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As I wrote this editorial, news came that Ottawa and five provinces have increased their tobacco taxes, one-third of Canadian retail outlets still illegally sell cigarettes to minors and the federal government is considering easing the tobacco advertising restrictions recently passed in the federal Tobacco Act (1997). It was a mixed report indeed. But nothing was as humbling as the fact that after a decade of decline, adolescent smoking rates have been rising since 1994 (1). In 1997, 39% of adolescent females and 22.5% of adolescent males smoked (2). Cigarettes are truly the marketing industry’s dream adolescent product – dangerous, cool, for adults only and very addictive; nothing is better to seduce the risk-taking, immortal teen with questionable self-esteem.
In 1996, approximately 100,000 Canadian adolescents began smoking (3). The average starting age was 12.5 years. (4). Half of these youths will still be smoking by age 30 years (5). If you consider that one in three smokers will die prematurely because of their addiction (6), the extent of the carnage becomes apparent. Forty-five thousand Canadians will die this year because of their habit, and 80% began smoking as teens. Smoking is the number one cause of preventable disease and the greatest single cause of disease in the country. Cigarettes will kill more people than AIDS, motor vehicle accidents, alcohol, suicide, homicide and illegal drugs combined (7).
In addition, almost half of all Canadian children are exposed to environmental tobacco smoke in their homes (8). The relationship between environmental tobacco smoke and sudden infant death syndrome (9), asthma (10), cancer (11) and cardiovascular disease (12) is well known.
The politics of tobacco is at the same time fascinating, sordid and brutal. Dr C Everett Koop, a former Surgeon-General of the United States, paediatric surgeon and anti-tobacco crusader, has called tobacco companies “lying and sleazy” (13). In an excellent review of the topic (1), former federal Health Minister David Dingwall, who championed the recently passed federal Tobacco Act, was quoted as characterizing the Ottawa tobacco lobbyists as “tough, vicious and personal”.
In 1994 Ottawa and five provinces cut their cigarette taxes in half to address the crossborder smuggling issue, which was a $5 billion per year industry serving two million Canadians (1). It was an industry fuelled by Canadian tobacco companies dumping cheap cigarettes in the United States. The federal government could have curtailed this by increasing the manufacturer’s export tax. However, this might have threatened tobacco industry jobs in prereferendum Quebec. Tobacco even plays a part in national unity!
South of the border, tobacco companies (directly or via leaked internal documents) have acknowledged the link between smoking and disease, that nicotine is addictive and nicotine levels in cigarettes were manipulated, and that ad campaigns targeted children as young as 12 years of age (14). The big five American tobacco companies are prepared to pay state governments US$365 billion over 25 years if those governments agree not to initiate health-related class action suits. Health critics point to numerous loopholes in this deal. The American Academy of Pediatrics has joined forces with other major American health organizations to lobby Congress and the public to support tough, comprehensive and effective legislation (15).
Of course, if sales ever dry up in the United States and Canada (and so far, this is not happening), the tobacco companies can always increase their efforts in such huge markets as China and the rest of the developing world. By the year 2025, 70% of the world’s 10 million tobacco-related deaths will occur in developing countries (6).
What are we as family physicians and paediatricians to do? In our offices and hospitals, we need to ask every school-aged child and parent about their smoking attitudes and practices. By age 10, 30% to 50% of children have experimented with cigarettes (16). We need to talk to preteens and teenagers alone for a few minutes in a confidential and nonjudgemental manner about smoking and other associated high risk behaviours (17). There are several excellent articles on this topic (16,18). We need to assist or refer those adolescents (more than half) or parents who wish to quit.
In our communities, we need to advocate for strong, well-enforced legislation governing against smoking in public places. The best way to decrease adolescent initiation may be to promote the concept of the smoke-free society, rather than focus solely on restricting youth access (5). We also need to support effective school education programs that stress peer refusal skills and media education (16).
How well do we teach medical students and residents the counselling skills involved in tobacco prevention and cessation? Considering the importance of the problem, the record in Canada is poor at best (19). One applauds the recent efforts of the Canadian Medical Association (CMA), several provinces and Health Canada in offering continuing medical education training to physicians in clinical tobacco intervention skills. Provincially, our medical associations need to advocate for strong, well-enforced legislation governing sales to minors. This has been shown to be effective in decreasing youth consumption (16), but enforcement rates across the country fluctuate widely (20).
Nationally, we need to ally ourselves with the CMA (21) and other health organizations in their vigorous efforts to urge the government to:
Lastly, we come to research. Despite great efforts, we must ask ourselves why are we still losing the war with respect to adolescents. In this new age of evidence-based medicine, are we doing enough research to establish which prevention and intervention strategies are most effective? With notable exceptions (22), the answer is no. As a medical community, we seem far more enamoured with the latest leukotriene receptor antagonist or angiotensin-converting enzyme inhibitor. There probably will never be a Nobel Prize for the person who figures out the best way to help an adolescent avoid or quit smoking, but there should be.