Health Committee on Dec. 9th, 2010

[The Chair, Conservative, Joy Smith]

Thank you, Mr. Glover.

Dr. Carrie.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Madam Chair.

I wanted to get back, Ms. Hazel, to some of the things you were talking about. I have three small kids. The oldest is 17. As a parent, I don't want my kids to start, because I believe if kids don't start by age 18, they won't become smokers. We know it's down to 18%, but how many out of that 18% are the younger people, the 18- to 25-year-olds?

You did mention that what we found in that age group and younger is that peer pressure, things along those lines, with the Facebook interaction.... I know my kids spend a lot of time on that type of multimedia. What do we know about that with these new multimedia things that we have available for our kids? How does that affect behaviour?

[Jane Hazel]

Thank you for the question.

I can link it back to the anti-drug campaign, which is what we're active on right now with the younger group, and prevention. We're seeing our multimedia approaches are having phenomenal results.

We've just done some survey work to see what kind of impact we're having, and using a combination of social media plus other traditional social marketing impacts, we're seeing that 25% of youth who either saw our ads or went to the Facebook page--a huge majority who saw the ad were driven to the Facebook page. They engaged, and one out of every four said as a result they were going to take some sort of action, whether it be to talk to their parents, look up some information, or consider saying no.

So those are some of the tangible, real results we're seeing when we launch these multimedia campaigns. Certainly the peer-to-peer interactions that we can make happen through social media are greatly impacting and I think improving the sort of impact we're having.

[Colin Carrie, Conservative, Oshawa, ON]

Do you have the numbers? I did give you a couple of questions. Out of that 18%, what percentage of the 18 to 25 group are smoking, the younger Canadians?

[Cathy Sabiston]

Do you mean percentages? I have percentages, not raw numbers, of the population. It's 18 to 24?

[Colin Carrie, Conservative, Oshawa, ON]

Yes, 18 to 24.

[Cathy Sabiston]

In Canada, 23% of 20- to 24-year-olds are smokers, and within that population you would find the breakdown is 26% male and 20% female. That is above the norm in Canada, which is 18%. So it is a key target group for us.

[Jane Hazel]

Interestingly, that corresponds to the highest users of Facebook and social media.

[Colin Carrie, Conservative, Oshawa, ON]

The approach makes a lot of sense to me. I know in Canada we have been leaders around the world. I don't know if any countries are taking this integrated, big-picture approach. I know there will be criticism about it, but it makes a lot of sense to me now that we've got the numbers down to 18%. Who is that 18%, where are the biggest numbers, and how will we best get the message out?

As a parent I don't want my kids to smoke. I think most people don't. We don't want them to engage in behaviours that we know down the road are going to be very difficult for them to quit. I do acknowledge you're cooperating with the provinces in a wonderful way, even as to how people buy cigarettes, as you said. I've never bought cigarettes, but I notice they're way behind the counter in Ontario now. It's not an easy thing to bring forward.

Thank you very much for your information today to the questions I had.

[The Chair, Conservative, Joy Smith]

Thank you very much.

Monsieur Dufour.

[Nicolas Dufour, Bloc, Repentigny, QC]

Thank you very much, Madam Chair.

I want to go back to the question that Mr. Kerry asked earlier.

I know that his government does not have the same position on public access to information as we do. For us, it is important. Unfortunately, we know what kind of politics the government is playing.

Mr. Glover, I still do not understand. That said, I understand that you want to have an integrated approach and put ads on Facebook, YouTube and such.

How does that prevent you from renewing warnings on cigarette packaging? It's a simple question.

[The Chair, Conservative, Joy Smith]

Go ahead, Mr. Glover.

[Paul Glover]

Thank you, Madam Chair, for the member's question.

The answer is simple too: an integrated plan is a more effective plan.

Simply put, a plan that is more integrated, that uses different multimedia technologies, as we've seen from Australia and others, is more effective.

While the member is correct that we could simply renew health warning messages, the impact those have over time and their reach is less than if we're able to go out with a larger, more integrated, more multimedia strategy that not only has images on packages but that drives people to the web and other content.

There was some suggestion that these images are very effective for youth. There is actual research--

[Nicolas Dufour, Bloc, Repentigny, QC]

I am sorry, Mr. Glover. Thank you, you have answered my question. I do not have a lot of time left.

I am going to ask you a series of quick questions.

Do you think that the warnings must be part of the strategy? If so, why spend $3 million if you weren't going to renew them?

Do the department and its minister intend to renew them? Yes or no.

[Paul Glover]

The government, as I understand it, through the minister's statement, has every intention of directing the department to continue to do further work on this, and health warning messages will be part of an integrated strategy. She has asked us to refine those. I believe that was the minister's response, and it still stands.

[The Chair, Conservative, Joy Smith]

Thank you very much, Mr. Glover.

I want to thank the witnesses for coming today, and I thank the panel for their questions.

I will suspend the committee for two minutes to allow the second panel to come forward, please.

[The Chair, Conservative, Joy Smith]

We need to convene now to allow us to get through our agenda.

We have our second committee in front of us. From the Canadian Cancer Society, we have Rob Cunningham, senior policy analyst. Welcome. From the Non-Smokers' Rights Association, we have Garfield Mahood, executive director. Welcome, Mr. Mahood. From Physicians for a Smoke-Free Canada, we have Cynthia Callard, executive director. Welcome, Cynthia. From the University of Waterloo, we have Dr. Geoffrey Fong.

I am very pleased to have you here today. We will have a five- to seven-minute presentation from each person.

We will begin with Mr. Garfield Mahood, please.

[Garfield Mahood, Executive Director, Non-Smokers' Rights Association]

Thank you, Madam Chair, and thank you to members of the committee for the opportunity to address you in relation to your inquiry into the government's decision not to proceed with implementation of Health Canada's tobacco package warnings—the new ones.

I'm the executive director of the Non-Smokers' Rights Association, founded 35 years ago. We are one of only three national organizations that work exclusively in the field of tobacco control.

For members of the committee who are not familiar with our association, we have a small staff of nine people located in offices in Ottawa, Toronto, and Montreal. We have members across Canada. I am proud to say that our association played a significant role in encouraging Parliament to introduce its landmark tobacco advertising ban in 1988 and its two generations of world precedent-setting warnings. We hope the discussion under way here today will now lead to the government revisiting its decision about the refreshed warnings.

As background to my presentation, I was privileged to have been asked by the World Health Organization to write an expert report on tobacco package warnings for that organization. I was deeply involved in the consultations over the refreshed warnings. Along with other members of this panel, I was involved in those consultations. Consequently, we know what has been blocked.

I wish to stress that tobacco warnings are a critical component of any comprehensive tobacco control plan. It is simply wrong to suggest that the utilization of social media, or any other tobacco control strategy, can substitute for an effective, revitalized tobacco package warning system. Tobacco warnings are the core of any comprehensive response to the tobacco epidemic

Let me explain why risk messages on the package in particular are so important and at the same time reveal why the tobacco industry will use almost any means to stop them coming forward.

First, the tobacco package is the core of all tobacco promotion. Everything the industry does to sell its products is centred on the package. All advertising, sponsorships, point-of-purchase displays, billboards--everything is tied to the package design. This is the hub of the wheel. With most of these promotional tools banned in Canada, the package takes on even greater importance. The package design is the industry's principal marketing tool in this country. But also important, what Canada does to warn consumers, especially kids, and to reduce the power of the package to promote sales will influence tobacco policy in countries around the world. That's why the industry will go to any length to block it.

I have told you about the marketing power of the package overall. Here is why the warnings on the package are so important and cannot be replaced by social media, or anything else for that matter.

There are 1.5 billion cigarette packages sold in Canada each year. These packages, even many contraband packages, carry the required warnings. Advertising experts will tell you that each package is a mini billboard. Each package produces what these experts call an advertising impression, just like a roadside billboard produces an advertising impression.

On average, a cigarette package is pulled out of a shirt pocket or a purse 20 times a day, the beautiful package design producing a positive, legitimizing image each time it appears. Conversely, and critically, on average, risk messages warn consumers and deter adolescent smokers or starters 20 times a day. With 1.5 billion packages in circulation each year, the package warning system creates an estimated 30 billion advertising impressions every year. About 30 to 40 billion times a year, the warnings undermine the image that the beautiful package tries to produce, a message that says the product inside the package is legitimate, even though it will kill a whopping one out of two of its long-term users. The package is critical.

In short, the package is the cornerstone of everything the industry does, and because the importance of the package is maintaining normalcy and legitimacy for the product, the industry will threaten litigation, threaten the closure of factories, offer to assist government with its contraband problems, or to withhold that help. It will do whatever it takes to delay, stall, or block improvement to the warning system.

In my statement that's been tabled with the committee, I've reviewed some of the things they've done in the past. I won't go into that now because of time restrictions. The point of reviewing the history of how they've tried to block warnings in the past is to show that effective warnings never materialize without a struggle, and we've seen this.

Once again, members of Parliament are being asked by health interests that are supported by millions of Canadians to work in a non-partisan way to encourage the government to implement these warnings. Because of tobacco industry-caused illness and death that can be prevented, this reform rises above party politics and above the pseudo and often dishonest arguments that tobacco lobbyists have put before well-intentioned legislators.

Our association's position is this. The existing warnings are extremely stale. The refreshed warnings were essentially finished months ago--not perfect, but a significant step forward. Over $3 million will be wasted if they sit on a Health Canada shelf, and if they do, kids will be addicted and they will later die. There is no--

[The Chair, Conservative, Joy Smith]

Mr. Mahood, your time is up.

[Garfield Mahood]

Two sentences, Madam Chair.

There is no credible reason for these warnings to be blocked. We are asking you to do whatever you can to bring the new warnings forward.

I know everybody on this panel would like to see these warnings, no matter what's said, and I encourage you. Thank you.

[The Chair, Conservative, Joy Smith]

We will now go to Dr. Geoffrey Fong from the University of Waterloo.

[Dr. Geoffrey Fong, Professor, Ontario Institute for Cancer Research, University of Waterloo]

Thank you, Madam Chair and members of the committee. My name is Geoffrey Fong. I am a professor of psychology at the University of Waterloo. I am also senior investigator of the Ontario Institute for Cancer Research. Eight years ago, I and my colleagues created the international tobacco control policy evaluation project, or the ITC project, to evaluate the impact of tobacco control policies of the WHO Framework Convention on Tobacco Control. Since 2003, 172 countries, including Canada, have become parties to the FCTC.

The ITC project is currently evaluating the impact of FCTC policies, such as health warning labels, smoke-free laws, higher taxes, and policies to reduce contraband across 20 countries using state-of-the-art longitudinal surveys of adult smokers. In Canada we have conducted the ITC survey for seven annual survey waves since 2002. The ITC project is recognized throughout the world as a leading source for evidence on the effectiveness of tobacco control policies. Last year the ITC project was honoured by CIHR and the CMAJ with a top Canadian achievement in health research award.

I am grateful for the opportunity to speak to you today about health warnings and to present evidence from our ITC project, showing definitively that the Canadian warnings have become less effective over time and that there is an urgent need to revise them now.

The overall objective of health warnings is to inform and educate people about the harms of tobacco products to inspire smokers to quit and to convince non-smokers, especially youth, not to start. The health warning is a health communication very much like an advertisement for public health, and as Gar has mentioned, a potentially powerful one, given the number of exposures, all in the right place, that is, on the pack.

Therefore, governments should endeavour to make the health warnings as strong as possible and to follow the principles of good communication and advertising in their design and implementation. I would like to highlight two such principles.

First, it is clear from many studies, including those conducted by Health Canada itself, that when it comes to warnings, size matters. Warnings will have more impact if they occupy 75% of the pack than if they occupy 50%. In fact, even from Health Canada's own studies, they looked at 90% warnings, and those were significantly more effective than the 75%.

Second, health warnings, like any other communication or advertisement, become less effective over time. This phenomenon--a very intuitive phenomenon--is known as “wear-out”. Thus, health warnings, like any other advertisement, must be revised on a regular basis to maintain their effectiveness. FCTC guidelines suggest that warnings be revised every one to three years. But 10 years, by any stretch of the imagination, is way too long. What would a marketing expert say about an ad campaign that was running unchanged for 10 years straight?

In October 2002, about two years after Canada introduced the graphic warnings, we began the ITC Canada survey, a nationally representative sample of 2,000 adult smokers throughout Canada.

I have prepared a document here--there will be a test on this later--showing how seven key indicators of health warning effectiveness have changed from 2002 to 2008. The ITC survey shows that every indicator of label effectiveness has declined dramatically.

Chart 2, on the first page, shows that the percentage of Canadian adult smokers noticing the warnings labels a lot declined from 60% in 2002 to 42% in 2008.

Chart 4, on the first page, shows that the percentage of smokers reporting that the warnings made them think about the health risks of smoking dropped from 17% to 12%.

On the second page, on the last row, chart 7 shows that the percentage of smokers reporting that the warnings made them forgo a cigarette fell from 18% to 13%. This is an important indicator because it is linked to future quit attempts.

Finally, chart 8, which summarizes all of the seven key indicators of label effectiveness, displays, of course, the steep decline.

These findings show clearly that the effectiveness of what once were the world-leading warnings labels from Canada have declined dramatically. In terms of odds ratios, I would say the effectiveness of the Canadian warnings has declined by 30% to 60% over the past six to seven years.

But it's not just the decline in effectiveness that has occurred. Today we know a lot more about the health consequences of cigarettes and how to communicate those risks. In 2000, many of the images that are still on the packs were of disembodied brains and hearts and lungs.

There are other effective ways of creating warnings that could create powerful emotions, which is a key ingredient of label effectiveness. For example, Health Canada has considered using the photo of Barb Tarbox as a way of depicting the human tragedy of cigarette use. By doing so, Canada would reassert its claim to be a world leader in health warnings.

As the ITC findings show, Health Canada's delay is having a pronounced detrimental effect on the tobacco control policy that is the key to informing the Canadian people. From these ITC charts I have presented, we can estimate that over three-quarters of a million Canadian smokers are no longer reading the warnings closely. From these results, we know that for over a quarter of a million smokers, the warnings are no longer making them think about the health risks of smoking.

If the warnings are not revised, fewer smokers will be inspired to quit, and greater numbers of youth will start smoking, undeterred by the stale 10-year-old warning labels. And in the future, the consequences of today's inaction and delay will result in many additional Canadian deaths from tobacco, which still, of course, is the number one preventable cause of death and morbidity in our country.

From the evidence, from state-of-the art longitudinal surveys of the evaluation of the Canadian warnings, there is no justification for delaying the revision of the health warnings and there is every reason for moving ahead quickly on the revision process.

I would like to thank the committee for this opportunity to speak on this matter.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Fong, and I'm sure you're going to be available for questions shortly, too.

We'll now go to Rob Cunningham from the Canadian Cancer Society.

[Rob Cunningham, Senior Policy Analyst, Canadian Cancer Society]

Good afternoon. My name is Rob Cunningham. I am a lawyer and senior policy analyst at the Canadian Cancer Society.

Health Canada has completed excellent research on new package health warnings, a crucial pillar of Canada's comprehensive tobacco control strategy. The Canadian Cancer Society recommends that the government introduce as soon as possible a new series of warnings covering 75% of the package, front and back, as well as a series of improved messages inside packages.

Before continuing, I would like to extend praise to Minister Aglukkaq and to the Prime Minister for bringing forward Bill C-32 last year, and to express appreciation to all political parties for their support of the bill, including the MPs here today who were on the health committee at that time. The legislation banning flavours in cigarettes and little cigars is the best of its kind in the world. Bill C-32 recently proved influential in the adoption of new international guidelines on flavoured tobacco products.

This newly released Canadian Cancer Society report, “Cigarette Package Health Warnings: International Status Report”, shows that Canada is increasingly falling behind other countries. In 2001, Canada was the first country with picture warnings, and Canada had the largest warnings, at 50%. Now 39 countries and territories have picture warnings, and many of the countries requiring picture warnings after Canada are now on their second, third, or fourth round of pictures. For size, Canada has fallen from first to fifteenth in the international rankings, with more countries leap-frogging over Canada all the time. Uruguay has the largest warnings at 80%, with Honduras also about to have 80%. That's Uruguay and Honduras.

Australia has decided to go even further and require plain packaging. That is, maintaining health warnings but removing all brand colours and logos from packages. Warning size is crucial. The larger the size, the larger the impact. As a bilingual country, Canada needs more space than most other countries.

The tobacco industry will undoubtedly bring forward legal arguments against larger warnings. But such arguments would be entirely without merit. As a lawyer focusing in this area, I know the tobacco industry always attempts to bring forward legal arguments to block legislation. For the existing 50% package warnings, when they were brought forward a decade ago, the industry claimed that the warnings could not be justified legally. However, in 2007, the Supreme Court of Canada soundly and unanimously rejected the industry's claims. The industry simply cannot be believed.

When picture warnings were initially considered in 2000, incredibly the industry argued that it was technically impossible in Canada to print colour pictures on cigarette packages. Imagine! But of course the impossible proved possible and picture warnings were easily printed, as we see today.

We join with provincial health ministers in supporting the inclusion of a quit line number on every package as part of warning messaging. This toll-free number would make it easier for smokers, including residents of rural and remote areas, to get help in quitting from trained specialists. The experience in other countries is that quit line calls increase substantially once the number is on the package.

Contraband is an important issue, and governments should take action. But as newspaper editorials have stated, the government should take action on both contraband as well as new warnings. It's also worth nothing that contraband volumes in Canada have decreased dramatically over the last 18 months, and that cigarettes with required package warnings represent the overwhelming volume of sales in Canada. Tobacco products are the leading preventable killer of Canadians. We need a multifaceted approach.

Last week the minister identified social media as a means to reach youth. There is potential here. Indeed the Canadian Cancer Society's smoking cessation services already use social media: Facebook, Twitter, text messaging, and web-based messaging. Social media, however, should be used in addition to warnings. It should not be a substitute. Social media should not delay warnings. Both social media and warnings should be used, and each could enhance the impact of the other. A web address on the package could provide a link to and increase the impact of social media.

It must be emphasized that package warnings have credible and unparalleled exposure, reaching every smoker every day, as well as individuals around smokers: friends, family, co-workers.

Tobacco companies oppose larger 75% warnings knowing full well that warnings will reduce tobacco sales. But that is exactly the point.

Well-designed warnings increase awareness of the health effects of tobacco and decrease consumption, among both adults and youth.

In conclusion, we reiterate our considered recommendation that the government proceed on a pressing basis with new, improved 75% picture warnings that include a toll-free (1-800) quit line number and a web address, as well as with improved interior messages.

Merci. Thank you.

[The Chair, Conservative, Joy Smith]

Thank you very much, Mr. Cunningham.

We'll now go to Ms. Callard.