Strengthening Bill S-5, An Act to amend the Act and the Non-smokers’ Health Act and to make consequential amendments to other Acts

Heart & Stroke Submission to the House of Commons Standing Committee on Health

February 12, 2018 Strengthening Bill S-5, An Act to amend the Tobacco Act and the Non-smokers’ Health Act and to make consequential amendments to other Acts: Heart & Stroke Submission to the House of Commons Standing Committee on Health Introduction Heart & Stroke supports Bill S-5 believing it represents an important step to bolster . We urge that Bill S-5 be further strengthened and suggest specific amendments to improve the impact of plain and standardized packaging legislation and prevent wide-spread marketing of vaping products which put young Canadians and non-smokers at risk. Tobacco Heart & Stroke strongly supports the adoption and expedited implementation of plain and standardized tobacco packaging. Plain and standardized packaging has been endorsed by the World Health Organization and adopted in many countries because of its strong potential to prevent uptake and discourage use.i Evidence indicates that plain and standardized tobacco packaging has a variety of associated benefits including accelerated declines in tobacco use, curbing deceptive marketing messages, increasing the visibility and effectiveness of health warnings, reducing the appeal of tobacco use among youth and increasing cessation attempts. i,ii,iii,iv,v,vi After the policy’s implementation in Australia, positive image association ratings fell for all tobacco brands, and the greatest decline was reported in adolescent smokers.vi,vii,viii,ix Concerns about contraband tobacco in relation to plain packaging are inaccurate and overstated/exaggerated by the .i Contraband concerns are often used as an industry narrative to stall tobacco control policies.i We applaud parliamentarians for forging ahead with plain packaging and recognizing the tactics used by the tobacco industry and its front groups. There is opportunity to strengthen Bill S-5 and plain and standardized packaging as a policy measure. We urge the government to leverage tobacco products as a means to communicate health information messages and quit support to users. The amendment should provide regulatory authority to require a health message on tobacco products themselves, as is already the case in the bill for e-. Messages like “tobacco kills” or the promotion of cessation programs on each itself could be highly effective in dissuading use and increasing quit attempts.x Tobacco-related amendments Heart & Stroke endorses the recommendations developed by the Canadian Cancer Society. A summary of these recommendations is listed below. 1. Establish regulatory authority to require health warnings on cigarettes and tobacco products themselves (as Bill S-5 provides for vaping products, and as mentioned in international guidelines under the WHO Framework Convention on Tobacco Control, the international tobacco treaty). There is no reason why the regulatory authority for tobacco products should be less than for vaping products. Among the benefits of this amendment would be that it would respond to concerns regarding contraband, and provide a marking identifying products intended for legitimate sale in Canada.

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2. Establish regulatory authority to restrict promotion within the tobacco trade (manufacturers-wholesalers-retailers). At present, promotions within the tobacco trade are completely exempt from the Act pursuant to s.18(2)(c) of the Act. Bill S-5 contains a new mechanism to require companies to report on promotions within the tobacco trade, but there is no mechanism to regulate such promotions based on the information reported. To fill this gap, Bill S-5 should be amended to establish regulatory authority to restrict advertising and promotion within the tobacco trade. For example, regulations could prohibit lifestyle advertising within the tobacco trade – lifestyle advertising is a frequent current practice being used in trade publications. These trade promotions are reaching thousands and thousands of employees of retailers and wholesalers, who may be consumers or potential consumers of tobacco products. Quebec banned lifestyle advertising within the tobacco trade through 2016 legislative amendments. 3. Establish regulatory authority for the government to apply some or all of the provisions of the Act to herbal (non-tobacco) water pipe products. Quebec legislation already does this. Newfoundland and Labrador legislation does this in part. The new Tobacco Products Directive also does this in part (articles 21, 22). In particular, there is a need to regulate non-tobacco herbal products intended for waterpipe smoking, such as advertising/promotion, packaging and labelling, sales to minors, flavours, and other measures. This would not apply to marijuana as separate legislation, Bill C-45, the Cannabis Act, would apply. 4. Amend Non-smokers’ Health Act to prohibit smoking of any products, not just tobacco and cannabis, wherever smoking is banned. Various provinces have done so. This amendment would provide health protection and would support enforcement. 5. Regarding regulatory process, repeal the current requirement in s. 42.1 of the Act that proposed regulations must be tabled in the House of Commons and be submitted to the Standing Committee on Health for potential approval. Almost no other federal statute contains such a provision. This provision slows regulatory action. should be able to respond with speed in dealing with an epidemic. No provision similar to the current s. 42.1 is intended in Bill S-5 for vaping product regulations, nor should there be. 6. Regarding the ban on vending machines, the ban should come into force 6 months after Royal Assent. Right now in Bill S-5 the ban is left indefinitely to proclamation (see clause 17, regarding section 12 of the Act, and clause 80(5)) which leads to delay and uncertainty.

E-cigarettes and vaping products With regard to vaping products, the Heart & Stroke position on e-cigarettes has evolved over time with advances in research. And while the evidence regarding e-cigarettes continues to grow, there is still much that is unknown about this fairly new technology. We continue to strive for a balance between the potential benefits and risks. To that end, it is important to have regulations that ensure safety standards and protect Canadians against possible harms. Experts agree that complete tobacco cessation over the long term, rather than reducing the number of cigarettes smoked per day, is the most effective way to reduce risk for and premature .xi,xii,xiii Heart & Stroke encourages people in Canada to strive for complete

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cessation as the best means of reducing the burden of tobacco related illness. We recommend Canadians use cessation tools like Replacement Therapy, quit and counselling. Some Canadians may find cessation benefit or reductions in tobacco consumption from the use of vaping products. In Canada, as with elsewhere in the world, dual use of both e- cigarettes and tobacco is common.xiv However, dual use is only likely to be beneficial if it leads to complete .xii,xiii,xv At present the evidence on whether e-cigarettes lead to complete cessation is inconclusive. Heart & Stroke agrees that e-cigarettes are less harmful than combustible tobacco. For this reason we support increased access to e-cigarettes for adults. However, e-cigarettes are not without risk. Claims made by researchers which quantify the difference in associated harm between e-cigarettes and combustible tobacco are based on faulty methods and draw inappropriate conclusions.xvi We know and have known for years that e-cigarettes are appealing to Canadian youth.xvii.xviii A Canadian study found that 18% of high school student non-tobacco smokers had tried e- cigarettes, and another 31% are interested in trying them.xix Current use of e-cigarettes among 15-19 year olds has more than doubled in the past few years. Studies also show that more teens are using e-cigarettes as they see them as “cool” or “fun”.xx Research in Canada shows a link between e-cigarette use among youth and tobacco use.xxi This suggests a potential gateway effect. We want to ensure that e-cigarettes do not result in youth onset of nicotine or tobacco use. It is essential that young Canadians be protected from marketing exposure aiming to increase use of these products. Not only are there potential harms with the liquid constituents of vaping devices, but we need to protect non-smokers and youth from nicotine which will become legal and more readily available once S-5 is passed. Nicotine is a highly addictive that increases blood pressure, makes your heart work harder and can result in blood clots.xxii It is essential that Bill S-5 be amended to further restrict the marketing of e-cigarettes in Canada. In its current state, a wide scope of marketing would be permitted with advertisements everywhere and anywhere - television, online, video and adver-games, newspapers, magazines, billboards, on public transit, social media, and the list goes on. Of great concern, is that marketing can happen in bars and nightclubs, places where young people gather and are often under the influence of alcohol. This could make them more susceptible to marketing messages thus creating the opportunity for young Canadians to experiment with e-cigarettes. There is no need for marketing in places frequented by youth or the wide spread marketing of vaping products to the general public. The only group that should be exposed to the marketing of these products are current smokers. The proposed bans on “lifestyle” advertising will not be strong enough to protect young people from the multi-million dollar marketing machinery. E-cigarette and vaping related amendments We align with the Canadian Cancer Society, and ask that Bill S-5 be amended in relation to e- cigarette and vaping products as outlined below. 7. Provide that vapour product advertising only be information advertising or brand preference advertising. This is the approach for tobacco in the Tobacco Act and for cannabis in Bill C-45, the Cannabis Act. This seems to be what the government intends, but this is not

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explicitly stated given the drafting style in the bill. While the current bill bans lifestyle advertising, with some exceptions, there is no provision that states that only information or brand preference advertising is allowed.

8. Remove provision that allows lifestyle advertising in bars and in publications sent to an adult. There is no need for lifestyle advertising (eg associating with fashionability, status, masculinity, feminity, etc.). This is especially the case in a bar, where the consumption of alcoholic beverages may mean that individuals have reduced inhibitions.

9. Restrict permitted vaping product incentive promotions (eg price discounts) to specialty vaping product retail stores. At present, Bill S-5 would permit, in places where young people do not have legal access, extensive incentive promotions for vaping products, namely gifts, bonuses, premiums, cash rebates, games, draws, lotteries or contests. Such promotions would be allowed in bars, casinos, specialty vape stores and other places where young persons under 18 did not have access. This should be amended such that the only place where incentive promotions would be allowed would be inside specialty vape stores, and that the only allowed incentive promotions would be monetary bonuses, premiums, cash rebates, and providing a vaping product in consideration of the purchase of another vaping product. At present Bill S-5 would allow draws and contests for individuals to win beach vacations, access to invitation-only parties, and tickets to rock concerts or sports events, among other examples – such promotions should not be allowed. At present, Bill S-5 would allow such incentive promotions to target young non-smokers, such as on a university or college campus. Ultimately the best approach would be to ban all incentive promotions.

10. Establish greatly strengthened restrictions on the location of vapour product advertising to match the provisions restricting tobacco advertising in the Tobacco Act, or alternatively cannabis advertising in Bill C-45, the Cannabis Act). At present, the bill contains no restrictions at all regarding the location of ads. Right now under the bill, such advertising could even appear on television, on billboards, at movie theatres, on public transit buses and shelters used by children going to school, at a local ice rink where minor hockey is played, etc. For tobacco products, permitted advertising is far more limited and is allowed in direct mail to identified adults, on signs in bars, and at retail. Provincial legislation allows displays of vaping products and other information provision in specialty vape shops, aspects that would still be allowed with this amendment. Current restrictions in Bill S-5 are far weaker than in the Tobacco Act for tobacco, and in Bill C-45 for cannabis. The Bill S-5 vaping product advertising restrictions are weaker than in almost any other developed country except the U.S.

Conclusion Heart & Stroke strongly supports the proposed legislation related to plain and standardized packaging and recommends amendments to increase the impact of the bill. We urge that this committee make Bill S-5 a piece of legislation that truly protects our kids and prevents uptake by non-smokers by further restricting e-cigarette marketing. Heart & Stroke fully endorses the recommendations and rationale proposed by the Cancer Society in their corresponding submission. In adopting these amendments, Bill S-5 will become a strong and powerful piece of legislation to drive tobacco control and put the health of Canadians first.

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i World Health Organization. Plain packaging of tobacco products: evidence, design and implementation, 2016. http://www.who.int/tobacco/publications/industry/plain-packaging-tobacco-products/en/ ii Personal pack display and active smoking at outdoor café strips: assessing the impact of plain packaging 1 year post imlpementation. Tobacco Control, 2015; 24:ii94 - ii97. iii Wakefield MA, Hayes L, Durkin S, Borland R. Introduction effects of the Australian plain packaging policy on adult smokers: a cross-sectional study. 3 BMJ Open, 2013; 3: e003175. iv Young JM, Stacey I, Dobbins TA, Dunlop S, Dessaix AL, Currow DC. Association between tobacco plain packaging and Quitline calls: a population-based, interrupted time-series analysis. MJA, 2014; 200:29–32. v Durkin S, Brennan E, Coomber K, Zacher M, Scollo M, Wakefield M. Short-term changes in quitting-related cognitions and behaviours after the implementation of plain packaging with larger health warnings: findings from a national with Australian adult smokers. Tobacco Control, 2015; 24:ii26 – ii32. vi Wakefield M, Coomber K, Zacher M, Durkin S, Brennan E, et al. Australian adult smokers’ responses to plain packaging with larger graphic health warnings 1 year after implementation: results from a national cross-sectional tracking survey. Tobacco Control, 2015; 24:ii17-ii25. vii Wakefield M, Germain M, Durkin S. How does increasingly plainer cigarette packaging influence adult smokers’ perceptions about brand image? An experimental study. Tobacco Control, 2008; 17:416–421. viii White V, Williams T, and Wakefield M. Has the introduction of plain packaging with larger graphic health warnings changed adolescents’ perceptions of cigarette packs and brands? Tobacco Control, 2015; 24:ii42-ii49. ix White V, Williams T, Faulkner A, and Wakefield M. Do larger graphic health warnings on standardised cigarette packs increase adolescents' cognitive processing of consumer health information and beliefs about smoking-related harms? Tobacco Control, 2015; 24:ii50-ii57. x Crawford Moodie, Philip Gendall, Janet Hoek, Anne Marie MacKintosh, Catherine Best, Susan Murray; The Response of Young Adult Smokers and Nonsmokers in the United Kingdom to Dissuasive Cigarettes: An Online Survey, Nicotine & Tobacco Research, , ntx261 xi Gawlik KS, Melnyk BM, Tan A. An epidemiological study of population health reveals social smoking as a major cardiovascular . Am J Health Promot. 2017 Jan 1:890117117706420. doi: 10.1177/0890117117706420. xii Centers for Disease Control and Prevention. Quitting Smoking xiii Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical settings: a and meta- analysis. Lancet Respir Med 2016;4:116-128 xiv Reid, J. L., Hammond, D., Rynard, V. L., Madill, C. L., & Burkhalter, R. (2017). Tobacco use in Canada: Patterns and trends (2017 edition). Retrieved from https://uwaterloo.ca/tobacco-usecanada/tobacco-use-canada-patterns-and-trends xv Christine Daria Czoli. Patterns of use and biomarkers of exposure among ‘dual’ tobacco cigarette and electronic cigarette users in Canada. Thesis Submission. Waterloo, Ontario, Canada, 2017 xvi Evidence about electronic cigarettes: a foundation built on rock or sand? BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4863 (Published 15 September 2015) xvii University of Waterloo, Tobacco Use in Canada, E-cigarette use in Canada, 2015. xviii Use of electronic cigarettes among Canadian studies in 2014-15: Prevalence and correlates of use. Montreuil A, MacDonald M, Asbridge M, Wild C, Hammond D, Manske S, Rutherford E. Canadian Medical Association Journal – Open 2017; 5(2): E460–E467. xix Canadian Cancer Society. (2014). The Canadian Cancer Society’s exclusive study: 5,000 children have already tried an electronic cigarette in Grade 6! One in three high school students have already smoked it (142,000 youths). Retrieved August 21, 2014, from Canadian Cancer Society Web site: http:// www.cancer.ca/en/about-us/for-media/media-releases/quebec/2014/ electronic- cigarette-study/?region=qc xx Khoury M, Manlhiot C, Fan CPS, et al. Reported electronic cigarette use among adolescents in the Niagara region of Ontario. CMAJ 2016 July 18 xxi Electronic cigarette use and smoking initiation among youth: a longitudinal cohort study. David Hammond, Jessica L. Reid, Adam G. Cole and Scott T. Leatherdale. CMAJ October 30, 2017 189 (43) E1328-E1336; DOI: https://doi.org/10.1503/cmaj.161002 xxii US Department of Health and Human Services. The health consequences of smoking: nicotine addiction. A Report of the Surgeon General, 1988. Rockville : Service, Centers for Disease Control, Office on Smoking and Health, 1988. (DHHS Publication No (CDC) 88-8406).

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