How did you celebrate World No Tobacco Day 2023? In Ottawa, the federal government marked the occasion with an announcement that new health warnings will soon be required for all cigarettes legally purchased in Canada. Until now, smokers have had to make do with grotesque photos of diseased lungs and other cadaverous body parts on their cigarette packages. Starting next year, however, printed slogans such as “Poison in every puff” will be mandated on each individual cigarette. This regulatory innovation “will make it virtually impossible to avoid health warnings,” Health Canada declared in its press release. Carolyn Bennett, then-federal Minister for Mental Health and Addictions, called it a “bold step” for Canada, the first country in the world to take such action.
Bennett’s move (she was subsequently shuffled out of cabinet) was loudly praised by a familiar set of anti-tobacco lobby groups in the Health Canada news release. “Requiring warnings directly on cigarettes – the first country to do so – will help to reduce their appeal, particularly for youth,” the Canadian Lung Association crowed. The Canadian Cancer Society called it a “precedent setting measure that will reach every person who smokes with every puff.” The Heart & Stroke Foundation declared itself “thrilled” at the prospect. The shared assumption was that an impossible-to-overlook warning affixed to every cigarette will finally convince die-hard smokers to give up the demon weed once and for all.
Despite all the thrills and self-praise, however, ample evidence suggests the new policy will be largely ineffective at further reducing Canadians’ dependence on cigarettes. Cigarette warnings have been a part of federal tobacco policy since 1972; the benefits arising from informing smokers of the risks they face “with each puff” has long since been achieved. Continued faith in the power of new printed warnings requires a grave misreading of smokers’ motivations and willpower – as well as willful ignorance about the size of the black market in tobacco.
This doesn’t mean, however, that it is impossible to help committed smokers improve their health. Ottawa had numerous other options available for announcement on World No Tobacco Day 2023 that, based on international experience and scientific evidence, would have a much better chance of reducing Canadians’ consumption of carcinogenic materials. But doing so would require that Ottawa adopt a radically new approach towards tobacco products – essentially reversing over 50 years of regulatory policy. And negotiating such a change appears beyond the ability of the federal Liberals.
Know Your Smokers
As recently as the mid-1960s, half of adult Canadians smoked – including many pregnant women. Driven by changing social norms, broadening public awareness of the health risks and a growing array of restrictive policies at the federal, provincial and municipal levels, that figure has since plunged to around 10 percent of our much larger current population. Health Canada has now set for itself the goal of cutting this rate to 5 percent by 2035. To this end, we can expect more of the same policies we have seen to date.
Under the Justin Trudeau government, federal smoking policy has been driven by two main urges. The first is a conceptualization of smokers as a group of misguided consumers who simply need to be educated about the consequences of their bad habit. It is an approach that seems dramatically at odds with how other social failings are treated in 2023. Consider that hard drug users as well as people who are obese, homeless or unemployed are generally considered to be victims of circumstances beyond their control and in need of direct government aid and support, as well as ample amounts of public sympathy. Yet Ottawa’s latest cigarette warning label gambit is one more iteration of a long-stale plan to stigmatize smokers as weak individuals of low moral character who can be hectored into quitting if simply presented with a sufficiently stern negative message.
No longer a majority: Canadian smoking rates have been in steady decline since the mid-1960s, when half the adult population smoked. (Source of graph: Tobacco Use in Canada: Patterns and Trends, 2022 Edition, by the University of Waterloo)
A lengthy train of scientific and historical evidence suggests it won’t work. Bennett’s replacement as federal addictions minister, Ya’ara Saks, would benefit herself and Canadians by taking the time to understand the true nature of smokers and to confront the nicotine environment of the present day. Most smokers are not willfully self-destructive or stupid. They crave nicotine to satisfy a powerful addiction while hating the health consequences that smoking inflicts upon them.
It is also important to understand that smoking is particularly prevalent within certain sub-populations. These include low-income individuals, Indigenous people, the LGBT+ community, schizophrenics, people suffering generalized anxiety disorder or ADHD, and prisoners. Smoking rates are about one-third for LGBT+ people and 70 percent for schizophrenics. For them nicotine is not only a compulsive habit but a cognitive aid and a balm for anxiety. There is also a significant cohort of middle-aged and elderly smokers who have been addicted to nicotine their entire adult lives. The pool of remaining smokers is thus a heterodox group, and helping them reduce the health effects of their nicotine addiction requires a nuanced and sensitive approach. Of central importance is recognizing that the weaponry to win the battle against smoking-caused cancer, stroke and cardiovascular disease has evolved in significant ways. Evidence from other countries points the way.
Consumption vs. Combustion
Sweden has far and away the lowest lung cancer rate in Europe. Yet Swedish nicotine usage per capita is similar to the European average. The reason is that cigarette smoking is quite rare in that country. Swedes instead tend to consume nicotine through oral smokeless tobacco: either snus (a powdered form of tobacco) or little sachets called “modern oral tobacco.” Both are wedged behind the user’s lip and yield a nicotine flow for about half an hour. While the Swedish nicotine-use rate is above 20 percent, the adult smoking rate is just 5 percent. In other words, Sweden has already reached Health Canada’s smoking rate target for 2035.
All the flavour, none of the combustion: Despite national nicotine consumption rates comparable with other European countries, Sweden’s preference for smokeless tobacco has resulted in a dramatically lower rate of death arising from tobacco use. (Source of graph: No Fire, No Smoke: The Global State of Tobacco Harm Reduction 2018, by Global State of Tobacco Harm Reduction)
Japan offers another example. Cigarette sales have plummeted in that country since the recent arrival of heated tobacco products (HTPs). These battery-driven devices warm a plug of tobacco about half the size of a cigarette, releasing nicotine without burning the tobacco. Research into Japan’s hospital admissions has revealed a “significant reduction in the number of hospitalizations for chronic obstructive pulmonary disease” since HTPs began to supplant cigarettes over the period 2010 to 2019.
These positive results from Sweden and Japan are due to the fact that burning tobacco is what is responsible for most of the toxins and carcinogens associated with the grave health outcomes of smoking. If nicotine consumption can be separated from tobacco combustion, the overall harm of smoking can be substantially reduced.
Lower-risk, non-combustion products available in Canada fall into two broad categories. The pharmaceutical industry offers products that provide varying concentrations of nicotine in the form of chewing gum, nasal sprays, slow-release patches and lozenges. Then there are the many newer replacements for traditional cigarettes. These include the entire “vaping” segment as well as HTPs and modern oral products. E-cigarettes and vaping devices differ from HTPs in that they heat a small amount of nicotine-infused liquid that is then converted into an aerosol that can be inhaled. While traditional cigarette manufacturers are active in the vaping segment, the majority of these products are produced by new entrants to the industry and they offer a wide range of options.
These “reduced-risk” nicotine products do not carry zero risk. But the health risks for cigarette replacements are much lower than from traditional smoking activities, as the examples of Japan and Sweden demonstrate. And there is substantial science to back this up. While nicotine has been implicated in neuro-developmental birth defects, it is not linked to cancer, cardiovascular disease or chronic pulmonary obstruction – the main harms caused by tobacco smoking.
“When nicotine is decoupled from the deadly toxins in inhaled smoke, it is substantially less harmful,” states a 2018 academic study in the Annual Review of Public Health. Its conclusion: “Alternative Nicotine Delivery Systems may provide a means to compete with, and even replace, combusted cigarette use, saving more lives more rapidly than previously possible.” British research published by both Public Health England and the Royal College of Physicians over many years has highlighted the significant differences in toxicity. This evidence shows e-cigarettes have a risk factor of 5 percent relative to combustible cigarettes, as estimated by the toxin content of smoke versus vapour. This is a mammoth difference – 20 to 1.
If smokers could be encouraged to switch to these lower-risk products – as opposed to being hectored into trying, and usually failing, to quit cigarettes altogether – aggregate health outcomes for smokers would be vastly improved. The problem is that encouraging such a shift in consumer behaviour requires a sea-change in smoking culture and regulation in Canada.
Opponents of vaping habitually cite high rates of e-cigarette use among youth and warn that this will ultimately lead to traditional smoking. Both claims are false. The rate of daily e-cigarette use among youth is currently about 5 percent – compared to a 25 percent daily smoking rate as recently as the 1990s. Daily cigarette smoking has plummeted to 1 percent and the sharpest declines have been recorded since the arrival of e-cigarettes in 2019.
Yet we have regular hysteria in the media about an e-cigarette epidemic. Given the aforementioned data from the UK showing that smoking is 20 times more toxic that vaping, today’s young vapers are consuming about 1 percent of the toxins consumed by youths who were smoking in the 1990s. This represents a huge reduction in toxin consumption and nicotine prevalence. While nicotine is dependence-forming and vaping among youth should be discouraged, we cannot disregard the health benefits before us.
It is also untrue that vaping is a gateway to smoking. Smoking among those in their early 20s has fallen more than for any other adult age group – from the highest adult smoking rate to the lowest. If vaping was a gateway, smoking rates should have increased in this age group. Concerns about a gateway are founded on studies showing that youth who vape are more likely to transition to smoking than youth who never vape. The absolute numbers for this are very small, however, and it is also the case that such patterns are equally explicable by common liability. That is, some teens are more prone to take risks of all sorts as compared to others: they are more likely to smoke, to vape, to consume cannabis or have earlier sex than others. The observation that one of these activities precedes another does not establish causation.
The Knowledge Gap
Smokers themselves, unfortunately, are largely unaware of the relative risks of consuming nicotine in different forms. In survey after survey only a handful of smokers appear to understand that e-cigarettes carry such a dramatically lower risk than cigarettes. The Canadian Tobacco and Nicotine Survey (CTNS) 2021 suggests the overall awareness rate among Canadians is less than 10 percent. Were smokers better aware of the relative risks, there is every reason to believe they would have a strong incentive to switch.
This lack of understanding is not restricted to smokers. Research in academic journals has shown that doctors frequently confuse the effects of nicotine with those of smoking and combustion. A poll of over 1,000 U.S. doctors published in the Journal of General Internal Medicine in 2020 found a stunning 80 percent of physicians thought that nicotine directly causes cancer. It does not. An earlier survey found that 60 percent of nurses were similarly mistaken. This lack of awareness, combined with the instinct of doctors to “do no harm”, means that the North American medical profession has not adopted a coherent “low-risk” approach to tobacco use or nicotine addiction.
In similar fashion, numerous medical and health-advocacy groups in Canada have vociferously argued against alternative nicotine devices. Those organizations offering hallelujahs to Ottawa’s new plan to impose warning labels on every cigarette have, in equally noisy fashion, also denounced vaping and e-cigarettes. The Heart & Stroke Foundation, for example, calls vaping “a public health nightmare.” The Canadian Lung Association says it entails “significant health risks.” Only the Canadian Cancer Society properly acknowledges that, “E-cigarettes are less harmful than conventional cigarettes” – but it then offers the rejoinder that “they still cause harm.” This campaign of disinformation impedes efforts to improve the health of smokers. The same goes for provincial regulations, municipal bylaws and corporate policies that conflate smoking with vaping, as witnessed by the proliferation of “No Smoking, No Vaping” signs in public spaces, stores and elsewhere.
Ottawa’s Big Tobacco Problem
Beyond misrepresenting the nature of tobacco use and nicotine addiction, the second main urge behind the federal Liberals’ anti-smoking policy is a near-religious determination to destroy the legal cigarette industry in this country, or what is commonly referred to as Big Tobacco.
There is, of course, no disputing that conventional tobacco products marketed by Big Tobacco have resulted in the premature deaths of countless Canadians over many decades. And in response to this, Canadian governments have implemented numerous controls on smoking. These include the previously-discussed health warnings, smoke-free mandates, workplace bans, exorbitant taxes and minimum age of access requirements. More recently, provincial governments have taken dramatic legal action, with massive lawsuits filed against Big Tobacco in an apparent effort to cover health care costs arising from smoking. The cumulative value of these lawsuits now exceeds $500 billion, with Quebec being the first to win a judgment of $17 billion. As a result of these efforts, the three main tobacco manufacturers in Canada are currently in bankruptcy protection.
A death-match conflict with tobacco companies has thus become the defining characteristic of Canadian governments’ smoking policy. The arrival of new, lower-risk nicotine delivery systems, however, means that policy needs to evolve. But instead of accepting the technological advances of non-combustible nicotine products and working to realize the health benefits that they could deliver, the public health sector and federal bureaucracy have refused to move away from their historic modus operandi of attacking manufacturers. In this context, the planned cigarette stick messages are not just needless overreach, they represent a government that has lost its focus.
A clear example of this dogmatic paralysis can be seen in current efforts that prevent an exchange of knowledge between public health organizations and the manufacturers of alternative products, such as e-cigarettes. The Canadian Public Health Association, for example, forbids representatives from the nicotine industry or individuals who have had any professional role or financial relationship with that industry – including doctors – from registering at their conferences or even listening to what its members promote. Health Canada’s financial support to these conferences thereby actively limits scientific exchange and learning and should be considered counter-productive in 2023. This is especially relevant given how the medical community habitually misunderstands the comparative risks of smoking and vaping.
While Big Tobacco continues to supply its deadly combustible products to consumers – and is making sizeable profits doing so – it is also the case that non-combustible products offer a clear path to improving the health of nicotine-addicted smokers. This is, in fact, what the tobacco manufacturers themselves claim to want. Imperial Tobacco’s website states, for example, that its “ambition is to increasingly transition revenues from cigarettes to non-combustible products over time.”
Meanwhile, public health officials take the stance that anything Big Tobacco wants must be evil by definition. This explains why regulators have repeatedly blocked efforts to promote vaping over smoking through regulations and restrictions on alternative products. Later this month, for example, Quebec will ban flavoured vape products in an effort to limit the appeal of the entire sector. But keep in mind Big Tobacco controls only about one-third of the vaping industry, which is dominated by smaller, newer firms. Traditional animosity towards tobacco firms has thus spilled over to the entire product line.
If public health authorities such as Health Canada allowed what was once Big Tobacco to transform itself into Big Nicotine, the health of Canadian smokers would gradually improve as they were pushed towards lower-risk products such as e-liquids, HTPs, e-cigarettes and nicotine pouches. Doing so, however, would require a major shift in focus by elected politicians, public health officials and regulators. They would have to move away from scolding smokers and seeking to destroy the tobacco industry to actively recommending they try lower-risk alternatives. This appears to be a bridge the Liberals are unwilling or unable to cross.
In any event, eliminating the legal tobacco industry will not put an end to smoking or nicotine addiction in Canada. It will simply force smokers into the hands of the black market, where there is no regard for anyone’s health. It is estimated that one-third of all cigarettes sold in Canada are produced illegally, typically on Indigenous reserves. This figure will only grow as the legal market is further constrained, regulated or bankrupted.
A Better Way to Help Smokers
There are clear alternatives to Ottawa’s Manichean drive to “stick it” to Big Tobacco – alternatives driven by scientific evidence, sound public policy and a basic understanding of human nature. A good place to start is in the UK, which recently held a major public inquiry on tobacco use headed by prominent public health promoter Javed Khan. The Khan Report, formally titled Making Smoking Obsolete, made four main recommendations to eliminate smoking in Britain. “Promote Vaping” was number three. “The government must embrace the promotion of vaping as an effective tool to help people to quit smoking tobacco,” Khan’s summary report states. “We know vapes are not a ‘silver bullet’ nor are they totally risk-free, but the alternative is far worse.”
This has since been turned into active government policy. In April, Conservative Prime Minister Rishi Sunak’s government announced a goal to reduce the national smoking rate to 5 percent by 2030. The main instrument to achieving this is the “Swap to Stop” program under which 1 million vaping starter kits will be handed out to smokers. That’s right: the British government is giving away vaping devices.
Like Canada with its individual cigarette warning labels, the UK government boasts it is the world’s first country to try its particular scheme. But the British effort has a much better chance of success because it is backed by science. It is also a natural complement to other ongoing efforts, such as the presence of vape shops in several UK hospital foyers as well as the advice of many UK doctors who encourage their patients to quit smoking by switching to vaping. This is the path Canada should follow. But to do so, nicotine must be recognized by regulators as a socially-acceptable substance akin to alcohol or cannabis. And treated accordingly.
Instead of making life more miserable for nicotine addicts, governments and the public health sector should be encouraging smokers to take up products that do not involve tobacco combustion. And it shouldn’t matter who produces or sells these low-risk products. It could be a pharmaceutical firm. A local vape supplier. Or even Big Tobacco. If Ottawa had the best interests of Canadian citizens at heart, it would put risk reduction at the centre of its tobacco strategy. Smokers need less dogma and more options.
Ian Irvine is a professor of economics at Concordia University in Montreal. He has acted as a paid consultant to the federal government on alcohol policy as well as Health Canada’s plain packaging project for tobacco products. He has also carried out private sector research funded by the Foundation for a Smoke-Free Canada.
Source of main image: Shutterstock.