Tobacco Use in New Zealand Key findings from the 2009 New Zealand Tobacco Use Survey

Tobacco Use in New Zealand Key findings from the 2009 New Zealand Tobacco Use Survey

Citation: Ministry of Health. 2010. Tobacco Use in New Zealand: Key findings from the 2009 New Zealand Tobacco Use Survey. Wellington: Ministry of Health. Published in November 2010 by the Ministry of Health PO Box 5013, Wellington 6145, New Zealand ISBN: 978-0-478-37408-7 (online) HP 5268 This document is available on the Ministry of Health s website: http://www.moh.govt.nz

Authors This report was prepared on behalf of the Tobacco Control Team, Ministry of Health, by Dr Anthea Hewitt and Erin Holmes, with statistical analyses conducted by Aloka Bhattacharya, Dr Deepa Weerasekera and Robert Templeton, Health and Disability Intelligence. Acknowledgements Thank you to the New Zealanders who gave their time to participate in the 2009 New Zealand Tobacco Use Survey. The authors are very grateful for comments received from the external peer reviewers: Associate Professor Nick Wilson, Associate Professor Chris Bullen and Dr Hayden McRobbie. We are also very grateful for comments received from internal Ministry of Health peer reviewers: Dr Ashley Bloomfield, Karen Evison, Kylie Mason, Robert Templeton, Dr Ann Sears, Natalie Talamaivao, Roimata Timutimu, Leonie McCormack and Dr Niki Stefanogiannis. Please note: Care must be taken when comparing smoking prevalences, as they may vary depending on the survey type, age range of respondents, definition used for smoking (ie, current or daily smokers) and statistical adjustments (eg, age standardisation). Tobacco Use in New Zealand iii

Contents Authors Acknowledgements Key Points Current smoking in New Zealand Regret and quitting behaviour Use of the ABC approach by health care workers Exposure to second-hand smoke iii iii xii xii xiii xiv xiv Chapter 1: Introduction 1 Chapter 2: Methodology 2 Survey design and analysis 2 What has been analysed and reported? 2 Total response ethnicity 3 Age standardisation 3 Neighbourhood deprivation: The New Zealand Index of Deprivation 2006 4 Small numbers 4 What is the quality of these results? 4 Time trend comparisons 6 How can readers access more survey results? 7 How to interpret graphs in this report 7 Chapter 3: Smoking in New Zealand 10 Supply of tobacco 10 Daily smoking 11 Tobacco-attributable mortality 12 Chapter 4: Current Smoking 15 Current smoking, 15 64 years 15 Current smoking, youth (15 19 years) 22 Chapter 5: Type of Cigarette Consumption 27 Roll-your-own cigarette consumption 27 Manufactured cigarette consumption 33 Type of cigarette consumption in youth 39 Chapter 6: Source of Cigarettes/Tobacco Products 40 Places of cigarette/tobacco purchase 40 Source of cigarettes/tobacco products among youth 41 Tobacco Use in New Zealand v

Chapter 7: Smoker Regret and Quitting Behaviour 43 Smoker regret 43 Quit attempts 43 Reasons for quitting 44 Quit smoking for at least 24 hours in the past 12 months 45 Quit smoking for at least a week in the past 12 months 46 Successful quitting 50 Chapter 8: Use of Quitting Advice or Products 51 Use of any quitting products or advice in most recent quit attempt 51 Services and products used in most recent quit attempt 56 Use of the Quitline 59 Use of nicotine replacement therapy 61 Preferred choice of services and products among youth 65 Chapter 9: Use of the ABC Approach by Health Care Workers 66 Use of the ABC approach by health care workers 67 Use of the ABC approach by general practitioners 76 Chapter 10: Exposure to Second-hand Smoke 91 Introduction 91 Exposure to second-hand smoke at home 91 Exposure to second-hand smoke at home in the past week in households with at least one child 94 Exposure to second-hand smoke in the car in the past week 98 Exposure to second-hand smoke at the workplace in the past month 102 Chapter 11: Discussion 105 Glossary 108 References 111 vi Tobacco Use in New Zealand

List of Tables Table 1: Estimated number of deaths attributable to tobacco smoking in New Zealand, by cause of death, among those aged 35+ years, 2003 2007 14 Table 2: Number of current smokers in New Zealand, by age group and dwelling type, 2009 15 Table 3: Current smoking among 15 64-year-olds, by ethnic group and sex, 2009 (unadjusted prevalence) 17 Table 4: Current smoking in youth aged 15 19 years, by ethnic group, 2009 (unadjusted prevalence) 22 Table 5: Roll-your-own cigarette consumption among current smokers aged 15 64 years, by ethnic group, 2009 (unadjusted prevalence) 28 Table 6: Manufactured cigarette consumption, among current smokers aged 15 64 years, by ethnic group, 2009 (unadjusted prevalence) 34 Table 7: Used quitting products or advice in most recent quit attempt, among recent quit attempters aged 15 64 years, by ethnic group (unadjusted prevalence) 52 Table 8: Use of the Quitline in most recent quit attempt, among recent quit attempters aged 15 64 years, by ethnic group (unadjusted prevalence) 59 Table 9: Use of NRT during most recent quit attempt, among recent quit attempters aged 15 64 years, by ethnic group (unadjusted prevalence) 62 Table 10: Asked smoking status by a health care worker in the past 12 months, 15 64-year-old total population, by ethnic group (unadjusted prevalence) 68 Table 11: Received the ABC approach from a health care worker in the past 12 months, among 15 64-year-old current smokers, by ethnic group (unadjusted prevalence) 74 Table 12: Asked smoking status by a GP in the past 12 months, among 15 64-year-old total population who had seen a GP in the past 12 months, by ethnic group (unadjusted prevalence) 77 Table 13: Provided with quitting advice and referral by a GP in the past 12 months, among current smokers aged 15 64 years who had seen a GP in the past 12 months, by ethnic group, 2009 (unadjusted prevalence) 81 Table 14: Received the ABC approach from a GP in the past 12 months, among current smokers, by ethnic group, 2009 (unadjusted prevalence) 86 Table 15: Exposure to second-hand smoke at home in the past week, among non-smokers aged 15 64 years, by ethnic group, 2009 (unadjusted prevalence) 92 Table 16: Exposure to second-hand smoke at home in the past week, households with at least one child aged 0 14 years, by respondents ethnic group, 2009 (unadjusted prevalence) 95 Table 17: Exposure to second-hand smoke in the car they usually travel in, in the past week, among non-smokers aged 15 64 years, by ethnic group, 2009 (unadjusted prevalence) 99 Table 18: Exposure to second-hand smoke indoors at the workplace, in the past month, among non-smokers aged 15 64 years, by ethnic group, 2009 (unadjusted prevalence) 102 Tobacco Use in New Zealand vii

List of Figures Figure 1: Annual number of tobacco products available for consumption in New Zealand per capita (15+ years), 1999 2009 11 Figure 2: Daily smoking among those aged 15 64 years, 1997 2009 (age-standardised prevalence) 12 Figure 3: Annual number of deaths attributed to smoking (all causes), among those aged 35+ years, by sex, 1950 2005 13 Figure 4: Current smoking among 15 64-year-olds, by age group and sex, 2009 (unadjusted prevalence) 16 Figure 5: Current smoking among 15 64-year-olds, by ethnic group and sex, 2009 (age-standardised rate ratio) 18 Figure 6: Current smoking among 15 64-year-olds, by NZDep2006 quintile and sex, 2009 (agestandardised prevalence) 19 Figure 7: Current smoking among 15 64-year-olds, by sex, 2006 2009 (age-standardised prevalence) 20 Figure 8: Current smoking among 15 64-year-olds, for Māori, by sex, 2006 2009 (age-standardised prevalence) 21 Figure 9: Current smoking in youth aged 15 19 years, by ethnic group, 2009 (unadjusted rate ratio) 23 Figure 10: Current smoking in youth aged 15 19 years, by neighbourhood deprivation, 2009 (unadjusted prevalence) 24 Figure 11: Current smoking in youth aged 15 19 years, by sex, 2006 2009 (unadjusted prevalence) 25 Figure 12: Current smoking in Māori youth aged 15 19 years, by sex, 2006 2009 (unadjusted prevalence) 26 Figure 13: Roll-your-own cigarette consumption, among current smokers aged 15 64 years, by age group, 2009 (unadjusted prevalence) 27 Figure 14: Roll-your-own cigarette consumption, among current smokers aged 15 64 years, by ethnic group, 2009 (age-standardised rate ratio) 29 Figure 15: Roll-your-own cigarette consumption, among current smokers aged 15 64 years, by NZDep2006 quintile, 2009 (age-standardised prevalence) 30 Figure 16: Roll-your-own cigarette consumption, among current smokers aged 15 64 years, by sex, 2006 2009 (age-standardised prevalence) 31 Figure 17: Roll-your-own cigarette consumption, among Māori current smokers aged 15 64 years, by sex, 2006 2009 (age-standardised prevalence) 32 Figure 18: Manufactured cigarette consumption, among current smokers aged 15 64 years, by age group, 2009 (unadjusted prevalence) 33 Figure 19: Manufactured cigarette consumption, among current smokers aged 15 64 years, by ethnic group, 2009 (age-standardised rate ratio) 35 Figure 20: Manufactured cigarette consumption, among current smokers aged 15 64 years, by NZDep2006 quintile, 2009 (age-standardised prevalence) 36 Figure 21: Manufactured cigarette consumption, among current smokers aged 15 64 years, by sex, 2006 2009 (age-standardised prevalence) 37 Figure 22: Manufactured cigarette consumption, among Māori current smokers aged 15 64 years, by sex, 2006 2009 (age-standardised prevalence) 38 Figure 23: Type of cigarette consumption, among youth current smokers aged 15 19 years, by age group, 2009 (unadjusted prevalence) 39 Figure 24: Places of cigarette/tobacco purchase by current smokers aged 15 64 years in the past month, by sex, 2009 (age-standardised prevalence) 40 Figure 25: Source of cigarettes/tobacco products in the past month, youth current smokers aged 15 19 years, by age group, 2009 (unadjusted prevalence) 41 viii Tobacco Use in New Zealand

Figure 26: Place of purchase of cigarettes/tobacco products in the past month, youth current smokers aged 15 19 years, by age group, 2009 (unadjusted prevalence) 42 Figure 27: Reasons for most recent quit attempt, among recent quit attempters aged 15 64 years, by sex, 2009 (age-standardised prevalence) 44 Figure 28: Quit smoking for at least 24 hours in the past 12 months, among current and casual smokers aged 15 64 years, by age group, 2009 (unadjusted prevalence) 45 Figure 29: Quit smoking for at least a week in the past 12 months, among current and casual smokers aged 15 64 years, by age group, 2009 (unadjusted prevalence) 47 Figure 30: Quit smoking for at least a week in the past 12 months, among current and casual smokers aged 15 64 years, by sex, 2008 2009 (age-standardised prevalence) 48 Figure 31: Quit smoking for at least a week in the past 12 months, among Māori current and casual smokers aged 15 64 years, by sex, 2008 2009 (age-standardised prevalence) 49 Figure 32: Used quitting products or advice in most recent quit attempt, among recent quit attempters aged 15 64 years, by age group (unadjusted prevalence) 52 Figure 33: Used quitting products or advice in most recent quit attempt, among recent quit attempters aged 15 64 years, by ethnic group (age-standardised rate ratio) 53 Figure 34: Used quitting products or advice in most recent quit attempt, among recent quit attempters aged 15 64 years, by neighbourhood deprivation (age-standardised prevalence) 54 Figure 35: Received advice or used any products to help quit, among recent quit attempters aged 20 64 years, by sex, 2006 2009 (age-standardised prevalence) 55 Figure 36: Services and products used in most recent quit attempt, among recent quit attempters aged 15 64 years (unadjusted prevalence) 56 Figure 37: Services and products used in most recent quit attempt, among recent quit attempters aged 20 64 years, 2006 2009 (age-standardised prevalence) 57 Figure 38: Services and products used in most recent quit attempt, among Māori recent quit attempters aged 20 64 years, 2006 2009 (age-standardised prevalence) 58 Figure 39: Use of the Quitline during most recent quit attempt, among recent quit attempters aged 15 64 years, by ethnic group (age-standardised rate ratio) 60 Figure 40: Use of NRT during most recent quit attempt, among recent quit attempters aged 15 64 years, by age group (unadjusted prevalence) 61 Figure 41: Use of NRT during most recent quit attempt, among recent quit attempters aged 15 64 years, by ethnic group (age-standardised rate ratio) 62 Figure 42: Source of NRT, among recent quit attempters aged 15 64 years who used NRT in their most recent quit attempt (unadjusted prevalence) 64 Figure 43: Services and products youth would consider using to help them quit, among current smokers aged 15 19 years, 2009 (unadjusted prevalence) 65 Figure 44: Asked smoking status by a health care worker in the past 12 months, 15 64-year-old total population, by age group, 2009 (unadjusted prevalence) 67 Figure 45: Asked smoking status by a health care worker in the past 12 months, 15 64-year-old total population, by ethnic group, 2009 (age-standardised rate ratio) 69 Figure 46: Asked smoking status by a health care worker in the past 12 months, 15 64-year-old total population, by NZDep2006 quintile, 2009 (age-standardised prevalence) 70 Figure 47: Provided with quitting advice and referral by a health care worker in the past 12 months, among 15 64-year-old current smokers who had seen a health care worker in the past 12 months, by age group, 2009 (unadjusted prevalence) 71 Figure 48: Provided with quitting advice and referral by a health care worker, among 15 64-yearold current smokers who had seen a health care worker in the past 12 months, by NZDep2006 quintile, 2009 (age-standardised prevalence) 72 Figure 49: Received the ABC approach from a health care worker in the past 12 months, among 15 64-year-old current smokers, by age group, 2009 (unadjusted prevalence) 73 Figure 50: Received the ABC approach from a health care worker in the past 12 months, among 15 64-year-old current smokers, by ethnic group, 2009 (age-standardised rate ratio) 74 Tobacco Use in New Zealand ix

Figure 51: Received the ABC approach from a health care worker in the past 12 months, among 15 64-year-old current smokers, by NZDep2006 quintile, 2009 (age-standardised prevalence) 75 Figure 52: Asked smoking status by a GP in the past 12 months, among the 15 64-year-old total population who had seen a GP in the past 12 months, by age group, 2009 (unadjusted prevalence) 76 Figure 53: Asked smoking status by a GP in the past 12 months, among the 15 64-year-old total population who had seen a GP in the past 12 months, by ethnic group, 2009 (agestandardised rate ratio) 78 Figure 54: Asked smoking status by a GP, among the total population aged 15 64 years who had seen a GP in the past 12 months, by NZDep2006 quintile, 2009 (age-standardised prevalence) 79 Figure 55: Provided with quitting advice and referral by a GP in the past 12 months, among current smokers aged 15 64 years who had seen a GP in the past 12 months, by age group, 2009 (unadjusted prevalence) 80 Figure 56: Provided with quitting advice and referral by a GP in the past 12 months, among current smokers aged 15 64 years who had seen a GP in the past 12 months, by ethnic group, 2009 (age-standardised rate ratio) 82 Figure 57: Provided with quitting advice and referral by a GP in the past 12 months, among current smokers aged 15 64 years who had seen a GP in the past 12 months, by NZDep2006 quintile, 2009 (age-standardised prevalence) 83 Figure 58: Provided with quitting advice and referral by a GP in the past 12 months, among current smokers aged 15 64 years who had seen a GP in the past 12 months, by sex, 2008 2009 (age-standardised prevalence) 84 Figure 59: Provided with quitting advice and referral by a GP in the past 12 months, among Māori current smokers aged 15 64 years who had seen a GP in the past 12 months, by sex, 2008 2009 (age-standardised prevalence) 85 Figure 60: Received the ABC approach from a GP in the past 12 months, among current smokers aged 15 64 years, by ethnic group, 2009 (age-standardised rate ratio) 87 Figure 61: Received the ABC approach from a GP, among current smokers aged 15 64 years who had seen a GP in the past 12 months, by NZDep2006 quintile, 2009 (agestandardised prevalence) 88 Figure 62: Received the ABC approach from a GP in past 12 months, among current smokers aged 15 64 years who had seen a GP in the past 12 months, by sex, 2008 2009 (age-standardised prevalence) 89 Figure 63: Received the ABC approach from a GP in the past 12 months, among Māori current smokers aged 15 64 years who had seen a GP in the past 12 months, by sex, 2008 2009 (age-standardised prevalence) 90 Figure 64: Exposure to second-hand smoke at home in the past week, among non-smokers aged 15 64 years, by age group, 2009 (unadjusted prevalence) 92 Figure 65: Exposure to second-hand smoke at home in the past week, among non-smokers aged 15 64 years, by ethnic group, 2009 (age-standardised rate ratio) 93 Figure 66: Exposure to second-hand smoke at home in the past week, among non-smokers aged 15 64 years, by NZDep2006 quintile, 2009 (age-standardised prevalence) 94 Figure 67: Exposure to second-hand smoke at home in the past week, households with at least one child aged 0 14 years, by respondents ethnic group, 2009 (age-standardised rate ratio) 96 Figure 68: Exposure to second-hand smoke at home in the past week, household with at least one child aged 0 14 years, by NZDep2006 quintile, 2009 (age-standardised prevalence) 97 Figure 69: Exposure to second-hand smoke in the car usually travelled in, in the past week, among non-smokers aged 15 64 years, by age group, 2009 (unadjusted prevalence) 98 x Tobacco Use in New Zealand

Figure 70: Exposure to second-hand smoke in the car usually travelled in, in the past week, among non-smokers aged 15 64 years, by ethnic group, 2009 (age-standardised rate ratio) 100 Figure 71: Exposure to second-hand smoke in the car usually travelled in, in the past week, among non-smokers aged 15 64 years, by NZDep2006 quintile, 2009 (agestandardised prevalence) 101 Figure 72: Exposure to second-hand smoke indoors at the workplace, in the past month, among non-smokers aged 15 64 years, by ethnic group, 2009 (age-standardised rate ratio) 103 Figure 73: Exposure to second-hand smoke indoors at the workplace, in the past month, among non-smokers aged 15 64 years, by NZDep2006 quintile, 2009 (age-standardised prevalence) 104 Tobacco Use in New Zealand xi

Key Points Current smoking in New Zealand In 2009 one in five (21.0%) adults aged 15 64 years were current smokers, with 19.2% of adults smoking daily. A current smoker is defined as someone who has smoked more than 100 cigarettes in their lifetime and at the time of the survey was smoking at least once a month (World Health Organization 1998). In this report, smoking refers to cigarettes, roll-your-own tobacco, cigars and pipes. There was no difference in the age-standardised prevalence of current smoking between males and females. Current smoking rates in New Zealand are continuing to decline. The age-standardised prevalence of current smoking in 15 64-year-olds fell significantly between 2006 (24.4%) and 2009 (21.8%). The prevalence of current smoking differed by ethnic group and by neighbourhood deprivation. Māori females were twice as likely to be current smokers as females in the total population, and Māori and Pacific males were one and a half times as likely to be current smokers as males in the total population. Following is a summary of current smoking in 15 64-year-olds, by ethnicity and sex: 49.3% of Māori females and 40.2% of Māori males were current smokers. 28.5% of Pacific females and 32.3% of Pacific males were current smokers. 18.9% of European/Other females and 20.6% of European/Other males were current smokers. 4.4% of Asian females and 16.3% of Asian males were current smokers. After adjusting for age, it was found that people living in the most deprived areas were more likely to be current smokers than those in less deprived areas. The age-standardised prevalence of current smoking for females fell significantly between 2006 (23.7%) and 2009 (20.8%), with no difference for males over this time period. There was also no significant change in the age-standardised prevalence of current smoking between 2006 and 2009 for Māori. Current smoking in youth Around one in five (18.0%) youth aged 15 19 years were current smokers. There was no significant difference by sex. The prevalence of current smoking in youth has decreased significantly since 2006 (22.9%). Māori youth were found to be more than twice as likely to be current smokers as youth in the total population, while Asian youth were significantly less likely to be current smokers. Youth living in the most deprived areas were significantly more likely than those in the least deprived areas to be current smokers. xii Tobacco Use in New Zealand

Regret and quitting behaviour Overall, 8 out of 10 (80.0%) current smokers aged 15 64 years said that they would not smoke if they had their life over again. After adjusting for age, females (82.5%) were significantly more likely to say that they would not smoke if they had their life over again than males (76.2%). Of the total New Zealand population aged 15 64 years, 0.8% had successfully quit smoking in the past 6 12 months. Following is a selection of other quitting facts for those aged 15 64 years. 63.2% of current and casual 1 smokers had tried to quit smoking in the past five years. 23.8% of current and casual smokers had quit for at least a week in the past year. There were no significant differences by ethnic group or neighbourhood deprivation. The age-standardised prevalence for males who quit smoking in the past 12 months for at least a week increased significantly between 2008 and 2009. There was no difference in the age-standardised prevalence for females in the total population who quit smoking in the past 12 months for at least a week between 2008 and 2009, or for Māori males and females. The most common reasons that current smokers gave for their most recent quit attempt were their own health (78.1%), cost (40.8%), being sick of smoking (37.1%) and someone else s health (25.9%). These were the top four reasons given by all ethnic groups. Use of quitting support and products More than a third (37.9%) of smokers who made a recent quit attempt used quitting products or advice in their most recent quit attempt. Among all smokers who made a recent quit attempt, 20.3% used nicotine replacement therapy (NRT) and 15.7% used the Quitline in their most recent quit attempt. Of those people who used NRT in their most recent quit attempt, nearly three-quarters (74.7%) received subsidised NRT. NRT was more commonly used by older people than by younger people. After adjusting for age, there was found to be no significant difference between 2006 and 2009 in the use of NRT in smokers most recent quit attempt. Among smokers who made a recent quit attempt, the age-standardised prevalence of those who used the Quitline in their last attempt increased by over 6% between 2006 (10.1%) and 2009 (16.5%), 2 while the prevalence of those who sought support from family and friends decreased (10.4% versus 4.4%), after adjusting for age. 1 2 Those who smoke less than once a month. Note that the age-standardised 2009 prevalence of use of the Quitline reported here differs from that reported in the first paragraph, because the former is a crude rate. Tobacco Use in New Zealand xiii

Of Pacific smokers who made a recent quit attempt, 15.6% used quitting products or advice in their most recent quit attempt. After adjusting for age, Pacific smokers who made a recent quit attempt were found to be only one-third as likely as all smokers who made a recent quit attempt to have used quitting products or advice in their most recent quit attempt. Nearly one-third (32.2%) of Māori smokers who made a recent quit attempt used quitting products or advice in their most recent quit attempt, which, after adjusting for age, was not significantly different from all smokers who made a recent quit attempt. Use of the ABC approach by health care workers The ABC approach for quitting smoking comprises the following steps: health care workers should Ask about smoking status, give Brief advice to stop smoking to all smokers, and provide evidence-based Cessation (quitting) support for those who wish to stop smoking. Nearly half (47.5%) of all 15 64-year-olds reported that, at some time in the past 12 months, a health care worker had asked if they had ever been or currently were a smoker. After adjusting for age, European/Other and Māori were found to be significantly more likely than the total population to report that they had been asked by a health care worker in the past 12 months if they had ever been or currently were a smoker. Approximately one-third (33.6%) of 15 64-year-old current smokers received the ABC approach from a health care worker in the past 12 months. Māori current smokers were slightly more likely to have received ABC from a health care worker in the past 12 months than the total population, after adjusting for age. After adjusting for age, those living in the most deprived areas were found to be more likely than those living in the least deprived areas to have been asked their smoking status, and if a smoker, to have been provided with ABC support by a health care worker, in the past 12 months. Exposure to second-hand smoke One in 16 (6.4%) non-smoking adults were exposed to second-hand smoke in their home in the past week. A similar proportion of non-smoking adults (6.1%) were exposed to second-hand smoke in the car they usually travel in during the past week. One in 22 (4.5%) non-smoking adults were exposed to second-hand smoke in the workplace in the past month. Māori non-smokers were more likely to be exposed to second-hand smoke in the home, in the car and at the workplace than non-smokers in the total population. Pacific non-smokers were more likely to be exposed to second-hand smoke in the car than non-smokers in the total population. There were no other differences for Pacific people in terms of exposure to second-hand smoke. xiv Tobacco Use in New Zealand

The 2009 New Zealand Tobacco Use Survey did not directly ask if children aged 0 14 years had been exposed to second-hand smoke at home. As a proxy for second-hand smoke exposure for children, the proportion of households where at least one resident (including the respondent) had smoked anywhere inside the house in the past week and that had at least one child aged 0 14 years living there has been used. In 1 in 10 (10.1%) households with one or more children aged 0 14 years living there, at least one resident had smoked anywhere inside the house in the past week. Around one in five (21.3%) Māori and one in seven (14.1%) Pacific households with at least one child aged 0 14 years had at least one resident who had smoked anywhere inside the house in the past week. After adjusting for age, for Māori, this was twice the prevalence of the total population with one or more children aged 0 14 years living at home. There was no significant difference between Pacific people and the total population. Tobacco Use in New Zealand xv

Chapter 1: Introduction This report provides an overview of tobacco use in New Zealand, predominantly for the year 2009. It includes findings from the 2009 New Zealand Tobacco Use Survey (NZTUS) and other relevant sources of data. There have been three comprehensive national tobacco use surveys conducted in New Zealand: in 2006, 2008 and 2009. The New Zealand Tobacco Use Surveys are part of the New Zealand Health Monitor, an integrated programme of household surveys and cohort studies managed by the Health and Disability Intelligence Unit of the Ministry of Health (Ministry of Health 2005). The 2009 NZTUS was carried out from January to May 2009. All New Zealanders aged 15 64 years who were usually resident in permanent, private dwellings at the time of the survey were eligible for selection in the 2009 NZTUS. The report uses sources beyond the NZTUS to present the prevalence of daily smoking among New Zealanders over time, the supply of tobacco in New Zealand and tobaccoattributable mortality. Findings from the 2009 NZTUS on current smoking, tobacco consumption, quitting behaviour (including history of quit attempts and use of quitting programmes/services), support from health services and health professionals, and exposure to second-hand smoke are also presented. Where data allow, results are presented by sex, age group, ethnic group and neighbourhood deprivation. Where possible, findings from the 2009 NZTUS are compared with earlier Tobacco Use Surveys (2006 NZTUS and 2008 NZTUS) and the 2006/07 New Zealand Health Survey. The information contained within this report will help in the evaluation of one of the six 2010/11 Health Targets: Better help for smokers to quit. The report will be of interest to anyone involved in tobacco control research or policy, or the provision of quitting products or services. Tobacco Use in New Zealand 1

Chapter 2: Methodology The 2008 NZTUS Methodology Report is available on the Ministry of Health s website (Ministry of Health 2009b). This report contains detailed information on the sample design and analysis. A 2009 NZTUS methodology report will not be produced, because there were very few differences between the two surveys in terms of methodology. Any changes from the 2008 NZTUS methodology are discussed in this section. Survey design and analysis In order to be consistent with previous Tobacco Use Surveys, the target population for the 2009 NZTUS was the usually resident population aged 15 64 years living in permanent private dwellings in New Zealand. A multi-stage, stratified, probability-proportional-to-size sampling design was used. The design included a Pacific stratum, as well as sampling by District Health Board area and a screen sample to boost the proportions of Māori, Pacific people and those aged 15 24 years. Participation in the 2009 NZTUS was voluntary, relying on the good will of participants, and consent was obtained without coercion. The survey was carried out by trained interviewers from January to May 2009 using a face-to-face computer-assisted personal interview system. A total sample size of 5222 people aged 15 64 years was achieved, with a weighted response rate of 71.3%. The total sample included 980 Māori, 522 Pacific people, 560 Asian people and 3202 European/Other people. 3 The survey data were weighted so that estimates of population totals, averages and proportions are representative of the total resident population of New Zealand. Survey weights can be thought of as the number of members of the population represented by each survey participant. Using weights in analyses ensures that no population group is under- or over-represented in estimates from the survey. The process used to calculate the survey weights is described in more detail in the 2008 Methodology Report (Ministry of Health 2009b). What has been analysed and reported? Data in this report have been presented for the total adult population aged 15 64 years, by sex. Analyses by age group, ethnic group and neighbourhood socioeconomic deprivation (NZDep2006) have also been reported, where possible. Important information about the analyses presented in this report is set out below. 3 Note that these sample sizes sum to more than 5222 because total response ethnicity was used. 2 Tobacco Use in New Zealand

Total response ethnicity Ethnicity is a self-defined concept. Participants in the 2009 NZTUS were able to report affiliation with multiple ethnicities, using the Statistics New Zealand standard ethnicity question and Level 4 response categories. For this report, participants ethnicity was output to the following ethnic groups: European/Other, Māori, Pacific, Asian. The Other ethnic group (comprising mainly Middle-Eastern, Latin-American and African ethnicities) was combined with European to avoid small number problems. Because participants could be counted in one or more of the four ethnic groups, the sum of the ethnic group populations exceeds the total New Zealand population. This method is referred to as total response ethnicity. For more information on total response ethnicity, refer to Statistics New Zealand s classification for ethnicity output (Statistics New Zealand 2009), or see Presenting Ethnicity: Comparing prioritised and total response ethnicity in descriptive analyses of New Zealand Health Monitor surveys (Ministry of Health 2008). In this report unadjusted prevalences by ethnic group for some indicators have been presented, to show the burden on different population groups, and include estimates of the number of people affected in each group. Age-standardised rate ratios are presented after the unadjusted prevalence to allow comparisons of each ethnic group with a reference group. For example, Pacific male current smokers are compared with male current smokers in the total population. The reference group does not represent the best outcome group but provides an indication of the current level in New Zealand for comparison. Ethnic groups should not be compared with each other (eg, comparing Māori and Pacific data) using either the unadjusted rates or the standardised rate ratios. Instead, comparisons should be made with the reference population as explained in the following section on How to interpret graphs in this report. Ethnic groups have not been compared with independent comparison groups (ie, Māori/ non-māori, Pacific/non-Pacific and Asian/non-Asian) in this report. These will be available in online web tables in 2011. Age standardisation Age is an important determinant of cigarette smoking, so populations with different age structures (such as males and females, due to females having a longer life expectancy) will have different rates of smoking due to these age differences. Age standardisation involves adjusting for the effects of any differences in the age distributions between population groups. For this report, age standardisation was performed by the direct method using the World Health Organization (WHO) world population age distribution (Ahmad et al 2000). This statistical method of standardising for age has been used in analyses by sex, ethnic group and neighbourhood deprivation (NZDep2006), and for time-trend comparisons. Age standardisation is not used when data are presented by age group and for youth. Tobacco Use in New Zealand 3

Neighbourhood deprivation: The New Zealand Index of Deprivation 2006 The New Zealand Index of Deprivation 2006 (NZDep2006) is used in this report as a measure of neighbourhood socioeconomic deprivation and as a proxy for individual socioeconomic position. The NZDep2006 is an area-based index of deprivation that measures the level of socioeconomic deprivation for each neighbourhood (meshblock) using nine census variables (receiving a means-tested benefit, having a low household income, not owning the home a person lives in, being part of a single-parent family, unemployment, lacking school qualifications, living in an overcrowded household, lacking access to a telephone and lacking access to a car) (Salmond et al 2007). In this report, NZDep2006 scores have been aggregated into five equally sized groups (quintiles), each containing approximately 20% of the population. The least deprived neighbourhoods (quintile 1 and sometimes also quintile 2) have been compared with the most deprived neighbourhoods (quintile 5 and sometimes also quintile 4). Small numbers In order to ensure the reliability of the survey data presented, and to protect the confidentiality of the participants, data have only been presented when at least 30 respondents were in the population group being analysed. In some cases, to obtain an adequate sample size, data have been presented in an aggregated form. Care has been taken to ensure that no individual participant can be identified in the results. What is the quality of these results? Best-practice survey techniques have been used throughout the 2009 NZTUS. Many steps have been taken to ensure that data collected are of high quality and are as robust as possible. This includes establishing advisory groups to advise on questionnaire content. External peer review of the sample design and this report has contributed to maintaining the high quality of the survey results. However, sampling errors can occur due to the selection of only some people in a population, or for other reasons (non-sampling errors). The quantifying of sampling errors and the prevention of non-sampling errors are discussed below. Sampling error Sampling error results from selecting a small number of people (a sample) in the population to represent the entire population, and is influenced by the complex design of the survey (resulting in some people having a higher chance of selection than others). That is, the estimates in this survey may differ from the true value that would have been produced if the information had been obtained for all the people in the population. 4 Tobacco Use in New Zealand

For example, the survey only covered the usually resident population aged 15 64 years living in permanent private dwellings. It did not include people living in institutions (such as prisons, hospitals, rest homes and boarding schools) and the homeless. Given that these groups are not included in the analyses, the estimated population numbers presented in this report will generally be slight underestimates of the numbers affected in the entire resident population of New Zealand. Table 2 in Chapter 4 presents an estimate of the undercount of the number of current smokers in New Zealand, as measured by 2009 NZTUS using data from the 2006 New Zealand Census (which includes private and non-private dwellings). Sampling errors for survey estimates from this survey were calculated using a replicate method, called the delete-a-group jackknife method (Kott 1998). 95% confidence intervals for prevalence estimates Ninety-five percent confidence intervals (95% CIs) have been used in this report to quantify the sampling errors for estimates. It should be noted that the confidence interval is influenced by the sample size of the group. When the sample size is small, the confidence interval becomes wider. Ninety-five percent confidence intervals have been presented in brackets after estimates in the text and as error bars in graphs. When the confidence intervals of two groups do not overlap, the difference in rates between the groups is statistically significant at the 5% level. Sometimes, even when there are overlapping confidence intervals, the difference between the groups being compared can still be statistically significant at the 5% level. In instances where there was a small overlap between groups (indicating possible significance), t-tests were conducted to determine whether the apparent difference between groups is significant. Statistically significant differences at the 5% level of significance are indicated in the text by p-value < 0.05. When a linear pattern was evident in a bar graph, but no significant differences were found between bars, the significance of the gradient was tested using logistic regression. No variables were controlled for in the logistic regression. 95% confidence intervals for rate ratios In rate ratio graphs, the 95% CIs are presented as vertical lines on the graph. If the confidence interval includes 1, then there is no statistically significant difference between the rate ratio for that particular group and the reference group. If the 95% CI does not include 1, then the rate ratio is statistically significant (ie, there is a significant difference between the group of interest and the reference group). For more information, see the example rate ratio graph at the end of this chapter. Statistical significance In this report the term significant (or significance ) is used to refer to statistical significance. Tobacco Use in New Zealand 5

Non-sampling errors Non-sampling errors may occur in any enumeration, regardless of whether it is a sample or a full enumeration. Possible non-sampling errors include coverage errors, response bias and measurement errors. Although these elements cannot be measured, it is useful to be aware of them when interpreting the results of the survey. Considerable effort has been made to reduce non-sampling errors by carefully designing and testing the survey, questionnaire and processes, and by ensuring quality control of procedures and data. In the 2009 NZTUS, coverage errors may have occurred; for example, because a small proportion of the population could not be covered by the survey (including people living in meshblocks with fewer than nine occupied dwellings, and people not living in the North Island, South Island or Waiheke Island). Response bias may have occurred if there was differential non-response; that is, if the survey was less likely to be answered by certain people, such as a certain population group (eg, young males) or people who were not often home. The interview introduction was an important part of trying to ensure that people take part in the survey. Measurement error might also have occurred in this survey. Many of the analyses in this report used self-reported information, which may have resulted in some inaccuracies. Measurement errors include recall error (eg, mistakes made when respondents recall how often they have done something over the last 12 months), under- and over-reporting (which may be influenced by the respondent s perception of what is socially desirable) and item non-response (if the respondent chooses not to answer certain questions). Time trend comparisons Where possible, and relevant, time trend comparisons are made between the 2009 NZTUS, 2008 NZTUS, 2006 NZTUS and the 2006/07 New Zealand Health Survey (NZHS). 4 Time trend analyses have been conducted for the total population by sex and for Māori by sex. Comparisons with earlier survey data for other ethnic groups have not been presented due to the limited space available. Where the sample size allows, time trend analyses for other ethnic groups will be presented in online web tables. Due to differences in how data have been collected and presented over time, the results presented in this report may be slightly different from those in earlier publications and caution should be used when comparing data. Direct comparisons with data that are not included in the time trend analysis in this report need to be treated with caution. In particular, the following should be noted. The 2006 NZTUS questionnaire comprised two sections: one for those aged 15 19 years and the other for those aged 20 64 years. There were some differences in the 4 To ensure as much comparability as possible, the 2006/07 New Zealand Heath Survey data set was re-weighted and limited to 15 64-year-olds. 6 Tobacco Use in New Zealand

questions asked of these groups. Given these differences, some time-trend comparisons presented in this report have been made for 20 64-year-olds only. There were some differences in question order and content between the 2006 NZTUS and the 2008 and 2009 NZTUS questionnaires. The 2008 and 2009 surveys had questions around quit attempts lasting 24 hours or more, prior to the questions about quit attempts lasting for more than a week. The 2006 NZTUS did not have questions about quit attempts lasting 24 hours or more. In the 2008 and 2009 NZTUS, participants who had quit for at least 24 hours but less than a week may have answered no to the quit for at least a week question because they would have already answered questions about quit attempts lasting 24 hours or more in the past 12 months. In other words, the 24-hour quit attempt questions appear to have filtered out those people who tried to quit in the past 12 months, but couldn t stay quit for a week or more. The filtering process of the 2008 and 2009 NZTUS may mean that these surveys are a better estimate of the prevalence of smokers who quit smoking for at least a week in the past 12 months than the 2006 NZTUS. For this reason, the 2006 NZTUS data were excluded from the time-trend analysis of smokers who quit smoking in the past 12 months for at least a week. It is possible that the findings of some other time-trends analyses (eg, services or advice used in last quit attempt) may be confounded by this methodological issue. Total response ethnicity (see above) was used for the 2008 and 2009 NZTUS reports, whereas prioritised ethnicity was used for the 2006 NZTUS report. How can readers access more survey results? Data for all analyses presented in this report will be available in data tables online in Excel format, on the publications web page (see www.moh.govt.nz) from early 2011. The analyses presented in this report are only a small proportion of those that could be undertaken, and in many ways pose more questions than they answer. Researchers are encouraged to use the 2009 NZTUS data set to explore topics of interest. The 2009 NZTUS CURF (confidentialised unit record file), with accompanying documentation and user guides, will be available in 2011. Researchers may apply to access CURF data sets. CURFs have had all identifying information about individuals removed, and have been modified to protect individual information. Approval is subject to certain criteria, terms and conditions, and the researcher s organisation must sign a microdata access agreement with the Ministry of Health. For more information and to download the application form, refer to the Health and Disability Intelligence Unit s Microdata Access Protocol online (http://www.moh.govt.nz/moh.nsf/indexmh/dataandstatistics-survey-access). How to interpret graphs in this report Bar graphs The bar graphs in this report show the proportions (or percentages) of people in different groups who demonstrated a particular smoking-related behaviour. The following diagram shows how to interpret the bar graphs presented in this report. Tobacco Use in New Zealand 7

The caption gives information about what the graph is about, and indicates whether the data are age-standardised The legend shows who or what is represented by the different colours in the graph Figure X: Current smoking among 15 64-year-olds, by age group and sex, 2009 (unadjusted prevalence) Percent 60 Males Females 50 40 The height of the bar indicates the prevalence for each population group 30 20 10 0 16.9 19.1 30.1 31.2 33.4 21.1 22.5 21.5 22.6 22.3 18.6 14.0 10.6 11.2 15 19 20 24 25 29 30 39 40 49 50 59 60 64 Age group (years) This number gives the prevalence value (%) for each bar The vertical line indicates the 95% confidence interval for the prevalence estimate. If any two confidence intervals do not overlap, the difference between the two prevalence estimates is statistically significant. However, in some cases, the difference between two prevalence estimates can be statistically significant even if the confidence intervals overlap. In instances where there was a small overlap between groups (indicating possible significance), t-tests were conducted to determine whether there was a significant difference between groups. 8 Tobacco Use in New Zealand

Rate ratio graphs The rate ratio graphs in this report show how the percentages in the different ethnic groups compare to that of a reference population (usually all current smokers aged 15 64). The following diagram shows how to interpret the rate ratio graphs presented in this report. The caption gives information about what the graph is about, and indicates whether the data are age standardised. Figure Y: Ratio 3.0 2.5 2.0 1.5 1.0 Current smoking among 15 64-year-olds, by ethnic group and sex, 2009 (agestandardised rate ratio) Males Females The legend shows who or what is represented by the different shapes and colours on the graph. This point indicates where the data point lies, compared with the whole population relevant to that data point: in this case, all current smoking males aged 15 64 years. This line is the 95% confidence interval. If this line does not cross the bold line at 1.0, there is a statistically significant difference between the rate for this group and the rate for all males or females in the total population. 0.5 0.0 0.96 0.95 1.72 2.32 European/Other Māori Pacific Asian Ethnic group Notes: 1. The reference group is indicated by the bold line with a rate ratio of 1.0, which represents the total male or female population aged 15 64 years. 2. Total response ethnicity has been used. 3. Age standardised to the WHO world population. 1.57 1.30 0.74 0.21 The reference group is represented with a line at rate ratio = 1. This number is the value for the standardised rate ratio for each data point. A value less than 1 means that the population group is less likely to have the outcome than the reference group, while a value greater than 1 means the population group is more likely to have the outcome. Tobacco Use in New Zealand 9

Chapter 3: Smoking in New Zealand This chapter covers the supply of tobacco, daily smoking and tobacco-attributable mortality over time. Many of the data reported in this chapter are from sources other than the 2009 NZTUS. Supply of tobacco In New Zealand, estimation of the tobacco supply is based on both the annual tobacco products released for consumption and the annual tobacco returns. The annual tobacco products released for consumption include the amount of manufactured (tailor-made) cigarettes and loose tobacco, imported or locally manufactured for sale in New Zealand, on which duty has to be paid. This information is reported annually by Statistics New Zealand. The annual tobacco returns identify the amount of tobacco products, including manufactured and loose tobacco, sold to retailers each year. As required by the Smoke-free Environments Act 1990, the returns are reported to the Director-General of Health annually by individual tobacco product manufacturers. When converting quantities of loose tobacco to the equivalent numbers of manufactured cigarettes, the standard measure used in this report was one gram of tobacco is equivalent to one manufactured cigarette. 5 Actual consumption can only be inferred from the supply of tobacco in New Zealand. The supply is reported per capita to minimise the effect of the increasing population. The amount of tobacco products per person aged 15 years and over available for consumption in New Zealand in 2009 decreased compared with the previous year (Figure 1). The total cigarettes and cigarette equivalents available per capita decreased by 5% from 2008 to 2009. There was a 5.8% decrease in the number of manufactured cigarettes per capita available and a 2.8% decrease in the number of cigarette equivalents of loose tobacco (one gram of loose tobacco = one cigarette) available per capita. 5 It has been argued that this standard for conversion from tobacco to cigarette equivalents may underestimate the true cigarette numbers. The equivalent may be as low as 0.5 grams (Laugesen 2009). 10 Tobacco Use in New Zealand