Restricting supply of tobacco products to pharmacies: a scoping review.

OBJECTIVE: We synthesised the published literature on proposals to restrict tobacco supply to pharmacies, covering (1) policy concept/rationale/attempts, (2) policy impact and implementation and (3) policy and research recommendations. DATA SOURCES: We searched eight databases (PubMed, CINAHL, Scopus, Web of Science, Embase, IPA, ProQuest and OATD) for publications with at least an English-language abstract. We searched reference lists of included publications manually. STUDY SELECTION: One author screened all publications, and a second author reviewed a 10% subset. We focused on approaches to restrict the supply of tobacco products to pharmacies, without any restrictions on study design, location, participants or publication date. DATA EXTRACTION: Data extraction adhered to the JBI Scoping Review Methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. DATA SYNTHESIS: We included 18 publications. Among the 13 studies conducted in specific geographical contexts, 8 were from Aotearoa/New Zealand. Most publications (n=8) focused on effectiveness domains, indicating potential reductions in retailer density, smoking prevalence, disease burden, cost and increased opportunities for cessation advice. Seven explored policy acceptability among experts, pharmacists and people who smoke. Publications noted that pharmacy-only supply aligns with other programmes involving pharmacists, such as needle exchange programmes, but conflicts with efforts to phase out tobacco sales from the US and Canadian pharmacies. CONCLUSIONS: Progress in tobacco retailing policy (eg, licensing, retailer incentives) and research (eg, assessment of policy equity and durability, application in other geographical contexts) are needed before a pharmacy-only tobacco supply model would be feasible.

A qualitative analysis of how underage adolescents access nicotine vaping products in Aotearoa New Zealand.

INTRODUCTION: Despite policies setting a minimum legal sales age, youth continue to access electronic cigarettes (ECs). Evidence of rising youth vaping prevalence in many countries suggests existing measures have serious loopholes and raise important questions about how youth source vaping products. METHODS: We explored how youth source ECs using in-depth interviews with 30 adolescents aged 16-17 who vaped at least once a month and lived in Aotearoa New Zealand. Our semi-structured interview guide probed participants' vaping experiences and how they developed and used social, quasi-commercial, and commercial supply routes to access ECs. We used an inductive reflexive thematic analysis approach to interpret the data. RESULTS: Nearly all participants shared ECs with peers and sharing was the sole access route for some. Many used proxies, often older relatives or people they knew socially, to purchase ECs on their behalf; however, others recruited proxies by approaching previously unknown people they identified on social media. Participants also sourced ECs via quasi-commercial networks that existed within schools and on social media, and some purchased in their own right, usually from smaller retail outlets that did not ask for ID. CONCLUSIONS: Disrupting social supply will be challenging, though reducing ECs' availability, appeal, and affordability could make social supply, including sharing and proxy purchasing, more difficult. Reports that youth purchase ECs from commercial retailers known to waive age verification suggests stronger monitoring and enforcement, along with escalating retailer penalties, is required. IMPLICATIONS: Vaping access routes sit on a continuum from informal, spontaneous sharing to carefully planned commercial purchases.While supply via friends, siblings and other social contacts is an important means of access, nicotine dependence drives some to use riskier access routes, including approaching unknown people to act as proxy purchasers.Evidence young people identify non-compliant retailers suggests policy makers should monitor and enforce existing measures more stringently and consider additional penalties for recidivist under-age suppliers.A more comprehensive response that reduces the appeal, addictiveness, affordability, and availability of vaping products would address factors fostering and maintaining youth vaping.

Nicotine beliefs and perceptions of low nicotine labels and mitigating statements among people who do and do not smoke: a cross-sectional study from Aotearoa New Zealand.

BACKGROUND: Aotearoa New Zealand proposed a new maximum nicotine content of 0.8 mg/g for smoked tobacco products, although the new government plans to repeal this legislation. Requiring 'Very low nicotine' (VLN) messages on cigarettes meeting this standard may reinforce misperceptions that they are less harmful than cigarettes currently sold. METHODS: To explore knowledge of nicotine and very low nicotine cigarettes (VLNCs), and perceptions of cigarette packs featuring different low nicotine messages (eg, 'Very low nicotine') and mitigating statements (eg, 'No cigarettes are safe'), we surveyed 354 people who smoked, 142 who formerly smoked, and 214 people who had never smoked regularly. RESULTS: Around half of all respondents believed VLNCs were less harmful than regular cigarettes and around two-thirds incorrectly thought nicotine causes most of the related health problems resulting from smoking. Nearly a third thought VLNCs would be less harmful than regular cigarettes; 34% believed they would be just as harmful. Mitigating statements did not affect perceptions of people who smoked, although people who formerly, or who had never smoked regularly, perceived mitigating statements referring to poisons and cancer as significantly more likely than the VLN message to discourage smoking. CONCLUSIONS: Misunderstanding of VLNCs as less harmful than regular cigarettes is widespread; VLN messages may reinforce this misperception, which mitigating statements did not correct among people who smoke. As an alternative to VLN messages, policy makers could consider introducing VLNCs on a specified date and developing public information campaigns; these measures would avoid phase-in confusion and obviate the need for VLN messaging.

New Zealand community pharmacists' perspectives on supplying smoked tobacco as an endgame initiative: a qualitative analysis.

INTRODUCTION: Tobacco endgame strategies often include measures to reduce tobacco availability by decreasing retailer numbers. Recently, some US pharmacies have delisted tobacco, though overall retailer numbers have not reduced markedly. Paradoxically, others have suggested limiting tobacco sales to pharmacies, to reduce supply and support cessation. We explored how pharmacists from Aotearoa New Zealand, a country planning to reduce tobacco supply, perceived supplying tobacco. METHODS: We undertook in-depth interviews with 16 pharmacists from Otepoti Dunedin; most served more deprived communities with higher smoking prevalence. We probed participants' views on supplying tobacco, explored factors that could limit implementation of this policy, and analysed their ethical positions. We used qualitative description to analyse data on limiting factors and reflexive thematic analysis to interpret the ethical arguments adduced. RESULTS: Most participants noted time, space and safety concerns, and some had strong moral objections to supplying tobacco. These included concerns that supplying tobacco would contradict their duty not to harm patients, reduce them to sales assistants, undermine their role as health experts, and tarnish their profession. A minority focused on the potential benefits of a pharmacy supply measure, which they thought would use and extend their skills, and improve community well-being. CONCLUSIONS: Policy-makers will likely encounter strongly expressed opposition if they attempt to introduce a pharmacy supply measure as an initial component of a retail reduction strategy. However, as smoking prevalence falls, adopting a health-promoting supply model, using pharmacies that chose to participate, would become more feasible and potentially enhance community outreach and cessation support.

Smoking, vaping and drinking: A qualitative analysis of Aotearoa New Zealand young adults who tried e-cigarettes to stop smoking tobacco.

BACKGROUND AND AIM: Social practices such as smoking-drinking co-use often go 'hand-in-hand', linked by the coordination of materials, skills and meanings. However, the experience of using e-cigarettes while drinking among people who smoke (and drink) remains underexplored. We used social practice theory to show how smoking, vaping and drinking intersect and to explain how vaping created two new social practices among people who tried e-cigarettes to stop smoking: 'vaping-drinking' co-use and 'smoking-vaping-drinking' poly-use. METHODS: We conducted five in-depth interviews over 18-24 weeks during 2018-19, with each of nine Aotearoa New Zealand young adults aged 20-29 years. Participants smoked daily, did not regularly use e-cigarettes at entry and wished to try vaping to stop smoking. We analysed participants' reports of smoking or vaping while drinking using thematic analysis. RESULTS: Individual participants reported both co-use and poly-use occasions throughout the study. Vaping-drinking co-use arose from practice 'replacement' processes, where vaping fully substituted smoking. Smoking-vaping-drinking poly-use arose from 'adjacency' processes where vaping complemented smoking. Participants used both processes flexibly over time, which required new skills in material, temporal, pleasure and social coordination to try to recreate valued meanings of comfort, security and communality associated with well-established smoking-drinking practices. Unsuccessful coordination attempts maintained smoking-drinking co-use. CONCLUSION: Among Aotearoa New Zealand young adult smokers who want to use vaping to stop smoking, drinking occasions may help to maintain existing smoking-drinking practices and facilitate the development of vaping-drinking co-use and smoking-vaping-drinking poly-use practices, potentially prolonging individuals' exposure to smoking.

A narrative analysis of a tobacco industry campaign to disrupt Aotearoa New Zealand's endgame policies.

BACKGROUND: Aotearoa New Zealand passed world-leading legislation to implement tobacco endgame policies, including greatly reducing the number of tobacco retailers. British American Tobacco New Zealand and Imperial Brands Australasia tried to undermine this policy via the 'Save Our Stores' (SOS) campaign, which purportedly represented small convenience store owners' interests. METHODS: We used the Policy Dystopia Model as a framework to review discursive and instrumental strategies employed in the SOS campaign. Specifically, we critically analysed the arguments, narratives and frames employed in the campaign. RESULTS: Most SOS arguments drew on discursive strategies that emphasised unanticipated costs to the economy and society, and presented a near-apocalyptic future. Adverse outcomes included economic mayhem, thriving illicit trade, increased violent crime, fewer police, and heavier individual tax burdens. The campaign framed the government as an authoritarian legislator with misplaced priorities and used disinformation to bolster these claims. We identified a new normalisation narrative used to present very low nicotine cigarettes (VLNCs) as experimental and, by implication, risky. A metanarrative of lawlessness and decreased public safety connected the different claims. CONCLUSION: To address the existential challenges they face, tobacco companies used several discursive strategies to oppose the retailer reduction and VLNC policies. Our findings could inform counterarguments, and help international policymakers and advocates anticipate opposition they may encounter when introducing endgame measures, such as reducing tobacco availability.

How do underage youth access e-cigarettes in settings with minimum age sales restriction laws? A scoping review.

BACKGROUND: Despite measures to reduce young people's access to electronic cigarettes (ECs), or "vapes", many countries have recorded rising youth vaping prevalence. We summarised studies documenting how underage youth in countries with minimum age sales restrictions (or where sales are banned) report accessing ECs, and outline research and policy implications. METHODS: We undertook a focused literature search across multiple databases to identify relevant English-language studies reporting on primary research (quantitative and qualitative) and EC access sources among underage youth. RESULTS: Social sourcing was the most prevalent EC access route, relative to commercial or other avenues; however, social sourcing dynamics (i.e., who is involved in supplying product and why) remain poorly understood, especially with regard to proxy purchasing. While less prevalent, in-person retail purchasing (mainly from vape shops) persists among this age group, and appears far more common than online purchasing. CONCLUSIONS: Further research examining how social supply routes operate, including interaction and power dynamics, is crucial to reducing youth vaping. Given widespread access via schools and during social activities and events, exploring how supply routes operate and evolve in these settings should be prioritized. Inadequate compliance with existing sales regulations suggest greater national and local policy enforcement, including fines and licence confiscation for selling to minors, is required at the retailer level.

New Zealand adolescents' responses to plain packaging and new pictorial warning labels: Repeat cross-sectional survey analysis.

OBJECTIVE: This article aims to examine the impact on adolescents of New Zealand's 2018 legislation introducing plain (standardised) packaging and enhanced pictorial warning labels (PWLs). METHODS: Data came from Year 10 (14-15 years old) students in the 2016 (2,884 participants) and 2018 (2,689 participants) Youth Insights Surveys conducted 2 years before and immediately after legislation implementation. We used binary and ordinal logistic regression to investigate changes in brand awareness and preference, brand and pack appeal, and PWL salience and impact. RESULTS: The proportion of all participants, and ever, ex/experimental and current smokers who could name one or five tobacco product brands decreased in 2018. There was a modest and nonstatistically significant decrease in the proportion of current smokers citing brand name and image, and a larger decrease in the proportion stating perceived harm to health, influenced preferred brand choice. Having a preferred brand among current smokers and pack appeal, and PWL salience and impact among ex/experimental and current smokers were largely unchanged. CONCLUSIONS: We found preliminary evidence that plain packaging and enhanced PWLs reduced tobacco brand awareness and salience, and misperceptions about tobacco brand harmfulness. Data collection occurred shortly after implementation. Additional studies are required to assess longer term impacts of these interventions. PUBLIC HEALTH IMPLICATIONS: The findings complement existing evidence documenting the impact of plain packaging and PWLs on adolescents. Given limitations due to the proximity of the 2018 survey to legislation implementation, further studies with longer follow-up are required.

Perceptions of Illicit Tobacco Sources Following a Proposed Reduction in Tobacco Availability: A Qualitative Analysis of New Zealanders Who Smoke.

INTRODUCTION: Tobacco companies claim that substantially reducing tobacco retail outlets in Aotearoa New Zealand will increase illicit tobacco trade and crime. However, we know little about whether people who smoke anticipate using illicit tobacco once this measure is implemented. Exploring current illicit tobacco use and expected market development would clarify the likely scale of this potential problem. AIMS AND METHODS: We undertook online in-depth interviews with 24 adults who smoke and explored their experiences of illicit tobacco, perceptions of illicit market growth once legal tobacco became less available, intentions to engage in this market, and potential measures that could curb illicit market development. We interpreted the data using a qualitative descriptive approach. RESULTS: Few participants had purchased illegally imported or stolen tobacco. While most did not know how to access illicit tobacco products, many expected illicit trade and crime would increase, if legal tobacco became difficult to access. While cheaper tobacco appealed to many, most perceived illicit supply routes as unsafe and saw products obtained via these sources as likely to be of poor quality. Few suggested measures to control illicit markets, though a minority called for social reforms to reduce poverty, which they thought fueled illegal practices. CONCLUSIONS: Although illicit trade may appear to threaten new policy initiatives, participants' limited knowledge of these markets and concerns regarding product safety suggest illegal tobacco may pose less of a threat than tobacco companies have claimed. Policy makers should not be deterred from reducing tobacco availability by industry arguments. IMPLICATIONS: Although participants believed illicit trade would increase if the number of tobacco retailers was substantially reduced, few anticipated purchasing illegal tobacco. They viewed supply routes as unsafe and product quality as likely to be low. Industry predictions that illicit tobacco trade will grow if tobacco becomes less available do not reflect how people who smoke expect to engage with these markets and should not deter the introduction of retail reduction measures.

Regulating flavours and flavour delivery technologies: an analysis of menthol cigarettes and RYO tobacco in Aotearoa New Zealand.

INTRODUCTION: Menthol facilitates smoking initiation among young people, enhances nicotine's addictiveness and fosters the false belief that menthol products are safer. As a result, several countries have banned use of menthol as a characterising flavour. Aotearoa New Zealand (NZ) could disallow menthol-flavoured cigarettes as part of its endgame legislation; however, little is known about the NZ menthol market. METHODS: To examine the NZ menthol market, we analysed tobacco company returns to the Ministry of Health from 2010 to 2021. We calculated the market share of menthol cigarettes as a percentage of total cigarettes released for sale, estimated capsule cigarettes' market share as a percentage of total cigarette released for sale and menthol released for sale, and calculated menthol roll-your-own (RYO) tobacco released for sale as a percentage of total RYO released. RESULTS: Menthol brands accounted for a relatively small but nonetheless sizeable proportion of NZ's tobacco market and in 2021 constituted 13% of NZ's factory made cigarette market and 7% of the RYO market, representing 161 million cigarettes and 25 tonnes of RYO. The introduction of capsule technologies using menthol flavours corresponded with a rise in menthol sales among factory made cigarettes. CONCLUSIONS: Capsule technologies using menthol flavours work synergistically to enhance the appeal of smoking and appear likely to encourage experimentation among non-smoking young people. Comprehensive policy that regulates menthol flavours and innovations used to deliver flavour sensations will support tobacco endgame goals in NZ and could inform policy in other countries.

How do people who smoke perceive a tobacco retail outlet reduction policy in Aotearoa New Zealand? A qualitative analysis.

BACKGROUND: Aotearoa New Zealand plans to greatly reduce tobacco retail outlets, which are concentrated in areas of higher deprivation and perpetuate health inequities caused by smoking and borne particularly by Maori. However, we lack in-depth analyses of how this measure could affect people who smoke. METHODS: We undertook in-depth interviews with 24 adults from two urban areas who smoke. We used a novel interactive mapping approach to examine participants' current retail outlets and their views on a scenario where very few outlets would sell tobacco. To inform policy implementation, we probed participants' anticipated responses and explored the measure's wider implications, including unintended impacts. We used qualitative description to interpret the data. RESULTS: Most participants anticipated accommodating the changes easily, by using alternative outlets or bulk-purchasing tobacco; however, they felt others would face access problems and increased costs, and greater stress. They thought the policy would spur quit attempts, reduce relapse among people who had quit and protect young people from smoking uptake, and expected more people to switch to alternative nicotine products. However, most foresaw unintended social outcomes, such as increased crime and reduced viability of local businesses. CONCLUSIONS: Many participants hoped to become smoke-free and thought retail reduction measures would prompt quit attempts and reduce relapse. Adopting a holistic well-being perspective, such as those developed by Maori, could address concerns about unintended adverse outcomes and provide comprehensive support to people who smoke as they adjust to a fundamental change in tobacco availability.

Ethics and ENDS.

As debate persists over regulating electronic nicotine delivery systems (ENDS), those favouring liberal ENDS policies have advanced rights-based arguments privileging harm reduction to people who smoke over harm prevention to children and never-smokers. Recent ethical arguments advocate regulating ENDS to prioritise their harm reduction potential for people who currently smoke over any future harm to young never-smokers. In this article, we critically assess these arguments, in particular, the assumption that ethical arguments for prioritising the interests of young people do not apply to ENDS. We argue that, when the appropriate comparators are used, it is not clear the weight of ethical argument tips in favour of those who currently smoke and against young never-smokers. We also assert that arguments from a resource prioritisation context are not appropriate for analysing ENDS regulation, because ENDS are not a scarce resource. Further, we reject utilitarian arguments regarding maximising net population health benefits, as these do not adequately consider vulnerable groups' rights, or address the population distribution of benefits and harms. Lastly, we argue that one-directional considerations of harm reduction do not recognise that ENDS potentially increase harm to those who do not smoke and who would not otherwise have initiated nicotine use.

An Analysis of Arguments Advanced via Twitter in an Advocacy Campaign to Promote Electronic Nicotine Delivery Systems.

INTRODUCTION: Advocates of electronic nicotine delivery systems (ENDS) increasingly use Twitter to promote liberal ENDS policies. "World Vape Day" (WVD) is an annual campaign organized by pro-ENDS advocacy groups, some of which have links to the nicotine industry (eg, via funding from the "Foundation for a Smoke-Free World"). In 2020, the campaign used dedicated social media accounts to disseminate WVD-branded images and campaign messages. We examined tweets posted as part of WVD 2020 to identify and analyze pro-ENDS policy arguments. AIMS AND METHODS: We extracted tweets posted between 26 May and 3 June 2020 that included the hashtag #WorldVapeDay. We used qualitative thematic analysis to code a random sample (n = 2200) of approximately half the original English language tweets (n = 4387) and used descriptive analysis to identify the most frequently used co-hashtags. RESULTS: Arguments related to four themes: harm reduction, smoking cessation, rights and justice, and opposition to ENDS restrictions. Tweets criticized individuals and groups perceived as opposing liberal ENDS regulation, and used personal testimonials to frame ENDS as a harm reduction tool and life-saving smoking cessation aid. Tweets also advanced rights-based arguments, such as privileging adults' rights over children's rights, and calling for greater recognition of consumers' voices. Tweets frequently used hashtags associated with the WHO and World No Tobacco Day (WNTD). CONCLUSIONS: The WVD campaign presented a series of linked pro-ENDS arguments seemingly aimed at policy-makers, and strategically integrated with the WHO's WNTD campaign. Critically assessing pro-ENDS arguments and the campaigns used to promote these is vital to helping policy actors develop proportionate ENDS policy. IMPLICATIONS: Social media platforms have considerable potential to influence policy actors. Tweets are easily generated and duplicated, creating an impression of sizeable and influential stakeholders. Evidence that the "World Vape Day" campaign was supported by groups with industry links, and targeted-at least in part-at WHO officials and those who follow the WHO World No Tobacco Day campaign, highlights the importance of critically reviewing such campaigns. Further research could examine how health advocates could engage in pro-ENDS campaigns to support balanced messaging and informed policy-making.