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Tobacco smoking remains a major cause of death and disability around the world, as well as a major contributor to health inequities.[[1]] Many countries have progressively implemented strong tobacco control policies and legislation to protect present and future generations from the considerable health, economic, social, and environmental impacts of tobacco.[[1]] In New Zealand, the Smokefree Environments Act 1990 was passed to “reduce the exposure of people who do not themselves smoke to any detrimental effect on their health caused by smoking by others”[[2]] and to regulate and control the marketing, advertising, and promotion of tobacco products. Legally-designated smokefree indoor spaces now have wide public and political support in New Zealand.[[3,4]] There is also growing interest and support for social denormalisation strategies, including the adoption of smokefree outdoor spaces; such as parks, playgrounds, and other public spaces.[[4]] Denormalisation strategies are designed to influence social norms and modify addictive nicotine-use behaviours (including vaping).[[4,5]] Denormalisation involves changing tobacco/nicotine use from acceptable and desirable to unacceptable and undesirable, across a broad range of settings.[[3]] Decreasing the social acceptability of smoking has been shown to be a highly effective policy tool in reducing consumption.[[5]]

However, the effectiveness of denormalisation strategies has been challenged in recent years by the emergence of increasingly sophisticated electronic nicotine delivery systems (ENDS) — most commonly, e-cigarettes.[[5]] There has been protracted debate about the regulation of vaping in spaces where conventional cigarettes are currently prohibited. Vaping legislation was not introduced in New Zealand until 2020, prohibiting vaping on aircraft, and inside workplaces, schools, early childhood centres, and some other indoor public spaces (the legislation does not cover outdoor spaces).[[6]] In addition, progress in translating smokefree and vapefree outdoor rules into national policy has been limited, leaving sub-national jurisdictions to enact rules or bylaws on a case-by-case basis.[[7,8]]

Whilst many councils across New Zealand have implemented smokefree outdoor spaces to some degree, the extension of these policies into business areas and the adoption of vapefree outdoor spaces is still limited.[[7,8]] Most examples of these initiatives have employed facilitative and promotional approaches and these initiatives primarily rely on signage and communication to build public support and promote compliance.[[7]] Despite the voluntary nature of New Zealand’s outdoor smokefree strategies, this approach can still arouse concern and resistance from some stakeholders. For example, some business owners may have concerns about economic harms, despite studies of smoking bans in the hospitality sector showing no overall substantial economic gains or losses[[9–11]] and such bans have been found to be popular with customers.[[12]]

Hospitality and tourism are important sectors for New Zealand and insufficient work has been done to investigate how acceptable smokefree and vapefree outdoor policies are to our domestic and international visitors. The aim of this mixed methods evaluation study was to obtain current information on the attitudes and level of support from visitors, residents, and businesses, for a smokefree and vapefree zone covering the central business streets of a New Zealand tourist town. The study also aimed to see if there were changes in observable smoking and vaping behaviours over the trial period (the study did not aim to demonstrate a change in the proportion of regular smokers/vapers within any group or over time).

To our knowledge, this is the first formal evaluation of a smokefree and vapefree zone simultaneously applied to the entire central business area of a tourist town in New Zealand (i.e., where there were no policies prior). The study also evaluated any reported impacts on stakeholders, including the hospitality and tourism-focused businesses that engaged with the evaluation interviews. This information may be helpful to local government authorities when considering whether public spaces adjacent to retail and other business premises can and should be both vapefree and smokefree.

Methods

This evaluation study used mixed methods to assess stakeholders’ experiences, perspectives, and attitudes towards the smokefree and vapefree zone trial. Broadly, the methods included online surveys, phone surveys, scheduled face-to-face interviews, public intercept surveys, pen and paper feedback cards, and field observations of smoking and vaping behaviours.

Intervention

Breathe easy in Hanmer Springs was a six-month trial of a smokefree and vapefree zone implemented across key public spaces, including the street frontage of the retail/business area of the village. The setting was Hanmer Springs, a popular tourist town in the South Island of New Zealand (population 960 in 2018; regular smokers 12.6%, 2018; 216,311 guest nights in the wider Hurunui District, with 33% international, 2018–2019 year).[[13,14]] The voluntary initiative was supported by signage and a communication plan. The aim of the communication plan was to raise public awareness of the initiative and to help empower the public to provide positive social reinforcement if smoking behaviours were observed in the zone. The majority of promotions were initiated at the launch of the trial (14 February 2019). A limited amount of reporting on the impending trial was seen in local and national print, online, and radio media in the months preceding the trial. The signage (placed just prior to the start of the trial) included one main display board/map and a range of metal and self-adhesive signs and posters, attached to all public picnic furniture, selected curbside poles, public toilet cubicles, council owned rubbish bins, and other public fixtures as suitable within the trial zone. Businesses were not required or requested to actively implement the no smoking/no vaping policy or messaging (although some may have done so to varying degrees).

Sample

Potential respondents were selected from three stakeholder groups within a specific geographical setting (a convenience sample). The three stakeholder groups were the local businesses (owners/managers), residents (or property owners/rate payers), and visitors to the township (both domestic and international). The recruitment of business owners/managers was via email and phone using contact information that had been compiled by a health promoter over the two years prior. Owners’/managers’ contact details were collated from lists provided by the local Business Association, and listings in local advertising and business directories, or displayed on premises within the village (if not identified via previous methods). The characteristics/classification of the recruited business respondents were: accommodation (n=15); hospitality (n=9, representing 13 businesses); retail (n=18, representing 21 businesses); tourism/outdoor activity (n=6); trade/service provider (n=6). Visitors were sampled via two methods: (1) random in-person point-intercept interviews on the streets within the zone; and (2) feedback cards placed at accommodation providers around the village. In total, 22 out of 38 identified accommodation providers agreed to include feedback cards in their guest room compendiums including motels, hotels, rental homes, backpackers, camping grounds and B&Bs (unlisted B&B and Airbnb were excluded). Residents were sampled via two methods: (1) random in-person point-intercept interviews on the streets within the zone; and (2) via invitations to engage online, including a URL link posted to a closed village social media group, QR codes on posters/signs within the zone, and via URL links posted in the local school and village newsletters.

Measures were put in place to reduce the possibility of multiple written responses (ballot stuffing) and multiple/duplicate online submissions (acknowledging that, with effort, these measures could have been circumvented). Firstly, manual scans were used to detect obvious duplication of tourist responses within each batch of handwritten response cards retrieved from each accommodation provider (one instance was detected, and copies removed). Secondly, the online survey platform collector settings used IP address to limit responses to one response per device.

Procedure

A base questionnaire (see Appendix) was drafted by the project team and peer reviewed by a public health physician. The base questionnaire included a core set of policy-relevant questions to be asked of all respondents. The central question assessed respondents’ level of support for the zone being specifically smokefree and vapefree (i.e., a vote in principle for vaping and smoking to be treated the same/differently with respect to outdoor public areas). The questionnaire also included questions on awareness of the zone and support for the zone becoming permanent (as implemented in the specific context of Hanmer Springs). In the interest of brevity, these secondary questions are not reported here. The base questionnaire did not include demographics, as the evaluation study was not intended to have enough statistical power to perform sub-group analyses (including smoking/vaping vs non-smoking/non-vaping).

The base questionnaire was then tailored to the different stakeholder groups by adding supplementary questions that explored different stakeholder perspectives and experiences (e.g., any impacts on business, tourists’ likelihood to visit other smokefree and vapefree tourist destinations, and residents’ perspectives). The questionnaire format was also optimised for use online, for pen and paper completion, and to suit a semi-structured face-to-face interview format.

The semi-structured interview schedules for use with the business representatives (see Appendix) were the most in-depth questionnaires. The interview schedule was developed using an applied qualitative research approach[[15]] whereby the questions were shaped by the information requirements of the stakeholders, as apparent from a prior scoping/consultation one year earlier.[[16]] The two interviewers (a Public Health Analyst and a Health Promoter, both from Community & Public Health, Canterbury DHB) used role play to practice and refine the interview schedule and feedback was provided by a third assessor (another Public Health Analyst, also from Community & Public Health, Canterbury DHB). The interviews with business representatives typically lasted 30 minutes and included open-ended questions and probes. The questions asked for detailed information about any effects of the zone on businesses’ operations and staff. All respondents were also given the opportunity to provide one open response on any aspect of the smokefree and vapefree trial. The business interview settings included retail and hospitality premises, accommodation providers, and other recreational and outdoor adventure providers.

The face-to-face interviews with members of the public were facilitated by a Health Promotion Advisor from Cancer Society, Canterbury West Coast Division, and three volunteer research assistants also provided by the Cancer Society (the volunteers undertook a site orientation and training session on the day). These interviews were conducted on public streets within the trial zone. All interviews and surveys were undertaken between 14 February and 18 July 2019.

The observations employed multiple four-minute scanning cycles, based on the methods developed by Thomson and colleagues.[[17]] Specifically, observations of the smoking and vaping behaviours of those who appeared to be over 12 years old (and who are inclined to smoke/vape in public on the street) were made across four defined 10–20m[[2]] sites within the smokefree and vapefree zone. Note that age 12 is a methodological classification not a legal classification, as used in Thomson and colleagues’ established observation protocol.[[17]] The observations were undertaken by two observers (from the Cancer Society, Canterbury West Coast Division, having undertaken specific training/field trials focused on minimising inter-observer bias). The observations were conducted over five weekend days, in two periods (daytime only, as the policy is in large part about denormalisation and modelling smokefree and vapefree to young people). The pre-intervention observations were conducted just prior to the introduction of the trial on February 14th (Valentine's Day). Hanmer Springs visitor numbers peak noticeably on weekends and school holidays and the “family friendly” attractions in Hanmer Springs draw large numbers of families. The high proportion of children typically present in the village during the school holidays and during the weekends may influence adults’ smoking and vaping behaviours (downwards),[[18–22]] therefore, all of the observation times were scheduled to provide a similar context (school holidays–weekends) for all observations. Additional observations comprised set walking loops and between site observations for the general monitoring of tobacco litter, any observed displacement of smokers/vapers to out-of-zone areas, and/or any other unanticipated effects.

Analysis

Qualitative data were analysed using a systematic iterative thematic approach to identify recurring patterns, following the method described by Pope and Mays and others.[[15]] The multi-choice and three-point Likert scale questionnaire (Appendix) responses were extracted from the different iterations of the surveys/interviews and the proportion of respondents in agreement with the various statements were calculated for each stakeholder group. Some respondents did not answer all questions and percentages were calculated excluding missing responses. The observational data (smoking and vaping behaviours) were analysed by means of Chi-squared tests (using SAS version 9.4, SAS Institute Inc., Cary, NC) to determine any differences in the observed smoking and vaping behaviours between baseline and follow-up.

Ethics

It was determined that this evaluation did not meet the criteria triggering a need for Health and Disability Ethics Committee review. The evaluation was considered low risk as it did not involve the collection of health information, age, gender, or ethnicity, and the responses were confidential and anonymous. Those invited could decline to participate, or choose not to answer any particular question, if they wished.

Results

Participants

In total, 956 individuals provided responses to the surveys, comprising 680 visitors, 222 residents, and 54 business representatives (Table 1). Of the 956 responses, 548 were completed via pen and paper feedback cards, 211 were completed face-to-face, and 197 were completed online. Most of the visitors’ responses were collected via the pen-and-paper feedback cards (n=548 out of 680 visitor responses) with an additional 132 visitors having provided information via face-to-face interviews on the street. Most of the residents’ responses were collected online (n=166) with an additional 56 residents interviewed on the streets within the smokefree and vapefree zone (total n=222 residents).

The response rate for businesses was approximately 36.5% (54 of 148 identified eligible businesses invited to participate). The response rates for the face-to-face interviews on the street, the residents’ online surveys, and the visitor feedback cards could not be calculated as the denominators were not known.

Key findings

Visitors

Overall, 84% (n=568) of responding visitors indicated that they supported the zone being both smokefree and vapefree (83%, n=118 International and 84%, n=450 Domestic visitors). A further 8% (n=53) of responding visitors indicated vaping should be allowed in the zone (but supported smokefree) and 9% (n=59) indicated both vaping and smoking should be allowed in the zone (i.e., didn’t support the zone) (Figure 1). Further, 54% of responding visitors (n=297) indicated that they would be more likely to visit other places with smokefree and vapefree zones, 40% (n=220) indicated no preference, and 6% (n=30) indicated that they would be less likely to visit other places with smokefree and vapefree zones. Overall, 95% of responding visitors said they would be more likely or as likely to visit other places in New Zealand that have no smoking/no vaping zones (97%, n=111 International and 94%, n=406 Domestic visitors). International visitors tended to indicate similar levels of support for the zone compared with domestic visitors. Approximately 150 visitors also provided either written or verbal comments regarding their experiences and opinions on voluntary smokefree and vapefree outdoor spaces (summarised in Table 2).

Residents

Overall, 67% (n=138) of the resident respondents indicated that they supported the zone being both smokefree and vapefree. A further 6% (n=12) indicated vaping should be allowed in the zone (but supported smokefree) and 27%(n=55) indicated both vaping and smoking should be allowed in the zone (i.e., didn’t support the zone) (Figure 1). In addition, the respondents provided 115 comments about their level of support for the zone or about different aspects of smokefree and vapefree regulation generally (summarised in Table 2).

Businesses

Overall, 63% (n=34) of 54 respondents from businesses indicated that they supported the zone being both smokefree and vapefree. A further 4% of responding businesses (n=2) indicated vaping should be allowed in the zone (while supporting smokefree) and 32% (n=17) indicated both vaping and smoking should be allowed in the zone (i.e., didn’t support the zone) (Figure 1). One respondent was undecided. Most respondents from this group reported that the trial had no overall effect on their business, including no notable effects on customer numbers, spending patterns, or customer feedback (no change, 70%, n=37; a positive effect, 13%, n=7; a negative effect, 17%, n=9). Most respondents from this group also reported that the trial had no notable negative effects on staff (no effect 87%, n=45; yes an effect 14%, n=7). The business owners and managers were also asked for their general opinion of the smokefree and vapefree zone and for any final comments on the zone’s effects or relevance to their business. In total, 80 responses were evaluated, including 53 general opinions and 27 business-related comments (summarised in Table 2).

View Figure 1 & Table 2.

Observations

The implementation of the smokefree and vapefree zone was associated with a quantifiable reduction in smoking and vaping behaviours within the designated area. The baseline observations showed a combined observed smoking/vaping point prevalence of 1.9% (of 3,355 people over 12 years old observed for up to four minutes, there were 3,292 non-smoking/vaping; 58 who were smoking; five who were vaping). This declined to 0.4% (of 3,740 people over 12 years old observed for up to four minutes, there were 3,725 non-smoking/vaping; 13 who were smoking; two who were vaping) post-implementation (p<0.001). Across the two observation periods, there were 10 hours and 46 minutes of field observations and a total count of 7,095 people over 12 years old. Approximately 20% of all passers-by were children (those judged to be 12 years or under). No obvious displacement effects (i.e., smokers/vapers simply moving somewhere else) or socially disruptive behaviours were observed.

View Figure 1 & Tables.

Discussion

The evaluation findings provide information on the feasibility of implementing smokefree and vapefree outdoor area policies in tourist-destination communities. This study indicates that smokefree and vapefree zones such as this can be implemented and are acceptable to most stakeholders. Given the voluntary nature of the policy, acceptability would appear to be important for successful implementation/up-scaling. This study, and others,[[18,19,22]] indicate that zones such as this can change people’s behaviour so that there is less observable smoking and vaping within a defined outdoor public area (although we do not claim to have established causality, only that the observed point estimate at baseline was statistically different to the observed point estimate at follow-up). There was also no observed displacement of smokers or vapers to out-of-zone areas, or anti-social behaviours, or other unanticipated effects noted.

This evaluation indicates support for smokefree and vapefree outdoor areas, particularly from tourists (including international tourists) and residents. Overall, a clear majority of the nearly 1,000 non-random respondents supported the implementation of the smokefree and vapefree zone as applied to the central business streets of a small tourist town (including, that the same rules be applied to smoking and vaping). The results indicate a supportive majority in each of the three stakeholder groups studied: businesses, residents, and notably, visitors. Understandably, some business owners and residents in tourist towns may be concerned that smokefree and vapefree outdoor areas will pose a deterrent to visitors. However, these evaluation findings suggest the opposite. Most respondents from the business group reported that the trial had no overall effect on their business, including no notable effects on customer numbers, spending patterns, or customer feedback. The support for the trial, in turn, led the Council to adopt the policy as an ongoing initiative, and hence the streets within the central district of the village now model the denormalisation of tobacco products.

Decreasing the social acceptability of smoking (denormalisation) has been shown to be an effective policy tool in reducing consumption.[[4,5]] These favourable results should provide reassurance to other local authorities that implementing smokefree/vapefree policies is feasible and is generally viewed favourably by most stakeholders. As with many policy decisions, the argument for smoking and vaping restrictions requires a weighing of the pros and cons and consideration of how the effects impact on different individuals.[[23–25]] Several themes relating to the ethics of denormalisation strategies, smokers’ preferences, and issues of freedom and autonomy, have been discussed at length in the literature[[26–28]] and are not discussed in detail here. However, it is important to acknowledge that while some groups may experience a wellbeing gain from the implementation of a smokefree/vapefree zone (e.g., by averting substantial health losses), others’ wellbeing might be negatively affected (e.g., loss of enjoyment, stigmatisation). Individuals and groups may weigh the benefits and potential costs of restrictions differently.

This evaluation suggests that the introduction of smokefree and vapefree outdoor policies in tourist areas in New Zealand can reduce how often young people see smoking behaviours. This can contribute to denormalisation (and by extension reduce initiation) and help provide a more supportive environment for those trying to quit. Considering the low-cost nature of policies such as these,[[1]] the high support among different stakeholder groups, and no reported impacts on the hospitality/tourism providers, we conclude net positive effects are possible, over the long term, which will support New Zealand’s smokefree 2025 goal and ultimately benefit public health.

This study is based on survey responses from business owners/managers, visitors and residents of a small tourist village in the South Island of New Zealand who agreed to participate in the evaluation. It is possible that some differences in views exist between those who chose to provide feedback and those who did not. The question of representativeness is relevant because this paper aims to provide reassurance to other local authorities that implementing smokefree/vapefree policies is feasible and is generally viewed favourably by most stakeholders. Considerable effort was directed towards accurately measuring support for the initiative in Hanmer Springs by seeking opinions from a broad range of stakeholder groups via a variety of survey methods. While the potential for response bias and/or mode effects cannot be discounted, the sampling and survey methods provided several accessible anonymous channels for individuals to provide feedback. Without any evidence to the contrary, we suggest that those opposed to the initiative or in support of the initiative were, on average, similarly able to speak up. Furthermore, our estimates of support for a smokefree and vapefree zone are high, consequently, any non-response bias would have to be very substantial to change the conclusions and implications of our study. Some differences in the characteristics of the language used across some response modes were noted (e.g., notable aggression in some survey responses linked via social media) but these differences could not be quantified, and no allowances were made in the analysis. Future initiatives may need to be adjusted/scaled for towns and cities with varied CBD size, layout, and amenity characteristics, and these factors should be considered when tailoring future intervention designs.

Conclusion

This study provides affirming information on the feasibility of implementing smokefree and vapefree outdoor area policies in tourist-destination communities. Smokefree and vapefree zones across key public spaces in retail/business areas can be implemented and are likely to be acceptable to most stakeholders. We conclude that net positive effects are possible over the long-term, that will support New Zealand’s smokefree 2025 goal.

View Appendix.

Summary

Abstract

Aim

To (a) evaluate the attitudes of local businesses, residents, and visitors regarding the trial of a voluntary smokefree and vapefree zone covering the central business streets of a popular tourist town in the South Island of New Zealand, and (b) observe smoking and vaping prevalence before and during the trial, to inform national and local smokefree environment advocacy work.

Method

The six-month smokefree and vapefree trial included an embedded mixed methods project evaluation to capture a range of stakeholder groups’ views about the smokefree and vapefree zone. Data collection methods included face-to-face interviews, non-random pen and paper and online surveys, and observational scans. Qualitative data were analysed using a systematic iterative thematic approach, and simple descriptive quantitative analyses were applied to the survey data.

Results

The analysis synthesised information from almost 1,000 respondents. A large majority of respondents supported smokefree and vapefree within the zone (visitors 84%; residents 67%; businesses 63%). A majority of responding visitors indicated that the same rules should apply to both smoking and vaping and that they would be either more likely or as likely to visit other tourist destinations in New Zealand if they had smokefree and vapefree zones. Implementing the initiative was associated with a reduction in the number of people visibly smoking and vaping within the zone.

Conclusion

The weight of evidence from the project evaluation points towards a net benefit both for individuals and for the community from implementing voluntary smokefree and vapefree zones in tourist destinations in New Zealand.

Author Information

Dr David Brinson: Public Health Analyst, Community & Public Health, Canterbury District Health Board, Christchurch. Charlotte Ward: Public Health Analyst, Community & Public Health, Canterbury District Health Board, Christchurch. Cheryl Ford; Health Promotion Advisor, Cancer Society of New Zealand Canterbury-West Coast Division Inc., Christchurch. Dr Annabel Begg: Public Health Specialist, Community & Public Health, Canterbury District Health Board, Christchurch.

Acknowledgements

The authors wish to acknowledge Gemma Claridge (Intern, Cancer Society, Canterbury West Coast Division) for undertaking several on-site smoking/vaping prevalence observations; Christina Lewis (Community & Public Health, Canterbury DHB) for her assistance with data collection (face-to-face interviews); Colleen Moore (Secretary, Community & Public Health, Canterbury DHB) for her data entry of these interview transcripts; and George Thomson (University of Otago) for his review of the manuscript. We also wish to thank the survey respondents for their participation, and the Cancer Society volunteers involved in participant recruitment and data collection.

Correspondence

Dr Annabel Begg: Community & Public Health, Canterbury District Health Board, 310 Manchester Street, Christchurch, PO Box 1475, Christchurch 8140, New Zealand.

Correspondence Email

annabel.begg@cdhb.health.nz

Competing Interests

Nil.

1) WHO. WHO report on the global tobacco epidemic, 2019. Geneva: Switzerland 2019.

2) Smoke-free Environments Act (1990) No 108 (Accessed: 14 March 2018).

3) Auckland Council. Review of Auckland Council’s Smokefree Policy 2013: Findings Report. Auckland: Auckland Council; 2016.

4) Ball J, Hoek J, Tautolo ES, Gifford H. New Zealand policy experts’ appraisal of interventions to reduce smoking in young adults: a qualitative investigation. BMJ Open. 2017;7(12): e017837.

5) Voigt K. Smoking Norms and the Regulation of E-Cigarettes. Am J Public Health. 2015;105(10):1967-72.

6) Smokefree Environments and Regulated Products (Vaping) Amendment Act 2020. (Accessed: 2 November 2020).

7) Health Promotion Agency. Maps of NZ Councils' Smokefree Outdoor Policies and Spaces. Retrieved 17 February from https://www.smokefree.org.nz/smokefree-resources/maps-of-nz-councils-smokefree-outdoor-policies-and-spaces2020.

8) Thomson G, Wilson N. Local and regional smokefree and tobacco-free action in New Zealand: highlights and directions. N Z Med J. 2017;130(1462):89-101.

9) Bethesda MD. The economics of tobacco and tobacco control: U.S. Department of Health and Human Services, National Institutes of Health; and the World Health Organization, Geneva, Switzerland; 2017.

10) Cornelsen L, McGowan Y, Currie-Murphy LM, Normand C. Systematic review and meta-analysis of the economic impact of smoking bans in restaurants and bars. Addiction. 2014;109(5):720-7.

11) Dobson Amato KA, Rivard C, Lipsher J, Hyland A. Five years after the Hawai'i smoke-free law: tourism and hospitality economic indicators appear unharmed. Hawaii J Med Public Health. 2013;72(10):355-61.

12) Cancer Society, Canterbury District Health Board. Evaluation of The Fresh Air Project: piloting smokefree outdoor dining areas in Christchurch. Christchurch: Cancer Society Canterbury-West Coast Division Inc, Community & Public Health (Canterbury DHB); 2017.

13) Adcock S. Personal communication, report by Shane Adcock, Marketing Manager of Hurunui Tourism Board: Presented to Hurunui Tourism Board at meeting 15 April 2019, p, 28-34. 2019.

14) Statistics New Zealand. 2018 Census place summaries, Hanmer Springs [Available from: https://www.stats.govt.nz/tools/2018-census-place-summaries/hanmer-springs#health.

15) Pope C, Ziebland S, Mays N. Qualitative research in health care. Analysing qualitative data. BMJ. 2000;320(7227):114-6.

16) Cancer Society. Consultation with business owners/managers on their views about introducing a smokefree street zone in Hanmer Springs. [Unpublished manuscript].

17) Thomson G, Russell M, Jenkin G, Patel V, Wilson N. Informing outdoor smokefree policy: methods for measuring the proportion of people smoking in outdoor public areas. Health & place. 2013; 20:19-24.

18) Gurram N. The point prevalence of smoking and vaping in Grey Street pocket square, Wellington: Report for the Wellington City Council on observations in Grey Street, Wellington in December 2018.; Wellington City Council. 2018.

19) Gurram N, Thomson G. The point prevalence of smoking and vaping in downtown locations in Wellington: Report for the Wellington City Council on observations in November 2018. Wellington City Council. 2018.

20) Martin N, McHugh H, Murtagh J, Oliver-Rose C, Panesar D, Pengelly H, et al. Observational study of the visibility of branded tobacco packaging and smoking at outdoor bars/cafes in Wellington, New Zealand. N Z Med J. 2014;127(1404):27-36.

21) Pearson AL, Nutsford D, Thomson G. Measuring visual exposure to smoking behaviours: a viewshed analysis of smoking at outdoor bars and cafés across a capital city’s downtown area. BMC Public Health. 2014;14(1):300.

22) Thomson G, Pathmanathan N. The point prevalence of smoking in selected sports fields and downtown locations in Wellington: Observations in Novembers 2015. University of Otago. 2016.

23) Bayer R. The continuing tensions between individual rights and public health. Talking Point on public health versus civil liberties. EMBO Rep. 2007;8(12):1099-103.

24) Bayer R. Stigma and the ethics of public health: not can we but should we. Soc Sci Med. 2008;67(3):463-72.

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Tobacco smoking remains a major cause of death and disability around the world, as well as a major contributor to health inequities.[[1]] Many countries have progressively implemented strong tobacco control policies and legislation to protect present and future generations from the considerable health, economic, social, and environmental impacts of tobacco.[[1]] In New Zealand, the Smokefree Environments Act 1990 was passed to “reduce the exposure of people who do not themselves smoke to any detrimental effect on their health caused by smoking by others”[[2]] and to regulate and control the marketing, advertising, and promotion of tobacco products. Legally-designated smokefree indoor spaces now have wide public and political support in New Zealand.[[3,4]] There is also growing interest and support for social denormalisation strategies, including the adoption of smokefree outdoor spaces; such as parks, playgrounds, and other public spaces.[[4]] Denormalisation strategies are designed to influence social norms and modify addictive nicotine-use behaviours (including vaping).[[4,5]] Denormalisation involves changing tobacco/nicotine use from acceptable and desirable to unacceptable and undesirable, across a broad range of settings.[[3]] Decreasing the social acceptability of smoking has been shown to be a highly effective policy tool in reducing consumption.[[5]]

However, the effectiveness of denormalisation strategies has been challenged in recent years by the emergence of increasingly sophisticated electronic nicotine delivery systems (ENDS) — most commonly, e-cigarettes.[[5]] There has been protracted debate about the regulation of vaping in spaces where conventional cigarettes are currently prohibited. Vaping legislation was not introduced in New Zealand until 2020, prohibiting vaping on aircraft, and inside workplaces, schools, early childhood centres, and some other indoor public spaces (the legislation does not cover outdoor spaces).[[6]] In addition, progress in translating smokefree and vapefree outdoor rules into national policy has been limited, leaving sub-national jurisdictions to enact rules or bylaws on a case-by-case basis.[[7,8]]

Whilst many councils across New Zealand have implemented smokefree outdoor spaces to some degree, the extension of these policies into business areas and the adoption of vapefree outdoor spaces is still limited.[[7,8]] Most examples of these initiatives have employed facilitative and promotional approaches and these initiatives primarily rely on signage and communication to build public support and promote compliance.[[7]] Despite the voluntary nature of New Zealand’s outdoor smokefree strategies, this approach can still arouse concern and resistance from some stakeholders. For example, some business owners may have concerns about economic harms, despite studies of smoking bans in the hospitality sector showing no overall substantial economic gains or losses[[9–11]] and such bans have been found to be popular with customers.[[12]]

Hospitality and tourism are important sectors for New Zealand and insufficient work has been done to investigate how acceptable smokefree and vapefree outdoor policies are to our domestic and international visitors. The aim of this mixed methods evaluation study was to obtain current information on the attitudes and level of support from visitors, residents, and businesses, for a smokefree and vapefree zone covering the central business streets of a New Zealand tourist town. The study also aimed to see if there were changes in observable smoking and vaping behaviours over the trial period (the study did not aim to demonstrate a change in the proportion of regular smokers/vapers within any group or over time).

To our knowledge, this is the first formal evaluation of a smokefree and vapefree zone simultaneously applied to the entire central business area of a tourist town in New Zealand (i.e., where there were no policies prior). The study also evaluated any reported impacts on stakeholders, including the hospitality and tourism-focused businesses that engaged with the evaluation interviews. This information may be helpful to local government authorities when considering whether public spaces adjacent to retail and other business premises can and should be both vapefree and smokefree.

Methods

This evaluation study used mixed methods to assess stakeholders’ experiences, perspectives, and attitudes towards the smokefree and vapefree zone trial. Broadly, the methods included online surveys, phone surveys, scheduled face-to-face interviews, public intercept surveys, pen and paper feedback cards, and field observations of smoking and vaping behaviours.

Intervention

Breathe easy in Hanmer Springs was a six-month trial of a smokefree and vapefree zone implemented across key public spaces, including the street frontage of the retail/business area of the village. The setting was Hanmer Springs, a popular tourist town in the South Island of New Zealand (population 960 in 2018; regular smokers 12.6%, 2018; 216,311 guest nights in the wider Hurunui District, with 33% international, 2018–2019 year).[[13,14]] The voluntary initiative was supported by signage and a communication plan. The aim of the communication plan was to raise public awareness of the initiative and to help empower the public to provide positive social reinforcement if smoking behaviours were observed in the zone. The majority of promotions were initiated at the launch of the trial (14 February 2019). A limited amount of reporting on the impending trial was seen in local and national print, online, and radio media in the months preceding the trial. The signage (placed just prior to the start of the trial) included one main display board/map and a range of metal and self-adhesive signs and posters, attached to all public picnic furniture, selected curbside poles, public toilet cubicles, council owned rubbish bins, and other public fixtures as suitable within the trial zone. Businesses were not required or requested to actively implement the no smoking/no vaping policy or messaging (although some may have done so to varying degrees).

Sample

Potential respondents were selected from three stakeholder groups within a specific geographical setting (a convenience sample). The three stakeholder groups were the local businesses (owners/managers), residents (or property owners/rate payers), and visitors to the township (both domestic and international). The recruitment of business owners/managers was via email and phone using contact information that had been compiled by a health promoter over the two years prior. Owners’/managers’ contact details were collated from lists provided by the local Business Association, and listings in local advertising and business directories, or displayed on premises within the village (if not identified via previous methods). The characteristics/classification of the recruited business respondents were: accommodation (n=15); hospitality (n=9, representing 13 businesses); retail (n=18, representing 21 businesses); tourism/outdoor activity (n=6); trade/service provider (n=6). Visitors were sampled via two methods: (1) random in-person point-intercept interviews on the streets within the zone; and (2) feedback cards placed at accommodation providers around the village. In total, 22 out of 38 identified accommodation providers agreed to include feedback cards in their guest room compendiums including motels, hotels, rental homes, backpackers, camping grounds and B&Bs (unlisted B&B and Airbnb were excluded). Residents were sampled via two methods: (1) random in-person point-intercept interviews on the streets within the zone; and (2) via invitations to engage online, including a URL link posted to a closed village social media group, QR codes on posters/signs within the zone, and via URL links posted in the local school and village newsletters.

Measures were put in place to reduce the possibility of multiple written responses (ballot stuffing) and multiple/duplicate online submissions (acknowledging that, with effort, these measures could have been circumvented). Firstly, manual scans were used to detect obvious duplication of tourist responses within each batch of handwritten response cards retrieved from each accommodation provider (one instance was detected, and copies removed). Secondly, the online survey platform collector settings used IP address to limit responses to one response per device.

Procedure

A base questionnaire (see Appendix) was drafted by the project team and peer reviewed by a public health physician. The base questionnaire included a core set of policy-relevant questions to be asked of all respondents. The central question assessed respondents’ level of support for the zone being specifically smokefree and vapefree (i.e., a vote in principle for vaping and smoking to be treated the same/differently with respect to outdoor public areas). The questionnaire also included questions on awareness of the zone and support for the zone becoming permanent (as implemented in the specific context of Hanmer Springs). In the interest of brevity, these secondary questions are not reported here. The base questionnaire did not include demographics, as the evaluation study was not intended to have enough statistical power to perform sub-group analyses (including smoking/vaping vs non-smoking/non-vaping).

The base questionnaire was then tailored to the different stakeholder groups by adding supplementary questions that explored different stakeholder perspectives and experiences (e.g., any impacts on business, tourists’ likelihood to visit other smokefree and vapefree tourist destinations, and residents’ perspectives). The questionnaire format was also optimised for use online, for pen and paper completion, and to suit a semi-structured face-to-face interview format.

The semi-structured interview schedules for use with the business representatives (see Appendix) were the most in-depth questionnaires. The interview schedule was developed using an applied qualitative research approach[[15]] whereby the questions were shaped by the information requirements of the stakeholders, as apparent from a prior scoping/consultation one year earlier.[[16]] The two interviewers (a Public Health Analyst and a Health Promoter, both from Community & Public Health, Canterbury DHB) used role play to practice and refine the interview schedule and feedback was provided by a third assessor (another Public Health Analyst, also from Community & Public Health, Canterbury DHB). The interviews with business representatives typically lasted 30 minutes and included open-ended questions and probes. The questions asked for detailed information about any effects of the zone on businesses’ operations and staff. All respondents were also given the opportunity to provide one open response on any aspect of the smokefree and vapefree trial. The business interview settings included retail and hospitality premises, accommodation providers, and other recreational and outdoor adventure providers.

The face-to-face interviews with members of the public were facilitated by a Health Promotion Advisor from Cancer Society, Canterbury West Coast Division, and three volunteer research assistants also provided by the Cancer Society (the volunteers undertook a site orientation and training session on the day). These interviews were conducted on public streets within the trial zone. All interviews and surveys were undertaken between 14 February and 18 July 2019.

The observations employed multiple four-minute scanning cycles, based on the methods developed by Thomson and colleagues.[[17]] Specifically, observations of the smoking and vaping behaviours of those who appeared to be over 12 years old (and who are inclined to smoke/vape in public on the street) were made across four defined 10–20m[[2]] sites within the smokefree and vapefree zone. Note that age 12 is a methodological classification not a legal classification, as used in Thomson and colleagues’ established observation protocol.[[17]] The observations were undertaken by two observers (from the Cancer Society, Canterbury West Coast Division, having undertaken specific training/field trials focused on minimising inter-observer bias). The observations were conducted over five weekend days, in two periods (daytime only, as the policy is in large part about denormalisation and modelling smokefree and vapefree to young people). The pre-intervention observations were conducted just prior to the introduction of the trial on February 14th (Valentine's Day). Hanmer Springs visitor numbers peak noticeably on weekends and school holidays and the “family friendly” attractions in Hanmer Springs draw large numbers of families. The high proportion of children typically present in the village during the school holidays and during the weekends may influence adults’ smoking and vaping behaviours (downwards),[[18–22]] therefore, all of the observation times were scheduled to provide a similar context (school holidays–weekends) for all observations. Additional observations comprised set walking loops and between site observations for the general monitoring of tobacco litter, any observed displacement of smokers/vapers to out-of-zone areas, and/or any other unanticipated effects.

Analysis

Qualitative data were analysed using a systematic iterative thematic approach to identify recurring patterns, following the method described by Pope and Mays and others.[[15]] The multi-choice and three-point Likert scale questionnaire (Appendix) responses were extracted from the different iterations of the surveys/interviews and the proportion of respondents in agreement with the various statements were calculated for each stakeholder group. Some respondents did not answer all questions and percentages were calculated excluding missing responses. The observational data (smoking and vaping behaviours) were analysed by means of Chi-squared tests (using SAS version 9.4, SAS Institute Inc., Cary, NC) to determine any differences in the observed smoking and vaping behaviours between baseline and follow-up.

Ethics

It was determined that this evaluation did not meet the criteria triggering a need for Health and Disability Ethics Committee review. The evaluation was considered low risk as it did not involve the collection of health information, age, gender, or ethnicity, and the responses were confidential and anonymous. Those invited could decline to participate, or choose not to answer any particular question, if they wished.

Results

Participants

In total, 956 individuals provided responses to the surveys, comprising 680 visitors, 222 residents, and 54 business representatives (Table 1). Of the 956 responses, 548 were completed via pen and paper feedback cards, 211 were completed face-to-face, and 197 were completed online. Most of the visitors’ responses were collected via the pen-and-paper feedback cards (n=548 out of 680 visitor responses) with an additional 132 visitors having provided information via face-to-face interviews on the street. Most of the residents’ responses were collected online (n=166) with an additional 56 residents interviewed on the streets within the smokefree and vapefree zone (total n=222 residents).

The response rate for businesses was approximately 36.5% (54 of 148 identified eligible businesses invited to participate). The response rates for the face-to-face interviews on the street, the residents’ online surveys, and the visitor feedback cards could not be calculated as the denominators were not known.

Key findings

Visitors

Overall, 84% (n=568) of responding visitors indicated that they supported the zone being both smokefree and vapefree (83%, n=118 International and 84%, n=450 Domestic visitors). A further 8% (n=53) of responding visitors indicated vaping should be allowed in the zone (but supported smokefree) and 9% (n=59) indicated both vaping and smoking should be allowed in the zone (i.e., didn’t support the zone) (Figure 1). Further, 54% of responding visitors (n=297) indicated that they would be more likely to visit other places with smokefree and vapefree zones, 40% (n=220) indicated no preference, and 6% (n=30) indicated that they would be less likely to visit other places with smokefree and vapefree zones. Overall, 95% of responding visitors said they would be more likely or as likely to visit other places in New Zealand that have no smoking/no vaping zones (97%, n=111 International and 94%, n=406 Domestic visitors). International visitors tended to indicate similar levels of support for the zone compared with domestic visitors. Approximately 150 visitors also provided either written or verbal comments regarding their experiences and opinions on voluntary smokefree and vapefree outdoor spaces (summarised in Table 2).

Residents

Overall, 67% (n=138) of the resident respondents indicated that they supported the zone being both smokefree and vapefree. A further 6% (n=12) indicated vaping should be allowed in the zone (but supported smokefree) and 27%(n=55) indicated both vaping and smoking should be allowed in the zone (i.e., didn’t support the zone) (Figure 1). In addition, the respondents provided 115 comments about their level of support for the zone or about different aspects of smokefree and vapefree regulation generally (summarised in Table 2).

Businesses

Overall, 63% (n=34) of 54 respondents from businesses indicated that they supported the zone being both smokefree and vapefree. A further 4% of responding businesses (n=2) indicated vaping should be allowed in the zone (while supporting smokefree) and 32% (n=17) indicated both vaping and smoking should be allowed in the zone (i.e., didn’t support the zone) (Figure 1). One respondent was undecided. Most respondents from this group reported that the trial had no overall effect on their business, including no notable effects on customer numbers, spending patterns, or customer feedback (no change, 70%, n=37; a positive effect, 13%, n=7; a negative effect, 17%, n=9). Most respondents from this group also reported that the trial had no notable negative effects on staff (no effect 87%, n=45; yes an effect 14%, n=7). The business owners and managers were also asked for their general opinion of the smokefree and vapefree zone and for any final comments on the zone’s effects or relevance to their business. In total, 80 responses were evaluated, including 53 general opinions and 27 business-related comments (summarised in Table 2).

View Figure 1 & Table 2.

Observations

The implementation of the smokefree and vapefree zone was associated with a quantifiable reduction in smoking and vaping behaviours within the designated area. The baseline observations showed a combined observed smoking/vaping point prevalence of 1.9% (of 3,355 people over 12 years old observed for up to four minutes, there were 3,292 non-smoking/vaping; 58 who were smoking; five who were vaping). This declined to 0.4% (of 3,740 people over 12 years old observed for up to four minutes, there were 3,725 non-smoking/vaping; 13 who were smoking; two who were vaping) post-implementation (p<0.001). Across the two observation periods, there were 10 hours and 46 minutes of field observations and a total count of 7,095 people over 12 years old. Approximately 20% of all passers-by were children (those judged to be 12 years or under). No obvious displacement effects (i.e., smokers/vapers simply moving somewhere else) or socially disruptive behaviours were observed.

View Figure 1 & Tables.

Discussion

The evaluation findings provide information on the feasibility of implementing smokefree and vapefree outdoor area policies in tourist-destination communities. This study indicates that smokefree and vapefree zones such as this can be implemented and are acceptable to most stakeholders. Given the voluntary nature of the policy, acceptability would appear to be important for successful implementation/up-scaling. This study, and others,[[18,19,22]] indicate that zones such as this can change people’s behaviour so that there is less observable smoking and vaping within a defined outdoor public area (although we do not claim to have established causality, only that the observed point estimate at baseline was statistically different to the observed point estimate at follow-up). There was also no observed displacement of smokers or vapers to out-of-zone areas, or anti-social behaviours, or other unanticipated effects noted.

This evaluation indicates support for smokefree and vapefree outdoor areas, particularly from tourists (including international tourists) and residents. Overall, a clear majority of the nearly 1,000 non-random respondents supported the implementation of the smokefree and vapefree zone as applied to the central business streets of a small tourist town (including, that the same rules be applied to smoking and vaping). The results indicate a supportive majority in each of the three stakeholder groups studied: businesses, residents, and notably, visitors. Understandably, some business owners and residents in tourist towns may be concerned that smokefree and vapefree outdoor areas will pose a deterrent to visitors. However, these evaluation findings suggest the opposite. Most respondents from the business group reported that the trial had no overall effect on their business, including no notable effects on customer numbers, spending patterns, or customer feedback. The support for the trial, in turn, led the Council to adopt the policy as an ongoing initiative, and hence the streets within the central district of the village now model the denormalisation of tobacco products.

Decreasing the social acceptability of smoking (denormalisation) has been shown to be an effective policy tool in reducing consumption.[[4,5]] These favourable results should provide reassurance to other local authorities that implementing smokefree/vapefree policies is feasible and is generally viewed favourably by most stakeholders. As with many policy decisions, the argument for smoking and vaping restrictions requires a weighing of the pros and cons and consideration of how the effects impact on different individuals.[[23–25]] Several themes relating to the ethics of denormalisation strategies, smokers’ preferences, and issues of freedom and autonomy, have been discussed at length in the literature[[26–28]] and are not discussed in detail here. However, it is important to acknowledge that while some groups may experience a wellbeing gain from the implementation of a smokefree/vapefree zone (e.g., by averting substantial health losses), others’ wellbeing might be negatively affected (e.g., loss of enjoyment, stigmatisation). Individuals and groups may weigh the benefits and potential costs of restrictions differently.

This evaluation suggests that the introduction of smokefree and vapefree outdoor policies in tourist areas in New Zealand can reduce how often young people see smoking behaviours. This can contribute to denormalisation (and by extension reduce initiation) and help provide a more supportive environment for those trying to quit. Considering the low-cost nature of policies such as these,[[1]] the high support among different stakeholder groups, and no reported impacts on the hospitality/tourism providers, we conclude net positive effects are possible, over the long term, which will support New Zealand’s smokefree 2025 goal and ultimately benefit public health.

This study is based on survey responses from business owners/managers, visitors and residents of a small tourist village in the South Island of New Zealand who agreed to participate in the evaluation. It is possible that some differences in views exist between those who chose to provide feedback and those who did not. The question of representativeness is relevant because this paper aims to provide reassurance to other local authorities that implementing smokefree/vapefree policies is feasible and is generally viewed favourably by most stakeholders. Considerable effort was directed towards accurately measuring support for the initiative in Hanmer Springs by seeking opinions from a broad range of stakeholder groups via a variety of survey methods. While the potential for response bias and/or mode effects cannot be discounted, the sampling and survey methods provided several accessible anonymous channels for individuals to provide feedback. Without any evidence to the contrary, we suggest that those opposed to the initiative or in support of the initiative were, on average, similarly able to speak up. Furthermore, our estimates of support for a smokefree and vapefree zone are high, consequently, any non-response bias would have to be very substantial to change the conclusions and implications of our study. Some differences in the characteristics of the language used across some response modes were noted (e.g., notable aggression in some survey responses linked via social media) but these differences could not be quantified, and no allowances were made in the analysis. Future initiatives may need to be adjusted/scaled for towns and cities with varied CBD size, layout, and amenity characteristics, and these factors should be considered when tailoring future intervention designs.

Conclusion

This study provides affirming information on the feasibility of implementing smokefree and vapefree outdoor area policies in tourist-destination communities. Smokefree and vapefree zones across key public spaces in retail/business areas can be implemented and are likely to be acceptable to most stakeholders. We conclude that net positive effects are possible over the long-term, that will support New Zealand’s smokefree 2025 goal.

View Appendix.

Summary

Abstract

Aim

To (a) evaluate the attitudes of local businesses, residents, and visitors regarding the trial of a voluntary smokefree and vapefree zone covering the central business streets of a popular tourist town in the South Island of New Zealand, and (b) observe smoking and vaping prevalence before and during the trial, to inform national and local smokefree environment advocacy work.

Method

The six-month smokefree and vapefree trial included an embedded mixed methods project evaluation to capture a range of stakeholder groups’ views about the smokefree and vapefree zone. Data collection methods included face-to-face interviews, non-random pen and paper and online surveys, and observational scans. Qualitative data were analysed using a systematic iterative thematic approach, and simple descriptive quantitative analyses were applied to the survey data.

Results

The analysis synthesised information from almost 1,000 respondents. A large majority of respondents supported smokefree and vapefree within the zone (visitors 84%; residents 67%; businesses 63%). A majority of responding visitors indicated that the same rules should apply to both smoking and vaping and that they would be either more likely or as likely to visit other tourist destinations in New Zealand if they had smokefree and vapefree zones. Implementing the initiative was associated with a reduction in the number of people visibly smoking and vaping within the zone.

Conclusion

The weight of evidence from the project evaluation points towards a net benefit both for individuals and for the community from implementing voluntary smokefree and vapefree zones in tourist destinations in New Zealand.

Author Information

Dr David Brinson: Public Health Analyst, Community & Public Health, Canterbury District Health Board, Christchurch. Charlotte Ward: Public Health Analyst, Community & Public Health, Canterbury District Health Board, Christchurch. Cheryl Ford; Health Promotion Advisor, Cancer Society of New Zealand Canterbury-West Coast Division Inc., Christchurch. Dr Annabel Begg: Public Health Specialist, Community & Public Health, Canterbury District Health Board, Christchurch.

Acknowledgements

The authors wish to acknowledge Gemma Claridge (Intern, Cancer Society, Canterbury West Coast Division) for undertaking several on-site smoking/vaping prevalence observations; Christina Lewis (Community & Public Health, Canterbury DHB) for her assistance with data collection (face-to-face interviews); Colleen Moore (Secretary, Community & Public Health, Canterbury DHB) for her data entry of these interview transcripts; and George Thomson (University of Otago) for his review of the manuscript. We also wish to thank the survey respondents for their participation, and the Cancer Society volunteers involved in participant recruitment and data collection.

Correspondence

Dr Annabel Begg: Community & Public Health, Canterbury District Health Board, 310 Manchester Street, Christchurch, PO Box 1475, Christchurch 8140, New Zealand.

Correspondence Email

annabel.begg@cdhb.health.nz

Competing Interests

Nil.

1) WHO. WHO report on the global tobacco epidemic, 2019. Geneva: Switzerland 2019.

2) Smoke-free Environments Act (1990) No 108 (Accessed: 14 March 2018).

3) Auckland Council. Review of Auckland Council’s Smokefree Policy 2013: Findings Report. Auckland: Auckland Council; 2016.

4) Ball J, Hoek J, Tautolo ES, Gifford H. New Zealand policy experts’ appraisal of interventions to reduce smoking in young adults: a qualitative investigation. BMJ Open. 2017;7(12): e017837.

5) Voigt K. Smoking Norms and the Regulation of E-Cigarettes. Am J Public Health. 2015;105(10):1967-72.

6) Smokefree Environments and Regulated Products (Vaping) Amendment Act 2020. (Accessed: 2 November 2020).

7) Health Promotion Agency. Maps of NZ Councils' Smokefree Outdoor Policies and Spaces. Retrieved 17 February from https://www.smokefree.org.nz/smokefree-resources/maps-of-nz-councils-smokefree-outdoor-policies-and-spaces2020.

8) Thomson G, Wilson N. Local and regional smokefree and tobacco-free action in New Zealand: highlights and directions. N Z Med J. 2017;130(1462):89-101.

9) Bethesda MD. The economics of tobacco and tobacco control: U.S. Department of Health and Human Services, National Institutes of Health; and the World Health Organization, Geneva, Switzerland; 2017.

10) Cornelsen L, McGowan Y, Currie-Murphy LM, Normand C. Systematic review and meta-analysis of the economic impact of smoking bans in restaurants and bars. Addiction. 2014;109(5):720-7.

11) Dobson Amato KA, Rivard C, Lipsher J, Hyland A. Five years after the Hawai'i smoke-free law: tourism and hospitality economic indicators appear unharmed. Hawaii J Med Public Health. 2013;72(10):355-61.

12) Cancer Society, Canterbury District Health Board. Evaluation of The Fresh Air Project: piloting smokefree outdoor dining areas in Christchurch. Christchurch: Cancer Society Canterbury-West Coast Division Inc, Community & Public Health (Canterbury DHB); 2017.

13) Adcock S. Personal communication, report by Shane Adcock, Marketing Manager of Hurunui Tourism Board: Presented to Hurunui Tourism Board at meeting 15 April 2019, p, 28-34. 2019.

14) Statistics New Zealand. 2018 Census place summaries, Hanmer Springs [Available from: https://www.stats.govt.nz/tools/2018-census-place-summaries/hanmer-springs#health.

15) Pope C, Ziebland S, Mays N. Qualitative research in health care. Analysing qualitative data. BMJ. 2000;320(7227):114-6.

16) Cancer Society. Consultation with business owners/managers on their views about introducing a smokefree street zone in Hanmer Springs. [Unpublished manuscript].

17) Thomson G, Russell M, Jenkin G, Patel V, Wilson N. Informing outdoor smokefree policy: methods for measuring the proportion of people smoking in outdoor public areas. Health & place. 2013; 20:19-24.

18) Gurram N. The point prevalence of smoking and vaping in Grey Street pocket square, Wellington: Report for the Wellington City Council on observations in Grey Street, Wellington in December 2018.; Wellington City Council. 2018.

19) Gurram N, Thomson G. The point prevalence of smoking and vaping in downtown locations in Wellington: Report for the Wellington City Council on observations in November 2018. Wellington City Council. 2018.

20) Martin N, McHugh H, Murtagh J, Oliver-Rose C, Panesar D, Pengelly H, et al. Observational study of the visibility of branded tobacco packaging and smoking at outdoor bars/cafes in Wellington, New Zealand. N Z Med J. 2014;127(1404):27-36.

21) Pearson AL, Nutsford D, Thomson G. Measuring visual exposure to smoking behaviours: a viewshed analysis of smoking at outdoor bars and cafés across a capital city’s downtown area. BMC Public Health. 2014;14(1):300.

22) Thomson G, Pathmanathan N. The point prevalence of smoking in selected sports fields and downtown locations in Wellington: Observations in Novembers 2015. University of Otago. 2016.

23) Bayer R. The continuing tensions between individual rights and public health. Talking Point on public health versus civil liberties. EMBO Rep. 2007;8(12):1099-103.

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Tobacco smoking remains a major cause of death and disability around the world, as well as a major contributor to health inequities.[[1]] Many countries have progressively implemented strong tobacco control policies and legislation to protect present and future generations from the considerable health, economic, social, and environmental impacts of tobacco.[[1]] In New Zealand, the Smokefree Environments Act 1990 was passed to “reduce the exposure of people who do not themselves smoke to any detrimental effect on their health caused by smoking by others”[[2]] and to regulate and control the marketing, advertising, and promotion of tobacco products. Legally-designated smokefree indoor spaces now have wide public and political support in New Zealand.[[3,4]] There is also growing interest and support for social denormalisation strategies, including the adoption of smokefree outdoor spaces; such as parks, playgrounds, and other public spaces.[[4]] Denormalisation strategies are designed to influence social norms and modify addictive nicotine-use behaviours (including vaping).[[4,5]] Denormalisation involves changing tobacco/nicotine use from acceptable and desirable to unacceptable and undesirable, across a broad range of settings.[[3]] Decreasing the social acceptability of smoking has been shown to be a highly effective policy tool in reducing consumption.[[5]]

However, the effectiveness of denormalisation strategies has been challenged in recent years by the emergence of increasingly sophisticated electronic nicotine delivery systems (ENDS) — most commonly, e-cigarettes.[[5]] There has been protracted debate about the regulation of vaping in spaces where conventional cigarettes are currently prohibited. Vaping legislation was not introduced in New Zealand until 2020, prohibiting vaping on aircraft, and inside workplaces, schools, early childhood centres, and some other indoor public spaces (the legislation does not cover outdoor spaces).[[6]] In addition, progress in translating smokefree and vapefree outdoor rules into national policy has been limited, leaving sub-national jurisdictions to enact rules or bylaws on a case-by-case basis.[[7,8]]

Whilst many councils across New Zealand have implemented smokefree outdoor spaces to some degree, the extension of these policies into business areas and the adoption of vapefree outdoor spaces is still limited.[[7,8]] Most examples of these initiatives have employed facilitative and promotional approaches and these initiatives primarily rely on signage and communication to build public support and promote compliance.[[7]] Despite the voluntary nature of New Zealand’s outdoor smokefree strategies, this approach can still arouse concern and resistance from some stakeholders. For example, some business owners may have concerns about economic harms, despite studies of smoking bans in the hospitality sector showing no overall substantial economic gains or losses[[9–11]] and such bans have been found to be popular with customers.[[12]]

Hospitality and tourism are important sectors for New Zealand and insufficient work has been done to investigate how acceptable smokefree and vapefree outdoor policies are to our domestic and international visitors. The aim of this mixed methods evaluation study was to obtain current information on the attitudes and level of support from visitors, residents, and businesses, for a smokefree and vapefree zone covering the central business streets of a New Zealand tourist town. The study also aimed to see if there were changes in observable smoking and vaping behaviours over the trial period (the study did not aim to demonstrate a change in the proportion of regular smokers/vapers within any group or over time).

To our knowledge, this is the first formal evaluation of a smokefree and vapefree zone simultaneously applied to the entire central business area of a tourist town in New Zealand (i.e., where there were no policies prior). The study also evaluated any reported impacts on stakeholders, including the hospitality and tourism-focused businesses that engaged with the evaluation interviews. This information may be helpful to local government authorities when considering whether public spaces adjacent to retail and other business premises can and should be both vapefree and smokefree.

Methods

This evaluation study used mixed methods to assess stakeholders’ experiences, perspectives, and attitudes towards the smokefree and vapefree zone trial. Broadly, the methods included online surveys, phone surveys, scheduled face-to-face interviews, public intercept surveys, pen and paper feedback cards, and field observations of smoking and vaping behaviours.

Intervention

Breathe easy in Hanmer Springs was a six-month trial of a smokefree and vapefree zone implemented across key public spaces, including the street frontage of the retail/business area of the village. The setting was Hanmer Springs, a popular tourist town in the South Island of New Zealand (population 960 in 2018; regular smokers 12.6%, 2018; 216,311 guest nights in the wider Hurunui District, with 33% international, 2018–2019 year).[[13,14]] The voluntary initiative was supported by signage and a communication plan. The aim of the communication plan was to raise public awareness of the initiative and to help empower the public to provide positive social reinforcement if smoking behaviours were observed in the zone. The majority of promotions were initiated at the launch of the trial (14 February 2019). A limited amount of reporting on the impending trial was seen in local and national print, online, and radio media in the months preceding the trial. The signage (placed just prior to the start of the trial) included one main display board/map and a range of metal and self-adhesive signs and posters, attached to all public picnic furniture, selected curbside poles, public toilet cubicles, council owned rubbish bins, and other public fixtures as suitable within the trial zone. Businesses were not required or requested to actively implement the no smoking/no vaping policy or messaging (although some may have done so to varying degrees).

Sample

Potential respondents were selected from three stakeholder groups within a specific geographical setting (a convenience sample). The three stakeholder groups were the local businesses (owners/managers), residents (or property owners/rate payers), and visitors to the township (both domestic and international). The recruitment of business owners/managers was via email and phone using contact information that had been compiled by a health promoter over the two years prior. Owners’/managers’ contact details were collated from lists provided by the local Business Association, and listings in local advertising and business directories, or displayed on premises within the village (if not identified via previous methods). The characteristics/classification of the recruited business respondents were: accommodation (n=15); hospitality (n=9, representing 13 businesses); retail (n=18, representing 21 businesses); tourism/outdoor activity (n=6); trade/service provider (n=6). Visitors were sampled via two methods: (1) random in-person point-intercept interviews on the streets within the zone; and (2) feedback cards placed at accommodation providers around the village. In total, 22 out of 38 identified accommodation providers agreed to include feedback cards in their guest room compendiums including motels, hotels, rental homes, backpackers, camping grounds and B&Bs (unlisted B&B and Airbnb were excluded). Residents were sampled via two methods: (1) random in-person point-intercept interviews on the streets within the zone; and (2) via invitations to engage online, including a URL link posted to a closed village social media group, QR codes on posters/signs within the zone, and via URL links posted in the local school and village newsletters.

Measures were put in place to reduce the possibility of multiple written responses (ballot stuffing) and multiple/duplicate online submissions (acknowledging that, with effort, these measures could have been circumvented). Firstly, manual scans were used to detect obvious duplication of tourist responses within each batch of handwritten response cards retrieved from each accommodation provider (one instance was detected, and copies removed). Secondly, the online survey platform collector settings used IP address to limit responses to one response per device.

Procedure

A base questionnaire (see Appendix) was drafted by the project team and peer reviewed by a public health physician. The base questionnaire included a core set of policy-relevant questions to be asked of all respondents. The central question assessed respondents’ level of support for the zone being specifically smokefree and vapefree (i.e., a vote in principle for vaping and smoking to be treated the same/differently with respect to outdoor public areas). The questionnaire also included questions on awareness of the zone and support for the zone becoming permanent (as implemented in the specific context of Hanmer Springs). In the interest of brevity, these secondary questions are not reported here. The base questionnaire did not include demographics, as the evaluation study was not intended to have enough statistical power to perform sub-group analyses (including smoking/vaping vs non-smoking/non-vaping).

The base questionnaire was then tailored to the different stakeholder groups by adding supplementary questions that explored different stakeholder perspectives and experiences (e.g., any impacts on business, tourists’ likelihood to visit other smokefree and vapefree tourist destinations, and residents’ perspectives). The questionnaire format was also optimised for use online, for pen and paper completion, and to suit a semi-structured face-to-face interview format.

The semi-structured interview schedules for use with the business representatives (see Appendix) were the most in-depth questionnaires. The interview schedule was developed using an applied qualitative research approach[[15]] whereby the questions were shaped by the information requirements of the stakeholders, as apparent from a prior scoping/consultation one year earlier.[[16]] The two interviewers (a Public Health Analyst and a Health Promoter, both from Community & Public Health, Canterbury DHB) used role play to practice and refine the interview schedule and feedback was provided by a third assessor (another Public Health Analyst, also from Community & Public Health, Canterbury DHB). The interviews with business representatives typically lasted 30 minutes and included open-ended questions and probes. The questions asked for detailed information about any effects of the zone on businesses’ operations and staff. All respondents were also given the opportunity to provide one open response on any aspect of the smokefree and vapefree trial. The business interview settings included retail and hospitality premises, accommodation providers, and other recreational and outdoor adventure providers.

The face-to-face interviews with members of the public were facilitated by a Health Promotion Advisor from Cancer Society, Canterbury West Coast Division, and three volunteer research assistants also provided by the Cancer Society (the volunteers undertook a site orientation and training session on the day). These interviews were conducted on public streets within the trial zone. All interviews and surveys were undertaken between 14 February and 18 July 2019.

The observations employed multiple four-minute scanning cycles, based on the methods developed by Thomson and colleagues.[[17]] Specifically, observations of the smoking and vaping behaviours of those who appeared to be over 12 years old (and who are inclined to smoke/vape in public on the street) were made across four defined 10–20m[[2]] sites within the smokefree and vapefree zone. Note that age 12 is a methodological classification not a legal classification, as used in Thomson and colleagues’ established observation protocol.[[17]] The observations were undertaken by two observers (from the Cancer Society, Canterbury West Coast Division, having undertaken specific training/field trials focused on minimising inter-observer bias). The observations were conducted over five weekend days, in two periods (daytime only, as the policy is in large part about denormalisation and modelling smokefree and vapefree to young people). The pre-intervention observations were conducted just prior to the introduction of the trial on February 14th (Valentine's Day). Hanmer Springs visitor numbers peak noticeably on weekends and school holidays and the “family friendly” attractions in Hanmer Springs draw large numbers of families. The high proportion of children typically present in the village during the school holidays and during the weekends may influence adults’ smoking and vaping behaviours (downwards),[[18–22]] therefore, all of the observation times were scheduled to provide a similar context (school holidays–weekends) for all observations. Additional observations comprised set walking loops and between site observations for the general monitoring of tobacco litter, any observed displacement of smokers/vapers to out-of-zone areas, and/or any other unanticipated effects.

Analysis

Qualitative data were analysed using a systematic iterative thematic approach to identify recurring patterns, following the method described by Pope and Mays and others.[[15]] The multi-choice and three-point Likert scale questionnaire (Appendix) responses were extracted from the different iterations of the surveys/interviews and the proportion of respondents in agreement with the various statements were calculated for each stakeholder group. Some respondents did not answer all questions and percentages were calculated excluding missing responses. The observational data (smoking and vaping behaviours) were analysed by means of Chi-squared tests (using SAS version 9.4, SAS Institute Inc., Cary, NC) to determine any differences in the observed smoking and vaping behaviours between baseline and follow-up.

Ethics

It was determined that this evaluation did not meet the criteria triggering a need for Health and Disability Ethics Committee review. The evaluation was considered low risk as it did not involve the collection of health information, age, gender, or ethnicity, and the responses were confidential and anonymous. Those invited could decline to participate, or choose not to answer any particular question, if they wished.

Results

Participants

In total, 956 individuals provided responses to the surveys, comprising 680 visitors, 222 residents, and 54 business representatives (Table 1). Of the 956 responses, 548 were completed via pen and paper feedback cards, 211 were completed face-to-face, and 197 were completed online. Most of the visitors’ responses were collected via the pen-and-paper feedback cards (n=548 out of 680 visitor responses) with an additional 132 visitors having provided information via face-to-face interviews on the street. Most of the residents’ responses were collected online (n=166) with an additional 56 residents interviewed on the streets within the smokefree and vapefree zone (total n=222 residents).

The response rate for businesses was approximately 36.5% (54 of 148 identified eligible businesses invited to participate). The response rates for the face-to-face interviews on the street, the residents’ online surveys, and the visitor feedback cards could not be calculated as the denominators were not known.

Key findings

Visitors

Overall, 84% (n=568) of responding visitors indicated that they supported the zone being both smokefree and vapefree (83%, n=118 International and 84%, n=450 Domestic visitors). A further 8% (n=53) of responding visitors indicated vaping should be allowed in the zone (but supported smokefree) and 9% (n=59) indicated both vaping and smoking should be allowed in the zone (i.e., didn’t support the zone) (Figure 1). Further, 54% of responding visitors (n=297) indicated that they would be more likely to visit other places with smokefree and vapefree zones, 40% (n=220) indicated no preference, and 6% (n=30) indicated that they would be less likely to visit other places with smokefree and vapefree zones. Overall, 95% of responding visitors said they would be more likely or as likely to visit other places in New Zealand that have no smoking/no vaping zones (97%, n=111 International and 94%, n=406 Domestic visitors). International visitors tended to indicate similar levels of support for the zone compared with domestic visitors. Approximately 150 visitors also provided either written or verbal comments regarding their experiences and opinions on voluntary smokefree and vapefree outdoor spaces (summarised in Table 2).

Residents

Overall, 67% (n=138) of the resident respondents indicated that they supported the zone being both smokefree and vapefree. A further 6% (n=12) indicated vaping should be allowed in the zone (but supported smokefree) and 27%(n=55) indicated both vaping and smoking should be allowed in the zone (i.e., didn’t support the zone) (Figure 1). In addition, the respondents provided 115 comments about their level of support for the zone or about different aspects of smokefree and vapefree regulation generally (summarised in Table 2).

Businesses

Overall, 63% (n=34) of 54 respondents from businesses indicated that they supported the zone being both smokefree and vapefree. A further 4% of responding businesses (n=2) indicated vaping should be allowed in the zone (while supporting smokefree) and 32% (n=17) indicated both vaping and smoking should be allowed in the zone (i.e., didn’t support the zone) (Figure 1). One respondent was undecided. Most respondents from this group reported that the trial had no overall effect on their business, including no notable effects on customer numbers, spending patterns, or customer feedback (no change, 70%, n=37; a positive effect, 13%, n=7; a negative effect, 17%, n=9). Most respondents from this group also reported that the trial had no notable negative effects on staff (no effect 87%, n=45; yes an effect 14%, n=7). The business owners and managers were also asked for their general opinion of the smokefree and vapefree zone and for any final comments on the zone’s effects or relevance to their business. In total, 80 responses were evaluated, including 53 general opinions and 27 business-related comments (summarised in Table 2).

View Figure 1 & Table 2.

Observations

The implementation of the smokefree and vapefree zone was associated with a quantifiable reduction in smoking and vaping behaviours within the designated area. The baseline observations showed a combined observed smoking/vaping point prevalence of 1.9% (of 3,355 people over 12 years old observed for up to four minutes, there were 3,292 non-smoking/vaping; 58 who were smoking; five who were vaping). This declined to 0.4% (of 3,740 people over 12 years old observed for up to four minutes, there were 3,725 non-smoking/vaping; 13 who were smoking; two who were vaping) post-implementation (p<0.001). Across the two observation periods, there were 10 hours and 46 minutes of field observations and a total count of 7,095 people over 12 years old. Approximately 20% of all passers-by were children (those judged to be 12 years or under). No obvious displacement effects (i.e., smokers/vapers simply moving somewhere else) or socially disruptive behaviours were observed.

View Figure 1 & Tables.

Discussion

The evaluation findings provide information on the feasibility of implementing smokefree and vapefree outdoor area policies in tourist-destination communities. This study indicates that smokefree and vapefree zones such as this can be implemented and are acceptable to most stakeholders. Given the voluntary nature of the policy, acceptability would appear to be important for successful implementation/up-scaling. This study, and others,[[18,19,22]] indicate that zones such as this can change people’s behaviour so that there is less observable smoking and vaping within a defined outdoor public area (although we do not claim to have established causality, only that the observed point estimate at baseline was statistically different to the observed point estimate at follow-up). There was also no observed displacement of smokers or vapers to out-of-zone areas, or anti-social behaviours, or other unanticipated effects noted.

This evaluation indicates support for smokefree and vapefree outdoor areas, particularly from tourists (including international tourists) and residents. Overall, a clear majority of the nearly 1,000 non-random respondents supported the implementation of the smokefree and vapefree zone as applied to the central business streets of a small tourist town (including, that the same rules be applied to smoking and vaping). The results indicate a supportive majority in each of the three stakeholder groups studied: businesses, residents, and notably, visitors. Understandably, some business owners and residents in tourist towns may be concerned that smokefree and vapefree outdoor areas will pose a deterrent to visitors. However, these evaluation findings suggest the opposite. Most respondents from the business group reported that the trial had no overall effect on their business, including no notable effects on customer numbers, spending patterns, or customer feedback. The support for the trial, in turn, led the Council to adopt the policy as an ongoing initiative, and hence the streets within the central district of the village now model the denormalisation of tobacco products.

Decreasing the social acceptability of smoking (denormalisation) has been shown to be an effective policy tool in reducing consumption.[[4,5]] These favourable results should provide reassurance to other local authorities that implementing smokefree/vapefree policies is feasible and is generally viewed favourably by most stakeholders. As with many policy decisions, the argument for smoking and vaping restrictions requires a weighing of the pros and cons and consideration of how the effects impact on different individuals.[[23–25]] Several themes relating to the ethics of denormalisation strategies, smokers’ preferences, and issues of freedom and autonomy, have been discussed at length in the literature[[26–28]] and are not discussed in detail here. However, it is important to acknowledge that while some groups may experience a wellbeing gain from the implementation of a smokefree/vapefree zone (e.g., by averting substantial health losses), others’ wellbeing might be negatively affected (e.g., loss of enjoyment, stigmatisation). Individuals and groups may weigh the benefits and potential costs of restrictions differently.

This evaluation suggests that the introduction of smokefree and vapefree outdoor policies in tourist areas in New Zealand can reduce how often young people see smoking behaviours. This can contribute to denormalisation (and by extension reduce initiation) and help provide a more supportive environment for those trying to quit. Considering the low-cost nature of policies such as these,[[1]] the high support among different stakeholder groups, and no reported impacts on the hospitality/tourism providers, we conclude net positive effects are possible, over the long term, which will support New Zealand’s smokefree 2025 goal and ultimately benefit public health.

This study is based on survey responses from business owners/managers, visitors and residents of a small tourist village in the South Island of New Zealand who agreed to participate in the evaluation. It is possible that some differences in views exist between those who chose to provide feedback and those who did not. The question of representativeness is relevant because this paper aims to provide reassurance to other local authorities that implementing smokefree/vapefree policies is feasible and is generally viewed favourably by most stakeholders. Considerable effort was directed towards accurately measuring support for the initiative in Hanmer Springs by seeking opinions from a broad range of stakeholder groups via a variety of survey methods. While the potential for response bias and/or mode effects cannot be discounted, the sampling and survey methods provided several accessible anonymous channels for individuals to provide feedback. Without any evidence to the contrary, we suggest that those opposed to the initiative or in support of the initiative were, on average, similarly able to speak up. Furthermore, our estimates of support for a smokefree and vapefree zone are high, consequently, any non-response bias would have to be very substantial to change the conclusions and implications of our study. Some differences in the characteristics of the language used across some response modes were noted (e.g., notable aggression in some survey responses linked via social media) but these differences could not be quantified, and no allowances were made in the analysis. Future initiatives may need to be adjusted/scaled for towns and cities with varied CBD size, layout, and amenity characteristics, and these factors should be considered when tailoring future intervention designs.

Conclusion

This study provides affirming information on the feasibility of implementing smokefree and vapefree outdoor area policies in tourist-destination communities. Smokefree and vapefree zones across key public spaces in retail/business areas can be implemented and are likely to be acceptable to most stakeholders. We conclude that net positive effects are possible over the long-term, that will support New Zealand’s smokefree 2025 goal.

View Appendix.

Summary

Abstract

Aim

To (a) evaluate the attitudes of local businesses, residents, and visitors regarding the trial of a voluntary smokefree and vapefree zone covering the central business streets of a popular tourist town in the South Island of New Zealand, and (b) observe smoking and vaping prevalence before and during the trial, to inform national and local smokefree environment advocacy work.

Method

The six-month smokefree and vapefree trial included an embedded mixed methods project evaluation to capture a range of stakeholder groups’ views about the smokefree and vapefree zone. Data collection methods included face-to-face interviews, non-random pen and paper and online surveys, and observational scans. Qualitative data were analysed using a systematic iterative thematic approach, and simple descriptive quantitative analyses were applied to the survey data.

Results

The analysis synthesised information from almost 1,000 respondents. A large majority of respondents supported smokefree and vapefree within the zone (visitors 84%; residents 67%; businesses 63%). A majority of responding visitors indicated that the same rules should apply to both smoking and vaping and that they would be either more likely or as likely to visit other tourist destinations in New Zealand if they had smokefree and vapefree zones. Implementing the initiative was associated with a reduction in the number of people visibly smoking and vaping within the zone.

Conclusion

The weight of evidence from the project evaluation points towards a net benefit both for individuals and for the community from implementing voluntary smokefree and vapefree zones in tourist destinations in New Zealand.

Author Information

Dr David Brinson: Public Health Analyst, Community & Public Health, Canterbury District Health Board, Christchurch. Charlotte Ward: Public Health Analyst, Community & Public Health, Canterbury District Health Board, Christchurch. Cheryl Ford; Health Promotion Advisor, Cancer Society of New Zealand Canterbury-West Coast Division Inc., Christchurch. Dr Annabel Begg: Public Health Specialist, Community & Public Health, Canterbury District Health Board, Christchurch.

Acknowledgements

The authors wish to acknowledge Gemma Claridge (Intern, Cancer Society, Canterbury West Coast Division) for undertaking several on-site smoking/vaping prevalence observations; Christina Lewis (Community & Public Health, Canterbury DHB) for her assistance with data collection (face-to-face interviews); Colleen Moore (Secretary, Community & Public Health, Canterbury DHB) for her data entry of these interview transcripts; and George Thomson (University of Otago) for his review of the manuscript. We also wish to thank the survey respondents for their participation, and the Cancer Society volunteers involved in participant recruitment and data collection.

Correspondence

Dr Annabel Begg: Community & Public Health, Canterbury District Health Board, 310 Manchester Street, Christchurch, PO Box 1475, Christchurch 8140, New Zealand.

Correspondence Email

annabel.begg@cdhb.health.nz

Competing Interests

Nil.

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