Anaru Waa’s research while affiliated with University of Otago and other places

Introduction For electronic nicotine delivery systems (ENDS) to reduce harms caused by smoking, people who smoke must be able to switch to exclusive ENDS use without subsequently returning to smoking. Identifying factors prompting a return to smoking among former exclusive ENDS users is crucial, yet few qualitative studies have probed experiences of this process. Aims and Methods We conducted in-depth, semi-structured interviews with 20 people (seven indigenous Māori and 13 non-Māori) who smoked tobacco at least weekly, had smoked at least 100 cigarettes in their lifetime, and reported using ENDS to stop smoking cigarettes for at least 30 days (ideally, within the preceding 6 months). We explored their experiences of ENDS use, probed critical return-to-smoking settings and triggers, and analyzed strategies that could promote sustained smoking abstinence. We managed data using NVivo12 and used a reflexive thematic analysis approach to interpret the transcripts. Results We identified three themes that explained participants’ experiences. ENDS performed a functional role by mimicking some aspects of smoking. Yet participants experienced ENDS as inauthentic and unsatisfying across physical, social, and affectual domains, including in the most common return-to-smoking situations. Furthermore, fewer constraints on ENDS usage led participants to feel they could perpetuate addiction and risk of harm. Conclusions Return to smoking reflected two factors: ENDS’ failure to replicate core smoking attributes that remained appealing, and the burden of self-regulation required when using ENDS. Understanding and informing people about the challenges involved in transitioning to ENDS, beyond obtaining sufficient nicotine, could help support informed ENDS use and may potentially prevent people returning to smoking. Implications Our study extends our understanding of the satisfaction people seek when attempting to transition from smoking to exclusive ENDS use, and how ENDS’ failure to replicate that satisfaction, in addition to uncertainty about ENDS-related risks, contributes to smoking resumption. Satisfaction went beyond nicotine delivery, and included affective experiences, maintenance of rituals, rewards, and social connections. Conceptualizing satisfaction more broadly could support a richer understanding of factors that prompt return to smoking. People might manage challenges more effectively if they understood these before attempting to switch from smoking to ENDS, and if they are advised to monitor and regulate their ENDS use. Educational resources and behavioral support could provide more guidance on these points.

Background Rangatahi Māori, the Indigenous adolescents of Aotearoa New Zealand (NZ), have poorer health outcomes than Pākehā (NZ European /other European/“White”) adolescents. We explored the influence of policies for Indigenous youth by presenting health trends, inequities and contrasting policy case examples: tobacco control and healthcare access. Methods Cross-sectional representative surveys of NZ secondary school students were undertaken in 2001, 2007, 2012 and 2019. Health indicators are presented for Māori and Pākehā adolescents (relative risks with 95% CI, calculated using modified Poisson regression) between 2001–2019 and 2012–2019. Policy examples were examined utilising Critical Te Tiriti Analysis (CTA). Findings Rangatahi Māori reported significant health gains between 2001 and 2019, but an increase in depressive symptoms (13.8% in 2012 to 27.9% in 2019, RR 2.01 [1.65–2.46]). Compared to Pākehā youth there was a pattern of persistent Māori disadvantage, particularly for racism (RR 2.27 [2.08–2.47]), depressive symptoms (RR 1.42 [1.27–1.59]) and forgone healthcare (RR 1.63 [1.45–1.84]). Tobacco use inequities narrowed (RR 2.53 [2.12–3.02] in 2007 to RR 1.55 [1.25–1.93] in 2019). CTA reveals rangatahi Māori-specific policies, Māori leadership, and political support aligned with improved outcomes and narrowing inequities. Interpretation Age-appropriate Indigenous strategies are required to improve health outcomes and reduce inequities for rangatahi Māori. Characteristics of effective strategies include: (1) evidence-based, sustained, and comprehensive approaches including both universal levers and Indigenous youth-specific policies; (2) Indigenous and rangatahi leadership; (3) the political will to address Indigenous youth rights, preferences, priorities; and (4) a commitment to an anti-racist praxis and healthcare Indigenisation. Funding Two Health Research Council of New Zealand Project Grants: (a) Fleming T, Peiris–John R, Crengle S, Parry D. (2018). Integrating survey and intervention research for youth health gains. (HRC ref: 18/473); and (b) Clark TC, Le Grice J, Groot S, Shepherd M, Lewycka S. (2017) Harnessing the spark of life: Maximising whānau contributors to rangatahi wellbeing (HRC ref: 17/315).

The public will soon have the opportunity to make submissions on the long-awaited Smokefree Environments and Regulated Products (Vaping) Amendment Bill ('the Bill') which will regulate vaping products and alternative nicotine delivery systems. In a previous blog, ASPIRE 2025 researchers summarised the strengths and limitations of the Bill, and concluded that it contained several important measures, yet could do more to protect the health of children, young people and non-nicotine users. This blog-intended as a follow-up article to further promote discussion-summarises emerging evidence of British American Tobacco's ambitious plans for its nicotine products, and highlights the disjunction between tobacco companies' profit goals and public health objectives. 2/26/2021 Regulating vaping and new nicotine products: Are tobacco companies' goals aligned with public health objectives?-Public Health Exper… https://blogs.otago.ac.nz/pubhealthexpert/regulating-vaping-and-new-nicotine-products-are-tobacco-companies-goals-aligned-with-public-health-object… 2/6

Aim: To estimate the numbers of people required to quit smoking in New Zealand to achieve the Smokefree 2025 goal and to compare these with current levels of quitting. Methods: We used the established BODE3 tobacco forecasting model to project smoking prevalence separately for Māori and non-Māori to 2025 under a business-as-usual (BAU) scenario. We then determined by what factor current annual cessation rates would have to increase to achieve an adult smoking prevalence of under 5% by the year 2025, while annual smoking uptake rates continued to follow BAU patterns. Comparisons were also made in terms of estimated current long-term quitters arising from official reports of smoking cessation service use (Quitline and face-to-face support services). Results: To achieve a below 5% smoking prevalence by 2025, there would need to be additional averages of 8,400 Māori long-term quitters per year (5.2 times the BAU level on average) and 8,800 extra non-Māori quitters per year during 2018 to 2025 (1.9 times the BAU level on average). We estimated that the Quitline and funded face-to-face smoking cessation services are generating 2,000 Māori and 6,100 non-Māori long-term quitters per year. But this represents only 19% of Māori and only 34% of the non-Māori quitters required. Conclusions: This modelling work suggests that to achieve the Smokefree 2025 goal, there would need to be very major increases in quit rates. To achieve this goal the New Zealand Government will need to massively increase investment in established interventions (smoking cessation support, mass media) while continuing with substantial tobacco tax increases, or else add substantive new strategies into the intervention mix.