Why do we still permit tobacco use?

Carswell Partners, London, Ontario Correspondence: Mr Norman H Tiffin, 22551 Jury Road, Kamoka, Ontario N0L 1R0. Telephone 226-376-1414, e-mail [email protected] Tobacco smoking has no health benefits. None. It can be argued that nicotine, one of the thousands of compounds in tobacco smoke, can have positive effects on some cognitive functions and may even confer some neuroprotection (1), but getting nicotine from tobacco products may be likened to sucking on a tail pipe to get oxygen – it’s there but it’s not going to do you any good. Yet tobacco is legally sold in virtually every country in the world and, after decades of understanding its harm, it remains not only legal but highly accessible and profitable (to everyone but the consumer) in Canada. Our governments collect $2.81 billion in tobacco sales taxes federally (2), which is >1% of all federal government spending in 2013 (3). That’s staggering. Fully 1% of federal spending from a substance that only produces disease, debilitation and death – with no benefits. The provinces collect an additional $4.67 billion (2012-2013) (2). Yes, there are benefits from tobacco taxation including fewer smokers, higher government revenues and a healthier society and, as respiratory therapists, we should applaud the use of the excise tax lever that the government can use discriminately. However, the direct and indirect cost of lung cancer, asthma and chronic obstructive pulmonary disease in Canada is $12.0 billion (2012 figure), of which smoking is considered to be the number one cause (4). That’s not a good trade-off, even if you only consider it economically. One of the main arguments for the continuance of tobacco sales is that the government should not dictate what vices the public engages in. This is a valid point. Alcohol and gambling are restricted but not prohibited; fast food is unrestricted (although New York City [USA] attempted the restriction of soft drink sizes but failed miserably); and, although government intervention is on the rise, few are protesting access to these products. These other ‘sins’, however, have at least some benefit. We need gasoline, we need to eat even if we occasionally do so at fast food restaurants, alcohol in moderation has benefits and gambling in moderation is entertaining for some. However, there is no moderation in tobacco. There is no level at which tobacco smoke is safe for the consumer or the people around them or, as we are seeing, even those who are exposed in a tertiary environment (5). So why do we, as a society, continue to approve of tobacco sales? And approve of it we do. The run-up to the federal election has had no discussion on tobacco use. Governments enjoy tobacco revenue and are willing to continue to allow disease and death from tobacco smoking. Yes, Alberta will soon restrict flavoured tobacco, but if tobacco smoking was invented today, it would be inconceivable that Health Canada would permit it, yet it is equally inconceivable that any of today’s governments will outlaw it. Public outcry (from smokers and nonsmokers alike), policing costs, illegal importation, antigovernment intervention and underground sales all virtually prohibit its full restriction. So there is the conundrum: tobacco has no benefit, yet it can’t be outlawed. So, as a society, and as health care professionals specifically, we are driven to what remains for us to use as tools for smoking cessation: rational or emotional arguments, structured cessation programs, drugs, patches, e-cigarettes and gum, among others. And these are working, albeit slowly. In 1965, almost one-half of the Canadian population smoked tobacco cigarettes and, in 2014, it was 18.1% (6), although the rate of reduction is slowing over the past several years. It has been several years since I practiced as a respiratory therapist clinically, but I can vividly recall in the first couple of weeks into my first clinical rotation watching an elderly man with end-stage emphysema literally suffocate and die on my shift wearing just a venti mask. It was a clarion moment for me as a young health care professional even though I never smoked. I have not forgotten that patient, nor that tobacco kills and debilitates and has no benefit. So, even many years after seeing patients, I steadfastly encourage, support and educate those around me who continue to use tobacco products. It still breaks my heart to see people smoking outside of buildings and just off school property. Yet they have the right to do so. As respiratory therapists, individually and collectively, you have a strong voice of authority in this issue because of your experience and education. You can speak directly and personally to the destruction from tobacco use; you can explain in detail the effects; you can instruct on what is the likely ugly outcome; you can suggest the latest in cessation techniques and programs; and you can get involved in advocating for further restrictions on tobacco. It’s our job and, regardless of whether we like it, it became so the day we received our RRT designation. And whether you still practice clinically, or are in administration, research or something else, that hasn’t changed. commentary