Awareness of cancer among adolescents: A study of nine focus groups in Aotearoa New Zealand.

ISSUE ADDRESSED: One third of cancers are potentially preventable by modifying key risk factors that arise during adolescence. To help inform prevention efforts, we investigated adolescents' understanding of cancer risk factors, symptoms and signs and barriers to help-seeking. METHODS: Nine focus groups were conducted with purposefully sampled, binary-gendered friendship groups of 12 to 17-year-olds. Interviews were analysed using a qualitative descriptive method based on the topic schedule, transcripts and field notes. RESULTS: Behavioural, genetic and environmental factors were commonly explored as risk factors. Most cancer symptoms identified focused on physical indicators, such as lumps and skin appearance. Facilitators and barriers to good health choices involved both external and internal factors: education, affordability, attitudes and the social environment. Most participants indicated they would talk to trusted friends and family members about health issues, but only when the condition became 'serious'. The most common source of health information was the internet. CONCLUSIONS: Adolescents have a good understanding of behavioural risk factors, but poor knowledge of some key cancer symptoms. A support system was recognised to be a substantive factor in dealing with health issues, as were youth-focused health services. Understanding of the preventability of many cancers was not widespread with participants. SO WHAT?: The results emphasise a requirement for appropriate, affordable and accessible youth-focused health services. There is a need for age- and culturally appropriate interventions that improve knowledge of cancer symptoms. Immunisation against the viruses implicated in cervical cancer is one example of a clinical cancer prevention intervention in adolescence.

Hepatitis C virus treatment with glecaprevir and pibrentasvir in patients co-prescribed carbamazepine: Three case reports.

BACKGROUND: Highly effective and well-tolerated direct-acting antiviral (DAA) therapies have revolutionised the management of hepatitis C virus (HCV); however, niche populations face treatment barriers. DAAs co-prescribed with several first-generation anti-epileptic drugs (AEDs) are contraindicated due to drug-drug interactions. A common example is carbamazepine whereby steady-state carbamazepine reduces the maximum concentration and area under the curve of velpatasvir, glecaprevir and pibrentasvir due to potent cytochrome P450 (CYP) 3A4 induction. Carbamazepine also induces P-glycoprotein which reduces glecaprevir and pibrentasvir's area under curve to infinite time. Sofosbuvir-velpatasvir and glecaprevir-pibrentasvir are contraindicated in patients who are co-prescribed carbamazepine due to the risk of reduced DAA therapeutic effect and consequently, virological treatment failure. This presents a challenge for patients in whom carbamazepine substitution is medically unfeasible, impractical or unacceptable. However, the properties of current generation DAA therapies, including high-potency non-structural protein 5A inhibitory effect, may be sufficient to overcome reduced bioavailability arising from carbamazepine related CYP 3A4 and P-glycoprotein induction. CASE SUMMARY: We present a case series of three patients with non-cirrhotic, treatment-naïve, genotype 1a, 1b, and 3a HCV who were treated with a 12 wk course of glecaprevir-pibrentasvir, while co-prescribed carbamazepine for seizure disorders. Glecaprevir-pibrentasvir combination therapy was chosen due to its potent in vitro activity and low barrier to pan-genotypic resistance associated variants. DAA therapy was dose-separated from carbamazepine to maximise time to peak concentration, and taken with meals to improve absorption. Sustained virological response at 12 wk was achieved in each patient with no adverse outcomes. CONCLUSION: DAA therapies, including glecaprevir-pibrentasvir, warrant consideration as a therapeutic agent in people with HCV who are co-prescribed carbamazepine, particularly if AED substitution is not feasible.

Is the neighbourhood context important for a tobacco retailer proximity policy?

A spatial modelling approach was used to explore how a proximity limit (150 m, 300 m, and 450 m) between tobacco retailers may impact different neighbourhoods in New Zealand. Neighbourhoods were categorised into three density groups (0, 1-2, 3+ retailers). As the proximity limit increases, there is a progressive redistribution of neighbourhoods in the three density groups with, the 3+ density group incorporating fewer neighbourhoods and the 0 and 1-2 density groups conversely each consisting of more. The differing measures available at the neighbourhood level enabled our study to discern potential inequities. More directed policies targeting these inequities are needed.

National Sporting Organisation policies: A health promotion opportunity?

ISSUE ADDRESSED: The objective was to identify whether National Sporting Organisations (NSOs) have policy documentation on healthy behaviours (smokefree, sun-protection, healthy food/beverages and alcohol) and, for organisations with such documentation, whether this was in-line with current scientific evidence of past best practice in cancer prevention. METHODS: This cross-sectional policy analysis study was performed September to December 2018 in Aotearoa/New Zealand. A content analysis was undertaken using NSO policy documents matched against a framework of key indicators for best practice within health behaviours of interest. Data analysis of the policy process was undertaken through key informant telephone interviews with NSO staff using semi-structured qualitative interviews. RESULTS: Of 96 NSOs, nearly half (49%) mentioned smokefree at least once in one of their policy documents, and 47% had an alcohol policy, although in both instances the policies lacked comprehensiveness. Two NSOs had a reasonably comprehensive sun protection policy. Seventeen had at least one specific nutrition policy/guideline. The contents of the latter were primarily related to short-term athletic performance rather than non-communicable disease prevention, specifically promoting hydration during sports participation, and food and nutrition to support sporting performance. Two NSOs had policies relating to the promotion of healthy food/nutrition more widely. For some NSOs, the lack of health-related policies was not a conscious choice but just not considered previously. Other NSOs reported they lacked resources or had other priorities. CONCLUSIONS: Although this study clearly demonstrates that many NSOs lack adequate health-related policies, this is not necessarily a conscious choice, but the result of a lack of resources, other priorities, or just that they had not considered developing policies in these areas. A number expressed support for these types of policies although it was apparent that some, particularly smaller NSOs, would require assistance in policy template development. It seems probable that the development of health-related policies will only occur if partner agencies become involved.

What impact would tobacco retailer proximity limit have on tobacco availability in New Zealand?

INTRODUCTION: One policy option to reduce the density of tobacco retailers is to restrict the distance retailers can be located to each other. This study examined the impacts of proximity limits of 150 m, 300 m and 450 m between tobacco retailers in New Zealand and if critical threshold reduction in tobacco retailers of 90%-95% would be achieved. METHODS: Using a spatial modelling approach, tobacco retailers were randomly removed based on a minimum distance between retailers until there were zero retailers within each scenario's minimum distance. This was repeated for all three proximity limit scenarios and descriptive statistics are provided for each. RESULTS: Implementation of 150 m, 300 m or 450 m distance restrictions between tobacco retailers would result in an average reduction in availability of 35%, 49% and 58%, respectively. On average, the current median distance to the closest retailer increases from 110 m to 377 m, to 568 m or to 718 m, respectively. The average median distance from a retailer to the closest school also increases across the three proximity limits, from 1017 m to 1087 m, to 1149 m or to 1231 m, respectively. Reduced clustering in deprived areas would be most apparent if a 450 m restriction policy was implemented. CONCLUSIONS: A proximity limit of 450 m would reduce retailers by 58%, but would not reach proposed critical behaviour-change threshold of 90%-95% required to reduce smoking prevalence independently. There is a need for a combination of policies, which focus on promoting equity, to achieve this bold endgame goal.

Indigenous Maori perspectives of smokefree parks.

OBJECTIVE: This study aims to understand the context of place associated with smoking in urban Hamilton parks from a Te Ao Maori perspective (the worldview of Maori, the Indigenous people of Aotearoa New Zealand). METHODS: Our study approached smokefree environments in Hamilton through a Maori lens, undertaking interviews with family groups and people from organisations involved in the local Smokefree environments policy. RESULTS: The majority of the 26 adult participants identified as Maori, with 30% being current smokers. Parks had a place in the sporting memories of participants. Smoking was merged with these memories. Important features of places that influenced smoking behaviours were raised, with signage a key talking point. CONCLUSIONS: The colonial construct of parks do not make visible Maori values and historical associations with the land, nor do they set a framework that would promote Maori ways of being and doing, including enacting smokefree spaces and places. IMPLICATIONS FOR PUBLIC HEALTH: This study provides the incentive to address change in parks and reserve management that would support Maori aspirations for their health and wellbeing associated with ancestral land, and give meaning to smokefree environments.

Could We See the End of Tobacco Being Sold in Bars and Pubs in New Zealand?

BACKGROUND: Disallowing the sale of tobacco wherever alcohol is consumed is one policy option to help achieve Smokefree 2025. This study aimed to investigate the prevalence of selling tobacco in New Zealand (NZ) on-license premises and explore attitudes toward the sale of tobacco. METHODS: A sample of managers of on-license premises were asked by telephone about the importance of tobacco to their business, advantages and disadvantages of selling tobacco, and the impact of not being able to sell tobacco in the future. Logistic and linear regression analyses were used to investigate associations between on-license characteristics and selling status and importance scores, respectively. RESULTS: Of on-license premises, 6.5% (95% CI: 5.3, 8.0) sold tobacco; 17.4% (95% CI: 14.0, 21.4) of hotels, 17.5% (95% CI: 13.8, 21.9) of taverns, and 1.3% (95% CI: 0.6, 3.2) of restaurants. Both retailer type and population density were associated with selling status. On-licenses were more likely to rate tobacco as "unimportant" (51.7%) to their business than "important" (30.0%), although premises where the closest tobacco retailer was at least 1 km away were associated with a higher score. Similar proportions of businesses were opposed to (45.7%) and supported (47.2%) the policy of removing all tobacco sales from on-license premises. CONCLUSION: Few on-license premises in NZ sell tobacco. Most retailers would support transitioning out of selling tobacco before the 2025 Smokefree goal, and they believed ending sales of tobacco would not negatively affect their business. However, businesses and customers in rural areas may be more affected than others. IMPLICATIONS: Many countries have tobacco-free goals, with several still developing their endgame strategies to achieve these goals. This study provides NZ and other jurisdictions with evidence useful in the development of such strategies. Having on-license alcohol retailers transition out of sales of tobacco would contribute to a reduction in tobacco availability. Moreover, the results of this study suggest that, in part due to declining tobacco sales and increased thefts, such a policy is likely to have the support of retailers. Policy developers should note, however, the potential for different impacts where the distance to the closest tobacco retailer is over 1 km or in rural areas.

Is the tobacco 'footfall' argument justified for tobacco purchases in New Zealand convenience stores?

INTRODUCTION: New Zealand's Smokefree 2025 goal aims to greatly decrease the availability of tobacco. One option is to cease the sale of tobacco from convenience stores. However, tobacco companies and retail trade associations oppose this move and have argued that customers who purchase tobacco drive footfall and spend more than non-tobacco customers. The aim of this study is to test the validity of industry claims about the importance of tobacco to convenience stores. METHODS: During November and December 2019, immediate postpurchase surveys were undertaken with customers on exit from a random sample of 100 convenience stores in two New Zealand cities. We estimated the mean number of items purchased, including tobacco and non-tobacco items, and mean expenditure on non-tobacco items. RESULTS: Of the 3399 transactions recorded, 13.8% included tobacco, of which 8.3% comprised tobacco only and 5.5% included tobacco and non-tobacco items. The mean number of transactions containing both tobacco and non-tobacco items was 1.98, and 1.87 for those containing non-tobacco items only. Customers who purchased tobacco and non-tobacco items spent on average NZ$6.99 on non-tobacco items, whereas customers who purchased non-tobacco items only, spent on average NZ$5.07. CONCLUSIONS: Our results do not support claims that tobacco drives one-quarter of footfall into stores or that customers who purchase tobacco spend almost twice as much as non-tobacco customers. Combined purchases of tobacco and non-tobacco items constituted 5.5% of transactions; the impact on a store's profitability of removing tobacco sales is unknown and could be the focus of future research.

Risk factors for SARS-CoV-2 seroprevalence following the first pandemic wave in UK healthcare workers in a large NHS Foundation Trust.

BACKGROUND: We aimed to measure SARS-CoV-2 seroprevalence in a cohort of healthcare workers (HCWs) during the first UK wave of the COVID-19 pandemic, explore risk factors associated with infection, and investigate the impact of antibody titres on assay sensitivity. METHODS: HCWs at Sheffield Teaching Hospitals NHS Foundation Trust (STH) were prospectively enrolled and sampled at two time points. SARS-CoV-2 antibodies were tested using an in-house assay for IgG and IgA reactivity against Spike and Nucleoprotein (sensitivity 99·47%, specificity 99·56%). Data were analysed using three statistical models: a seroprevalence model, an antibody kinetics model, and a heterogeneous sensitivity model. FINDINGS: As of 12th June 2020, 24·4% (n=311/1275) HCWs were seropositive. Of these, 39·2% (n=122/311) were asymptomatic. The highest adjusted seroprevalence was measured in HCWs on the Acute Medical Unit (41·1%, 95% CrI 30·0-52·9) and in Physiotherapists and Occupational Therapists (39·2%, 95% CrI 24·4-56·5). Older age groups showed overall higher median antibody titres. Further modelling suggests that, for a serological assay with an overall sensitivity of 80%, antibody titres may be markedly affected by differences in age, with sensitivity estimates of 89% in those over 60 years but 61% in those ≤30 years. INTERPRETATION: HCWs in acute medical units working closely with COVID-19 patients were at highest risk of infection, though whether these are infections acquired from patients or other staff is unknown. Current serological assays may underestimate seroprevalence in younger age groups if validated using sera from older and/or more symptomatic individuals. RESEARCH IN CONTEXT: Evidence before this study: We searched PubMed for studies published up to March 6th 2021, using the terms "COVID", "SARS-CoV-2", "seroprevalence", and "healthcare workers", and in addition for articles of antibody titres in different age groups against coronaviruses using "coronavirus", "SARS-CoV-2, "antibody", "antibody tires", "COVID" and "age". We included studies that used serology to estimate prevalence in healthcare workers. SARS-CoV-2 seroprevalence has been shown to be greater in healthcare workers working on acute medical units or within domestic services. Antibody levels against seasonal coronaviruses, SARS-CoV and SARS-CoV-2 were found to be higher in older adults, and patients who were hospitalised.Added value of this study: In this healthcare worker seroprevalence modelling study at a large NHS foundation trust, we confirm that those working on acute medical units, COVID-19 "Red Zones" and within domestic services are most likely to be seropositive. Furthermore, we show that physiotherapists and occupational therapists have an increased risk of COVID-19 infection. We also confirm that antibody titres are greater in older individuals, even in the context of non-hospitalised cases. Importantly, we demonstrate that this can result in age-specific sensitivity in serological assays, where lower antibody titres in younger individuals results in lower assay sensitivity.Implications of all the available evidence: There are distinct occupational roles and locations in hospitals where the risk of COVID-19 infection to healthcare workers is greatest, and this knowledge should be used to prioritise infection prevention control and other measures to protect healthcare workers. Serological assays may have different sensitivity profiles across different age groups, especially if assay validation was undertaken using samples from older and/or hospitalised patients, who tend to have higher antibody titres. Future seroprevalence studies should consider adjusting for age-specific assay sensitivities to estimate true seroprevalence rates.

Erythemal ultraviolet radiation exposure of high school rowers in Aotearoa/New Zealand.

Athletes who compete in outdoor sports can receive potentially harmful levels of solar ultraviolet radiation (UVR). Rowing is a popular outdoor sport that takes place during the peak UVR season. Using electronic dosimeters attached to the shoulder strap of the rower's uniform, this study aimed to quantify the real-time solar UVR exposure experienced by high school rowers during competition. We measured personal UVR exposure (PE) during the time spent on the water in order to compete in a single rowing-race (race-time), when rowing administrators are responsible for athletes' wellbeing. Data collection took place in Aotearoa (New Zealand) at Lake Ruataniwha (44.28°S, 170.07°E), during two consecutive rowing seasons (December-February 2018-19 and 2019-20). Analysis of dosimeter data generated from 56 race-times over five regattas revealed a median personal UVR exposure (PE) of 1.15 standard erythemal dose (SED), where 1 SED is defined as an effective radiant exposure of 100 Jm-2. Mean race-time was 46 min. Over two-thirds of race-times (69.6%) exceeded the Australian Radiation Protection and Nuclear Safety Agency recommendation of 1 SED being considered safe for most people in a day. An exposure of 1.5-3.0 SED produces perceptible erythema for people with light coloured skin and the lower parameter of 1.5 SED was exceeded in 14 (25.0%) of the race-times. By regatta, the median SED/h ranged from 0.96-2.40 and the median percentage of total concurrent ambient UVR ranged from 17 to 31%. Our results indicate that rowing is a high UVR sport and that races outside of peak UVR times also warrant the use of sun protection even when the UVI < 3. Given that acute and cumulative UVR exposure are recognised risk factors in the development of ocular diseases and skin cancers later in life, risk management guidelines for competitive school rowing will be incomplete until a long-term approach to well-being is considered and comprehensive sun protection measures adopted.

Association between density and proximity of tobacco retail outlets with smoking: A systematic review of youth studies.

BACKGROUND: Reducing the retail availability of tobacco has been proposed as a component of tobacco endgame, yet it is not known whether retail availability has a direct impact on smoking behaviours. A narrative review and a meta-analysis have been undertaken to examine the density and proximity of tobacco retail outlets, but were limited in scope, exposure and outcome variables. The aim of this current study was to undertake a systematic review of the international literature on the density and proximity of tobacco retail outlets to homes, schools and communities and their association with smoking behaviours among youth. METHODS: We reviewed and critically appraised the evidence documenting the association between density or proximity of tobacco retail outlets and smoking behaviours among school-age youth (18 and under), between 1 January 1990 and 21 October 2019. We reviewed original quantitative research that examined the associations of tobacco retail outlet density and proximity with individual smoking status or population-level smoking prevalence; initiation of smoking; frequency of tobacco use; sales to minors; purchasing by minors; susceptibility to smoking among non-smokers; perceived prevalence of smoking, and quitting behaviours. FINDINGS: Thirty-five peer-reviewed papers met the inclusion criteria. This review provided evidence of a relationship between density of tobacco retail outlets and smoking behaviours, particularly for the density near youths' home. A study using activity spaces also found a significant positive association between exposure to tobacco retail outlets and daily tobacco use. The review did not provide evidence of an association between the proximity of tobacco retail outlets to homes or schools and smoking behaviours among youth. CONCLUSIONS: The existing evidence supports a positive association between tobacco retail outlet density and smoking behaviours among youth, particularly for the density near youths' home. This review provides evidence for the development and implementation of policies to reduce the density of tobacco retail outlets to reduce smoking prevalence among youth.

Risk factors for SARS-CoV-2 seroprevalence following the first pandemic wave in UK healthcare workers in a large NHS Foundation Trust.

Background: We aimed to measure SARS-CoV-2 seroprevalence in a cohort of healthcare workers (HCWs) during the first UK wave of the COVID-19 pandemic, explore risk factors associated with infection, and investigate the impact of antibody titres on assay sensitivity. Methods: HCWs at Sheffield Teaching Hospitals NHS Foundation Trust were prospectively enrolled and sampled at two time points. We developed an in-house ELISA for testing participant serum for SARS-CoV-2 IgG and IgA reactivity against Spike and Nucleoprotein. Data were analysed using three statistical models: a seroprevalence model, an antibody kinetics model, and a heterogeneous sensitivity model. Results: Our in-house assay had a sensitivity of 99·47% and specificity of 99·56%. We found that 24·4% (n=311/1275) of HCWs were seropositive as of 12th June 2020. Of these, 39·2% (n=122/311) were asymptomatic. The highest adjusted seroprevalence was measured in HCWs on the Acute Medical Unit (41·1%, 95% CrI 30·0-52·9) and in Physiotherapists and Occupational Therapists (39·2%, 95% CrI 24·4-56·5). Older age groups showed overall higher median antibody titres. Further modelling suggests that, for a serological assay with an overall sensitivity of 80%, antibody titres may be markedly affected by differences in age, with sensitivity estimates of 89% in those over 60 years but 61% in those ≤30 years. Conclusions:  HCWs in acute medical units and those working closely with COVID-19 patients were at highest risk of infection, though whether these are infections acquired from patients or other staff is unknown. Current serological assays may underestimate seroprevalence in younger age groups if validated using sera from older and/or more severe COVID-19 cases.

Bar Atmospherics and Smoking: A Qualitative Analysis of New Zealand Young Adult Smokers.

INTRODUCTION: Smoking among young adults is often associated with social contexts and alcohol use. Although many countries, including New Zealand, have prohibited smoking inside licensed premises, outdoor areas have enabled smoking and alcohol co-use to persist. We examined whether and how outdoor bar areas facilitate and normalize young adult smoking and explored potential policy implications. METHODS: We conducted in-depth interviews with 22 young adults who had recently smoked in a New Zealand bar or nightclub and investigated how physical design attributes (atmospherics) influenced experiences of smoking in outside bar settings. We used qualitative description to identify recurring accounts of the outdoor bar environment and thematic analysis to explore how participants experienced the bar in relation to smoking. RESULTS: Participants valued outdoor smoking areas that were comfortable and relaxing, and saw attributes such as seating, tables, heating, protection from inclement weather, and minimal crowding, as important. We identified four themes; these explained how participants used smoking to gain respite and make social connections, showed how bar settings enabled them to manage smoking's stigma, and identified potential policy measures that would decouple smoking and alcohol co-use. CONCLUSIONS: Evidence bar environments facilitate and normalize smoking among young adults questions whether smokefree policies should be expanded to include all bar areas. Introducing more comprehensive smokefree outdoor policies could reduce the influence of design attributes that foster smoking while also reframing smoking as outside normal social practice. IMPLICATIONS: Bar environments contain many stimuli that cue and reinforce smoking and integrate smoking into social experiences. Expanding smokefree bar settings to include outdoor areas would reduce exposure to these stimuli, decrease opportunities for casual smoking, help maintain young people's smokefree status, and support longer-term goals of sustained reductions in smoking prevalence.

How would the tobacco retail landscape change if tobacco was only sold through liquor stores, petrol stations or pharmacies?

OBJECTIVE: To examine the potential impact of tobacco being available only from pharmacies, only from liquor stores or only from petrol stations on the New Zealand tobacco retail landscape. METHODS: Tobacco retailers and pharmacies were mapped using GIS. Comparisons were made between tobacco retailers and pharmacies. Simple linear regression was used to assess the relationship between outlet types and deprivation. RESULTS: A total of 5,243 tobacco outlets, including liquor stores and petrol stations, and 1,035 pharmacies were identified. The density of all outlets was greater in areas of higher deprivation. The majority of tobacco retailers and pharmacies were located in urban areas. Outlets were mapped in relation to walking distances from secondary schools; significant differences between outlet types are presented. CONCLUSIONS: The policy options examined in this study would considerably reduce the overall availability of tobacco, decrease cues to smoke and reduce the density of tobacco sales around schools. However, inequities in availability would exist with access to tobacco in rural areas disproportionately reduced, and a positive sociodemographic gradient remaining. Implications for public health: Substantially reducing tobacco availability has been identified as a crucial tobacco control strategy. This study provides information on the impact of different policy options to support Smokefree 2025.

An Analysis of E-Cigarette Marketing in New Zealand Tobacco Retail Outlets Prior to Legislative Change.

INTRODUCTION: In 2017, the New Zealand (NZ) Government announced its intention to liberalize the sale and promotion of electronic nicotine delivery systems (ENDS), including permitting any outlet to sell ENDS. This research estimated the proportion of tobacco outlets selling ENDS prior to legislative change, documented ENDS point-of-sale (POS) marketing, and examined associations between ENDS availability and outlet type, area-level deprivation, study region, and proximity to a secondary school. AIMS AND METHODS: After drawing a proportional random sample of 281 tobacco outlets from two NZ regions that included convenience stores, supermarkets, and petrol stations, we conducted observational in-store assessments to record ENDS product ranges and promotions. Data were collected between October and December 2017 and analyzed using descriptive statistics and regression modeling. RESULTS: Of tobacco outlets sampled, 22% sold ENDS; these were typically convenience stores (85%) and located in high deprivation areas (53%). Of stores selling ENDS, products were visible at POS in 89% of stores, including 15% with self-service displays and 15% with displays adjacent to children's products. ENDS advertising was present in 31% of the outlets and generally promoted ENDS as cheaper than smoked cigarettes. CONCLUSIONS: Liberalizing access to ENDS could reduce harms caused by smoking; however, extensive use of POS promotions will reach children and young people as well as smokers. While reducing harm among smokers is important, policy makers also need to ensure that regulations protect children from ENDS promotions. IMPLICATIONS: Careful regulation is required to ensure increases in ENDS availability are not accompanied by an increase in young people's exposure to ENDS marketing at the POS.

The long-term supply of tobacco and nicotine: some goals, principles and policy implications.

There is a growing literature on regulating the supply of tobacco products to achieve tobacco-free goals. This article suggests three goals and eight principles that could underpin regulatory approaches to the supply of tobacco and non-prescription nicotine products. The primary principles are that tobacco and nicotine products should not be seen as normal consumer products, should not be supplied for profit, and that the tax revenue from the supply of the products should first be used to reduce tobacco and nicotine use.

New Zealand tobacco retailers' understandings of and attitudes towards selling Electronic Nicotine Delivery Systems: a qualitative exploration.

INTRODUCTION: In 2017, the New Zealand Government signalled its intent to legalise the widespread sale of Electronic Nicotine Delivery Systems (ENDS), which many New Zealand retailers have actually sold for several years. Although ENDS uptake may reduce the harm smokers face, it requires them to adopt an entirely new practice; we therefore explored how effectively existing non-specialist tobacco retailers could advise and support potential quitters. METHODS: Using in-depth interviews with 18 tobacco retailers (prior to legislative change), we explored knowledge of ENDS, attitudes towards selling ENDS and supporting customers' cessation attempts, perceptions of ENDS' risks and benefits, and views on the proposed legislation. RESULTS: Participants generally had poor knowledge of ENDS products and provided either no advice or gave incorrect information to customers. They believed that the main benefit consumers would realise from using ENDS rather than tobacco would be cost savings; relatively, few saw ENDS as smoking cessation devices. Those who stocked ENDS did so despite reporting very low customer demand, and saw tobacco as more important to their business than ENDS, citing higher repeat business, ancillary sales and rebates. Participants typically supported liberalising ENDS availability, though several expressed concerns about potential youth uptake. CONCLUSIONS: Tobacco retailers' limited understanding of ENDS, and the higher value they placed on tobacco, suggests they may have little capacity or inclination to support ENDS users to quit smoking. Licensing schemes for both ENDS and smoked tobacco could simultaneously reduce supply of smoked tobacco while requiring ENDS retailers to meet minimum knowledge standards.

Butting out: an analysis of support for measures to address tobacco product waste.

BACKGROUND: Cigarette butts are ubiquitous litter items, causing major environmental damage and imposing significant clean-up costs. Tobacco companies frame smokers as both the cause of this problem and the source of its solution. However, an extended producer responsibility perspective challenges this view and holds tobacco companies to account for the full life cycle costs of tobacco product waste (TPW). METHODS: Using an online cross-sectional survey of 396 New Zealand smokers and 414 non-smokers, we estimated awareness of TPW, attribution of responsibility for TPW and support for interventions to reduce TPW. Descriptive analyses and logistic regression models examined associations between demographic attributes and smoking behaviours, and perceptions of TPW and potential solutions to this problem. RESULTS: Most respondents saw butt litter as toxic to the environment and held smokers primarily responsible for creating TPW. However, when knowledge of butt non-biodegradability increased, so too did the proportion holding tobacco companies responsible for TPW. Changes to product design, fines for littering and expanded smoke-free spaces were considered most likely to reduce TPW. Smokers and non-smokers held different views on measures to address TPW, with smokers favouring more educative approaches and non-smokers more restrictive policies. CONCLUSIONS: Strategies to increase awareness of tobacco companies' role in creating TPW could foster political support for producer responsibility measures that require the industry to manage TPW. Nevertheless, policy measures should continue to foster smoking cessation and decrease uptake, as reducing smoking prevalence presents the best long-term solution to addressing TPW.

The contribution of smokefree outdoor areas in achieving New Zealand's Smokefree 2025 goal.

ISSUES ADDRESSED: With the adoption of Smokefree 2025, further commitment from local government to extend smokefree outdoor area policies is becoming increasingly important in the presence of high public support. The aim of this study was to identify local government commitment in the Canterbury/West Coast (CWC) region to the New Zealand Smokefree 2025 goal through provision of smokefree outdoor areas. METHODS: Document analysis of the different stages of council long-term plans (LTPs) was undertaken, including 239 draft LTP documents, 5926 public submissions on these documents and 13 final LTP documents. A comparison between the 2015 final document and the 2012 final document was undertaken. Following this, semi-structured telephone interviews were undertaken with council staff. RESULTS: No council had referred to Smokefree 2025 or smokefree community spaces in any 2015 LTP draft document. Each of the CWC councils received a number of smokefree-related submissions, with the main theme being the extension of current Smokefree Outdoor Area Policy. The final LTP documents showed that 5 councils had included a brief statement about Smokefree 2025. Smokefree issues were mentioned more often in the 2012 LTP compared to the 2015 LTP. CONCLUSIONS: This research highlights a need for more commitment by local government to achieving the Smokefree 2025 goal. So what? There are opportunities for health groups to work with councils to try and enhance their overall commitment to Smokefree 2025 and promote wellbeing.

Estimating the effect of a potential policy to restrict tobacco retail availability in New Zealand.

INTRODUCTION: Reducing tobacco retailer density is suggested to be a key component of tobacco endgames. Where tobacco retail reduction policies exist, 'grandfathering' is typically used, where existing retailers are exempt from restrictions aimed at reducing outlet density. We examined the possible impact on tobacco outlet density in New Zealand of a policy preventing new retail outlets from selling tobacco, but allowing existing retail outlets to continue selling tobacco until they ceased trading or relocated. METHODS: We obtained data on numbers of tobacco outlets and the number of outlet closures recorded annually from 2006 to 2016. We calculated the mean and the lowest and highest 3-year rolling average closure rates for each type of tobacco outlet. We projected decreases in the number of tobacco outlets that would hypothetically be permitted to sell tobacco from 2020 onwards and estimated when the combined number of tobacco outlets would decline by 50% and 95%. RESULTS: Based on mean annual closure rates, the total number of tobacco outlets would decrease by 50% by 2032 and a 95% reduction could be achieved by 2072. By 2025, the number of tobacco outlets would decrease by 27%; by 2050, this reduction would reach 84%. CONCLUSION: A tobacco retail reduction policy that prevented new retail outlets from selling tobacco and grandfathered existing retailers would be unlikely to achieve New Zealand's target of a 95% reduction in tobacco outlet density within several decades of being enacted. Nonetheless, this policy could achieve a 50% reduction in tobacco retail availability in the first decade of implementation.