Commentary – Is “less than 5 by 35” still achievable?

Five years of struggle and setbacks

This year marks the fifth anniversary of Canada’s Tobacco Endgame Summit. On September 30, 2016, dozens of tobacco control researchers, leaders, advocates and policy makers from across the country converged at Queen’s University in Kingston for an ambitious, two-day deliberation on the future of tobacco control in Canada.^{Footnote 1} The lofty goal of the summit was to reshape and reignite tobacco control in Canada and to set the stage for accelerated and substantial reductions in tobacco use, referred to as the “endgame.” One of the major outcomes of the summit was a proposed new national target—to reduce tobacco use to less than 5% prevalence by 2035 (“<5 by 35”).

The proposed target of <5 by 35 was quickly adopted by Health Canada following a national consensus forum convened by Health Minister Jane Philpott in Ottawa in March 2017.^{Footnote 2} At the forum, the Minister delivered a clarion call for strong and immediate measures to accelerate tobacco reduction in Canada. Prior to the forum, Health Canada published an ambitious guiding document titled Seizing the Opportunity: The Future of Tobacco Control in Canada^{Footnote 3} that proposed a number of endgame measures. It appeared that tobacco control was on a renewed path with greater focus, unanimity and resolve and that the endgame was in sight.

Five years later, Canada continues to engage in incremental, erratic and reactive tobacco control with no coherent plan to reduce tobacco use or to achieve <5 by 35, and with little buy-in from subnational governments and nongovernmental stakeholders. There are no milestones, benchmarks or tangible national plans beyond optimistic guidance documents. The federal government has never put forth an operational plan to achieve <5 by 35, and only one province (New Brunswick) has reportedly adopted the goal.^{Footnote 4} The territories would likely struggle to achieve this target, due to elevated rates of tobacco use that are well above the national average. Although progress has been made in prohibiting flavoured tobacco products, securing plain packaging and restoring federal grants and contributions, the clarion call from Minister Philpott has gone largely unheeded. Provincial governments have done little to fill the gap, with some isolated exceptions such as age 21 laws in Nova Scotia and Prince Edward Island and retail reforms in Quebec. Moreover, the legalization of nicotine vaping products and cannabis followed by the COVID-19 pandemic have created further delays and obstacles to substantive endgame action.

Tobacco control has suffered numerous setbacks since September 2016.

The 2018 legalization of nicotine vaping products and their resulting mass promotions contributed to an explosive rise in youth vaping that governments and tobacco control stakeholders are desperately attempting to reverse engineer.  After a 50-year absence from broadcast media, tobacco companies were effectively given the green light by the federal government to promote nicotine products on television and radio and to aggressively target youth through extensive social media promotions. Over 400 000 school-aged Canadian youth are now vaping and risking nicotine addiction and potential tobacco use.^{Footnote 5} According to a recent meta-analysis, youth who vape are three times more likely to start smoking.^{Footnote 6} This inescapable distraction has absorbed immense time, energy and resources from those who should be working fervently to tackle tobacco use head-on. The final impact of vaping on youth smoking initiation and adult smoking cessation continues to remain in question.

The untimely closure of the Non-Smokers’ Rights Association (NSRA) in 2017 represents another significant setback. The restoration of Health Canada tobacco control grants in 2018 did not come soon enough to save the NSRA or the Canadian Council on Tobacco Control, which closed its doors several years earlier. The recent termination of the Ontario Campaign for Action on Tobacco is another unfortunate casualty of reduced funding for tobacco control. The capacity of tobacco control NGOs is now at its lowest point in three decades.

Cannabis legalization and its widely sanctioned public consumption may jeopardize tobacco control efforts through the potential renormalization of smoking,^{Footnote 7Footnote 8} although these effects have yet to be fully identified and reported. Health Canada’s <5 by 35 proposal to increase the national minimum age for tobacco sales to 21 was effectively killed when the legal age for cannabis sales was coincidentally aligned with the legal voting age of 18. The federal government’s simultaneous approval of cannabis pre-rolls (combustible joints) conflicted with its own reduced risk guidelines for cannabis use and facilitated the use of tobacco blunt wraps, which are often smoked with cannabis. Many cannabis smokers are also joint tobacco users, with about one-third of users mixing tobacco and cannabis.^{Footnote 9}

On top of these serious challenges, the COVID-19 pandemic has exacted an enormous toll on tobacco control, with public health staff, funding and resources redeployed to fight the coronavirus. Health charities laid off precious tobacco control staff across the country due to the impact of the pandemic restrictions on public fundraising efforts. Numerous federal, provincial and regional tobacco control staff have been redeployed to COVID-19 mitigation efforts, including the Director-General of Health Canada’s Tobacco Control Directorate. The capacity of governments, civil society and health professionals to fight the tobacco epidemic has been reduced substantially by the impact of COVID-19. The need for sustainable funding for tobacco control has never been greater.

The tobacco industry continues to innovate and has transformed itself in the past few years by taking over a substantial portion of the vaping business. The sharp rise of the youth and young adult nicotine vaping market and the development of high-nicotine formulations and heat-not-burn products reveal an industry that has no plans to phase itself out of existence. While the long-term public health impacts of nicotine vaping are not well established, current evidence indicates a high degree of likelihood of substantial respiratory and cardiovascular effects.

Moreover, there is considerable evidence indicating that nicotine vaping by youth has the potential to increase smoking rates if governments allow it to happen, although these effects have yet to be reported in Canada. The potential smoking cessation benefits of nicotine vaping products will continue to be outweighed by the public health liabilities of youth and recreational nicotine use until these problems are successfully curbed. According to one model, for every smoker who quits smoking by vaping, there are an estimated 80 youth vapers who will become smokers.^{Footnote 10}

Obvious deficiencies

Canada is still struggling with major shortcomings in its tobacco control strategy that jeopardize its <5 by 35 target.

One obvious deficiency is Canada’s incomplete implementation of the World Health Organization (WHO) MPOWER policy package. Although the MPOWER package has been criticized as a relatively conservative policy approach, Canada does not meet this minimum global standard. Several MPOWER components have yet to be implemented in Canada, including raising tobacco taxes to 75% of the retail price; deploying evidence-based, well-financed and sustained mass media campaigns; and subsidizing smoking cessation treatment for all. In sharp contrast, Brazil and Turkey have fully implemented MPOWER, and several other countries are poised to follow suit.^{Footnote 11}

Canada has yet to adopt the global WHO protocol to reduce contraband tobacco despite substantial and ongoing smuggling.^{Footnote 12} The federal and provincial governments often turn a blind eye to the illegal distribution of untaxed commercial tobacco products from factories on First Nations reserves. Tobacco taxes remain repressed in Quebec and Ontario due in large part to the impact of the contraband market and the political sensitivities that accompany this overt criminal activity.

Mass media campaigns remain in suspended animation due to the sustained political fallout of a federal government scandal that occurred almost two decades ago, which resulted in a national commission of inquiry into federal sponsorship and advertising activities.^{Footnote 13}

Canadian governments continue to collaborate with tobacco companies in violation of Article 5.3 of the WHO Framework Convention for Tobacco Control (FCTC). One such disturbing collaboration involves the development of a potential new COVID-19 vaccine that is co-sponsored by Philip Morris and the federal government.^{Footnote 14}

These are serious deficiencies that are stalling progress in tobacco control and threatening efforts to achieve <5 by 35.

Getting back on track

The goal of <5 by 35 is in serious jeopardy. A concerted, expedient and determined effort is required to get tobacco control back on track. The five years since the declaration of <5 by 35 have been horrendous. Virtually none of the important measures needed to get there have been adopted. These measures are spelled out clearly in the reports of the national endgame initiative,^{Footnote 1Footnote 15} and in an excellent report on modernizing Ontario’s tobacco control strategy.^{Footnote 16} They include:

1. introducing substantially higher tobacco taxes, effective price control policies and stronger measures to reduce contraband activity;
2. preventing the industry from circumventing tax increases by reducing the price differential between different types and brands of cigarettes and prohibiting volume discounts;
3. fully implementing the WHO MPOWER policy package and endorsing the FCTC global protocol to reduce contraband tobacco;
4. banning all industry incentives offered to retailers;
5. reducing the number of tobacco retailers;
6. reducing the supply of tobacco products in a systematic manner that aligns with the <5 by 35 target;
7. increasing government support for free and effective smoking cessation treatment;
8. restoring and expanding evidence-based mass media campaigns that include tobacco industry denormalization;
9. ensuring full government adherence to Article 5.3 of the FCTC to minimize tobacco industry interference; and
10. implementing system enablers, including:
    • substantial and sustainable funding for tobacco control derived from tobacco industry levies;
    • a coherent national strategy with concrete workplans, benchmarks, milestones and oversight; and
    • full engagement of provincial and territorial governments, NGOs, health professions and researchers.

There is now an additional urgent need for a plan to reduce the use of all nicotine products to ensure that the tobacco smoking epidemic is not replaced by a nicotine vaping epidemic, and to avoid the resulting implications for nicotine addiction, tobacco dependence, respiratory and cardiovascular health.^{Footnote 17} With over 400 000 school-aged youth using vaping products in 2019, the potential for a lasting epidemic of nicotine addiction and increased tobacco use should not be underestimated.

Seizing the opportunity

It appears that Minister Philpott’s ambitious appeal has fallen on deaf ears, especially when examining the report and policy proposals that accompanied her 2017 directive. Several of the promising measures proposed in Seizing the Opportunity remain largely or completely unimplemented.

The federal government could use more nudging, direction and support. Perhaps it is time for provincial and territorial governments, NGOs, health professions and researchers to come together and collectively set the national agenda in consultation with the federal government. A truly national tobacco control strategy will involve all key stakeholders, with the federal government playing a coordinating role and with leadership coming from all parties. The next clarion call needs to be delivered by an orchestra instead of a lone bugler.

Much of the heavy lifting on tobacco control has occurred at the regional level over the past two decades, including workplace smoking bans, tobacco tax increases, flavour bans, mass media campaigns and smoking cessation programs. All provinces and territories have adopted their own tobacco control strategies to complement the federal strategy.

The legal jurisdiction over public health and tobacco control is shared between provinces or territories and the federal government, according to the Constitution Act. This shared responsibility has been very apparent during the COVID-19 pandemic, with provinces and territories playing pivotal roles that are reflected in weekly meetings between the prime minister and the premiers.

A renewed and united clarion call is desperately needed for all Canadian health ministers to commit to achieving < 5 by 35 and to putting concrete measures in place to get there. Other countries, including Ireland^{Footnote 18} and New Zealand,^{Footnote 19} have developed coherent action plans with tangible strategies, benchmarks, milestones and oversight to achieve “5 by 25.”

Almost 50 000 Canadians die annually from tobacco-related illness, and this number has not changed appreciably in over two decades.^{Footnote 20Footnote 21} More than 400 000 youth vapers are currently risking nicotine addiction and potential tobacco use.^{Footnote 5} Almost a million Canadians are currently suffering the direct consequences of tobacco use according to an established 20:1 morbidity to mortality ratio.^{Footnote 22} The health care system is overburdened by chronic diseases, of which tobacco use is a major cause. Our economy is also suffering from the consequences of tobacco use due to reduced productivity, which accounts for almost half of the total economic impact.^{Footnote 23}

Hopefully, the COVID-19 pandemic will create a renewed national focus on public health that will encourage Canadian governments, civil society, health professions and other key players to take further collective action to substantially reduce tobacco use.

Perhaps we all need to seize the opportunity presented by COVID-19.

Conflicts of interest

LH is employed by an organization that receives public and private sector funding that is not derived from tobacco or vaping companies. RS declares no conflicts of interest.

Statement

The content and views expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.

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