The tobacco endgame: Radical proposals part of strategy to win faltering war on smoking

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In the faltering war against cigarettes, the latest battle cries are eye openers: prohibit smoking for anyone born after the year 2000; require a licence to buy cigarettes; nationalize the tobacco industry.

Or just make selling cigarettes illegal.

All have been proposed as part of the “tobacco endgame,” a radical — and controversial — new approach to the smoking scourge that a select group of Canadian public-health experts will discuss later this year.

Endgame proponents note that a stubborn 20 per cent of the population continues to smoke — tens of thousands of themScreen Shot 2016-02-23 at 10.14.10 dying annually as a result — and argue the numbers are unlikely to decrease much under current anti-smoking policies.

So, they say, it’s time for innovative, out-of-the-box ideas that might just stamp out Western society’s biggest-single source of disease.

“We’ve got to do something,” says Rob Schwartz, executive director of the Ontario Tobacco Research Unit. “I’m an academic, not an advocate, but when I have the data in my hands, I feel a moral responsibility to make it known.”

Canada’s first tobacco-endgame “summit” is planned for Queen’s University in Kingston, Ont., this fall. It will be headed by Dr. Elizabeth Eisenhauer, the oncology department chairwoman, with about 100 invitation-only public-health and policy experts brainstorming a blueprint for dramatic action.

The proposals already floated elsewhere represent government intervention in the tobacco marketplace on a whole new level, and the industry will no doubt fight them “tooth and nail,” said one summit organizer.

But even in the anti-smoking world, a minority is questioning the concept on both practical and philosophical grounds, calling the most-discussed endgame tactics autocratic pipe-dreams that would likely achieve little.

Most of the proposals are variations on prohibition — an idea that has failed in most other domains and eras, says David Sweanor, an Ottawa lawyer and long-time anti-smoking activist.

“There is … this view that whatever we do, we have to control the market, with government telling people what they can have,” he says. “It would take a tremendous amount of political capital to get through and one would wonder, to what end?”

If there is a rationale for any kind of endgame, it begins with smoking trends.

A combination of tools, from tax hikes to graphic warning labels and public smoking bans, has until recently been a resounding success. It has slashed rates in Canada from 50 per cent in 1965 to about 15 per cent — and delivered the biggest single blow to the cancer epidemic.

But that number has barely shifted since 2008-09, and modeling by the Ontario Tobacco Control Unit offers more bad news.

Even if the full panoply of control measures recommended by the World Health Organization — like deeper tax hikes and the plain cigarette packaging promised by the Trudeau government — were implemented, the number would fall only to about 12 per cent by 2035, Schwartz says.

“We need to bend that curve,” says Eisenhauer. “There’s a sense in some communities that … ‘Well, we’ve been there done that, it’s fixed.’ But the data don’t support that.”

‘We don’t need prohibition. What we need is help for people who want to get off cigarettes’

The Canadian endgame goal is “five by 35,” a five-per-cent smoking rate by 2035, which would mean millions fewer people inhaling highly carcinogenic fumes.

Academic researchers, experts from health charities like the Canadian Cancer Society and anti-smoking activists — essentially, the brain trust behind most of the current tobacco-reduction measures — will meet Sept. 30-Oct. 1 at Queen’s; some government officials are also expected to attend.

Minds are open, says Eisenhauer. She points to an article by researchers at the University of California at San Francisco as a guide to what the international endgame movement has dreamed up so far.

This includes mandating lower levels of addictive nicotine in cigarettes, changing the pH balance to make them more acrid, limiting sales by requiring a tobacco licence, or prohibiting a whole generation — everyone born after, say, 2000 — from smoking.

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Even more dramatic is the proposal to nationalize tobacco companies, with government owners working to phase out the businesses.

Less controversial would be government funding to cover the cost of nicotine-replacement products and treatments.

Eisenhauer says an outright ban on smoking — as some have proposed — is unlikely to be advocated by her summit’s participants, though she noted surveys show many smokers support prohibition.

The Canadian endgame group is not about to urge a raft of radical ideas all at once, but a more gradual process, says Schwartz.

“We’re not calling for a revolution.”

Even so, Clive Bates is convinced the endgame plans are generally “terrible ideas that won’t work.”

Any kind of partial or full ban or attempt to make legal tobacco less appealing would drive smokers to contraband products like never before, says Bates, a former head of Britain’s chief anti-smoking group, Action on Smoking and Health.

Smokers would compensate for reduced nicotine by smoking more, a generational ban would be impossible to implement and attempts to nationalize the industry mammothly expensive, suggests Bates, now a policy consultant and critic of the tobacco-control community.

“They’re just engaging in strange, authoritarian fantasies,” he charges. The ideas “are harmful, they are a distraction from thinking about things that will actually work.”

Both Bates and Canada’s Sweanor favour a fundamentally different approach, one that uses market forces to draw people away from tobacco, rather than legislative muscle to try to wipe it out.

A good way to start would be for regulators to make it easier for new, non-tobacco nicotine products, like e-cigarettes, to get on the market, they say.

“We don’t need prohibition,” says Sweanor. “What we need is help for people who want to get off cigarettes.”

National Post

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