Canada has had enormous success in reducing smoking, but certain groups are hard to reach, so it is still the top cause of preventable death.
This past spring, Health Minister Jane Philpott announced plans to implement the Liberal Party’s campaign commitment on plain packaging for cigarettes and other tobacco products. After a period of consultation and the drafting of regulations, we should see plain packages sometime in 2018.
Plain packaging measures will require a uniform, standardized colour and font on packages and restrict the use of logos and trademarks.
This will represent an important victory, but the war against tobacco is far from won and will require sustained action by all levels of government.
Over the past 40 years, health interventions that address smoking in the general population have been very successful. Smoking prevalence dropped from 50 percent in 1965 to 25 percent in 1999 to 18 percent in 2014. Yet, the trend line has fallen less steeply in recent years, and for reasons I discuss here, it’s getting harder to reach many smoking populations.
A strong Canadian record
The passage of the 1997 Tobacco Act by Health Minister David Dingwall created important regulatory powers that were game changers. The reforms it enabled included constitutionally upheld prohibitions on lifestyle advertising in 1997 and on sponsorship advertising in 2003, and picture warning labels in 2001 (later improved by Health Minister Rona Ambrose). The banning of “light” and “mild” descriptors was initiated in 2001 and fully implemented by 2012. The disastrous tax rollback of 1994 to reduce smuggling was rectified somewhat by federal tax increases in 2001, 2002, and 2014, as well as provincial tax increases.
Every province and territory brought an end to visible point of sale displays in retail stores between 2002 and 2010. The municipal smoking bans that were ferociously contested in in the early 2000s by bars and restaurants are widely accepted now, and opposition to them is a historical footnote.
The availability since 1999 of the archives of the British American Tobacco Company in England brought to light tobacco industry practices and continues to provide value in terms of cost-recovery lawsuits and constitutional defences of tobacco-control legislation.
Furthermore, the industry’s public relations impact in Canada has been all but eliminated. The tobacco trade association was largely deactivated in 2001, and production has partially been moved to foreign countries.
Stephen Harper’s Conservative government gradually reduced Health Canada funding for the Federal Tobacco Control Strategy (FTCS). What had been an annual budget of $84 million in 2003-04 had decreased to $38 million by 2012. The government diminished the federal capacity but did leave a workable base. Health Canada continues to have a stellar international reputation in this regard. All mass media advertising to discourage smoking was eliminated. Canadian nongovernmental organizations have driven change, and they are a key element in this country’s success. The Canadian Cancer Society, the Non-Smoker’s Rights Association and Physicians for a Smoke Free Canada are recognized across the globe for their work.
The achievement of plain packaging is a key milestone in this fight against tobacco use. It is the result of 30 years of advocacy by Canada’s health communities, and only a handful of countries in the world have accomplished it. Reforms like these have a global impact, as they inspire other jurisdictions to follow. The Canadian Cancer Society reports that the precedent-setting picture-warning labelling system introduced in 2001 by Allan Rock has now been adopted in 105 countries.
Plain packaging will undoubtedly make an important difference. Australia, the first country to adopt it, has experienced promising early results. Plain packaging also has enormous symbolic value by removing all brand imagery, which helps to denormalize cigarettes as a product. But in the Canadian context, it really represents incremental change. The packs already contain large graphic picture warnings, taking up 75 percent of the pack, and light and mild descriptors have been prohibited. The elimination of Canadian lifestyle, point-of-sale and sponsorship advertising has diminished the link to glamorous images of cowboys, cool yuppies and slim female models. Yet the companies still use the packs extensively for promotion, and use special pack formats such as super slim “purse packs” aimed at young women.
Another bright spot is the evidence that young Canadians are taking up smoking in smaller numbers and smoking fewer cigarettes in total. The Canadian Student Tobacco, Alcohol and Drugs Survey shows that only 11 percent of students in grades 10 to 12 are smokers. This is the lowest rate of smokers since the survey began in 1994.
Yet for all this progress, cigarette consumption still remains too high and kills too many: more than 37,000 Canadians per year. It is still the biggest source of preventable death in Canada, causing heart attacks, strokes and cancer.
It also remains firmly embedded within certain vulnerable populations: the less affluent, the less educated, those with mental health problems and depression, those in northern territories and Indigenous populations. Smoking rates in these groups are substantially higher than in the general population. Addiction rates are also higher. This translates into much shorter life expectancy.
Smoking statistics linked to mental illness are jarring: people who have been diagnosed with a psychiatric disorder or a substance abuse problem are two to four times more likely to smoke than those in the general population. Up to 88 percent of people with schizophrenia and 83 percent of people with bipolar disorder smoke. Individuals with severe mental illness die 25 years earlier than the general population, with 60 percent of the preventable deaths due to tobacco-related causes. They are also much less likely to be offered smoking cessation support in a primary care setting.
The numbers for Indigenous people in Canada are also discouraging. Smoking rates among Indigenous populations are, on average, twice as high as those among non-Indigenous people. Rates are highest for Inuit (49 percent), followed by First Nations people (40 percent) and Métis (37 percent).
The delivery of health-promotion messaging and cessation support in these populations has been uneven. They are harder to reach, with complex issues in play: lack of access to programs, barriers to treatment such as cultural traditions, and reluctance of treating physicians to tackle what can be seen as an insurmountable challenge.
Tobacco litigation has been moving slowly. The federal government was pursuing the tobacco companies in court over illegal smuggling in 1990s, and settled with them in 2008 and 2010. These settlements have been criticized by the health community over their terms and lack of transparency. There are 12 provincial and territorial cost-recovery suits and 9 major class action litigations weaving their way through the courts.
For all the reputational upheaval they experienced, tobacco companies still generate billions in revenue. The industry conglomerates have expanded their operations and business attention toward low- and middle-income countries. The companies have also moved into selling nicotine in vapour form: a potential gateway for tobacco and a subject of great debate in the health community. Philpott’s announcement in September about regulating e-cigarettes is most welcome.
What can Canada do to move the yard sticks in tobacco control? The following suggestions would make a good starting point:
- Create an expert panel to set the course for the next phase of tobacco control; identify gaps in our knowledge, plan a series of new action measures, design a specific tobacco-control strategy for vulnerable populations, and study the effects of e-cigarettes.
- Increase funding for the FTCS to make it more comprehensive and effective, including mass media public awareness campaigns; improved research, surveillance and enforcement; increased capacity for legislative and policy development; and enhanced programming for youth prevention, Indigenous populations and adult cessation.
We know that the tobacco industry views the developed world as a mature and declining market and continues to focus on regions where it can still operate without strong regulatory controls. As Prime Minister Justin Trudeau considers ways to make a meaningful impact on the world stage, perhaps he can give tobacco control a thought. Canada has a world-class NGO community and policy expertise that we can export to the developing world. A Canada-led global strategy on tobacco control or increased focus on the World Health Organization’s Framework Convention on Tobacco Control could save millions of lives across the globe.
Photo: NeydtStock / Shutterstock.com
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