THE REGIONAL MUNICIPALITY OF YORK REPORT NO. 6 OF THE REGIONAL NO-SMOKING BY-LAW TASK FORCE MEETING HELD ON MARCH 1, 2000

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1 432 THE REGIONAL MUNICIPALITY OF YORK REPORT NO. 6 OF THE REGIONAL NO-SMOKING BY-LAW TASK FORCE MEETING HELD ON MARCH 1, 2000 For Consideration by The Council of The Regional Municipality of York on March 9, 2000 Chair: Members: Regional Councillor J. Frustaglio Regional Councillor R. Aselin Regional Councillor J. Mabley Councillor P. Hall, Newmarket Councillor J. Hastings, Georgina Councillor J. Heath, Markham J. Bard, Canadian Cancer Society H. Johnson, Whitchurch-Stouffville Chamber of Commerce A. Mackey, York Catholic District School Board B. Scollick, Richmond Hill Chamber of Commerce S. Strelchik, Youth Representative Staff Present: Dr. Troy Herrick, R. Metcalfe, V. Morley, S. Wong and J. Williams Guests: Michael Perley, Director, Ontario Campaign for Action on Tobacco Bruce Davis, Urban Intelligence Inc., Ontario Campaign for Action on Tobacco The No-Smoking By-law Task Force began its meeting at 9.15 a.m. on March 1, 2000.

2 433 1 SMOKING CESSATION PRODUCTS The No Smoking By-law Task Force recommends the adoption of the following report, February 11, 2000, from the Associate Medical Officer of Health: 1. RECOMMENDATIONS It is recommended that: 1. Regional Council endorse the resolution regarding smoking cessation products (Attachment 1); 2. Regional Council endorse the resolution for a smoke-free Ontario (Attachment 2); 3. Regional Council recommend to the Ministry of Health and Long-Term Care and the insurance industry that smoking cessation products be covered under both public and private health insurance; and 4. This report and the attached resolutions be distributed to area and surrounding municipalities. 2. PURPOSE The purpose of this report is to address the issues associated with smoking cessation products and access to these products. This report was requested by the Regional No- Smoking Task Force at its meeting of February 2, The report will also address the frequently misunderstood components associated with smoking cessation products. It is anticipated that Regional Council, employers, and residents of York Region would be interested in, and support greater access to, smoking cessation products. 3. BACKGROUND Currently, some 6.8 million Canadians aged 15 and over are smokers, with a majority (86%) of them smoking on a daily basis (Health Canada, 1999). However, access to smoking cessation products by smokers is somewhat restricted. Recent research concluded that smoking cessation products are safe, effective, governmentapproved medications that will promote either cessation or reduction in tobacco use (Ontario Medical Association, 1999).

3 Prevalence of Tobacco Dependency Across Canada, almost 25% of daily smokers consume their first cigarette within 5 minutes of waking and 60% within 30 minutes of waking (Health Canada, 1999). Only 17% of smokers in Canada indicated that nothing, or only their own death, would make them quit smoking. At present, tobacco dependence can be successfully treated by the two recognized, effective smoking cessation medications: nicotine replacement therapies (NRT) and bupropion hydrochloride (Zyban) (U.S. Department of Health Services, 1988). Both NRT and Zyban have been found to approximately double the quitting rates compared to placebo (Ontario Medical Association, 1999). 3.2 Nicotine Replacement Therapies (NRT) Nicotine replacement therapies (NRT) are regarded as one of the first cessation products available in the United States and the United Kingdom to help smokers to quit. In Canada, NRT are available in the form of nicotine gum and nicotine patches. Other forms of NRT include nicotine inhaler and nicotine nasal spray. These products are only available in the United States. NRT provide a safe, "clean" nicotine delivery system, as they replace some (not all) of the nicotine obtained from tobacco. Hence, NRT reduce withdrawal symptoms such as cravings due to tobacco abstinence without the harmful constituents found in cigarettes Common Myths about NRT NRT provide nicotine without the dangerous chemical toxins present in cigarettes. Major adverse effects from nicotine gum and the patch are rare. As well, they also have little or no addictive potential (Ontario Medical Association, 1999; Benowitz, 1998). The use of NRT do not increase smokers' risk of heart attack, as the cardiovascular effects (such as atherosclerosis, acute myocardial infarction, stroke, and sudden death) are caused primarily by cigarette combustion components not nicotine (Benowitz, 1998). Nicotine is a stimulant, as it can increase heart rate and contractility. One of the largest longitudinal Lung Health Studies (1998) concluded that there was no increase in cardiovascular risk among those who used tobacco and NRT together. The Ontario Medical Association (1999) recommended that cardiac patients, pregnant women, and youth under 18 years who cannot quit smoking should be among the first to consider using NRT, and that they should be closely monitored by their physicians. 3.3 Bupropion Hydrochloride (Zyban) Zyban was approved as a smoking cessation medication by Health Canada in 1998, in the form of a sustained released (SR) tablet. Zyban is the first government approved, nonnicotine based medication (available in pill form) that helps smokers to quit. It is also

4 435 marketed as an anti-depressant. Zyban has positioned itself along with NRT as the first-line therapy for treating tobacco dependence (Hughes et al., 1999). Although the exact mechanism as to how Zyban operates is unclear, a recent study demonstrated that Zyban alleviates cravings associated with nicotine deprivation by affecting noradrenaline and dopamine receptors (Goldstein, 1998). The use of Zyban needs to be closely monitored by physicians. However, patients with certain medical conditions such as seizure disorders, anorexia and bulimia, or those on medications that contain buproprion or monoamine oxidase inhibitors should not be prescribed Zyban. 3.4 Combined NRT Gum and Patch Therapy or NRT in Combination with Zyban Current research on NRT and Zyban concluded that the combination of NRT gum and patches or NRT in combination with Zyban are effective treatments for tobacco dependency Combined NRT and Patch Therapy Recent studies reported that combined nicotine gum and patch therapy provides higher cessation rates than gum or patch alone, without an increase in adverse effects (American Psychiatric Association, 1996; Hughes et al., 1999). The dual therapy helps to reduce withdrawal symptoms, as it provides smokers with a steady intake of nicotine (via the patch). With nicotine gum, it addresses the sudden tobacco urges (Fagerstrom et al., 1993). Patients who are on dual NRT should be closely monitored by their physicians. In 1999, a group of prominent US smoking cessation experts revised the clinical guidelines on smoking cessation by recommending the use of nicotine gum with the nicotine patch Combined NRT and Zyban NRT can be used in combination with Zyban. Jorenby et al. (1999) reported that some patients considered the combined use of Zyban and NRT to be an effective strategy, especially if single therapy is inadequate. Again, patients on NRT and Zyban should be closely monitored by their physicians for any adverse effects. 4. ANALYSIS AND OPTIONS Given that cigarettes are addictive, toxic and cause ill health, smokers should be encouraged to either quit or reduce their tobacco use. Cessation programs should be available to smokers in order to facilitate this. 4.1 Inaccessibility of NRT and Zyban Currently, individuals who are nicotine dependent can obtain their nicotine via NRT or tobacco products. The purposes behind the manufacturing, marketing, and distribution of

5 436 these two nicotine products are in total contrast. NRT and Zyban are non-addictive and designed for smoking cessation; tobacco promotes and maintains an addiction to nicotine. Compared to tobacco products, NRT products are both highly regulated and inaccessible to consumers in terms of cost and availability. Tobacco manufacturers are relatively free to alter the taste and sensory characteristics of their products, while any changes to NRT products (i.e. palatability or acceptance among smokers) must be approved by Health Canada. At present, tobacco products are widely distributed in a variety of retail outlets such as corner stores, gas stations, supermarkets, restaurants and donut shops. In contrast, NRT products are only available in local pharmacies in Canada. This inaccessibility prevents smokers from replenishing their NRT supply at certain times of the day. They should have the same opportunity to obtain NRT products as cigarettes. Although the unit costs of NRT and cigarettes are similar, the one-time purchase of NRT (about $30 for a week's supply) is much higher than a one-time purchase cost of a package of cigarettes. For low-income individuals, this large single expenditure is problematic. A recent study indicated that individuals from lower socio-economic status have higher smoking rates and lower quitting rates (Shiftman et al., 1997). 5. FINANCIAL IMPLICATIONS It is widely known that tobacco dependency is similar to other drug dependencies. It is a progressive, chronic and relapsing disorder (Henningfield, 1995). In Ontario, it is estimated that the total health and social costs attributed to tobacco use was $3.7 billion in Consistently, research demonstrates that there are significant economic benefits for government, employers, and society if smokers quit. 5.1 Cost-effectiveness of Smoking Cessation A recent US study reported that society would gain 1.7 million new quitters at an average cost of $3,779 per quitter. The savings would be $2,587 per life year, and $1,915 for every quality adjusted life year. The costs per quality adjusted life year saved ranged from $1,108 to $4,542 (Cromwell et al., 1997). Cromwell et al. (1997) concluded that smoking cessation interventions are extremely cost-effective, with more intensive interventions yielding the most benefits. 6. LOCAL MUNICIPAL IMPACT Promoting greater accessibility to smoking cessation products would have significant impact locally, as it would enable York Region's smokers to quit or reduce their tobacco consumption. Considering the health care and social costs associated with tobacco use, York Region can take a proactive position by encouraging smokers to quit and by working collaboratively with

6 437 the Ministry of Health and Long-Term Care, and both the pharmaceutical and insurance industries to ensure that smoking cessation products become more accessible. 7. CONCLUSION York Regional Council can take a leadership role by advocating to the Ministry of Health and Long-Term Care that smoking cessation products should be accessible to smokers. Furthermore, York Regional Council should encourage the Ministry of Health and Long- Term Care to work collaboratively with both the pharmaceutical and insurance industries to make smoking cessation products more readily available in all retail outlets where cigarettes are sold, and to include the smoking cessation products under both public and private health insurance plans. It is widely recognized that tobacco is harmful to one's health. Thus, every effort should be made to encourage current smokers to quit, as this not only reduces health care costs in terms of decreased morbidity or mortality across a wide range of illnesses, but also social costs. At present, York Regional Council has taken a proactive position related to tobacco prevention and education. The aforementioned recommendations are consistent with the position taken by the Ontario Medical Association on the issue of smoking cessation products. (A copy of the attachments referred to in the foregoing has been forwarded to each Member of Council with the March 1, 2000 No Smoking By-law Task Force agenda and a copy thereof is also on file in the office of the Regional Clerk.) 2 UPDATE COMMITTEE PROCEEDINGS The No Smoking By-law Task Force advises Council of the following matters having been considered by the No Smoking By-law Task Force with the action as noted: PRESENTATION The Task Force received the following presentation: 1. Michael Perley, Director, Ontario Campaign for Action on Tobacco, made a presentation to the Task Force on ventilation technology as a solution to the second-hand smoke exposure problem, stating that no appropriate standard has been set in any North American jurisdiction.

7 438 COMMUNICATIONS The Task Force received the following communications: 2. Amarjit Singh, International Trade & Purchasing Consultant, February 21, 2000, commending York Region s No-Smoking By-law Task Force s efforts to make all public places smoke-free under the York Region No-Smoking By-Law. 3. Robert Kyle, Coordinator, Central East Cancer Prevention and Screening Network, Cancer Care Ontario Regional, Central East Region, January 27, 2000, congratulating the Regional Municipality of York for establishing the York Region No-Smoking By-law Task Force. 4. Robert A. Grossi, Mayor, Town of Georgina, January 26, 2000, supporting the York Region No-Smoking By-law Task Force. 5. John R. Turner, Chemical Safety Consultant, January 31, 2000, commending Hillcrest Mall, Richmond Hill, for creating a smoke-free environment. 6. Ruth Burkholder, President and C.E.O., Markham Board of Trade, February 8, 2000, regarding the processes followed by the Task Force. 7. Joyce Frustaglio, Chair, No-Smoking By-law Task Force, February 17, 2000 to the Acting Director General of the Bureau of Tobacco Control, Ottawa, in support of the federal government s proposal of creating new tobacco warnings on every tobacco product packaging. COMMUNITY CONSULTATION MEETINGS 8. Soo Wong, Health Educator, informed the Task Force that the meetings were well received and that there was a good turnout, plus a number of written submissions. Task Force members then discussed how to amend the format of the public meetings so that maximum benefit can be derived from the information given and received. 9. The last scheduled public meeting is on March 9, 2000 at the Town of Georgina Council Chamber, Keswick, from p.m. Chair Frustaglio urged every Task Force member to attend if possible.

8 ENVIRONMENTAL SCAN INFORMATION: March, 2000 Various articles and newspaper clippings were distributed for discussion purposes, including copies of the Burlington By-law that had been requested at a previous meeting. Received. The No Smoking By-law Task Force adjourned at a.m. Respectfully submitted, March 1, 2000 Newmarket, Ontario J. Frustaglio Chair (Report No. 6 of the No Smoking By-law Task Force was adopted, without amendment, by Regional Council at its meeting on March 9, 2000.)