A National Strategy

5.0 A Framework for Action

Tobacco control initiatives over the past three decades have been directed primarily, although not exclusively, to the creation of social environments that support smoke-free living, and to influencing individual decisions about smoking and smoking behaviours. Action has been taken at the national, provincial/territorial, regional and community levels, through many governments and non-governmental organizations. Having shared responsibility for tobacco control has provided Canada with a history of different jurisdictions leap-frogging forward to provide leadership and models for action.

Some major activities to date have included:

• Informing Canadians about the health effects of smoking and second-hand smoke;
• Providing programs to support those who choose to quit smoking;
• Reducing access to tobacco products by minors (through federal and provincial laws);
• Deterring smokers by increasing product pricing through taxation (at the federal and provincial/territorial level);
• Placing restrictions on where smoking may occur (through federal and provincial/territorial laws and municipal bylaws; and through organizational policy);
• Restricting tobacco product advertising and promotion;
• Encouraging Canadians to become involved in creating social environments that support smoke-free living;
• Educating and building skills among school-age Canadians;
• Requiring tobacco companies to release information on the composition of cigarettes and cigarette smoke; and
• British Columbia challenged the tobacco industry to recover the costs due to tobacco related illnesses.

All of these initiatives have had a measure of success and should be continued, although the focus may shift to reflect the current learnings. For example, Canadians have high levels of awareness that smoking is bad for their health, but have limited understanding of the specific risks of smoking and second-hand smoke and smokeless tobacco.

There is an emerging interest in taking actions directed specifically at the tobacco industry. Recent access to thousands of tobacco industry documents has created public awareness about the strategies and tactics of the tobacco industry. In the United States, for example, specifically questions arise as to how young smokers are recruited. Accordingly, it is appropriate to examine how the tobacco industry has dealt with Canadians and whether they have exhibited fair play or responsible corporate conduct. This examination is a necessary exercise because, unlike other legally available consumer products, tobacco is inherently hazardous and addictive.⁽²⁸⁾, ⁽²⁹⁾

5.1 Goals for a Renewed Tobacco Control Strategy

The epidemic of death and disease among Canadians resulting from tobacco use, can only be stopped by ending the use of tobacco products. It is recognized it will take several decades to achieve the vision of a smoke-free society.⁽³⁰⁾ However, taking collaborative action can lead to significant progress toward that objective. The four goals and five strategic directions presented in this paper provide a framework for continuous and increasing efforts by governments and non-governmental organizations, individuals, health intermediaries and communities.

The four goals are:

• Prevention: Preventing tobacco use among young people.
• Cessation: Persuading and helping smokers to stop using tobacco products.
• Protection: Protecting Canadians by eliminating exposure to second-hand smoke.
• Denormalization: Educating Canadians about the marketing strategies and tactics of the tobacco industry and the effects the industry's products have on the health of Canadians in order that social attitudes are consistent with the hazardous, addictive nature of tobacco and industry products.⁽³⁾ (See also Appendix C).

5.2 Strategic Directions

Recognized effective tobacco control interventions and actions rarely address only one of the prevention, cessation, protection, or denormalization goals. An intervention that primarily addresses one goal also contributes to achieving other goals, or the action may be broad based and support three or four goals. An example of the former is restrictions on smoke-free places. Such policies or legislation primarily address protection from second-hand smoke. However, such restrictions also support prevention by reducing role modelling of smoking as socially acceptable behaviour, encourage smokers to reduce smoking, and are an environmental support for those who are trying to, or have quit smoking. Other activities, such as researching the relationship between smoking and other determinants of health, or building community coalitions, support all four goals.

Similarly, actions specifically directed at youth have not been singled out as these are not necessarily the most effective approaches to reduce tobacco uptake and use among young people. Tobacco control initiatives that have proven to be effective, focus not only on youth but all aspects of society in which young people live. There are actions that affect all people but have greater impact on young people. An example is increasing the price of tobacco through taxation, which affects the smoking patterns of all smokers, but youth significantly more than adults.

For this reason, actions are presented by strategic directions which help identify the type of intervention needed.

This section identifies five strategic directions to achieve the goals of prevention, cessation, protection and denormalization :

Policy and Legislation:

To ensure coordination of tobacco policy across sectors, and implementation of organizational policies and legislation across sectors that support reducing tobacco use.

Public Education:

To make available and accessible information, services and programs about tobacco and tobacco related issues, which address prevention, cessation, protection and denormalization.

Industry Accountability and Product Control:

To regulate the manufacturing, marketing, and sale of tobacco products to reduce addiction and disease.

Research:

To increase knowledge of tobacco and tobacco use, the tobacco industry, effective interventions for tobacco control and health and socioeconomic impacts of tobacco use.

Building and Supporting Capacity for Action:

To increase the ability of individuals, health intermediaries and communities at the national, provincial/territorial and local levels to take action.

5.3 Priorities for Action Under Each Strategic Direction

The priorities for action outline a comprehensive, long-term strategy based on practices, and interventions known to be effective. While some of these actions have been implemented, the scope and depth varies across Canada.

No one type of organization could, on their own, undertake all these activities. Effective tobacco prevention control requires integration, coordination and complementarity of a diverse array of strategies at the local, provincial/territorial, national and international levels, with the participation of a range of organizations.

The strategic directions provide the basis for planning, implementation and evaluation of collaborative action on tobacco control at the local, provincial/territorial and national levels by governments and non-governmental organizations to achieve the goals. Strategic directions should be reviewed periodically to determine what changes should be made to reflect socioeconomic, health promotion, research, and industry developments.

Specific detailed plans from partners need to ensure that program activities are based on best practices, acknowledge the needs of Canadians (such as addressing gender-sensitive issues) and integrate evaluation of interventions as an ongoing part of their activity. While each partner will make a contribution to the overall strategy, there needs to be a co-ordinating mechanism to ensure that collective action is addressing all the priorities for action.

Policy and Legislation⁴

• Recognizing that higher prices are a deterrent for tobacco use, contribute to a long-term joint federal-provincial-territorial strategy for increasing taxation for tobacco products across Canada.
• Enforce tobacco control legislation by adopting a comprehensive approach which includes traditional enforcement measures, as well as citizen engagement to influence community practices.
• Develop legislation and policies to support protection from second-hand smoke in public places, the workplace and schools.
• Encourage and support pro-health policies on tobacco among all media in order to influence editorial and advertising policies to be supportive of smoke-free living.
• Support the development of the World Health Organization (WHO) Framework Convention on Tobacco Control. (See Appendix D for information about the Framework).
• Participate in international policy initiatives to coordinate control of the transnational tobacco industry.
• Develop policies to provide adequate funding for tobacco control initiatives.
• Align policies across relevant departments/ministries such as health, finance, agriculture, trade, justice and education to support the health agenda related to tobacco control.

Public Education (Information, Mass Media, Programs and Services)

• Develop public education campaigns that denormalize the tobacco industry and tobacco products, and the consumption of tobacco products, exposing the strategies and tactics of the industry, and informing the public of the true costs and the health impact of tobacco use.
• Identify gaps in existing programs, relevant to specific populations, e.g., First Nations, Metis and Inuit peoples, Francophones, youth, ethnic groups, pregnant women and develop and implement evidence-based programs involving these populations.
• Provide Canadians with relevant information concerning tobacco products, such as ingredients, constituents of smoke, etc.
• Provide Canadians who want to stop smoking, including lower income groups, with access to appropriate smoking cessation programs, supports, and nicotine replacement therapy when appropriate and explore the feasibility of establishing a national 1-800 counselling line.
• Reach and involve youth in a range of programs and activities in a variety of settings, including school based prevention programs. Youth can also be reached through a range of other settings such as youth groups, teen wellness centres, community centres, youth at risk programs, cultural centres, detention centres, group homes, etc.

Industry Accountability and Product Control

• Establish comprehensive restrictions on brand name advertising of tobacco products, and related promotion and sponsorship.
• Encourage the development of enabling legislation to recover from tobacco companies the health care costs resulting from tobacco product use.
• Require the tobacco industry to report on: marketing research, financial statements, sales volumes, toxic constituents of tobacco smoke from each of its products, activities and expenditures on marketing, promotion and sponsorship, etc.
• Develop a strategy for the implementation of product standards to reduce addiction and disease from tobacco products.
• Continue to introduce measures to make tobacco packaging more informative.

Research (Research, Evaluation, Monitoring)

• Analyze and disseminate research findings to support the
• development and adoption of best practices.
• Examine a range of tobacco use cessation strategies, including comprehensive strategies that match clients to appropriate interventions, and recruitment strategies to increase the number of tobacco users who access cessation supports. This includes research to develop effective cessation programs for youth. Programs should also identify when nicotine replacement therapy (NRT) is appropriate.
• Research to better understand interactiveness among interventions, with a view to developing guidelines for the best mix of interventions for optimal impact for prevention, cessation, protection, and denormalization.
• Research the "world" (culture) in which youth live, to understand the multiple and varied factors and influences that contribute to youth uptake of tobacco use.
• Research to better understand the impact of health determinants on tobacco use.
• Research to better understand the potential for use and abuse of nicotine available in products other than tobacco products, e.g., nicotine replacement therapy.
• Research how product modification (in nicotine/tar, content, delivery systems, additives, taste, size, etc.), including the examination of unintended negative effects, can change use patterns and reduce addiction and disease.
• Monitor knowledge, attitudes and behaviour about smoking and second-hand smoke among children, youth and adults on an ongoing basis.
• Monitor and evaluate intervention activities and outcomes on an ongoing basis. In some cases, it may be necessary to establish a baseline.
• Monitor emerging issues, such as changing tobacco industry marketing practices, availability and use of nicotine replacement products, etc.

Building and Supporting Capacity for Action

• Build capacity of communities by providing training, resources, and technical expertise in areas such as best practices, social marketing, communications, partnerships, advocacy, research and evaluation.
• Ensure access to information on tobacco, including through the National Clearinghouse on Tobacco and Health.
• Assist Canadians to acquire the knowledge and skills necessary for action on tobacco control.
• Support coalition development, including those specifically for Francophones, Aboriginal peoples, and minority ethnic groups.
• Hold regular tobacco conferences or workshops nationally/regionally to promote knowledge development and networking.
• Involve youth as advisors, activists and peer models.
• Involve people who are role models for children and youth, including parents and other care givers, school teachers and sports leaders, visitors to the family home, and older siblings.
• Ensure the curriculum for health and other relevant professionals includes tobacco issues and relevant professional practices.
• Promote the implementation of practice guidelines for health professionals to identify, counsel and monitor patients who use tobacco.

3. This includes a broad understanding of the health, social and economic burden resulting from the use of tobacco, and practices undertaken by the industry to promote its products and create social goodwill towards the industry.

4. Additional policy and legislative initiatives are placed under the strategic directions of "Industry Accountability" and "Product Control".