The Māori Affairs Select Committee (MASC) Inquiry in New Zealand on tobacco has released a report that is "bold and visionary" on many grounds.1 Firstly, it sets an ambitious but achievable goal of making New Zealand smokefree by 2025, with a clear interim target of halving tobacco consumption and smoking prevalence among all groups by 2015. The smokefree goal is, to our knowledge, the first such proposal in the world by an official body (e.g. the Finnish Government goal is not tied to a date2). Secondly, the Report recommends a comprehensive and cutting-edge programme of measures to achieve this goal—some of which would be new for New Zealand (e.g. removing point of sale displays), some new for anywhere in the world (e.g., direct intervention to reduce retail supply of tobacco products) and others which intensify existing interventions (e.g. additional tobacco tax increases). It further recommends that an updated tobacco control strategy be developed, and addresses the issue of the structure of tobacco control management. Thirdly, it clearly targets the vector of the tobacco epidemic, the tobacco industry rather than the smoker, and suggests that tobacco control innovations "should place financial, ethical and legal pressure primarily on the tobacco industry". Fourthly, the MASC Report challenges the current strategy which focuses mainly on smoking cessation support, and makes it clear that broad policy interventions are necessary. One of the most innovative features is an additional focus on reducing the supply of tobacco, e.g. consideration of annually reducing tobacco imports and the number of retail outlets. The recommendation of empowering local councils to limit the numbers and location of retailers is an important and innovative aspect of the Report, which fits well with the strong community drives to limit alcohol and gambling outlets in New Zealand.3 Finally, the Report places primacy on those who are disproportionately affected by the tobacco epidemic, Māori smokers and their whānau (extended family). It recommends Māori participation and leadership, kaupapa Māori approaches and a focus on interventions to reduce smoking among Māori. Implementation of the approach recommended by the Select Committee would contribute substantially to improving Māori health and reducing health inequalities.4 It is critical to note that the MASC is not running against public opinion. Rather, it is legitimised by strong and increasing public support (including among smokers) for stronger actions on tobacco.5-11 For example, new data indicates that those agreeingwith the statement ‘the number of places allowed to sell cigarettes and tobacco should be reduced to make them less easily available' remained high at 65% and 67% during 2008-2010. Likewise, those agreeing with the statement ‘tobacco companies should not be allowed to promote cigarettes and tobacco by having different brand names and packaging' increased from 54% to 60.12 Thus, the New Zealand public (including smokers) support the direction of this bold policy prescription, legitimising government and societal action to achieve the smokefree goal. The full list of the MASC Report's 43 recommendation, and two commendations, are listed in Table 1. This is a comprehensive list, covering most important domains of tobacco eradication. The remainder of this Editorial is grouped in three Parts: Part 1 is an analysis of the MASC's recommendations, with a particular view to what should happen next and in what priority order. Part 2 examines what else might be needed to ensure a Smokefree New Zealand is achieved by 2025. Part 3 is a summary and our view of what we need to do now. Part 1: Analysis of the MASC recommendations The MASC's recommendations can be grouped into four categories: Done or in progress—The already in-train tobacco tax rises and the ban on smoking in prisons are the most obvious examples. The planned legislation announced by Minister Turia the day after the Report's release addresses six more of the recommendations (Table 1). Do now—Many other recommendations in the MASC Report could be implemented now, without great cost, and without limiting options on the harder decision making needed for finalising the comprehensive strategy. We identified 14 such ‘Do now' options, ranging from getting rid of vending machines to ensuring the age of the person selling tobacco is 18 years plus. Develop policy options in 2011—Some recommendations require careful policy analysis and decision-making. For example, the MASC was very careful in pointing to the need for more deliberative decision making about: using declining import quotas, regulating tobacco constituents (e.g. changing the palatability and/or nicotine content of tobacco products13,14), the role of alternative nicotine delivery systems, and (most importantly in the medium term) what the exact shape of a new strategy should be to get to a halving of prevalence and consumption by 2015. The MASC, understandably, was not able to do this detailed strategy development work, but it urgently needs doing by mid 2011 at the latest. Options for this responsibility include the Ministry of Health, or a Taskforce that reports back to Parliament. Information for decision-making is of course imperfect, but there is sufficient information to formulate a strategy that will guarantee achievement of firstly the 2015 goal, then with revision a high probability of achieving the ultimate goal by 2025. The strategy development work needs to be co-ordinated with other work and sectors. The Ministry of Health has just approved funding (November 2010) for the development of a Māori Tobacco Control Strategy; strong partnerships will be essential to ensure that the emphasis expected by MASC of Māori-focused outcomes within a national strategy is achieved. One of the most promising recommendations in the Report is that additives and nicotine levels in tobacco products should be regulated. Reducing nicotine levels as an over-arching strategy is an avenue for which there is some evidence.15-20 The mandatory removal of all sweeteners and other additives could ensure tobacco products are less addictive or palatable, and thus reduce demand and initiation.21-23 These approaches require much greater attention to progress beyond aspirations to concrete policy development and implementation—with ongoing evaluation. We believe they could have a key role alongside price increases, and a tobacco import reduction policy.24 Clarifying how these mechanisms should be used in New Zealand in the next 5-15 year is a crucial output of the policy analysis and decision making work during 2011. Develop an overall social marketing plan—The MASC commend past campaigns, and recommends strengthening some of these (e.g. increasing support, including financial, to iwi and communities to promote smokefree events). It recommends the introduction of new mainstream campaigns (e.g. on tobacco and tobacco industry ‘denormalisation' similar to that promoted by Te Reo Marama) and new approaches (e.g. Internet and social network websites). One recommended marketing strategy is, in our view, so urgent that it should happen now, i.e. campaigns to reduce social supply to minors. Otherwise we think a cohesive and planned overall strategy of marketing is required to be developed in parallel with the policy planning (i.e. Category C above). Part 2: Ensuring a smokefree 2025 is achievable Policy articulation, then implementation, may be particularly challenging in this area, since it is highly contested by tobacco companies and their allies. Maintaining, building and extending bipartisan political leadership is critical. Here we address two aspects arising from the MASC Report that need further development to maximise the chance of success: An overarching mechanism to ensure the goal is achieved by 2025; and Several key elements of the package that need greater emphasis and better specification. The need for an overarching mechanism Imagine you are the newly appointed Director of the proposed Tobacco Control Agency charged with achieving the 2025 smokefree goal. What are going to be the key mechanisms to ensure success? The MASC Report suggests a comprehensive range of measures with increased activity proposed in many effective domains of tobacco control. However, most are incremental steps, and even implementing all of these measures will not ensure that the goal is achieved by 2025. If we were the Director(s) of the agency accountable for achieving the 2025 goal, we would want the necessary legal powers, including the goal of a smokefree Aotearoa embedded in law; and we would require an effective overarching mechanism supported by legislation and sufficient resources. The MASC Report highlights three potential mechanisms that we think could act as the backbone for achieving the goal (together or separately): annually reducing tobacco imports such that zero retail supply is guaranteed by 2025; an ongoing series of substantial tax rises that will achieve near zero demand by 2025; or regulation of tobacco constituents (the moving to zero-nicotine cigarettes being the most obvious ‘key' mechanisms). Decisions will be required on what over-arching mechanism New Zealand is going to use, how best to integrate this with the full package of adjuncts measures listed in the MASC Report, and how to deal with potential sequelae and ethical issues (e.g. will we need a system of licensed smokers near 2025 for those smokers who at that stage cannot quit?). If rising tax is chosen as the best overarching mechanism,25-27 a predefined programme of sufficiently large tobacco price increases, could ensure smoking prevalence is near-zero by 2025. A series of 10% per tax rises annum may not be enough, unless accompanied by other measures such as changes to tobacco constituents, and massive increases in cessation and social marketing. We believe that achieving the smokefree goal with tax as the main mechanism will need a clear 10-15 year programme of large annual tobacco tax rises, probably at well over 20% a year. The effects would need to be well monitored, to ensure that smoking prevalence is dropping across all groups. Similar policy analysis would be needed to develop the strategies for implementing the reducing imports or zero-nicotine approaches. Some suggested additions to the recommended measures As well as an over-arching mechanism, we propose some additional details that may increase clarity and the chances of success of a tobacco control strategy based on the MASC Report recommendations. These activities do not need to be in place immediately; rather they can be phased into the early parts of the implementation. Clearer goal definition—The MASC Report does not elaborate on what is meant by a ‘smokefree' nation. We suggest that this should mean the complete end of tobacco sales and that smoking prevalence is close to zero per cent. This would not be ‘prohibition', as it would allow for persisting smokers to consume their home-grown tobacco, or to perhaps receive tobacco under some license system. Ensuring Maori health gains—Ensuring particularly rapid progress in reducing the tobacco burden on Māori is critical, and the MASC Report appropriately focuses on this. The Report suggests many useful strategies such as targeted funding and services, support for Māori specific responses, strong Māori participation at all levels of decision making, and monitoring of outcomes for Māori. It will be critical to ensure that Government understand the wider population support for reducing smoking rates for Māori, and that encouragement is given from all communities and agencies to ensure that recommendations aimed particularly at improving outcomes for Māori are realised. Identifying the most cost-effective approaches—To maximise the cost-effectiveness of efforts to achieve a smokefree Aotearoa, the Government needs to clearly identify which tobacco control interventions are the most cost-effective (preferably either cost-saving or near cost neutral) to run.35 36 For instance, tobacco tax interventions can be revenue generating, as would a sales quota auction system.35 37 38 Regulations - to ensure larger pictorial health warnings and to eliminate marketing on packs and in point-of-sale displays - are also a very effective and low cost intervention (i.e. it is the industry which pays for printing the warnings on tobacco packaging).39 Smoking cessation approaches also need to be considered in terms of reach (especially to Māori), effectiveness and cost-effectiveness. However, we also note that there will be a need to implement measures that logically have a high chance of success, but that have not been implanted or evaluated before. We should be brave enough to implement such groundbreaking interventions, but also to evaluate them to ensure they are actually effective and cost-effective. Reducing the power of the tobacco industry—The MASC Report recommends that Government holds the tobacco industry accountable, and proposes a range of measures to eliminate the interference of the industry in undermining public health policies, including considering embedding Article 5.3 of the Framework Convention on Tobacco Control in legislation, and legislating various aspects of the Article 5.3 Guidelines. The latter requires that "in setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law."41 In addition to these highly desirable measures, we suggest at least two other policy avenues. First, legislation requiring the divestment by all public agencies, (national and local) of tobacco industry investments (manufacturing and retailing). Second, legislation requiring tobacco industry marketing, public relations, lobbying, donations and accounts to be public. This would help to limit their ‘ability to operate, to hide and to obscure their behaviour and their ability to neglect the externalities of their products and escape responsibility for them'42 and facilitate implementation of Article 5.3. Part 3: Summary, and what we need to do now In summary, we congratulate the MASC for providing bold leadership towards ending the tobacco epidemic for Māori and for all other New Zealanders, and in setting out a comprehensive range of options in the countdown towards a smokefree nation. The MASC Report is the first New Zealand tobacco control strategy document from an ‘official' source which proposes measures commensurate with the scale and the urgency of the ongoing public health disaster from the tobacco epidemic. We have suggested some refinements and additions about next steps, but these should not detract from the overall assessment that this is a landmark Report. Furthermore, there are good signs that the political leadership to act on these recommendations exists (e.g. a plan for new tobacco control legislation was introduced by Hon Tariana Turia). However, getting sufficient change will also depend on the activities of advocates and health professionals in getting behind the Report, building coalitions and generating active public and media support so that politicians see action as a necessity. So what should we and you do next? First and foremost, commend the MASC Report to colleagues, patients, friends and civil society. Second, enter the public debate about the recommendations. Third, we all need to advocate for and contribute wherever we can to the implementation of the strategy. As a health workforce we have all seen the carnage of the tobacco epidemic, and we are now starting to coalesce around the goal of being smokefree as a nation. We need to further communicate this goal to the whole health sector, the media and the public. Let the countdown to a Tupeka Kore Aotearoa begin.

The Māori Affairs Select Committee (MASC) Inquiry in New Zealand on tobacco has released a report that is "bold and visionary" on many grounds.1 Firstly, it sets an ambitious but achievable goal of making New Zealand smokefree by 2025, with a clear interim target of halving tobacco consumption and smoking prevalence among all groups by 2015. The smokefree goal is, to our knowledge, the first such proposal in the world by an official body (e.g. the Finnish Government goal is not tied to a date2). Secondly, the Report recommends a comprehensive and cutting-edge programme of measures to achieve this goal—some of which would be new for New Zealand (e.g. removing point of sale displays), some new for anywhere in the world (e.g., direct intervention to reduce retail supply of tobacco products) and others which intensify existing interventions (e.g. additional tobacco tax increases). It further recommends that an updated tobacco control strategy be developed, and addresses the issue of the structure of tobacco control management. Thirdly, it clearly targets the vector of the tobacco epidemic, the tobacco industry rather than the smoker, and suggests that tobacco control innovations "should place financial, ethical and legal pressure primarily on the tobacco industry". Fourthly, the MASC Report challenges the current strategy which focuses mainly on smoking cessation support, and makes it clear that broad policy interventions are necessary. One of the most innovative features is an additional focus on reducing the supply of tobacco, e.g. consideration of annually reducing tobacco imports and the number of retail outlets. The recommendation of empowering local councils to limit the numbers and location of retailers is an important and innovative aspect of the Report, which fits well with the strong community drives to limit alcohol and gambling outlets in New Zealand.3 Finally, the Report places primacy on those who are disproportionately affected by the tobacco epidemic, Māori smokers and their whānau (extended family). It recommends Māori participation and leadership, kaupapa Māori approaches and a focus on interventions to reduce smoking among Māori. Implementation of the approach recommended by the Select Committee would contribute substantially to improving Māori health and reducing health inequalities.4 It is critical to note that the MASC is not running against public opinion. Rather, it is legitimised by strong and increasing public support (including among smokers) for stronger actions on tobacco.5-11 For example, new data indicates that those agreeingwith the statement ‘the number of places allowed to sell cigarettes and tobacco should be reduced to make them less easily available' remained high at 65% and 67% during 2008-2010. Likewise, those agreeing with the statement ‘tobacco companies should not be allowed to promote cigarettes and tobacco by having different brand names and packaging' increased from 54% to 60.12 Thus, the New Zealand public (including smokers) support the direction of this bold policy prescription, legitimising government and societal action to achieve the smokefree goal. The full list of the MASC Report's 43 recommendation, and two commendations, are listed in Table 1. This is a comprehensive list, covering most important domains of tobacco eradication. The remainder of this Editorial is grouped in three Parts: Part 1 is an analysis of the MASC's recommendations, with a particular view to what should happen next and in what priority order. Part 2 examines what else might be needed to ensure a Smokefree New Zealand is achieved by 2025. Part 3 is a summary and our view of what we need to do now. Part 1: Analysis of the MASC recommendations The MASC's recommendations can be grouped into four categories: Done or in progress—The already in-train tobacco tax rises and the ban on smoking in prisons are the most obvious examples. The planned legislation announced by Minister Turia the day after the Report's release addresses six more of the recommendations (Table 1). Do now—Many other recommendations in the MASC Report could be implemented now, without great cost, and without limiting options on the harder decision making needed for finalising the comprehensive strategy. We identified 14 such ‘Do now' options, ranging from getting rid of vending machines to ensuring the age of the person selling tobacco is 18 years plus. Develop policy options in 2011—Some recommendations require careful policy analysis and decision-making. For example, the MASC was very careful in pointing to the need for more deliberative decision making about: using declining import quotas, regulating tobacco constituents (e.g. changing the palatability and/or nicotine content of tobacco products13,14), the role of alternative nicotine delivery systems, and (most importantly in the medium term) what the exact shape of a new strategy should be to get to a halving of prevalence and consumption by 2015. The MASC, understandably, was not able to do this detailed strategy development work, but it urgently needs doing by mid 2011 at the latest. Options for this responsibility include the Ministry of Health, or a Taskforce that reports back to Parliament. Information for decision-making is of course imperfect, but there is sufficient information to formulate a strategy that will guarantee achievement of firstly the 2015 goal, then with revision a high probability of achieving the ultimate goal by 2025. The strategy development work needs to be co-ordinated with other work and sectors. The Ministry of Health has just approved funding (November 2010) for the development of a Māori Tobacco Control Strategy; strong partnerships will be essential to ensure that the emphasis expected by MASC of Māori-focused outcomes within a national strategy is achieved. One of the most promising recommendations in the Report is that additives and nicotine levels in tobacco products should be regulated. Reducing nicotine levels as an over-arching strategy is an avenue for which there is some evidence.15-20 The mandatory removal of all sweeteners and other additives could ensure tobacco products are less addictive or palatable, and thus reduce demand and initiation.21-23 These approaches require much greater attention to progress beyond aspirations to concrete policy development and implementation—with ongoing evaluation. We believe they could have a key role alongside price increases, and a tobacco import reduction policy.24 Clarifying how these mechanisms should be used in New Zealand in the next 5-15 year is a crucial output of the policy analysis and decision making work during 2011. Develop an overall social marketing plan—The MASC commend past campaigns, and recommends strengthening some of these (e.g. increasing support, including financial, to iwi and communities to promote smokefree events). It recommends the introduction of new mainstream campaigns (e.g. on tobacco and tobacco industry ‘denormalisation' similar to that promoted by Te Reo Marama) and new approaches (e.g. Internet and social network websites). One recommended marketing strategy is, in our view, so urgent that it should happen now, i.e. campaigns to reduce social supply to minors. Otherwise we think a cohesive and planned overall strategy of marketing is required to be developed in parallel with the policy planning (i.e. Category C above). Part 2: Ensuring a smokefree 2025 is achievable Policy articulation, then implementation, may be particularly challenging in this area, since it is highly contested by tobacco companies and their allies. Maintaining, building and extending bipartisan political leadership is critical. Here we address two aspects arising from the MASC Report that need further development to maximise the chance of success: An overarching mechanism to ensure the goal is achieved by 2025; and Several key elements of the package that need greater emphasis and better specification. The need for an overarching mechanism Imagine you are the newly appointed Director of the proposed Tobacco Control Agency charged with achieving the 2025 smokefree goal. What are going to be the key mechanisms to ensure success? The MASC Report suggests a comprehensive range of measures with increased activity proposed in many effective domains of tobacco control. However, most are incremental steps, and even implementing all of these measures will not ensure that the goal is achieved by 2025. If we were the Director(s) of the agency accountable for achieving the 2025 goal, we would want the necessary legal powers, including the goal of a smokefree Aotearoa embedded in law; and we would require an effective overarching mechanism supported by legislation and sufficient resources. The MASC Report highlights three potential mechanisms that we think could act as the backbone for achieving the goal (together or separately): annually reducing tobacco imports such that zero retail supply is guaranteed by 2025; an ongoing series of substantial tax rises that will achieve near zero demand by 2025; or regulation of tobacco constituents (the moving to zero-nicotine cigarettes being the most obvious ‘key' mechanisms). Decisions will be required on what over-arching mechanism New Zealand is going to use, how best to integrate this with the full package of adjuncts measures listed in the MASC Report, and how to deal with potential sequelae and ethical issues (e.g. will we need a system of licensed smokers near 2025 for those smokers who at that stage cannot quit?). If rising tax is chosen as the best overarching mechanism,25-27 a predefined programme of sufficiently large tobacco price increases, could ensure smoking prevalence is near-zero by 2025. A series of 10% per tax rises annum may not be enough, unless accompanied by other measures such as changes to tobacco constituents, and massive increases in cessation and social marketing. We believe that achieving the smokefree goal with tax as the main mechanism will need a clear 10-15 year programme of large annual tobacco tax rises, probably at well over 20% a year. The effects would need to be well monitored, to ensure that smoking prevalence is dropping across all groups. Similar policy analysis would be needed to develop the strategies for implementing the reducing imports or zero-nicotine approaches. Some suggested additions to the recommended measures As well as an over-arching mechanism, we propose some additional details that may increase clarity and the chances of success of a tobacco control strategy based on the MASC Report recommendations. These activities do not need to be in place immediately; rather they can be phased into the early parts of the implementation. Clearer goal definition—The MASC Report does not elaborate on what is meant by a ‘smokefree' nation. We suggest that this should mean the complete end of tobacco sales and that smoking prevalence is close to zero per cent. This would not be ‘prohibition', as it would allow for persisting smokers to consume their home-grown tobacco, or to perhaps receive tobacco under some license system. Ensuring Maori health gains—Ensuring particularly rapid progress in reducing the tobacco burden on Māori is critical, and the MASC Report appropriately focuses on this. The Report suggests many useful strategies such as targeted funding and services, support for Māori specific responses, strong Māori participation at all levels of decision making, and monitoring of outcomes for Māori. It will be critical to ensure that Government understand the wider population support for reducing smoking rates for Māori, and that encouragement is given from all communities and agencies to ensure that recommendations aimed particularly at improving outcomes for Māori are realised. Identifying the most cost-effective approaches—To maximise the cost-effectiveness of efforts to achieve a smokefree Aotearoa, the Government needs to clearly identify which tobacco control interventions are the most cost-effective (preferably either cost-saving or near cost neutral) to run.35 36 For instance, tobacco tax interventions can be revenue generating, as would a sales quota auction system.35 37 38 Regulations - to ensure larger pictorial health warnings and to eliminate marketing on packs and in point-of-sale displays - are also a very effective and low cost intervention (i.e. it is the industry which pays for printing the warnings on tobacco packaging).39 Smoking cessation approaches also need to be considered in terms of reach (especially to Māori), effectiveness and cost-effectiveness. However, we also note that there will be a need to implement measures that logically have a high chance of success, but that have not been implanted or evaluated before. We should be brave enough to implement such groundbreaking interventions, but also to evaluate them to ensure they are actually effective and cost-effective. Reducing the power of the tobacco industry—The MASC Report recommends that Government holds the tobacco industry accountable, and proposes a range of measures to eliminate the interference of the industry in undermining public health policies, including considering embedding Article 5.3 of the Framework Convention on Tobacco Control in legislation, and legislating various aspects of the Article 5.3 Guidelines. The latter requires that "in setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law."41 In addition to these highly desirable measures, we suggest at least two other policy avenues. First, legislation requiring the divestment by all public agencies, (national and local) of tobacco industry investments (manufacturing and retailing). Second, legislation requiring tobacco industry marketing, public relations, lobbying, donations and accounts to be public. This would help to limit their ‘ability to operate, to hide and to obscure their behaviour and their ability to neglect the externalities of their products and escape responsibility for them'42 and facilitate implementation of Article 5.3. Part 3: Summary, and what we need to do now In summary, we congratulate the MASC for providing bold leadership towards ending the tobacco epidemic for Māori and for all other New Zealanders, and in setting out a comprehensive range of options in the countdown towards a smokefree nation. The MASC Report is the first New Zealand tobacco control strategy document from an ‘official' source which proposes measures commensurate with the scale and the urgency of the ongoing public health disaster from the tobacco epidemic. We have suggested some refinements and additions about next steps, but these should not detract from the overall assessment that this is a landmark Report. Furthermore, there are good signs that the political leadership to act on these recommendations exists (e.g. a plan for new tobacco control legislation was introduced by Hon Tariana Turia). However, getting sufficient change will also depend on the activities of advocates and health professionals in getting behind the Report, building coalitions and generating active public and media support so that politicians see action as a necessity. So what should we and you do next? First and foremost, commend the MASC Report to colleagues, patients, friends and civil society. Second, enter the public debate about the recommendations. Third, we all need to advocate for and contribute wherever we can to the implementation of the strategy. As a health workforce we have all seen the carnage of the tobacco epidemic, and we are now starting to coalesce around the goal of being smokefree as a nation. We need to further communicate this goal to the whole health sector, the media and the public. Let the countdown to a Tupeka Kore Aotearoa begin.