Seizing the opportunity: the future of tobacco control in Canada

A new approach to tobacco control is needed.

The expiry of the current Federal Tobacco Control Strategy (FTCS) in March 2018 presents an opportunity to modernize the federal approach. Partners and stakeholders are also calling for bold federal leadership on tobacco control, including setting an aggressive prevalence target, enhancing support for smoking cessation, adopting a harm reduction approach, and addressing high prevalence rates among Indigenous peoples and sub-populations.^{Footnote *}

The Government of Canada is committed to achieving a radical reduction in tobacco use in Canada.

This consultation is part of a comprehensive approach that the Government of Canada is taking toward charting a new course in helping Canadians lead healthier, tobacco-free lives. In the past year, the Government has moved forward on prohibiting menthol flavour in most tobacco products, and introduced legislation to address vaping products as well as support the implementation of plain and standardized packaging requirements for tobacco products.

It is now time to take stock of the accomplishments of the past and set out a bold new federal approach driven by an aggressive target. This paper serves to inform public consultations from February 22 to April 13, 2017 as well as discussions at the National Forum on the Future of Tobacco Control in Canada from February 28 to March 2, 2017.

The Government of Canada is looking forward to hearing from a wide range of Canadians, including Indigenous peoples, on this important social and public health issue. The series of options, measures and questions presented are not necessarily the policy positions of the Government of Canada and are presented for discussion.  We are excited to engage on whether and how these could be incorporated into a new strategy.

We need to challenge ourselves collectively to find the best way to achieve our ultimate objective: healthy Canadians living tobacco-free lives.

2. Background

Tobacco Control in Canada

Canada has a long history in tobacco control. In 1963, Canada was one of the first countries to declare that smoking causes lung cancer, and there have been tobacco control strategies in place in this country for the past thirty years.

The current Federal Tobacco Control Strategy (FTCS) was launched in 2001 as a comprehensive, integrated and sustained approach to achieving reductions in tobacco use. It is led by Health Canada in partnership with the Public Health Agency of Canada, Public Safety Canada, the Royal Canadian Mounted Police, Canada Border Services Agency and Canada Revenue Agency.

The current phase of the strategy is focused on preserving the gains of the previous decade and continuing the downward trend in smoking prevalence.

The Ongoing Problem of Tobacco use in Canada

The significant harms of tobacco, combined with its persistent and widespread use, burdens all Canadians. Tobacco-related disease results in a loss of quality of life for families and friends caring for the ill and grieving the dead. Canada also has a contraband tobacco market in which tobacco control measures are not followed.  

Health Harms

Tobacco use is harmful. It causes dozens of preventable, debilitating and fatal diseases in users and those exposed to second-hand smoke.^{Footnote 9} This places a heavy burden on the healthcare system. Exposure to smoke is also associated with low quality of life.^{Footnote 10}

Tobacco Use and Health and Social Inequity

Despite declines in tobacco use over the past decades, there are still 4.6 million Canadians who use tobacco,^{Footnote †,Footnote 11} including 3.9 million cigarette smokers (13%).^{Footnote 12} Worryingly, youth (10%) and young adult (18%) smoking has not declined since 2013.^{Footnote 13}

Tobacco use also contributes to health and social status inequity in Canada. Though the number of Canadians who smoke cigarettes has declined, certain groups have much higher smoking rates. These groups include Canadians with low incomes (33%) and those diagnosed with a mood and/or an anxiety disorder (30%).^{Footnote 14} Commercial tobacco use among Indigenous peoples is also much higher than in the general population. 2010 data shows that 57% of First Nations people 18 years of age and older who lived on-reserve or in northern communities were smokers.^{Footnote 15} In 2012, 73% of Inuit in Inuit Nunangat^{Footnote ‡} 15 years of age and older were smokers.^{Footnote 16}  

Addiction and Appeal to Youth

Tobacco use is not a habit. The ongoing use of tobacco among Canadians is driven in large part by addiction, which in the majority of circumstances begins during youth. Young Canadians are particularly sensitive to the dependence-causing effects of nicotine in tobacco.^{Footnote 17} Eighty-two percent (82%) of current adult daily smokers smoked their first cigarette by the age of 18.^{Footnote 18} Recruitment of new people who use tobacco remains a major concern. In 2015, approximately 115,000 Canadians began smoking daily.^{Footnote 19}

Nicotine addiction makes quitting difficult. In 2015, only 6% of former smokers had quit within the past year, but 1.3 million daily smokers made at least one quit attempt.^{Footnote 20} It takes an average of 30 attempts before someone can quit smoking for a year and, even then, there is a risk of starting again.^{Footnote 21}

3. Discussion Issues – Elements of a New Long-term Plan

The Government of Canada is committed to a target of less than 5% tobacco use by 2035. This commitment will focus long-term federal action and help to mobilize all Canadians to fight tobacco use. The Government will collaborate with partners and stakeholders to meet this aggressive target. This will be a challenge, given that Canada has already implemented most internationally-recognized practices in tobacco control, according to the World Health Organization.^{Footnote 22} Relying on current measures alone is not expected to reduce tobacco use fast enough. If we continue with current policies, smoking prevalence is only forecast to decrease by four percentage points from 13% to 9% by 2036, according to current estimates.^{Footnote 23} This means that approximately three million Canadians would still be smoking 19 years from now.^{Footnote 24}

To address this unacceptably slow rate of decline, current practices in tobacco control will need to be improved and bolstered by innovative measures. A comprehensive long-term plan to drive down the number of Canadians who use tobacco would be based on six key elements designed to put the health of Canadians first.

1. Less than 5% by 2035 and other targets – in addition to the goal of less than 5% tobacco use by 2035 for the general population, setting other tobacco use and sub-population targets.
2. Protecting youth – preventing young people and others from starting to use tobacco and vaping products, and protecting them from second-hand smoke and vapour.
3. Helping Canadians who use tobacco – enabling access to treatment to help people quit tobacco and reducing harm to those who are not ready to quit.
4. Indigenous peoples – supporting the development of a shared approach to address higher prevalence rates of commercial tobacco use among Indigenous peoples.
5. Tobacco use and health and social inequities – addressing higher rates of tobacco use in groups such as those living with mental illness and those with lower socioeconomic status.
6. Building capacity – ensuring that the Government of Canada has the resources, information and partnerships it needs to achieve its targets and to support partners in their roles. 

The sections below set out each of these elements in terms of important considerations, possible options and questions for feedback. For each of these elements, the Government of Canada wants to hear your views about what has worked in the past and what innovative actions should be taken to ensure a successful future tobacco control strategy.

Please note that options are being presented for discussion and are not necessarily the policy positions of the Government of Canada.

The Government also recognizes the need to consider links between addressing tobacco use and the approach being developed to legalize, strictly regulate and restrict access to cannabis. You are encouraged to provide your views on where these links exist and what the Government can do to align approaches on tobacco and cannabis, where appropriate.

A. Less than 5% by 2035 and Other Targets

Considerations

Driving down tobacco use is everyone’s concern. To help focus action, a target of less than 5% tobacco use by 2035 is being set. The Government of Canada believes that this commitment strikes the right balance between being aggressive and what is realistically achievable.

As set out in Table 1, aggressive long-term targets for the general population have been adopted by some provinces, including British Columbia and Quebec, and internationally by Finland, Ireland and New Zealand.

The target of less than 5% by 2035 for the general population is not the only goal being considered. For example, sub-targets could also be considered for daily cigarette smoking and for youth and young adults.

More specific targets could also be set for other groups or communities of Canadians. With respect to addressing higher prevalence rates among Indigenous peoples, section D of this paper underscores the Government of Canada’s commitment to meaningful dialogue to support the development of a shared approach.

Possible Options

In addition to less than 5% by 2035 for tobacco use among the general population, the Government of Canada’s long-term plan could include the following targets or categories of targets.

1. Daily cigarette smoking – an aggressive target for reducing daily cigarette smoking.
2. Youth and young adults – an aggressive target for reducing tobacco use among youth and young adults.
3. Tobacco use and health and social inequities – targets for sub-populations that have higher prevalence rates.

Questions

1. Should all tobacco use be included in the less than 5% by 2035 target for the general population?
2. Should a target for vaping product use among youth and others who do not use tobacco be included?
3. What other sub-targets should the Government adopt?

B. Protecting Youth

Considerations

Preventing young people and others from starting tobacco use has been a key pillar of federal, provincial and territorial approaches to tobacco control. Enforcement of the federal Tobacco Act and its regulations is a key measure to protect youth. Under the FTCS, Health Canada has also developed and disseminated tobacco use prevention resources to Canadians of all ages, including publications for parents and web-based materials. Federal partners also monitor and assess the contraband tobacco market in which sellers do not follow measures intended to protect youth such as minimum age restrictions and labelling requirements.

With respect to vaping products, the Government of Canada has introduced new legislation (Bill S-5, An Act to amend the Tobacco Act and the Non-smokers’ Health Act and to make consequential amendments to other Acts).The bill contains provisions to protect youth from nicotine addiction and tobacco use. These include restricting promotions and the promotion of flavours like candy, and prohibiting sales to youth (those under 18). The bill also supports the Government of Canada in delivering on its commitment to implement plain and standardized packaging for tobacco products.

All provincial and territorial strategies include the use of a range of tools to protect youth from tobacco use uptake. Depending on the jurisdiction, these include sales to youth restrictions, prohibitions on flavoured tobacco, tobacco display bans, tobacco-free school grounds, school and sports based education programs, programs for at-risk youth and pregnant women, and anti-tobacco social marketing campaigns.  All provinces and territories and many municipalities have rules for smoke-free spaces in place. Eight provinces have also passed legislation to protect youth from the risks of vaping product use.

Increasing the price of tobacco products has also contributed to reductions in the number of youth who start smoking. Historically, federal and provincial tobacco tax increases have helped to reduce demand for tobacco products by making them more expensive. However, some may argue that increased prices have the potential to impose disproportionate economic pressures on disadvantaged populations and increase trade in contraband.

Canada is not alone in facing the challenges of preventing young people from starting to use tobacco products. Internationally, there has been movement to implement innovative prevention measures. The minimum age to purchase tobacco has been raised to 21 in the states of Hawaii^{Footnote 30} and California.^{Footnote 31} However, as Canada seeks to legalize, strictly regulate and restrict access to cannabis, careful consideration would be required to ensure that age of access for tobacco and non-medical cannabis do not work at cross purposes.

To address tobacco addictiveness, research on a nicotine dependence threshold in youth and adults, and the potential impact of nicotine reduction on tobacco product use behaviour, has been identified as a priority for the United States Food and Drug Administration’s Center for Tobacco Products.^{Footnote 32}

Possible Options

As part of a future strategy, the Government of Canada would continue to enforce key measures that protect youth. In addition to these, other proven and innovative measures could be considered.

1. Raising the minimum age of access nationally – Collaborate with provincial and territorial counterparts to increase the minimum age to be sold tobacco to 21 years (recognizing that doing so would require careful consideration of age of access for non-medical cannabis).  
2. Tobacco addictiveness reduction – Develop regulatory options for reducing the addictiveness of tobacco products in order to prevent people from becoming users.
3. Smoke- and vapour-free spaces – Work with partners to support broadening smoke- and vapour-free spaces, including bans on use on post-secondary campuses, in public parks, or in multi-unit dwellings. This work could also consider where cannabis could be smoked or vaporized.
4. Contraband – In an effort to combat contraband tobacco over and above current actions, the federal government could work with partners to tighten controls around the supply and movement of materials needed to manufacture tobacco products as well as the actual sales of illicit tobacco.

Questions

1. Should the Government work with provinces and territories to increase the minimum age to be sold tobacco products to 21 years? 
2. Should the Government develop regulatory options to reduce the addictiveness of tobacco products in order to prevent people from becoming users?
3. What additional interventions should the Government consider to reduce the contraband market?
4. Should the Government support broadening the application of smoke-free and vapour-free space rules? If so, how?
5. What other innovative measures should be considered to protect youth and others from starting to use tobacco and vaping products?

C. Helping Canadians Who Use Tobacco

Considerations

Addiction is an important driver of tobacco use. Nicotine addiction helps to explain why such a small proportion of people who use tobacco successfully quit each year. In 2015, only 6% of former smokers had quit within the past year, but 1.3 million daily smokers had made at least one quit attempt.^{Footnote 33}

The harms to people from tobacco use and addiction can be reduced in two different ways. Through treatment (e.g., nicotine replacement therapy, prescription medication, counselling) and on their own (e.g., cold turkey), people can quit all nicotine and tobacco use. While quitting is the best way for someone to improve their health, harms could also be reduced for people who use tobacco, but that are not able to quit by switching to less harmful sources of nicotine.

Cessation

Current federal support for smokers who wish to quit is provided through the pan-Canadian Quitline and web portal that appears on cigarette and little cigar packages. It is also provided through programs that are funded by the Public Health Agency of Canada and the First Nations and Inuit Health Branch of Health Canada.

Health Canada disseminates cessation resources to Canadians of all ages, including publications and web-based materials. Due to relatively high prevalence rates among young adults aged 20 to 24 (18%),^{Footnote 34} Health Canada has also funded the Canadian Cancer Society’s Break it Off campaign that helps young adults to quit smoking. The Government of Canada also funds the Canadian Partnership Against Cancer which provides cessation programs for cancer patients who want to quit smoking.^{Footnote 35}

At the provincial and territorial level, there are a broad range of cessation programs, resources and supports. Some provinces and territories have comprehensive cessation programs that combine online information, counselling (by phone and in person) and stop-smoking medications. Certain provincial and territorial governments also subsidize the cost of nicotine replacement therapy or prescription cessation medications through their drug benefit or other programs.^{Footnote 36}

Increasing the price of tobacco products has also contributed to reductions in the number of people who smoke.^{Footnote 37} Historically, this has been done by federal and provincial governments raising tobacco taxes.

The federal government sees an opportunity to use a variety of tools and work with a range of partners to improve access to and the effectiveness of smoking cessation interventions.

Harm reduction

The Government of Canada is considering how it can support people who use tobacco who are not ready or able to quit using all nicotine to reduce harms to their health. The proposed Tobacco and Vaping Product Act would allow adult smokers to legally choose vaping products, which expose them to fewer harmful chemicals than cigarettes.^{Footnote 38} The federal government is considering whether and how it should take a more active role in encouraging adult smokers to switch to vaping products. This approach is already in place in the United Kingdom where a report published by the UK government states that encouraging people who cannot or do not want to stop smoking to switch to vaping products could help reduce smoking related disease, death and health inequities.^{Footnote 39}

In addition to vaping products, there are also new tobacco products emerging on the global market. Data published by the tobacco industry reports that certain new tobacco products produce fewer harmful emissions; however, these claims have not been independently verified and the effects on human health are currently unknown.

Possible Options

The Government of Canada may consider a combination of options that would help Canadians to stop using tobacco and to reduce harms to their health if they continue to use nicotine.

1. Cessation – Working with a variety of partners and a range of tools (e.g., public education campaigns, funding for cessation support, and research into new programs or treatments) to enable Canadians, in particular youth and young adults, to quit tobacco.
2. Harm reduction – Using a range of tools (e.g., a public education campaign) to actively encourage those who cannot quit tobacco use to switch completely to less harmful products, while continuing to inform youth and non-users of their harms.
3. New tobacco products – Supporting research on the relative harms of new tobacco products.

Questions

1. How should the Government balance efforts between cessation and harm reduction?
2. While maintaining protections for youth, to what extent and how should the Government encourage Canadians who cannot quit tobacco use to switch completely to less harmful products?
3. Which best practices or innovative measures in cessation should the federal government consider?
4. Where should the Government focus its policy and support for research on new tobacco products?

D. Indigenous Peoples

Considerations

The Government of Canada recognizes the sacred and ceremonial role that traditional tobacco plays in certain Indigenous communities. It also recognizes the interest and efforts of Indigenous partners and communities in addressing commercial tobacco use, which is far more prevalent among Indigenous peoples than in the general population.^{Footnote 40,Footnote 41}  

The current First Nations and Inuit component of the FTCS aims to promote information and knowledge sharing. It supports the development and implementation of comprehensive tobacco control projects that are holistic, and socially and culturally appropriate. It also strives to reduce commercial tobacco use, while maintaining respect and recognition for traditional forms and uses of tobacco within Indigenous communities.

Project activities include:

• reducing youth access to tobacco products;
• enhancing no-smoking policies and by-laws;
• promoting smoke-free homes, public spaces and workplaces through community and partner collaboration;
• promoting awareness of the dangers of smoking and second-hand smoke;
• engaging and encouraging youth to adopt healthy lifestyles;
• offering tobacco cessation training for community workers;
• delivering cessation programs to pregnant women and young mothers; and
• tracking success through indicators and sharing best practices.

There have also been provincial programs developed to support Indigenous peoples. These included creating smoke-free public spaces and homes, and providing nicotine replacement therapy and cessation counselling.

As part of its long-term plan on tobacco, the Government of Canada is considering how to collaborate and partner with Indigenous peoples and others to co-develop and co-deliver an approach to address high rates of commercial tobacco use in a manner that recognizes First Nations rights, and respects the sacred and ceremonial role tobacco plays in certain communities.

The Government is also interested in working with Indigenous peoples to build on the successes of and learn from current federal programs dedicated to supporting Indigenous communities in developing and implementing their own commercial tobacco control strategies. A separate mutually agreed upon consultation and engagement with Indigenous peoples is proposed to help inform this element of a federal strategy.

E. Tobacco Use and Health and Social Inequities

Considerations

There are certain groups of Canadians where rates of tobacco use are higher than in the general population. Canadians living in rural and remote communities, those with low incomes, or people experiencing addictions or poor mental health are much more likely to use tobacco products.^{Footnote 42,Footnote 43}

Some people also begin and continue to smoke as a means of coping with sources of chronic stress that interfere with their ability to live a normal life.^{Footnote 44} These sources of stress can include psychological trauma. Higher rates of tobacco use coupled with its health harms can also make health and social inequity worse, particularly among people that live with other social disadvantages (e.g., illiteracy).

The Government of Canada would work with partners to develop tobacco use prevention, cessation and harm reduction interventions that address health and social inequities related to tobacco use. Interventions could include tailored tobacco control approaches that could be integrated into existing programs and initiatives.

Questions

1. What research is needed to better understand tobacco use in certain sub-populations?
2. Which existing programs that reach populations affected by health and social inequities could be augmented with tobacco prevention, cessation and harm reduction measures? What could these measures look like?

F. Building Capacity

Considerations

Addressing the societal burden of tobacco use requires that governments and partners have the capacity to take action to support Canadians to live healthy, tobacco-free lives.

Industry Accountability

Tobacco manufacturing and importing remains one of the most profitable global industries, while society is burdened with the costs associated with the use of its products. Canadian tobacco control stakeholders have called for action to increase the transparency of industry activities aimed at influencing public policy. ^{Footnote 45}  In some countries (e.g., U.S., ^{Footnote 46}  France^{Footnote 47}), the tobacco industry is required to make a direct contribution to the costs of tobacco control efforts.

Research

Identifying and implementing innovative tobacco control measures will require investments in research. In order to reach ambitious targets, measures need to be effective at reducing tobacco use. A better understanding of the motivations and obstacles for people to start and stop smoking would help to better tailor programs. Research on the relative harm of different products and detailed use patterns is another important area for research. As well, there may be a need for further studies on tobacco product addictiveness in the Canadian context.

Surveillance

New surveillance tools (e.g., new surveys) may also be necessary to support actions by the Government and partners.  Surveys on tobacco sources and the prevalence of contraband products could also be explored.

Partnerships

The Government of Canada currently works with a wide range of tobacco control partners, including all levels of government, international organizations such as the World Health Organization, federal regulators in other countries, law enforcement, scientific and research communities (including the Canadian Institutes of Health Research) and non-governmental organizations. The Government’s work with these groups includes:

• addressing tobacco-related issues that affect multiple countries;
• participating in the World Health Organization Framework Convention on Tobacco Control (WHO-FCTC) to promote international public health and provide a Canadian perspective;
• getting the best advice on policies and regulations from external experts and partnering to effectively deliver programs to Canadians (e.g., Break it Off and the Canadian Partnership Against Cancer’s programs that help cancer patients quit smoking);
• supporting other levels of governments’ regulatory bodies in delivering their mandates; and
• increasing collaboration, policy, and programming coherence nationally.

Supporting existing partnerships will continue to be a key role in the future of tobacco control. There is also an opportunity to develop new roles, in particular as a facilitator of knowledge transfer and exchange, and as a convenor and leader of partners in our shared work to reduce the burden of tobacco use on Canadian society.

International

The public health problem of tobacco use is not only a domestic issue, but a significant international problem.

The Government of Canada is considering an appropriate international role to continue to advance tobacco control.  Canada could fulfil this role with a variety of measures including continuing Canada’s domestic implementation of WHO-FCTC as well as sharing research results and best practices to support global efforts to address tobacco use.

Possible Options

1. Industry accountability – Measures could be considered to enhance industry accountability.
2. Research and surveillance – The research needed to support a new agenda for tobacco control in Canada could be sought through new ways of working with partners that would provide coordination and cooperation among scientists with varied experience.
3. Partnerships – Enhance knowledge transfer and exchange between existing and new partners, both domestically and internationally.
4. International – The Government could continue domestic implementation of WHO-FCTC and work more closely with international partners.

Questions

1. How should the Government work with partners to ensure that the tobacco industry is held to better account for the societal burdens caused by its products?
2. How should the Government best support research to provide the evidence needed to inform a new agenda in tobacco control?
3. What mechanisms should be used by the Government to better facilitate knowledge transfer and exchange with tobacco control partners?
4. Which new partners should be engaged by the Government to support its work in tobacco control?
5. Where should Canada focus its work with international partners?

4. We Want Your Feedback

The Government of Canada is committed to charting a new course in tobacco control that seeks to radically reduce the unacceptable burden inflicted on our society by tobacco use by putting the health of Canadians first and driving down tobacco use.

We are seeking input from interested Canadians on the measures set out in this document related to tobacco control. You can provide your input using the information set out below. Respondents are also encouraged to provide input or concerns related to tobacco control that fall outside of the scope of this consultation paper.

Canada is a Party to the World Health Organization Framework Convention on Tobacco Control (WHO FCTC).  Article 5.3 of the WHO FCTC obliges Parties, in setting and implementing their public health policies with respect to tobacco control, to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law. Therefore, the Government of Canada must actively exclude tobacco industry influence with respect to tobacco control policy. You must declare any perceived or actual conflicts of interest with the tobacco industry when providing input to this consultation.

We are also interested in being aware of perceived or actual conflicts of interest with the vaping and/or pharmaceutical industry. As such, we request that you please declare this upon providing input.

Email your comments to ftcs-sflt@hc-sc.gc.ca

Write to us at:

Consultations on the Future of Tobacco Control in Canada
Room 1605-626
Mail Stop 0301A
150 Tunney's Pasture Driveway
Ottawa, Ontario
K1A 0K9

Please do not include any personal information when providing feedback to Health Canada. The Department will not be retaining your email address or contact information when receiving your feedback and will only retain the comments you provide.

All feedback received on or before April 13, 2017 will be considered.

Health Canada will make a summary of the results of this consultation available online. No identifying information will be used in the summary without your explicit permission.

Thank you for taking the time to consider this document and for contributing to helping Canadians to lead healthier, tobacco-free lives.