Smoking is the epidemic we no longer see

As parties debate New Zealand’s future, one of the country’s leading causes of preventable death risks fading from view. The next government will inherit remarkable progress against smoking, but also the responsibility to finish the job.

The Black Death, the 1918 influenza pandemic and Covid-19 commanded attention because their threats were immediate and visible. Smoking is different. Its harms accumulate over decades, largely out of sight. As smoking rates fall, complacency can take hold.

Reading historian Thomas Asbridge’s The Black Death: A Global History, I was struck not by the scale of death, but by the sense of helplessness. Families watched loved ones die without understanding what was happening or how it could be stopped. As an epidemiologist and public health physician, I have spent more than four decades studying how societies respond to epidemics.

Foreign affairs officials endorsed WHO health rules before Peters rejected them
Beginning in 1347, the plague swept across Europe, Asia and North Africa, killing an estimated 75 million to 100m people. It remains one of history’s defining catastrophes because there was so little anyone could do.

Modern societies have faced their own pandemic shocks. The 1918 influenza pandemic killed an estimated 50 million people worldwide. More recently, Covid-19 caused more than seven million officially reported deaths worldwide, although the World Health Organisation estimates that almost 15 million excess deaths occurred during the first two years of the pandemic. Yet all these crises shared one defining characteristic: they were impossible to ignore.

Smoking presents a different challenge. Unlike those confronted by the Black Death, we are not powerless. We know what smoking does, understand nicotine dependence, and have effective ways to reduce smoking. The danger is not ignorance, but complacency.

It is not contagious. The cancers, heart disease, strokes and chronic respiratory illnesses caused by smoking rarely arrive in dramatic waves. Yet the toll is no less devastating.

Unlike the Black Death, smoking’s toll is measured not in years but generations. More than 50,000 New Zealanders have died from smoking-related causes since 2010, and tobacco continues to claim about 4000 lives every year. Globally, tobacco use causes more than 7 million deaths each year, making it one of the world’s largest and most persistent public health threats.

New Zealand shows what sustained public health action can achieve. In more than four decades in public health, few developments have been more encouraging than the country’s dramatic decline in smoking.

In 2012, 16 percent of New Zealand adults smoked daily. By 2025, that figure had fallen to under 7 percent, reducing the number of daily smokers from about 572,000 to 294,000. Māori smoking prevalence more than halved from 37 percent to 15 percent over the same period, although substantial inequities remain. Few countries have achieved such rapid progress.

The gains reflect decades of sustained action, including tobacco taxation, smoke-free environments, restrictions on marketing, improved cessation services and, more recently, the contribution of vaping to adult smoking cessation.

Concern about youth vaping is understandable. But it has also blurred an important distinction. Surveys now suggest that many New Zealanders believe vaping is as harmful as smoking, or nearly so.

The evidence does not support that conclusion. Vaping is not harmless, and concerns about youth uptake are real. But vaping exposes users to far fewer toxic substances than cigarette smoke and is much less harmful than smoking for adults who would otherwise continue smoking.

This distinction matters because smoking is responsible for overwhelmingly more disease, disability and premature death than vaping. Deaths attributable solely to nicotine vaping have not been convincingly established.

Ironically, New Zealand’s success may be creating its own challenge. 

As smoking becomes less common, it also becomes less visible. Youth smoking has fallen to levels that would have seemed unimaginable a generation ago; we have achieved a smokefree generation. For many New Zealanders, smoking no longer feels like an urgent issue.

Success should not be confused with completion. Smoking remains a major cause of preventable illness and premature death. The burden continues to fall disproportionately on older people, Māori, Pacific peoples and people living in more disadvantaged communities.

This context is important when considering recent tobacco-control debates, including the repeal of the smokefree generation legislation. Regardless of one’s view of that decision, the central challenge remains the same: how to continue reducing smoking while maintaining public and political support for effective tobacco control.

The lesson from New Zealand’s experience is that persistence matters. Success has come not from any single intervention, but from decades of sustained action and a willingness to adapt as evidence evolves.

The Black Death eventually passed. Over time, societies developed the knowledge and institutions needed to understand and respond more effectively to epidemic disease. With smoking, the challenge is different. We already know what works.

As parties debate New Zealand’s future, smoking remains one of the country’s leading preventable causes of death. The next government will inherit one of public health’s greatest success stories, but also one of its most important unfinished tasks.

New Zealand has shown the world what sustained tobacco control can achieve. The challenge now is not discovering what works, but sustaining the commitment to keep doing it. If smoking is to become part of New Zealand’s history rather than its future, we must resist complacency and finish the job.