Submission to the Standing Committee on Finance and Economic Development

Transcription

1 Submission to the Standing Committee on Finance and Economic Development In support of Bill 164, An Act to Rename the Tobacco Control Act, 1994, repeal the Smoking in the Workplace Act, and make complementary amendments to other Acts April 28, 2005 Cancer Care Ontario

2 STATEMENT OF SUPPORT FOR BILL 164 Cancer Care Ontario fully supports the Government s commitment to protecting the health of all Ontarians by introducing Bill 164 which would lead to the creation of the Smoke-Free Ontario Act. The implementation of 100% smoke-free public and workplace legislation and comprehensive bans on tobacco marketing, which include bans on the display and promotion of tobacco products at point-of-sale and in other settings, are integral components of a comprehensive tobacco control strategy. These measures will help to protect and promote the health of all Ontarians by directly addressing tobacco use, the leading cause of preventable illness and death in Ontario and Canada. With the proclamation into law of Bill 164, Ontario will join the growing number of Canadian, U.S. and international jurisdictions that have already implemented comprehensive smoke-free legislation or are in the process of doing so. (See Appendix A for a list of these jurisdictions.) CANCER CARE ONTARIO Cancer Care Ontario is an agency of the Government of Ontario, and acts as the government s principal advisor on cancer issues. In this role, Cancer Care Ontario is responsible for long-term planning of the cancer care system and the financing and coordination of large parts of that system. We are responsible for setting direction, providing leadership and funding cancer surveillance, prevention, screening, research, treatment and supportive care. THE FACTS A. The Cancer Burden in Ontario and Tobacco Like many other chronic diseases, cancer creates today a high burden of suffering and cost for Ontario. Unlike other chronic diseases however, the cancer burden will increase significantly over the next 25 years. We estimate that, in 2005, 59,000 Ontarians will be newly diagnosed with cancer and 25,200 deaths will be registered from cancer. Barring dramatic changes in prevention and screening activity, the number of newly diagnosed cancer cases in Ontario will increase by two-thirds by The overall incidence of cancer in Ontario is growing, driven in large measure by population aging and population growth. Tobacco is the single most important cause of cancer. In Ontario, one-quarter of all cancer deaths are due to tobacco. 2

3 Tobacco causes lung cancer, many upper airway (mouth, throat, larynx) and urinary tract (bladder and kidney) cancers, cervical cancer, and acute myeloid leukemia, as well as some cancers of the stomach and pancreas. 1 Tobacco is also a major cause of death from other common conditions, such as cardiovascular and lung diseases. People who stop smoking substantially reduce their chances of dying from cancer or cardiovascular diseases. Early detection and prevention programs are key factors in the ongoing struggle against cancer. Our Prevention Unit is a catalyst for the development of cancer prevention strategies for all Ontarians. Currently, our Prevention Unit focuses on tobacco control; nutrition, physical activity and healthy body weight; and systems planning. B. Tobacco-Attributed Mortality and Morbidity in Ontario More Ontarians die as a result of tobacco use than from alcohol abuse, suicide, motor vehicle accidents, AIDS, drugs and homicide combined. Every day, approximately 50 Ontarians die as a result of tobacco use (Holowaty et al, 2002). Over the past 50 years, almost 500,000 deaths have occurred among Ontarians that can be directly attributed to tobacco. Between 1999 and 2003, tobacco use caused approximately 72,000 deaths in Ontario. Cancer accounted for approximately 46% of these deaths. In 2005, it is expected that there will be more than 15,000 tobacco-attributed deaths among Ontarians. C. Morbidity and Mortality Attributed to Environmental Tobacco Smoke Involuntary exposure to environmental tobacco smoke (ETS), or second-hand smoke, is also an important cause of premature morbidity and mortality. The Ontario Tobacco Research Unit estimates that between 1100 and 7800 deaths per year in Canada are caused by exposure to ETS. At least one-third of these deaths occur in Ontario. 1 U.S. Department of Health and Human Services. The Health Consequences of Smoking:A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health,

4 We conservatively estimate that, for 2001, 151 Ontarians died from lung cancer attributable to involuntary exposure to ETS in the home. 2 ETS is classified as a human carcinogen by the United States Environmental Protection Agency, the United States National Toxicology Program and the IARC Programme in Carcinogenic Risk Assessment. More specifically, the International Agency for Research on Cancer (IARC) has concluded that existing scientific evidence is sufficient to conclude that involuntary smoking is a cause of lung cancer in never-smokers. (IARC, 2002) At least 15 major disease groups or conditions are now known or suspected to be caused by ETS. Exposure to ETS causes heart disease, lung cancer, and nasal sinus cancer in adults. There is no safe level of exposure to ETS. It is also proven that ventilation technologies proposed by the hospitality and tobacco industries do not work. They cannot effectively remove ETS from indoor air. Comprehensive smoking bans provide the most effective protection against exposure to ETS. Protection from exposure to ETS has improved considerably since the implementation of the Ontario Tobacco Control Act in 1994, which amended the Ontario Municipal Act, giving municipalities the power to implement more restrictive smoke-free bylaws. By October 2004, approximately 90% of Ontarians lived in communities with smoke-free bylaws, which included bars and restaurants (OTRU, 2004) 3. Despite this progress, levels of protection from exposure to ETS remain inconsistent across the province, with many municipalities having implemented weaker smoke-free bylaws which permit separately ventilated, separately enclosed smoking areas (DSRs), unenclosed smoking in bars and restaurants, or have limited indoor smoke-free areas to municipal buildings only. Bill 164 will remedy this situation by ensuring comprehensive protection from exposure to second hand smoke for all Ontarians regardless of where they live. D. Costs of Treating Tobacco Use The direct health care costs associated with smoking in Ontario in 1992 were approximately $1.1 billion. This estimate likely represents only a minority of the real economic toll of smoking because the costs associated with lost productivity and earnings as a result of illness, disability and death are estimated at another $2.6 billion (Single et al, 1996). The costs of tobacco-attributed hospitalizations and day surgeries among cancer patients for FY2001/02 are conservatively estimated at approximately $134 million. 2 Estimate based on ETS prevalence data in the Statistics Canada. Survey on Smoking in Canada, 1994/95, Cycle 1 (unpublished tabulations). Ottawa. 3 Note: approx 54% of the population covered by these bylaws lived in communities with bylaws permitting Designated Smoking Rooms in bars and restaurants. 4

5 Smoking exacts a devastating toll cutting lives short and robbing Ontarians of their productive years. In 2001, it is estimated that approximately 217,946 total years of life were lost due to premature death from tobacco use in Ontario. This amounts, on average, to approximately 14.1 years of life lost per smoking death. The average years of life lost per cancer attributed smoking death is higher at about 17 years of life lost per cancer attributed smoking death. THE EFFECTS OF IMPLEMENTING 100% SMOKE-FREE LEGISLATION The impact of implementing smoke-free legislation is both dramatic and immediate. (See Appendix A for a fuller discussion of these impacts.) Air quality, and consequently, the respiratory health of hospitality workers have been demonstrated to improve immediately upon implementation of smoking bans. There is also growing evidence associating smoke-free workplace bans with reductions in smoking prevalence and tobacco product consumption. A recent study found that complete smoke-free workplace bans are associated with a 3.8 % reduction in smoking prevalence, and 3.1 fewer cigarettes smoked per day per continuing smoker. Further, research conducted by the Ontario Tobacco Research Unit, has found that workers employed in settings without smoking restrictions are 2.3 times more likely to be daily smokers than those working under complete bans. Daily smokers working under no smoking restrictions also smoked 4.7 cigarettes per day more (30.5%) than those working under complete bans. It is also well documented that the implementation of smoking restrictions does not result in negative economic impacts. In any event, any negative economic impacts to the hospitality and retail industries must be considered in light of the significant health care costs associated with treating tobacco-attributed disease and death and the socio-economic costs of lost productivity and earnings as a result of illness, disability and premature death resulting from tobacco use and involuntary exposure to ETS. TOBACCO DISPLAY AND PROMOTION AT RETAIL Cancer Care Ontario supports a complete ban on the retail display of tobacco without exception. As such, CCO recommends that the clause except in accordance with the regulations be deleted from Section 3.1(1) of the Smoke-Free Ontario Act (see Section 5of Bill 164.) The retail setting provides a powerful marketing channel for the tobacco industry. Large powerwalls of cigarettes, countertop displays and associated signage are ubiquitous in Ontario retail outlets. Contrary to tobacco industry claims that they only market their products to adults, these promotional displays are in full view of everyone, including children and youth. 5

6 Comprehensive advertising bans can reduce tobacco consumption. A recent study has found that comprehensive advertising bans would reduce cigarette use by 7.4 %. 4 The effects of partial bans are limited as the tobacco industry can adeptly shift its marketing efforts from one channel to another. Comprehensive bans on tobacco industry advertising and promotion, including retail display bans form a critical component of an effective tobacco control strategy. THE IMPORTANCE OF A COMPREHENSIVE TOBACCO STRATEGY As an integrated whole, a comprehensive strategy has been shown to be associated with reductions in the prevalence of tobacco use (Siegel M et al, 2000 and Weintraub et al, 2002) and in the burden of tobacco attributable cancers and other diseases at a population level (MMWR, 2000 and Barnoya J et al, 2004). 5 Cancer Care Ontario and the Canadian Cancer Society have established long-term cancer prevention and screening targets for achievement by the year 2020 (Canadian Cancer Society and Cancer Care Ontario, 2003). In order to achieve the tobacco use reduction targets set for 2020, a comprehensive mix of tobacco control policy and program interventions is required (Centers for Disease Control and Prevention, 1999). It is estimated that over 6,000 premature (i.e., under 65 yrs) cancer deaths could be prevented in Ontario by the year 2020 by implementing a comprehensive tobacco control strategy (Canadian Cancer Society and Cancer Care Ontario, 2003). Smoke-free public and workplace legislation and comprehensive marketing bans are critical policy components of such a strategy. SUMMARY OF RECOMMENDATIONS Cancer Care Ontario fully supports the Ontario government in its introduction of Bill 164 and recommends the following measures be undertaken to reduce the burden of tobacco caused illness and death in Ontario: 1. Implement comprehensive 100% smoke-free workplace and public place legislation without exemption. 2. Implement comprehensive restrictions on tobacco industry advertising and promotion, including complete bans on the point of sale display and promotion of tobacco industry products without exemption. As such, CCO recommends that the clause except in accordance with the regulations be deleted from Section 3.1(1) of the Smoke-Free Ontario Act (see Section 5of Bill 164.) 4 Saffer H, Chaloupka F. The effect of tobacco advertising bans on tobacco consumption. Journal of Health Economics 2000; 19: See also Fichtenberg CM, Glantz SA. Association of the California Tobacco Control Program with declines in cigarette consumption and mortality from heart disease.n Engl J Med Dec 14;343(24):

7 3. Immediately raise the price of cigarettes in Ontario to the national average with subsequent increases to match price levels in the highest province or neighbouring state. 4. Implement a comprehensive and coordinated tobacco control strategy in the province of Ontario, with sustained funding at levels consistent with internationally recognized best practice guidelines. The adoption and implementation of the above measures will protect and promote the health of all Ontarians and will reposition Ontario in a leadership role within Canada and the world with respect to tobacco control and public health. 7

8 REFERENCES Barnoya J, Glantz S. Association of the California tobacco control program with declines in lung cancer incidence. Cancer Causes Control Sep; 15(7): California Department of Health Services, Tobacco Control Section. Eliminating Smoking in Bars, Taverns and Gaming Clubs: The California Smoke-Free Workplace Act Sacramento, California: 2001 [online] available from: Canadian Cancer Society and Cancer Care Ontario. Targeting cancer: an action plan for cancer prevention and detection. Summary Report. Toronto, ON: Canadian Cancer Society, Cancer Care Ontario. Smoking rates still too high. Ontario Cancer Facts. January [online] available from: Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs August Atlanta GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, August Cowling DW, Kwong SL, Lloyd JC, Bal DG. Declines in Lung Cancer Rates California, MMWR, 2000; 48(47): Travers MJ, Cummings KM, Hyland A. Indoor Air Quality in Hospitality Venues Before and After implementation of a Clean Indoor Air Law Western New York. MMWR. Nov 12, 2004; 53(44): Eisner MD, Smith AK, Blanc PD. Bartenders respiratory health after establishment of smoke-free bars and taverns. JAMA Dec 9; 280(22): Fichtenberg CM, Glantz SA. Effect of smoke-free workplaces on smoking behaviour: systematic review. BMJ July 27; 325(7357): 188. Fichtenberg CM, Glantz SA. Association of the California Tobacco Control Program with declines in cigarette consumption and mortality from heart disease.n Engl J Med Dec 14;343(24): Holowaty E, Chin Cheong S, Di Cori S, Garcia J, Luk R, Lyons C, Thériault ME. Tobacco or Health in Ontario. Toronto, ON: Surveillance Unit and Prevention Unit, Division of Preventive Oncology, Cancer Care Ontario and the Ontario Tobacco Research Unit, May Holowaty E. Personal communication. Cancer Care Ontario Hopkins P, Briss PA, Ricard CJ, Husten CG, Carande-Kulis VG, Fielding JE, Alao MO, McKenna JW, Sharp DJ, Harris JR, Woollery TA, Harris KW (The Task Force on Community Preventive Services). Reviews of Evidence Regarding Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke Am J Prev Med, 2001;20(2S): International Agency for Research on Cancer. IARC Monographs on the Evaluation of Carcinogenic Risk of Chemicals to Humans: Involuntary Smoking. Vol. 83. Lyon, France RTI International. First Annual Independent Evaluation of New York s Tobacco Control Program Final Report. (Prepared for the New York State Department of Health). Research Triangle Park, NC: Nov 2004 [online] Available from: 8

9 Ontario Tobacco Research Unit. Indicators of OTS Progress. [Special Reports: Monitoring and Evaluation Series, (Vol. 10, No. 3)]. Toronto, ON: Ontario Tobacco Research Unit, Dec Ontario Tobacco Research Unit. Workplace Restrictions on Smoking: Are They Good for the Smoker, Too? (Research Update), October [online] Available from: Ontario Tobacco Research Unit. The economic impact of a smoke-free bylaw on restaurant and bar sales in Ottawa, Canada (Research Update). June [online] Available from: Ontario Tobacco Research Unit. Protection from second-hand tobacco smoke in Ontario - a review of the evidence regarding best practices. Toronto, Ontario: Ontario Tobacco Research Unit, University of Toronto, May Physicians for a Smoke-free Canada. Tobacco company payments to retailers for cigarette promotions increase by 50% (Press Release), January 17, [online] Available from: Repace J. Respirable Particles and Carcinogens in the Air of Delaware Hospitality Venues Before and After a Smoking Ban. Journal Occup Environ Med. 2004; 46: Repace J. An Air Quality Survey of Respirable Particles and Particulate Carcinogens in Boston Pubs Before and After a Smoking Ban. [online] Available from: Saffer H, Chaloupka F. The effect of tobacco advertising bans on tobacco consumption. Journal of Health Economics 2000; 19: Scollo M, Lai A, Hyland A, Glantz S. Review of the quality of studies on the economic effects of smokefree policies on the hospitality industry. Tobacco Control 2003; 12:13-20 Single E, Robson L, Xie X, et al.the Costs of Substance Abuse in Canada: A Cost Estimation Study. Canadian Center on Substance Abuse. Ottawa Travis H, Florescu A, Ferrence R, Selby P, Bondy S, Kreiger N, Greenspan N. The Impact of a 100% smoke-free bylaw on ETS exposure in non-smoking Toronto bar workers: pre-post comparison with concurrent control (Poster presentation 11 th Annual SRNT Conference), March Weintraub JM, Hamilton WL. Trends in prevalence of current smoking, Massachusetts and states without tobacco control programmes, 1990 to Tobacco Control 2002; 11 (Suppl II): ii8-i 9

10 A. SMOKING RATES IN ONTARIO APPENDIX A BACKGROUNDER Rates of smoking have been falling in Ontario since the mid 1960s (Cancer Care Ontario, 2005). Despite this reduction, smoking remains a major public health concern. In 2003, 23% of Ontario adults were current smokers (i.e. smoke daily or occasionally in the past month and at least 100 cigarettes in their lifetime). Current smoking rates were not significantly different between men and women in Rates of smoking among Ontario youth are also declining, but are still substantially higher than the 2% Cancer 2020 target. In 2003, 11% of 15 to 19 year olds were current smokers. Smoking rates were similar among male and female youth (OTRU, 2004). Rates of smoking vary across the province, with lower rates of smoking found in the Toronto area, Ottawa, and some South Western areas of the province. Smoking rates tend to be higher in the Northern and Eastern parts of the province (Cancer Care Ontario, 2005). B. TOBACCO ATTRIBUTED MORBIDITY AND MORTALITY IN ONTARIO Overall, tobacco caused approximately 72,000 deaths among Ontario men and women between 1999 and Tobacco-attributed mortality (TAM) in Ontario females Over the period , there were approximately 27,400 deaths in females attributed to tobacco. This represents about 14% of all deaths among Ontario women over this period. Cancer was the most common cause of tobacco-attributed death in Ontario women, accounting for approximately 42% of all TAM (Table 1). These cancer deaths were also dominated by lung cancer, which accounted for approximately 80% of female tobacco-attributed cancer deaths. Ischaemic heart disease and chronic obstructive lung disease both accounted for approximately 20% of female TAM respectively. Tobacco-attributed mortality (TAM) in Ontario males Over the period , there were approximately 44,600 deaths in males attributed to tobacco. This represented approximately 23% of all deaths among men over this period. Cancer was the most common cause of tobacco-attributed deaths in Ontario men, accounting for approximately 48% of all TAM (Table 2). These cancer deaths were dominated by lung cancer, which accounted for 70% of male tobacco-attributed cancer deaths. The second and third leading causes of male TAM were chronic obstructive lung disease and ischaemic heart disease, which accounted for approximately 16% and 22% of male TAM respectively. 1

11 Table 1. Tobacco-attributed mortality (TAM) in Ontario females, * Disease** Tobacco-attributed deaths Non-tobacco-attributed deaths Total Deaths # % # % # % Malignant Neoplasms 11, % 43, % 55, % Lip, Oral Cavity, Pharynx % % % Esophagus % % % Stomach % 1, % % Pancreas % 2, % % Larynx % % % Trachea, Lung, Bronchus 9, % 3, % % Cervix Uteri % % % Kidney and Renal Pelvis % % % Urinary Bladder % % % Acute Myeloid Leukemia % % % Non-tobacco-related cancers 0 0.0% 34, % % Cardiovascular Diseases 9, % 60, % 69, % Ischemic Heart Disease 5, % 32, % % Other Heart Disease 1, % 9, % % Cerebrovascular Disease 1, % 15, % % Atherosclerosis % 1, % % Aortic Aneurysm % % % Other Arterial Disease % % % Respiratory Diseases % 5, % % Pneumonia, Influenza % 4, % % Bronchitis, Emphysema % % % Chronic Airway Obstruction 4, % 1, % % All other causes of death 0 0.0% 59, % % Total Deaths 27, % 169, % 196, % * counts are estimated based on actuals. ** Disease groupings are based on ICD-10 classification For methodology, see 2

12 Table 2. Tobacco-attributed mortality (TAM) in Ontario males, * Disease** Tobacco-attributed deaths Non-tobacco-attributed deaths Total Deaths # % # % # % Malignant Neoplasms 21, % 39, % 61, % Lip, Oral Cavity, Pharynx 1, % % % Esophagus 1, % % % Stomach % 1, % % Pancreas % 2, % % Larynx % % % Trachea, Lung, Bronchus 15, % 1, % % Cervix Uteri 0 0.0% 0 0.0% 0 0.0% Kidney and Renal Pelvis % % % Urinary Bladder 1, % 1, % % Acute Myeloid Leukemia % % % Non-tobacco-related cancers 0 0.0% 30, % % Cardiovascular Diseases 15, % 52, % 67, % Ischemic Heart Disease 9, % 33, % % Other Heart Disease 1, % 6, % % Cerebrovascular Disease 1, % 10, % % Atherosclerosis % % % Aortic Aneurysm 1, % % % Other Arterial Disease % % % Respiratory Diseases % 4, % % Pneumonia, Influenza % 2, % % Bronchitis, Emphysema % % % Chronic Airway Obstruction 6, % 1, % % All other causes of death 0 0.0% 54, % % Total Deaths 44, % 150, % 195, % * counts are estimated based on actuals. ** Disease groupings are based on ICD-10 classification For methodology, see Tobacco-attributed Mortality by Ontario Riding A detailed profile of tobacco attributed mortality in 2001 by Ontario electoral riding is provided in Attachment 1. 3

13 Common Cancers in Ontario, both sexes combined This pie chart shows the dominance of tobacco-related cancers as a fraction of all cancer deaths (Figure 1). The term tobacco-related refers to those cancers for which some or all are attributed to smoking. Figure 1. Most common cancer causes of death in Ontario, All other cancers 20.9% Ovary 2.5% Leukemia 3.4% Non-Hodgkin Lymphoma 4.1% Prostate 5.7% Tobacco-related cancers 42.9% Breast 8.0% Colorectum 12.5% Trends in Cancer Mortality Lung cancer dwarfs other cancers commonly related to smoking (Figures 2, and 3). Temporal trends are similar for lung and laryngeal cancer, but not for oropharyngeal and oesophageal cancers, which are not as strongly associated with smoking and are attributable to other causes as well. 4

14 Figure 2. Age-standardized mortality rates (3-year moving average) for tobacco-related cancers among Ontario females, Age-standardized rate per 100,000 population Lung Lip, Oral Cavity, Pharynx Esophagus Larynx Year of death Figure 3. Age-standardized mortality rates (3-year moving average) for tobacco-related cancers among Ontario males, Lung Lip, Oral Cavity, Pharynx Esophagus Larynx 10 0 Year of death 5

15 Annual burden of tobacco-attributed deaths, since 1950 Over the past 50 years, almost 500,000 deaths have occurred among Ontario men and women that can be directly attributed to tobacco (Figure 4). Compared to men, the epidemic of tobaccoattributed deaths in women has lagged by about years (data not shown). Since the mid 1990s, there has been a slow but steady fall in the burden of TAM among Ontario men, unfortunately this trend is not yet seen among Ontario women. (Holowaty, 2005) In the current year, 2005, the annual number of TAM deaths among Ontario women is expected to exceed 6,000 deaths; among men more than 9,000 deaths will be directly attributed to tobacco (data not shown). Figure 4. Annual number of tobacco-attributed deaths in Ontario, by sex,

16 C. ENVIRONMENTAL TOBACCO SMOKE Environmental tobacco smoke (ETS) or second-hand smoke is a complex mixture formed from the escaping smoke of a cigarette or other tobacco product, as well as the smoke exhaled by the smoker (IARC, 2002). ETS is an important source of exposure to toxic gases and particulates in indoor air and is classified as a human carcinogen by both the United States Environmental Protection Agency and the United States National Toxicology Program (OTRU, 2001). At least fifteen major disease groups or conditions are now known or suspected to be caused by ETS. Exposure to second-hand smoke causes heart disease, lung cancer, and nasal sinus cancer in adults. Among children it is a known cause of sudden infant death syndrome, fetal growth impairment, bronchitis, pneumonia, and other lower respiratory tract infections, asthma exacerbation, middle ear disease, and respiratory symptoms. Among adults, ETS has also been linked to numerous other diseases and adverse health conditions including stroke, breast cancer, cervical cancer, and miscarriages. Among children, ETS is linked to adverse impacts on cognition and behaviour, decreased lung function, asthma induction, and exacerbation of cystic fibrosis (OTRU, 2001). There is no safe level of exposure to ETS (OTRU, 2001). It is also proven that ventilation technologies proposed by the hospitality and tobacco industries do not work. They cannot effectively remove ETS from indoor air (OTRU, 2001). Comprehensive smoking bans provide the most effective protection against exposure to ETS (Community Guide to Preventive Services, 2001). ETS attributed Morbidity and Mortality Involuntary exposure to environmental tobacco smoke (ETS) is also an important cause of premature morbidity and mortality. The Ontario Tobacco Research Unit estimates that between 1100 and 7800 deaths per year in Canada are caused by exposure to ETS. At least one-third of these deaths occur in Ontario (OTRU, 2001). D. COSTS OF TREATING TOBACCO USE The direct health care costs associated with smoking in Ontario in 1992 were approximately $1.1 billion. It is likely that this represents only a minority of the real economic toll of smoking because the costs associated with lost productivity and earnings as a result of illness, disability and death have been estimated to be another $2.6 billion (Single et al, 1996). Tobacco Attributed Cancer Hospitalizations, Day Surgeries and Associated Costs The costs of tobacco attributed hospitalizations and day surgeries among cancer patients for FY2001/02 are conservatively estimated to be approximately $134 M. This estimate is based on an analysis of 10 cancers, which are related to tobacco use (data not shown). A similar number of tobacco attributed hospitalizations and same day surgeries occurred during the terminal phase of cancer care as occurred during the initial phase. 7

17 Tobacco-Attributed Potential Years of Life Lost Smoking exacts a devastating toll cutting lives short and robbing Ontarians of their productive years. In 2001, it is estimated that approximately 217,946 total years of life were lost due to premature death from tobacco use in Ontario. (Table 3) This amounts on average to approximately 14.1 years of life lost per smoking death. The average years of life lost per cancer attributed smoking death is higher at about 17 years of life lost per cancer attributed smoking death. Table 3 - Smoking Attributed Years of Potential Life Lost, 2001 Disease Category Male Female Total Malignant Neoplasms 70,723 42, ,507 Lip, Oral Cavity, Pharynx 4,119 1,213 5,332 Esophagus 5,541 1,580 7,121 Stomach 2, ,635 Pancreas 2,781 2,525 5,306 Larynx 2, ,496 Trachea, Lung, Bronchus 48,602 34,837 83,438 Cervix Uteri Kidney and Renal Pelvis 1, ,205 Urinary Bladder 2, ,571 Acute Myeloid Leukemia Cardiovascular Diseases 45,832 26,278 72,110 Ischemic Heart Disease 31,167 14,573 45,740 Other Heart Disease 4,214 2,636 6,850 Cerebrovascular Disease 5,503 6,499 12,002 Atherosclerosis Aortic Aneurysm 4,018 1,770 5,788 Other Arterial Disease Respiratory Diseases 16,261 16,067 32,328 Pneumonia, Influenza 1,812 1,905 3,718 Bronchitis, Emphysema 1,783 1,716 3,499 Chronic Airway Obstruction 12,666 12,445 25,111 Total 132,816 85, ,946 Mortality: Ontario, 2001 Prevalence: OHS 1990 Survey Relative Risk: CPS-II(82-88) Life Expectancy: Ontario For methodology, see 8

18 E. LEADING SMOKE-FREE JURISDICTIONS A growing number of North American and international jurisdictions have already implemented comprehensive smoke-free legislation or are planning to do so in the foreseeable future. Ireland, Norway, Bhutan, Italy, and Malta have already enacted smoke-free legislation, which includes smoking bans in restaurants and bars. Most recently (Dec 2004), New Zealand implemented smoke-free workplace legislation, which includes, restaurant, bars and casinos. Sweden will implement 100% smoke-free workplace legislation in June Scotland has announced plans to implement indoor smoke-free legislation, to include bars and restaurants, by the spring of Seven US states California, Delaware, New York, Connecticut, Maine, Massachusetts, and Rhode Island have enacted smoke-free workplace legislation for all workers, including restaurant and bar workers. The following states are likely to enact similar legislation in 2005: Minnesota, Maryland, Utah, Colorado, Washington, Oregon, New Jersey, Vermont, and possibly Pennsylvania. In Canada, several provinces and territories have implemented 100% smoke-free legislation. Saskatchewan, Manitoba, New Brunswick, the North West Territories and Nunavut have each implemented smoke-free legislation, which includes complete bans on smoking in restaurants and bars without exemption. Both the provinces of Quebec, and Newfoundland and Labrador have recently launched consultation processes to implement 100% smoke-free legislation. New legislation is anticipated for the Spring of 2005 in each of these provinces. F. THE EFFECTS OF IMPLEMENTING 100% SMOKE-FREE LEGISLATION Air Quality The impact of implementing smoke-free legislation is both dramatic and immediate. Air quality has been demonstrated to improve immediately upon implementation of smoking bans. In Delaware, an air quality study was conducted before and after the implementation of this state s indoor smoking ban. Prior to the smoking ban, indoor levels of respirable particle air pollution (RSP) were 20 times greater than outdoor background levels. Levels of polycyclic aromatic hydrocarbons (PPAH) were also measured to be five times greater than outdoor background levels. Two months after implementation of the state s indoor smoking ban, both RSP and PPAH levels were reduced to normal outdoor background levels (Repace, 2004). The authors repeated this study in sample of Boston bars before and after the implementation of the City of Boston s 100 % smoke-free bylaw. Similar results were found with pre-smoking-ban RSP levels measured to be 23 times higher than post-ban levels and pre-ban PPAH levels 12 times higher than post-ban levels. After the ban the levels of both pollutants returned to normal background (Repace, 2003). An indoor air quality study was also conducted in Western New York by the Roswell Park Cancer Institute in order to assess the impact of New York State s 9

19 comprehensive indoor smoking legislation. Changes in respirable particles (RSP) were measured before and after the ban. RSP levels dropped on average by 84 percent after the ban in the bars and restaurants sampled (Travers MJ et al, 2004). A study currently in progress has measured self-reported ETS exposure among non-smoking bar and restaurant workers in Toronto and Windsor, Ontario before and after the implementation of the City of Toronto s smoke-free bylaw on June 1, Preliminary data indicate significant reductions in self-reported hours of workplace ETS exposure among Toronto area workers four and eight weeks after bylaw implementation as compared to pre bylaw levels. No significant declines occurred among hospitality workers in the control city, Windsor, where only a partial smoking ban was in effect during the research period. The results of the full study, which will include a third follow-up period and measures of change in urine cotinine levels, are still pending (Travis et al, 2005). Health effects Rapid improvements have also been found in the respiratory health of bar workers after the implementation of smoke-free legislation. In California, 59% of bartenders sampled who reported respiratory symptoms at baseline no longer reported these symptoms at follow-up one to two months after the implementation of a state-wide smoking ban. 78% of workers who reported sensory irritation symptoms at baseline no longer reported these symptoms after the ban. Significant improvements in respiratory capacity (forced vital capacity FVC) were also found (Eisner et al, 1998). In New York State, a 62% reduction in salivary cotinine was measured in a sample of nonsmoking hospitality workers 3 months after the implementation of a state-wide smoking ban. 6 Following the ban, the percentage of workers reporting irritation of the eyes, nose, and throat declined by 62 percent, 34 per cent and 45 percent respectively (RTI International, 2004). There is also growing evidence associating smoke-free workplace bans with reductions in smoking prevalence and tobacco product consumption. A recent systematic review conducted by Fichtenberg and Glantz of twenty-six studies conducted in the United States, Australia, Canada, and Germany found that complete smoke-free workplace bans are associated with a 3.8 % reduction in smoking prevalence and 3.1 fewer cigarettes smoked per day per continuing smoker. The authors estimate that a tax increase of $0.76 to $3.05 (US dollars) per pack of cigarettes would be required to produce a similar effect (Fichtenberg et al, 2002). A recent analysis of 2001 Canadian Community Health Survey data by the Ontario Tobacco Research Unit found that workers employed in settings without smoking restrictions are 2.3 times more likely to be daily smokers than those working under complete bans. Daily smokers working under no smoking restrictions also smoked 4.7 cigarettes per day more (30.5%) than those working under complete bans (OTRU, 2004). 6 Cotinine is a metabolite of nicotine 10

20 Economics It is well documented that the implementation of smoking restrictions does not result in negative economic impacts. In an economic analysis of the City of Ottawa s 100% public and workplace bylaw (implemented August 2001), the Ontario Tobacco Research Unit found no significant impact on restaurant and bar sales. The OTRU also concluded that our results and those of previous studies indicate that communities considering implementing smoke-free bylaws need not be concerned that bars and restaurants will be adversely affected (Ontario Tobacco Research Unit, 2003). In California, taxable sales from liquor licensed establishments increased every quarter for two consecutive years following the implementation of the California Smoke free Workplace Act in January 1998 (California Department of Health Services, 2001). No adverse economic effects have been found to result from the implementation of New York State s comprehensive indoor smoke-free law in July Total alcohol excise tax collections increased after the law (August 03- June 04) in comparison with the same period the year prior to implementation. Per capita employment in New York State s food service and drinking sector increased in each of the five months following the ban when compared to the same period the previous year. The total number of bars in New York State has also increased since implementation of the law (RTI international, 2004). In a recent review of studies assessing the economic impact of smoke-free policies conducted by Scollo et al, none of the sixty non tobacco industry funded studies reviewed reported a negative economic impact from restaurant and bar policies. Only the tobacco industry funded studies reported a negative economic impact and these studies were of lesser quality (i.e. more likely to use subjective measures, and to not be peer reviewed) (Scollo et al, 2003). G. TOBACCO DISPLAY AND PROMOTION AT RETAIL Federal bans on tobacco product advertising and the recent implementation of a sponsorship advertising ban in Canada make the retail environment one of the last remaining channels for tobacco industry marketing efforts. Countertop displays, large power walls of cigarette packages, and associated signage are ubiquitous in convenience stores, grocery stores and gas stations in Ontario, and across much of Canada. These promotional displays are placed adjacent to candy and other impulse purchases. Contrary to tobacco industry claims that they only market their products to adults, these promotional displays are visible to everyone including children. This visible retail presence of tobacco products increases the social acceptability of tobacco products and their use, and minimizes public perception of the risks. Retail promotions constitute a major marketing expenditure for the tobacco industry, and one, which is growing. In 2003, the tobacco industry made approximately $88 million dollars in payments to Canadian retailers to promote tobacco products. Between 2001 and 2004, the average payment made to retailers by tobacco companies increased by over 50% (Physicians for a Smoke-free Canada, 2005). Comprehensive bans on tobacco industry advertising and promotion, including retail display bans form a critical component of an effective tobacco control strategy. Comprehensive 11

21 advertising bans can reduce tobacco consumption. A study utilizing data from 22 high income countries for the time period 1970 through 1992, found that that comprehensive advertising bans would reduce cigarette use by 7.4 % (Saffer et al, 2000). The effects of partial bans are limited as the tobacco industry can adeptly shift its marketing efforts from one channel to another. Several Canadian jurisdictions have enacted legislation restricting the retail promotion of tobacco products or have announced their intent to do so. In Saskatchewan, the Tobacco Control Act, enacted on March 1, 2002, banned the retail promotion and display of tobacco industry products in any location where minors are permitted entry. This legislation was repeatedly appealed by the tobacco industry, but was ultimately upheld by the Supreme Court of Canada in January Manitoba and Nunavut also have passed legislation containing provisions to ban retail tobacco displays, but implementation had been suspended pending the outcome of the Supreme Court decision. In August 2001, Iceland banned all forms of tobacco advertising including retail tobacco displays. Ireland has also banned self-service displays of tobacco products and has further limited product displays. The implementation of the Irish law is currently suspended pending appeal by Irish and European tobacco companies (Tilson Consulting, 2004). 12

22 Attachment 1 Tobacco Attributed Mortality in 2001 by Ontario Electoral Riding Tobacco Attributed Deaths Ontario Cancer CVD Resp. Disease Numbers are rounded, and based on the number of deaths for each riding For methodology, see Tobacco Attributed Deaths Central East Haliburton - Victoria - Brock Peterborough Simcoe North Simcoe - Grey Northumberland Barrie - Simcoe - Bradford Oshawa Durham Oak Ridges Whitby - Ajax Pickering - Ajax - Uxbridge Vaughan - King - Aurora Markham York North Thornhill Cancer CVD Resp. Disease For methodology, see 1

23 Attachment 1 Tobacco Attributed Mortality in 2001 by Ontario Electoral Riding Tobacco Attributed Deaths Central South St. Catharines Niagara Centre Brant Niagara Falls Erie - Lincoln Haldimand - Norfolk - Brant Hamilton Mountain Stoney Creek Hamilton West Ancaster - Dundas - Flamborough - Aldershot Hamilton East Cancer CVD Resp. Disease For methodology, see Tobacco Attributed Deaths Central West - Kitchener Guelph - Wellington Kitchener Centre Cambridge Kitchener - Waterloo Dufferin - Peel - Wellington - Grey Waterloo - Wellington Cancer CVD Resp. Disease For methodology, see 2

24 Attachment 1 Tobacco Attributed Mortality in 2001 by Ontario Electoral Riding Tobacco Attributed Deaths Central West - Peel Burlington Oakville Halton Brampton West - Mississauga Mississauga East Mississauga South Mississauga Centre Bramalea - Gore - Malton - Springdale Mississauga West Brampton Centre Cancer CVD Resp. Disease For methodology, see Tobacco Attributed Deaths East - Kingston Prince Edward - Hastings Hastings - Frontenac - Lennox and Addington Kingston and the Islands Cancer CVD Resp. Disease For methodology, see

25 Attachment 1 Tobacco Attributed Mortality in 2001 by Ontario Electoral Riding Tobacco Attributed Deaths East - Ottawa Renfrew - Nipissing - Pembroke Ottawa West - Nepean Leeds - Grenville Lanark - Carleton Stormont - Dundas - Charlottenburgh Glengarry - Prescott - Russell Ottawa South Ottawa Centre Ottawa - Vanier Nepean - Carleton Ottawa - Orléans Cancer CVD Resp. Disease For methodology, see Tobacco Attributed Deaths North East Sudbury Parry Sound - Muskoka Timiskaming - Cochrane Nipissing Sault Ste. Marie Algoma - Manitoulin Timmins - James Bay Nickel Belt Cancer CVD Resp. Disease For methodology, see

26 Attachment 1 Tobacco Attributed Mortality in 2001 by Ontario Electoral Riding Tobacco Attributed Deaths North West Thunder Bay - Superior North Thunder Bay - Atikokan Kenora - Rainy River Cancer CVD Resp. Disease For methodology, see Tobacco Attributed Deaths South West - London Bruce - Grey - Owen Sound Huron - Bruce Elgin - Middlesex - London Oxford London West London North Centre Perth - Middlesex London - Fanshawe Cancer CVD Resp. Disease For methodology, see

27 Attachment 1 Tobacco Attributed Mortality in 2001 by Ontario Electoral Riding Tobacco Attributed Deaths South West - Windsor Chatham - Kent Essex Lambton - Kent - Middlesex Windsor West Sarnia - Lambton Windsor - St. Clair Essex Cancer CVD Resp. Disease For methodology, see Willowdale Etobicoke Centre Eglinton - Lawrence York Centre Etobicoke - Lakeshore Don Valley West St. Paul's Scarborough Centre Scarborough - Agincourt Don Valley East Scarborough Southwest York South - Weston Parkdale - High Park Toronto Centre - Rosedale Beaches - East York Etobicoke North Scarborough East Toronto - Danforth Trinity - Spadina Scarborough - Rouge River Davenport York West Tobacco Attributed Deaths Toronto For methodology, see Cancer CVD Resp. Disease