Physicians for a Smoke-Free Canada

Introduction Nous avons comparé l’initiation à l’usage du tabac et l’arrêt du tabac au Québec et dans le reste du Canada en vue d’expliquer pourquoi l’usage de la cigarette restait plus répandu au Québec. Méthodologie Les données proviennent de l’Enquête sur la santé dans les collectivités canadiennes (ESCC). Nous avons comparé les taux estimés moyens et stratifiés selon le sexe en ce qui concerne 1) l’usage de la cigarette chez les 15 ans et plus, 2) l’initiation à l’usage de la cigarette au cours de l’année précédente chez les 12 à 17 ans et chez les 18 à 24 ans et 3) l’arrêt du tabac au cours de l’année précédente chez les adultes de 25 ans et plus, au Québec par rapport aux neuf autres provinces canadiennes et dans chaque cycle de deux ans l’ESCC entre 2007-2008 et 2017-2018. Résultats Entre 2007-2008 et 2017-2018, le taux de tabagisme est passé de 25 % à 18 % chez les 15 ans et plus au Québec, et de 22 % à 16 % ailleurs au Canada. Le taux d’initiation chez les 12 à 17 ans a chuté de 9 % à 5 % au Québec et de 7 % à 3 % dans le reste du Canada. L’initiation au tabac chez les 18 à 24 ans (respectivement 6 % et 7 %) et l’arrêt du tabac chez les adultes de 25 ans et plus (environ 8 %) sont restés stables au fil du temps au Québec et dans le reste du Canada. Lors de chaque cycle de deux ans de l’ESCC, l’initiation au cours l’année précédente chez les 12 à 17 ans était systématiquement plus élevée au Québec que dans le reste du Canada, mais il n’y avait aucune différence importante ou soutenue en ce qui a trait aux taux d’initiation chez les 18 à 24 ans ou à l’arrêt au cours de l’année précédente. Les résultats demeuraient comparables lorsqu’ils étaient stratifiés selon le sexe. Conclusion Les proportions accrues d’initiation à l’usage du tabac chez les jeunes de 12 à 17 ans pourraient être une cause immédiate de la persistance de taux supérieurs d’usage du tabac au Québec en comparaison du reste du Canada.

Background and challenges to implementation The recent widespread marketing of alternative nicotine devices and heated tobacco products is heralded by some as a viable harm reduction strategy, and feared by others as a means of perpetuating the smoking epidemic. Missing from the often heated debate are proposals for ways to ensure that combustible products are removed from the market as these ´reduced risk´ products are introduced. Intervention or response In other markets involving such diverse consumer products as light bulbs, automobile fuel, refrigerators, the introduction of less harmful goods has been accompanied by requirements that the more harmful products are removed from the market. Such interventions have yet to be implemented for the manufactured cigarette or other combustible tobacco products. Regulatory approaches developed for these other goods are available as an ENDGAME tool for tobacco control, and prototype legislation developed for Canada illustrates one of many ways in which this can be done. Results and lessons learnt Much has been learned from how harmful products can be successfully phased out. The challenge remains to see how well these lessons can be applied to a proposed phase-out of combustible tobacco products. Conclusions and key recommendations Voluntary efforts by tobacco companies to remove combustible products from the market cannot be relied upon. Legislative approaches to remove the most harmful products from circulation can be developed as a next generation tobacco control measures.

Background and challenges to implementation In most developed countries, most smokers visit a retail store a few times a week to buy cigarettes, providing a hundred or more moments of contact over a year. Tobacco companies invest heavily in their relationship with retailers to control these moments of contact and to maximize influence on price, word of mouth and other promotions. Yet controls on retail are almost absent from globally-recommended tobacco control strategies, like the Framework Convention on Tobacco Control, the Bloomberg-funded MPOWER measures, or the European Union Directive. None of these offer a model for tobacco retail management. This is in contrast with international guidance on comparable health concerns like alcohol, where the World Health Organization recommends a range of supply-controls, like minimum pricing, government retail monopolies and retail licensing. Intervention or response To address this global policy gap, researchers and advocates are independently contributing to a menu of new options for localized retail reform. These proposals draw on the experience with tobacco and other products in diverse countries. Results and lessons learnt Requirements can be imposed by law or conditions of license to better align tobacco retail practice with public health goals. Financial and non-financial requirements already exist in tobacco retailing, including mandatory training of retailers in health consequences of tobacco use, requirements to provide health authorities with data on local sales, requirements to distribute materials to support cessation, restrictions on locations, types of venues or types of license-holders. Other licensing requirements can be adapted from existing distribution controls currently applied to alcohol, pharmaceutical products, cannabis and other products with risks associated with public health risk. Conclusions and key recommendations Retail reform has been identified as a next frontier for tobacco control. A wide range of options are available for adaptation to local or national circumstances.

Although governments have imposed controls on tobacco company behaviour, they have not yet aligned tobacco industry goals to public health objectives. As a result, tobacco companies have delayed or diminished the impact of imposed public health measures and have not contributed to curbing the epidemic of tobacco use. Over the past decade, several regulatory innovations have been proposed as ways to better align industry actions with public health needs, but none have been put in place. These policy suggestions share the goal of providing a supply-side complement to conventional demand reduction strategies, but they differ in the assumptions they make and in the regulatory and governance approaches they take. Similarly, differing views on ideology and political context within the tobacco control community and between governments may hinder the establishment of a global consensus on the ideal supply-side intervention. A government willing to implement innovative supply-side strategies as part of a tobacco control endgame may not require such consensus if factors specific to their national public health systems or political contexts are supportive.

Four authoritative reviews of active smoking and breast cancer have been published since 2000, but only one considered data after 2002 and conclusions varied. Three reviews of secondhand smoke (SHS) and breast cancer (2004-2006) each came to different conclusions. With 30 new studies since 2002, further review was deemed desirable. An Expert Panel was convened by four Canadian agencies, the Ontario Tobacco Research Unit, the Public Health Agency of Canada, Physicians for a Smoke-Free Canada and the Canadian Partnership Against Cancer to comprehensively examine the weight of evidence from epidemiological and toxicological studies and understanding of biological mechanisms regarding the relationship between tobacco smoke and breast cancer. This article summarises the panel's full report (http://www.otru.org/pdf/special/expert_panel_tobacco_breast_cancer.pdf). There are 20 known or suspected mammary carcinogens in tobacco smoke, and recognised biological mechanisms that explain how exposure to these carcinogens could lead to breast cancer. Results from the nine cohort studies reporting exposure metrics more detailed than ever/never and ex/current smoker show that early age of smoking commencement, higher pack-years and longer duration of smoking increase breast cancer risk 15% to 40%. Three meta-analyses report 35% to 50% increases in breast cancer risk for long-term smokers with N-acetyltransferase 2 gene (NAT2) slow acetylation genotypes. The active smoking evidence bolsters support for three meta-analyses that each reported about a 65% increase in premenopausal breast cancer risk among never smokers exposed to SHS. The Panel concluded that: 1) the association between active smoking and breast cancer is consistent with causality and 2) the association between SHS and breast cancer among younger, primarily premenopausal women who have never smoked is consistent with causality.

At the beginning of this decade, Canadians working in tobacco control claimed leadership on tobacco issues. At the Seventh World Conference on Tobacco or Health, a leading Canadian activist boasted that ‘from 1983 to 1989, tobacco sales fell by 20% in absolute terms. The adult per capita fall was 29%. If there is another country with such a significant decline, we would like to learn more about that country’s experience’ (Mahood). The descriptor ‘world precedent-setting’ became hackneyed through overuse by justifiably proud anti-tobacco lobbyists to describe Canada’s landmark 1988 legislation, its rapid tax increase on cigarettes in the late 1980s and its 1994 health warnings.