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The Dose Transcript for October 12, 2023

Host: Brian Goldman

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BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. Doctors and public health experts would prefer it if the number of teens and young adults who smoked cigarettes is as close to zero as possible. The U.K. government has just proposed what it's calling a smoke free generation policy. It wants to ban the legal sale of cigarettes to anyone who is currently 14 years of age or younger. And as those teens grow up, they'll never be able to buy cigarettes legally. New Zealand has passed a similar law. It's one way to tackle what is still a major public health problem. So this week, we're asking how effective is a total cigarette ban in curbing smoking, beginning with youth? Hi, Michael. Welcome to The Dose.

MICHAEL CHAITON: Really glad to be here.

BRIAN GOLDMAN: I'm glad that you're here too to help us explain this policy. I'm just curious. Have you ever been a smoker?

MICHAEL CHAITON: I definitely tried. I grew up in the 90s. And back then, nearly everyone at least tried sometimes. It was everywhere, and I was also part of that group.

BRIAN GOLDMAN: And, you know, Michael, I'm going to tell you that I used to con myself into believing that because I had asthma, childhood asthma, that I could never get used to smoking. But there was a moment when I was part of a group of people who stayed after work. And in a clandestine way, you know, we started playing one of these first person shooter games. And somebody lit up a cigarette and started passing it around. And that was the first time that I got that sick, nauseating feeling that you get when you're smoking a cigarette for the first time. And it felt mellow and the vibe was great. And I thought, oh, oh, I could become a smoker. And I stopped right there, but that was my experience. Before we begin, can you give us a Hi, my name is? Tell us what you do and where you do it. Just adlib.

MICHAEL CHAITON: Sure. My name is Michael Chaiton. I am a senior scientist at the Centre for Addiction and Mental Health, and I work at the University of Toronto and at the Ontario Tobacco Research Unit.

BRIAN GOLDMAN: I want to begin by having you, Michael, explain to us what the U.K. is trying to do in simple terms. Because on the surface, it sounds complicated.

MICHAEL CHAITON: What they're doing is called a smoke free generation law. In Canada as well as the U.K., they currently have minimum ages to buy cigarettes. So here in Canada, it’s either 18 or 19. And what they're proposing to do in the U.K. is that for every year for a particular generation, that is for people who are currently 14, when they get to that minimum age, they'll raise it by one year and keep raising it one more year each year. So that means that people who are currently 14 will never be old enough to be able to legally purchase cigarettes in that country.

BRIAN GOLDMAN: And how does that differ from Canada?

MICHAEL CHAITON: So it… well, right now, we have a static law. So we have a minimum age, but that age is only 18 or 19. And so once you hit 19 or 20 years old, you can purchase cigarettes. And right now, there's no indication that such a kind of smoke free generation law will be implemented in Canada.

BRIAN GOLDMAN: Is that sort of policy legal? You know, I'm thinking that it sets an arbitrary distinction that people in theory who are, you know, cohorts of people who are a year different in ages, one will be allowed to smoke and the other won't.

MICHAEL CHAITON: Yeah. I mean, that's currently what happens now. We set boundaries on who can purchase and where we can sell different types of drugs. There are many drugs, for instance, you can't purchase at all from a convenience store or a gas station. So I don't think there's an issue with legality. There have been many calls for the phasing out or banning of tobacco entirely, and this is one way of doing it. It will take many, many decades before tobacco would be phased out from being able to be sold legally in the U.K., but it's sort of a slow process of making that happen without limiting access to those who are currently smoking.

BRIAN GOLDMAN: Are there any countries where this sort of a ban is already in place?

MICHAEL CHAITON: No countries where it's in place, but the New Zealand already has a law on the books that is coming into force in a couple of years.

BRIAN GOLDMAN: All right. So these are early days. It's a proposal in the U.K. and it may be just getting started in New Zealand. And as a scientist at the Centre for Addiction and Mental Health and someone who has been interested in smoke cessation and reducing smoking rates for your entire career, what do you think of this idea, this proposal?

MICHAEL CHAITON: Well, it's a really exciting one. I think in tobacco, we've really moved into a new phase of thinking about tobacco control. There's discussion about a tobacco end game that instead of sort of nudging people towards, you know, changing their behaviours, essentially nagging them to say well, smoking isn't cool, you shouldn’t start or you should try and quit, that we should actually make some real changes to the system. And this is, I think, part of that process of really starting to think about tobacco as not a normal consumer product, but as a drug that, you know, shouldn't be available in the same way that, you know, food and toys and candy are.

BRIAN GOLDMAN: What do we know in terms of research, in terms of the science about how effective this sort of a ban might be?

MICHAEL CHAITON: Well, it's tricky. The best way of doing it, it would be actually to evaluate places that have actually done it. But because these are new and innovative proposals, of course, we don't know exactly what's going to happen. We can infer some things. So that we know that minimum age laws can work, that we've seen this in Canada and in the U.S. Most recently, the U.S. raised their minimum age from mostly 18 years old to 21, and we've seen that that had a significant impact on youth use of cigarettes. In Canada, we've also done some studies that show that the rates of smoking initiation in people who aren't legally able to buy is significantly lower than that among people who once they reach the age that they can buy from a store. Having products more available means that more people are likely to use them. And the optimistic take would be that for people who are younger, that there would be a full cohort of generations who would… where no one would ever start smoking. And I think of a more realistic expectation from laws like that is not that it would fully stop everyone from starting smoking, but it would dramatically reduce the rate at which they start. We already see very low rates of tobacco use among youth in Canada and in the U.K. Back in my day when I was a teenager, most people tried at least to puff on a cigarette and many people did more. In the year 2000, we see in Ontario, 22% of youth in high schools were daily smokers. That number has dropped dramatically. It's less than 2% now, more closer to 1% for people who are smoking daily in high school. And the numbers of people who even try and puff have gone from 60 to 70% down to about 15%. It's a huge dramatic reduction. And these kinds of laws where there isn’t a huge amount of interest or access to cigarettes would likely only accelerate that.

BRIAN GOLDMAN: I'm interested in the idea that there would be cohorts of people who can smoke and cohorts of people who can't smoke. Obviously, if this played out, you know, 50, 60, 70 years from now, it wouldn't matter that, you know, all of Canadian society would be unable, not permitted to smoke. But there is a concept of free will. And is there a risk here that by trying to create a law, that you're messing with people's free will and that there'll be a backlash against it simply because people are saying I'm an adult and I can decide whether I want to smoke or not?

MICHAEL CHAITON: I think that's a really interesting point. And part of it, I think, is less about individual free will and more about the ability of and rights of the retailers themselves, that this law in the U.K., and we would expect that any law in Canada would be the same, is not about criminalizing behaviour. It's not saying you can't smoke if you don't want to and you would be thrown in jail if you were a smoker, but about changing the distribution system for tobacco. So the regulation is about stopping retailers from selling rather than preventing people from using. And that's a really important distinction there, that it's not repeating the mistakes that we did with cannabis, for instance, where we saw substantial impacts on the criminal justice system and from the people who were targeted by those criminal justice laws to prevent them from using cannabis. But instead, it's focusing on changing the availability. If you ask most people if they were happy that they started smoking, the vast majority say that they're not. And in the U.K., the most recent surveys of even people who are currently smoking suggests a strong support from smokers for this type of regulation.

BRIAN GOLDMAN: Is there any risk or to what extent is there a risk that this kind of a law would simply boost the illegal distribution and sales of cigarettes, which we have certainly seen with other commercial laws that are designed to curb smoking or curb the purchase of cigarettes?

MICHAEL CHAITON: I think it'll be interesting to see what happens in the U.K. One of the differences with this law is that tobacco would still be allowed to be sold, that you could still buy cigarettes or people who are old enough would be allowed to buy it. I actually think that that might mediate the difference, that it's really about enforcing of those laws in stores that are still able to access sort of the normal legal mechanisms for wholesaling and purchasing and distribution of tobacco rather than creating a whole new industries and to supply to people who, you know, who wouldn't otherwise be able to receive them. It’s certainly comparing to if, for instance, if we just put in a full ban saying tomorrow, we wouldn't be able to… nobody would be able to sell tobacco, in that scenario, there would be a huge market for other sources, and I think big black markets would emerge in that scenario. But here, we're really just limiting the people who wouldn't, aren't able to purchase currently anyways. So it's not that the market would… it would slowly shrink rather than a sort of a quick dramatic exit.

BRIAN GOLDMAN: I think I understand what you're saying, but I do want to get at the larger issue, and as someone who's an expert in this field, about what works and what doesn't work. You know, the first thing I thought about when I saw this smoke free generation concept was prohibition, you know, in the 1930s, which, you know, that was the blanket banning that you've just talked about. And that led to bootleg liquor sales in speakeasies. And in other words, I mean, there's this general sense in our society that it didn't work. So what's different here? You know, in general, do bans tend to work or are there other ways of trying to discourage people from, in this case, smoking?

MICHAEL CHAITON: Yeah. I mean, I think one slight misconception about prohibition is it didn't work and it certainly had problems. And in certainly the way that they did in the criminalization associated with prohibition in the 1930s was ineffective. But it also on other dimensions, it did work. We saw dramatic decreases in things like liver cirrhosis rates, dramatic decreases in the amount that people drank during that time and that it wasn't a complete disaster in some ways. I think what we've learned in the meantime is the importance, again, one, of not criminalizing individual behaviour, but two, that those we need to have some sort of distribution for substances, you know, that particularly for the people who are continuing to use, that they're addicted and will seek out other sources for those products. So it is, you know, that this sort of new lesson is about focusing on retail, on that, you know, that we shouldn't have the kind of commercial distribution, that it shouldn't necessarily… that selling products like cigarettes is not something that we need to have an open market for, that there are other ways of doing it.

BRIAN GOLDMAN: And as you mentioned, in Canada, fewer and fewer young people are smoking. And, you know, why is that? Is that mainly because of the bans on advertising to young people and banning cigarette smoking among young people or retail sales to young people, that is?

MICHAEL CHAITON: Yeah. I think all of these sort of comprehensive approach that we've taken to tobacco control has been one of the most successful public health initiatives. And, you know, we have a number of different policies and regulations that I think have been very effective at reducing smoking again, particularly among new cohorts. It’s, I think, easier to prevent somebody from starting than it is to help somebody quit.

BRIAN GOLDMAN: And yet, you know, while smoking rates among youth are on the decline, vaping rates are increasing. What do you make of that?

MICHAEL CHAITON: Well, I mean, essentially with vaping, what happened is we did the opposite of what we've been doing with tobacco. So vaping has been around in Canada probably since 2002, 2006, somewhere in that range where the first product started to appear in Canada. But it wasn't until 2017 when the government formally, I guess, legalized nicotine vaping products. And with that legalization, they allowed nicotine products to be sold in stores, in convenience stores and gas stations, allowed for some advertising and promotion of different products, allowed for the, you know, the entry into the market of the big tobacco companies and their more sophisticated vaping devices. And with that, we saw a dramatic increase in youth, in use of vaping products among youth in particular.

BRIAN GOLDMAN: So, you know, we've talked around the impact of cigarette smoking, and I want you to talk about it for a moment. What is the burden of disease caused by tobacco that we're preventing in youth right now, that we're trying to prevent by one legal remedy or another?

MICHAEL CHAITON: Yeah. So cigarettes today are certainly the number one preventable cause of death and disease. It’s certainly globally and one of the top ones in Canada. In Canada, we see the best estimates are about 45,000 people die every year because of tobacco. And globally, that number is about eight million people. With the reduction in prevalence of smoking over the past 50 years or so, we've seen substantial health benefits already. We see rates of lung cancer, for instance, has been dropping, particularly among males because of the decline in smoking. And we will expect that if current trends continue, that we will see even lower levels of cancer, heart disease and COPD in particular. We have over $6 billion a year in health care costs that are directly attributable to smoking as well.

BRIAN GOLDMAN: So that's all good news. Based on what we're seeing, the news from the U.K. and New Zealand, what would you like to see from the Canadian government in terms of tobacco policy?

MICHAEL CHAITON: I think that the New Zealand model is a really great goal for the Canadian policy. It combines a couple of different important features. One, it really focuses on the most dangerous product, the cigarette, that vaping is certainly an issue, but it's really cigarettes that cause a huge amount of burden disease. And getting that product off the market, the cigarette off the market, especially when there are alternative forms available, is really the primary piece. So they're getting rid of the addictive properties of the cigarette. They're limiting that availability to youth. They're also doing things like reducing where and how many places it can be sold, with a real focus on examining the health equity impacts of it, as well as providing smoking cessation support. And that package together I think could be a really powerful one in bringing about sort of the tobacco end game, moving it from a commercial product to one where, you know, where we have the less harmful form on the market.

BRIAN GOLDMAN: Well, I can tell you that as an emergency physician, the idea of a tobacco end game sounds wonderful. And Michael Chaiton, I want to thank you for explaining the ideas behind this policy proposal in the U.K. and for coming on to The Dose to talk about it.

MICHAEL CHAITON: Okay. Thank you very much.

BRIAN GOLDMAN: Michael Chaiton is a senior scientist at the Centre for Addiction and Mental Health in Toronto. Here’s your dose of smart advice. Cigarette smoking continues to be a major cause of preventable illness and death in Canada. Public health experts say preventing teens and young adults from smoking is an important way to reduce the burden of tobacco related diseases in Canada. Banning tobacco use in young people is an effective way to reduce teen smoking. Studies show that once such laws are enacted, there is a predictable drop in teen smoking rates, something we have seen in this country. The proposed law in the U.K. aims to create a smoke free generation by banning the sale of cigarettes to people under a specific age. What makes the proposal different from what we have in Canada is that the ban on sales would continue for those younger people as they age. Since this kind of ban is a novel idea, we don't know how effective it will be in the long run. In terms of social policy, the key is that legal bans prohibit the sale and marketing of tobacco to young people, instead of criminalizing people for smoking. New Zealand is trying something similar. In addition, that country is also gradually reducing the nicotine content of cigarettes and is keeping e-cigarettes on the market. Teen vaping rates continue to rise substantially in Canada. While vaping is considered less harmful than tobacco, the long term effects remain unknown. The current recommendation is that young people who have never smoked should not take up vaping. The key is to reduce the burden of tobacco use in Canada. As is, existing laws in this country have resulted in a drop in the rates of lung and heart disease and lung cancer. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca If you like this episode, please give us a rating and review wherever you listen. This edition of The Dose was produced by Isabelle Gallant and Stephanie Dubois. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

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How effective is a cigarette ban in curbing smoking among youth? - Transcript

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