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Tobacco Centre for Addiction
and Mental Health

Submission to the Standing Committee on Finance and Economic Affairs regarding the Smoke-free Ontario Act (Bill 164) 2005

Submission to the Standing Committee on Finance and Economic Affairs regarding the Smoke-free Ontario Act (Bill 164) 2005

The Issue Within its Historical Context

In 1992, the Ontario government announced the initiation of an Ontario Tobacco Strategy, with specific goals in the areas of prevention, protection and cessation. The essential components of a comprehensive tobacco control strategy were subsequently articulated in The Report to the Minister of Health from Her Expert Panel on the Renewal of the Ontario Tobacco Strategy (Ashley et al., 1999). These included tax increases, province-wide smoke-free legislation, funding and assistance for smoking cessation interventions, and public education campaigns, including bans on tobacco industry marketing.

Following the Report to the Minister of Health, the Ontario Tobacco Strategy Steering Committee (OTSSC) provided a detailed description of each of these components, including a review of supporting evidence (OTSSC, 2002). The report's recommendations were confirmed as evidence-based and consistent with the international guidelines put forth by the Atlanta-based Centers for Disease Control (CDC, 1999). The OTSSC subsequently produced a report providing estimates of the annual costs for each of the components, with the total estimated at $90 million (OTSSC, 2003). The part of the government's 2004 election platform that addressed tobacco was based on the Expert Panel's Report to the Minister of Health. Support from the tobacco control field for the Strategy has been unanimous and The Centre for Addiction and Mental Health (CAMH) has indicated its support for the Smoke-free Ontario Act in a recent letter to the Minister of Health.

CAMH has a major mandate to improve the lives of those affected by addiction and mental health problems and to promote the health of people in Ontario. Within this mandate we address drug addiction and substance misuse in its many, varied, and complex forms. This provides CAMH with a unique perspective from which to comment upon tobacco use in Ontario and elsewhere.

Tobacco: Ontario's #1 Drug Addiction Problem

Tobacco has been long recognized as the most pervasive addiction, whether we measure it by the number of Ontarians who are addicted to it, the number who fall ill from it, or the number who die as a result. In less human terms, but nonetheless important, it is also the most costly form of drug addiction to the Ontario economy.

Costs to the Ontario Economy

Overall costs of tobacco use to the Ontario economy have been estimated at a staggering $3.7 billion each and every year. This amounts to almost 1% of Ontario's GDP. Of these costs, $1.1 billion is related directly to health care. In sum, these tobacco-related costs amount to 52% of all drug-related costs for Ontario (Xie et al.,1996; Single et al.,1996).

Dependence

More Ontarians are addicted to tobacco than to either alcohol or other drugs. The CAMH Monitor (2003) has surveyed Ontario adults and has provided evidence for dependence among Ontario adults at 8.6% for tobacco, 5.9% for alcohol, and 1.2% for cannabis. Earlier estimates of dependence on the most commonly used prescribed medications have ranged from 0.6% to 0.7% of Ontario adults (Addiction Research Foundation, 1994). Some caution must be used in the interpretation of these data since dependence measures come from different studies using different measures of dependence. However, the gulf between the estimate for tobacco dependence and that of the others is so large that, even with a considerable allowance for error, there is little doubt that dependence on tobacco is a major issue.

Illness and Injury

Indicators of the actual harm caused by tobacco and other drugs are more certain. In Ontario, tobacco accounts for 68.6% of drug-related hospitalizations, and 74.0% of drug-related days spent in hospital (Single et. al., 1996).

Deaths

In Ontario, approximately 12,000 people die each year from smoking, and that amounts to 82% of Ontario's drug-related deaths - more than four times the number caused by alcohol and all street drugs combined (Luk and Single, 2003; Xie et al., 1996; Chief Medical Officer of Health, 1996).

The significance of these deaths becomes even more compelling when we juxtapose them with other familiar drug-related tragedies in Ontario. Occasionally, the tragic death of one of our young people, attributable to illegal drugs, or the death of a family caused by a drunk driver, capture the headlines of the media, the concern of the public and the attention of government. Occasionally, a handful of deaths resulting from the side effects of a pharmaceutical product attract a similar response. The concern, in all three cases, is justified. But let us consider that tobacco has resulted in the deaths of thousands of Ontarians each and every year for a long time now, with relatively little reaction from the press, the public, or until now, from government. The introduction of comprehensive measures to address tobacco dependence is long overdue.

Some will argue that Bill 164 is harsh and extreme. Given the prominence of tobacco use as Ontario's most serious drug problem, we think the Bill is appropriately measured in both its intent and its scope. Without it, tobacco-related disease, suffering, and death will continue at staggering costs to the Ontario economy. These costs will continue to drain funds that could be applied in so many more constructive ways.

In the coming weeks, the economic impact of the Smoke-free Ontario Act will be debated. In some cases, positions will be taken by parties with their own financial interests at stake. We would encourage the government to remain steadfast in its recognition of the recent research, conducted in both Ontario and elsewhere, that shows that smoking bans do not adversely affect the economic prosperity of the hospitality industry (OTRU, 2003; Scollo et. al., 2003). In assessing the merits of tobacco legislation, we cannot abide a parochial view of its costs and benefits. The overall impact on Ontario's public health and on its economic well-being must hold priority.

CAMH's Role in Tobacco Control

CAMH addresses tobacco use in Ontario through ongoing basic and applied research initiatives and through the development and delivery of prevention and cessation programs. We are a co-sponsor of The Ontario Tobacco Research Unit (OTRU), which provides an evidence base to inform the development and implementation of programs and policy initiatives. We provide smoking cessation interventions for smokers through our Nicotine Dependence Unit. Through our Regional Offices, we maintain a province-wide presence and active partnerships with many local and provincial organizations. This has helped us to make substantial contributions to the development of municipal non-smoking bylaws and public education initiatives. Public awareness initiatives are supported by the development of information resources on tobacco by our Education and Publishing Department.

CAMH's advice to government on tobacco policy issues is coordinated through a Tobacco Policy Group that draws upon CAMH's varied research, clinical, policy, and dissemination expertise, as well as the Ontario-wide perspective provided by its network of community offices across the province.

CAMH's Recommendations

Our recommendations for tobacco control and their rationale draw heavily on a recent report from the Ontario Tobacco Research Unit (2003). The report provides additional detail and references that support the effectiveness of the initiatives proposed in the recommendations. The report also provides responses to the challenges that are customarily directed at the individual components of the strategy. Not only are the recommendations based upon the scientific evidence available, they are also supported by Ontarians 18 years of age and over, as determined in surveys conducted through the CAMH Monitor (2003). The results of these polls, related to the strategy components, are presented for each of our recommendations.

Recommendation #1: Ontario should implement a comprehensive tobacco control strategy that includes multiple components to meet the tobacco control goals of prevention, protection, and cessation.

Rationale: Evidence has shown that comprehensive tobacco control strategies have achieved dramatic reductions in tobacco use in both the U.S. and New Zealand. Each of the following components (of a comprehensive plan) comprises evidence-based practice.

Recommendation #2: Ontario should increase tobacco taxes to at least the level of the Canadian national average within the next two years.

Rationale: Tax increases have been proclaimed as the single most effective intervention to reduce demand for tobacco. Yet, despite a recent price increase, Ontario still has the second lowest cigarette price in Canada (Cunningham, 2005). During the 1990's in Canada, a 10 per cent price increase led to a decrease in consumption by about 4.5 per cent, after controlling for the impact of smuggling. Furthermore, total tobacco tax revenues rose at both the provincial and federal levels. From the 2003 CAMH Monitor, we know that half (53%) of Ontarians support increasing the cost of cigarettes by at least $1.00 per pack. Some may express concern about an increase in smuggling. Given the legal action now being brought against the industry by the Federal and Quebec governments, along with tough new proposals to control smuggling, smuggling is not expected to pose a serious threat.

Recommendation #3: Ontario should implement provincial smoke-free legislation, with no exemptions.

Rationale: Environmental tobacco smoke, or second hand smoke, is a complex mixture of thousands of chemicals - over fifty compounds have been identified as carcinogens (Ontario Tobacco Research Unit, 2001). The scientific evidence is clear: involuntary exposure to second hand smoke is harmful and should be eliminated (Ontario Tobacco Research Unit, 2001; U.S. Surgeon General, 2004). Smoke-free public places protect non-smokers (and smokers) from environmental tobacco smoke, thereby reducing associated illness and premature death. International research also shows that smoke-free public places decrease tobacco consumption and overall prevalence of smoking, and also deter young people from smoking.

Once again, the CAMH Monitor (2003) shows that support among Ontarians for smoke free environments is high with 3 out of 5 (62%) supporting smoke-free environments in bars and taverns. The level of support rises to 4 out of 5 (84%) for restaurants, and 9 out of 10 (88%) for workplaces. Allowing exemptions compromises the message that second hand tobacco smoke is a dangerous toxin. It also suggests that exposure to this toxin is less important than other considerations. Accordingly, CAMH would propose the following:

  1. Exemptions should not be made for health care facilities, including community- or hospital-based mental health, addictions or withdrawal-management centres;
  2. Supports for smoking cessation should be made available to patients/clients and staff who are smokers.

Recommendation #4: Ontario should provide funding and other assistance for smoking cessation and reduction interventions.

Rationale: As an organization involved in helping people who want to quit smoking, or decrease the amount that they smoke, CAMH also applauds the Minister's recognition of the costs borne by smokers and their loved ones who live with the personal, financial, health, and social impacts. The measures introduced by the Minister will be conducive to more Ontarians quitting this dangerous and costly addiction, and will discourage young people from beginning to smoke in the first place.

CAMH's Nicotine Dependency Clinic champions the use of evidence-based interventions, and practical, immediately beneficial interventions for those currently addicted to tobacco. The use of Nicotine Replacement Therapy and Buproprion, is both an effective intervention for smokers and a cost-effective health care policy strategy. However, as these interventions are expensive, smokers do not experience an immediate economic incentive when they switch to them from cigarettes. Government subsidization of Nicotine Replacement Therapy and Buproprion is highly recommended, as is improved funding for a range of cessation support programs.

Recommendation #5: Ontario should fund effective mass media public education campaigns, and enact legislation that eliminates cigarette displays and requires plain packaging for cigarettes.

Rationale: While various restrictions have been implemented that have limited tobacco advertising and promotion, tobacco manufacturers still advertise through distinctive packaging and displays in a variety of tobacco sales outlets. It is also important to realize that the impact of advertising is not fully realized in the immediate period in which the advertising occurs. Rather, the consumer's perception of a product is determined by the cumulative sum of previous advertising campaigns. This implies that, despite recent prohibitions, Ontario consumers continue to be influenced by the extensive mass media advertising of the tobacco industry of the last four decades. It is therefore important to prohibit all forms of tobacco promotion. Public opinion, as revealed by the CAMH Monitor (2003), is again supportive. Half (50%) of Ontarians think that cigarette companies should not be allowed to sponsor sporting or cultural events, and three out of five (62%) Ontarians oppose cigarette displays in tobacco retail outlets. Displays are the most visible promotion of cigarettes and act to normalize the product for young people and to trigger relapses of smokers who are attempting to quit. Government should hold fast on its commitment to banning cigarette retail displays.

Given that several studies have found that increased spending on anti-smoking advertising campaigns reduces tobacco use (The Ontario Tobacco Research Unit, 2003; Ontario Medical Association 2003), government should also consider enhancing mass media campaigns and school-based programs that reiterate the messages that tobacco is harmful to smokers and non-smokers, that tobacco use is not glamorous, and that tobacco is exceptionally addictive.

Fiscal Viability

The Ontario Tobacco Research Unit (2003) has reported on investigations of the fiscal viability of the type of comprehensive strategy that we have outlined today. The central question has been whether there are sufficient benefits accruing to the government, in the form of reduced health care expenditures and higher revenue, to justify the increased allocations that would be required to implement such a strategy. The report concludes that the strategy, over a period of five years, will save the provincial government approximately $16 billion. Furthermore, the strategy will prevent more than 5,000 premature deaths and over 140,000 hospital days in the ten years following the program's inception (OTRU, 2003, p.19). The cost of such extraordinary success is estimated at $90 million annually. This win-win scenario is best captured in the report's own concluding remarks:

"There are many programs that have benefits for the citizens of Ontario, and clearly the provincial government cannot fund all good initiatives. In this case, the province is not forced to choose between social spending and responsible fiscal management - it can accomplish both goals through one policy" (OTRU, 2003).

How can CAMH support and assist the government with the adoption, implementation, and ultimate success of the Smoke-free Ontario Act?

For all of the reasons related to the promise of a healthier and wealthier Ontario, we urge the government to remain steadfast in all aspects of its originally proposed comprehensive tobacco strategy. Ontarians will continue to reap the benefits for generations to come, and will look back on May 31st 2006 as a milestone in the ongoing evolution of a healthier Ontario.

With a provincial mandate in health promotion and prevention programs for addictions and mental health and a network of satellites and partnerships across Ontario, CAMH can serve as an important resource to the government as it proceeds with the implementation of this important legislation. CAMH is committed to providing the government with its best advice based on research, evidence-based programs and public input. CAMH will continue to collaborate with the Ontario Tobacco Strategy and with other provincial bodies. CAMH will continue to work with local coalitions across the province to implement public education campaigns that will secure public support for the Bill. CAMH will also continue to support the implementation of prevention programs with a focus on youth and programs that encourage current smokers to quit.

CAMH welcomes the opportunity to work with the government to achieve this milestone and to make Ontario the healthiest province in Canada.

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