Thursday, 10 May 2018

Ontario's "Next Chapter" for tobacco control

Last week a copy of the Ontario government's new 5-year plan for tobacco control was provided to us. (You can read it here!)

In many ways, this is an up-to-date strategy that modernizes the province's efforts to help smokers quit. In its acknowledgement of e-cigarettes and cannabis, the province clearly understands that circumstances in 2018 are very different than when the previous strategies were designed (The province first adopted a legislative approach in the mid 1990s when it became the first province to ban cigarette sales in pharmacies).

But in all significant other ways, the province has adopted a "forward to the past" approach. The objectives of the three strategic priorities - cessation, prevention and protection - are very little different than they were decades ago, although they are expressed in a modern management-speak.

There is little in the document to require tobacco companies to meet public health objectives, despite compelling reasons for doing so. Those who hoped that Ontario's slow-moving lawsuit against the companies would be a mechanism to assert industry change can only be disappointed by the complete silence on that file in this strategic document.

Smoke-Free Ontario - the Next Chapter for a Healthier Ontario

This government's "next chapter" for tobacco control is in most ways a shrunk-down and expurgated version of previous chapters. Future policy measures - like reducing availability of retail - are punted to never-never land of "exploring options". There are no new restrictions on tobacco industry practices. The much-discussed but not officially announced decision to de-fund major tobacco control activities (including research, training and youth mobilization) is kept in wraps. Previous commitments to mass media campaigns have been replaced with more modest suggestions of "public education" to "inspire people to quit."

It didn't have to be this way. Not so long ago, the Ontario government sought advice of experts and encouraged the compilation of evidence that was to inform its renewed strategy. In 2016, the Smoke-Free Ontario Scientific Advisory Committee, which included government and non-government scientists, identified the evidence to support a fourth strategic direction - - the "industry", and the importance of "innovative" approaches like restructuring retailing or imposing requirements on tobacco manufacturers to meet certain public health objectives (i.e. with respect to the quantity of cigarettes they sold).

Evidence to Guide Action:Comprehensive tobacco control in
Ontario (2016) Smoke-Free Ontario Scientific Advisory Committee

This report was followed up the following year with recommendations of the Executive Steering Committee of the Smoke-Free Ontario modernization process.  At the head of their list of priority actions were ways to "Challenge and Contain the Tobacco Industry", suggestions for which included reducing the availability of tobacco in retail settings, reducing the supply of tobacco products in Ontario and making industry practices more transparent. Other suggestions were focused on beefing up the cessation system, providing protection from smoke in multi-unit dwellings, raising the minimum age from 19 to 21, and making university campuses smoke-free.

One might have thought that because these advisory processes were established by the ministry that some of the results would have been reflected in the final strategy. Few of the policy advances -- and none of the innovative measures -- appear to have survived the cut.

Not surprisingly, the government has done little to draw attention to its new plan. It is not, for example, listed on the Smoke-Free Ontario site and has been released without fanfare.

Where Ontario fails to lead, will Ottawa follow?

Health Canada's renewal of its tobacco control strategy was due to be renewed in April 2017, but was delayed to give the department an extra year to develop what we were told would be "bold" and "innovative" measures.

The extra year has come and gone without any signal from the department about what it has decided upon. In the meantime, the words "bold" and "innovative" have been dropped during discussions with outsiders.

Given what we know about tobacco industry behaviour, governments should be bringing the tobacco industry to heel, not giving them a free pass.  The tobacco industry is the source of the tobacco epidemic that is killing over 45,000 Canadian a year.

If neither the Ontario government nor the federal government is willing to make bold moves to address the problem at its source, who will protect Ontarians?

Tuesday, 24 April 2018

Do smoking cessation programs work?

After all we have learned about smoking since the 1950s, why have we still not conquered the tobacco epidemic? The tobacco epidemic is persistent. The Canadian Community Health Survey reports that from 2000 to 2014, the percentage of former smokers in the Canadian population changed barely all, hovering around 37% (Physicians for a Smoke_Free Canada, 2016).

New quitters only just replace the proportion of those who relapse or die. The tobacco industry has long known how few smokers quit, which is why it seldom opposes smoking cessation programming. According to tobacco industry monitoring data, from 1971 to 1991, people who managed to stay quit for one year as a percentage of ever-smokers was almost always in the very narrow range of 1–2% per year. The lowest value was 0.4% in 1983 and the highest was 2.2% in 1976 (Imperial Tobacco Ltd., 1991). More recent, but similar low rates of quitting in Ontario were reported by the Ontario Tobacco Research Unit (OTRU; 2016). During the period 2007–2014, annualized quit rates were reported to be in the range of 1.3–2.2%.

Still, people do successfully quit, eventually. It may take them many tries, but many are successful. By 2014, there were about twice as many former smokers as current smokers in Canada, as illustrated above.  (Physicians for a Smoke_Free Canada, 2016).

How do people quit? Most successful quitters do so on their own. In Ontario in 2014, only 1.7% of smokers succeeded in quitting for a full year, and most of these quit on their own.  About two-thirds of those successful quitters did not use any of the ten cessation services evaluated by OTRU (OTRU; 2016). Currently, about two-thirds to three-quarters of Americans who quit do so on their own (Chapman & Mackenzie, 2010). Looking back in time, the figures are even higher. In 1986, it was estimated that over 90% of Americans who had quit smoking up to that point in time had done so on their own (American Cancer Society, 1986). In earlier years, less assistance for smoking cessation was available.  Most people quit on their own.

But what of the others, those who do seek assistance for smoking cessation? How successful are they? Nicotine replacement therapy (NRT) is a popular form of providing smoking cessation assistance and a Cochrane review of over 130 studies found that NRT achieved a success rate that was 50–70% greater than that achieved with placebo (Stead et al.,2012). However, there are sound reasons to believe that this apparent success is not maintained when the therapy moves from the research environment to the real world. John Pierce and his colleagues reported that after three or more months of follow-up, Americans who quit smoking on their own had slightly higher success rates than those who used NRT or some other form of assistance. Among heavy smokers, the NRT three-month success rates was 9%, compared with 15% among those who quit unassisted (Pierce et al., 2012).

Cessation programs have neither broad reach nor outstanding success rates. The Ontario government provides support to 10 different smoking cessation programs. These programs all use well-established forms of assistance of proven worth. They range from minimal interventions like helplines to intensive system-wide interventions in health care settings. Their reach and effectiveness were carefully evaluated. Collectively they reached 139,000 people—about 7% of all Ontario smokers. Of these, it was estimated that about 12,000 actually quit smoking, which amounts to only about 0.6% of all smokers in Ontario (OTRU, 2016). Ten government-supported forms of smoking cessation assistance yielded a barely perceptible increase in the number of people in Ontario who successfully quit smoking.

Many have been hopeful that electronic cigarettes (e-cigarettes) would help people quit smoking.  However, the evidence is not encouraging.  Those who use e-cigarettes every day, particularly the newer tank systems, do show modest rates of success at quitting cigarette smoking.  However, in the United States daily e-cigarette users account for only 19% of the users of these products. (Berry et al., 2018). When the overall picture is considered, taking into account all users of e-cigarettes, the evidence shows that e-cigarettes depress smoking cessation behaviour. Moreover, they serve as a gateway drug.  Young users of e-cigarettes are more likely to take up regular smoking. (Glantz and Bareham,2018).

The picture is bleak. Smoking cessation rates are low. Few people use assistance, and assistance is not very helpful.  E-cigarettes, a hoped-for solution to tobacco addiction are proving to be anything but.  The weight of evidence shows that, a population level, they depress quitting and serve as a gateway drug to regular cigarette smoking.

Yet no comprehensive tobacco control programs will be credible unless it includes smoking cessation programming. Even if smoking cessation is one of the least effective tobacco control measures, it is a necessary part of a comprehensive tobacco control policy.  Indeed Article 14 of the Framework Convention on Tobacco Control obliges Parties to provide smoking cessation programs.

The Canadian federal, territorial and provincial governments all fund smoking cessation programs. While funding for these programs should continue, we should not expect them to be more successful in the future than they have been in the past.  Progress towards the Canadian government's stated goal of achieving less than 5% tobacco use prevalence by 2035 will not be made by greatly increasing smoking cessation programming, but rather by strengthening other areas of comprehensive tobacco policies and programs.  In future entries on this blog, we will explore some of these other ways that real progress could be made in tobacco control. 


American Cancer Society. (1986). Cancer facts and figures. Atlanta, GA.

Berry, K.M., Reynolds, L.M., Collins, J.M., et al. (2018).  E-cigarette initiation and associated changes in smoking cessation and reduction: the Population Assessment of Tobacco and Health Study, 2013-2015. Tobacco Control.

Chapman, S. & Mackenzie, R. (2010). The global research neglect of unassisted smoking cessation: Causes and consequences. PLoS Medicine, 7(2):

Glantz, S.A. and Bareham, D.W.  E-cigarettes: Use, effects on smoking, risks and policy implications. (2018).  Annual Review of Public Health. 39(28). 1-28.21. 

Imperial Tobacco Canada Ltd. (1991). The Canadian Tobacco Market at a Glance–December 1991. Montreal, QC: Retrieved from Industry Documents Library website.

Ontario Tobacco Research Unit. (2016). Smoke-Free Ontario Strategy Monitoring Report. Toronto.

Pierce, J.P., Cummins, S.E., White, M.M., Humphrey, A. & Messer, K. (2012). Quitlines and nicotine replacement for smoking cessation: Do we need to change policy? Annual Review of Public Health, 33, 341–356.

Physicians for a Smoke-Free Canada (2016).  Tobacco Use 2000-2014:  Insights from the Canadian Community Health Survey. 

Stead, L.F., Perera, R., Bullen, C., Mant, D., Hartmann-Boyce, J., Cahill, K. & Lancaster, T. (2012). Can nicotine replacement therapy (NRT) help people quit smoking? Cochrane Database of Systematic Reviews. Plain Language Summaries.

Wednesday, 24 January 2018

Even low-dose smoking is hazardous

A new study published on January 24 by Allan Hackshaw and his colleague in the British Medical Journal reports that smoking even one cigarette per day carries a high risk for heart disease and stroke.  One cigarette a day accounted for fully half of the excess heart disease risk associated with smoking 20 a day in men and one third of the risk in women.

To arrive at their results, Hackshaw and colleagues pooled data from 141 studies covering 5.6 million people for heart disease and 7.3 million people for stroke.  The studies came from 20 different countries and covered a span of fifty years.  Now we know the shape of the dose-response curve.  Risk increases rapidly for a low-dose and more slowly after that.  But it took 50 years and hundreds of thousands of deaths caused by smoking to arrive at this result.

A related editorial written by Canadian researcher Kenneth Johnson points out that second-hand smoking has also been shown to carry high risks for heart disease and stroke.  Use of e-cigarettes and heat-not-burn cigarettes are also forms of low-dose smoking that produce ultrafine particles and many of the same toxic substances that cause adverse effects on the cardiovascular system in light smokers and passive smokers.

We do not have fifty years of experience with e-cigarettes and heat-not-burn cigarettes, nor should we wait for fifty years for definitive epidemiological evidence to emerge.  We should recognize that these are forms of low-dose smoking that probably carry substantial increased risk for heart disease and stroke, similar to the risks of light cigarette smoking and passive smoking.  A cautious policy response is recommended that would restrict marketing of these products and, as much as possible, limit their use to current smokers only.

The government of Canada is committed to achieving less than 5% tobacco use by 2035. Our new knowledge that even light smoking is hazardous makes it imperative that firm plans be put in place to achieve this goal.  We should start by phasing out the most dangerous tobacco product of them all - combustible cigarettes.

Tuesday, 23 January 2018

With new nicotine products claimed to be less risky, why allow the sale of combustible cigarettes?

Getting the smoke out of cigarettes

2017 saw an acceleration in the move by Philip Morris International and British American Tobacco to rehabilitate their reputation and to re-invent their market.

For the first time in decades, the companies’ executives are not keeping a low profile in the media or staying out of tobacco control discussions. Instead, they have launched pro-active campaigns, including media events, speaking tours and pro-active lobbying for changes to tobacco laws.

Their message? Heated tobacco is a disruptive technology that should be used to drive down smoking rates. Their goal? Looser rules on how they can sell their new devices.

The industry wants relaxed regulation of new “reduced risk” products

Over the past year, both BAT and ITL have introduced electronic devices which produce an aerosol by heating tobacco sticks that resemble short cigarettes. In support of the claim that these are “reduced risk” products, the companies point to a number of studies which show lower levels of toxins in the aerosol compared with the smoke from conventional cigarettes.

For the moment these products lie in a kind of legal limbo in Canada – they are subject to the federal laws that apply to all tobacco products (like restrictions on advertising), but are not captured by the regulations which are more product-specific (like health warnings and bans on flavourings). They also reveal a vulnerability in Canada’s health laws. Unlike the United States, Australia, New Zealand and many other developed countries, there is no requirement for them to be approved by any government before they can be marketed in Canada. 

There is not even an appropriate tax category for heated tobacco products — they are currently taxed at the rate set for oral tobacco. This is set on a per-gram basis, which makes the tax less than half the tax for cigarettes on a per-stick basis.

The manufacturers of these new types of cigarettes are using private visits with policy-makers, news events and other means to encourage regulators that the health of Canadian smokers would benefit if even fewer rules and lower taxes were in place for these products.

A better option: stronger measures on the old “high risk” cigarettes. 

We agree with the companies that federal law should respond to these new products. We agree that the new technologies should prompt a review of tobacco laws. But instead of justifying relaxing the rules on how nicotine is marketed, we think these products justify strengthening restrictions on conventional cigarettes.

Now that the companies have shown that they can produce a a product they claim is a less harmful form of inhaling tobacco, we think they should be required to remove their more harmful products from the market.

It’s time to stop exempting tobacco manufacturers from consumer protection laws that ensure products are no more dangerous than necessary.
Canadian law makes it relatively easy to put such a phase-out in place. Tobacco companies must regularly test the levels of toxins produced by their cigarettes and report the findings to government. They have recently used the same tests to show that their newer cigarettes are less toxic (and have published the results). The results of the toxic emission reports on the heated tobacco products could become a performance standard for all heated or ignited tobacco products.

This would give the marketing edge that the companies claim they need to encourage smokers to switch to a less bad option.

It is a much more prudent approach than granting their request to be able to use the tools of modern advertising and marketing to promote these brands– tools we know they would use to grow the number of people who use tobacco or other forms of nicotine.

Parliament has an opportunity in S-5 to ensure that nicotine, like gasoline and paint, is regulated so that most harmful products are phased out when better options become technically feasible. Either by amending the bill in committee -- or rejecting it and sending it back for a 're-do', the House of Commons can bring tobacco law up to date with technology. 

Monday, 22 January 2018

Bill S-5: The threat of widespread advertising for nicotine

E-cigarettes and other vaping products currently occupy a legal grey zone. Although the sale of these products is against the Food and Drugs Act, Health Canada has chosen not to enforce this law since about 2012.

The illegality of selling e-cigarettes has kept Big Tobacco (and mainstream retailers) out of the e-cigarette and nicotine vaping market, even though they have developed many such products and are marketing them in other countries.

All this will change when S-5 (the proposed Tobacco and Vaping Products Act) becomes law. Tobacco companies will likely enter the vaping market as aggressively in Canada as they have elsewhere. (S-5, which began in the Senate more than a year ago, in November, 2016, is now being studied by the House of Commons.)

This is a cause for concern. S-5 as it is now drafted gives e-cigarette and vaping manufacturers the right to advertise these products in all available media - TV, radio, internet, video-games, newspapers, billboards, corner store windows, bars, text messages, social media, etc. The types of "Vaping Rocks" promotions that BAT is using for its Vype Pebble in the U.K. may soon be invading the e-space of young Canadians.

The not-very safeguards

The government currently relies on three safeguards in the bill to protect young people and non-smokers from nicotine marketing:
  • a ban on ads if there are “reasonable grounds” to believe that they would appeal to young persons, 
  • restricting lifestyle ads to publications sent to adults or places where young persons are not permitted (information ads would be allowed in other publications)
  • The power for government to impose regulations on e-cigarette advertising. (This was not included in the original bill, but was inserted by the Senate).
Decades of experience with enforcing tobacco laws suggest that tobacco companies will see these safeguards as a challenge, not a barrier.

The same experience suggests that the government will wait until a large number of people have been harmed by this advertising before they impose any stronger measures. Indeed, in the proposed regulations circulated late this summer, the government suggests regulations that are virtually identical to those in place under the tobacco industry voluntary code between the 1960s and the mid-1980s. 

A better approach is available 

Non-combustible nicotine and tobacco products are widely acknowledged to lower cancer risk when compared to regular cigarettes on a stick-to-stick basis. But they are only better for public health if smokers, and only smokers, use them. Dual use of combustible and non-combustible nicotine or tobacco, or use by former smokers or non-smokers, could all worsen the problems of nicotine addiction. These circumstances could result in more, not less, harm from these new vaping and heat-not-burn products.
The benefits of a legal, regulated market for nicotine products can be achieved without the risks contained in Bill S-5.

If the government wishes smokers to be informed about the availability of alternative forms of nicotine, targeted communications at smokers (including through tobacco package warnings and inserts) are a more prudent approach than risking the spill-over effect of television advertising and billboards.

Physicians for a Smoke-Free Canada continues to recommend to parliamentarians that Bill S-5 not be passed in its current form.
  • Like cannabis and tobacco, nicotine products should not be advertised on billboards, television or radio.
  • Promotions for products accepted as reduced harm should be allowed if targeted only at smokers, perhaps at the time of tobacco sale. 

(More information on how Canada compares with other countries is available here.)

Sunday, 21 January 2018

National Non-Smoking Week and the challenging year ahead

The third week of January has for many years been used as an occasion to reflect on public and personal measures that can be taken to reduce the toll from tobacco use. "Weedless Wednesday" falls in the middle of the week, and has long been promoted as a quit day for smokers. But Ministers of Health have in past years often used this week to reaffirm their commitment to address what, despite decades of progress, is still the largest preventable cause of death. (Last research funded by Health Canada concluded that the annual death toll from tobacco use in Canada exceeded 45,000 deaths, with Statistics Canada reporting more than 5 million Canadians smokers.)

Ottawa health advocates will be all ears this week for any signal from the new Minister of Health about her vision for tobacco control. Five months have passed since Ms. Petitpas Taylor was appointed to this position, but she has not yet publicly or privately said much to indicate whether tobacco is on her personal priority list. (Her mandate letter from the Prime Minister re-iterates a responsibility to implement plain packaging, but nothing more). She has  re-iterated the new goal of achieving 5% tobacco use by the year 2035, but has

This silence is not in itself worrisome (yet!). Over the past months opioid deaths and cannabis commercialization have dominated the political health agenda, and it may be a simple case of a political inbox piled too high.

But the clock is set, and soon she will have to decide how she will leave her mark on tobacco use.
Will she follow the footsteps of Ministers like Judy LaMarsh, John Munro, Jake Epp and Allan Rock and set a new course for protecting public health?  Or will she, like Marc Lalonde, Perrin Beatty, Anne McLellan and Rona Ambrose, oversee the diminishment of departmental ambition and resources for this file.

The federal vision for tobacco will be revealed this spring

In only 11 weeks, on March 31, 2018, the federal tobacco control strategy (FTCS) expires and will be replaced by a new 5-year plan for tobacco control. Although the department and Minister affirm the goal of reducing smoking prevalence to 5% by 2035, there are no signs on how they intend to get there.

The reboot on the FTCS will be the fourth 'refreshing' exercise on the federal approach since it was set up as a multi-departmental initiative in 2001. As I understand it, each of these renewals has required the buy in of senior health officials as well as the central agencies (Treasury Board, Privy Council Office, etc).

Sadly, each of these renewals has produced a smaller and less ambitious successor. What was once unveiled as a priority program has decayed into just-another-departmental-program. 
  • Initially designed as a $110 million a year program, the budget for the FTCS is now only $43 million, of which Health Canada receives $37 million. Once inflation is taken into consideration, the budget has fallen by two-thirds from the original design.
  • Whole swathes of federal activity have been abandoned: advertising and public education, community programming and international support. 
  • Other aspects, like smoke-free environments, retail regulations, youth-programming and cessation support have largely been handed off to provincial governments. 
  • Even in some areas of core federal responsibilities, such as those affecting the health of some indigenous communities, surveying tobacco use, funding research or controlling contraband, federal activities were pulled back.
Despite this attrition, the FTCS is generally viewed as a successful federal program and Health Canada is still regarded as a global leader in the area of tobacco product regulation. Health Canada's activities --  particularly in the early 2000s —are acknowledged as having made a real contribution to the changed social attitudes around tobacco use, to achieving smoke-free spaces across Canada, to adopting innovative regulations (like picture based warnings) and to reducing the smoking rate. 

It would be a mistake for planners to take a continued downward momentum for granted.

New challenges, new ideas

Circumstances are very different now than they were when the FTCS was initially designed, and there is general acknowledgement that it is time for a deep re-think of tobacco control strategies, and for the development of qualitatively different approaches.

Outside of government, a lot of deep-thinking has taken place about the pro-active steps that government can take to accelerate reductions in tobacco use. Last year, Health Canada received thoughtful input from experts and community leaders won how to modernize and strengthen tobacco control. Prominent among these are the results of an “Endgame” Summit in 2016 and the recommendations of the Executive Steering Committee for the Modernization of Smoke-Free Ontario, convened by the Ontario government.

The recommendations flowing from both of these expert-driven reviews were for governments to scope out their strategies (i.e. by including stronger controls over supply) and to scale up effective interventions. "Bold and innovative" was the catch-phrase often used to describe the elements of a modernized approach.

What worked yesterday may not work tomorrow 

"Bold and innovative" also describes the approach taken by the tobacco industry in recent years.

The regulatory and programming approach to tobacco that has developed over the past decades is now facing new challenges for which public health tools have not yet been adopted. These include the upcoming legalization and increased commercialization of two products closely linked with tobacco use — cannabis and nicotine vaping products. They also include the impact of emerging technologies developed by the tobacco industry (like heat-not-burn tobacco products).

The development by governments and health advocates of reactive strategies to respond to these challenges is lagging. How to respond to the tobacco industry's new approach to marketing a spectrum of nicotine products? To the potential that increased cannabis use will drive up tobacco use? (The Ontario Tobacco Research Unit reports that one third of Ontario cannabis users mix tobacco in their joint). 

The government's discrete and binary approach to nicotine
regulation fits poorly against the continuum of tobacco, nicotine,
hybrid and mixed products under development by BAT and other companies 

These challenges require new research, a willingness to innovate and stable and long-term funding. National Non-Smoking Week would be a good time for the Minister of Health to reassure Canadians that these are on the table. 

Having to wait until April for an articulated vision for tobacco control by the new government is a cause for concern. It may also be a symptom of the larger challenge we face in maintaining political and social interest in the long-standing crisis of tobacco use.

Monday, 4 December 2017

Imperial Tobacco's new hockey (and other) promotions.

I have been intrigued at what I think is a recent development in tobacco advertising in Canada - colourful lifestyle-ish ads inside the tobacco package.

I first noticed these inside packages manufactured by British American Tobacco's Canadian subsidiary, Imperial Tobacco when I tripped  over -- almost literally -- a discarded package. Inside the slide pack were two ads: one for a version of the brand with a novelty filter which allows the smoker to rotate the filter overwrap and adjust the amount of ventilation.

On the other side of the package was a picture that seems close to the style of promotions which I had thought were no longer allowed. Canada's federal Tobacco Act does not permit lifestyle advertising for tobacco products, and defines it as "advertising that associates a product with, or evokes a positive or negative emotion about or image of, a way of life such as one that includes glamour, recreation, excitement, vitality, risk or daring."

Well, the always-brief Canadian summer is over now, and this ad no longer seems to be running in the packages. We may never know whether Health Canada's enforcement team took action, or whether it was rotated out with the turn of the seasons.

Today I similarly stumbled one of its replacements - an ad that links this cigarette brand with Canada's famous pastime, ice hockey.

"Taste is always on its game. Inside the Circle." is the line that runs across a picture of the goal light. (For the uninitiated, every time a goal is scored against the visiting team, the illuminated goal light is accompanied by a klaxon).

Underneath the image of the goal light is small text which invites smokers to "show us your game" and to send pictures to the company (care of What they do with those pictures is another mystery ...

There was a time when the Player's logo was plastered across the scoreboards of many hockey arenas - (one from 1990 can be seen here). Now, it seems, the company has found another way to associate itself with Canada's national sport.

I came across another package advertisement on the sidewalk a block or two further down. This one associates the John Player Brand (JP) with chilling, and with popcorn and a screen in the background, evokes movie going.  (or is it evoking Netflix and chill?)