The heated tobacco products excise cut – a trial, but not as we know it

Opinion: On July 1 this year the excise tax on heated tobacco products was cut by 50 percent. The Associate Health Minister Casey Costello subsequently claimed this was “a trial”, an assertion reiterated by the Prime Minister earlier this week in an interview on Radio New Zealand.

“This is a 12-month trial. We’ll review it. Then if it works, we’ll make it permanent. If it doesn’t, we won’t, okay.” This statement is misleading as the Cabinet paper makes clear that the excise cut will become permanent from January 1 next year and will need primary legislation to reverse it. But what about the claim that the excise cut is a trial?    

Trials are studies designed to investigate the effects of interventions on health outcomes. For policy interventions that require data on key outcome measures to be collected rigorously and consistently before and after implementation to assess if change occurs after the policy is introduced.

The interviewer, Corin Dann, asked Prime Minister Christopher Luxon the following: “How are you going to monitor this? How are you going to get the research? How do we know it will be independently verified?” The Prime Minister didn’t answer directly, but reiterated: “ … we’re up for trying anything and everything to get from 6.8 percent to 5 percent daily smoking. The minister’s committed to that, the Government’s committed to that. We’re going to try all the alternatives. This is one of them, and we’ll see how it goes.”

Conducting trials of plausibly effective policy interventions is an excellent idea. There has been a lamentable lack of robust evaluation of most policy measures, by all New Zealand governments. However, there are several major problems with the Government’s claim that the heated tobacco products (HTP) excise tax is a ‘trial’ and claiming it’s a key justification for its introduction.

First, cutting excise on HTPs is a curious policy innovation to prioritise for a trial. The Ministry of Health and Treasury were opposed, pointing out the lack of evidence that HTPs help people who smoke to stop smoking completely and that HTPs are almost certainly more harmful than vaping products. It is therefore questionable whether this intervention will increase smoking cessation, and people who switch to HTPs may still be exposed to considerable harm. It is also plausible the excise cut will cause harm through more young people being attracted to and becoming addicted HTP users, and through people who smoke switching to HTPs rather than to less harmful vapes.

Far more promising and more evidence-based policy innovations exist that seem a much higher priority to trial. These include the repealed measures from the Smokefree Legislation: de-nicotinising cigarettes, reducing retailer numbers and a smokefree generation policy. For example, there is substantial supporting evidence for de-nicotinisation of cigarettes. Modelling studies predict this measure would rapidly and equitably reduce smoking prevalence. Numerous randomised trials in which people who smoke have been provided with de-nicotinised cigarettes mostly demonstrate positive outcomes such as reduced intensity of smoking and increased quitting compared to people given standard strength cigarettes.

Unlike the cut in excise for HTPs, which has been promoted by Philip Morris International, the Smokefree Legislation measures are untainted by support from commercial interests; indeed all were strongly opposed by the tobacco industry.

Second, the Government’s championing of trials for this innovative policy displays astonishing double standards. The Prime Minister in justifying the HTP excise tax reduction says it is “evidence-based” and will try “anything and everything” to achieve the Smokefree goal.

However, as noted above, Luxon led a Government that prevented trials of more plausibly effective policy innovations by repealing the Smokefree legislation. Ironically, one of the reasons given for the repeal (echoing tobacco industry arguments) was that interventions like de-nicotinising cigarettes were too experimental and had not previously been implemented.

However, the Government has now reframed being innovative and experimental as a virtue in the case of the excise tax cut for HTPs.

Third, Corin Dann’s follow-up questions about the conduct of the trial are important, as it seems doubtful that the excise cut was ever part of a meaningful trial. For example, where is the protocol describing the evaluation design, data to be collected and primary outcome measures? What baseline data was collected to ensure the evaluation is valid and meaningful. What monitoring is in place to assess whether the excise cut results in price reductions for HTPs and increased cessation through HTPs by people who smoke? How will the equity impacts be assessed?

As researchers who lead the only population-based studies we are aware of that collect data on HTP use, overall and for cessation (the NZ Health Survey does not record this), it is curious that we were neither informed nor consulted.  

If we had been approached, we might have reconfigured our studies to ensure they were informative as possible for the ‘trial’. For example, the timing of the fieldwork could have been adjusted to collect the most useful baseline and post-implementation data, and the survey questionnaires amended to include more detailed questions on HTP use. That we were not consulted and the lack of any plans for an evaluation study raises questions about whether this intervention was truly part of a trial. I think we can safely say that if this ‘trial’ was submitted for research funding it would be marked D for ‘do not fund’.

The impression this is an exceptionally poorly designed trial is heightened by subsequent revelations that due to changed regulations for vaping products the main HTP available on the market has now been withdrawn from sale. If a hospital entered patients into a trial of a new treatment, which could not then be provided due to hospital regulations, heads would surely roll.

Richard Edwards and Andrew Waa are co-directors of ASPIRE Aotearoa at the University of Otago in Wellington. Chris Bullen is a Professor in the Department of General Practice and Primary Health Care at the University of Auckland.