Background Smoking is a leading cause of preventable death and disability with approximately 5,000 people killed annually in New Zealand and 7 million deaths annually worldwide attributable to smoking. Smoking is also a major contributor to inequalities in health and wellbeing between Māori and non-Māori in New Zealand. Furthermore, smoking exerts a heavy burden on the economy from lost productivity due to sickness and death, and health care costs to treat smoking-related illnesses, which are often chronic. For these reasons, tobacco control has been at the forefront of social and health policy in New Zealand over the past decade.

In March 2011, the New Zealand Government adopted the Smokefree Aotearoa 2025 goal (Smokefree goal) in response to the recommendations of a landmark Parliamentary inquiry by the Māori Affairs Select Committee into the consequences of tobacco use for Māori. The Smokefree goal aims to reduce the smoking prevalence to 5% or less by the year 2025. The three main pillars of the Smokefree goal include: protecting children from exposure to tobacco marketing and promotion; reducing the supply of, and demand for tobacco; and providing the best possible support for quitting smoking.

Vaping, the act of using an electronic cigarette (also called an e-cigarette), is a relatively new behaviour that has become increasingly popular across the world, particularly among smokers and young people. The majority of vapers are smokers who cannot or do not want to quit smoking, and the rapid success of e-cigarettes appears in large part to be related to their close resemblance to smoking in the behavioural aspect of use (i.e. vaping), reduced harm (vaping does not involve actual tobacco or the combustion process) and their low cost compared with traditional cigarettes. Increasingly evidence suggests that vaping can help people to reduce cigarette smoking or to quit smoking, to relieve the withdrawal symptoms of tobacco, and to continue having a “smoking” experience, but with significantly reduced health risks. For these reasons, the New Zealand Ministry of Health has been supportive of vaping as part of a smoking cessation process. However, until recently (27 March 2018), it was illegal to sell e- cigarettes containing nicotine in New Zealand but people could import up to a three-month supply for personal use.

Before this project, literature was lacking on smoking and vaping patterns of tertiary students (university, institutes of technology and polytechnics, and wānanga) in New Zealand and students’ awareness of, support for, and perceptions about the Smokefree 2025 goal.

Objectives This study sought to: (i) estimate the prevalence and patterns of smoking among university students in New Zealand when it was illegal to buy or sell e-cigarettes containing nicotine (i.e. time point 1 or T1) and after “policy change” that allowed people to buy or sell e-cigarettes containing nicotine (i.e. time point 2 or T2); (ii) assess e-cigarette use behaviour, reasons for use, and perception of harm, compared with tobacco cigarettes among university students in New Zealand at T1 and T2; (iii) assess the awareness of, support for, and perceptions about the Smokefree 2025 goal among university students in New Zealand at T1 and T2, and (iv) compare the results of New Zealand university students (smoking and vaping) at T1 with results of Australian university students.

Methods A quantitative descriptive cross-sectional approach was used for this research. Data collection for T1 in New Zealand took place between 01 March and 01 May 2018 and although people could legally buy or sell e-cigarettes containing nicotine in New Zealand from 27 March 2018 (following a Court ruling in Philip Morris v Ministry of Health), e-cigarettes containing nicotine were not immediately available. It took at least several weeks for large consignments of e-cigarettes containing nicotine to arrive in New Zealand.

Information on demographic characteristics of participants, smoking, vaping, thoughts and feelings during “the last month” and health in the previous 12 months was collected in both countries and information on the Smokefree 2025 goal was collected in New Zealand. Analysis in this thesis focused on the questions on smoking and vaping (both countries), the Smokefree 2025 goal (New Zealand), and associations between history of mental illness (HMI) with smoking and vaping (New Zealand). New Zealand responses were weighted to account for oversampling and undersampling based on gender and university size. Ethnicity responses were prioritised for Māori.

Descriptive statistical analysis of data was carried out using IBM SPSS Statistics version 25 and two-sided p<0.05 was considered statistically significant. The analysis included, but was not limited to, calculation of proportions, assessing associations between variables and groups, and some regression analyses. Main comparisons included by age (<25 years and ≥25 years), gender (male and female), ethnicity (Māori and non-Māori), smoking status (current smoker and non-smoker), vaping status (current vaper and non-vaper) and HMI (HMI vs no HMI).

Results Cigarette smoking: Overall, at times T1 and T2 in the New Zealand sample, ever smoking (T1 49.9%, T2 48.5%), current smoking (T1 10.4%, T2 11.3%), daily smoking (T1 5.6%, 4.5%), and smoking prevalence were similar and the majority of smokers smoked 1-5 cigarettes/day (T1 64.2%, T2 70.0%), smoked their first cigarette >60 minutes after waking up (T1 69.7%, T2 67.1%), did not smoke in smokefree spaces (indoors T1 87.4%, T2 90.6%, outdoors T1 65.1%, T2 67.8%) and planned to quit smoking (T1 68.7%, T2 61.1%). Furthermore, males were significantly more likely than females to smoke (ever, current, daily) and older respondents were significantly more likely than younger respondents to report smoking the first cigarette within 60 minutes of waking up, and planning to quit smoking. Māori were significantly more likely than non-Māori to report ever smoking. In addition, the majority of respondents agreed or strongly agreed that “Being smokefree is part of New Zealand way of life” (T1 50.7%, T2 51.2%), that “The number of places allowed to sell cigarettes and tobacco should be reduced” (T1 68.7%, T2 68.3%), and that “Cigarettes should no longer be sold in New Zealand in 10 years” (T1 53.0%, T2 55.0%).

In the Australian sample, 43.5% of participants had ever smoked, 8.6% currently smoked and 5.0% smoked at least daily. As in the New Zealand sample, the majority of smokers smoked 1-5 cigarettes/day (61.9%), smoked their first cigarette >60 minutes after waking up (68.1%), did not smoke in smokefree spaces (indoors 98.3%, outdoors 83.5%), and planned to quit smoking (61.3%). Similarly, males were significantly more likely than females to smoke (ever, current, and daily) and older respondents were significantly more likely than younger respondents to report ever smoking, smoking at least daily, smoking >5 cigarettes/day, and smoking the first cigarette within 60 minutes of waking up. The majority of respondents agreed or strongly agreed with the statement “I prefer to be in a smokefree environment” (92.2%), that “The number of places allowed to sell cigarettes and tobacco should be reduced” (82.1%) and that “Cigarettes should not be sold in Australia in 10 years” (75.9%).

E-cigarette use: In New Zealand, ever vaping (37.0% vs 45.6%), current vaping (6.5% vs 12.6%) and daily vaping (2.5% vs 5.1%) e-cigarette use were all significantly higher at T2, and more respondents reported not vaping in indoor smokefree spaces (79.6% vs 70.0%) or outdoor smokefree spaces (71.3% vs 63.0%) at T1 than T2. Vaping to quit smoking (6.2% vs 5.7%) or for curiosity (63.7% vs 63.8%) was similar at both time points, but vaping for enjoyment was higher at T2 than at T1 (T1 13.4% vs T2 16.3%). Prevalence estimates for use of nicotine- containing devices were similar (80.3% vs 80.3%). More respondents at T1 than at T2 perceived e-cigarettes to be less harmful than tobacco cigarettes (75.3% vs 71.7%); the response rates to this question were similar at T1 and T2 (70.4% vs 72.5%).

Younger participants were significantly more likely to report ever vaping and vaping out of curiosity, while older respondents were significantly more likely to report vaping to quit smoking. Males were significantly more likely than females to vape (ever, current, and daily) and to perceive that e-cigarettes were less harmful than tobacco cigarettes. Māori were significantly more likely than non-Māori to report ever use.

Furthermore, current smokers were significantly more likely than non-smokers to vape (ever, current, and daily), while non-smokers were significantly more likely to report not vaping in smokefree spaces, and to report curiosity as the primary reason for use. In addition, the majority of respondents in both surveys disagreed that “People should be allowed to vape/use e- cigarettes in indoor places where smoking is not allowed” (T1 74.2%, 73.1%) and that “People should be allowed to vape/use e-cigarettes in outdoor places where smoking is not allowed” (T1 53.5%, 53.0%), but not with the statement “If someone vapes around me they are causing me harm because of second-hand vapour” (T1 30.6%, T2 33.4%).

In the Australian sample, 19.9% of respondents reported ever vaping, 1.8% current vaping and 0.7% daily vaping; 9.3% vaped daily for a month or more and 40.1% used nicotine-containing e-cigarettes. Of those who vaped, 91.5% reported not vaping in indoor smokefree spaces and 84.5% in outdoor smokefree spaces, 5.8% vaped to quit smoking, 8.8% for enjoyment and 71.2% vaped out of curiosity. Overall, 71.8% of respondents (regardless of e-cigarette use status) perceived e-cigarettes to be less harmful than tobacco cigarettes. Older participants were significantly more likely to report vaping daily, vaping to quit and using nicotine-containing e- cigarettes than younger participants. Males were significantly more likely than females to vape (ever, current, and daily), to use nicotine-containing e-cigarettes and to perceive that e- cigarettes were less harmful than tobacco cigarettes.

The Smokefree 2025 goal: Fewer than half of respondents in both surveys were aware of the Smokefree goal before completing the survey (T1 43.3%, T2 47.2%); however, support for the goal (T1 95.5%, T2 96.1%) and belief that the goal can be achieved (T1 87.3%, T2 89.8%), and that e-cigarettes/vaping can help achieve it (T1 85.4%, T2 83.6%) were all strong. Māori were significantly more likely to be aware of the Smokefree goal than non-Māori; younger participants were significantly more likely than older participants to believe that that e- cigarettes/vaping can help to achieve the goal; females were significantly more likely than males to think the goal can be achieved; current smokers were significantly more likely than non-smokers to be aware of the goal, but less likely to support it or to think that it can be achieved, and current vapers were more likely than non-vapers to be aware of the goal and to think that e-cigarettes/vaping can help achieve it, but less likely to support it or to think it can be achieved.

Conclusion The patterns of smoking in New Zealand students were similar at both time points, but the prevalence of vaping (ever, current, daily) and potentially in smokefree spaces, increased by large margins twelve months after e-cigarettes containing nicotine became more easily accessible; however, this increase in vaping was not matched with declines in cigarette smoking.

E-cigarette use was significantly lower in Australian students than in New Zealand students. Furthermore, Australian students were less likely to smoke or vape in smokefree spaces than New Zealand students. Overall, the majority of respondents vaped out of curiosity and perceived e-cigarettes to be less harmful than tobacco cigarettes.

Less than half the respondents were aware of the Smokefree 2025 goal, but support for it, belief that it can be achieved, and optimism that e-cigarettes/vaping can help to achieve it were strong.