3-10.Bullen C. Impact of tobacco smoking and smoking cessation on cardiovascular risk and disease. Expert Rev Cardiovasc Ther. 2008;6:883-95.Max W. The financial impact of smoking on health-related costs: a review of the literature. Am J Health Promot. 2001;15:321-31.Blakely T, Fawcett J, Hunt D, Wilson N. What is the contribution of smoking and socioeconomic position to ethnic inequalities in mortality in New Zealand? Lancet. 2006;368:44-52.Blakely T, Wilson N. The contribution of smoking to inequalities in mortality by education varies over time and by sex: two national cohort studies, 1981-84 and 1996-99. Int J Epidemiol. 2005;34:1054-62.Ponniah S, Bloomfield A. Sociodemographic characteristics of New Zealand adult smokers, ex-smokers, and non-smokers: results from the 2006 Census. N Z Med J. 2008;121;1284:34-42.Wilson N, Thomson G, Tobias M, Blakely A. How Much Downside?: Quantifying the Relative Harm from Tobacco Taxation. J Epidemiol Community Health. 2004;58:451-4.

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Tobacco affordability in New ZealandThe affordability of tobacco products is a major determinant of smoking prevalence in New Zealand,1-3 as it is elsewhere in the world.4,5Tobacco affordability reflects a combination of tobacco product prices and levels of consumer disposable incomes.6 Affordability is particularly important for children and youththe cheaper the price of tobacco, the more likely children and youth are likely to start smoking.7,8 It is also important for those on low incomes, with tobacco price increases reducing both smoking prevalence and tobacco consumption far more for those on low incomes compared to those on medium and high incomes.9,10In New Zealand, tobacco product prices are largely determined by the level of tobacco taxation (about 70% of the price is tobacco tax or GST).11 However, tobacco companies and retailers can also affect the price. For example, in July 2009, British American Tobacco and Imperial Tobacco reduced the prices for several of their brands in New Zealand.12 Public health and other organisations in New Zealand and elsewhere have argued that tobacco taxes should be increased, in order to reduce smoking prevalence and tobacco consumption.13,14The Framework Convention on Tobacco Control Treaty, which New Zealand has ratified, states that countries: ...should take account of its national health objectives concerning tobacco control and adopt or maintain, as appropriate, measures which may include: (a) implementing tax policies and, where appropriate, price policies, on tobacco products so as to contribute to the health objectives aimed at reducing tobacco consumption.15 Trends in tobacco consumption and real cigarette prices To inform discussions around appropriate tobacco tax levels, we examined the rates of per capita (15 years plus) tobacco consumption and the real cigarette prices, from 1975 to 2008. For detail on the data sources for real tobacco prices and consumption, see pp.25-6 of our 2007 report,11 and Table A.2 of the report Volume 2. In this work consumption is measured by the manufactured cigarettes and loose tobacco released by tobacco companies from bond. For cigarette consumption, one gram of loose tobacco is counted as one cigarette. There can be some year to year trend variations, if there are fluctuations in tobacco product releases close to the start or end of a data year. Figure 1 shows the change in the real price (adjusted for inflation) of cigarettes against per capita consumption of manufactured and roll-your-own (RYO) cigarettes. The results indicate two key points. The first is that from 1975 to 1984, while the real price was very stable, there was a considerable decline in per capita consumption, from 3168 to 2724 cigarettes a year. This decline occurred before most established evidence-based tobacco control interventions were implemented in New Zealand, and suggests that during that period other factors, such as increasing information about health risks in the mass media, were sufficiently compelling for some groups to prompt quitting and reductions in the amount smoked. The second key point is the reciprocity of price and consumption since 1984. When the real price rose, consumption fell markedly. For example, between 1988 and 2001 the real price of cigarettes more than doubled, and per capita consumption approximately halved. However, when the price was stable, per capita consumption was also fairly stable; see for example the periods between 1992-1997 and 2002-2008. The real price of tobacco products in New Zealand has changed little since the last tobacco tax rise (beyond inflation), in 2000. Furthermore, because of rising average real incomes, the affordability of tobacco products has effectively been increasing over this time period, despite the annual inflation adjustment in the tobacco tax rate.11pp.45-46 Figure 1. Real cigarette prices and per capita tobacco consumption, 1975-2008* *Consumption is from tobacco released from bond data, and includes both RYO and factory made cigarettes. Scale is the same for both series. Real cigarette prices are expressed relative to all groups consumer price index (June 1999 = 1000). Measuring the effects of tobacco control Besides tobacco consumption, a more widely used measure of smoking at the population level is adult smoking prevalence. Some survey (self-reported) data indicate that daily smoking rates fell 5% in absolute terms between 2003 and 2007.16 However, this may be misleading, and may reflect that as smoking becomes less normalised, smokers are increasingly giving socially desirable responses to survey questions and stating that they are non-smokers. This can result in an increasing underestimate of true smoking prevalence over time.17 The lack of decline in per capita consumption during this period supports this explanation. There are also some potential problems with the use of annual consumption measures. For example, these could be distorted by higher or lower releases at the beginning or end of the measurement year, or prior to implementation of interventions like tax and duty changes; or due to changes in stock ordering and invoicing procedures. However, these are unlikely to result in systematic bias over long periods of time, and so should not distort observed trends. Hence, for multi-year periods, per capita consumption, measured through cigarettes and tobacco released to the market, may be a more robust measure of overall levels of smoking in the New Zealand population. The consequences of stable tobacco prices The stability of capita tobacco consumption (and possibly adult smoking prevalence) since 2002 suggests that tobacco control activities in New Zealand have been undercut by increased tobacco affordability, due to the failure to increase real cigarette prices. It further suggests that all the other tobacco control interventions introduced during this period in New Zealand besides tax (e.g., graphic health warnings, extension of the smokefree indoor workplaces legislation, mass media campaigns, and enhanced smoking cessation assistance) have been needed just to keep per capita tobacco consumption stable. The tobacco control spending and efforts appear to be running hard just to maintain the status quo. Do smokers and non-smoking New Zealanders want tobacco taxes to stay unchanged in real terms? There is public (combined smoker and non-smoker) support for a tobacco tax increase, provided the extra revenue raised is used to help smokers. For example, in a 2008 national survey of over 1600 people, 64% agreed with the statement Tax on cigarettes and tobacco should be increased and all the extra money used to help smokers wanting to quit.18 The data about smokers views is more mixed. In the same survey, only 30% of current smokers agreed with this statement (46% of those who had made two or more quit attempts).18 However, in another national survey of over 1300 smokers and recent quitters in 2007-8, almost 60% supported an increase in tobacco tax, if all the extra revenue was used to promote healthy lifestyles, including helping smokers wanting to quit.19 The need for government action on tobacco affordability The possibility of raising alcohol taxation levels has currently been raised by the Law Commission.20 The government could take this opportunity to also review tobacco taxation, and to put in place an effective health-driven tobacco price strategy that extends beyond episodic and ad-hoc revenue raising decisions. Besides the overall tobacco tax rates, there is the urgent need to consider the relative cheapness of RYO tobacco, because smoking thinner RYO cigarettes is cheaper and provides an alternative to quitting.21 Over 80% of New Zealand RYO smokers give lower cost as a reason for their RYO preference, with this being the most common reason given.22 RYO cigarettes are also more likely to be used by young smokers, due to the lower cost,23 with 69% of smokers aged 15-19 smoking RYO.24 In 2008, 12% of New Zealand year 10 students were regular smokers (and 31% of M ori girls).25 Of these regular smoking students, 57% (68% of M ori) usually smoked RYO.26 New Zealand smokers regret starting smoking and want to quit,27,28 with over 60% attempting to quit over a five year period.24 They need far more help. For instance, the Quitline and its associated media work, (the most prominent cessation intervention by government) results in less than 10% of smokers contacting the Quitline annually.29 Less than 5% of tobacco tax revenue in New Zealand is used for preventing the tobacco problem. There are strong practical arguments for a much greater proportion of the revenue being used for prevention.30 Extra tobacco tax revenue could help pay for more prime-time mass media campaigns and greater Quitline capacity.31 Furthermore, there are strong ethical grounds for all tobacco tax revenue to be used to help smokers quit.32 Decisions about tobacco tax rates should be informed by the evidence that tobacco smoking is highly addictive.33,34 The addiction causes a huge burden of avoidable disease, disability, premature death,23,35 and economic costs.36 Tobacco use is a major contributor to health inequalities in New Zealand, with M ori and those on low incomes particularly affected.37-39 In terms of life lost, the harm to populations on low incomes from tobacco tax rises, due to increased economic hardship among continuing smokers, is far less than the gains from quitting and reducing smoking.40 Households where smokers quit as a result of a tax increase experience considerable financial gains (in 2007 calculated as about $2200 per year on average).11 Real increases in tobacco product prices are a highly effective public health measure to reduce smoking uptake and consumption, and to increase smoking cessation.4,7 The revenue raised by tobacco tax increases represents an opportunity to fund support for smokers to quit, and other interventions to reduce smoking. Successive governments have refused to institute a long term tobacco tax plan, with regular above inflation tax increases.11 This represents a failure to implement evidence-based policy, which has resulted in repeated missed opportunities to reduce smoking and save lives. This failure also means that tax-payers are not getting full value-for-money from government expenditure on tobacco control. These failures have contributed to the continuing high death toll from the tobacco epidemic, the persistence of youth smoking, and result in a continuing tobacco epidemic which kills over 4000 New Zealanders every year,23 and causes and exacerbates health inequalities.37

Summary

Abstract

Tobacco affordability, prices and tobacco tax rates have considerable effects on smoking uptake, consumption, and quitting. We examined the trends in New Zealand per capita tobacco consumption and real cigarette prices from 1975-2008. Since 1984, there has been a close inverse relationship between real price and per capita tobacco consumption. Thus price increases drive consumption falls. However, in the periods of 1992-1997 and 2002-2008, both price and consumption were largely stable. The stability since 2002 means other tobacco control interventions have been undercut by increased tobacco affordability (due to increased average real incomes). Furthermore, the lack of tobacco tax increases (to be used to fund better tobacco control) is against majority surveyed New Zealand public opinion, and may be contrary to even smokers views. The great majority of smokers, who want to quit, could be assisted by more extensive programmes funded by the extra revenue from tobacco tax increases. These could include more prime-time mass media campaigns and greater Quitline capacity. Tobacco tax increases are a highly evidence-based policy that could help reduce harm to the health of New Zealanders and reduce health inequalities.

Aim

Method

Results

Conclusion

Author Information

George Thomson, Des ODea, Nick Wilson, Richard Edwards; Public Health Researchers; Department of Public Health, University of Otago, Wellington

Acknowledgements

This work had funding support from the Health Research Council of New Zealand (the Smokefree Kids Policy Project and the ITC Project (NZ arm)).

Correspondence

George Thomson, Department of Public Health, University of Otago, Box 7343 Wellington, New Zealand

Correspondence Email

george.thomson@otago.ac.nz

Competing Interests

Although we do not consider it a competing interest, for the sake of full transparency we note that all of the authors have undertaken work for health sector agencies working in tobacco control.

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Prices, policies and youth smoking, May 2001. Addiction. 2003;98 Suppl 1105-22.Ding A. Curbing adolescent smoking: a review of the effectiveness of various policies. Yale J Biol Med. 2005;78:37-44.Gallet CA, List JA. Cigarette demand: a meta-analysis of elasticities. Health Econ. 2003;12:821-35.Siahpush M, Wakefield MA, Spittal MJ, et al. Taxation reduces social disparities in adult smoking prevalence. Am J Prev Med. 2009;36;4:285-91.ODea D, Thomson G, Edwards R, Gifford H. Tobacco Taxation in New Zealand. Wellington: Smokefree Coalition and ASH NZ; November 2007 http://www.uow.otago.ac.nz/academic/dph/research/heppru/research/TobTaxVolOneNovemberUnTracked%2011-07.doc.Hotton M. Tobacco giant says price cuts legal. Southland Times 4 July 2009.Jha P, Chaloupka F. Curbing the epidemic: governments and the economics of tobacco control. Washington DC: World Bank; 1999.Smokefree Coalition. Smokefree Coalition submission to the Finance and Expenditure Committee on the Budget Policy Statement 2007. Wellington: Smokefree Coalition; January 2007. Accessed 5 August 2009: http://www.sfc.org.nz/pdfs/sfcbudgetsub2007.pdfWorld Health Organization. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003. Accessed 5 August, 2009: http://www.who.int/tobacco/framework/WHO_FCTC_english.pdfMinistry of Health. A portrait of health: Key results of the 2006/07 New Zealand Health Survey: Appendix 6. Wellington: Ministry of Health; June 2008. Accessed September 8, 2008: http://www.moh.govt.nz/moh.nsf/pagesmh/7690/$File/a6-ch2-adult.xlsLaugesen M. Has smoking prevalence markedly decreased despite more cigarettes released for sale? N Z Med J. 2009;122;1290:76-82.National Research Bureau. Health Sponsorship Council 2008 health and lifestyles survey: Tables of results. Auckland: National Research Bureau; June 2008.Wilson N, Edwards R, Weerasekera D, Thomson G. Most Smokers Support a Dedicated Tobacco Tax Increase (ITC Project: New Zealand). [POS1-3]. Joint Conference of SRNT and SRNT-Europe, Dublin, Ireland; 27-30 April 2009.http://www.wnmeds.ac.nz/academic/dph/research/HIRP/Tobacco/posters/Wilson%20et%20al%202009%20SRNT%20Tax%20poster.pdfNew Zealand Law Commission. Alcohol In Our Lives. Wellington: New Zealand Law Commission; 30 July 2009. Accessed August 3, 2009: http://www.lawcom.govt.nz/ProjectIssuesPaper.aspx?ProjectID=154Laugesen M, Epton M, Frampton C, et al. Hand-rolled cigarette smoking patterns compared with factory-made cigarette smoking in New Zealand men. BMC Public Health. 2009;18:194.Wilson N, Young D, Weerasekera D, et al. The importance of tobacco prices to roll-your-own (RYO) smokers (national survey data): higher tax needed on RYO. N Z Med J. 2009;122;1305:92-6.Ministry of Health. Tobacco Trends 2008: A brief update of tobacco use in New Zealand. Wellington: Ministry of Health; June 2009.http://www.moh.govt.nz/moh.nsf/pagesmh/9081/$File/tobacco-trends-2008.pdfMinistry of Health. New Zealand Tobacco Use Survey 2006. Wellington: Ministry of Health; June 2007.Paynter J. National Year 10 ASH Snapshot Survey, 1999-2008: Trends in tobacco use by students aged 14-15 years [Report for the Ministry of Health, Health Sponsorship Council and Action on Smoking and Health]. Auckland: ASH New Zealand; 2009.Health Sponsorship Council. 2008 HSC Year 10 In-depth Survey Report. Wellington: Health Sponsorship Council; July 2009.Bullen C, Wilson N, Edwards R, et al. Quitting Intentions and Behaviour of Smokers by Ethnicity, Deprivation and Financial Stress. [Poster POS3-54]. Joint Conference of SRNT and SRNT-Europe, Dublin, Ireland; 27-30 April 2009.http://www.wnmeds.ac.nz/academic/dph/research/HIRP/Tobacco/posters/Bullen%20et%20al%20Quitting_Intentions%20-%20Final.pdfWilson N, Edwards R, Weerasekera D. High levels of smoker regret by ethnicity and socioeconomic status: national survey data. N Z Med J. 2009;122;1292:99-100.Quit Group. The Quit Group Quit Service Client Analysis Report: January-December 2008. Wellington: Quit Group; 2009. Accessed 5 August 2009: http://www.quit.org.nz/file/research/Yearly%20Callers%20Report%20200801-200812.pdfThomson G. Dedicated tobacco taxes - experiences and arguments [Report for Smokefree Coalition and ASH NZ]. Wellington: Smokefree Coalition and ASH NZ; November 2007.http://www.uow.otago.ac.nz/academic/dph/research/heppru/research/DedicatedTaxNovember%2007.docBala M, Strzeszynski L, Cahill K. Mass media interventions for smoking cessation in adults. Cochrane Database of Systematic Reviews. 2008;1:CD004704.Wilson N, Thomson G. Tobacco Taxation and Public Health: Ethical Problems, Policy Responses. Soc Sci Med. 2005;61:649-59.Hatsukami DK, Stead LF, Gupta PC. Tobacco addiction. Lancet. 2008;371:2027-38.Benowitz NL. Neurobiology of nicotine addiction: implications for smoking cessation treatment. Am J Med. 2008;121, Suppl 1:S3-10.Bullen C. Impact of tobacco smoking and smoking cessation on cardiovascular risk and disease. Expert Rev Cardiovasc Ther. 2008;6:883-95.Max W. The financial impact of smoking on health-related costs: a review of the literature. Am J Health Promot. 2001;15:321-31.Blakely T, Fawcett J, Hunt D, Wilson N. What is the contribution of smoking and socioeconomic position to ethnic inequalities in mortality in New Zealand? Lancet. 2006;368:44-52.Blakely T, Wilson N. The contribution of smoking to inequalities in mortality by education varies over time and by sex: two national cohort studies, 1981-84 and 1996-99. Int J Epidemiol. 2005;34:1054-62.Ponniah S, Bloomfield A. Sociodemographic characteristics of New Zealand adult smokers, ex-smokers, and non-smokers: results from the 2006 Census. N Z Med J. 2008;121;1284:34-42.Wilson N, Thomson G, Tobias M, Blakely A. How Much Downside?: Quantifying the Relative Harm from Tobacco Taxation. J Epidemiol Community Health. 2004;58:451-4.

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