H2024053059 Response Letter.pdf

133 Molesworth Street
PO Box 5013
Wellington 6140
New Zealand
T+64 4 496 2000
29 October 2024
P Robins
By email:  [FYI request #28646 email]
Ref:
H2024053059
Tēnā koe P Robins
Response to your request for official information
Thank you for your request under the Official Information Act 1982 (the Act) to the Ministry of
Health – Manatū Hauora (the Ministry) on 4 October 2024.
On 7 October 2024, you were advised that the Ministry had partially transferred your request to
the Office of the Associate Minister of Health, Hon Casey Costello as the information is held by
the Minister’s office. Please find a response to your request for the Ministry’s internal
communications on heated tobacco products.
I am writing to formally request all communications related to the independent advice
referenced and released to the media by the Associate Minister of Health concerning the
excise reduction for heated tobacco products. This request encompasses communications
within the Ministry as well as between the Associate Minister and her office and the
Ministry, including between Ministry executives and staff and the Minister, political staff
and departmental private secretaries. Communications pertaining to articles that were
identified but not released should also be included.
The Ministry has identified three documents within scope of your request. Al  documents are
itemised in Appendix 1 and copies of the documents are enclosed. Please note that this was a
rapid assessment of the data at hand, and a follow-up email (also enclosed) further clarifies
some of the information. Where information is withheld under section 9 of the Act, I have
considered the countervailing public interest in release in making this decision and consider that
it does not outweigh the need to withhold at this time.
I trust this information fulfils your request. If you wish to discuss any aspect of your request with
us, including this decision, please feel free to contact the OIA Services Team on:
[email address].
Under section 28(3) of the Act, you have the right to ask the Ombudsman to review any
decisions made under this request. The Ombudsman may be contacted by email at:
[email address] or by calling 0800 802 602.

Please note that this response, with your personal details removed, may be published on the
Manatū Hauora website at: www.health.govt.nz/about-ministry/information-releases/responses-
official-information-act-requests

Nāku noa, nā

Jane Chambers
Group Manager, Public Health Policy and Regulation
Public Health Agency | Te Pou Hauora Tūmatanui

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Appendix 1: List of documents for release
#  Date
Document details
Decision on release
1
2-3 October 2024
Email correspondence: Lancet
Some information withheld
comment on tobacco harm
under section 9(2)(a) of the
reduction – embargoed
Act, to protect the privacy of
natural persons.

Information deemed out of
scope of your request has
been excluded.
2
4 October 2024
Email correspondence: Overview  Some information withheld
of HTP/s
under section 9(2)(g)(i) of the
Act, to maintain the effective
conduct of public affairs
through the free and frank
expression of opinions by or
between or to Ministers and
officers and employees of any
public service agency.
2A
Attachment: overview of htp
Released in full.
documents

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Document 1
From: Fiona Callaghan <[email address]>
Sent: Thursday, October 3, 2024 9:55 AM
To: Kristie Carter <[email address]>; Jane Chambers <[email address]>; Emma
Hindson <[email address]>
Cc: Greg Martin <[email address]>
Subject: RE: Lancet Comment on tobacco harm reduction - embargoed
Kia ora
Here are a few bits and pieces that may help – also Greg may have thoughts! I could go on but won’t.
 The ar cle is an opinion piece from 2024, albeit in a highly respected journal (Lancet). An opinion piece is
meant to be backed up by evidence, but it isn’t aiming to be a complete or rigorous evidence review, but
it is supposed to be more of a ‘reasonable’ posi on on the data, argued from a par cular point of view.
 The main focus is to argue that the WHO (par cularly the WHO Framework Conven on on Tobacco Control
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(FCTC)) should more strongly emphasise harm reduc on for smoking addic on. There is reasonable
evidence that vaping or e-cigare es may help with smoking cessa on/qui ng smoking, but  no evidence for
other products such as snus (tobacco and non-tobacco) or heated tobacco products (HTPs) are eﬀec ve
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for smoking cessa on.
 The ﬁrst issue is the author conﬂates e-cigare es with tobacco products like snus and heated tobacco
products --lumping them all together as “novel nico ne products” or harm reduc on devices -- with no
jus ﬁca on. There is no evidence that snus or HTPs are used or eﬀec ve for smoking cessa on, whereas
there are several studies evalua ng e-cigare es.
 The second issue is that the evidence that the author cites for HTPs and snus and smoking rates, is very
weak, simply ci ng two countries with low smoking rates who also use those products (Japan and
Sweden). This is known in epidemiology as the ‘ecological fallacy’, where two characteris cs from a
popula on of people are said to be causally related without any evidence that they are related. As we know,
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correla on is not causa on, so a claim such as ‘a country has high snu use and low smoking rates, therefore
snus may help people quit smoking’ needs to be evaluated with a study designed to evaluate that ques on,
and cannot be inferred from two separate trends in the data.
 Sweden has a ‘long tradi on’ of snu use, and declining smoking rates, with the author implying that snus
have contributed to that decline. This is not very likely, especially if snu use has remained prevalent over
that  me period, and there are no studies evalua ng snus as a smoking cessa on tool. The Public health
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Agency of Sweden explicitly (cited by the author) also states “Nico ne snus and e-cigare es are not smoking
cessa on drugs” and that  “Terms such as vape, tobacco-free snus and white snus can make them
appear less harmful, but nico ne's toxic and addic ve proper es can nega vely aﬀect health.”
THE
Nico ne products and health risks — Public Health Agency of Sweden (folkhalsomyndigheten.se)
 In addi on, an analysis of 8 studies have found that snu use has been associated with increased
all-cause mortality in Sweden: snu users had a 28% higher mortality risk compared to never-
smokers, primarily due to higher risk of cardiovascular disease.
h ps://www.ncbi.nlm.nih.gov/p
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 The author also cites Japan having uptake of HTPs and a ributes a link to lowering smoking rates. The study
cited for the claim that HTPs have helped to lower smoking rates in Japan (Cummings et al) is funded by
Philip Morris: “Data used for this study come from the Tobacco Ins tute of Japan and Philip Morris
Interna onal”.
 There is no evidence linking HTPs to declining smoking rates, and in fact smoking rates in Sweden, Japan,
and New Zealand have all declined at about the same rate, with New Zealand having the lowest smoking
rate, without prevalent snu, HTP or use of other similar products. h ps://ourworldindata.org/smoking. See
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below.
 The author also claims that not including nico ne products as part of harm reduc on plans would ‘favour’
cigare e use and ‘may discourage’ vaping, without evidence for those claims.
2

Document 1
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From: Kristie Carter <[email address]>
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Sent: Wednesday, October 2, 2024 4:45 PM
To: Jane Chambers <[email address]>; Fiona Callaghan <[email address]>; Emma
Hindson <[email address]>
Subject: FW: Lancet Comment on tobacco harm reduction - embargoed

Fiona is already onto it

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From: Jane Chambers <[email address]>
Sent: Wednesday, October 2, 2024 4:42 PM
THE
To: Kristie Carter <[email address]>
Cc: Emma Hindson <[email address]>; Media MOH <[email address]>; Sanjana George
<[email address]>
Subject: FW: Lancet Comment on tobacco harm reduction - embargoed

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Kia ora Kris e

Could someone please review this document and provide any comment that may inform any media requests we
get. We have no meframes or requests at present, but we have been asked to be prepared. Happy to discuss.

Thanks - Jane

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Jane Chambers (she/her)
Group Manager, Public Health Policy and Regulation
Public Health Agency | Te Pou Hauora Tūmatanui
+64 4 496 2000
Mobile: S9(2)(a)

[email address]
Manatū Hauora, 133 Molesworth Street, Thorndon, Wel ington 6011

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Document 2A
Overall
• While not all the studies are of poor quality, overall these studies do not form an up-to-date,
balanced view of the latest evidence on the impact of alternatives to tobacco cigarettes on
smoking rates. Some studies are older, using data from prior to the widespread use of e-
cigarettes (eg 2016 and before), and evidence has developed since then, and others are
opinion pieces, and others relate to studies of trends in other counties that do not relate well
to the New Zealand context, e.g., when e-cigarettes could not be marketed in Japan, or
related to Sweden’s tradition of ‘snu’ use, an alternative tobacco product developed in
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Sweden.
Royal Col ege of Physicians report, 2016, “Nicotine without smoke: tobacco harm reduction”
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https://www.rcp.ac.uk/improving-care/resources/nicotine-without-smoke-tobacco-harm-reduction/
• The RCP report is from 2016, and evidence has developed since that time. Vaping has grown
substantially in popularity.
• The essential argument of the report is that non-tobacco, nicotine products are far less
harmful than tobacco cigarettes, and their use should be encouraged in smokers. They
acknowledge that there are harms and unknown potential harms associated with e-
cigarettes, but that these are far outweighed by the known, substantial harm associated with
tobacco cigarettes.
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• They acknowledge that nicotine replacement therapy (NRT) patches are a less harmful
nicotine replacement method, but that e-cigarettes are preferred by smokers.
• The report considers that non-smokers may vape also and this could lead to unintended
harm if e-cigarettes are made widely available, but says “…are being used almost exclusively
as safer alternatives to smoked tobacco…”. This was likely true in 2016, but since then
evidence has shown that there are a substantial number of young people who vape who are
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non-tobacco smokers.
Cummings et al What Is Accounting for the Rapid Decline in Cigarette Sales in Japan? 2020,
THE
International Journal of Environmental Research and Public Health https://www.mdpi.com/1660-
4601/17/10/3570
• This study uses data from smoking rates and HTP use rates (2011-2019), and shows that the
rates of smoking declined at the same time that the rates of HTP use increased. This is not a
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study designed to show causation, such as prospective study of smokers and non-smokers
fol owed over time, or a detailed questionnaire of smokers and HTP users. They do not show
one trend is casual y linked to the other, just that the trends occurred at the same time on a
national level.
• They do not consider e-cigarette trends, and in fact state that Japan “…prohibits the
marketing of electronic nicotine delivery systems (ENDS)…”. Hence, it only considers the
impact of H
RELEASED TP use in a country where HTPs are marketed but e-cigarettes are not. This limits
the applicability to most countries, including New Zealand.
• Data used for this study come from the Tobacco Institute of Japan and Philip Morris
International.
Ramstrom et al 2016 Patterns of Smoking and Snus Use in Sweden: Implications for Public Health .
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5129320/pdf/ijerph-13-01110.pdf

Document 2A
•  ‘snus’ are a non-combustible, lower-toxicity (compared to regular tobacco cigarettes), oral
tobacco product. This product was developed in Sweden in the 1970s by the then
government-owned tobacco company, in the context of high smoking rates, to provide a less
harmful alternative to tobacco cigarettes. Snus accounts for a substantial proportion of the
tobacco market there, but is not a product widely used outside of Sweden.
•  The paper reports that snu users are less likely to become smokers than non-snu users, and
that smokers who also use snus, tend to quit using regular tobacco cigarettes. This study is
more than simply a report of a correlation of trends in smoking, but does involve a relatively
detailed survey of people and their smoking habits.
•  The paper states that snus are not associated with a mortality risk, except for acute
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myocardial infarction risk. Evidence has grown since 2016. Subsequent studies have shown
that snus are associated with around a 30% increased al -cause mortality risk and a similar
increased risk of cardiovascular-related death. Swedish snus use is associated with mortality:
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a pooled analysis of eight prospective studies | International Journal of Epidemiology |
Oxford Academic (oup.com)
•  It is unknown if snus or any other alternative to tobacco cigarettes would have the same
impact on a population, or even if the availability of alternatives leads to lower smoking rates
Smoking rates were declining in many countries prior to the availability of e-cigarettes or
other products. The lower smoking rates in Sweden or elsewhere could also be due to other
public health actions occurring at the same time, e.g., anti-smoking campaigns, greater
awareness, increases in cost of tobacco products, changes in public attitudes to smoking etc.
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Levy et al 2022 A Decision-Theoretic Public Health Framework for Heated Tobacco and Nicotine
Vaping Products https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9602493/pdf/ijerph-19-13431.pdf
•  This paper proposed a framework for how HTPs, e-cigarettes and other non-tobacco
cigarette products might be regulated and rolled-out with the overall goal of reducing
tobacco smoking rates. It is proposed policy road map, but does not provide evidence that
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this framework would be successful, or evidence on the harms of smoking, smoking
cessation eﬃcacy, or other related issues.
THE
Beaglehole et al 2014 Harnessing tobacco harm reduction Harnessing tobacco harm reduction -
ScienceDirect
•  [I’ve updated from my previous email below with changes in red]
•  The article is an opinion piece from 2024, albeit in a highly respected journal (Lancet). An
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opinion piece is meant to be backed up by evidence, but it isn’t aiming to be a complete or
rigorous evidence review, but it is supposed to be more of a ‘reasonable’ position on the
data, argued from a particular point of view.
•  The main focus is to argue that the WHO (particularly the WHO Framework Convention on
Tobacco Control (FCTC)) should more strongly emphasise harm reduction for smoking
addiction. There is reasonable evidence that vaping or e-cigarettes may help with smoking
cessation/quitting smoking, but  no evidence for other products such as snus (tobacco and
RELEASED
non-tobacco) or heated tobacco products (HTPs) are eﬀective for smoking cessation.
•  The ﬁrst issue is the author conﬂates e-cigarettes with tobacco products like snus and
heated tobacco products --lumping them al  together as “novel nicotine products” or harm
reduction devices -- with no justiﬁcation. There is no evidence that snus or HTPs are used or
eﬀective for smoking cessation, whereas there are several studies evaluating e-cigarettes.
•  The second issue is that the evidence that the author cites for HTPs and snus and smoking
rates, is very weak, simply citing two countries with low smoking rates who also use those

Document 2A
products (Japan, Sweden). This is known in epidemiology as the ‘ecological fal acy’, where
two characteristics from a population of people are said to be causal y related without any
evidence that they are related. As we know, correlation is not causation, so a claim such as ‘a
country has high snu use and low smoking rates, therefore snus may help people quit
smoking’ needs to be evaluated with a study designed to evaluate that question, and cannot
be inferred from two separate trends in the data.
•  Sweden has a ‘long tradition’ of snu use, and declining smoking rates, with the author
implying that snus have contributed to that decline. This is not very likely, especial y if snu
use has remained prevalent over that time period, and there are no studies evaluating snus
as a smoking cessation tool. The study observes that in Sweden individuals that start using
snus, tend to stay using snus, and that smokers wil  often switch to snus, and many people 1982
use neither. However, this doesn’t provide evidence that snus are used as a smoking
cessation tool, only that in a country where both are available, the use of one or other or
both are prevalent, and one is associated with less harm. The Public health Agency of
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Sweden explicitly (cited by the author) also states “Nicotine snus and e-cigarettes are not
smoking cessation drugs” and that  “Terms such as vape, tobacco-free snus and white snus
can make them appear less harmful, but nicotine's toxic and addictive properties can
negatively aﬀect health.” Nicotine products and health risks — Public Health Agency of
Sweden (folkhalsomyndigheten.se)
•  In addition, an analysis of 8 studies have found that snu use has been associated with
increased al -cause mortality in Sweden: snu users had a 28% higher mortality risk
compared to never-smokers, primarily due to higher risk of cardiovascular disease.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7825961/
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•  The author also cites Japan having uptake of HTPs and attributes a link to lowering smoking
rates. The study cited for the claim that HTPs have helped to lower smoking rates in Japan
(Cummings et al) is provided by tobacco companies: “Data used for this study come from
the Tobacco Institute of Japan and Philip Morris International”.
•  There is no evidence linking HTPs to declining smoking rates, and in fact smoking rates in
Sweden, Japan, and New Zealand have al  declined at about the same rate, with New Zealand
OFFICIAL
having the lowest smoking rate, without prevalent snu, HTP or use of other similar products.
https://ourworldindata.org/smoking. See below.
•  The author also claims that not including nicotine products as part of harm reduction plans
THE
would ‘favour’ cigarette use and ‘may discourage’ vaping, without evidence for those claims.
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RELEASED

Document 2A
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