By Neil Collishaw, February 28, 2023

I have often thought that I could retire once the nicotine addiction problem was solved.  While nicotine addiction has abated somewhat, the problem has not been 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 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 (99.5%), 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 the Cancer Centre of the Ottawa Hospital. Realistically, the best treatment available  will add some months or even years to my life.  Cure is unlikely.

But what of my dream – an end to the nicotine epidemic?  To be sure, I have made some contributions over my career, but going forward my contributions will be fewer in number.  My friends and colleagues around the world will have to continue the fight.

To be clear, no one individual can solve the nicotine addiction problem.  The problem is social 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?  Governments are quick to embrace smoking cessation programs and various forms of education and health promotion.  These kinds of programs are useful placeholders in that they employ people and give them time to think about what is really needed to control the nicotine epidemic.  With nicotine addiction, corporate greed and bags of money on their side, the tobacco and vaping industries can easily overwhelm whatever effectiveness education and cessation programs might have had.

To truly end the tobacco and vaping epidemics, we have to attack the tobacco and vaping industries and we have to win.  If we are to deal with this venomous creature, chasing tails will no longer suffice. We have to cut off the head of the snake.

Throughout my career, I have contributed to some changes that have made the world a somewhat safer place, even if the nicotine epidemic continues.

Here are some highlights of public health improvements to which I have contributed:

1980s – Health Canada

• Helping to creeate a smoke-free federal public service
• Helping to draft Canada’s first meaningful tobacco control law, the Tobacco Products Control Act (TPCA).
• Helping lawyers defend the TPCA.  Even though the 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.

1990s – World Health Organization

• Helping to create credible estimates of the number of deaths worldwide from tobacco.  At the time we estimated that the number was three million deaths and that it would rise to 10 million by 2020, if nothing changed.  Fortunately, things changed for the better, so there are only eight million deaths per year from tobacco.
• Helping to spark changes that led to better tobacco control policies around the world, with special emphasis on Central and Eastern Europe.
•  Helping to initiate discussions and changes that led to the creation of the Framework Convention on Tobacco Control.

2000 to the present – Physicians for a Smoke-Free Canada

• Helping lawyers defend the Tobacco Act.  It was upheld by a 9-0 decision of the Supreme Court in 2007.
• Travelling across Canada with Heather Crowe.  Thanks to our efforts, by 2009 every province, every territory and the federal government had laws in place guaranteeing smoke-free indoor public places and workplaces.
• Helping plaintiffs’ lawyers sue the tobacco industry in Quebec.  Thanks to our efforts $13 billion dollars was awarded by the Quebec Court of Appeal to sick smokers in Quebec in 2019.  However, not a penny has been paid to plaintiffs.  The tobacco industry has stalled this decision while they are in bankruptcy protection.  They have also stalled tobacco cost-recovery lawsuits that have been initiated by all provinces.  Settlement negotiations are taking place in a Toronto bankruptcy court under the provisions of the Companies’ Creditors Arrangements Act.

What remains to be done

In Canada

• Provincial and federal governments need to wrest control of the current bankruptcy proceedings from the tobacco industry and certain lawyers for certain provinces.  They then should impose the following settlement terms on the tobacco industry:
  • Immediate execution of the rulings against the tobacco industry by the Quebec Superiof Court and the Quebec Court of Appeal with full payment to the plaintiffs and their heirs.
  • A requirement for the tobacco industry to phase out tobacco and vaping products by 2035, with continuous monitoring by the court and a requirement to meet interim milestones enforced by the court with significant penalties for failure to meet them.  An analysis by Hans Krueger and Associates showed that even a reduction in tobacco use to 5% prevalence by 2035 would result in nearly $50 billion in direct and indirect costs avoided in Ontario and Quebec.  This is a far greater sum than would ever be realized by a monetary settlement with the provinces.  Moreover, thousands of tobacco-related deaths would be avoided and future smokers would not be paying for the wrongs done to past smokers.
  • A new Tobacco Act is needed to replace the Tobacco and Vaping Products Act.  Vaping products would be deemed to be tobacco products and subject to all the same restrictions and regulations as tobacco products.
  • We have an epidemic of vaping among young people.  As young vapers grow older, the vaping epidemic will eventually spread to all age groups.  It must be stopped.  Sales of vaping products must be limited to purchase by hospital-based accredited smoking cessation programs.  Such programs that wish to use vaping products in smoking cessation could provide them in a strictly limited and monitored manner to their clients.  All other sales of vaping products in vape shops, convenience stores, other stores and online should be prohibited.
  • The court-ordered requirement for a compulsory phase-out of tobacco and vaping products should be duplicated in law.

Around the world

• The Framework Convention on Tobacco Control (FCTC) has proven to be very useful tool to slow the global progress of the tobacco epidemic.  Its application needs to be taken much further.  Under the authority of the FCTC, Parties could agree to impose a new tax on tobacco company revenues.  In countries that send tobacco revenues to overseas locations, this could be the last tax before the money leaves the country.  Provided a large number of countries agree to impose such a tax simultaneously, this could be a very effective public health measure, A very small tax could easily yield about $400 million per year.  Countries could agree to spend about half of that money on domestic tobacco control projects and assign the other half to international projects, some run by the FCTC Secretariat and others through other bilateral or multilateral arrangements.
  • The FCTC also authorizes countries to implement tobacco control measures that go beyond the provisions of the treaty (Article 2.1).  Parties should be encourage to expand the reach of the treaty to cover all recreational nicotine products, not just tobacco.  Countries should also be encouraged to embark on planned programs to phase out commercial tobacco and nicotine products.

Dreaming?

Some 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 “Is not the tobacco problem solved? Can we not move on to other things?”  No, the problem is not solved,  There are still eight 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 never smoked, are addicted to nicotine form their vapes.  There should be widespread public outcry about these statistics, but there is not.  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 at the very heart of the tobacco and vaping industries.  My time and ability to contribute to such and effort is coming to an end.  Who else is ready to take up the fight?