Priorities for reducing adult smoking: Best ... - David Hammond

Priorities for Reducing Adult Smoking
BEST PRACTICE TO REACH 12% BY 2011
Prepared for:
Health Canada &
The Canadian Tobacco Control Research Initiative
David Hammond
Jessica Reid
March 2009
i

TABLE OF CONTENTS
Executive Summary ........................................................................................... ii
Trends and Patterns Among Adult Smokers .................................................. 1
Current Practice: What We Know Works ....................................................... 16
Priorities for Action: Specific Interventions .................................................. 25
Priorities for Action: Systems and Tools ...................................................... 30
Priorities for Action: Research and Evidence ............................................... 33
Summary .......................................................................................................... 36
Additional Information Sources ..................................................................... 37
Appendix A: Stakeholder Feedback – Specific Interventions ..................... 38
Appendix B: Stakeholder Feedback – Systems & Tools .............................. 46
Appendix C: Stakeholder Feedback – Research & Evidence ...................... 49
References ....................................................................................................... 54
i

EXECUTIVE SUMMARY
Despite impressive declines in the prevalence of smoking over the past four decades,
approximately 3.9 million Canadians over the age of 25 continue to smoke. As a consequence,
interventions to reduce tobacco use remain among the most important and cost-effective public
health measures.
This report reviews best practices and priorities for reducing smoking prevalence among adults.
Recommendations are based upon feedback from 30 key stakeholders from the tobacco control
community in Canada, representing different sectors and 7 provinces. Recommendations for
programs and policies were identified in each of the following areas: specific interventions,
priorities for collecting research and evidence, and priorities for developing systems and tools.
The primary theme of responses from stakeholders was that Canadian smokers are not receiving
adequate services and support to quit smoking, and that Canada risks falling further behind in
terms of regulations to reduce tobacco use. Priorities for action with potential for immediate
impact include:
Priorities for short-term reductions in prevalence:
Curb contraband tobacco and enforce price and taxation measures
Improve access and use of existing cessation services
Renew commitment to comprehensive media campaigns
Priorities for longer-term reductions in prevalence:
Expand and coordinate cessation services
Enforce existing regulations, particularly with respect to contraband sales
of cigarettes
Develop and implement the next generation of policies: more
comprehensive marketing bans, greater sales/access restrictions,
stronger taxation measures, plain packaging, product regulation, and
smoke-free areas
Enhance partnerships with health professionals
Develop new and ―alternative‖ cessation interventions
Tailor cessation services to reach high-burden special populations
Link policies, services and programs to a greater extent
ii

TRENDS AND PATTERNS AMONG ADULT SMOKERS
Decrease in prevalence among adult smokers has slowed.
o Current smoking prevalence in Canada among adults over 25 years of age is 17%.
o Approximately 3.9 million Canadians over the age of 25 currently smoke—80% of all
smokers in Canada are over 25.
o The decline in prevalence has slowed or even stopped.
o Overall smoking prevalence among adults over 25 declined slowly between 1999 and
2005 before reaching a plateau at 18-19% in the past few years.
Smoking prevalence* (%), Canada, adults 25+, CTUMS 1999-2008 1,2
*Daily and nondaily smoking
** First half of 2008 (Feb-June) only
1

There are substantial differences in adult prevalence across provinces.
o Between 1999 and 2007, smoking prevalence among adults over 25 declined in all
provinces, before reaching a plateau in recent years.
o Quebec has experienced the greatest decrease during this time (from 29 to 21%).
o British Columbia has consistently had the lowest smoking prevalence.
Smoking prevalence (daily & non-daily), by province, adults 25+, CTUMS 2008* 2
* First half of 2008 (Feb-June) only
Smoking prevalence* (%), by province, adults 25+, CTUMS 1999-2007 1
1999 2000 2001 2002 2003 2004 2005 2006 2007
CANADA 24 24 21 20 20 19 18 18 19
Newfoundland 27 26 24 23 22 21 20 21 21
PEI 24 25 25 22 20 21 19 19 18
Nova Scotia 28 30 24 25 21 19 21 21 20
New Brunswick 25 25 24 20 24 24 21 22 21
Quebec 29 27 23 24 23 21 21 19 21
Ontario 22 22 19 19 19 18 16 16 18
Manitoba 22 25 24 20 20 20 21 19 19
Saskatchewan 24 28 24 19 22 21 20 23 23
Alberta 24 22 24 22 19 20 20 21 20
British Columbia 19 19 16 16 16 14 14 16 15
2

Smoking prevalence, %
Number of smokers in Canadian provinces, by sex, 2005 4
More males smoke than females, but the gap is narrowing.
o 15.5% of females (1.8 million) and 19% of males (2.1 million) over 25 are current smokers.
o In the most recent years, smoking prevalence appears to have continued to slowly decline
among males, but increased slightly among females, narrowing the gender gap.
30
25
Smoking prevalence (%), by sex, Canada, adults 25+, CTUMS 1999-2007 1
Males
Females
20
15
10
5
0
1999 2000 2001 2002 2003 2004 2005 2006 2007
Survey year
3

Smoking prevalence is highest in 25-44 age group, and then declines.
o Prevalence appears to decrease with age in all survey years.
o Within age groups, smoking prevalence was higher among males in most years, although
the gap between males and females for smokers over 65 appears to have closed in recent
years.
o Between 2006 and 2007, while smoking continued to decline for older age groups,
prevalence appeared to increase for smokers aged 25-44.
Smoking prevalence*, by age group and sex, adults 25+, CTUMS 1999-2007 1
‗*Daily and nondaily smoking
4

% Current Smokers
Lower SES Canadians are more likely to smoke, but prevalence has
declined at similar rates across all SES levels.
o Smoking prevalence declined in all educational groups between 1999 and 2006.
o Persistent educational differences were observed: smoking prevalence was lowest among
university graduates in all years.
Smoking Prevalence by Education Level, 1999-2006
Smoking prevalence among Canadian adults (25+), by education level, 1999-2006 3
35
30
25
20
15
10
5
0
1999 2000 2001 2002 2003 2004 2005 2006
Year

There are more middle/high income than low income smokers in Canada.
Number of smokers in Canada, by family income and age group, 2005 4
Rates of non-daily smoking have remained stable over time.
o Non-daily smoking is far more common among 25-34-year olds (approximately 8% in the
first half of 2008) vs. older adults (approximately 3% or less).
o Males have higher non-daily smoking rates than females within each age group.
Daily and non-daily smoking prevalence (%), by sex, adults 25+, CTUMS 1999-2007 1
6

Daily and non-daily smoking prevalence (%), by sex, adults 25+, CTUMS 1999-2007 1
Focus on Non-daily Smokers
Smoking patterns:
Smoke an average of 2.8 days over the past week and 4.2 cigarettes per day
Evenings and weekends (Fri/Sat) most common time to smoke
Buy all or most of their cigarettes and fairly regularly smoke less than a whole cigarette
Triggers include: socializing, stress and strong emotion, meals, alcohol, coffee, certain people
Smoking history:
Average age when they started to smoke regularly: 20 years
Three quarters reported having smoked daily at one point, most within the past 5 years
Opinions and attitudes:
Most consider themselves smokers; those who don‘t report greater control or reduced CPD
More than half think they will be smoking less than 12 months from now
More perceive smoking as a habit rather than an addiction, except smokers aged 45-54 years
Many concerned about health and report having cut back, particularly former daily smokers
Most perceive a risk from smoking, but less than daily smoking
Quitting:
80% have tried to quit (majority stated one or more times in past year)
6 in 10 are seriously thinking of quitting in the next 6 months; 9 in 10 are confident they can quit
Source: Health Canada. What Works on Quitting: Why Smokers Smoke. [presentation at TCD Strategic Planning Session]. 2008.
7

Consumption levels among daily smokers continue to decline.
o Over the past two decades, average cigarette consumption among daily smokers has
dropped 27%, from 20.6 cigarettes per day (CPD) in 1985 to 15.0 in the first half of 2008.
o There are significant differences in CPD between provinces: e.g., smokers over 45 in
Newfoundland reported 14.1 CPD, compared to 18.4 CPD in New Brunswick.
o Males have higher daily CPD than females within all age groups except 35-44 years.
o Among males, CPD increases with age and is highest among smokers over 55.
o Among females, the 35-44 age group has the highest daily consumption.
o University graduates smoked ~3 fewer CPD than those with the lowest levels of education.
o Time-to-first cigarette, a common measure of dependence, is similar across age groups
among adult smokers, and only marginally greater for females than males.
Average cigarettes smoked per day (daily smokers), by sex, adults 25+, CTUMS 1999-2008 1,2
*First half of 2008 (Feb-June) only
Average cigarettes smoked per day (daily smokers), by age and sex, adults 25+, CTUMS 2008* 2
*First half of 2008 (Feb-June) only
8

What is a ‘Hardcore’ Smoker?
Health Canada has defined ―hardcore‖ smokers as: older than 25 years, smoked for at least five years,
smoke 15 or more cigarettes per day, no quit attempts in past 12 months, and no intent to quit in the next
6 months. Ten percent of adult smokers meet this criteria and have been characterized as follows:
Older (mean age: 49 years) than both occasional smokers (35 years) and daily smokers (39 years)
Started smoking daily at a slightly younger age (17.2 years vs. 17.9 years for daily smokers)
More likely to have first cigarette within 5 minutes of waking
Smoking patterns:
Smoke wherever and whenever they can
Home and car are two places they feel comfortable smoking
Resent smoking bans - feel marginalized in society
Opinions and attitudes:
Justify their smoking behaviour
Main barrier to quitting is fear of failure
Aware of health risks - no lack of knowledge
Rationalize and minimize the risks
Less receptive to health warnings: they use personal experience rather than evidence
Quitting:
• By definition, hardcore smokers are not planning to quit in the next six months
• What do they need to hear or see before they would be encouraged to try to quit?
o Hard pressed to find anything anyone could do; they enjoy smoking and don‘t want to give it up
o If the government was serious about wanting smokers to quit they would pay the cost of quitting
Source: Health Canada. What Works on Quitting: Why Smokers Smoke. [presentation at TCD Strategic Planning Session]. 2008.
The proportion of adult smokers who intend to quit is increasing.
o The proportion of smokers who intend to quit smoking has increased from around half in
1999 to nearly two thirds in the first half of 2008; only 25% of smokers report ―no intention
to quit.‖
o Age and gender differences in intention to quit were modest (see next page).
% who intend to quit in the next 6 months, by age, CTUMS 1999-2008 1,2
*First half of 2008 (Feb-June) only
9

% who intend to quit in the next 6 months, by sex, adults 25+, CTUMS 1999-2008 1,2
* First half of 2008 (Feb-June) only
Almost half of adult smokers have tried to quit in the past year.
o Younger smokers are more likely to attempt to quit: 60% of smokers aged 25-34 attempted to
quit in past year compared to 45% of smokers 35 years and older.
o Gender differences are modest.
o Lower SES smokers appear to be equally likely to try to quit smoking; however, recent UK
data suggests they may be less successful when doing so. 5
o Inconsistencies in question coverage make comparisons over time difficult/inappropriate.
10

% who attempted to quit in the past year* adults 25+, CTUMS 1999-2008 1,2
*Note: Question coverage is inconsistent: 2000-2002 surveys included current smokers [probably also 1999 –
unconfirmed]; 2003 survey included only smokers who had tried to quit in the past 2 years; 2004-2007 included current
smokers and former smokers who had quit in past 12 months [probably also 2008 – unconfirmed]
** First half of 2008 (Feb-June) only
11

TV and cigarette packs are the most common sources of cessation
information among adult smokers.
o Television was the most common source of information on the dangers of smoking and
information on quitting. 6
o Just under half of smokers had received advice from a healthcare professional. 6
o Lower income and lower education level appear to be associated with slightly decreased
likelihood of noticing/receiving anti-smoking messages. 6
o There were no significant differences across income groups in receiving antismoking/cessation
information from health care sources. 6
Sources of anti-smoking information for adult daily smokers, ITC 4-Country Survey, 2006/07 (n=1622) 6
12

Half of adult smokers received some form of cessation assistance in
the past year.
o The majority of Canadian smokers surveyed in the 2006-07 wave of the ITC Four
Country Survey had used some form of cessation assistance since they were last
surveyed (in the past year). 7
o Almost half of Canadian smokers surveyed in the ITC study had received assistance
from a health professional through advice, a pamphlet, a referral, or a prescription; when
only those who had visited a health professional were included, this proportion increased
to almost two-thirds. 7
o Recent research shows that Canadian smokers are receptive to quit advice
from physicians, but less likely to ask other health professionals. Few smokers
received advice from pharmacists and dentists. 8
o Few of the smokers surveyed in the ITC study had used other forms of assistance, such
as telephone helplines, the internet, and local services. 7
o The most recent data suggests that approximately 17% of daily smokers in
Canada report using nicotine replacement therapy (NRT) in the past year. 9
o
Among NRT users, the patch is approximately twice as popular as nicotine
gum, with very low rates of use for the nicotine inhaler and lozenge. 9
Use of various forms of cessation assistance in the past year ITC 2006/07, Canada (n=2022) 7
13

Use of cessation assistance in the past year (or since last surveyed), by income group, ITC 2006/07,
Canada (n=2022) 7
Most smokers pay full price for stop-smoking medications.
o Among NRT users surveyed in the 2006/07 wave of the ITC:
o Six in ten had obtained their NRT over-the-counter. 7
o 73% paid full price for NRT at last use; less than 10% received NRT ―free.‖ 7
o A third received NRT by prescription rather than ―over the counter.‖ 7
o Approximately 6 out of 10 smokers would be interested in NRT if it were offered for free. 10
Many Canadians hold false beliefs about nicotine replacement
therapy.
o Approximately one third of smokers report that stop-smoking
medications might harm their health. 11
o Approximately one third of smokers believe nicotine in
cigarettes causes ―most of the cancers.‖ 11
o Many smokers use NRT for an insufficient amount of time. 11
Smokers want more information about quitting.
o Approximately 9 out of 10 smokers report a desire for more information on quitting. 12
o Knowledge of stop-smoking medications and other types of formal assistance may
increase likelihood of trying to quit and adoption of assistance when doing so.
14

SUMMARY OF PATTERNS AND TRENDS
The prevalence of smoking has steadily decreased for approximately 4 decades;
however, the rate of decline may have slowed in recent years.
The evidence does not support a ―hardening‖ of Canadian smokers; rather, intentions
to quit and quit attempts have increased among adults in recent years.
Socioeconomic inequalities persist; however, prevalence has declined among all SES
groups at a similar rate over the past 10 years.
There is a serious lack of information on patterns of quitting among Canadian adults,
as well as the effectiveness of different cessation services and interventions.
Adult smokers express a strong desire for additional cessation information and
support.
15

CURRENT PRACTICE: WHAT WE KNOW WORKS
Tobacco control policies work.
Tobacco control regulations and population-level policies are primarily responsible for the
significant declines in smoking prevalence observed over the past 40 years. Measures to
increase the price of tobacco products, comprehensive restrictions on
tobacco industry marketing, comprehensive smoke-free policies, mass
media campaigns, and large pictorial health warnings on tobacco
packaging are among the most effective policy measures to reduce
tobacco use among adults. Although Canada has set international
precedents in several of these policy domains in the past, it has
recently fallen behind in a number of policy areas and has yet to fulfill
its obligations under the WHO Framework Convention on Tobacco
Control in several key areas. In order to achieve further declines in
smoking prevalence in the medium and longer-term, Canada must
develop and implement the next generation of tobacco control
policies, several of which are discussed in the next section under
Priorities for Action.
Increasing accessibility and use of cessation services
A range of cessation methods increase the likelihood of long-term abstinence from smoking.
Although an increasing proportion of Canadians report using some form of cessation
assistance when attempting to quit, most smokers still try to quit without any type of formal
help. Increasing the use of the cessation services reviewed below is likely to increase
population-level cessation rates in the short to medium term.
Self-help materials
Standard self-help materials can increase quit rates compared to no intervention, but the
effect is typically modest. 13 There is evidence that materials that are tailored for individual
smokers are more effective than untailored materials, although the absolute effect size is
small. There is a lack of evidence that self-help materials provide additional benefit when
used alongside other interventions such as advice from a healthcare professional, or
nicotine replacement therapy.
Contests and incentives
―Quit & Win‖ contests and providing financial incentives for smoking cessation are an
increasingly common community-based intervention to reduce tobacco use. Although
contests and incentives do not appear to increase the likelihood of long-term abstinence for
a given quit attempt, they have the potential to reduce prevalence by stimulating a greater
number of quit attempts in the population. 14
Mass media
Mass media interventions involve communication through television, radio, newspapers,
billboards, posters, leaflets or booklets, with the intention of encouraging smokers to quit,
16

and of maintaining abstinence in non-smokers. Media campaigns contribute to a reduction in
smoking when used as part of a comprehensive set of interventions. 15 There is a growing
evidence base on effective themes and executional styles to direct campaign strategies. 16
Face-to-face counselling
Individual face-to-face counselling (often with supplemental telephone support) can help
smokers quit, but there is insufficient evidence regarding whether more intensive counselling
is better. 17 Group counselling 18 is more effective for helping people to stop smoking than
self-help materials without face-to-face instruction and group support. It is unclear whether
groups are better than individual counselling or other advice, but they are more effective
than no treatment. Not all smokers making a quit attempt want to attend group meetings, but
for those who do, group counselling is likely to be helpful.
Telephone counselling
Counselling via telephone hotlines can be provided as part of a program or on its own, and
can potentially reach large numbers of people. A review of trials found telephone counselling
to be effective; multiple sessions are likely to be most helpful. 19
Web-assisted interventions
The internet can be an effective medium for providing smoking cessation counselling and
providing self-help materials. Web-assisted interventions can be very cost-effective and
seem to appeal to a reasonable number of Canadian smokers. 20,21
Counselling & brief advice from health professionals
Advice from doctors increases long-term abstinence from
smoking. 22 Even brief advice increases the likelihood of
abstinence one year later, while more intensive advice
may result in slightly higher rates of quitting. Providing
follow-up support after offering the advice may further
increase quit rates. Advice and support from other health
professionals, including dentists, 23 nurses, 24 and
pharmacists, 25 can also increase abstinence rates,
particularly when delivered in a hospital setting.
Pharmacotherapy
Seven ―first-line‖ medications reliably increase long-term smoking abstinence rates:
bupropion SR, varenicline, and 5 nicotine-based medications: nicotine gum, inhaler,
lozenge, nasal spray, and patch. 26,27,28 In addition, two ―second-line‖ medications increase
the odds of quitting: clonidine and ortriptyline. Certain combinations of first-line medications
have also been shown to be effective smoking cessation treatments, most notably long-term
(>14 weeks) nicotine patch + other NRT (gum and spray), the nicotine patch + the nicotine
inhaler, and the nicotine patch + bupropion SR.
Workplace interventions
Proven stop-smoking methods, like group therapy, individual counselling and nicotine
replacement therapy, are equally effective when offered in the workplace. 29 The evidence is
less clear for self-help methods. Social and environmental support, competitions and
incentives, and comprehensive programs do not show a clear benefit in helping smokers to
quit at work.
17

CASE STUDY: Increasing use of cessation services in the UK
Recent data suggest that only 4% of smokers make use of the UK‘s national stop smoking services.
A consultation report provided the following recommendations:
Increasing access and accessibility:
Stop smoking services need to be available in a variety of settings, including: the workplace;
community pharmacies; schools and colleges; and, community resources;
Cessation information and resources should be widely available and provided in different
languages with internet-based resources;
‗Smoke-free families‘ initiatives should be available through schools and Children‘s Centres;
Outreach services should be made available through mobile units;
Services should operate extended hours;
A 24 hour helpline is needed; and,
Stop smoking services should be open to smokers who have had an unsuccessful quit attempt as
soon as they are ready to try again.
Identifying and reaching smokers proactively:
Hospitals should record the smoking status of all patients;
Routine screening for tobacco use among pregnant women;
Clinical staff, including midwives and oral health professionals, should be able to provide brief
interventions and referral to stop smoking advice, and there should be training and protected time
for this;
Referral to stop smoking services should be part of the GP‘s Quality and Outcomes Framework;
and,
Proactive contact of previous service users who failed to quit.
Vulnerable groups and hard to engage groups:
Smoking cessation should be embedded as part of a wider drive to improve general health and
well-being promotion in services working with the most marginalised groups, including drug
treatment services;
GPs should ask patients with severe mental illness to be registered for annual physical health
checks, using this as an opportunity to offer cessation support;
Tailored smoking cessation programs for people with mental health problems; and,
Cessation services should be located in prisons, as this would create an opportunity to reach
target groups, among them disadvantaged young males, who are otherwise hard to reach; and in
deprived areas, where prevalence is high.
Source: UK Department of Health. Consultation on the future of tobacco control: consultation report, 2008.
Available online at: http://www.dh.gov.uk/en/Consultations/Responsestoconsultations/DH_091382.
Comprehensive and integrated tobacco control programs work.
Comprehensive tobacco control programs have consistently been demonstrated as the most
effect approach to reducing prevalence. 30,31,32 The most dramatic declines in prevalence
observed within jurisdictions are difficult to attribute to any one intervention or approach;
rather, they reflect the combined effects of multiple programs and a comprehensive set of
tobacco control regulations. 30,31
18

Effective tobacco control programs not only have a comprehensive list of policies and
programs, they also link and integrate these programs and policies to maximize their
effectiveness. In Canada, different levels of government have largely failed to exploit the
potential to link different types of mass media campaigns and to link these campaigns with
effective cessation services. The case study below illustrates the potential benefit of
developing stronger links across individual initiatives. Other possibilities include linking brief
advice from health professionals—one of the most common and effective sources of
cessation information—with concrete cessation services beyond the health care setting.
CASE STUDY: Linking policies and programs
In 2006, Australia provided an effective example of linking three types of programs and policies: new
health warnings on packages, telephone quitlines, and mass media campaigns. Providing telephone
quitlines on packages has proven to be an excellent way of stimulating additional quit attempts and
linking smokers making these quit attempts to an effective cessation service. Evidence from the
Netherlands, UK, Brazil, and Australia all
demonstrate that calls to quitline services jump significantly
when these numbers are provided on packages.
New South Wales, one of the Australian states, also featured
images from the new health warnings in a mass media
campaign, including television, print, and billboard ads.
These advertisements helped to make the information on
health warnings more vivid and provided a compelling
narrative to the pictures and text. Smokers who see these
advertisements are likely to recall them each time they see
the related images on the pack. An evaluation of this media
campaign indicated that it was among the most effective
mass media campaigns in the state.
For more information on this campaign, please visit:
http://www.cancerinstitute.org.au/cancer_inst/campaigns/healthwarnings2006.html.
Source: Hammond D. Tobacco labelling and packaging toolkit: A guide to FCTC Article 11. Available online at:
www.tobaccolabels.org.
Recruiting the services of health professionals works.
Brief advice from health professionals is among the most common sources of cessation
information and support for Canadian smokers, and is extremely cost-effective. A series of
clinical practice guidelines have been developed for a variety of health professionals;
however, the potential role of health professionals in promoting smoking cessation among
adults has yet to be fully realized. In addition, cessation services have yet to be properly
integrated with the primary care system, as described below.
19

Comprehensive cessation services work….at a cost.
A number of countries have recently invested in national smoking cessation services. 33
Although there is no formal definition of what constitutes a comprehensive cessation
service, several common factors include: 1) a centralized, nationally coordinated structure,
2) dedicated cessation ―clinics‖ with expanded access to behavioural and pharmacotherapy
services, and 3) subsidies and expanded coverage for the costs of services, particularly for
disadvantaged groups. In several cases, such as the UK and South Korea, responsibility for
coordinating and funding cessation services falls within the primary health care system.
Comprehensive cessation services are resource intensive, as illustrated by the examples
below. Advocates of comprehensive services argue that cessation services are an extremely
cost-effective investment relative to other health expenditures; however, the cost of creating
such a system remains a barrier in many jurisdictions, particularly where cessation services
must be developed outside of agencies responsible for primary health care.
Do comprehensive cessation services help to significantly reduce smoking prevalence?
There is strong evidence that the individual components in a cessation service are effective.
There are also a number of evaluations of the impact of the national service implemented in
the UK (see example below). For example, data from a cohort of smokers in the UK and in 3
other countries (Canada, the US, and Australia) suggest that UK smokers are no more likely
to intend or attempt to quit smoking than smokers in Canada, the US, and Australia;
however, it appears that UK smokers making quit attempts are somewhat more likely to
succeed and remain abstinent than smokers attempting to quit in Canada, the US and
Australia. 7 Although this difference cannot necessarily be attributed to the national cessation
service operated by the National Health Service in the UK, it does provide some intriguing
cross-country comparisons using population-based data.
CASE STUDY: Evaluation of comprehensive cessation services in the UK
Approximately 10 years ago, the UK government developed a comprehensive national cessation
service under the National Health Service. Smoking cessation services included behavioural and
pharmaceutical interventions, such as brief advice and counselling, intensive support, and the
administration and subsidization of nicotine replacement therapy (NRT) and bupropion.
Comprehensive services, such as the one introduced by the NHS in the UK are expensive. For
example, approximately 300 million dollars was invested over a 3-year period.
An evaluation of the NHS cessation services concluded that: NHS intensive interventions are
―reasonably‖ effective at increasing cessation rates in the long-term. The report also indicates:
1. The content of the interventions may influence their effectiveness.
‗Intermediate interventions‘ appear to be effective in facilitating smoking cessation. Group
interventions may be more effective than those delivered one-on-one, although both types of
intervention are essential for the continuation of the services.
...continued on following page
20

CASE STUDY: Evaluation of comprehensive cessation services in the UK
2. The settings may have an effect.
There is some indirect evidence that the setting may influence effectiveness, but this evidence is not
conclusive. However, there is strong evidence that inpatient interventions in hospital settings are
effective in facilitating smoking cessation
3. External factors affect success rates.
Factors such as target setting appear to have influenced the effectiveness of intensive smoking
cessation interventions.
4. Sub-group & client characteristics are important.
The characteristics of certain sub-groups also have an effect on the effectiveness of the NHS services.
Age, sex, level of addiction and previous quit attempts are all correlated with quitting success. While
females set more quit dates than males, they were less likely to succeed in quitting than males. Older
smokers (both male and female) were also more likely to quit successfully than younger smokers.
Also, several sub-populations face unique barriers in attempting to quit smoking. Pregnant women,
smokers from ―blue collar‖ professions, and institutionalised populations all face substantial barriers
that impede smoking cessation attempts.
Source: Bell K, McCullough L, Greaves L, et al. NICE Rapid Review: The Effectiveness of National Health Service Intensive
Treatments for Smoking Cessation in England, 2007.
At present, Canada does not have anything approaching a comprehensive, national
smoking cessation service. However, the province of Quebec has implemented the most
comprehensive subsidization program for pharmacotherapies, as described below.
CASE STUDY: Subsidizing stop-smoking medication in Quebec
In September 2000, Quebec added coverage of three stop-smoking medications to its provincial
medication insurance plan: bupropion, nicotine patch, and gum, followed by the nicotine lozenge.
Between 2000 and 2004, coverage cost $55 million for approximately 306,000 individuals, or
approximate $181/user.
The subsidization plan has resulted in greater use of NRT.
Overall, the plan is a cost-effective measure relative to other types of medication coverage.
Strong majorities of health professionals support the plan.
The only other province with special coverage for stop-smoking medications is PEI, where
coverage is provided for participants in group and individual counselling, up to a maximum of
$75/year. Manitoba has removed the PST on nicotine replacement therapy.
Source: Institute National De Sante Publique du Quebec. Remboursement des aides pharmacologiques a l‘arret
tabagique au Quebec. Phase II. 2007. Available online at: http://www.inspq.qc.ca/pdf/publications/707-PCAPFinal.pdf.
A review of subsidization programs from other jurisdictions concluded that:
“Increasing the level of health insurance coverage or reducing direct costs of smoking
cessation treatment may increase the number of smokers who quit successfully, as well
as the number of quit attempts and the use of treatment. There is not enough evidence to
show whether offering financial incentives to healthcare providers for identifying and
treating smokers is effective in increasing the number of smokers who quit.”
Source: Kaper J, Wagena EJ, Severens JL, Van Schayck CP. Healthcare financing systems for increasing the use of
tobacco dependence treatment. Cochrane Database of Systematic Reviews 2005, Issue 1.
21

Target audiences and special populations
Population-based interventions that are targeted at the entire population are likely to have
the greatest impact on prevalence rates. Interventions that have a relatively modest effect
on individuals can have a significant impact on population-level trends if they have sufficient
reach. As a result, tailoring interventions to specific target groups can limit their impact if it
also limits the reach and audience of smokers.
A recent review in the area of mass media campaigns also provides encouraging evidence
that interventions do not need to target sub-groups to be highly effective. The review
examined the effectiveness of targeting media at different age groups (e.g., youth vs. adults)
and different ethnicities, and concluded that campaigns that were effective with adults were
also those most likely to be effective with youth and other sub-groups. Another common
approach is to tailor media campaigns based upon intentions to quit, such as creating
separate messages for ―hardcore‖ smokers. However, the evidence suggests that smokers
who are not interested in quitting respond to the same types of messages as those that are
willing to quit: emotionally-engaging messages that also provide concrete information and
support for cessation. In other words, the evidence suggests only limited value in expending
significant resources to create tailored media campaigns for different subgroups. 16 Not all
interventions are similar, and there may be sound reasons for targeting sub-groups of
smokers for some types of interventions. For example, nicotine replacement therapy has not
been demonstrated to be very effective among individuals who smoke fewer than 10
cigarettes per day. Nevertheless, unless there is a compelling reason to limit the target
audience for a particular intervention, policies and programs should adopt a broad,
population-based approach, particularly where resources are limited. Canadian trends in
smoking prevalence and consumption also provide general support for this approach:
prevalence and consumption have been declining at approximately the same rate for
different genders and socio-economic groups in Canada. Reviews from other countries also
suggest population-based policies reduce, rather than exacerbate, inequalities. 34
Nevertheless, there is a strong argument for targeting services at disadvantaged groups.
There is also an increasing evidence base concerning effective strategies to do so. 35 Where
targeting does take place, it should focus upon sub-groups that bear a significant proportion
of the health burden from tobacco use. Three of these special populations (First Nations,
persons with mental illness, and pregnant women) are described below.
First Nations
Prevalence of smoking among First Nations is estimated at more than 50%—approximately
three times the levels of the general population—and does not appear to be declining at the
same rate as other Canadians. 36,37 Alarming levels of smoking have also been observed
among other Aboriginal populations, particularly among the Inuit,
where prevalence estimates reach as high as 70%. 38 In addition to the
high prevalence of smoking, there are a number of other compelling
reasons for developing specific strategies for First Nations
communities, including the prevalence of other addictive behaviours,
traditional use of tobacco and other cultural factors, as well as the
presence of tobacco manufacturing in some communities.
22

Persons with mental illness
Individuals with psychiatric illness have a much higher prevalence of smoking, as well as
substantially higher levels of daily consumption. 39 Prevalence among the mentally ill is
approximately double that of the general population, and may be as high as 90% among
people diagnosed with schizophrenia. 40 A number of biological, psychological, and social
factors may explain these high smoking rates, including the lack of smoking cessation
treatment in mental health settings. The most effective interventions to help psychiatric
patients stop smoking are similar to those that are effective in the general population;
however, there are a number of special considerations for this sub-population, including
factors such as demographics, diagnosis and concurrent medication use. 41 In addition, an
over-emphasis on the ―self-medication hypothesis‖ to explain the high rates of tobacco use
in psychiatric populations may result in inadequate attention to other potential explanations
for this addictive behaviour among those with mental disorders.
Pregnant women
In 2002, over 200,000 Canadian women (~14%) smoked while pregnant. 42 Significant
numbers of pregnant women are also exposed to second-hand smoke. Smoking during
pregnancy is associated with several serious risks, including preterm delivery, spontaneous
abortion, growth restriction, increased risk of sudden infant death syndrome (SIDS), as well
as long-term behavioural and psychiatric disorders. 43 Interventions to reduce smoking during
pregnancy also provide the opportunity to promote long-term abstinence, as well as to
reduce post-natal exposure to second-hand smoke. Pregnant smokers and mothers with
young children merit tailored interventions and more intensive efforts to overcome barriers. 44
Is there an optimum setting to reach adults?
Health care settings
Hospitals, pharmacies, long-term care, mental facilities, walk-in clinics and other health care
settings are among the most effective settings in which to reach adult smokers. Health care
professionals are already an important partner for smoking cessation interventions;
however, these efforts need to be enhanced to accelerate reductions in prevalence. In
particular, interventions should link health care professionals and health care consumers
within these settings to effective cessation services outside of these settings. Telephone
quitlines, web-assisted interventions, subsidized access to stop-smoking medications, and
other formal sources of support can be used supplement existing services and as a way to
offer concrete support in addition to brief advice to quit.
Media
Comprehensive media campaigns are a critical component of any tobacco control program
and are an important means of increasing quit attempts and encouraging the use of effective
cessation methods. Cessation campaigns also help to generate public and political support
for more comprehensive policies and programs. Canada has lagged far behind many other
jurisdictions in this critical area and a renewed commitment to strong media campaigns is
essential to reductions in smoking prevalence in both the near and longer term.
23

Occupational settings
Workplaces provide an opportunity to reach large numbers of smokers. Proven stopsmoking
methods, like group therapy, individual counselling and nicotine replacement
therapy, are equally effective when offered in the workplace. 45 Where resources are scarce,
workplaces with higher proportions of smokers should be targeted. 46 Alternatively, some
occupational settings have lower prevalence rates, but have very large numbers of
employees; as a result, there may be larger absolute numbers of smokers in these settings.
Retail settings
Retail outlets are an excellent setting in which to target adult smokers. Most smokers
continue to purchase their cigarettes from retail settings, primarily from convenience stores
or small grocery stores.Retail outlets also have incredibly high reach among the general
population, including children and youth. To date, the potential to use retail settings to
promote smoking cessation and tobacco control has largely gone unexploited. Tobacco
control agencies should explore whether paid media in retail outlets is a cost-effective
medium. Retail settings could also be targeted through more comprehensive regulation. For
example, at least one Australian state requires a telephone quitline to be prominently
displayed in any retail outlet where tobacco is sold. The province of British Columbia also
requires a sign to be displayed at the point of sale. The effectiveness of these interventions
could be improved significantly by requiring a rotating series of messages and by providing
concrete information on quitting. These messages should also be linked with other media
campaigns, including television advertisements, health warnings on tobacco packages, etc.
Levels of government (federal, provincial, municipal)
The fragmentation of services across different levels of government is perhaps the most
significant barrier to a comprehensive cessation strategy in Canada. At present, there is a
lack of coordination across jurisdictions, resulting in major gaps and inequalities in the types
of services available to smokers. Of the three levels of government, Health Canada has the
strongest mandate—and bears the greatest responsibility—for coordinating services on a
national level. The example of telephone quitlines illustrates both the challenges and
opportunities for developing services at a national level. Recently, the renewal of health
warnings on cigarette packages provided an opportunity to print a telephone quitline number
on all packages. However, not all provinces offered quitlines and those that did, used
different telephone numbers. Health Canada has been working with the various
stakeholders to ensure that a single number printed on all packages sold in Canada will
allow smokers to contact a helpline in every province.
Centralization of services across different levels of government is also a cost-effective
option. Major interventions, such as web-based cessation interventions, materials for
training health professionals, etc., need not be duplicated at various levels of administration.
Not all types of interventions—such as workplace interventions and the implementation of
various policies—are as easily centralized or standardized as telephone quitlines.
Nevertheless, Health Canada must take the lead in developing a coordinated level of
service across jurisdictions. Ultimately, it makes no difference to the smoker whether a
particular service is provided by a local, provincial, or federal program; what matters is that
these services are available and of comparable quality across the country.
24

PRIORITITES FOR ACTION: SPECIFIC INTERVENTIONS
In order to identify priorities for action, approximately 50 key tobacco control stakeholders
were contacted via email and invited to submit recommendations and proposals. A total of
30 stakeholders replied. These stakeholders represented 7 different provinces and various
sectors, including the research/academic community (n=13) and the public sector, including
several program providers (n=5), as well as non-governmental organizations (n=12).
The purpose of this exercise was not to conduct an exhaustive consultation with a
representative sample of stakeholders, but to solicit a range of ideas and perspectives to
help frame a national discussion on strategies to reduce adult prevalence. The following
sections describe common themes, as well as illustrative quotes within each area.
More comprehensive policy measures and regulations (20 comments)
Price measures: taxation and contraband (28 comments)
There was almost unanimous agreement among
stakeholders that measures to increase the price of
cigarettes and address the threat from contraband tobacco
are the most important strategies for reducing adult smoking
both in the immediate future and in the long term.
“Controlling the illicit market and raising prices. In the short term, nothing else will have
much effect.”
“ Ensure continued tobacco tax increases on a regular basis equivalent to or
exceeding inflation... Increase taxes on roll-your-own (loose/RYO) tobacco
proportionally more than manufactured cigarettes to equalize prices. Taxes on loose
or RYO tobacco should be increased in proportionally greater amounts than
manufactured cigarettes until the tax on approximately 0.5 grams of loose tobacco is
equal to the tax on one cigarette.”
“Authorize and implement First Nations tobacco taxes for 600+ First Nations. End tax
deductibility for tobacco promotion expenses....Ensure that new urban reserves are
required to implement a First Nations Tobacco Tax for sales of tobacco products.”
Stakeholders also recommended using taxation as a means to reduce the cost of
pharmacotherapies, as well as to shift tobacco users to less harmful tobacco products.
“Remove GST from nicotine replacement products and prescription cessation products
such as Zyban and Champix.”
“Differential regulation and taxation of tobacco/nicotine products that put cigarettes at
the greatest marketplace disadvantage.”
25

Smoke-free policies (10 comments)
A number of stakeholders recommended broader restrictions on smoking, including in
outdoor areas, cars and households, as well as multi-unit dwellings.
“Expanding smoke-free legislation to outdoor public places such as patios, doorways,
parks, playgrounds and other recreation areas, and vehicles across Canada.”
However, at least one stakeholder questioned whether more comprehensive smoking
restrictions would impact smoking rates:
“Further restrictions on permitted locations for smoking (private vehicles, outdoor
venues etc.) may be justified, but are unlikely to have much impact on smoking
prevalence."
Reducing availability of tobacco and retail outlets (10 comments)
There was strong consensus among stakeholders regarding the importance of reducing
the availability of tobacco products, mainly through a reduction in the number of retail
outlets.
“Experience with alcohol sale, among other products, shows that the number and ease
of access to sales outlets has a significant effect on consumption. Currently, tobacco
industry products are sold in over 17,000 outlets in Ontario, and many thousands
more in other provinces. The number of outlets must be drastically reduced and all
types of sale more effectively controlled.”
“Severe restrictions on availability, making it a chore for people to find the product,
accompanied by measures to curtail illicit activity.”
Plain packaging (8 comments)
Plain packaging was recommended as an important strategy for correcting false beliefs
about tobacco products, for ―denormalizing‖ tobacco use, as well as restricting tobacco
industry marketing. There was also support for prohibiting misleading brand descriptors,
such as ―smooth‖ and ―slims‖ from packages.
“Regulating tobacco packaging and marketing to minimise or eliminate any and all
misleading or false assumptions on the dangers of tobacco (misleading descriptors,
plain packaging, etc.)”
“A law requiring plain/standardized packaging would strongly and quickly impact social
norms regarding tobacco, and would likely also have a direct impact on smokers’
opinions of their addiction.”
26

Mass media campaigns & public education (8 comments)
A number of stakeholders stressed the lack of effective mass media campaigns in
Canada, as well as their importance in educating the public about the need for more
comprehensive measures in other policy areas.
“A sustained and compelling mass media campaign...”
“Any and all of [other interventions] to be accompanied by large investments in public
education and media campaigns.”
“Have a clear and over-arching communications objective. This objective should be to
“increase public appreciation for the need for government and societal initiatives to
reduce tobacco use and its resulting harm”. The priority should not be to please
people or to increase smokers’ desire to quit, but rather to shift public attitudes about
tobacco products and tobacco manufacturers, about industry actions that increase
tobacco use and about the effective measures that can be taken to reduce it.”
“Tobacco industry denormalization (TID): a strategy to tell the public the truth about the
tobacco industry’s role in the perpetuation of the epidemic in appropriate language
including demonstration of why the industry falls outside the boundaries of normal
business behaviour and recommended interventions to reverse the industry’s
decades-long attempt to normalize its behaviour and products.”
Health warnings (6 comments)
Stakeholder recommendations for health warnings highlighted the need for larger
warnings, more regular updates to the warnings, as well as linking the health warning
campaign with other media interventions.
“Stronger, larger and more compelling warnings would increase awareness of the true
dangers of tobacco. Very large warnings would also reduce the normalization /
glamorization generated by tobacco brands.”
Marketing ban (5 comments)
A number of stakeholders stressed the importance of enforcing existing
restrictions on advertising and promotion, as well as the need for a
complete ban on all forms of tobacco marketing.
“Implement a total ban on advertising/promotion.”
“Ensure effective enforcement of [advertising and promotion restrictions
under the ] Tobacco Act.”
27

Product regulation (4 comments)
Four stakeholders identified the need to place restrictions on tobacco products
themselves. The main themes were the need to ban flavours, as well as to pursue
reductions in the addictive potential of products by targeting nicotine, rather than efforts to
reduce the harmfulness of conventional cigarettes.
“Ban the sale of flavoured tobacco products.”
“Regulations should prohibit any aspect of cigarette contents or design that promotes
tobacco dependence and repeated use, including the use of flavours. Regulations
should also consider restrictions on nicotine content”
“Developing a national policy on nicotine, based on the risks of the delivery system.”
Provision/Access to cessation services (12 comments)
A strong majority of stakeholders recommended measures to improve the availability of
cessation services and treatments to smokers, including disadvantaged groups. Many
stakeholders stressed that existing levels of cessation support and access to cessation
services in Canada is completely inadequate. Several stressed that focussing upon specific
interventions was lower priority than developing a comprehensive, coordinated cessation
system—these comments are included under the ―Systems & Tools‖ section. A number of
stakeholders specifically mentioned subsidies to reduce the cost of pharmacotherapies as
an important component of comprehensive cessation services.
“Freely accessible smoking cessation pharmacotherapy. The great majority of adult
smokers are chronically dependent on tobacco and nicotine replacement therapy and
medications such as varenicline and sustained-release buproprion will be required to
achieve abstinence. Cost of these drugs is a significant barrier that must be removed.”
“Differential regulation and taxation of tobacco/nicotine products that put cigarettes at
the greatest marketplace disadvantage.”
Greater focus on special populations (6 comments)
Several stakeholders stressed the need to reach ―high burden‖ sub-populations and to
ensure an equitable level of access to cessation services and support. Several comments in
this area were linked to the need to subsidize the cost of smoking cessation in order to
reduce the cost barrier for disadvantaged groups.
28

“Rather than focus on smoking prevalence rates, switch attention to policies and
practices which will have the greatest effect on expected future burden. Program
providers tend to go after the "low hanging fruit who coincidently have the low future
expected burden of tobacco related disease". The net effect is that groups that bare a
greater proportion of the burden such as Aboriginals, persons with mental health
problems, etc. tend to be left out of the research and practice equation.”
“Greater access to free smoking cessation products and advice from health care
providers, especially for lower SES and other key target groups”
Novel/non-traditional therapy, including harm reduction (5 comments)
Several stakeholders stressed the need to pursue non-traditional cessation therapies,
particularly for smokers who fail to respond to conventional methods.
“Testing and making available, where appropriate, new smoking cessation aids for
those that do not respond to NRTs and other traditional forms of treatments
(denicotinized cigarettes?, snus, e-cigarettes etc.)”
“Distinguish between the drug & the delivery vehicle. Most smokers are seeking
nicotine and were we to give alternative sources of the drug by non-combustion and
medicinal sources we could drastically reduce smoking prevalence.”
“A concerted effort at harm reduction...could have a substantial impact in the medium
term. The two obstacles are regulatory inertia and the prohibitionist mindset of much
of the tobacco control community. The latter may be insurmountable (though it would
still be worth a try). Clear statements on relative risk and a substantial risk-based
premium built into taxation would be two important steps to moving smokers to less
hazardous products.”
29

PRIORITIES FOR ACTION: SYSTEMS & TOOLS
Stakeholders were also asked to suggest priorities for the development of ―systems‖ and
―tools‖. There was considerable overlap in each of these areas with the themes and needs
identified for specific interventions: more comprehensive policy and regulatory systems, as
well as systems to improve the availability and use of cessation systems. The following
section highlights unique comments specific to the development of systems and tools.
Comprehensive, coordinated cessation system (10 comments)
The most common theme related to ―systems‖ was the need to develop a more
comprehensive smoking cessation system with expanded services and fewer barriers to
access. There was a clear consensus among stakeholders that the existing level of
cessation services is inadequate and an implicit sense that Canada is rapidly falling behind
other jurisdictions in this critical area.
“Any and all of [other interventions] need to be accompanied by a comprehensive
smoking cessation system that will include a smokers' registry with proactive
outreach to smokers offering tailored interventions and combinations of
interventions.”
“An integrated effort to promote cessation, including wider access to a wider range of
NRT-type products and a thorough public education effort to dispel myths about
nicotine.”
“...integrated multi-level smoking cessation system incorporating all elements (media
promotions, pharmacoptherapies, minimal through intensive interventions, intake
and referral systems, smoker registries)...”
“Despite years of discussion and some initiatives in some jurisdictions, there is still
no comprehensive, readily-accessible cessation system available for all Canadians.
Key elements of such a system include funding of stop-smoking medications for all
those on low-income drug benefit plans; publication of the Smokers’ Helpline
telephone numbers on all cigarette packages; much broader promotion of available
services; implementation of Ottawa Heart Institute-type cessation protocols for all
hospitals and similar health care facilities; mandated cessation counselling training
for all health care professionals and allied professions.”
“Establishment and co-ordination of a national level best practises system for
implementing and monitoring treatment that is consistent across jurisdictions.”
“Consolidate effort (due to a variety of not unrelated factors, there are multiple
sources of multiple initiatives, usually nickel and diming to the best of their ability
with great intentions and little effect).”
30

Better use of tool and training for health professionals (7 comments)
A number of stakeholders emphasized the importance of developing tools for health
professionals, as well as systems to promote the use of existing tools and resources that
have already been developed. 47
“Clinical Interventions - this is where Canada falls short. We have no clinical practice
guidelines at national level and very poor availability of treatments...”
“Tools to provide better guidance for primary care providers (family physicians, nurse
practitioners, registered nurses, dentists etc) in providing smoking cessation support
(better dissemination and uptake) -- skill development rather than knowledge
dissemination.‖
“A systems approach to smoking cessation that is embraced and implemented by all
health practitioners, e.g., should be the same as checking blood pressure with every
patient.”
“Cessation counselling and brief intervention workshops for healthcare providers and
workplaces.”
“Systems to triage or match smokers with the most appropriate intervention to
maximize resources and effectiveness of services.”
Services for special populations (4 comments)
Several stakeholders stressed the importance of developing a cessation system that meets
the needs of high-burden ―special populations‖, including the need to tailor resources.
““An Aboriginal tobacco control program that is not merely an adaptation of, or add-on
to, that intended for general pop.”
“Improve early education and support to pregnant women...”
Knowledge exchange system (2 comments)
Only two stakeholders referred to knowledge exchange systems and tools:
“Ways to improve knowledge transfer amongst Canadians engaged in tobacco control
efforts and between tobacco control and other social networks. Ways to improve
knowledge transfer amongst federal government agencies regarding tobacco control.”
“Better integration of research into treatment...”
31

Better funding system for tobacco control (3 comments)
Several stakeholders highlighted the importance of a stable and efficient funding system for
tobacco control.
“With recent disbanding of CTCRI, we need mechanisms to maintain (and hopefully
build) capacity in tobacco control research in Canada.”
“Efforts to increase knowledge and expertise within Health Canada, and to link this
issue to other public health issues.”
“Funding for anti-tobacco groups should not solely be linked to projects. Core funding
to promote tobacco control and respond to tobacco industry manipulation and
misinformation is essential, not just (or mainly) project funding. Organizations
receiving funding should not be overburdened by reporting requirements, which
currently represents a ridiculous workload. Provincial coalitions should be able to
count on federal core funding, especially if provincial funding is weak.”
32

PRIORITIES FOR ACTION: RESEARCH AND EVIDENCE
Develop evidence base for new regulatory changes (11 comments)
The most common research theme identified by stakeholders was the need to collect
evidence to support the next generation of policies and regulations. The topic areas were
fairly broad and similar to the themes identified under ―specific interventions‖.
“A clearer idea of the relationship between tax levels, tax structure, and short-term and
long-term impacts with respect to prevalence, disease levels, etc.”
“Research evidence to plan, implement, monitor and evaluate strategies [including to]
vastly reduce tobacco retail outlet density”
“What messages and support systems encourage smokers, especially heavy
smokers, to quit.”
“...more research on non-drug cessation methods for individuals, and mass media
campaigns for smoking cessation.”
“Conduct studies on impact of generic packaging”
“Research to understand the impact of regulations on nicotine content of products”
Treatment delivery / provision of services (10 comments)
Stakeholders identified a range of research needs for improving cessation services,
including the reach and efficiency of these services.
“Studies of the effectiveness of comprehensive cessations systems with proactive
smokers' registries.”
“What mix and dose of interventions would have the most impact in the shortest period
of time (or at least in a three to five year time horizon). Do specific interventions
produce synergistic, additive or subtractive effects when combined? I might also
want to know what the minimum dose of specific interventions are required in order
to be impactful. My rationale is that we don't need to know what interventions are
most successful. Rather, we need to know which ones will likely have the most
impact WITH THE EXPECTED LEVEL OF RESOURCES AVAILABLE.”
“Developing an evidence base for treatment matching (which treatments are most
likely to work for whom).”
“Methods for “triaging” smokers to most appropriate level of intervention as a means to
maximize the cost-effectiveness of cessation systems.
33

Improve monitoring (8 comments)
Stakeholders also highlighted the need for improved monitoring of key patterns and trends
to evaluate existing initiatives, as well as to inform future policies and programs. Several
recommendations focussed on improved tracking of patterns of use, particularly quitting
activities, and better understanding of the use of cessation services, while other
stakeholders wanted to know more about ―hardcore‖ smokers and improve industry
monitoring.
Patterns of use and quitting
“Though a fair bit has been written on whether there is a "hard core" of smokers that
simply can't achieve abstinence, more info would be useful. What nicotine-specific (or
tobacco-specific) needs do tobacco products meet, and are there practical
alternatives?”
“Increase awareness of what smokers know about relative risks of different tobacco and
treatment products, including beliefs about smokeless tobacco and NRT. Compare
beliefs to reality.”
Product and Industry monitoring
“Recent media and research articles report expansion in both marketing and/or use of
both smokeless and non-traditional combustible products (such as hookahs/sheesha).
E-cigarettes (devices which resemble cigarettes but which emit vaporized nicotine)
are a more recent phenomenon. Acceptability, market penetration, and in some
cases impacts on either health or addiction status of users, should be more carefully
investigated for these products. Recent purchases of smokeless tobacco
manufacturers by main-brand companies (e.g. USTC by Philip Morris) suggest the
North American industry is planning expansion of non-cigarette products.”
Research on novel/non-traditional treatments (3 comments)
Several stakeholders indicated a need for evidence on non-traditional cessation
interventions, including the use of potential ―harm-reduction‖ products.
“Safety profile and efficacy of novel treatments such as denicotinized cigarettes, snus,
e-cigarettes.”
“...grow the body of evidence for "off-label" treatment using pharmacotherapy.”
34

Improve understanding of special populations (5 comments)
Additional evidence on the barriers to reach specific sub-populations of smokers was a
common research theme.
“The huge impact on the Aboriginal community: what are the socio-behavioural
conditions that result in 50% – 70% smoking rates? Smoking is the norm in this
context – how can that be countered?”
“Impact in different high prevalence populations -- e.g. Aborginal, occupational groups
(e.g. skilled labourers, truckers, miners), and cultural appropriateness of cessation.”
“More analysis of nicotine self-medication in specific populations (some listed under
“specific interventions”) and what this means.”
Monitor the contraband situation more closely (5 comments)
A number of stakeholders identified a need to collect independent evidence on the extent of
illicit/contraband tobacco. Several stakeholders also requested information on the likelihood
that smokers will turn to illicit tobacco in response to other policy measures.
“...objective studies to estimate size of contraband market.”
“Smokers' reactions to the drastic measures and the likelihood that they will seek
illegal sources. Ways to channel them to the cessation system rather than to illicit
activity. Knowledge about advantages and disadvantages of varying degrees of
staged (graduated) measures.”
“As brand recognition/equity slowly disintegrate (or possibly quickly, once we have
plain packaging), a critical thing will be to know what factors might keep tobacco
users out of the illicit market. This is market research the large companies are almost
certainly conducting already, but it would be good to have independent research to
verify the industry's claim.”
Expand training and capacity (2 comments)
Two stakeholders highlighted the need for a greater investment in research capacity.
“We need to promote Transdisciplinary networks and Centres like in US with
NIDA/NIAAA/NCI TTURC's, and a better investment in training the next generation, if
we are going to make progress - basic scientist, clinical and policy researchers need
better communication, and more resources! ... the investment in tobacco research
especially at basic science and clinical level is woefully inadequate “
35

SUMMARY
After decades of decline, smoking prevalence among adults appears to have stagnated.
This report includes a wide range of possible measures to decrease smoking prevalence.
The primary theme of responses from stakeholders was that Canadian smokers are not
receiving adequate services and support to quit smoking, and that Canada risks falling
further behind in terms of regulations to reduce tobacco use. Stakeholders also expressed
skepticism regarding the possibility that any of the proposed strategies could reduce
prevalence to 12% by 2011 given the extremely short timeline. There was some level of
consensus that the highest priority should be to invest in a comprehensive set of programs,
policies, and services that may take longer to implement, but would have the potential to
significantly reduce prevalence over the long term, rather than to rush to implement a
handful of individual measures that are likely to be insufficient on their own.
Priorities for short-term reductions in prevalence:
Curb contraband tobacco and enforce price and taxation measures
Improve access and use of existing cessation services
Renew commitment to comprehensive media campaigns
Priorities for -term reductions in prevalence:
Expand and coordinate cessation services
Enforce existing regulations, particularly with respect to contraband sales of
cigarettes
Develop and implement the next generation of policies: more comprehensive
marketing bans, greater sales/access restrictions, stronger taxation measures,
plain packaging, product regulation
Enhance partnerships with health professionals
Develop new and ―alternative‖ cessation interventions
Tailor cessation services to reach high-burden special populations
Link policies, services and programs to a greater extent
36

ADDITIONAL INFORMATION SOURCES
Patterns and trends among Canadian smokers
Physicians for a Smoke-Free Canada. Smoking in Canada: A statistical snapshot of
smokers. 2005. Available at: http://www.smoke-free.ca/pdf_1/SmokinginCanada-2005.pdf
The Lung Association. Making quit happen: Canada‘s Challenges to Smoking Cessation.
2008. Available at: http://www.lung.ca/_resources/Making_quit_happen_report.pdf
Reid JL, Hammond D, Driezen P. Socioeconomic status and smoking in Canada, 1999-
2006: Has there been any progress on disparities in tobacco use? Submitted to the
Canadian Journal of Public Health. Available on request.
Comprehensive cessation services
Bell K, McCullough L, Greaves L, et al. NICE Rapid Review: The Effectiveness of National
Health Service Intensive Treatments for Smoking Cessation in England. 2007.
NHS National Institute for Health and Clinical Excellence. Smoking cessation services in
primary care, pharmacies, local authorities and workplaces, particularly for annual working
groups, pregnant women and hard to reach communities. UK National Health Service. 2008.
Available at: http://www.nice.org.uk/PH10
Institute National De Sante Publique du Quebec. Remboursement des aides
pharmacologiques a l‘arret tabagique au Quebec. Utilisation par less Quebecois assure par
le regime public d‘assurance medicaments et couts associes: Phase II. 2007. Available at:
http://www.inspq.qc.ca/pdf/publications/707-PCAPFinal.pdf
National strategies from other countries
Commonwealth of Australia. Tobacco Control in Australia: making smoking history.
Prepared for the National Preventative Health Taskforce by the Tobacco Working Group.
2008. Available at:
http://www.preventativehealth.org.au/internet/preventativehealth/publishing.nsf/Content/96C
AC56D5328E3D0CA2574DD0081E5C0/$File/tobacco-10octpdf.pdf
UK Department of Health. Consultation on the future of tobacco control: consultation report.
2008. Available at:
http://www.dh.gov.uk/en/Consultations/Responsestoconsultations/DH_091382
37

APPENDIX A: Stakeholder Comments – Specific Interventions
Price measures: taxation and contraband
“Tax/price increases, or maintaining current tax/price structure, will lead to biggest
impact in prevalence in the short/medium/long-term. Lots of literature on this.”
“Increasing taxation”
“…of course, the issue of contra-band remains”
“increase tobacco prices (and control contraband)”
“address the smuggling problem…”
“…raise tobacco taxes…”
“reducing contraband cigarettes… and pricing/taxation”
“Differential regulation and taxation of tobacco/nicotine products that put
cigarettes at the greatest marketplace disadvantage.”
“maintaining current high taxation rates, while substantially reducing
contraband and smuggling”
“The most immediate impact would result from a hike in tobacco taxes – this
despite the contraband problem. Most smokers still purchase their cigarettes
from legal sources.”
“Appropriate levels of taxation and measures to fight smuggling”
“Ensure continued tobacco tax increases on a regular basis equivalent to or
exceeding inflation… Increase taxes on roll-your-own (loose/RYO) tobacco
proportionally more than manufactured cigarettes to equalize prices. Taxes
on loose or RYO tobacco should be increased in proportionally greater
amounts than manufactured cigarettes until the tax on approximately 0.5
grams of loose tobacco is equal to the tax on one cigarette…”
“Tax increases”
“In light of the magnitude of the contraband problem in Quebec and Ontario
(which hold the largest populations of smokers), aggressive contraband
control is essential. Data from CTUMs, CCHS and YSS all show flattening of
declines in prevalence: while this phenomenon is occurring nationwide (e.g.
also in provinces with little or no contraband problem), available research
strongly suggests that at least one-quarter of cigarettes now smoked in
Ontario and Quebec – and perhaps considerably more – are contraband.
RCMP and other seizures of contraband are dealing with 1-2% of the problem
at best. No effective strategy to replace economic benefits of tobacco
manufacturing in sale on First Nations reserves with “non-toxic” alternatives
exists: until on-reserve manufacturing plants in New York State, Ontario and
Quebec are shut down, problem will persist and likely grow.”
“Aside from direct health impacts, contraband has led governments to avoid
additional tax increases: there has been no federal tobacco tax increase
38

since 2002, and no Ontario tobacco tax increase since 2006. Ontario and
Quebec are the second-lowest and lowest-tobacco tax jurisdictions in
Canada, respectively (which also demonstrates that contraband is a supplyside
rather than a demand-side problem). Research has consistently
demonstrated tobacco tax increases to be the single most effective
intervention in reducing initiation and consumption.”
“Unquestionably, making cigarettes less affordable by raising the retail price
through a substantial hike in tobacco taxes at both the federal and provincial
levels.”
“There needs to be cooperation and concerted action on a tax hike on the
part of the feds, Ontario and Quebec. Part of the cooperation has to be a
serious response to smuggling.”
“Increase tobacco taxes for cigarettes, sticks, roll-your-own. For roll-your-own,
there is a loophole that allows these products to be taxed at a lower rate
than cigarettes… Authorize and implement First Nations tobacco taxes for
600+ First Nations… End tax deductibility for tobacco promotion
expenses....Ensure that new urban reserves are required to implement a First
Nations Tobacco Tax for sales of tobacco products... Remove GST from
nicotine replacement products and prescription cessation products such as
Zyban and Champix.”
“Eliminate illegal production on the U.S. side of the Akwesasne/St. Regis
reserve… Eliminate illegal production on some Canadian reserves…”
“Eliminating contraband tobacco, which will reduce consumption by
effectively increasing price and encourage cessation.”
“Big price increases (i.e. through taxes) accompanied by measures to curtail
contraband.”
“Controlling contraband and raising tobacco taxes”
“Controlling the illicit market and raising prices. In the short term,
nothing else will have much effect.”
“Specific interventions to increase social control include development of:
community norms that the sale of contraband cigarettes is not a victimless
crime”
Smoke-free policies
“Continue to expand restrictions on smoking (e.g. smoking bans in households
with children)”
“Stonger/enhanced restrictions on second-hand smoke (e.g., apartment
buildings, beaches, patios in bars/restaurants, employee-only DSRs, etc).”
“continued high profile legislation that impacts social norms (legislation to reduce
smoking in cars)”
39

“…bans on smoking in other places (MUDs including hotels/motels, outdoors)”
“expanding smoke-free legislation to outdoor public places such as patios,
doorways, parks, playgrounds and other recreation areas, and vehicles
across Canada… Smoke free multi-unit housing is also important but I think this
has to be done through a voluntary approach rather than through legislation
in the short term and perhaps the climate will be right for a legislative
approach in long-term.”
“Bans on smoking in workplaces and all public places where there are none.”
“Protection from secondhand smoke (smoke-free environments)… Ban
smoking in outdoor areas such as patios and school grounds.”
“Gradually reducing the number of places people can smoke, e.g.,
eliminating smoking in parks, on beaches, etc… Eliminating smoking in social
housing (and other multi-unit dwellings)”
“Bans on outdoor smoking…Bans on smoking in MUDS.”
“Further restrictions on permitted locations for smoking (private
vehicles, outdoor venues etc.) may be justified, but are unlikely to have much
impact on smoking prevalence.”
Reducing availability of tobacco and retail outlets
“I also think availability is an important factor in adult smoking prevalence
and associated interventions would include… continuing work on disparities in
access to cigarettes through POS”
“Expand and enforce restrictions on tobacco promotion and sales… Expand
restrictions on tobacco sales.”
“Address tobacco sales and outlet density…”
“Experience with alcohol sale, among other products, shows that the number
and ease of access to sales outlets has a significant effect on consumption.
Currently, tobacco industry products are sold in over 17,000 outlets in Ontario,
and many thousands more in other provinces. The number of outlets must be
drastically reduced and all types of sale more effectively controlled.”
“Severe restrictions on availability, making it a chore for people to find the
product, accompanied by measures to curtail illicit activity.”
“Specific interventions to increase social control include development of:
community norms opposed to selling tobacco products in 'normal'
environments like convenience stores”
“Restrictions on density of retail outlets, or transfer of tobacco outlets to singlepurpose
outlets, may well backfire by further encouraging illicit trade and
creating a smaller (but still quite large) constituency in the retail sector that is
completely dependent on tobacco sales.”
“vastly reduce tobacco retail outlet density”
“Restrictions or bans on activities which encourage or induce smoking
(including retail and other promotions) “
40

“Prohibit tobacco sales in pharmacies, universities and colleges, bars and
restaurants, athletic and recreational facilities, and through vending
machines.”
Plain packaging
“Population based approaches have not been exhausted yet. We need to
look at plain packaging next.”
“Plain packaging and anything that prevents use of the pack or other
'stretched' advertising”
“…plain packs…”
“A law requiring plain/standardized packaging would strongly and quickly
impact social norms regarding tobacco, and would likely also have a direct
impact on smokers‟ opinions of their addiction… Regulating tobacco
packaging and marketing to minimise or eliminate any and all misleading or
false assumptions on the dangers of tobacco (misleading descriptors, plain
packaging, etc.)”
“Require plain packaging.”
“Implementation of plain packaging”
“Introducing generic packaging”
“Plain packaging is worth doing for various reasons, in particular to diminish
misconceptions about relative harm of different cigarette brands and to
reduce the attractiveness of cigs for teens. However, neither effect is likely to
be very large or very rapid on a population level.”
Mass media campaigns & public education
“Public campaigns about the potential dangers of 3rd hand smoke (e.g.
could hugging your child after being exposed to tobacco smoke have
negative health consequences for them?)”
“implement evidence-based mass media campaigns”
“An integrated effort to promote cessation, including wider access to a wider
range of NRT-type products and a thorough public education effort to dispel
myths about nicotine. This needs to include efforts by Health Canada to end
its own actions that demonize nicotine. A proper understanding of nicotine
and the role NRT can play in smoking cessation is important in order to get
those making quit attempts to use as much NRT as they should for as long as
they should in order to best stay off cigarettes.”
“mass media quit campaigns combined with quit-lines”
“Have a clear and over-arching communications objective. This objective
should be to „increase public appreciation for the need for government and
41

societal initiatives to reduce tobacco use and its resulting harm‟. The priority
should not be to please people or to increase smokers‟ desire to quit, but
rather to shift public attitudes about tobacco products and tobacco
manufacturers, about industry actions that increase tobacco use and about
the effective measures that can be taken to reduce it… Illustrate the scope
and nature of the tobacco epidemic to Canadians. This information should
be presented in ways appropriate to the scale of the harm that has been
caused, and with a view to sparking the type of discussion that leads to social
norm change. Canadians should understand the size and devastation of the
tobacco epidemic, especially in comparison to other feared risks, such as
SARS, West Nile virus, car accidents, AIDS and so on.”
“Implement a strategic mass media/counter-advertising campaign to support
young adults and at-risk populations.”
“Tobacco industry denormalization (TID): a strategy to tell the public the truth
about the tobacco industry‟s role in the perpetuation of the epidemic in
appropriate language including demonstration of why the industry falls
outside the boundaries of normal business behaviour and recommended
interventions to reverse the industry‟s decades-long attempt to normalize its
behaviour and products. The Ontario Tobacco Research Unit should be asked
to produce a summary report of options for introducing TID as a mass media
intervention under the SFOS.”
“Public awareness campaign on the use of tobacco product packaging as
advertising and the advantage of plain packaging… Public awareness
campaign on contraband tobacco and organized crime”
“Any and all of [other interventions] to be accompanied by large investments
in public education and media campaigns.”
“Conducting nationwide public campaigns in support of these policies”
Health warnings
“implement a comprehensive cessation system that is well integrated with
mass media campaigns and warning labels”
“…effective warnings…”
“Stronger, larger and more compelling warnings would increase awareness of
the true dangers of tobacco. Very large warnings would also reduce the
normalization / glamorization generated by tobacco brands.”
“Ensure next round of package warnings is as effective as possible… Require
a health warning or other message directly on the cigarette.”
“New package warnings – and a timetable for regularly changing them (not
just rotating them, but refreshing them every X years)”
“Changing and improving health warnings on tobacco packaging”
Marketing ban
42

“Stronger/enhanced restrictions (or complete prohibition) of all tobacco-related
marketing.”
“Restrictions or bans on activities which encourage or induce smoking…”
“Expand and enforce restrictions on tobacco promotion and sales”
“Implement a total ban on advertising/promotion…Require warnings on
permitted advertising/promotion in interim period until a total ban is in
place…Ensure that there is a federal ban on retail displays, through adoption
of measures in Tobacco Promotion Regulations, or amendments to the
Tobacco Act….Ensure effective enforcement of [advertising and promotion
restrictions under the] Tobacco Act….Respond to violations of tobacco
industry advertising codes.”
“Introducing total ban on advertising and promotion”
Product regulation
“A ban on flavours as well as single sale / mini packs of cigarillos (or any other
product that resembles cigarettes) would have an immediate impact on
youth and young adults, since this is the product of choice for many (in fact
for the majority of youths in Quebec). There is no evidence that occasional
smokers of flavoured cigars would automatically turn to other tobacco
products.”
“Ban the sale of flavoured tobacco products”
“Developing a national policy on nicotine, based on the risks of the delivery
system.”
“Regulations should prohibit any aspect of cigarette contents or design that
promotes tobacco dependence and repeated use, including the use of
flavours. Regulations should also consider restrictions on nicotine content”
Provision/Access to cessation services
“Testing and making available, where appropriate, new smoking cessation
aids for those that do not respond to NRTs and other tradtional forms of
treatments (denicotinized cigarettes?, snus, e-cigarettes etc.)…Health care
reimbursement for smoking cessation treatments”
“Freely accessible smoking cessation pharmacotherapy. The great majority
of adult smokers are chronically dependent on tobacco and nicotine
replacement therapy and medications such as varenicline and sustainedrelease
buproprion will be required to achieve abstinence. The cost of these
drugs is a significant barrier that must be removed.”
“We have no clinical practice guidelines at national level and very poor
availability of treatments”
“…campaigns combined with quit-lines”
“Expand, promote and provide greater funding to a „quit line‟ for smoking
cessation.”
43

“Greater access to free smoking cessation products and advice from health
care providers, especially for lower SES and other key target groups”
“…with proactive outreach to smokers offering tailored interventions and
combinations of interventions.”
“Differential regulation and taxation of tobacco/nicotine products that put
cigarettes at the greatest marketplace disadvantage.”
“Population-based smoking cessation programs, in conjunction with widely
available individual programs.”
“cessation interventions for parents that go far beyond pharmacotherapy”
“implement a comprehensive cessation system…”
“integrated multi-level smoking cessation system incorporating all elements
(media promotions, pharmacoptherapies, minimal through intensive
interventions…”
Novel/non-traditional therapy, including harm reduction
“Testing and making available, where appropriate, new smoking cessation
aids for those that do not respond to NRTs and other tradtional forms of
treatments (denicotinized cigarettes?, snus, e-cigarettes etc.)”
“Distinguish between the drug & the delivery vehicle. Most smokers are
seeking nicotine and were we to give alternative sources of the drug by noncombustion
and medicinal sources we could drastically reduce smoking
prevalence.”
“Explore alternatives to smoking”
“A concerted effort at harm reduction, either via snus or a Nigel Grey-style
"highly addictive NRT", could have a substantial impact in the medium term.
The two obstacles are regulatory inertia and the prohibitionist mindset of
much of the tobacco control community. The latter may be insurmountable
(though it would still be worth a try). Clear statements on relative risk and a
substantial risk-based premium built into taxation would be two important
steps to moving smokers to less hazardous products.”
“…by giving alternative sources of nicotinics or simply alternative therapies”
Greater focus on special populations
“Clinical Interventions… including for special populations (mentally ill,
addicted, chronic pain, pregnancy etc).”
“Special efforts to deal with those who are evidently self-medicating with
nicotine to treat a wide range of conditions (schizophrenia, depression,
Tourette's, ADHD, anxiety disorders, etc.) by giving alternative sources of
nicotinics or simply alternative therapies.”
“…Program providers tend to go after the "low hanging fruit who coincidently
have the low future expected burden of tobacco related disease". The net
effect is that groups that bare a greater proportion of the burden such as
44

Aboriginals, persons with mental health problems, etc. tend to be left out of
the research and practice equation”
“Implement a strategic mass media/counter-advertising campaign to support
young adults and at-risk populations.”
“…especially for lower SES and other key target groups”
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APPENDIX B: Stakeholder Feedback – Systems and Tools
Comprehensive, coordinated cessation system
“Establishment and co-ordination of a national level best practises system for
implementing and monitoring treatment that is consistent across jurisdictions.”
“Consolidate effort (due to a variety of not unrelated factors, there are
multiple sources of multiple initiatives, usually nickel and diming to the best of
their ability with great intentions and little effect).”
“In cessation, systematic intervention across health care systems will move
things forward (eg. Ottawa Model )”
“We don't always know what each other are doing, so might be useful to
have a national research bank or knowledge exchange network... perhaps
we already have this in various forms, but I don't think existing networks are
well used or sustainable in long term and there is much overlap”
“…ways to improve knowledge transfer amongst Canadians engaged in
tobacco control efforts and between tobacco control and other social
networks… ways to improve knowledge transfer amongst federal government
agencies regarding tobacco control (a 'whole of government' approach)
and between levels of Canadian governments”
“Improved communication between the various health delivery sectors
involved in smoking cessation”
“Any and all of these to be accompanied by a comprehensive smoking
cessation system that will include a smokers' registry with proactive outreach
to smokers offering tailored interventions and combinations of interventions.”
“An integrated effort to promote cessation, including wider access to a wider
range of NRT-type products and a thorough public education effort to dispel
myths about nicotine…”
“integrated multi-level smoking cessation system incorporating all elements
(media promotions, pharmacoptherapies, minimal through intensive
interventions, intake and referral systems, smoker registries..”
“Despite years of discussion and some initiatives in some jurisdictions, there is
still no comprehensive, readily-accessible cessation system available for all
Canadians. Key elements of such a system include funding of stop-smoking
medications for all those on low-income drug benefit plans; publication of the
Smokers‟ Helpline telephone numbers on all cigarette packages; much
broader promotion of available services; implementation of Ottawa Heart
Institute-type cessation protocols for all hospitals and similar health care
facilities; mandated cessation counselling training for all health care
professionals and allied professions.”
46

Better use of tool and training for health professionals
“Tools to provide guidance for primary care providers (family physicians, nurse
practitioners, registered nurses, dentists etc) in providing smoking cessation
support (better dissemination and uptake) -- skill development rather than
knowledge dissemination”
“Implementation needs to be supported by training and technical
assistance”
“Despite years of discussion and some initiatives in some jurisdictions, there is
still no comprehensive, readily-accessible cessation system available for all
Canadians. Key elements of such a system include…mandated cessation
counselling training for all health care professionals and allied professions.”
“Capacity building, particularly among health professionals, bureaucrats
working in tobacco control, and public policy advocates (in that order)”
“Cessation counselling and brief intervention workshops for healthcare
providers and workplaces”
“Clinical Interventions - this is where Canada falls short. We have no clinical
practice guidelines at national level and very poor availability of
treatments...”
“A systems approach to smoking cessation that is embraced and
implemented by all health practitioners, e.g., should be the same as checking
blood pressure with every patient.”
Services for special populations
“Specifically – an Aboriginal tobacco control program that is not merely an
adaptation of, or add-on to, that intended for general pop.”
“How best to work with Aboriginal peoples on all aspects of tobacco control,
including contraband issues”
“Improve early education and support to pregnant women”
“Addition of smoking cessation component for treatment of high risk
populations for other problems (e.g. addictions, mental health)”
Knowledge exchange system
“Ways to improve knowledge transfer amongst Canadians engaged in
tobacco control efforts and between tobacco control and other social
networks. Ways to improve knowledge transfer amongst federal government
agencies regarding tobacco control.”
“Better integration of research into treatment...”
47

Better funding system for tobacco control
“With recent disbanding of CTCRI, we need mechanisms to maintain (and
hopefully build) capacity in tobacco control research in Canada.”
“Efforts to increase knowledge and expertise within Health Canada, and to
link this issue to other public health issues.”
“Funding for anti-tobacco groups should not solely be linked to projects. Core
funding to promote tobacco control and respond to tobacco industry
manipulation and misinformation is essential, not just (or mainly) project
funding. Organizations receiving funding should not be overburdened by
reporting requirements, which currently represents a ridiculous workload.
Provincial coalitions should be able to count on federal core funding,
especially if provincial funding is weak.”
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APPENDIX C: Stakeholder Feedback – Research and Evidence
Develop evidence base for new regulatory changes
“much work needs to be done: obtain evidence to plan, implement,
monitor and evaluate the following strategies:
increase tobacco prices (and control contraband)
vastly reduce tobacco retail outlet density
implement evidence-based mass media campaigns
implement a comprehensive cessation system that is well integrated
with mass media campaigns and warning labels”
“more research should be done on the impact on smoking initiation in the
following areas: comprehensive tobacco control program that includes
education, clinical interventions, regulatory measures, economic
approaches and social strategies, expanding smoke-free legislation to
outdoor public places, smoke free multi-unit housing, reducing contraband
cigarettes, continuing work on disparities in access to cigarettes through
POS, and pricing/taxation”
“applied research to test mass media campaign ideas and concepts…ongoing
evaluation research to test efficacy of mass media interventions”
“Public opinion polling on the new warnings… A legal opinion on the
feasibility of plain packaging…Public opinion polling on plain packaging
(before and after an awareness campaign)”
“Conduct studies on impact of generic packaging”
“A clearer idea of the relationship between tax levels, tax structure, and
short-term and long-term impacts with respect to prevalence, disease
levels, etc.”
“Research evidence to plan, implement, monitor and evaluate strategies
[including to] vastly reduce tobacco retail outlet density”
“What messages and support systems encourage smokers, especially
heavy smokers, to quit.”
“There needs to be more research on non-drug cessation methods for
individuals, and mass media campaigns for smoking cessation.”
“Research to understand the impact of regulations on nicotine content of
products”
49

Treatment delivery/provision of services
“Studies of the effectiveness of comprehensive cessations systems with
proactive smokers' registries.”
“obtain evidence to plan, implement, monitor and evaluate the following
strategies: …implement a comprehensive cessation system that is well
integrated with mass media campaigns and warning labels”
“What mix and dose of interventions would have the most impact in the
shortest period of time (or at least in a three to five year time horizon). Do
specific interventions produce synergistic, additive or subtractive effects
when combined? I might also want to know what the minimum dose of
specific interventions are required in order to be impactful. My rationale is
that we don't need to know what interventions are most successful. Rather,
we need to know which ones will likely have the most impact WITH THE
EXPECTED LEVEL OF RESOURCES AVAILABLE.”
“Methods for “triaging” smokers to most appropriate level of intervention as
a means to maximize the cost-effectiveness of cessation systems.”
“Developing an evidence base for treatment matching (which treatments
are most likely to work for whom)”
“There needs to be more research on non-drug cessation methods for
individuals, and mass media campaigns for smoking cessation. “
Monitoring: Patterns of use and quitting
“Though a fair bit has been written on whether there is a "hard core" of
smokers that simply can't achieve abstinence, more info would be useful.
What nicotine-specific (or tobacco-specific) needs do tobacco products
meet, and are there practical alternatives?”
“Increase awareness of what smokers know about relative risks of different
tobacco and treatment products, including beliefs about smokeless
tobacco and NRT. Compare beliefs to reality [then blush . . .]”
“Better treatment monitoring so that we understand what works when for
whom… Increased attention on understanding former smokers; how did
they quit, what were biggest challenges etc.”
“In area of cessation, we need to grow the body of evidence for "off-label"
treatment using pharmacotherapy.”
“We need more accurate assessments of smoking rates and trends.
Telephone surveys are no longer particularly reliable. We certainly need to
stop pretending that gross under-reporting of consumption is not an issue,
and must end the delusion that 'reported prevalence' is actual
prevalence..”
50

“Health care providers, and public, awareness of the effects of quitting, use
and effectiveness of cessation medications... Best practice evidence for
cessation programs”
Product and Industry monitoring
“The impact of the tobacco industry‟s renewed advertising efforts on
consumption, especially among teens and young adults”
“Continued monitoring of tobacco industry marketing activities”
“Recent media and research articles report expansion in both marketing
and/or use of both smokeless and non-traditional combustible products
(such as hookahs/sheesha). E-cigarettes (devices which resemble
cigarettes but which emit vaporized nicotine) are a more recent
phenomenon. Acceptability, market penetration, and in some cases
impacts on either health or addiction status of users, should be more
carefully investigated for these products. Recent purchases of smokeless
tobacco manufacturers by main-brand companies (e.g. USTC by Philip
Morris) suggest the North American industry is planning expansion of noncigarette
products.”
Research on novel/non-traditional treatments
“Safety profile and efficacy of novel treatments such as denicotinized
cigarettes, snus, e-cigarettes”
“…grow the body of evidence for "off-label" treatment using
pharmacotherapy.”
Improve understanding of special populations
“The huge impact on the Aboriginal community: what are the sociobehavioural
conditions that result in 50% – 70% smoking rates? Smoking is
the norm in this context – how can that be countered?”
“We need more research $$ directed to Clinical Studies and special
populations (e.g. mental health and addictions subset of smokers”
“Impact in different high prevalence populations -- e.g. Aborginal,
occupational groups (e.g. skilled labourers, truckers, miners), and cultural
appropriateness of cessation”
“More analysis of nicotine self-medication in specific populations and what
this means. For instance, I estimate that schizophrenics are now likely
51

accounting for over 10% of all cigarettes smoked in Canada, but they are
not being addressed.”
“How to reach the hard to reach?... Empower people who feel
disenfranchised and see smoking as the only pleasure/escape in life.”
Monitor the contraband situation more closely
“First, independent evaluation of the GfK contraband studies carried out
for the Canadian Tobacco Manufacturers Council in 2006-08 is needed. If
these studies are validated, their conclusions can then be adopted as
acceptable evidence of the extent of the contraband problem. If they
are not validated, appropriate similar studies need to be carried out on an
urgent basis in all provinces, with special attention to Ontario and Quebec,
to determine the exact extent and nature of the contraband problem and
its likely future growth patterns.”
“A better handle on contraband activities and sales…The impact of
contraband tobacco on consumption by age cohort”
“Smokers' reactions to the drastic measures and the likelihood that they will
seek illegal sources. Ways to channel them to the cessation system rather
than to illicit activity. Knowledge about advantages and disadvantages of
varying degrees of staged (graduated) measures…Studies of likely
developments in illicit activity and how this can be addressed.”
“Conduct objective studies to estimate size of contraband market”
“As brand recognition/equity slowly disintegrate (or possibly quickly, once
we have plain packaging), a critical thing will be to know what factors
might keep tobacco users out of the illicit market. This is market research
the large companies are almost certainly conducting already, but it would
be good to have independent research to verify the industry's claim.
Examples:
1) How effective are scare tactics about illicit product likely to be
(rat droppings etc.), given their somewhat dubious factual basis?
2) Is consistency in taste and other characteristics something that
smokers are willing to pay a high premium for? Do they get that from
illicit product?”
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Expand training and capacity
“We need more research $$ direct to Clinical Studies and special
populations (e.g. mental health and addictions subset of smokers). We
need to promote Transdisciplinary networks and Centres like in US with
NIDA/NIAAA/NCI TTURC's, and a better investment in training the next
generation, if we are going to make progress - basic scientist, clinical and
policy researchers need better communication, and more resources!”
“Awareness and development of cessation counselling practices among
healthcare providers”
53

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57