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.