Can Endgame Tobacco radically reduce cigarette smoking?
Smoking can feel like a public health success story; an issue in the past. But more than 37,000 Canadians still die of tobacco-related causes every year. A push called Endgame Tobacco has a goal to drive the number of smokers down from around 20 percent today to less than five percent by 2035.
“We’re not talking about prohibition; this doesn’t mean we’re shutting out cigarettes tomorrow,” says Robert Schwartz, Executive Director of the Ontario Tobacco Research Unit. “What we’re saying is, we’re going to diminish the ability of tobacco companies to kill people. That’s radically said, but that is what it is.”
An estimated 100 Canadians die every day from tobacco-related causes.
“It’s something we’ve become immune to,” says Elizabeth Eisenhauer, an oncologist and co-chair of the Canadian Cancer Research Alliance. “That’s equivalent to a plane falling out of the sky every day. How many days would go by before the government closed down that airline?”
Smoking rates hover around 18 percent nationally, with prevalence at a low of 13 percent in British Columbia and a high of 62 percent in Nunavut. Smoking restrictions are working: In the 1960s, tobacco use was around 30 percent. But rates of decrease have remained almost unchanged since 2008.
“We see that all these little measures that are being taken aren’t going to get us there. Plain and standardized packaging – people are hyped about that, it’s important to do, but at the same time, it’s not going to get us there,” Schwartz says.
What makes Endgame Tobacco different is that its goal is more aggressive and to achieve it, the proposed actions are more radical. At an October 2016 summit, the group discussed possibilities such as establishing quotas on the number of cigarettes available for sale and raising the legal age to obtain cigarettes to 21 to bring it in line with proposed age restrictions on the purchase of marijuana.
“They’re measures that are going to disrupt the whole system through which tobacco is marketed and distributed with the aim of decreasing availability,” Schwartz says.
Tactics: What it takes to quit tobacco
Endgame is a global movement, with countries like New Zealand, Scotland and Ireland all trying to lower smoking rates to less than five percent by as early as 2025, and Finland aiming for zero percent by 2040.
Tactics being considered include regulating lower levels of nicotine, introducing a “smoker’s licence” that would be needed to buy cigarettes, selling cigarettes only with a prescription, and raising taxes or setting mandatory price floors for cigarettes to circumvent tiered-pricing introduced by cigarette makers in 2002.
“Ontario and Quebec have the lowest tobacco taxes in Canada, and we know that taxation is a very effective control measure,” Schwartz says. (Coincidentally, Ontario raised taxes on cigarettes by $2 a pack in its latest budget, which takes effect in January 2018. As of April 2017, a carton of 200 cigarettes costs $99.98 in Ontario and $88.67 in Quebec, including taxes, compared to $135.40 in Manitoba, $129.10 in Nova Scotia and $101.65 in Alberta.)
While raising taxes has been thought to fuel black market trade, Schwartz says that’s a myth unsupported by the evidence: he conducted a review of international studies, finding that contraband use is not correlated with changes in tobacco taxes and that even when contraband use rises, it settles again within a few months. (Although the studies did not collect specific data to answer the question of why, possible explanations include a desire to be law abiding; more difficulty in accessing contraband cigarettes and that the quality of contraband cigarettes may be lower.)
Restricting sales to a limited number of stores is another option being considered.
“There is huge excess compared to what we really need,” says Rob Cunningham, senior policy analyst at the Canadian Cancer Society. “Compare it to the number of post offices or liquor stores. Making buying cigarettes so convenient when an ex-smoker has cravings is not helpful. And it makes it more difficult to enforce laws.”
Medicalizing smoking cessation
Endgame’s supporters say preventing people from taking up smoking by limiting access is only half the battle: helping current smokers quit is essential to meeting the less than five by 2035 goal.
“The burden on smokers to fix this themselves has also been challenging because it isn’t their fault that this is happening,” Eisenhauer says. “Many long-term smokers tried cigarettes when they were as young as 14 years old. What informed choices does a 14-year-old make, really?”
Endgame’s proponents are still discussing which interventions might help reach the goal. But they’re also encouraging hospitals and clinicians to adapt the Ottawa Model for Smoking Cessation, which involves developing a system to consistently identify, treat and follow up with all patients who smoke.
“When they are captive in hospital because they’re ill, they’re already going to be a few days without smoking. It’s a great time to intervene,” Eisenhauer says.
The model, currently in use at more than 350 sites across Canada, including emergency rooms and family doctors’ offices, connects patients with counselling and other supports for quitting.
It has been found to result in more quit attempts and more successful attempts: 35 percent of the patients treated via the OMSC were smoke-free at six months, compared with only 20 percent of the participants who received standard care. There were fewer hospital readmissions and emergency room visits among OMSC patients. Most importantly, patients who were treated through the OMSC had a 40 percent reduction in risk of death over two years.
Its success is why Eisenhauer says more physicians need to treat smoking the same as they would any other risk factor, like high blood pressure or high cholesterol.
“The medical profession needs to call it out and offer help,” she says. “They need to see this as something that people, after a certain point, can’t easily free themselves from.”
David Mowat, the Senior Scientific Lead for Population Health at the Canadian Partnership Against Cancer, says provinces also need to make it easier for smokers to access counselling, and to offer more financial help for cessation aids like nicotine replacement therapy and products like Champix, which help control withdrawal symptoms.
While the evidence suggests e-cigarettes are a less harmful alternative to traditional cigarettes, public health officials worry that e-cigarettes – and the legalization of marijuana – will normalize smoking tobacco as well.
Marijuana users are already mixing tobacco in their joints, Schwartz says, opening more risk of addiction.
“That’s how it might move us backwards,” Schwartz says. But there are opportunities too. “If we regulate distribution of marijuana such that it’s not available at every corner store, then that’s a good argument for saying, if you’re that doing for marijuana, which is not as harmful, then of course you have to do it for tobacco.”
Can tobacco truly be eliminated?
Tobacco control advocates are bracing for pushback from the tobacco industry. Endgame Tobacco calls for greater controls on tobacco lobbying, more transparency in government and tobacco industry interactions and immediate divestiture of tobacco-related stocks from all government and quasi-government organizations.
Eisenhauer says there is likely to be resistance to untried, untested means of curbing smoking, like the tactics Endgame Tobacco is considering, pointing to the battles waged over plain packaging and mandatory health warnings.
“If you’re really going to be charting new ground in public health and public health policy, by doing so you are generating the evidence of whether it works,” Eisenhauer says. “Evidence-based policy-making assumes the evidence exists. In some times, in some places you need to move ahead when there is no evidence yet. If it doesn’t work, you and rest of the world have learned.”
Eisenhauer says one group that is unlikely to resist Endgame’s goals are smokers themselves. The 2016 Smokers Survey shows at least half of all smokers are in favour of the initiative’s core tactics, with 80 percent in favour of raising the age to purchase cigarettes and 81 percent supporting reducing nicotine levels in cigarettes.
Half said they would support a complete ban on tobacco within the next 10 years, if given appropriate support to quit.
“Some people are a little bit fearful about being too intrusive, but in fact the people who would be affected most – those people who are already smokers and addicted to tobacco products – most of them don’t want to be that way and most would look forward to opportunities to quit,” Eisenhauer says.
Setting the target at less than five percent – as opposed to zero – would shrink the market to the point smoking is denormalized, leaving little incentive for retailers to sell tobacco. “With time those few die-hard smokers would diminish and there would be very little uptake such that we would move even closer to zero,” Schwartz says. “Note that less than five percent can also mean zero. Setting the goal as ‘less than five percent’ also indicates an understanding for addicted smokers and a signal that this is not about prohibition, which is a non-starter.”
The biggest obstacle will be finding the money and resources needed to the fund the initiative. No cost estimates have yet been generated for the Endgame initiative.
Endgame Tobacco is gaining momentum: the aim of getting to less than five percent by 2035 was recently adopted by the federal government and will be the basis of the new national tobacco control strategy currently being developed.
“Like everything else in the Endgame, it’ll happen if there’s overall leadership in the Endgame,” Mowat says. “Adoption of the goal by the federal government is a big step forward, but now we need a body that’s visible and that’s responsible for reaching the target to generate support and resources to go with it.”
“The amount of progress we’re going to make depends on how quickly we implement measures,” Cunningham says. “The sooner we implement measures, the sooner we’re going to have impact. Lower smoking rates further contribute to even lower smoking rates. It’s a virtuous cycle.”