Thursday, 31 May 2018

World No Tobacco Day 2018: The endgame is not in sight

Today was a very busy day on the communications front of the battle against tobacco use in Canada. Federal Health Minister, the Hon. Ginette Petitpas-Taylor appeared before delegates to the 2018 tobacco conference in Montreal to outline the next 5-year federal tobacco control strategy.

This was the latest in more than 50 years of similarly-designed ambitious-sounding federal plans to wrestle the problem of smoking to the ground. The first was set by Judy Lamarsh, whose 1964 strategy aimed at "the reduction or elimination of this health hazard". The way to do it in 1964 was by providing the public with information, encouraging smokers to quit and discouraging non-smokers from starting.

54 years later, much is the same. Today's goal is to "drive down the smoking rate in Canada to less than 5% by 2035." The way to do it is by "helping Canadians quit tobacco, protecting young people and non-tobacco users" with a nod also to "evidence-based decision-making" and "collaboration". (This year there are about 5.2 million smokers in Canada, about 17% of all people over 12.)

A well trodden path

The Minister and her advisors may believe that by repeating this established approach it will continue to make progress in much the same way as it has over past decades. There is no doubt that the the slow introduction of incremental measures has contributed to a steady decline. Tobacco packaging is a case in point: progress was announced with the first voluntary warnings in 1970s, as it was with small mandatory warnings in 1988, graphic warnings in 2000 and bigger graphic warnings in 2014, and as it will with plain packaging in a few years.

The problem with incrementalism is that it is just so, well, incremental.

Many other knowledgeable Canadians have spent considerable efforts to demonstrate that bolder measures are needed. Endgame reports, scientific reviewsexpert consensus, and citizen's groups have called for bolder and more innovative measures.

As we veterans of several past federal strategies wrote in the Gazette earlier this week, what is needed now is "a strategy that acknowledges the fundamental role of the tobacco industry as the continuing vector of tobacco-related disease. This would include a true harm-reduction strategy with firm plans to eliminate the most dangerous of all tobacco products, the combustible cigarette. We also need measures to prevent price-based manipulations that undermine taxation, and well-funded mass media campaigns."

A year ago, there were signs that Health Canada was preparing for bigger steps. Speaking to a hundred or more people from across Canada who had paid their way to the Ottawa Convention Centre to participate in a Forum on the Future of Tobacco Control, the former Minister of Health, Jane Philpott encouraged the believe that the process was headed for "a bold and innovative plan".

Over the past year, the tobacco file at Health Canada has been handed to a new minister, a new assistant deputy minister, a new director general and a new director of policy. It soon became apparent that it was not only the planners who changed, but also the plan.

And some new directions.

It would be incorrect to suggest that  there is nothing new or different in the federal approach to tobacco. One key new element may well have a dramatic and long-lasting effect. Last week Royal Assent was given to bill S-5, which set the rules for vaping products. Harm reduction is here.
This is not the first time that harm reduction has appeared as an element of the federal plan -- the the version adopted in 2001 had used it as a fourth pillar in addition to prevention, protection and cessation. But the department's view of what harm reduction meant was only made public when it introduced Bill S-5 in the fall of 2016.

Harm reduction and the potential benefits and risks of vaping products remains controversial and much disputed in Canada, as it does elsewhere. Unlike most areas of tobacco control, there is no scientific consensus about the population impacts of the use of e-cigarettes.

By adopting a bullish view in favour of a market-driven transformation of the nicotine market, the Minister and her advisors have departed from their usual practice of insisting on a solid scientific footing before taking action. The department says that this approach will  "save lives". More on the evidence behind that claim in a later blog.

The candy coating

There are several welcome moves in the new strategy. Many of these were included in the Minister's speech, and do not yet appear on Health Canada's web-site. These notably are for measures that have been the target of recent advocacy efforts by some important health charities. The Minister announced that plain packaging will be implemented in the traditional Canadian slide-and-shell package and that warnings on individual cigarettes are under consideration. It was also announced that some funding may be available for some tobacco NGOs. (Full disclosure - we are among those who received funding before federal support ended in 2012).

There was more good news in the fine-print of the material made public. This includes the intention to make accessible to researchers more of the important information provided by the tobacco industry and a renewed (hopefully expanded) commitment to support the Framework Convention on Tobacco Control.

From a population approach to a sub-population approach

A key element of strategy is a focus on communities and groups of Canadians who smoke at higher rates than others. Special call-outs were given to Indigenous communities, LGBTQ+, young adults and construction workers -- all of whom smoke at rates much higher than the average. 

One month before cannabis is scheduled to become legal, the department made no mention of the risks of smoking associated with cannabis use. Yet our review of 2013-2014 Canadian smoking rates found that cannabis users (those who reported using it two or more times in the past year) were, at 49%,  the highest of any identified Canadian sub-population.

An important part of arithmetic missing from the federal strategy is the matching of higher smoking rates with the size of the population affected by the inequities. Gender is a case in point -- among those who self-identify as LGBTQ to Statistics Canada, smoking rates in 2013-2014 were are almost double (34% vs. 19%) the rate as those who self-identify as heterosexual. Those who self-identify as men were similarly more likely to smoke than those who self-identify as women (22% vs. 16%). By Health Canada presents this in a way that frames the inequity associated with sexual orientation as being more severe than that related to gender. From the perspective of the absolute number of people whose health is being harmed, however, the gender-related difference is higher. It appears likely that inequity results in about 900,000 additional male smokers and fewer than 100,000 additional LGBTQ smokers.