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No time to lose

I have often thought that I could retire once the nicotine addiction problem was solved. As fate would have it, however, I must face the reality that the problem is far from being solved and I am running out of time.I was recently diagnosed with bladder cancer of two histological types – a high grade urothelial carcinoma combined with a small cell bladder cancer. The latter is rare, occurring in only about 0.5% of cases. It is an aggressive cancer, and the prognosis is poor. Most of the time bladder cancer, if caught early, is easily treated and mostly curable. But my case is not most cases. I am getting treatment by a highly qualified care team at the Montfort, Ottawa and Queensway-Carleton Hospitals. Realistically, the best treatment available might add some months or even years to my life, but cure is unlikely.But what of my dream – to live to see the end to the nicotine epidemic? Whatever progress I have been able to support over my career, going forward my contributions will be fewer in number. It will be up to my friends and colleagues around the world to continue this fight.To be clear, no one individual can solve the nicotine addiction problem, and no group of individuals can do so without support in their communities. The problem is societal in nature and there needs to be widespread social consensus that the problem must be solved. Individuals can help create that consensus and help steer the resulting policy actions towards successful conclusions. Without that consensus and widespread clamour for change, the epidemic of nicotine addiction will continue.What kind of change is needed? Decades of experience have taught us what works, and what does not work well enough. Governments are quick to embrace smoking cessation programs and various forms of education and health promotion. While these efforts are useful in that they employ people and give them time to think about what is really needed to control the nicotine epidemic, they are not sufficient to get the job done. With nicotine addiction, corporate greed and bags of money on their side, the tobacco and vaping industries can easily overwhelm whatever effectiveness public education and cessation programs might have.To truly end the tobacco and vaping epidemics, we must attack the tobacco and vaping industries, and we must win that battle. Chasing the tail of such a venomous creature will no longer suffice: we have to cut off the head of the snake.We have made great progressThe importance of addressing the commercial root of the nicotine epidemic is the key lesson from my over 40 years’ experience on this file.When I signed up to work on tobacco control at Canada’s Department of National Health and Welfare (now Health Canada) in the early 1980s, the federal government was finally willing to end the era of voluntary agreements, and to put regulatory controls on the industry. I was proud to help create a smoke-free public service, to help draft Canada’s first meaningful tobacco control law (the Tobacco Products Control Act) and to help the lawyers defend it against the legal assaults that followed. Even though this law was overturned by the Supreme Court in 1995, many previously secret tobacco industry documents were made public and the way was paved for the replacement law – the Tobacco Act.In the early 1990s I moved to the World Health Organization, which was also preparing to take more meaningful action against smoking. A foundation for this work was the development of credible estimates of the number of deaths worldwide from tobacco. At the time we estimated that the number of deaths would rise from 3 million in the mid 1990s to 10 million by 2020 if nothing changed. Fortunately, things did change for the better, and in 2020 there were only (!) 8 million deaths per year from tobacco. At the WHO I was proud to promote the adoption of strong and comprehensive strategies around the world, with special emphasis on Central and Eastern Europe. I was especially proud to see the speed with which the discussions we initiated towards establishing a global tobacco treaty bore fruit. The Framework Convention on Tobacco Control, now almost 20 years old, shows how quickly our community can build a new social consensus and legal framework.Since the turn of the century, I have pushed for reform as part of the small team at Physicians for a Smoke-Free Canada. This work has reminded me of the strength and importance of legal reforms. Travelling across Canada with Heather Crowe, I watched every province, every territory and the federal government put laws in place to guaranteeing smoke-free indoor public places and workplaces. I was proud to help federal lawyers defend the Tobacco Act (to a 9-0 victory in the Supreme Court in 2007) and to help class action lawyers defend injured smokers (to a $13 billion award for some injured Quebec smokers by the Quebec Court of Appeal in 2019). More discouraging was the ability of the industry to avoid paying a penny to those they have hurt, to use federal insolvency laws to stall the impact of these rulings, and to impose a veil of secrecy on their negotiations with provincial governments.But much more needs to be doneMuch more needs to be done if future generations are to be spared the harms of addiction and disease manufactured by this industry.In Canada, provincial and federal governments need to wrest control of the current insolvency proceedings from the tobacco industry and from those lawyers who are working towards ensuring that the tobacco industry emerges from this process intact and is allowed to continue “business as usual”. Government can use this process to impose settlement terms on the tobacco industry, including payments to those smokers they have injured, a phase-out of tobacco and vaping products by 2035, with continuous monitoring and enforcement by the court of interim milestones set out in a settlement. As the analysis by Hans Krueger and Associates showed, reducing smoking will provide greater financial rewards to provincial health care systems than any monetary settlement the provinces might realize. It would prevent thousands of tobacco-related deaths. It would prevent the lunacy of maintaining a tobacco business for the purpose of paying back previous victims of tobacco industry wrongdoing.We need a new tobacco and vaping law – one which recognizes that selling vaping products with fewer restrictions than tobacco does not solve the problem of tobacco, it only makes it worse. We can end the youth vaping epidemic by ensuring that electronic nicotine products are provided through accredited smoking cessation services or by pharmacists. Just as Canada can write laws to reduce pollution emissions or to phase out products that harm the environment, we need health laws that require a phase-out of tobacco and vaping products.Globally, the challenge can be met by expanding the application of the Framework Convention on Tobacco Control (FCTC). This treaty can be used to impose a tax on tobacco company revenues before they are returned to the international headquarters. A very small tax imposed simultaneously by a large number of countries could be a very effective public health measure, easily yielding $400 million or more each year. Split between domestic tobacco control projects and international projects, this should close the revenue gap that has plagued FCTC implementation.The FCTC also authorizes countries to implement tobacco control measures that go beyond the provisions of the treaty (Article 2.1). Parties should be encouraged to expand the reach of the treaty to cover all nicotine sold as consumer products, not just tobacco, and to embark on efforts to phase out commercial tobacco and nicotine products.Time to step up our gameSome may protest that these ideas are unrealistic dreams that would never gain popular support and would never be implemented.The same was once said of a ban on tobacco advertising and the creation of smoke-free public places and workplaces. While it took a long time to achieve these advances, and despite massive opposition, largely led by the tobacco industry, these advances were achieved because many people wanted them and were willing to persist until these changes were achieved.Some will say “Isn’t the tobacco problem solved? Can we not move on to other things?” No, the problem is not solved. There are still 8 million deaths per year from tobacco around the world and over 50,000 tobacco-caused deaths every year in Canada. Canada is also home to a growing vaping epidemic. Over half a million people under 25, most of whom have never smoked, are addicted to nicotine from their vapes. There should be a widespread public outcry about these statistics, but there is none.Public health advocates around the world need step up their game to create that public outcry. Only then will the climate be ready to entertain some of the epidemic-ending solutions I have proposed. Of course, there may be other epidemic-ending solutions too. All good ideas should be pursued. However, we do not need more time-wasting smoking cessation and health promotion programs. To end the tobacco and nicotine epidemics, we need to attack the very heart of the tobacco and vaping industries.My time and ability to contribute to such an effort are coming to an end. I ask you – please – to take up this fight. The time to act is now. Do not let these industry-caused tobacco and vaping epidemics continue.
Neil Collishaw
Research Director
Physicians for a Smoke-Free Canada
613 297 3590