Looking Forward: The Future of Federal Tobacco Control

Consultation Document

September 12, 2011

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Table of Contents

• Purpose
• Context
• What has been achieved?
• How has this been achieved
• Taking Stock - Lessons from the FTCS
• Challenges in Tobacco Control Remain
• Seeking your input on the next phase of tobacco control
• Appendix A: Submitting your Comments

Purpose

Health Canada, as the lead federal department for the Federal Tobacco Control Strategy (FTCS), would like to hear from Canadians about what the focus of the federal government should be in tobacco control over the next five years. The purpose of this document is to provide an overview of the FTCS, and to provide a forum for public input.

All interested Canadians are invited to provide feedback on this document, and their views on the future role of the federal government in tobacco control. To do so, please refer to the instructions on how to participate, presented in Appendix A.

Context

The Federal Tobacco Control Strategy (FTCS) was introduced in 2001 as a 10-year comprehensive, sustained and integrated strategy to achieve significant reductions in disease and death due to tobacco use. The FTCS has four strategic pillars - prevention, cessation, protection and product regulation. It builds on the progress made under successive federal strategies that have positioned Canada as a world leader in tobacco control. The FTCS complements the increasing tobacco control efforts of provinces, territories and municipalities since 2001.

The FTCS is led by Health Canada in partnership with Public Safety Canada, the Royal Canadian Mounted Police (RCMP), Canada Revenue Agency, Canada Border Services Agency, and the Office of the Director of Public Prosecutions.

In March 2011, the Government of Canada extended the FTCS for one year, to implement several high-profile tobacco initiatives such as the Cracking Down on Tobacco Marketing Aimed at Youth Act and proposed new, larger graphic health warning messages that would feature new diseases and, for the first time, testimonials from individuals affected by tobacco use. The warnings would cover 75% of the front and back of cigarette and little cigar packages, up from the current 50%. This extension will also allow for the completion of the ten-year FTCS summative evaluation.

What has been achieved?

Canada has made substantial progress in tobacco control over the last 10 years. Few countries have witnessed similar reductions in prevalence, or a similar shift in public attitudes towards tobacco use.

Key objectives of the FTCS that have been met include:

• Prevalence has decreased - Smoking prevalence is at an all-time low of 17%. This is down from 22% when the FTCS was launched. As a result, there are now seven hundred thousand fewer smokers than in 2001 - a drop from 5.4 to 4.7 million smokers.^{1, 2}
• Youth smoking has declined - The most significant reduction in smoking rates is among youth, aged 15-19 (23% in 2001 to 12% in 2010) and young adults aged 20-24 (32% in 2001 to 22% in 2010).^{1, 2}
• Canadians smoke less - Daily smokers smoke fewer cigarettes now, averaging 15 per day in 2010, down from 16 in 2001.^{1, 2}
• Sales to youth have decreased - Retail compliance has increased to almost 85% in 2009 from 70% in 2000.^3,
• Second-hand smoke bans are in place - Canadians are now more than ever protected from exposure to second-hand smoke in public places, with close to 100% of Canadians protected from second-hand smoke in enclosed public places.
• Canada is an international leader - Canada is recognized internationally as a leader for developing and implementing a strong, comprehensive and effective tobacco control environment. Canada is a Party to the World Health Organization Framework Convention on Tobacco Control, which provides a foundation for countries to manage and implement tobacco control, and has supported its implementation globally.

How has this been achieved?

The FTCS has placed a strong emphasis on collaboration between the federal, provincial, territorial and municipal governments, as well as non-governmental organizations, tobacco control researchers, academics, and community organizations. Federal, provincial and territorial investments in tobacco control now total more than $150 million each year.⁴ Through this partnership, Canada has created a comprehensive tobacco control environment that is recognized around the world.

Table 1 - International Comparison of Select Tobacco Control Measures⁵

Country	Daily Smoking Ratesa %	Smokefree Spaces	Advertising Bans (Domestic)	Retail Display Bans	Quit Line	Health Warning Message Size %	Taxes %
a WHO globally weights country provided data to enable cross-country comparisons. The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily smokers in a country. b Canada's comprehensive advertising bans permit publications provided by mail to a named adult and signs in places where young persons are not permitted by law. c Canada has proposed new, larger graphic health warning messages which include a toll-free quitline number on cigarette and little cigar packages. The messages would occupy 75% of the package, front and back. d Policy adopted but not implemented as of December 31, 2010. e Legislation for retail display bans has been passed, but implementation to take place in 2012 and 2015. f Australia has tabled legislation calling for plain packaging. g Legislation for retail display bans has been passed, but implementation to take place in 2012.
Canada	14	Yes	Yesb	Yes	Yes	50c	67
Brazil	15	No	Yes	No	Yes	50	60
U.S.	16	No	No	No	Yes	50d	45
United Kingdom	16	Yes	Yes	Noe	Yes	35	77
Australia	17	Yes	Yes	Yes	Yes	60f	64
Finland	17	Yes	Yes	Yes	Yes	39	79
New Zealand	20	Yes	Yes	Nog	Yes	60	72
Uruguay	22	Yes	Yes	No	Yes	80	72
France	27	Yes	Yes	No	Yes	35	80

Federal Initiatives

A key component of Canada's tobacco control effort is the Tobacco Act of 1997. The focus of the Act is to regulate manufacture, sale, labelling, and promotion of tobacco products in Canada. It aims to protect all Canadians, with particular emphasis placed on youth, and the health consequences associated with tobacco use.

The federal government has implemented a strict regulatory environment that severely limits the tobacco industry's ability to use marketing to attract new smokers, combined with programs that provide Canadians with information on the dangers of smoking. Key initiatives introduced under the strategy include:

• Protecting youth by banning flavours and additives - Under the Cracking Down on Tobacco Marketing to Youth Act, Canada became the first country in the world to ban the use of certain additives, including flavours like chocolate and bubble gum in cigarettes, little cigars and blunt wraps that were making tobacco products more appealing to youth.
• Restricting advertising for tobacco products - The advertising of tobacco products by means of information advertising or brand-preference advertising is limited to publications provided by mail to a named adult and on signs in places where young persons are not permitted by law. Provinces and territories have taken further action to ban tobacco retail displays.
• Health warning messages - Canada was the first country to require pictorial health warnings on tobacco packages in 2000. In June 2011, the Minister of Health laid proposed new regulations before the House of Commons to renew and strengthen these messages, which feature new graphic images, health information messages, and a pan-Canadian toll-free quitline that would connect smokers to local cessations services.
• Taking action on contraband - The RCMP's Contraband Tobacco Enforcement Strategy launched in May 2008 makes an important contribution to the federal government's efforts to stop the illicit trade in tobacco. In 2010, 15% of smokers aged 15 years and older said they had purchased contraband cigarettes, a decrease from 21% in 2008.⁶
• Taking action on counterfeit tobacco products - The Canada Revenue Agency's introduction of a new excise stamp will allow authorities to more easily identify legitimate tobacco products and detect counterfeit products.

Provincial, territorial and municipal initiatives

Since the FTCS was launched in 2001, the role of provincial and territorial governments has grown consistently. All provinces and territories (P/T) have major tobacco legislation or comprehensive tobacco control strategies in place, and P/T investment in tobacco control has more than doubled since 2001. This spending now represents more than half of total tobacco control expenditure in Canada. Provinces are also increasingly expanding their programs to include funding for pharmacotherapies such as nicotine replacement therapy. Many municipalities also have by-laws that protect people in public spaces from second-hand smoke, and undertake activities that support prevention and cessation.

Taking Stock - Lessons from the FTCS

An important part of the FTCS has been the ongoing evaluation of its effectiveness, and that of other tobacco control measures. It is clear that the comprehensiveness of the FTCS approach to tobacco control has contributed to the decline of smoking prevalence. It is also an important part of a cumulative foundation created by federal, P/T and municipal interventions in tobacco control.

Key interventions that have shown measured success over the past ten years include:

• The addition of health warning messages to tobacco packages
  • Studies relating to the use of graphic health warning messages have consistently shown positive results with respect to changes in smoking behaviour.⁷
• The strategic use of taxation
  • Taxation has been identified as one of the major factors for the decline in smoking between 1999 and 2008. The collaborative use of taxation by federal and provincial governments as a policy tool to make cigarettes less accessible to consumers has contributed to reducing smoking prevalence.
• The implementation of second-hand smoke bans
  • While provincial and municipal smoking bans in public space were largely designed to protect non-smokers from the negative health effects of second-hand smoke, evidence has shown demonstrated association with declines in smoking rates in both adults and youth.⁸
• The established legal age of sales prohibitions
  • The Tobacco Act provides that no person shall furnish tobacco to a person who is less than 18 years of age. This is the minimum age found in similar provincial and territorial legislation, but several jurisdictions have legislated a minimum age of 19. Evidence from the evaluation shows that a higher legal age contributes to a lower smoking prevalence.

While representing different policy levers, there is an important similarity shared by each of these interventions referenced above - reach, or their ability to have an impact on a large number of people across a variety of population groups. Evaluations have shown that the highest degree of measurable behavioral change is observed when interventions reach the largest population. This is particularly important given the profile of the Canadian smokers. While there are pockets of certain populations with higher prevalence, the vast majority of smokers are spread across all population groups in Canada. Measures such as the recently announced proposed pan-Canadian quitlines that would connect smokers to provincial and territorial phone cessation support services are designed with this in mind.

Challenges in Tobacco Control Remain

In spite of this progress, almost five million Canadians continue to smoke. Each year, smoking kills an estimated 37,000 Canadians, making smoking the country's leading cause of preventable death. Sixteen percent (16%) of deaths in Canada are attributable to tobacco use.

Tobacco use represents a substantial cost to the Canadian health care system, and to the Canadian economy. Total direct health care costs linked to tobacco use are over $4.4 billion per year. When indirect cost (e.g. lost wages, productivity, etc.) are included, the total annual economic cost of tobacco to the Canadian economy is more than $17 billion.⁹

Smoking rates remain high for some groups, particularly First Nations and Inuit communities where the smoking rate is more than three times the rate of other Canadians.

Although youth smoking has declined, preventing youth from smoking is critical to reducing smoking prevalence in the short-term and long-term.

Despite a rise in the sales of legal cigarettes in 2010, the demand for contraband and discount tobacco products continues to pose a threat to the objective of reducing tobacco use in Canada, and undermines health measures, such as the inclusion of health warning messages on packages, put into place to discourage and reduce tobacco consumption. Also, organized crime is heavily involved in the manufacture and distribution of contraband tobacco products, proceeds from which are often used to support other forms of criminal activity such as firearms, illicit drugs, and money laundering.

Seeking your input on the next phase of tobacco control

Tobacco control remains an important public policy issue. Health Canada and its partners are seeking innovative approaches to tobacco control as well as measures to reduce smoking rates and protect the health of Canadians.

You have read the consultation document entitled "Looking Forward: The Future of Federal Tobacco Control", now Health Canada wants to hear you on the following questions:

Questions for consideration:

• What elements of the current Federal Tobacco Control Strategy have been successful?
• Are there elements of the current FTCS that have not been successful or could be improved?
• What should the focus of the federal government be with respect to tobacco control over the next five years?

Appendix A - Submitting Your Comments

You can send your comments, in English or French, by e-mail, fax or regular mail. Please note that Health Canada is committed to reviewing and considering all comments received by October 11, 2011.

• Email: FTCS-SFLT@hc-sc.gc.ca
• Fax: 613-946-6460
• Mail: FTCS Consultations
  Office of Policy and Strategic Planning
  Controlled Substances and Tobacco Directorate (CSTD)
  Healthy Environment and Consumer Safety Branch
  Health Canada
  123 Slater Street
  Ottawa, Ontario K1A 0K9
  Address Locator: 3509D

To help us keep track of your input, please ensure that you clearly identify who you are, and note your stakeholder affiliation, if applicable (e.g. patient organization, industry, health professional, etc.) when responding.

The following is a list of acceptable submission formats: Word, WordPerfect, PDF, Txt or RTF.