Public Health Research
Written July 2021
Cigarette smoking in Sudbury and Ontario, and the need for primary prevention
Introduction
We’ve all heard about how bad smoking is for our health, being encouraged not to ever try smoking, especially in elementary and secondary school health classes. These messages don’t seem to be fully received and understood, however, as the tobacco industry continues to flourish, and we continue to see people all over the world burning through cigarettes rapidly. With the effects smoking can have on human health, and it’s prevalence across Canada, it has become a major concern to public health officials, who have been putting policies and practices in place to try to improve the situation, many of which might not be the best approach. Understanding why cigarette smoking is such a significant public health concern, as well as how we’ve dealt with it in the past, can allow us to develop more efficient methods for reducing the prevalence of smokers in our populations.
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Background
Starting to smoke tobacco, and becoming addicted to the nicotine found in cigarettes, can happen to anyone. In Sudbury, we do see a higher prevalence among certain groups (based on sex or income bracket, for example), which will be touched on in the next section. The decision to begin smoking, and continuing to smoke, can be impacted by both environmental culture (access, bans, cost, social acceptability, and parental influence) and the individual (genes, conditions, and personality) (Hatsukami et al., 2008).
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The natural history of becoming addicted to nicotine shows a different pattern to other drug dependencies. Nicotine addiction stabilizes in adulthood, whereas other drug dependencies tend to show a decline starting in the twenties (Kandel, 2003). Typically, first exposure to tobacco happens in late childhood or early adolescence, before becoming more present throughout adolescence in general (Kandel, 2003). As adolescents age and mature, chronic and regular (daily) smoking becomes much more common than casual cigarette smoking (Kandel, 2003). Adolescence is a critical time for nicotine addiction and dependence, as a study found that 86% of smokers between the ages of 20-34 had begun smoking by the age of 18 (Kandel, 2003). When smoking, the nicotine that is inhaled is brought through the lungs, into the bloodstream where it travels to the heart, before being sent directly to the brain (Hatsukami et al., 2008). With how quickly the high amounts of nicotine are inhaled, it becomes easy for a nicotine addiction to develop, though individual differences in nicotine metabolism lead to differences in how quickly dependency develops (Hatsukami et al., 2008). Nicotine affects the release of neurotransmitters in the brain, which can lead to changes in arousal, mood, performance, and weight-loss (citation). Chronic use of nicotine can affect receptors to the point where a new homeostasis within the body is reached, after which trying to cut out nicotine can cause withdrawal symptoms (Hatsukami et al., 2008; Jha et al., 2006). Psychological and economic circumstances can help to support or end a tobacco addiction (Jha et al., 2006). With how easy it can be to become addicted to smoking, as nicotine is one of the most addictive substances consumed (Kandel, 2003), it’s not a surprise that in 2008 there were around 1.2 billion smokers in the world, and 5 million deaths per year as a result (Hatsukami et al.).
The reason this addiction to nicotine is so problematic is the many severe health consequences and complications that arise from smoking that lead to these 5 million, or more, deaths per year. According to the Centers for Disease Control and Prevention [CDC], smoking can harm almost every organ in the body, and can cause various cancers, heart and lung diseases (including chronic obstructive pulmonary disease), stroke, and diabetes, while increasing the risk for other diseases as well (2020). Smoking can lead to almost any form of cancer around the body through damaging cells and weakening the immune system, and is the cause of 90% of lung cancers (CDC, 2020). In terms of heart disease, smoking can lead to changes in the body that put an individual more at risk for developing heart disease or having a stroke, such as increasing plaque buildup and making blood more likely to clot (CDC, 2020). Lung diseases arise from damages to lung tissue, or development when smoking in adolescence (CDC, 2020). One half to two-thirds of chronic smokers will die from their addiction, with typical years of life lost landing around 20-25 years (Jha, 2006). Smoking is such a significant issue because it is far from being without consequences; allowing those chemicals to enter the body on a regular basis leaves the potential for several life-threatening conditions to develop, which is why public health intervention is needed to help reduce smoking in our populations.
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Local Impact
Public Health Sudbury and Districts has shared comprehensive data about smokers in Sudbury from 2007-2014, highlighting certain groups that smoke more than others. As of 2014, 25.2% of adults ages 20 and up were smokers at the time of the survey (Adult Current Smokers, 2018). When compared with Northeastern Ontario, this number was normal; in all of Ontario, however, the prevalence rate was only 18.8% (Adult Current Smokers, 2018). Thisstudy also found that males, people ages 30-44, those in the lowest income quintile, and those with less than a high school education were more likely to smoke when compared to other groups (Adult Current Smokers, 2018). Surprisingly, while with more education the smoking prevalence followed a decreasing pattern, smoking based on income brackets varied so that those in quintile 4 smoked more than those in quintiles 2 and 3, before dropping to the lowest prevalence seen among those in quintile 5 (the highest income bracket) (Adult Current Smokers, 2018). Among age groups, smoking was next most prevalent in 45-64 year-olds, and lowest for those 65+ (Adult Current Smokers, 2018). One of the most shocking details found in this survey is that from 2013-2014, there was a 44.4% prevalence of former smokers (Smoking, 2018). When combined with the prevalence of current smokers at the time, this statistic meant that around 70% of adults over 20 in Sudbury were at one point smokers, a scarily large number. Between the data collected from 2007-2008, and this data from 2013-2014, Public Health Sudbury and Districts did not see a significant change in smoking prevalence (Smoking, 2018).
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Following this point, the Vital Signs Report for Sudbury developed in 2016 by the Sudbury Community Foundation found some data that is not shocking after seeing the high prevalence of smoking, but still worrisome. It was noted that the top two leading causes of death from 2002-2011 included ischemic heart disease (19%) and lung cancer (9%), higher than the numbers seen in the rest of Ontario and across Northeastern Ontario (Sudbury Community Foundation, 2016). Lung cancer and heart disease can both be caused by smoking, as discussed previously (CDC, 2020). With the other types of cancer, and other negative health conditions that can be caused by smoking, the 28% of deaths caused by ischemic heart disease and lung cancer doesn’t even begin to cover the fatal effects of smoking in Sudbury (CDC, 2020). It is disappointing to see so many lives being lost as a result of such a high prevalence of smoking in our city, especially when compared with the rest of Ontario. These differences aren’t largely significant, however, with ischemic heart disease and lung cancer as causes of death sitting at 17% and 7%, respectively, for the province, highlighting the impact of smoking on a larger scale (Sudbury Community Foundation, 2016). When discussing smoking and deaths from diseases caused by smoking in this report, we don’t even touch on the impact of second hand smoke at home, where the prevalence in Sudbury is also significantly higher than rates in Ontario and across Canada, bringing with it even more health concerns (Sudbury Community Foundations, 2016).
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The Role of Public Health
It appears that much of the public health approach to tobacco control has relied on secondary and tertiary prevention and intervention measures. While new initiatives for reducing smoking in Ontario propose ways to prevent young people from starting to smoke (primary prevention), still much of what we’re doing now and what has been done in the past focuses on smoking cessation as opposed to initial prevention (Government of Ontario, 2019; Quitting Tobacco, 2019).
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When looking back over the history of tobacco interventions in Ontario and across Canada, the common theme that emerges is continually increasing tobacco taxes, and implementing restrictions on where people can and can’t smoke (History of tobacco control, n.d.). Much of this work started from the creation of the ‘Smoke-Free Ontario Act’, active since 2006 with revisions over time (Government of Ontario, 2018). This focus means reducing opportunities to smoke, as opposed to the act of smoking itself, and while the inconvenience may deter some from smoking, the main benefit that comes from this is reducing second hand smoke. Other efforts that have been implemented include banning advertisements and flavoured cigarettes, as well as increasing graphic warnings on cigarette packages (History of tobacco control, n.d.). The statistics surrounding smoking in the province do suggest that some of these measures have had success in the past. A report from 1996 found that 27% of adults (18+) in Ontario were current smokers at the time (Bondy & Ialomiteanu). This is in contrast to the prevalence found in 2014, as discussed previously, of 18.8% of individuals ages 20+ (Adult Current Smokers, 2018). This suggests a relatively impressive improvement of 9% over 18 years, though these data points are not directly comparable due to the nature through which they were collected and the age ranges selected. A report from the Government of Ontario indicated a decrease in smoking rates from 24.5% to 16% in Ontario from 2000 to 2016, with the goal of the Government being to reach 10% prevalence by 2023 (2018). With relatively little improvement from 2008-2012 (Adult Current Smokers, 2018), it seems that the practices put into effect through the Smoke-Free Ontario Act in 2006 were not overly effective at the start, and further improvements have only begun to show more recently. What this observation suggests is that while public health practices in Ontario and across Canada have been able to reduce the prevalence of smoking through the limited measures that have been put in place, these measures have not always remained effective in continuing to reduce smoking over time, and may not remain effective as society changes. While we have been making significant progress, smoking is still very much a significant concern that will continue to require new approaches for prevention and intervention.
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As of 2018, the Government of Ontario has laid out a framework for achieving three goals in reducing smoking incidence; increasing the number of those who quit each year by 80,000, preventing initial use so no more than 10,000 people start smoking each year, and implementing policies to reduce second-hand smoke exposure (Government of Ontario, 2018). Their plan includes ensuring easy access to cessation services, inspiring smokers to quit, increasing the tobacco tax rate, raising awareness, protecting youth from tobacco products, and creating more smoke-free spaces (Government of Ontario, 2018).
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In Sudbury, our Public Health unit currently offers services, listed on their website, to help people quit smoking (Quitting tobacco, 2019). These services include a ‘Quit Smoking Clinic’ where individuals can get help setting up a personal plan for quitting, with free nicotine replacement therapy available for some clients, telephone support, group workshops and group cessation support, as well as additional resources (Quitting tobacco, 2019). There is also a short description for youth to let them know the risks of smoking, to encourage them to get involved with the Public Health Youth Group, and to explore what youth can beinvolved with in regards to smoking prevention, though some of this information is out of date (Tobacco, Vaping, and Electronic Cigarettes, 2019). In personal experience, there is very little being done in the public to alert people of these services, and even less to try to reduce the number of people who start smoking in Sudbury each year.
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Recommendations
What is surprising to see is that in the aforementioned plan by the Government of Ontario to meet three goals regarding tobacco use, they have seven plans of action for tackling cessation, while only three each for reducing initial smoking and second-hand smoke (Government of Ontario, 2018). If we truly want to reduce the prevalence of smoking in our communities we cannot only focus on cessation, as then there will always be an influx of new smokers who then need to cease smoking, too. While getting people to stop smoking is important, as emphasized by the finding shared earlier that the highest prevalence of smoking occurs among those ages 30-44 (Adult Current Smokers, 2019), targeting initiatives towards preventing the start of smoking (not just for youth, but for everyone) has the chance to keep numbers down permanently. By implementing plans for primary prevention, making sure people don’t start smoking in the first place, the need for cessation clinics and programs will be reduced in our communities. These preventions can be done through programs and policies in workplaces, schools, and other relevant businesses or organizations, advertisements and media campaigns, and public discussions. A review by M. Golechha determined that an effective approach would need three-tiers; reaching the mass public, reaching the individual, and mobilizing the community (2016). By combining effective methods of marketing to the public first, and then focusing on the individual, while working to change public perceptions and attitudes towards smoking, smoking prevalence could decrease significantly (Golechha, 2016). As Golechha suggests in their review (2016), mass media campaigns can be extremely helpful for reaching youth and adults alike, and we should be utilizing this especially for preventing smoking in young people. In addition to focused prevention programs, finding other ways to reduce the presence of tobacco companies in our city and province, besides increasing tobacco taxes, would be a step towards reducing smoking significantly; if tobacco can only be sold in very limited locations, in limited quantities, and sold to individuals with further restrictions, we can begin to remove tobacco from the equation altogether.
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Conclusion
In conclusion, we can see that smoking is not a health issue to take lightly, and while we’ve been aware of the need to reduce the prevalence of smoking for a long time, practices have not yet been effective enough at preventing smoking from the start. If our public health units can implement a comprehensive plan for primary prevention, stopping people from even picking up a single cigarette to start, and removing the power that tobacco companies have over our populations, we will see nothing but improvements. With such measures in place, not only would the incidence of smoking, and therefore exposure to second-hand smoke, decrease, but we would see a significant drop in deaths caused by cancers and heart or lung diseases that develop as a result of smoking. It’s time for us to implement a stronger strategy so that our city, province, and country can see significant improvements in population health and overall well-being.
References
Adult Current Smokers. (2018, August 22). Public Health Sudbury & Districts. https://www.phsd.ca/resources/research-statistics/health-statistics/public-health-sudbury-districts-population-health-profile/health-behaviours/smoking-2/adult-current-smokers/
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Bondy, S. J., & Ialomiteanu, A. R. (1997). Smoking in Ontario, 1991 to 1996. Canadian journal of public health, 88(4), 225-229.
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Centers for Disease Control and Prevention. (2020, April 28). Health Effects of Smoking and Tobacco Use. U.S. Department of Health and Human Services. https://www.cdc.gov/tobacco/basic_information/health_effects/index.htm
Golechha, M. (2016). Health promotion methods for smoking prevention and cessation: a comprehensive review of effectiveness and the way forward. International journal of preventive medicine, 7.
Government of Ontario. (2018, April). Smoke-Free Ontario: The Next Chapter - 2018. Queen’s Printer for Ontario. https://health.gov.on.ca/en/common/ministry/publications/reports/SmokeFreeOntario/SFO_The_Next_Chapter.pdf
Hatsukami, D. K., Stead, L. F., & Gupta, P. C. (2008). Tobacco addiction. The Lancet, 371(9629), 2027–2038. https://doi.org/10.1016/S0140-6736(08)60871-5.
History of tobacco control. (n.d.). Canadian Cancer Society. https://action.cancer.ca/en/get-involved/advocacy/what-we-are-doing/tobacco-control/history-of-tobacco-control
Jha, P., Chaloupka, F. J., Moore, J., Gajalaksmi, V., Gupta, P. C., Peck, R., Asma, S., & Zatonski, W. (2006). Tobacco Addiction. In D. T. Jamison, J. G. Breman, A. R. Measham, G. Alleyne, M. Claeson, D. B. Evans, A. Mills, & P. Musgrove (Eds.), Disease Control Priorities in Developing Countries (2nd ed., pp. 869–885). World Bank Publications. https://www.ncbi.nlm.nih.gov/books/NBK11741/.
Kandel, D. (2003, January). The Natural History of Smoking and Nicotine Dependence. ResearchGate. https://www.researchgate.net/publication/237810073_The_Natural_History_of_Smoking_and_Nicotine_Dependence
Quitting Tobacco. (2019, July 31). Public Health Sudbury & Districts. https://www.phsd.ca/health-topics-programs/tobacco/quitting/
Smoking. (2018, August 8). Public Health Sudbury & Districts. https://www.phsd.ca/resources/research-statistics/health-statistics/public-health-sudbury-districts-population-health-profile/health-behaviours/smoking-2/
Sudbury Community Foundation. (2016, October). VitalSigns 2016 Greater Sudbury’s Annual Check-up. http://vitalsignssudbury.ca/
Tobacco, Vaping, and Electronic Cigarettes. (2019, December 4). Public Health Sudbury & Districts. https://www.phsd.ca/health-topics-programs/tobacco/