April 20, 2018 rendez-vous 5
with Marewa Glover
Thank you Marewa for accepting our rendez-vous. May I ask you to introduce yourself?
Marewa Glover: Fresh white clouds are chasing the last of the summer rays across the sky above me. I can smell the damp earth from last night’s rain. The scent of flowers, the bush, the sea... these are the aromas of what is now our almost Smokefree New Zealand. If I’m bothered by particles blown on the breeze, it’s pollen or the occasional whiff of smoke from a neighbour’s chimney. It’s a very different atmosphere to the one I grew up with which, from birth, smelt of cigarettes.
Both my parents smoked. They smoked inside the house, inside the car. It was just something all grown-ups did. At 13, I tried my first cigarette and at 16, as soon as I was employed, I took up smoking. Luckily, I say, I got chronic and repeating bronchitis early in my smoking career, about 6 years in. It was easy for me to believe the stop smoking ads on TV - if I kept smoking, it would kill me.
After a few years of off-again-on-again smoking, I managed to stay quit. But, I had to avoid everything associated with smoking: coffee, places where people smoked, smokers. I ate up negativity about smoking to bolster myself against relapse. I came to hate the smell of cigarette smoke, developing a psychosomatic chest-tightening response to it. Before smoking bans were introduced, smokers were brazen, ubiquitous, everywhere. They smoked in restaurants, in offices, in shops. They showed not a care for non-smoking bystanders, children, dogs.
My dislike of smoking deepened, if that was possible, when I started in public health. This is when I began working with Dr Murray Laugesen, the grandfather of tobacco control in New Zealand. I learned that smoking-related illnesses were the biggest killer of Maori. From then, I dedicated my career to reducing tobacco smoking.
What Maori wanted then, in the early 1990s, was funding for smoking cessation. Unfortunately, the cost-effectiveness of such services was very poor at that time. There were however some Maori stop smoking approaches that appeared to have high success rates. The lack of evidence to back up a case for funding them led me to undertake my PhD on Maori smoking cessation.
We didn’t get Government funding for cessation until 2000, just as I graduated. I subsequently played a pivotal role in the design of the first Government funded cessation programmes and the training of the health workforce in supporting quitting. Tobacco control finally had a comprehensive programme using legislative restrictions, tax, health promotion and education, stop smoking support, a research strategy and constant advocacy for increased funding.
In 2006, the Government subsidised nicotine replacement patches and gum. By then Murray and others had founded End Smoking NZ (initially called Smokeless NZ) and they were lobbying for Swedish Snus to be legalised for import and sale. I joined End Smoking on the end of this unsuccessful bid.
With the doors closed on Snus, Murray searched for another harm reduced alternative to smoking that wouldn’t be blocked by our existing Smoke-Free Environments Act (SFEA). This is when he began investigating the Ruyan electronic cigarette. After that, End Smoking NZ, which I now Chair, took on lobbying for electronic cigarettes to be accepted as a harm reduction alternative to smoking tobacco.
Q1. Can you tell us what is the present regulatory situation in New Zealand as far as e-cigs and other non-combustible nicotine delivery products are concerned?
Marewa Glover: As soon as electronic cigarettes hit the USA market, New Zealand smokers started accessing ecigs and switching to vaping. This began a slow organic spread of vaping from vaper to smoker.
The devices were not covered by the SFEA. Nicotine for vaping, as a product manufactured from tobacco, had to either be covered by the Medicine’s Act or the SFEA. But the SFEA only referred to tobacco that was combusted and smoked, or “oral” tobacco products that were intended for “chewing”. Advocacy for electronic cigarettes grew and early research indicated that ecigs might have potential as an attractive harm reduced alternative to smoking. The tobacco control workforce began having to deal with an increasing number of enquiries about vaping. Schools wanted to know what to do about students caught with ecigs. Smokers began to ask their Doctors and stop smoking services if they should switch to an e-cigarette. Smokefree enforcement officers started to receive complaints about people ‘smoking’ e-cigarettes inside bars and restaurants where smoking was banned. The Ministry of Health received reports that shops were selling nicotine e-liquids. More and more people were openly blowing clouds in public.
Pressed for information, the Ministry of Health posted on their website that nicotine was a fatal poison. They decided to classify nicotine e-liquid as an oral tobacco product and thus claimed that it was illegal to import nicotine containing e-cigarettes or nicotine e-liquids for sale and distribution. People could however import nicotine vaping products for personal use. This position was never tested, nor enforced. Though the Ministry of Health did from time to time send warning letters to advertisers or retailers threatening prosecution.
Tobacco control academics invested in elimination of the tobacco industry and denormalisation of smoking through the stigmatization and marginalization of smokers saw e-cigarettes as a time-wasting diversion. They began to express strong opposition to vaping and called for a total ban on the devices, e-liquids and vaping as a behaviour. In response, consumer and vaping industry groups formed and began lobbying for the legalisation of nicotine for vaping.
By now many people had completely switched to vaping or had successfully temporarily used vaping to stop smoking. Independent organisations, not funded by Government, began to provide peer to peer and group support for smokers to assist them to switch to vaping.
A Government consultation on ecigs netted overwhelming recognition that electronic cigarettes were indeed a route out of smoking. The Government announced that they would introduce regulations around electronic cigarettes which would include ‘legalising’ nicotine for vaping. They also announced the establishment of a process that could consider other proven harm reduced alternatives to smoking tobacco, such as, Swedish Snus.
Then there was an election, a new coalition took over Government, and the aspirational goal of Smokefree 2025 was put on a back burner.
It’s six months in and two events have prodded the new Associate Minister of Health Jenny Salesa to bring Smokefree 2025 to the top of her pile (as she assured me when I saw her last Thursday).
Firstly, the Ministry of Health lost their prosecution of Philip Morris who were charged with illegally importing and selling iQos Heet sticks. The Ministry applied the same SFEA oral product clause mentioned above that they used to say nicotine e-liquid was illegal. The judge disagreed! He said the Heet sticks were not an oral tobacco product intended for chewing which the clause was specific to, and anyway, banning a reduced harm product was contrary to the intent of the legislation! Read that again – banning a tobacco harm reduced product is contrary to the intent of New Zealand’s Smoke-Free Environments Act! This logic calls into question all of the Government funded tobacco control work that is aimed at undermining access to, and sabotaging the efficacy of, ecigs, for example, banning vaping!
The second surprise was the introduction, by the previous Associate Minister of Health Nicky Wagner, of a Private Member’s Bill to, regulate ecigs and vaping. If the incumbent Government want to accept the accolades for future reductions in smoking prevalence in NZ, they need to quickly take responsibility for this critical change in policy and it seems they are about to.
Q2. You have been involved in tobacco control for 25 years. How do you explain the divide between people who favor a harm reduction strategy and those who deny any substantial benefit to alternatives to combustibles? How divisive or not is the climate within the health community in New Zealand?
Marewa Glover: In New Zealand, funding for public health is always thought of as hard won. Prevention is the poor-cousin to treatment, and primary health can’t be trusted to not snatch back the relative pittance allocated to health promotion. Public health has always had to build a strong case, convince peers, the public and politicians, and they have had to lobby repeatedly to hang on to any funding won, let alone increase the pot.
One result of constant lobbying for more funding, for more regulation, more tax hikes, more mass media campaigns, more research, is media (and public) fatigue. How many ways can you say smoking kills? This isn’t news. To attract media attention for our public health demands, we’ve had to create ever more shocking headlines. We’ve gone from giving out ‘no smoking’ stickers and putting posters around town, to marching in the streets, to suing people who disagree with us – all to grab a headline.
Advocacy became the tail wagging the public health dog. All public health strategies depend upon it and thus have to deliver the message-du-jour. Also, you can’t get more funding from Government if the key stakeholders disagree about what needs to be done. So, commitment to ‘sing from the same song sheet’ became an essential job requirement. This sentiment is mirrored in the current national Health Strategy which stipulates that we must take a “more cohesive team approach” as we “work towards shared goals” and “foster greater trust and collaboration”. To ensure this occurs, the Strategy warns that Government will get “rid of fragmentation”. Tobacco control, similarly, harbours no dissent.
In New Zealand, tobacco control is a small community. Over the last 25 years we have from time to time formed cross-sector committees to provide ‘leadership’. These groups compose the ‘song’. We’d give it a title invoking national anthem status, teach it via seminars and in this way control the sectors’ thinking, discourse and focus of their activities. Difference of opinion about how to achieve Smokefree is not allowed because it threatens the ability to secure Government support for harsher tobacco control measures and more funding.
When the use of electronic cigarettes began to increase beyond a few early adopters, the National Smokefree Working Group, that is, the sector’s self-formed ‘leadership’ committee, were aiming for a complete ban on the sale of tobacco products, and eventually zero smoking prevalence. Support for a harm reduction approach, for the use of any tobacco or nicotine products in any form, regardless of relative risk to health was antithetical to the group’s vision. Quite simply, the Group informed the sector that electronic cigarettes were a threat to tobacco control and everyone was to lobby to ban vaping products and vaping.
The Ministry of Health were conducting a review of their funded smoking cessation services and tobacco control co-ordination (i.e. advocacy) services at the time. All the contracts were ended in 2016 and new more results-focused service specifications were put out to tender. The ‘Realignment’ swept the board clean removing many long term tobacco controllers. The National Smokefree Working Group disbanded. The tight directing of the discourse in tobacco control was temporarily disrupted.
The change in workforce depleted the prohibitionists’ influence. Meanwhile, vaping was spreading and the evidence that the benefits to public health from smokers switching to vaping was going to outweigh the negatives encouraged many people to shift from a completely opposed position to a supportive position. The tide against vaping turned. The few remaining prohibitionists retreated to lobbying for heavy restrictions. They’re particularly targeting the new Associate Minister of Health with ‘gateway’ tales and the spectre of Juul. As is common in this fake news era, people who themselves have fallen victim to fake news about vaping, in turn exaggerate the risks of vaping, seed doubt and fear, and manufacture ‘evidence’ of toxicity.
Q3. Indigenous people often have a high tobacco smoking prevalence, higher than other groups. What could/should they do to alleviate the health risks associated with smoking? Are there examples of harm reduced alternatives being used successfully? Does raising taxes have an impact on the smoking prevalence among indigenous people?
Marewa Glover: Tobacco was introduced to Maori men and women in the late 1700s by the early whalers, explorers and settlers. Tobacco was used as an item of trade so it was convenient to addict women as well as men to smoking. European women, by contrast, did not take up smoking until 100 years later during the 1920-1930s. It is this single difference, that both parents - mothers as well as fathers, smoked for many generations that explains our disproportionately higher rate of smoking than Anglo-Europeans and Asians. Maori smoking rates are two to three times higher than NZ European. That we were colonised is also critical. Smoking prevalence across similarly colonised Indigenous peoples - the Native Americans, the First Nations people of Canada, the Aboriginal and Torres Strait Islander tribes of Australia, the Kanaks of New Caledonia and the Inuit of Greenland - all have strikingly similar high rates of smoking.
Maori strategies for reducing smoking that are based on Maori beliefs and cultural practices have been developed from time to time. But, the Anglo-European dominated tobacco control sector has never left these strategies to operate in a Maori way. The workers in Maori programmes (including my younger self), particularly because of the political clout of Maori, had to join the same choir and sing the same song.
Tobacco control’s harshest intervention has been ever-increasing excise tax on tobacco. At national meetings with Maori stakeholders in 1993, and again in 1997, the attendees did not support the use of tax. It was contrary to Maori cultural values of aroha (love) and awhina (providing caring support). They believed it would harm those who were worse off (and as it turned out, they were right). So, the strategy for getting Maori support was changed. After 1997, Maori people were employed directly by the European dominated health and tobacco control organisations and they were told what to say and what to support. Maori health providers were encouraged to align with the dominant tobacco control position - they were provided with “scientific evidence” showing tobacco tax would reduce Maori smoking. Conveniently, the Maori community was never again consulted in the traditional way for their opinion. Only Maori medical doctors and Maori health employees who were converts, or who could be convinced to bow to the non-Maori experts, were included going forward.
The support for smokers to switch to vaping in New Zealand today, is largely due to Maori embracing vaping as a solution to financial strain and smoking’s threat to health. Because of colonization and ongoing discrimination, Maori are over-represented among the lower socio-economic groups. Many Maori individuals got hold of e-cigarettes in the early years of vaping. Several of them became vaping product retailers to help others make the switch. Maori vapers were among the first to set up vape community meets and support via, for instance, a radio programme and a National Vape Day. One Maori family went in to manufacturing e-liquids. I meanwhile, was busy advocating for ecigs as a harm reduced alternative. Maori health workers, often unable to openly support vaping at work, meanwhile got all their family members who smoked on to vaping.
Following my attendance at the Global Forum on Nicotine in 2015, and Dave & Gill Dorn’s subsequent visit to help me educate people about vaping, Rebecca Ruwhiu-Collins began Vape2Save. Outside of the Government funded tobacco control sector, Vape2Save provided a group stop smoking program and access to subsidized starter kits. Over 200 people, mainly Maori, have now been through the programme.
Electronic cigarettes might not be a traditional aid, but the way Maori have embraced and shared ecigs, is being done in a Maori way - with aroha and awhina. I fully expect to see Maori smoking prevalence rates starting to drop from now on, assuming the Government doesn’t introduce restrictions that dampen the exodus from smoking that is happening.
Q5. While the controversy is still very high in many countries between people in favor of a harm reduction strategy and those opposed to vaping and any non combustible alternative, how do you imagine the future? What role do you think the consumers/vapers can play in New Zealand (if they are organized) and elsewhere?
Marewa Glover: Consumers who smoke and who vape or who use other harm reduced alternatives are critical to the shift that is occurring around the world in public health, as outlined in a recent paper my colleagues Trish Fraser, Dr Penny Truman and I wrote.
Tobacco control has been operating in a vacuum for the last three decades. We have taken a paternal role, believing people who used tobacco were mentally incapable of expressing a free and clear opinion on smoking because they were ‘addicted’. The nicotine had addled their brains - we had to think for them, we had to enact tough laws and hurtful taxes to break them free of the tobacco industry’s hold on them. If we didn’t feel disdain for smokers when we started, our dehumanizing campaigns depicting them as selfish negligent parents, ‘losers’ and fools effectively scrubbed us clean of any compassion for those involved in keeping the tobacco industry going – smokers, retailers and politicians.
Having broken free of tobacco smoking, vapers expected us to shower them with praise and let them back in to the fold. They’d done what we asked. But, tobacco control laughed in their face, mocked them for being sheep under the control of tobacco company crooks. Vapers’ rightful anger will be no match for the prohibitionists who are taking public health to ideological extremes way beyond their mandate. Furthermore, the defensive and abusive behaviour being exhibited by some anti-vaping lobbyists is so contrary to the oath they took, if they are medical doctors, or the mission of public health they claim to champion, that investigations will increase in number and some of the most extreme healthist behaviours will be exposed as unethical.
I for one, am grateful for the vapers’ passion and visibility – even the most militant of them. Smoker’s had never organized and complained loud enough about what we in public health were doing to them. For almost 25 years, all I heard was the preacher at whatever World tobacco or health conference I was at, cheering us on, telling us we were on the side of right, like David against Goliath, we were saving people from the devil (the tobacco industry) or the demon nicotine. Perverse effects? We were told either the stories about a growing black market and robberies of stores for tobacco were tobacco company lies, or we were told, to think of the greater good – more people are helped than are harmed.
The vaping revolution is not just helping people stop smoking. It’s part of a long overdue critique of public health ethics (or lack thereof). It’s shining light on the flaws in the scientific publication review process. It’s revealing that some researchers and doctors are not honest, that academic freedom is an illusion, suppression of science is real, and that many so-called leaders in society are as gullible to disinformation as ‘the little guy’.
Realising that others can also see that the Emperor is naked, my belief is that new communities of people will form who, as Paulo Freire counselled, will “re-examine themselves constantly" in order to liberate us all from the tyranny of the times.
Thank you Marewa for having taken the time to answer our questions.
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