dangers of tobacco use emerged, but the epidem- ... years) among 100 000 Canadian boys 15 years old who smoke. .... Imasco, the parent of Imperial Tobacco.
Canadian physicians and tobacco Andrew Pipe, MD; James Walker, MD, FRCPC; David Esdaile, MD, CCFP in two major reports.2'3 Nicotine addiction is as powerful as cocaine or heroin addiction.2 The destructive effects of tobacco are less immediate, but there is little doubt which substance causes the greatest human carnage. Canadian physicians are only too familiar with the variety of conditions that inevitably follow tobacco addiction and with the frustrations that often accompany attempts to counsel patients about their tobacco use. Certain principles regarding smoking cessation seem clear. Smokers are victims, not villains, and a positive, supportive approach is indicated. Patients should decide why they want to quit before deciding how. The difficulties associated with cessation should not be underestimated by the physician. A well-thought-out strategy can be invaluable. Help from family and friends is important. Nicotine-containing gum, when properly prescribed and used, can significantly enhance the likelihood of success, especially in those highly addicted to tobac30 co.4 The chances of success increase with each 25959 attempt at quitting. Attempts to assist individual smokers with their 25 addiction, though an important professional responsibility, may not ultimately be as productive as activities designed to prevent youngsters from becoming smokers and to limit the availability and acceptability of tobacco products. Many physicians have recognized that the most effective way to deal with the tobacco issue is to focus on the true villain: Z: 10the tobacco industry. While serving the needs of Oaddicted patients we must realize the limitations of that approach alone and ensure that practitioners, professional associations and the main voluntary 18089 health organizations use their credibility, their energies and their resources to secure the development of "healthy public policy." Legislation and appropriate regulations to control the tobacco industry and the will ultimately accomplish far Fig. 1: Projected causes of premature death (before age 70 spread of its products tobacco-related diseases in battle the more against years) among 100 000 Canadian boys 15 years old who for our patients in can we provide anything than smoke. AIDS = acquired immunodeficiency syndrome. Rerooms. and clinics operating produced with modifications from Mao et all and permisEvents in Canada over the past 3 years have sion from the publisher. It is almost 30 years since the first evidence of the
dangers of tobacco use emerged, but the epidemic of tobacco-related diseases continues to grow. Tobacco is now the leading cause of preventable disease, disability and death in Canada. The magnitude of the health problem posed by nicotine addiction can be readily understood by an examination of the projected causes of premature death among 100000 Canadian boys 15 years old who smoke (Fig. 1).' No one can deny that efforts to eliminate the spread and consumption of tobacco products should become a public health priority. Tobacco is the -only consumer product that is lethal when used as intended and has no valid benefit other than the prevention of withdrawal symptoms resulting from the addiction it creates. The addictive nature of tobacco (more specifically of nicotine) has been thoroughly documented recently
0
0
1
Smoking
accident
Suicide
Murder
AIDS
Drug abuse
Cause of death
Drs. Pipe and Walker are former chairmen and current directors of Physicians for a Smoke-Free Canada; Dr. Esdaile is the chairman.
Reprint requests to: Physicians for a Smoke-Free Canada, PO Box 4849, Stn. E, Ottawa, ON KIS SJI -
For prescribing information see page 239
CAN MED ASSOC J 199 1; 144 (2)
demonstrated the power of advocacy as a public health tool. The Tobacco Products Control Act5 and the Non-smokers Health Act,6 both passed in 1988, are significant achievements in the struggle to control tobacco advertising and to provide protection against the hazards of secondhand smoke. Despite the passage of such landmark legislation the federal government has been remarkably delinquent in developing, promulgating and enforcing the regulations made possible by this legislation. The tobacco industry - which continues to deny any link between its products and disease - is a powerful political force in Canada and until only recently has been virtually unopposed. Regrettably it is still successful in impeding the implementation of public health measures that would control its lethal products. The next time they are confronted with a tobacco victim Canadian physicians might recall that Mr. William Neville, a leading figure in the Conservative party and a close friend of the prime minister, is the president of the Canadian Tobacco Manufacturers Council. Mr. Neville has been very successful in representing the interests of that industry. We find it offensive that he and his colleagues are paid lavish salaries to do everything in their power to forestall the development of laws to control the tobacco industry. Patients with tobacco-related diseases have no such well-paid, highly placed people acting on their behalf. At present, there is an unfortunate degree of complacency among many in the health community who view the battle as almost over, the turning point being the passage of the 1988 legislation. Such a perspective ignores the facts that the legislation is being vigorously challenged by the industry, appropriate regulations have not been developed or have been seriously delayed, existing regulations are being evaded by the industry and the rates of smoking among the young, particularly young women, are
increasing.' It is naive to assume that times and trends have changed, that little more needs to be done. Notwithstanding the strenuous denials of the tobacco manufacturers minors are still their favoured targets. Documents produced in court during the industry's challenge to the existing legislation detail the advertising strategies designed to render tobacco products attractive to the young. In many areas of Canada "kiddy-packs", small packages of cigarettes designed to be affordable to youngsters, have been introduced. Some store owners even sell individual cigarettes to their young customers. The Tobacco Restraint Act8 (1908) forbids the sale of tobacco to minors; the fine for a first offence is a maximum of $10! Tough, realistic legislation is needed to eliminate the promotion and sale of tobacco products to the young. 138
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It seems clear that governments have no longterm, comprehensive programs to deal with the problems posed by tobacco, despite the best advice of numerous task forces and committees. The federal government has allocated only $3.3 million in 1991 to deal with tobacco (Neil Collishaw, Department of National Health and Welfare: personal communication, 1991) and an industry that earned $260 million from selling tobacco to minors in 1986 (David Sweanor, Non-smokers Rights Association: personal communication, 1991). An increase of 10% in the price of tobacco causes a decrease in consumption of 4% overall but 12% among teenagers.9 '0 Quite clearly an increase in the level of taxation of tobacco products is a powerful determinant of smoking behaviour among the young and should be advocated at every opportunity. Surprisingly, perhaps, polls have demonstrated that most smokers and nonsmokers are in favour of such increases, particularly if the revenues were to be used for health purposes. Many tobacco-control authorities feel that tax increases are one of the most effective ways to change smoking behaviour. Cigarettes are cheaper today, relatively speaking, than they were 25 years ago. Clearly significant gains have been made in the past few years, and smoking is now considered socially unacceptable. That in itself may be the most powerful modifier of smoking behaviour and as such is a trend that must be accelerated. For this reason and because of concerns about exposure to secondhand smoke the development of smoke-free environments should be encouraged. All public places should be smoke-free. Regrettably, health care facilities have shown minimal leadership in this regard; many offices of private practitioners are in buildings where smoking is permitted and tobacco products are sold. (Doctors may wish to ensure that leases with restaurants, stores and other businesses in physician-owned buildings specify that tobacco products are not to be sold on the premises.) Pharmacies account for almost 25% of all cigarette sales in Canada."I The incongruity of such a situation is obvious. Fortunately, in several provinces the pharmacists themselves are declaring that the selling of tobacco products is incompatible with the professional standards and practices of pharmacy. The colleges of pharmacy in Alberta, Ontario and Quebec are currently developing regulations that will forbid the sale of tobacco products in drugstores in the near future. Not surprisingly, this is a development strenuously opposed by one of Canada's largest chains, Shoppers Drug Mart, which is owned by Imasco, the parent of Imperial Tobacco. The great pathologist Virchow once observed that there were two causes of disease, one biologic and the other political. It is our view that political,
not clinical, activity will be more successful in conquering tobacco-related diseases. Physicians as individuals and as members of broadly based organizations like the CMA or of issue-oriented groups like Physicians for a Smoke-Free Canada (PSC) must make a concerted commitment to deal effectively with this modem epidemic. If each of the 60 000 Canadian physicians were to make a one-time donation of $50 this would produce a $3 million trust fund, generating interest in excess of $300 000 annually, which could be specifically allocated to the battle against the tobacco epidemic. In its short life the PSC has been instrumental in ending tobacco sponsorship of amateur sports events, in lobbying for the passage of the Tobacco Products Control Act and the Non-smokers Health Act, in spearheading the movement to end the sale of tobacco products in pharmacies (by publicly praising and promoting those pharmacies that chose not to sell tobacco products), in lobbying for increased levels of tobacco taxation and in speaking out clearly and unequivocally as physicians on matters pertaining to tobacco and health. At the same time our organization has recognized the value of partnerships. Much of its recent success is attributable to the degree to which various health organizations have been able to work together. The Canadian Cancer Society, the Non-smokers Rights Association, the CMA, the Canadian Council on Smoking and Health and the PSC have shared strategies, pooled resources and expertise and developed a coordinated approach in supporting the passage of tobacco legislation. This coalition has become the model for nations attempting to develop similar legislation. The battle against tobacco is truly worldwide, especially since the tobacco companies have chosen to aggressively market their products in Third World nations. Success in the battle against tobacco will not
come easily, but it will come. We do not need more pamphlets or slogans. We can do without the hollow rhetoric of politicians preaching prevention while steadfastly failing to exercise their responsibilities. We require carefully considered, forthright tobaccocontrol programs, politicians who respond to health interests rather than to the interests of the tobacco industry and physicians who, in the best traditions of their profession, will speak out forcefully and thoughtfully for public health.
References 1. Mao Y, Morrison H, Nichol RD et al: The health consequences of smoking among smokers in Canada. Can J Public Health 1988; 79: 390-391
2. Nicotine Addiction: the Health Consequences of Smoking, a Report of the US Surgeon General, US Dept of Health and Human Services, Rockville, Md, 1988 3. Tobacco, Nicotine and Addiction, Royal Society of Canada, Ottawa, 1989 4. Tonnesen P, Fryd V, Hansen M et al: Effect of nicotine chewing gum in combination with group counseling on the cessation of smoking. N Engl J Med 1988; 318: 15-18 5. Tobacco Products Control Act, rev Stat Ont, 1988, ch 20 6. Non-smokers Health Act, rev Stat Ont, 1988, ch 21 as amended 1989, ch 7 7. Smoking Behaviour in Canadians, 1986, Health Services and Promotion Branch, Dept of National Health and Welfare, Ottawa, 1988 8. Tobacco Restraint Act, rev Stat Ont, 1908, ch T-9, sec 1 9. Lewit EM, Coate D: The potential for using excise taxes to reduce smoking. J Health Econ 1982; 1: 121-145
10. Grossman M: Health benefits of increases in alcohol and cigarette taxes. Br J Addict 1989; 84: 1193-1204 11. Collishaw NE, Rogers B: Tobacco in Canada. Can Pharmaceut J 1984; 1 17: 147-150
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