By the Ontario Medical Association
January 22, 1996
Ms. Carol Lacombe
Director
Office of Tobacco Control
Health Canada
11 Holland Avenue
Tower A, Suite 513
Ottawa, ON K1A 0K9
Dear Ms. Lacombe:
On behalf of the Ontario Medical Association, I am writing to provide comments on Tobacco Control, A Blueprint to Protect the Health of Canadians. The Minister of Health and the government are to be commended for the excellence and comprehensiveness of the Blueprint. On behalf of its 24,000 physician members, the Ontario Medical Association strongly supports the government's intention to transform the Blueprint's contents into legislation at the earliest opportunity this year.
In order to avoid duplication of material between the OMA's submission and the many submissions you will be receiving from national health agencies including the Canadian Medical Association, the attached submission is structured as follows:
A brief section summarizing the OMA's views on each element of the Blueprint;
Discussions of specific issues of particular concern to the OMA, such as the need to make cigarettes fire-safe and the need to comprehensively address the addicitivity of nicotine.
The OMA also requests an opportunity to consult with Health Canada in more detail following the January 31 deadline for submissions, at which time we would be pleased to provide additional medical and technical information as required by the Department.
Please do not hesitate to contact me if you require additional information or have questions about this brief.
Sincerely,
Ian M. Warrack, M.D., C.C.F.P.
President
The OMA is a founding member of the Ontario Campaign for Action on Tobacco, which successfully advocated passage of Ontario's Tobacco Control Act, which was proclaimed in November, 1994. Currently, the OMA is supporting provincial initiatives to ban smoking in workplaces and public places throughout Ontario, and to reintroduce provincial tobacco taxation. The OMA is also collaborating with the Canadian Medical Association, the Medical Society of Prince Edward Island and the British Columbia Medical Association on a project funded by Health Canada to improve the clinical tobacco interventions of Ontario physicians.
I) IntroductionDuring the past 20 years, the OMA has taken a strong stand in support of reduction of society's number one preventable cause of disease and death: tobacco use. Organized medicine in Ontario is very concerned about the continuing use of tobacco, as it recognizes that such use contributes to over 13,500 deaths annually among Ontarians. For many years, the OMA's Public Health Committee has addressed the issue of smoking in detail. The Committee's policies and positions have included:
Encouraging physicians to actively participate in programs directed at prevention and reduction of tobacco use and involuntary exposure to environmental tobacco smoke (ETS);
Urging both the federal and provincial governments to substantially increase retail cigarette prices, and recommending that revenues received through taxation be used to promote on-going research into smoking cessation as well as programs to prevent children from becoming addicted to tobacco;
Raising the awareness of all Ontarians regarding the hazards of ETS in the home, and informing patients and particularly parents of infants and young children, and those with asthma and bronchitis, of the long-term effects of ETS exposure.
Against this background of long-standing commitment to the reduction of tobacco use, the OMA was please to join with other Ontario health agencies in 1992 in forming the Ontario Campaign for Action on Tobacco. The OCAT's successful advocacy in support of the province's Tobacco Control Act established many important tobacco control measures at the provincial level, including the banning of cigarette sales in pharmacies and from vending machines, restrictions on sales to minors, and designation of a number of smoke-free public places.
Unfortunately, the effectiveness of this legislation was seriously undermined by the February-March 1994 reductions in federal and provincial tobacco taxes. It is not the purpose this submission to debate the merits of the tax reduction, but rather to point out that research recently published by the Ontario Tobacco Research Unit shows that:
Smoking among women 20 years of age and older has increased from 17.8% in 1993 to 24.7% in 1995;
There is evidence of substantial increases in smoking among Ontario male youth during 1995. 28.2% of males students in Ontario smoked daily or occasionally in 1995;
Ontario females aged 15-19 had a 1994 daily smoking rate of 19.7%, up from 16.1% in 1990 and 14.3% in 1986. Further substantial increases appear to have occurred in 1995. 27.5% of female students in Ontario smoked daily or occasionally in 1995.
Tobacco use in Ontario costs the provincial government and Ontario business billions of dollars each year. Research from the University of Toronto estimates that direct impacts to the Ontario health care system and to forests and property from tobacco use in 1988 totalled $3.6 billion, up from $2.9 billion in 1979. These figures, the most recent available, have almost certainly increased since then.
Equally significant is recent evidence that in a non-tobacco-dependent economy such as Ontario, tobacco-related economic activity actually harms the economy by reducing potential employment compared to what it would be if resources now devoted to tobacco were instead devoted to other non-lethal economic pursuits.
In light of this urgent situation, it is essential that the federal government take the most restrictive and comprehensive approach possible to reducing the use of tobacco products. The Minister's Blueprint contains many excellent initiatives in this regard, and the OMA offers the following summary comments on each of the Blueprint's main sections:
The OMA strongly supports such a ban, as there is a significant body of evidence which clearly demonstrates the relationship between tobacco advertising and cigarette consumption, much of which is summarized in the U.S. Surgeon General's 1994 report, "Preventing Tobacco Use Among Young People: A report of the Surgeon General." Having reviewed analyses of the relationship between advertising and tobacco consumption by the U.S. Surgeon General, the National Clearinghouse on Tobacco and Health, the Canadian Cancer Society and others, the OMA believes that sufficient evidence in support of a ban exists to withstand any constitutional challenge by the tobacco industry.
The OMA also strongly recommends that the tobacco industry's recently-announced voluntary advertising code be summarily rejected by the government. The Non-Smokers' Rights Association has extensively documented frequent violations of the industry's previous voluntary code, and any industry initiative in this area simply has no credibility.
The government's intention to ban the use of tobacco industry trademarks on non-tobacco goods and services is an essential component in a comprehensive plan to eliminate the visibility and acceptability of tobacco products in Canadian society.
The government's proposed restrictions on tobacco industry sponsorship of arts, cultural and sporting events, while a step in the right direction, do not go far enough. In order to be effective, a health-oriented policy on sponsorships must require that brand names and brand colours not appear anywhere in sponsorship promotions, either on billboards, in programs, at event sites, or anywhere they can be seen by the public.
The OMA regrets the initial criticisms of the government's proposals by some members of the arts community, and recommends that the government consider an excess profits tax or similar levy on the industry as a means of replacing funds which would be withdrawn from the industry following a total ban on sponsorships.
The OMA also recommends that the Minister of Health publicly indicate support for such a proposal in principle, in order to encourage affected groups to develop a proposal suitable to their financial requirements and long-term planning needs. Finally, the OMA also recommends that health promotion activities similar to those underway in Australia and New Zealand also be funded from such an excess profits tax or levy.
Youth access to tobacco products continues to be a serious problem, one which will never be entirely addressed by rendering sales to minors illegal. Nevertheless, progress can be made in this area through enhancement of enforcement budgets. The OMA notes that there are now no longer any federal enforcement personnel in this area in Ontario, owing to implementation of provincial legislation and related enforcement activity. The federal government could make a significant contribution to further reducing youth access to tobacco products by underwriting the relatively modest cost of additional enforcement personnel in various centres in Canada, in order to enhance reductions in retailers' willingness to sell to young people. Furthermore, the complete ban on vending machines required by Ontario's Tobacco Control Act should be extended to the rest of Canada.
The government's proposals concerning restrictions at point of sales are important and deserving of strong support. Self-service displays promote the acceptability of tobacco products and encourage shop-lifting, while in-store displays enhance the visibility and acceptability of tobacco products. The OMA strongly supports the Canadian Cancer Society's recommendations concerning further reforms in this area, notably the elimination of manufacturer or promotional allowances to retailers and the need for mandatory anti-tobacco promotions at point of sale.
Packaging and Labelling Requirements
The OMA has closely monitored the evolution of research in the area of plain packaging, and believes that there is now no doubt that a strong rationale in support of plain packaging exists. Again, the Canadian Cancer Society has provided a comprehensive list of suggestions about improvements in packaging and labelling controls, all of which are supported by the OMA. The OMA wishes in particular to emphasize the need for health promotion information, including the use of a 1-800 quit line telephone number on packages, as a means of supporting the efforts of smokers to quit. It is the experience of many OMA members that smokers are often frustrated at the difficulty they face in easily locating cessation counselling assistance. As noted earlier, the OMA has embarked on a project in cooperation with the Canadian Medical Association and other provincial medical associations to enhance our memberships' ability to effectively intervene with patients who now use tobacco.
The OMA strongly supports the need to regulate the constituents and emissions of tobacco products as toxicological and social science knowledge regarding these products and their use evolves. One measure which can be undertaken immediately and is of particular concern to the OMA is the need to make cigarettes fire-safe, an issue which will be addressed in more detail later in this submission.
The OMA supports the requirements that would guarantee the greatest degree of disclosure possible from the tobacco industry about the constituents of its products, sales data and product research.
The remainder of this submission will highlight several issue areas of particular interest to the OMA, namely:
a) The seriousness of nicotine addiction
Perhaps the most important factor in determining Canadians' continuing attachment to tobacco products is the addictivity of nicotine. While the addiction to nicotine of long-term smokers is certainly of no surprise to health professionals, its importance in maintaining the presence of tobacco in our society is less well understood by the general population. The tobacco industry's clear understanding of the addictive nature of nicotine, and its efforts to manufacture its products so as to guarantee sufficient doses of nicotine to smokers, has now been well documented.
The most graphic description of the industry's role in this process is contained in articles in the July 19 issue of the Journal of the American Medical Association which describe documents from the Brown and Williamson Tobacco Company in the United States dealing with the company's view of and work on nicotine:
Another important facet of the addictiveness of nicotine problem is that young people who may be tempted to experiment with cigarettes can have little or no conception of the real nature of addiction, and therefore may be tempted to experiment with the product well before they are capable of understanding how difficult it will be to stop such use once they are addicted. This difficulty in turn ensures that efforts to encourage young people not to smoke will always be at least partially unsuccessful as long as 1) nicotine addiction takes hold before young users have the possibility of understanding the nature of addiction and dealing with it in their adult years; 2) they are associated with positive images and practices, either directly through tobacco advertising or indirectly through sponsorship advertising; 3) cigarettes are widely available.
An additional dimension to the addictivity problem lies in the many objections raised by restaurateurs and other business people who argue against restrictions on exposure to environmental tobacco smoke through such measures as smoke-free restaurants and smoke-free recreational facilities. One of the basic arguments presented by these groups is that smoking is a matter of freedom of choice and the marketplace should dictate what restrictions are put in place. The addictivity of nicotine, described above, clearly point out the fallacy of these arguments. Yet they are repeated and often accepted by municipal and provincial officials to whom they are presented. As one among many examples of this phenomenon, the Ontario Restaurant Association has made presentations to municipal councils across Ontario during the past year, in which it argues that "the marketplace" should dictate the pace of reducing exposure to environmental tobacco smoke through municipal by-laws. No mention is made of the addiction status of those in the marketplace.
The OMA offers these comments as encouragement to Health Canada to strongly emphasize the seriousness of the addiction problem, and the fact that tobacco use is not a matter of freedom of choice or individual rights, in all its presentations and proposals concerning tobacco use reduction. The Canadian public, and particularly its youngest members, must clearly understand that even minimal experimentation with tobacco products when young may lead to life-long addiction culminating in an early death, with much pain, suffering and economic loss in the interim.
b) The need to change the legal status of tobacco products
Much of the Blueprint involves measures which will take significant steps toward de-normalizing the presence of tobacco products in Canadian society. The OMA wishes to underline the importance of this change, particularly because of the mixed message that their current presence in society gives to Canadian youth.
If a Canadian teenager can walk into virtually any convenience store in the country and see a large display of tobacco products, and if such products are freely accessible at any time of the day or the night in any town in Canada, all the health promotion messages our young people receive in schools, through advertisements, at home and in publications are seriously weakened (if not entirely neutralized) by the mixed message young people receive as a result. The government must not only restrict the marketing and manufacture of tobacco products; such products must be seen to be limited in their sale and display, and unattractive in their commercial presentation, which must include significant health warnings and disclosure of their toxic constituents.
The OMA would be pleased to consult further with the government on ways in which the current normal status of these products can be changed at the earliest opportunity.
Tobacco use in Ontario costs the provincial government and Ontario business billions of dollars each year. The OMA has worked closely with governments of all parties for many years to reduce health care costs in this province, but such efforts will be continually undermined if the entirely preventable cost of tobacco use to the health care system in this province is not eventually eliminated.
As a member of the Ontario Campaign for Action on Tobacco, the OMA has been party to briefings on the extent and quality of data describing the costs of tobacco use in Ontario, and we have offered to assist the OCAT in improving and broadening our understanding of the current costs of the use of tobacco products.
The OMA recommends that, as a basis to future tobacco control activity, the federal government generate current, high-quality data for Canada as a whole, which would describe the following:
Decreased on-the-job productivity due to tobacco use;
Data concerning the health care costs of involuntary exposure of non-smokers to environmental tobacco smoke.
At a time when fiscal constraints are the order of the day for all Canadian governments, the government's arguments in support of the need to further reduce tobacco use should be basedin large part on how the economics of the health care system are driven by the need to treat tobacco-induced morbidity and mortality. Employers must also understand how much each smoking employee costs business, not only in terms of off-the-job time, but in terms of decreased productivity on-the-job. Some data has been previously generated in this regard, but it is significantly out-of-date, and in any case is rarely used in government advertising, ministerial statements, or other government information materials about tobacco use. As an example of this data, analyses carried out by Labour Canada provide the following estimates of annual cost due to smoking in Canadian workplaces:
Decreased productivity due to on-the-job smoking: $1,440 per smoking employee
Increased life and health insurance premiums: $300 per smoking employee as of 1981
Increased property damage and depreciation: $242 per smoking employee as of 1983
Increased maintenance and cleaning costs: $240 per smoking employee as of 1983
Costs from involuntary exposure of non-smokers to ETS: $40-283 per non-smoking employee as of 1983.
d) The need to make cigarettes fire-safe
In the fall of 1995, the OMA worked with the Non-Smokers' Rights Association and the Ontario Campaign for Action on Tobacco to prepare for a December inquest into a cigarette-caused fire death in the municipality of Etobicoke. The OMA's interest in this problem lies in the fact that many of its members must treat the terrible results of cigarette-caused fires on a regular basis, injuries which are in all cases preventable. There are nearly 100 deaths annually in Canada from cigarette-caused fires, and hundreds of serious injuries which result from the same fires. Many of those who die or are injured are children and/or adults who have never smoked.
As testimony from Dr. Andrew McGuire of San Fransisco's Trauma Foundation at the inquest clearly showed, the matter of cigarette-caused fires has been exhaustively studied in the United States, and a related report forwarded to the U.S. Congress. Fire-safe cigarettes have been produced in the United States, have been consumer-tested according to appropriate research techniques, and a standard test has been developed for testing the fire-safety of cigarettes. It has been shown further that tobacco companies can produce fire-safe cigarettes as cheaply as the cigarettes currently in production, and some cigarettes presently on the U.S. market in fact come close to meeting the test standard for fire-safe cigarettes mentioned above.
The conclusions of the Etobicoke inquest, and a transcript of Mr. McGuire's testimony, are appended to this submission for the information and further reference of Health Canada. The Ontario Medical Association strongly supports the coroner's jury's verdict that the federal government of Canada require by law that all cigarettes sold in Canada meet the condition of being fire-safe, and that the federal government issue standards regarding the manufacture and sale of cigarettes in Canada.
Tobacco use is an epidemic in Canadian society which requires comprehensive reforms and controls at all levels of government and throughout society if its negative consequences to our health and to Canada's economy are to be eventually eliminated. In its Blueprint, the federal government has demonstrated a new level of leadership in attacking many facets of this epidemic. This effort deserves the full support of the medical and health communities in Canada. Physicians also have opportunities to work towards solutions to this epidemic both during their interactions with patients and in their efforts to persuade governments to enact the strongest possible controls on environmental tobacco smoke, sales to minors, and other dimensions of tobacco use in Canada which are within provincial jurisdiction. The OMA will continue to vigorously pursue negotiations with the provincial government in this regard, and looks forward to maintaining alliances already forged with other sectors of the health care community in working to eliminate the tobacco epidemic in Ontario.
The OMA looks forward to an additional opportunity to consult with Health Canada directly during the process of transforming the Blueprint into legislation, and will be pleased to act as a resource in developing the scientific and technical case supporting the legislation as necessary and if requested by Health Canada. To arrange a consultation or for any further information concerning this submission, please contact Carol Jacobson, Manager of Health Policy (Telephone: 416-340-2984; Fax: 1-800-267-6973).