Perspective on Cancer Control: Whither the Tobacco Endgame for Canada?

Aims: In 2014, in response to evidence that Canada's tobacco use would lead, inexorably, to substantial morbidity and mortality for the foreseeable future, a group of experts convened to consider the development of a "Tobacco Endgame" for Canada. The "Tobacco Endgame" defines a time frame in which to eliminate structural, political, and social dynamics that sustain tobacco use, leading to improved population health. Strategies: A series of Background Papers describing possible measures that could contribute to the creation of a comprehensive endgame strategy for Canada was prepared in advance of the National Tobacco Endgame Summit hosted at Queen's University in 2016. At the summit, agreement was reached to work together to achieve <5% tobacco use by 2035 (<5 by '35). A report of the proceedings was shared widely. Achievements: Progress since 2016 has been mixed. The Summit report was followed by a national forum convened by Health Canada in March 2017, and in 2018, the Canadian Government adopted "<5 × '35" tobacco use target in a renewed Canadian tobacco reduction strategy. Tobacco use has declined in the last 5 years, but at a rate slower than that which will be needed to achieve the <5 by '35 goal. There remain > 5 million smokers in Canada, signaling that smoking-related diseases will continue to be an enormous health burden. Furthermore, the landscape of new products (e-cigarettes and cannabis) has created additional risks and opportunities. Future directions: A bold, reinvigorated tobacco control strategy is needed that significantly advances ongoing policy developments, including full implementation of the key demand-reduction policies of the WHO Framework Convention on Tobacco Control. Formidable, new disruptive policies and regulations will be needed to achieve Canada's Endgame goal.

Initiation or cessation: what keeps the prevalence of smoking higher in Quebec than in the rest of Canada? / Initiation à l'usage du tabac ou arrêt du tabac : comment expliquer une prévalence supérieure du tabagisme au Québec en comparaison du reste du Canada?

INTRODUCTION: We compared smoking initiation and cessation in Quebec versus the rest of Canada as possible underpinnings of the continued higher cigarette smoking prevalence in Quebec. METHODS: Data were drawn from the Canadian Community Health Survey (CCHS). We compared average and sex-stratified prevalence estimates of (1) current cigarette smoking in persons aged 15 years and older; (2) past-year initiation of cigarette smoking in those aged 12 to 17 and 18 to 24 years; and (3) past-year cessation in adults aged 25 years and older in Quebec versus the other nine Canadian provinces in each two-year CCHS cycle from 2007/08 to 2017/18. RESULTS: The prevalence of current smoking decreased from 25% to 18% among adults aged 15 years and older in Quebec from 2007/08 to 2017/18, and from 22% to 16% in the rest of Canada. Initiation among those aged 12 to 17 years decreased from 9% to 5% in Quebec, and from 7% to 3% in the rest of Canada. Neither initiation among people aged 18 to 24 (at 6% and 7%, respectively) nor cessation among adults aged 25 and older (approximately 8%) changed over time in Quebec or in the rest of Canada. In each two-year CCHS cycle, past-year initiation among those 12 to 17 years of age was consistently higher in Quebec than in the rest of Canada, but there were no substantial or sustained differences in initiation among people aged 18 to 24 or in past-year cessation. Findings were similar when stratified by sex. CONCLUSION: Higher levels of smoking initiation among youth aged 12 to 17 years could be a proximal underpinning of the continuing higher prevalence of smoking in Quebec versus the rest of Canada.

Mind the Gap: Disparities in Cigarette Smoking in Canada.

OBJECTIVES: The Government of Canada has proposed an 'endgame' target for cigarette smoking that aims to reduce prevalence below 5% by 2035. To meet this difficult goal, it will be necessary to identify populations where interventions will (1) have the greatest impact in reducing the number of smokers and (2) have the greatest impact in addressing smoking disparities. METHODS: Using data from the Canadian Community Health Survey, smoking prevalence was estimated for populations that differed with respect to demographic, substance use, and mental health factors. Risk difference, relative risk, and attributable disparity number, which describes the magnitude of the potential impact if the disparity were addressed, were calculated for each group. RESULTS: The strongest disparities (relative risk ⩾ 2) were associated with immigration status (for women), substance use, marital status, and lifetime experience of mental health or substance use disorders. The smallest disparities (relative risk ⩽ 1.5) were associated with sexual orientation, household income, immigration status (men), and province of residence. The groups with the largest attributable disparity number were among those who used cannabis, and those who were not immigrants, not married, and white. CONCLUSIONS: Disparities which were both strong and had a large potential impact on prevalence overall were found for populations facing mental health and substance use concerns. Differences in rankings were found depending on the scale of the measure. Addressing disparities in smoking rates is an important component of developing tobacco endgame strategies.

Cigarette pricing 1 year after new restrictions on tobacco industry retailer programmes in Quebec, Canada.

OBJECTIVES: Over the past 15 years, tobacco companies operating in Canada abandoned their long-standing unitary price model in favour of price differentiation. Concerns about low cigarette prices were identified by the Quebec government in 2015 when it introduced restrictions on the types of incentives that tobacco manufacturers may offer to retailers. This study sought to explore cigarette prices in Quebec 1 year after these restrictions came into effect. METHODS: Details on cigarette trading terms and programmes were obtained from websites maintained by retailer groups. Visits were made to tobacco retailers in four Quebec municipalities in the autumn of 2017. The price displayed for cigarettes was observed and recorded in 273 convenience stores. RESULTS: Two forms of price differentiation were observed. The first was price-segmentation between brands, reflected in a difference of $3 or more in the average displayed price between premium and discount brands of each manufacturer (ie, $10.48 vs $7.43 for a package of 20 cigarettes of the most and least expensive brands sold by Philip Morris International). Price localisation was also observed, reflected in a $2 range of prices between retail outlets for the same package of cigarettes. Even among outlets of a given chain of convenience stores, the price of the least expensive brands varied by more than $1 per package. The size of the variance in prices rivals or exceeds the size of tobacco tax increases in Quebec over the past decade. CONCLUSIONS: Recent restrictions on tobacco industry incentive programmes for retailers have not ended price differentiation. Tobacco manufacturers' and retailers' pricing policies continue to provide price-sensitive smokers with ways to avoid the impact of tobacco tax increases.

Tobacco control and the World Trade Organization: mapping member states' positions after the framework convention on tobacco control.

OBJECTIVE: To note the frequency of discussions and disputes about tobacco control measures at the World Trade Organization (WTO) before and after the coming into force of the Framework Convention on Tobacco Control (FCTC). To review trends or patterns in the positions taken by members of the WTO with respect to tobacco control measures. To discuss possible explanations for these observed trends/patterns. METHODS: We gathered data on tobacco-related disputes in the WTO since its establishment in 1995 and its forerunner, the General Agreement on Tariffs and Trade (GATT), prior-FCTC and post-FCTC. We also looked at debates on tobacco control measures within the WTO more broadly. To this end, we classified and coded the positions of WTO member states during discussions on tobacco control and the FCTC, from 1995 until 2013, within the Technical Barriers to Trade (TBT) Committee and the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Council. RESULTS: There is a growing interest within the WTO for tobacco-related issues and opposition to tobacco control measures is moving away from high-income countries towards low(er) income countries. CONCLUSIONS: The growing prominence of tobacco issues in the WTO can be attributed at least in part to the fact that during the past decade tobacco firms have been marginalised from the domestic policy-making process in many countries, which has forced them to look for other ways and forums to influence decision-making. Furthermore, the finding that almost all recent opposition within the WTO to stronger tobacco regulations came from developing countries is consistent with a relative shift of transnational tobacco companies' lobbying efforts from developed to developing countries.

The 'common knowledge' of Quebecers: quantifying the evidence of historians testifying for defendant tobacco companies.

The 'common knowledge' defence is a legal strategy which has been successfully used by defendant tobacco companies to avoid legal responsibility for the harms caused by smoking. Tobacco companies have hired professional historians to try to persuade courts about a longstanding high level of public awareness regarding the risks of tobacco use. To support this argument, they have used archival news clippings and media reports. Two historians were hired by tobacco companies to offer this defence during a recent class action trial in Canada, following which they were required to submit to the court the collection of media materials which had been gathered by history students to assist their testimony. Included in this collection were tobacco advertisements and other news items about tobacco products which the students had inadvertently also collected. Quantifying this collection reveals that even by the tobacco industry's own construct, the information environment surrounding Quebec smokers in the middle 20th century included more prosmoking messages than information about the risks of smoking.

Supply-side options for an endgame for the tobacco industry.

Although governments have imposed controls on tobacco company behaviour, they have not yet aligned tobacco industry goals to public health objectives. As a result, tobacco companies have delayed or diminished the impact of imposed public health measures and have not contributed to curbing the epidemic of tobacco use. Over the past decade, several regulatory innovations have been proposed as ways to better align industry actions with public health needs, but none have been put in place. These policy suggestions share the goal of providing a supply-side complement to conventional demand reduction strategies, but they differ in the assumptions they make and in the regulatory and governance approaches they take. Similarly, differing views on ideology and political context within the tobacco control community and between governments may hinder the establishment of a global consensus on the ideal supply-side intervention. A government willing to implement innovative supply-side strategies as part of a tobacco control endgame may not require such consensus if factors specific to their national public health systems or political contexts are supportive.

Follow the money: how the billions of dollars that flow from smokers in poor nations to companies in rich nations greatly exceed funding for global tobacco control and what might be done about it.

The business of selling cigarettes is increasingly concentrated in the hands of five tobacco companies that collectively control almost 90% of the world's cigarette market, four of which are publicly traded corporations. The economic activities of these cigarette manufacturers can be monitored through their reports to shareholders and other public documents. Reports for 2008 show that the revenues of these five companies exceeded $300 billion, of which more than $160 billion was provided to governments as taxes, and that corporate earnings of the four publicly traded companies were over $25 billion, of which $14 billion was retained after corporate income taxes were paid. By contrast, funding for domestic and international tobacco control is not reliably reported. Estimated funding for global tobacco control in 2008, at $240 million, is significantly lower than resources provided to address other highmortality global health challenges. Tobacco control has not yet benefited from the innovative finance mechanisms that are in place for HIV/AIDS, tuberculosis and malaria. The Framework Convention On Tobacco Control (FCTC) process could be used to redirect some of the earnings from transnational tobacco sales to fund FCTC implementation or other global health efforts.

Secret science: tobacco industry research on smoking behaviour and cigarette toxicity.

A lack of scientific data remains the principal obstacle to regulating cigarette toxicity. In particular, there is an immediate need to improve our understanding of the interaction between smoking behaviour and product design, and its influence on cigarette deliveries. This article reviews internal tobacco industry documents on smoking behaviour research undertaken by Imperial Tobacco Limited (ITL) and British-American Tobacco (BAT). BAT documents indicate that smokers vary their puffing behaviour to regulate nicotine levels and compensate for low-yield cigarettes by smoking them more intensely. BAT research also shows that the tar and nicotine delivered to smokers is substantially greater than the machine-smoked yields reported to consumers and regulators. Internal documents describe a strategy to maximise this discrepancy through product design. In particular, BAT developed elastic cigarettes that produced low yields under standard testing protocols, whereas in consumers' hands they elicited more intensive smoking and provided higher concentrations of tar and nicotine to smokers. Documents also show that BAT pursued this product strategy despite the health risks to consumers and ethical concerns raised by senior scientists, and paired it with an equally successful marketing campaign that promoted these cigarettes as low-tar alternatives for health-concerned smokers. Overall, the documents seem to reveal a product strategy intended to exploit the limitations of the testing protocols and to intentionally conceal from consumers and regulators the potential toxicity of BAT products revealed by BAT's own research. Tobacco industry research underscores the serious limitations of the current cigarette testing protocols and the documents describe deceptive business practices that remain in place.