Monday, 20 February 2017

France leads the way with four (and counting!) innovative tobacco control measures in 2017

Since the beginning of the year, France has implemented a series of ground-breaking tobacco control measures - and signalled that more will come into force next year.


Plain Packaging
After a long fight against the tobacco industry and its mouthpieces, France has adopted laws requiring plain packaging of cigarettes. The new law was phased in and came fully into force on January 1, 2017. The long struggle for plain packaging was well described by French tobacco control advocate Emmanuelle Béguinot in a presentation she gave at the World Cancer Congress in Paris in November, 2016.

A taxing problem
In a lesser known but equally important tobacco control initiative, France has adopted a new tax of 5.6% on tobacco company revenue. The money so raised, expected to be about 130 million Euros per year (about 180 million Canadian dollars) will be used to finance further tobacco control initiatives in France. This is a very significant advance in tobacco control in France and worthy of emulation by other countries. The path to this achievement was a difficult one and the road ahead to effective implementation may be very bumpy as well.
The European Union has brought many social and economic benefits to its citizens, but the benefits afforded to corporate citizens do not always benefit the flesh-and-blood citizens. For Big Tobacco, France is a high-tax regime. To keep their money away from the French fisc (tax authority), tobacco companies have made their corporate presence in France all but disappear. All of their manufacturing and warehousing operations of cigarettes destined for France have been moved to other European Union countries. Even distribution operations have been off-loaded to another company – Logista. This left the French government with a taxing problem. Tobacco company profits earned in France were estimated to be around 850 million Euros per year (Annexe 10: Fiches d'évaluation préalabe des articles du projet de loi, pages 128 à 137), but there was no big tobacco company present in France that could be taxed. What to do?

Further study of the problem revealed that Logista is no ordinary distribution and wholesaling company. It is both of creation of and a front for the tobacco industry. It is 70% owned by Imperial Brands, itself a corporate front for Imperial Tobacco, one of the big four tobacco companies that sell cigarettes in France. The others are British American Tobacco, Philip Morris and Japan Tobacco Industries. By a sweetheart arrangement among these four, all of them distribute their cigarettes in France through Logista.

At the same time that tobacco company revenue is largely escaping taxation in France, consumption taxes (excises taxes and value-added tax) on tobacco products are among the highest in the European Union. The government, knowing that any further increase in tobacco excise taxes would be politically unwise at the current time, decided on a tax on tobacco company revenues. Still, the problem remained on how to tax companies that are not in France.

A taxing solution
France has an extensive and complex system of health and social security. Every year, the law governing the financing of this system needs to be revised and updated. Revisions to the 2017 edition of the law were completed in 2016. Inserted into this complex law (the text runs to 70 pages) was a single provision, Article 28, that creates a new 5.6% levy on suppliers (fournisseurs) of tobacco. By taxing suppliers, the government casts a wide net that catches the largest supplier of tobacco in France – Logista. Brands distributed by Logista account for 98% of tobacco product sales revenue in France. The government anticipates that Logista will pass this new charge on to the big tobacco companies whose products they distribute, and that the yield of 130 million Euros per year will be coming indirectly from the revenues of Big Tobacco that will be earned in France. A key feature of this new tax is that all the money will be devoted to government anti-tobacco initiatives. This will increase France’s current government spending on anti-tobacco work (about 30 million Euros) more than four times over.

New money for tobacco control
The government agency normally responsible for tobacco control in France is the Health Department. However, because the new tax measure was included in the law that governs universal health insurance, the new tobacco control funds will be administered by a national health insurance agency, known by its French acronym CNAMTS (Caisse nationale de l’assurance maladie des travailleurs salariés / the French national health insurance fund for salaried workers). CNAMTS is used to administering health insurance claims, but has little experience in tobacco control. Happily, the CNAMTS will not be alone in managing the tobacco control funds. A government decree of December 5, 2016 specified that the funds are to be administered by a 12-member Board of Directors made up of the directors-general and directors of several health insurance funds, directors-general of the Health Department, the Social Security Department, the Public Health Agency, the National Cancer Institute, and two members at large appointed by the Minister of Health. On February 7, 2017, Karine Chevreul, a public health physician and health economist, and Daniel Thomas, a cardiologist and Vice-President of the French Alliance Against Tobacco were named to fill these two latter positions. One hopes that this new Board of Directors can bring enough tobacco control knowledge and experience to the table to ensure that the new 130 million Euros per year for tobacco control will be spent effectively and wisely.

These three new measures, plain packaging, the tobacco company revenue tax and the new tobacco control fund all came into force on January 1, 2017.

Cigarette brand names will no longer be in vogue
Article 13 of the Directive 2014/40 of the European Union directs member states to greatly restrict tobacco product presentation. Among other restrictions, member states are advised that neither the packaging nor the product shall include any element that “promotes a tobacco product or encourages its consumption,” nor any element that “suggests that a particular tobacco product is less harmful than others or aims to reduce the effect of some harmful components of smoke or has vitalising, energetic, healing, rejuvenating, natural, organic properties or has other health or lifestyle benefits,” nor any element that “suggests that a certain tobacco product has improved biodegradability or other environmental advantages.”

Now the French government has taken this Directive to heart with a remarkable application of it in French law. A regulation issued on February 1, 2017, lists all the brands of tobacco products available for sale in France, their current price and the new prices that will be in effect in 2017. Every brand variant is listed separately. The list is 213 pages long and lists over 8,000 products. If an asterisk appears beside the name of a tobacco product, it means some element of its name is judged to be contrary to the European Union Directive noted above and its sale will only be authorized for one more year. Cigars marked with an asterisk can still be sold for two more years. Of the 8,000 or so products listed, about 1,300 of them are manufactured cigarettes distributed in France by Logista and account for more than 98% of the cigarettes consumed in France. The other brand names are fine cut tobacco, pipe tobacco and cigars distributed by Logista, together with tobacco products distributed by other small suppliers. For manufactured cigarettes, certain descriptors, like colours, will continue to be allowed, but others will disappear. Brand names containing certain descriptors like anis (licorice), biodégradable, menthol and slims will all disappear in 2018. The ban on “slims” necessarily bans the well-known brand name “Virginia Slims” from France. “Vogue” will no longer be in vogue. The Logista cigarette brand names and descriptors slated for extinction are summarized in Table 1.

Table 1. Logista cigarette brand names and descriptors that will no longer be allowed in France after 2018.

Brand names disallowed by 2018
Number of variants
Allure
3
Alluvé
3
Corset
5
Fine
22
Parisienne Ultra
1
Virginia Slims
2
Vogue
3
Subtotal
39


Brand names not already counted above that will disappear in 2018 because they contain one of the following descriptors:
Number of occurrences
Anis (licorice)
1
Biodégradable
1
Menthol
33
Slims
4
Subtotal
39


Total number of Logista cigarette brands to be disallowed in 2018
78

As well, many Logista-distributed cigar brands, bearing descriptors with positive connotations like Vanilla, Delight, Fine, Finos, Senorita, Esplendidos, Exquisitos, Genios, Magicos, Distinguidos, Maravillas, Delicias, Majestic, Gourmet, Tropical, Grand Luxe, Exotic, Trendy, Classic, Premium and several others, are slated for extinction in 2019. Among the cigar brands distributed by Logista, three will completely disappear – Paradise, Punch and Café Crème. 

Vogue cigarettes and Café Crème cigars are also sold in Canada. The Canadian government has no plans to ban any brand names – yet. Our friends at the Coalition québécoise contre le tabagisme (CQCT) have called upon Minister of Health Jane Philpott to follow France’s lead and do just that. They have asked her to ban Canadian cigarette descriptors and brand names that have unacceptably positive connotations. We could not agree more.

Minister Philpott should not stop there. We would also urge her to follow France’s lead by requiring plain packaging for cigarettes, taxing tobacco company profits and using the proceeds to fund tobacco control.


Stay tuned for information on France's 5th innovative measure!



Friday, 6 January 2017

How many Canadians smoke pot ? Depends on who is asking

Making evidence informed policy for marijuana will rely on the availability of evidence - and that  includes having a good handle on how many Canadians are using this dependence-producing drug.

It would appear that usually reliable research methods are get conflicting results on the prevalence of marijuana use. Take, for example, three recent surveys of marijuana use by respected organizations.
  • The Canadian Tobacco, Alcohol and Drugs Survey, which is managed by Health Canada and which questioned 15,000 Canadians 15 years and older in 2015 with a participation rate of 58%. The questions asked were "During the past 12 months have you used marijuana?
    During the past three months have you used marijuana? During the past three months how often did you use marijuana?"
    The results would have included both recreational and medical use.
  • A survey by Ekos Canada, commissioned by Health Canada and released under the (very helfpul) guidelines on release of public opinion research. It surveyed 2,201 Canadians 13 years of age and over in May and June 2016, with a participation rate of 20%. The questions asked were: "Have you used marijuana in the past 12 months?"/ "Over the past 12 months, how often have you used marijuana on average?" "When legalized in Canada how likely would you be to use/try marijuana?"The results would have included both recreational and medical use.
  • The third is a business-oriented report by Deloitte and Riwi Corp, which surveyed 5,000 Canadians aged 19 and over in March-April 2016. The participation rate was not stated and the questionnaire has not been located. The results state that medical use of marijuana was excluded.
The results, as shown below, give very different pictures of the situation.


CTADS
EKOS
DELOITTE
Age:
15 +
13 +
19 +
Sample size
15,000
2,200
5,000
Survey period
 2015
 Summer 2016
 Spring 2016
Past year use or occasional use
12 %
(incl. medical)
38%
(incl. medical)
22%
(excl. medical)
Daily use
2.8%
8.4%
7%
Might use if it were legalized (but don’t currently use)
 n/a
14%
17%

Friday, 18 November 2016

The missing smokers

A cheer went out when Health Canada released the results of the Canadian Tobacco, Alcohol and Drugs Survey (CTADS) for 2015.

The number of people who identify themselves as smokers in Canada had fallen to an all-time low -- only 3.8 million smokers representing only 13% of the population. If we consider only those who smoke on a daily basis, the results were even more encouraging: fewer than 10% said that they lit up ever day. This is one of the lowest rates among developed countries - lower than the rates observed for any OECD country!

But is it maybe too good to be true?  


The CTADS is a relatively recent survey. It was developed a few years ago when the (former) government decided to reduce its investment in monitoring tobacco use, and decided to compress the annual Canadian Tobacco Use Monitoring Survey (CTUMS) into a bi-annual survey which also covered other sin behaviours, like drinking and drug use. 

Meanwhile, Statistics Canada continues to manage a far larger survey which produces much higher estimates of smoking.  The Canadian Community Health Survey (CCHS) covers a wide range of health behaviours, of which tobacco use is a regular but small component. CTADS gets responses from 15,000 Canadians every 2 years: the CCHS covers 120,000 individuals. Two thirds of those asked to participate in the CCHS agree to do so (an overall response rate of 66%). Fewer than half of those asked to participate in the CTADS agree to do so (an overall response rate of 48%).

Even though they use the same questions, the CCHS has always produced higher estimates of smoking behaviour than either CTUMS and CTADS. 

It may now be that the gap between the results of these surveillance tools is growing. The 1.6 million fewer smokers identified by CTADS in 2015 than by CCHS in 2014 represents about 40% more smokers. This is a big difference.

We may not have to wait much longer to learn of the CCHS estimates for 2015. Information on risk factors for heart disease are scheduled for release on December 12, 2016.

Perhaps we can leave the champagne on ice for a while.

Canadian Tobacco Use Monitoring Survey (CTUMS)
Canadian Community Health
Survey (CCHS)
Smokers #
%
95% CI
Smokers
%
95% CI
1999
6,121,992
25
2000
6,007,562
24
2001
5,411,822
22
6,677,856
26
25.5-26.4
2002
5,414,335
21
2003
5,332,326
21
20.0-21.8
6,080,504
23
22.7-23.4
2004
5,116,200
20
18.5- 0.7
2005
4,966,600
19
17.6-19.8
5,874,689
22
21.4-22.1
2006
4,934,022
19
17.6-19.6
2007
5,176,302
19
18.2-20.2
6,112,442
22
21.6-22.5
2008
4,880,488
18
16.8-18.9
6,009,311
21
20.9-21.9
2009
4,851,274
18
16.5-18.6
5,730,321
20
19.6-20.7
2010
4,701,868
17
15.8-17.7
5,967,259
21
20.2-21.3
2011
4,910,520
17
16.2-18.4
5,764,843
20
19.3-20.4
2012
4,629,987
16
15.0-17.3
5,933,095
20
19.6-20.9
Canadian Tobacco, Alcohol and Drugs Survey
2013
4,233,300
14.6
13.5-15.8
5,722,635
19
18.7-19.9
2014
5,400,000
18
17.5-18.6
2015
3,846,800
13
11.9-14