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.