The National Forum on the Federal Tobacco Control Strategy began very strongly with a clear and articulate message from the Health Minister, Dr.Jane Philpott. She talked about patients in her general practice who had suffered because of tobacco. She told us that she wanted Canada to return to being a world leader in tobacco control. She committed to a target of a smoking rate of 5% by 2035. She asked us to be bold and innovative, to come up with new approaches which may not have been tried before. She reminded us that lives are at stake.
One hundred and ninety-two Canadians died from tobacco use during the two and a half days we spent talking.
With great respect to my new friends in the tobacco control community, I did not hear many bold or innovative ideas during the Forum. I know you are smart, hard-working, underfunded and underpaid, but I worry that you have spent so long working inside cubicles that you have lost your ability to think outside the box! Everyone seemed to be trotting out the tried and true.
The 2016 Tobacco EndGame Summit report stated that “transformative and disruptive ideas” are required to reach our target.
Here are some ideas which could be considered “bold and innovative”. I don’t pretend that any of them are proven or implementable, and maybe some have already tried and failed, but we were asked to “think different”.
TAKE STANDARDIZED PACKAGING TO THE MAX
The idea of standardised packaging is to reduce the value of tobacco brands. The current plan eliminates brand-specific colours and fonts, but still allows for the use of the manufacturer’s brand and the name of a specific product
Taking this approach to its logical conclusion, each brand variant should be assigned a random three-digit number. DuMaurier Regular becomes 482; Export ‘A’ Green gets assigned 936, Canadian Classic White King will only be labelled as 685. Conversion charts would be available online, as an app, and at the point of sale.
Many smokers smoke a pack a day. If packs only contained 19 cigarettes, maybe some of them would eliminate their least-favoured cigarette of the day and only smoke 19, for a 5% reduction in cigarette consumption.
The extra space could be used for a dummy cigarette, a small tube of Tic-Tacs or other candy, or be filled with a nicotine replacement product.
If the number of cigarettes in standard-sized pack declined by one per year, by 2035, twenty-a-day smokers would have to buy seven packs of cigarettes every day.
THE INCREDIBLE SHRINKING CIGARETTE
An alternative way to slowly wean smokers off cigarettes would be to reduce the length of cigarettes by, for example, 1 mm every year. Assuming most people would not smoke more cigarettes to compensate, they would get a lower dose of toxins and nicotine from each cigarette. The initial effect would be minimal, but eventually, cigarettes would be too short to be worth the effort.
SMOKE-FREE RESERVES AND COMMUNITIES
If a super-majority of people (perhaps 80%) in a reserve or community voted in favour of becoming smoke-free they would be given the resources to help everyone quit together. They would be helped to enforce a ban on bringing cigarettes into the community. This concept would work best in remote and fly-in communities where enforcement would be relatively easy.
HOSPITALS BECOME “QUIT FACTORIES.”
All patients scheduled for elective surgery should be required to take a “Quit Course”, explaining the risks of perioperative smoking and the benefits of quitting, before being entered on the surgical waiting list. (Note that actually quitting would not be required, just being made aware of the risks and benefits and being given the time and opportunity to quit).
Hospitals are already non-smoking environments so all smoking inpatients should be offered NRT and given supplies and support to encourage them to continue not to smoke after discharge
MAKE CIGARETTES NORE DEADLY
*** I AM KIDDING *** The idea of brainstorming is to encourage people to voice stream-of-consciousness, unfiltered possibly outrageous ideas and then let others riff off the idea and see if there is something workable in it.
At present, it takes about 40 years of smoking to kill a smoker. If cigarettes were four times as dangerous and killed after ten years of smoking, this would reduce the prevalence by 75%. If the LD50 of cigarettes was 100 cigarettes, and twenty-year-olds suddenly collapsed, dead, on the street, with their last cigarette still between their lips, then the smoking epidemic would look like the opioid crisis. It would garner the same amount of media attention and resources. The problem with cigarettes is that they kill too slowly.
INSTITUTE A SMOKERS ID CARD
To minimise the issues related to fake ID, there should be a specific government-issued photo ID for smokers. In order to get the ID card, smokers would have to watch video testimony from people who had had their health destroyed by tobacco, take a multiple-choice test, and then agree hat they had been informed of the risks of smoking and wanted a smokers’ ID card. The card would have to be scanned with each tobacco purchase, creating a paper trail. Retailers would have to match tobacco sales with verified purchases. This could be used for research into the effectiveness of various smoking cessation strategies. It could also be used to enforce a rationing system for tobacco or to limit young smokers to nicotine-reduced products.
NATIONALIZE THE TOBACCO INDUSTRY
It used to be fashionable for governments to run strategically important businesses directly. Some countries, like Ethiopia, do have a National Tobacco Enterprise. Canada should nationalise the tobacco industry, and then – and this is the important point – put the people who were in charge of the gun registry, e-Health, Ornge and Ontario Hydro in charge of running the tobacco business. Hopefully, it would go bust, or make cigarettes unaffordably expensive.
More seriously, Canada should get out of the tobacco industry, as we got out of mining asbestos.. We should not grow tobacco or manufacture cigarettes. While we continue to do so, we are part of the problem. This would mainly be a symbolic gesture, but it would show the tobacco industry they are not welcome in Canada.
DECLARE TOBACCO A “NOXIOUS WEED.”
There are some weeds which farmers are required to remove from their land. The tobacco plant should be added to this list. As long as we grow tobacco in Canada, we are part of the problem, not part of the solution.
NOT-SMOKING IS A “CANADIAN VALUE.”
When considering who should be allowed to enter and live in Canada, preference should be given to non-smokers. Smokers who are allowed in would be encouraged to quit before arriving or provided with counselling and free NRT on arrival. (This would only have a small effect. Canadians smoke more cigarettes per person than the global average.)
PASS THE TEST, GET FREE NRT
The government should create a course on how to use nicotine replacement therapy to quit smoking. The course would be available in print, online, and as an app. People who completed the course and passed a test would get a pre-paid credit card (like a Tims card) which they could redeem for a supply of NRT.
CREATE A “SIN TAX” FOR MONEY EARNED FROM TOBACCO
There should be a social stigma attached to working for the tobacco industry and from making money by being complicit in the death of smokers. Money earned from the growing, manufacture, promotion, administration or sale of tobacco should be taxed more heavily than income from other sources. This would include money earned by lobbyists and lawyers working on behalf of big tobacco.
THE GOVERNMENT SHOULD GET INTO VAPING
It is becoming increasingly obvious that some people find vaping an effective way to stop smoking. It is a cessation method which seems to appeal to a group which have failed by using other methods and is especially attractive to the counter-cultural subgroups where smoking is still common. At present, smokers who want to use vaping as a way to quit have to rely on dubious products sold in convenience stores, and e-liquids which may be improperly manufactured, and incorrectly labelled. As e-liquids containing nicotine are technically illegal in Canada, they can, in effect, only buy the smoking-cessation products they need from criminals.
So far, no company has stepped forward to go through the hoops necessary to be certified as a medical product by Health Canada. If no company can be incentivized to do this, then the government should commission the manufacture of an e-cigarette and a collection of e-liquids to medical standards. This product could then be sold in pharmacies and be covered by provincial health plans and/or private health insurance. It would be an additional tool for smoking cessation counsellors, and it would be the standard product for use in research.
I know that some people at the Forum felt constrained by their position, and were unable to comment freely in a public forum. If anyone else has ideas that they would like me to post, either with their name or anonymously, please send them to email@example.com.
We have a Federal Minister of Health who is a physician, who understands the size and importance of the tobacco problem, who wants Canada to return to being a world leader in tobacco control and is prepared to publicly commit to the challenging target of “5% by 2015”.
Let’s not waste the opportunity. How often, in the average lifetime, do we get asked to be “Bold and innovative”?