CANCER PREVENTION INSTITUTE OF CANADA

Last updated: 6-Jul-2011

Tobacco

While much has been accomplished in the control of tobacco use in Canada, much still remains to be done. Even with the country being an international leader in this area, 6,085,209 Canadians over the age of 12 still smoked in 2003.

• interventions to reduce initiation rates, especially among youth

• interventions to increase cessation rates and prevent relapse

• interventions to reduce exposure to second hand smoke

Reducing Initiation Rates

Adolescents are at the highest risk of initiating smoking behaviour. Indeed, few individuals start smoking after the age of 20. It is this reality that has resulted in the aggressive targeting of adolescents by the tobacco industry in its marketing campaigns.

Preventing the uptake of smoking among youth thus stands out as one of the most vital efforts in public health. The immediate and aggregate benefits over generations can be significant, especially given the demonstrable “multiplier effects” of prevention: non-smoking teens influence their peers in the direction of abstinence; non-smoking adults (and smoke-free homes) influence children similarly. The result of such cumulative trends over a society is a “denormalization” of tobacco, that is, the creation of a social stigma against smoking (and against the tobacco industry) which continues the momentum towards abstinence.

The school environment is a natural platform for health promotion. Unfortunately, the assessment of the many school anti-smoking programs has been somewhat pessimistic. Small positive results have been seen with a social influence training approach, which includes tobacco resistance skills education, recognizing high-risk situations, and so on.

Community-wide campaigns that include counter-advertising, and are sometimes linked to school programs, show more promise. In such cases, the design of the advertising may be the key. Studies show that anti-smoking advertisements should stress the manipulation of tobacco companies and the addictive nature of nicotine even more than health effects per se, since disease impacts many years in the future are highly “discounted” by youth and adults alike.

The most effective interventions to reduce initiation rates, however, are in the arena of regulatory and economic interventions. These fall into three main categories:

• regulation of tobacco sales to minors

• regulations on advertising

• taxation to increase the unit price of cigarettes

Of these three, controlling tobacco sales to minors is the weakest intervention. The main gap in the policy is not recalcitrant shop owners, but the fact that motivated (especially addicted) teens are adept at overcoming all institutional barriers to accessing tobacco. On the other hand, taxation is a highly effective intervention (even today, the financial means of youth are limited), and advertising regulations are an important complement to counter-advertising. An intriguing subset of marketing directed at youth which needs more attention is the influence of tobacco introduced as product placement in movies and television.

Increasing Cessation Rates

While increased taxation is a very effective intervention to reduce initiation rates, it is also very successful in increasing cessation rates. In fact changing the price of tobacco through taxation is probably the single most effective intervention to reduce the prevalence of tobacco use.

Mass media education / counter-advertising campaigns are also an important component of a comprehensive program but tend to have minimal effectiveness on their own.

There is enough support for the effect of smoking restrictions in workplaces, which are now very common, to continue to encourage this form of intervention. Not only do they reduce exposure of non-smokers to second hand smoke, but they also reduce the amount consumed by smokers, possibly leading to increased cessation rates.

Interventions for smoking cessation directed at individuals are varied in format and impact. Counselling a patient to quit, given by a primary care provider, is quite successful, especially when an appropriate level of support is provided and nicotine replacement therapy is utilized. Group therapy can match the results of more intensified one-to-one counselling. A major impediment, however, is the lack of appropriate funding mechanisms to provide financial support for these interventions.

An important “window of opportunity” to counsel smoking cessation may exist when patients face a major health event. In addition, post-surgical results are improved if smokers ‘fast’ from their habit for at least six weeks prior to surgery.

Broader-based interventions such as proactive telephone support lines and self-help materials have a marginal effect on cessation rates. The evidence for the impact of web-based resources such as ‘QuitNet’ is not yet available. Each of these interventions, however, has the advantage of potentially reaching a large number of people at minimal cost. They may also be important in supporting the large percentage of people who manage to quit on their own.

Reducing Exposure to Second Hand Smoke

Interventions related to second-hand smoke, apart from the impact of smoking bans in workplaces noted earlier, have focused on settings where children in particular are exposed and more generally on public spaces. Bans on smoking in public places have been a fixture in British Columbia since 1992 and are now well-accepted in many developed countries. The extension to formerly excluded locations in the hospitality industry should be made relatively easily given the independent research which shows no negative impact on revenue or employment in these establishments.

Lessons Learned from the Anti-Tobacco Campaign

No single intervention in the campaign to reduce smoking prevalence can account for all the significant changes that have occurred since the 1960s. Each intervention, from media advocacy to school programs to social support systems, is enhanced synergistically by the presence of other components. Supportive systemic changes and social denormalization of both the tobacco industry and the smoking habit were required to achieve the population-based cessation rates that have been observed.

The one possible exception to the preceding principle is tobacco product price increases (usually through taxation), which has been shown to have a strong and sustained effect independent of other interventions

Whether interventions involve taxation or other forms of regulations, senior levels of government must shape their efforts to maximize support for policies and programs operating in local jurisdictions and targeted communities; there must be multi-level, integrated strategizing to ensure the greatest impact on risk factor reduction. In addition, adequate financial and organizational resources must be ensured for all effective efforts over a long time frame.

An important aspect of planning noted in this report is the impact of socioeconomic factors on health and disease. With respect to those in poverty, the unintended consequence on household income of interventions such as taxation, and differential ability to respond to health education, must be considered when setting policy.

Finally, interventions must be available to assist individuals who seek to make a lifestyle change.

Lessons from the campaign against tobacco suggest that successful prevention programs include the following key elements:

• Interventions must address the fundamental behavioural and social causes of disease, illness and disability.

• Multiple approaches must be used simultaneously – education, social and community support, laws, economic incentives and disincentives.

• Multiple levels of influence must be accessed – individuals, families, schools, workplaces, communities, nations.

• Interventions must recognize special needs of specific groups such as teens, seniors, or other at-risk communities.

• Interventions must have long durations because change takes time and needs to be constantly supported for each subsequent generation.

• Interventions need to involve a variety of sectors that are not traditionally associated with “health,” such as business, engineering, urban planning, law, and the media.

• Interventions need to be created with a view to serving all socioeconomic groups effectively.