Proceedings of the Standing Senate Committee on
Energy, the Environment and Natural Resources

Issue 13 - Evidence

The Standing Senate Committee on Energy, the Environment and Natural Resources, to which was referred Bill S-20, to enable and assist the Canadian tobacco industry in attaining its objective of preventing the use of tobacco products by young persons in Canada, met this day at 5:30 p.m. to give consideration to the bill.

Senator Mira Spivak (Chair) in the Chair.

[English]

The Chair: Honourable senators, we have a quorum. We are here to begin our hearings on Bill S-20. I welcome the media that are here. We certainly would like them to feel free to videotape part or all of the proceedings or take still photos at any time during the proceedings, but this is a small room, and we would ask you just to be careful not to disrupt the witnesses who will be here.

Our first witnesses are the sponsors of the bill. I would ask Honourable Senator Kenny and Honourable Senator Nolin to begin their testimony, please.

[Translation]

The Honourable Pierre Claude Nolin: I am pleased to be here with my colleague Senator Kenny, to initiate the consideration of this important bill that, in our opinion, will revolutionize how Canadians address the very serious and sinister issue of smoking among young persons.

As you noted earlier, Bill S-20 was tabled and given first reading in the Senate on April 5, 2000; it was then debated at second reading and referred to your committee on May 9, 2000.

Every year in this country, smoking causes the deaths of 45,000 Canadians. Unfortunately, this sombre figure is on the rise; not long ago it was 40,000 persons, but has now risen to 45,000 persons.

Furthermore, this cause of death can be avoided, unlike others equally serious. For example, smoking is 10 times more deadly than driving a vehicle: traffic accidents -- including drunk driving -- cause the deaths of 4,000 Canadians each year.

Studies have shown that 85 per cent of smokers start smoking before they reach the age of 16 years; hence the importance of the bill before you. In 1994, the federal government lowered taxes on tobacco. Since that time, smoking by 15- to 19-year-olds has only increased, and today 30 per cent of young Canadians are smokers.

If we compare this rate with that in California, for example, we can see that three times more persons in this age group smoke in Canada than in California. Later I shall leave Senator Kenny all the time he needs to explain to you how California and other jurisdictions have managed to stem this tide. Unfortunately, it can be said that the present level of smoking among young persons constitutes a crisis.

I referred to California, which is only one state among 50. Proportionally speaking, of course, we can draw social and economic comparisons between the population of the United States and that of Canada.

In August 1999, the United States Department of Health and Human Services, Centres for Disease Control and Prevention, published a report stating that a country like Canada should be spending between $9 and $24 dollars per capita on smoking reduction programs. If we compare this estimate with what is being done in Canada, we have an enormous deficit here: at present Canada spends 66 cents per capita on these programs. The bill before you is one measure aimed at alleviating this deficit.

I shall now give the floor to Senator Kenny who is, of course, much better informed on this subject than I am. Then we shall be available to answer your questions.

[English]

Hon. Colin Kenny: Honourable senators, thank you for hearing us today. There is one thought I would ask committee members to keep in mind as they are considering the evidence before this bill, and that is that there are currently 1.5 million young Canadians between the ages of 10 and 19 in Canada today, and 30 per cent of them are likely to end up as smokers. That is 45,000 children that are at risk. The purpose of this bill is to try to address the health of those 45,000 children that we currently have and those children who will be coming in the future.

Senator Nolin has reviewed for you the broad picture that we have in Canada. He has talked to you about the percentage of smokers that we see in Canada and he has compared that to solutions that we have seen elsewhere. Fundamentally, this bill is to try to put in place something similar to what we have seen in other jurisdictions, in an effort to try to get the same results for Canadian kids.

The bill is designed with a levy of three-quarters of one cent per cigarette. That works out to 19 cents per pack or $1.50 per carton, and that will generate $360 million a year. That amounts to $12 per capita. You will recall that Senator Nolin described the ranges that the Atlanta Centers for Disease Control's best practices document recommended. They recommended -- in Canadian dollars -- between $9 and $24 per carton. This bill will be in the bottom quartile of that range at $12. However, we think it is a significant step forward from the 66 cents that Senator Nolin referred to earlier.

The proposal calls for an arm's-length foundation, which we believe is important for a variety of reasons. First and foremost, everyone in this room is familiar with how governments function. They are familiar with the pact that is made between ministers and deputy ministers at the start when they agree, "If you make me look good, I will make you look good," and the efforts that occur in government departments to puff up good programs and dampen down bad programs. That is not unique to this government -- that is true in governments around the world.

The nature of tobacco control and having an impact on adolescents is a very imperfect process. No one has a clear handle on how adolescents think or how they work. I look around the table and see many parents or grandparents who have had difficulty at one stage or another with their children going through adolescence. Smoking is part of adolescence for one third of our kids, and the question is how best to address them.

In California, they have a list as long as your arm of failures -- programs they have tried that have not worked. They have a shorter list of programs they have tried that have worked. Currently, California has a youth smoking rate of just about 11 per cent -- one third of what we have. The principle reason in suggesting an arm's-length foundation in this bill is to move the project out of government, because you cannot have failures in government. Fundamentally, if you are a minister of the Crown and things start going wrong in your department, you end up dealing with it in Question Period, where there are critics -- in this case there are four -- who are paid to criticize every program you have. If you have transparency and evaluation -- and this bill calls for transparency and for every project to be evaluated -- and you have the program inside government, then inevitably you will have a tobacco control program that is politicized. We believe that the program should be one step removed from government. That will diminish the likelihood of having a program that is politicized. We can then proceed on a medical basis with the programs as they come forward.

The vehicle of a levy is also important. One of the major problems that confront health groups today is unstable funding. Funding levels spike one year and then drop off the next, or the funding is uncertain at the end of the year and people do not know whether they are able to continue with programs. By providing funding through the process of a levy that is tied directly to tobacco sales, the funding that will be available in future years will be relatively predictable. Therefore, people will be able to plan, with some level of certainty, what sort of programming they can have in the future.

Thus, we believe that the levy is important, that the arm's-length foundation is important, and that the amount of the levy is reasonable, given the evidence that we have from the Atlanta Centers for Disease Control. We can also cite examples of states, such as Vermont, which spends Can. $22 per capita, or Mississippi, which spends Can. $18.95 per capita, or Massachusetts, which spends Can. $15 per capita. Those states all have programs underway right now and that money is being spent right now.

The bill before you is relatively straightforward. It has corporate governance that is virtually identical to the CIHR, the Canadian Institutes of Health Research, that the government has recently brought forward. There is a requirement for transparency. There is a requirement for an audit by the auditor general. There is a requirement for an annual report to Parliament and a five-year review by Parliament. I believe that this bill merits your support.

Senator Cochrane: Senator Kenny, would you elaborate on the successes in California? Please tell us what processes they went through to achieve those successes. There were many failures, as you said, but would you elaborate on the successes? How did they arrive at those successes?

Senator Kenny: I will try, but I will not do the same sort of justice as the witness that we will have one week from tonight. The witness will come from California to describe precisely how it works. We will have a witness before us who will provide the real goods in one week's time.

California has what I would call a comprehensive tobacco control program. They understand that no one measure works by itself -- there is no magic bullet in tobacco control. You have to come at the problem from a variety of different directions, and that is because kids smoke for a whole lot of different reasons. California has understood, as we have come to learn, that children are starting to smoke younger and younger. In recently released figures from Health Canada, it is stated that 80 per cent of smokers in Canada start before the age of 16. If that question had been asked one year ago, they would have said that 80 per cent start before the age of 18. They are discovering that kids are starting to smoke at the ages of 10, 11 and 12.

They have found in California that you need a multiplicity of programs at the regional level, the local level and the state level, and that programs in combination tend to have an impact. They also have programs that vary according to the ethnic group or the race of the individual. For example, they have discovered that blacks smoke for different reasons than Asians. Further to that, each ethnic group, such as Asian, can be broken down into a variety of subgroups and they smoke for different reasons. The kinds of messages that would be sent to a 10-, 11-, or 12-year old would be very different than the sort of message that would be sent to a 16- or 17-year old.

One of the most notable features of the California campaign is a very strong media message. In California, they entered into their program at the same time that there was a full tobacco campaign. There were no restrictions on advertising. In fact, it appeared that spending on tobacco advertising increased as the program started in California. In the face of that, they still managed to get out other messages to young people that persuaded them not to smoke.

They came up with four principle areas. Peer pressure was one area that was addressed. Some of the ads in the presentation show the focus towards peer pressure. Another area was hero worship, where a movie star or an athlete is smoking. That encourages people to smoke. Another area was with young women giving the impression that they would stay thin if they smoked because their metabolism would speed up. The final area was rebellion, which is part of adolescence, where if dad says not to do that, it will virtually guarantee that it will happen. The California programs came up with a variety of different strategies to try to address all four of those motivators.

Senator Cochrane: Where did their funding come from to do all these ads?

Senator Kenny: I should tell you that their legislature was very reluctant to go forward with anything. In California, they have a system of government that allows for popular votes on initiatives. They put forward an initiative called Proposition 99. The process, very briefly, is that a petition must be completed with a certain number of signatures on it. If enough signatures are obtained, the proposition goes on the ballot. Every citizen of the state gets to vote on it.

Proposition 99 put a tax of 25 cents on every package of cigarettes sold. A portion of that 25 cents was allocated towards tobacco control.

Senator Cochrane: Was this legislated?

Senator Kenny: No, every citizen of California voted upon it. In fact, as time went by, the legislature in California saw so much money coming in that they diverted some of the funds away from tobacco control programs and started to spend it on other programs. The American Cancer Society in California sued them successfully and recovered the funds. The funds were returned to the program.

Senator Cochrane: Would you explain a bit about the levy that you are talking about? How much do you think that this arm's-length foundation would cost to put in place and to maintain?

Senator Kenny: There is a requirement in the bill that the total administrative cost never exceed 5 per cent of the total funds spent. We estimate that the budget would be in the area of $360 million a year. That amount would be generated by a three-quarter of a cent tax on each cigarette sold. It is 19 cents a pack, $1.50 per carton, and that multiplies out to $360 million a year.

There is also a provision in the bill that requires that 10 per cent be set aside for evaluation, and that is very important. The number of programs that go ahead in the health community and never get evaluated is astonishing. This bill requires that evaluation be put in place.

In the California example, they require not only that evaluation be put in place but also that before you apply for the funds you must have an evaluator selected and a plan of evaluation approved with benchmarks so that the public can see whether or not the program is a success or a failure. That is part of the process from the very start. Ten per cent is aside for evaluation, which is taken as a matter of course.

Senator Cochrane: You presented a tobacco bill similar to this one previously. The speaker of the House of Commons turned it down. Have you had any indications of where this bill might go?

Senator Kenny: Hopefully, it will go to the Commons, but that depends on the members in this room and then the members in the chamber.

I think you are really asking me why this bill would succeed procedurally although the other one did not. I would draw your attention first to the preamble of the bill and then to clause 3 of the bill.

We spent much time examining the speaker's ruling in the other place. The preamble draws to the speaker's attention various facts that he appeared not to be aware when he made his last ruling. Clause 3 of the bill points to benefits that we think would accrue to the industry, which he felt was an issue of some importance when he looked at the previous bill.

We have tested the bill with a variety of procedural experts. In fact, we have five written opinions on the bill, all of which say that they believe that this bill is procedurally in order in every respect. I must tell you that the bill was drafted very much with Speaker Parent's comments in mind.

Senator Adams: Welcome to the committee. Forty-five thousand people die every year from smoking. Since the changes in the Criminal Code on drunken driving, according to the statistics at Transport Canada, about 3,000 people a year die from car accidents.

Senator Kenny: That is correct, senator. It is just over 3,000, including drunk drivers.

Senator Adams: If this bill passes through the committee here and the House of Commons, do you have a statistic for the reduction of deaths from smoking?

Senator Kenny: Frankly, I do not see why we could not match California's performance. I do not see why, over time, our objective should not be to do as well, or better, than they have in California, where they are down to 11 per cent.

I should like to think we could eliminate it all, but that is overly optimistic. Frankly, if we could cut the number of deaths in half, it would be a huge win for Canada. If we could reduce the rate to 11 per cent, that would be terrific. However, it is not possible to predict the statistical changes in smoking behaviour during year one and year two. I could say that we would probably see a quick reduction that would slow down after a period of time.

I had a conversation in January with the physician who runs the program in California. He has a bit of a sense of humour and was sort of complaining to me about his funding problems. He said, "Colin, things are really terrible here. I am having terrible funding problems." I said, "How can that be? You have the best tobacco control program in North America." He said, "You must understand that five years ago, the per capita consumption of cigarettes in California was 120 packs a year. This year, the per capita consumption is 60 packs a year." Of course, his is directly tied to the number of packs sold, so his funding has been reduced accordingly. In five years, the reduction has been 50 per cent in California.

Senator Adams: I am mostly concerned about the younger people. People are smoking at the age of 13 where I live. Cigarettes are in the corner store or any other store in the community. How do you stop those kids? I think that right now the minimum age to buy cigarettes is 18 years.

Senator Kenny: There is no question in my mind, senator, that communities like Rankin Inlet will have to have special programs designed for them that meet the cultural needs of the community. This bill contemplates exactly that.

There would be programs designed precisely for people who live in the North. They have different pressures. They have different circumstances. They have a different language and a different culture. The programs that would be effective there are clearly going to be different than the programs that would function in Toronto or Hamilton or southern Ontario.

Senator Adams: I am concerned. We see kids in restaurants or on the streets, and the older kids may have the packs of cigarettes but the younger ones will always ask them for a smoke. Under this bill, is there some way that, if minors are caught smoking, they can be fined?

Senator Kenny: The most successful programs have been educational and motivational in a positive way, as opposed to programs that were punishing, dealing with people in a negative way. Witnesses are coming next week from Florida, Massachusetts and California. You will have an opportunity to talk to them about their programs and you will find that they lean much more towards education, persuasion and motivation, rather than punishment or making it illegal.

Senator Adams: I do not know what part of Canada has the most strict smoking rules right now, but we do not have such instruction yet in Nunavut. Most of our municipalities are very small. They do not have the resources to impose smoking regulations on the restaurants and bars to protect people from second-hand smoke, but I know there are such policies in other places in Canada. How can our municipalities come up with more strict policies? People want to smoke and when they buy cigarettes, we are making money. We should be using that money to pay for strict enforcement.

Senator Kenny: I do not pretend to be an expert on Nunavut, senator, but I can say this. For a successful program to be developed in Nunavut, the people and the youth of Nunavut must be involved in the design.

The report of the Centers for Disease Control gives us a clear message that any program that does not involve young people both in the design and the delivery is doomed to failure. Programs for Nunavut must be developed by people from Nunavut, particularly the young people, or they will not work. Programs must function at the municipal level, the regional level and the national level.

Senator Adams: Before we do that, though, we need some funds. Strict laws in the community need enforcement. Right now, the municipalities do not have the facilities to enforce their laws, be they criminal laws or community bylaws. If inspectors are needed, then more financing is needed. The money must come from somewhere, either from Canada or from the community.

Senator Kenny: The funding in this bill is designed to come from the foundation. The $360 million that we are discussing would go into the community.

Does everyone here have the executive summary for the CDC report? You will see broken out in the summary suggested spending levels for communities. How much should be spent per student? How much should be spent on mass media campaigns? These are suggested guidelines, because costs will vary according to the needs of each individual community. It is a useful template to see how your community would be affected.

Senator Taylor: Is there any research on smoking patterns as tied to alcohol use? The bars in British Columbia made a fuss about smoking restrictions. Do alcohol users tend to smoke more often?

Senator Kenny: You are asking me a question that is beyond my competence. Physicians will be appearing soon who are much more knowledgeable. Perhaps you could put the question to them.

Senator Taylor: British Columbia is attempting to sue the tobacco companies for damages. The other provinces are probably watching. Will there be anything left in the pool if the provinces get into a feeding frenzy on the tobacco companies?

Senator Nolin: The answer is yes.

Senator Kenny: We did not mention this at the start, but the federal government takes in about $2.4 billion per year between excise taxes and GST. Contrast that against the $20 million being spent on tobacco control right now. There is still a lot of tax money floating around that seems to be going into the Consolidated Revenue Fund rather than into tobacco control.

If the provincial lawsuits to which you refer are successful, the cigarette companies will likely pass those costs through to the consumers. That was certainly the case in the United States. A settlement there with 48 states amounted to $247 billion. Within a matter of weeks, the price of cigarettes rose in the United States. Prices there are significantly above those in Canada right now.

Senator Taylor: I gather also that, in the U.S., five or ten years was given to pay those fines. Were they not invited to take the money from the consumer's hide over time, rather than to take it from profits?

Senator Kenny: You are right. I do not think the fines are coming from their profits at all. I am not an expert on the elasticity of cigarettes, but, yes, they do have a period of time to pay it.

Senator Wilson: Can you flag for us, maybe in point form, how the bill differs from current government policy? You have already said you want to move the programs out of government. There is also the levy. You have spoken about the positive education and motivation, rather than the horror tactics of how smoking can rot your lungs. Those three things I have identified. Are there other areas? I should like to watch for them as the hearings proceed.

Senator Kenny: Senator Wilson, the panel planned for next Tuesday is specifically designed to evaluate what the Canadian government is doing. They will review what has happened over the past 20 years in terms of Canadian federal legislation and outline it in much greater detail.

There are specific things that I should like to draw to your attention. As a parliamentarian, I have a great deal of difficulty getting information from the Department of Health. It takes weeks and months to get what seems to me to be fairly straightforward pieces of information. This foundation calls for transparency. The board meetings are public. The grants will be made public. Everyone will know who is getting what when they get it. That is a significant difference that will allow us to evaluate success and failure much more easily.

Second, the dedicated 10 per cent for evaluation is fundamental to any form of medical endeavour. If we are not evaluating our programs, how do we know how to separate the winners from the losers? At present, that evaluation is haphazard because it takes place within a government department. This could happen with any government. It need not be the Liberals. It could be any province. If you announce that you have a program and it is not working right, you will get beaten up in Question Period for the next two or three weeks. We need to put it in an environment where it is treated in a more mature way and where people will accept that you will have some failures but that that does not necessarily mean that the whole program is wrong. The nature of the process is trial and error until you can get to the right solution.

The second major point that I draw to your attention is evaluation. First transparency, second evaluation. Those two principles are very salutary and are very different from what we have in a government program.

The third thing that is worth looking at is the Atlanta Centers for Disease Control's best practices document of August 1999. There, you will see a template that they developed after studying the tobacco control programs in the 50 U.S. states. They have come forward with their recommendations, and they recommend ranges. All of the figures that you are looking at now are in U.S. dollars, so you need to convert them into Canadian dollars. As its first step, the bill calls for the foundation to examine existing tobacco control programs and to develop a Canadian template to follow. The CDC template is excellent, but we need to have one that is unique to Canada and one that spells out for Canadians the overall policy. The important point we must remember is that no one element will solve this problem. It will take a collection of interventions before we change young people's behaviour.

Senator Christensen: For a number of years I was involved with developing legislation to go through the territorial government to create a foundation in the Yukon. This bill follows all the things that we did but for one exception -- and I am assuming it is because of the levy process -- namely, the minister making the regulations. We say that we are trying to get this away from government, yet there is a provision in the bill that the minister will make regulations. Could you elaborate on that?

Senator Kenny: Inevitably, when you are writing legislation, you do not contemplate every eventuality. You need to make provision for regulations down the road, because I do not believe that even the best-intentioned legislators can come forward with something that will work perfectly forever. A provision that allows for some adjustment over time seems to be appropriate.

Senator Christensen:The bill allows for the bylaws for the foundation. It sets out how members will be appointed, the meetings, the transparency, the auditing, the reporting, and so on, yet it still allows the minister to make regulations. I assumed that was because of the requirement of a levy; that is to say, the minister must have some authority in order to impose that sort of levy.

Senator Kenny: If you would cite the clause, I could refer to it and perhaps give you a better answer.

Senator Christensen: Clause 40 says "The Minister may make regulations," and then it goes on to clause 41. In all other things, the bill establishes the foundation and gives the foundation authority, et cetera.

Senator Kenny: In this case, all the regulations concern the collecting of the money and only the collecting of the money. That is why it is there.

[Translation]

The Chair: Senator Nolin, I would like to know whether the number of young smokers varies from one province to another, depending on individual provinces' levels of taxation. For example, the situation is not the same in Quebec as in Manitoba.

Senator Nolin: Yes, the number of new smokers does vary from one province to another, and you have put your finger on the reason for these variations: it is financial. You will hear witnesses explain in detail how this situation has come about, and you will see how the purpose of Senator Kenny's bill is, rightly, to create incentives, rather than prohibitions, to reduce the number of new smokers.

Cigarette prices greatly influence consumption. In 1994, when we witnessed a massive reduction in taxes on tobacco, an increase in smoking automatically followed, not only among young persons, but certainly in that age group, of which 30 per cent are now smokers.

[English]

The Chair: Thank you very much for your introduction. I hope that we can call you back if we need to do so. I hope you are readily available.

Senator Kenny: We will be around.

The Chair: I would be remiss if I did not congratulate you both for what I consider to be a fine initiative in the public interest. We will see how it works out.

I would ask our next witnesses to come forward: Dr. Roberta Ferrence and Dr. Robert Cushman. First, I would ask you to make your presentation, and then I am sure senators will have questions for you. Please proceed.

Dr. Roberta Ferrence, Director, Ontario Tobacco Research Unit: I am very pleased to be here tonight and very privileged to speak to the Senate committee on behalf of a very important bill. I am a researcher. I have been involved in addictions research for three decades and specifically in tobacco research for the past 15 years. I have brought some of my research with me tonight; some of it may help to answer questions that have been raised. I have also attached my business card to the handout. If anyone would like more information, please contact me.

The problems with smoking in Canada are relatively high at this point in history, and the highest rates of smoking are among young people aged 18 to 22 years. I wish to discuss the health effects of tobacco use and exposure to second-hand smoke and to make the point that these effects are very serious and have been confirmed in research literature. The costs to Canadians of tobacco use are enormous. Tobacco use is preventable, as are the associated costs. However, many segments of society, ourselves included, are complicit in maintaining this problem.

The list of health effects caused by smoking is a long litany of diseases. I will not go through them all, but there are almost 10 forms of cancer -- not just lung cancer -- many forms of lung disease, ulcers, osteoporosis, cataracts, gum disease, surgical complications, and heart disease and stroke, which are major killers. There is new evidence that smoking may also be a cause of breast cancer, leukemia, cervical cancer, asthma, pneumonia, Crohn's disease, diabetes, hearing loss and several other diseases. As the research progresses, we learn that more and more of these are confirmed.

Young people do not escape the health effects even in their youth. Smoking is a main cause of heart disease in young people. Young women on oral contraceptives have a 20-fold increase in heart disease and stroke, decreases in lung function and physical fitness, increases in gum disease, decreases in fertility, complications of pregnancy, and, more recently, we are seeing increases in small cell lung cancer in younger smokers.

Second-hand smoke, and that comes with smoking, has very serious effects on both adults and children. As well, there are major physical effects that include lung cancer, heart disease, stroke, sudden infant death syndrome, low birth weight, asthma and so forth. There are also important social effects. Smokers are models for other smokers and that perpetuates the problem.

In Canada in 1999, in more than 80 per cent of homes where children live with a daily smoker, the children are exposed to second-hand smoke. In Canada, as a whole, the figure is close to 40 per cent. Thus, we have major problems with children being exposed to second-hand smoke. We also still have substantial work site exposure not only for adults but for young people as well. There are many young people in the workforce at this point.

The figure 45,000 was mentioned in respect of deaths attributable to tobacco. Different kinds of research have been done and have produced a different estimate, which is also seriously high, over 33,000 deaths attributable to tobacco. That is 17 per cent of all deaths. Compare that to fewer than 7,000 deaths from all alcohol-related causes and slightly more than 700 deaths from illicit drugs. We are talking about a few orders of magnitude here. We are talking about almost half of one million years of potential life lost in Canada. We are talking about over 200,000 hospitalizations and more than 3 million hospitalization days. We have enormous health costs and costs to human beings.

The best estimates at this point for the total economic costs of tobacco are based on 1992 data and they probably have not changed significantly since that point. There are direct health care costs of $2.7 billion, other direct costs of $0.07 billion, and indirect costs of almost $7 billion. These have to do with productivity losses due to death, disease and crime. The total is $9.6 billion in Canada. The proposed levy is really a very small fraction of what we are paying out.

There are examples of successful programs. The CDC guidelines were mentioned earlier this evening. I should like to mention one specific U.S. campaign that was carried out in four different communities over four years. In that campaign, communities that had school prevention alone were compared with communities that had school prevention plus a major media campaign. After four years, there was a 5.5 per cent difference in past week smoking among youth. They measured cost-effectiveness and found that the cost per student for this program was $41, the cost per student smoker potentially averted was $754, and the cost of life-year gained was $696. Costs on a national basis would be much lower. Those estimates were cost per student nationally, $8, and life-year gained, $138. Therefore, these programs are very cost-effective and apparently they are more cost-effective than physician advice and other cessation interventions that have been shown to be very worthwhile.

There are two interesting findings from the literature, and the figures are based on U.S. data. The number of cigarettes smoked per day is closely related to the actual prevalence of smoking. That means you get a lot of bang for your buck. When you reduce the proportion of people who smoke, those who are still smoking smoke less, so you get a very large impact on health costs and social costs.

The other key figure, to my mind, is that there is a very strong correlation between smoking in adults and frequent smoking among adolescents. Even though many of our interventions and our interests focus on youth, youth patterns are reflecting adult patterns. It is very important to look at the whole picture.

To summarize -- and this is my personal general synopsis, which I hope is shared by many others -- we need to reduce the availability of tobacco. The prime means for doing that are through taxes, which is long overdue, and through reducing outlets for tobacco. We have a situation where tobacco is available 24 hours a day on any corner and, despite many programs aimed at retailers, kids are still able to buy tobacco. It is also very easy for adults to buy tobacco. We need to reduce the visibility of smoking.

One of the key things happening now is the ban in restaurants and bars. We did some research recently where we looked at the context for relapse and the reasons people gave for their relapse to smoking. We found that, particularly among young people, other people around them smoking and when they were drinking were two of the main reasons for their relapse. Those are situations that take place in restaurants and bars, at parties and so forth.

We need a clear, targeted message to fill information gaps. We need a systematic program that keeps going and does not stop because the funding runs out. We need to reduce society's ambivalence about smoking. That is a separate talk, but I should like to mention that we need to divest ourselves. Just the other day, I saw that the University of Western Ontario is nominating Purdy Crawford, the head of Imperial Tobacco, as businessman of the year. That does not send a good message. As well, we need research and surveillance so that we can evaluate what is happening.

At this point, despite major progress in many areas, particularly in restrictions, warnings and other kinds of regulations, we still have cigarettes available everywhere, and in Ontario and Quebec they are at the lowest prices in North America. We still have smokers visible on the street in many public places. We do not have a consistent media program. Tobacco industry leaders are still held in esteem in many parts of society. We do not have a good surveillance system in place.

Bill S-20 will provide the opportunity to change behaviour in this country and, almost as important, to change public opinion. Those are both critical underpinnings of reducing tobacco use.

Dr. Robert Cushman, Medical Health Officer, Health Department, Region of Ottawa-Carleton: I am delighted to be here today to comment on how we might control the tobacco epidemic. If I am not mistaken, yesterday was the anniversary of D-Day, and that took the navy, the army, the air force and the marines. When you control the tobacco epidemic, you need prevention, protection and cessation.

In the municipal field, protection is an area that we are very concerned with. We have seen tighter no-smoking workplace and public place bylaws. We are now, in fact, into a second generation of these bylaws. Some 10 to 15 years ago, the concern was that non-smokers did not want to be exposed to the inconvenience of direct smoke. Now we know that it is a very toxic substance and in fact, after first-hand smoke and alcohol, is probably the number three poison out there in our society. As a consequence, there has been renewed interest, and new, tighter and better bylaws are fast becoming the norm. These are often a municipal responsibility, sometimes a provincial responsibility. In this country there is a range, and the best are in British Columbia.

As my colleague mentioned, there are additional benefits of the protection of non-smokers. First, it reduces tobacco consumption amongst smokers. It encourages quitting and it discourages youth and new smokers. The second benefit is in the area of smoke cessation. Would it not be nice if we could say that the young will be young and one-day they will give up their youthful ways? That is far from easy in the case of tobacco. It is a tenacious, stubborn addiction. Those in the addictions field say that the addiction is much worse than alcohol, cocaine and heroin. Given its easy access and readily deliverable method, that is understandable.

Of interest to my field are stories of personality changes by folks who have tried numerous times to quit. They relate how their family life is disrupted during the throes of trying to kick that addiction. The tentacles of the addiction control them. I might add that no other addiction starts as early as that of tobacco. Name addictions that start at the age of 16 years or even the age of 12 years. We know, in fact, that the earlier one starts to smoke, the greater the nicotine addiction. However, we seem to think that it is fine for 12-year-olds and 14-year-olds to become addicted to nicotine without declaring it a national disaster.

The key is prevention. That is why I am here today and why you are here today. This brings us to Bill S-20. We know that if smokers start fewer than half will be able to quit. About one third of those who do not quit will die from tobacco-related illnesses. How are we performing with that knowledge? We currently have a youth tobacco epidemic.We are back to the statistics of 1980. We have had a decade of increasing rates, essentially failure. That followed 10 years of declining rates, a success.

I wish to share this Ottawa-Carlton report card on youth smoking, which we released last week. In a survey of Grade 7 to 10 students, the proportion of students reporting daily smoking increases from 6 per cent in Grade 7 to 32 per cent in Grade 10. The proportion of students reporting any cigarette usage increases from 23 per cent in Grade 7 to 66 per cent in Grade 10. Thirty-eight per cent of students in the Grade 7 to Grade 10 category reported that they used their first cigarette before Grade 7. An additional 30 per cent reported smoking their first cigarette in Grade 7. In other words, by the time children in our community finish Grade 7, 68 per cent of them have smoked cigarettes.

The price of cigarettes in Ottawa-Carleton, western Quebec and eastern Ontario is cheaper than that in all the neighbouring Canadian provinces and the United States. I was in Boston some months ago and seeking change for a dollar bill to make a phone call. The person in line before me bought a pack of cigarettes. I was flabbergasted that the cost of those cigarettes was U.S. $5.00 for a pack of Camels.

Twenty-three per cent of students in this age group in Ottawa-Carleton report daily smoking. I think those statistics speak for themselves. I will leave the report for you in both languages.

The high rate of youth smoking is the most important public health problem of our time. If we ignore it, we will condemn our children to unhealthy futures and shorter lives.

The tobacco companies will argue that kids are just being kids and that it is out of their control. Why have the smoking increases paralleled price decreases and advertising increases? Why does the rate vary so much from jurisdiction to jurisdiction? Yes, there will always be a few young smokers. There will always be the odd James Dean. However, 30 per cent is unacceptable. It has a very simple explanation.

As for the burden of illness, we have seen declining rates of lung cancer and heart disease based on the work done some 15 to 30 years ago. These trends will soon turn around and start to mount again. In will be a crushing burden on our already overburdened health care system.

For those interested in privatization of the health system, take a note from the life insurance companies. Watch what happens when it comes to private health insurance. Watch for differentials between smokers and non-smokers. I would caution you that this is a slippery slope. It will start with tobacco. It will go on to diabetes, genetic illness and down the way. That will be the end of our health care system.

There is a better way. Bill S-20 is an example. A levy on tobacco that is volume dependent and that would be paid into prevention is a better way. It would also reduce health care costs down the line.

There is wide recognition that we have a youth tobacco epidemic. The price is too low. Tobacco companies are predatory. There is inadequate funding for prevention programs. Compare what we spend in prevention to what tobacco companies spend in advertising.

There are billboards next to schools. Parents and educator are beside themselves on this issue. I was talking to the director of the francophone school system for Ottawa-Carleton today. He says that we must get the message into the schools. Yet, I have only five nurses or six nurses for the entire four school boards and the entire student body of Ottawa-Carleton.

What are we spending in Ottawa-Carleton? What is my department spending? We are probably spending about 50 cents per capita, maybe a little more. We are spending between $300,00 to $500,000 for all the activities -- protection, cessation and promotion. Let me tell you, I am rich compared to other health departments. In fact, I have moved monies in our health department from non-tobacco issues to tobacco issues. Yet, we have only one inspector or two inspectors surveying 1300 stores in our community. We have one nurse for roughly 10,000 students. No wonder we are not getting results.

It is time to draw a line in the sand for prevention -- our kids versus the tobacco companies. It is very simple. Bill S-20 addresses that problem, and people want it.

There are 45,000 deaths a year. The tobacco companies must replace their customers, and that is why tobacco is a pediatric disease. No one knows this better than the tobacco companies and smokers and past smokers. They know that they started this habit as early as the age of 12 years.

The war on tobacco must be comprehensive. I alluded to this as the D-Day approach. Isolated initiatives are limited and will not have multiplier effects. We need a systematic approach. The federal government must address price, packaging regulation and funding for prevention programs on a per sale basis, which is exactly what this bill addresses. There is overlap with the provincial government. They, of course, control the age of purchase. As for medicine, we must look into improved psychology and improved pharmacology. Municipalities have to look at bylaws, enforcement and better programming at the community level, particularly in the schools. We need to boost our kids against tobacco the way we boost them against measles and rubella and meningitis in the schools. That is why this bill is so important. We need the funding.

My understanding is that this bill comes within the criteria defined by the Centers for Disease Control, which is between $9 and $24 per capita. I was reading earlier a paper written by Senator Kenny that said that this country puts $1 into tobacco prevention for every $1000 it gains from taxes on tobacco.

We need national ads, local programming and an independent agency. Bureaucrats do not have the creativity to do this. They are under the gun politically. Counter ads to smoking do work. Look at the ads from the U.S. Large, prominent marketing companies did those ads. Wait until the kids have a shot at this themselves. The kids will do a great job if we give them the means to do it, and if we distribute what they have to say to their colleagues across the country.

Last, evaluation is very important. When addressing heart disease, cancer or any other major problem, clearly one must evaluate what is being done. This is new territory and we want to learn by our mistakes. We also want to multiply our victories.

Senator Kenny is an expert in this field. He knows the best practices and the formulas for success. He has made the rounds. He knows what works, and he knows what does not work. This bill is the best tobacco initiative that I have seen in my career, in Ottawa-Carleton, in Ontario and in Canada. We can reduce smoking from 30 per cent to 11 per cent in the same way that they have done in California.

The question before you today is simple, ladies and gentlemen: How do we protect our children from the ravages of tobacco, the addiction of nicotine and the predatory behaviour of the industry? Bill S-20 is by far the best immunization available. Support it and protect our kids. Remember, if we are not part of the solution, we are part of the problem. Thank you.

Senator Christensen: Dr. Ferrence, what evidence have you found in your studies that youth were being targeted in the sale of tobacco?

Dr. Ferrence: A variety of research has been done. You probably know of the recent release of documents from the Guildford Depository that show very clearly that the industry was targeting youth. We have done earlier work, as have other people.

In one of our studies, students were presented with event sponsorship ads with the brand name scrambled. Most students very clearly recognized the ads as tobacco or cigarette advertising. They did not think of the ads as promoting a racing car event or something else. They identified cigarettes.

That is just one example of the kind of research that suggests that kids recognize they are being targeted. It is very clear that they know about it. There is also a famous U.S. study in which children as young as six years old were able to identify Joe Camel, but similar things are happening in Canada.

Senator Kenny: Dr. Ferrence, could you talk to the committee about attitude change and indifference? You touched on it and said that it is a whole other topic. It seems to be a key question as we approach tobacco control. Would you share with the committee your views on why so many Canadians appear to be indifferent to this issue?

Dr. Ferrence: There are a number of reasons. Tobacco has been acceptable for many years, for the past century at least, in North America. It takes people a while to view it as something that is unacceptable. People are pressured by family and friends and certainly by the media.

Tobacco is still sold like a typical product, like bread or milk. That gives out a message that there is nothing special about it. We do not sell guns that way, in corner stores. We do not sell prescription drugs that way and they are relatively safer. We do not treat tobacco like the dangerous product that it is. This is not original with me, but certainly we need to "de-normalize" tobacco, to let people know that this issue is serious and that this is not just another product.

Statistics do not impress people. Most tobacco deaths are not sudden and violent. Such deaths take many years. People tend to die of tobacco-related diseases at older ages. A few years ago, there was more concern about the few smuggling-related deaths than about the approximately 40,000 deaths of Canadians due to smoking. People are more concerned about violence and things over which they have no control. They somehow do not see tobacco as something over which they have no control.

There is an opportunity here to change attitudes, to de-normalize tobacco use, to let people know what is really going on. Dr. Cushman referred to the predatory tactics of the industry to inform people. People do not know how bad tobacco is, although they know generally that it is bad for them. They do not know all the health effects. They do not know what the industry does. They do not know what other segments of society do to keep tobacco going. Tobacco is still a buy. Why is that? There is a lot of potential there for action.

Senator Kenny: Please elaborate on the cost-effectiveness of a program like this. Generally, when people hear a figure like $360 million, they ask what the return is for that money. Could you review again that section of your testimony for us?

Dr. Ferrence: We certainly found, in one study done in four communities, that comprehensive media programs were cost-effective in terms of getting people to quit and in terms of reducing health costs. This bill would provide for many different interventions as well as media programs.

We do have very good evidence from CDC that we need to have comprehensive programs that focus in many different areas so that there is a synergistic effect. There is good evidence from the states where major decreases have been seen, not only in California but also in Massachusetts, to some extent in Florida and, I believe, now in Arizona. These kinds of programs worked there and in British Columbia as well.

You must convey the idea that you really are serious about it. It is the same as being a parent, and many of you are parents. Kids see through you if you are not really serious, if you do not really mean it. On a societal basis, that happens, too. Until we are really serious and we really want to do something, we will not see much change.

We must have clear messages through our pricing of tobacco, through the availability, through the media campaigns, through everything that we do. How do we treat the industry? How do we treat people connected with the industry? What are the social and business relationships with the industry? There is just tremendous scope there for changing attitudes and changing behaviour.

Senator Kenny: Dr. Cushman, beside you is a copy of the executive summary of the CDC report. Please turn to the third page. Listed there are community programs and a base funding of $850,000 to $1.2 million. Somewhere between 70 cents and $2 per capita, all in U.S. funds, is suggested for community programs. Item 3 talks about school programs, spending between $4 and $6 per student. Item 4 talks about spending between 43 cents and 80 cents per capita per year on enforcement programs. With those figures in mind, could you tell us the size of Ottawa-Carleton?

Dr. Cushman: There are three quarters of a million people in Ottawa-Carleton. The figures I gave you are global figures. They are paltry compared to the three community initiatives outlined in this report. You can see that the boost in funding would certainly affect programming.

Senator Kenny: Imagine for a moment that the bill was passed and that we had a program in place similar in nature to the template developed by the CDC. Could you give us some sense of how it would be different in your community? What could you do? How would life change for you as the medical officer of health for this region?

Dr. Cushman: It is clear that we are underfunded in the school program. The kids are in the schools. Kids seem to understand non-smoking early on, but something goes off the tracks in the intermediate levels. That is where we must boost funding. This would be a dramatic influx of funding for our school programming. It would allow us to do essentially what we would like to do here.

I alluded to the fact that we have very little funding in terms of enforcement. This, again, would allow us to have a presence. It is not only the compliance of the vendors that is significant but also whether underage kids are consuming cigarettes. One figure I did not give you is that 66 per cent of Grade 7 to 10 students in Ottawa-Carleton say they do not buy their own cigarettes. At the same time, 85 per cent of our vendors have been compliant. With what little enforcement we do have, and with public education and the willingness of the vendors, we have fairly good compliance there. However, the kids are still buying cigarettes from their friends. That is where the additional enforcement would come into play.

The other important thing is more community programming. We find that we cannot afford glitzy advertisements, neither to develop them nor to run them, but we run a lot of programming parallel to that, which helps. For example, there are little stickers in support of non-smoking bylaws. I want to get those into every mailbox in Ottawa-Carleton so that when people go to a restaurant they can put a sticker on the bill. But, guess what? I do not have the money I need to do that. That is another example where further funding would allow us to do something.

Senator Kenny: What would you say to someone who said, "This is too much money for you to handle. The program is too rich. You could not cope with this level of funding"?

Dr. Cushman: Given the magnitude of the problem that we are dealing with, this funding falls within the norms. You are coming in at $12 per capita. The CDC recommendations are $9 to $24 per capita. The more you spend, the bigger return you will get. Remember also that tobacco is the gateway to other drug use. Often, the skills that you need to resist tobacco are general skills, risk reduction skills, coping mechanisms, the ability to say "No," understanding advertising, and so on. A lot of those are life skills, too. By and large, we will not only protect our kids but also educate them in other ways, which will be beneficial.

Senator Wilson: I am interested to learn what you discover when young people themselves take on an educational campaign. How do they target their peers either to prevent them from smoking or to stop smoking? Is there any difference between how girls view the problem and how boys view the problem? How are they are received by their peers? Are they considered to be goody goodies and they cannot get anywhere?

Dr. Cushman: We have run contests in this city for advertising slogans. I should have brought some of the material with me tonight. It is very creative. There is a lot of talent out there. They are very crisp messages.

I often laugh when I think about all the money that tobacco companies are spending on their message. Their message is very vulnerable because it is false and it does not advertise their product. When you turn this material over to people, the counter messaging can be very dramatic. I would assume that a lot of you have seen some of these counter messages, advertisements from the United States, for example, and some that Health Canada and the other provinces have done. The problem is that we do not have enough and there is a cost associated with airing them and re-broadcasting them. Kids have a lot of good material, and a lot of it is worthy of being raised. To claim ownership of this material and to have the kids know that it was designed by other kids is extremely helpful.

Regarding the second part of your question, yes, there are very different groups out there. For boys, it tends to be peer pressure. For girls, a lot of it happens in the home. They are concerned with body image. We have to target the messages somewhat differently, there is no doubt about that. That is why the marketing message that is done at either the national or the public level must be refined and tailored for the niche markets as we go into the schools. We know that, but we do not have the funding to do it. People who work in my department say that if they had more people and more resources, they think they could do it. I am convinced that they could, too, for a lot of the reasons that I mentioned earlier. I think the falsehoods contained in the tobacco companies' messages are very vulnerable.

Senator Wilson: To follow up on that, young people normally think they will live forever, so they would not see this as a health issue; or would they? How do they view the issue?

Dr. Cushman: That is true. We have to get away from lung cancer and heart disease. We must think in terms of addiction -- that is, how hard it is to kick the habit. That is the whole message. Public health messaging has focussed on addiction in the last 10 years or so. That has been a big leap forward.

The other thing about kids is that the impact is greater on them when the issues that are dealt with cover not only addiction but also more immediate issues. For example, a comparison can be drawn wherein kissing a smoker is the equivalent of kissing an ashtray. There is a lot of material out there that can be brought to bear. There are also the predatory practices of the industry. If you think you have a problem with your father, try on Rob Parker for size in terms of creating someone that teenagers would want to know about in this society.

Senator Cochrane: Dr. Cushman, what have you done with the drawings you received as part of the competitions that you have held within the schools?

Dr. Cushman: We still have them. We cannot afford to reproduce them and distribute them. One that comes to mind in French is publicité, which is shortened to peut tuer -- that is, publicity kills -- with tobacco material behind it. There is another one with a target and the arrow is a huge cigarette. There is a lot of good material. It is sort of back-of-the-envelope-type creativity.

While desktop publishing has helped us in the past few years, we are competing with the deepest-pocket marketers in the world. We are competing with the guys who put Madison Avenue on the block. We can compete with them, but we need a nickel for every dollar they have.

Senator Cochrane: It seems a waste to have items like that sitting on a shelf. It might take a bit of money, but it might be more creative to do something else with them. Children have their own computers. They can put those messages on the Internet and send them to their friends.

Dr. Cushman: Once the material is in their hands, they will be able to do something with it. We had a mock trial last year that was very popular. We have a significant amount of interactive material that ensures that every child sees black lungs, and we encourage the children to touch them. However, this requires more money and more people than we have. Think of the immunization model. What we are looking at here is a dose and a number of boosters. That all boils down to money.

Returning to your point, if we get this material into the hands of children, we will begin to see a multiplier effect.

Senator Finnerty: Dr. Cushman, my children were raised in the 1970s in London. What stopped them from smoking was what you referred to a few moments ago. The police used to go around from school to school with the lung and show them the cigarette. The kids touched the black tar that was left and then they were also shown movies of children with addictions. That was the biggest deterrent I have ever seen. I do not know of any children that went to those schools that ever tried smoking or drugs. It was very effective to use volunteers. Has that ever been done here, to your knowledge?

Dr. Cushman: We do that, but, again, it is the market penetration. Ms Spring, a woman from Thunder Bay, spoke to our group the day we released the report card. We presented the slogans and released the report cards. She got up and, covering her tracheotomy hole, spoke to the students. I said to her afterwards, "In a day or a week, most of this will be a blur, but they will remember you for a long time." The kids must be exposed to this, so it is not 1,000 children and a television screen but rather a room of this size where they actually feel it and the other senses start to work.

Senator Adams: I do not know how many radio or television channels participate in the health information messages such as you see on packages of cigarettes that tell you what will happen if you smoke. At least in my own family, they do not really watch those commercials. In some places, you have over a hundred channels on the television. How many of those channels have commercials with smoking information? How do we ensure that these messages are heard? If we wish to get the message out to young smokers, how do we get it heard through the loud rock music being played on the radio and so on? There are a lot of messages, but I do not think the public is hearing them.

Dr. Cushman: I do agree that there is a lot of surfing when it comes to television. However, the kids like the advertising culture. If an advertisement is good, they will watch it. Much depends on the quality.

You also mentioned another point. Certainly the tobacco companies are very wise to this and have moved to point-of-purchase advertising. While we need those advertisements, there are other forms of advertising, just as we mentioned previously. The handbill type of material is something that we could really use to advantage. It does get down to the fact that there is no single solution. The stuff has to be good. There is a multiplier effect if you take a comprehensive approach to it. I think your point of departure is putting all of your eggs in one basket and having a single attack or a single form of advertising. That just will not do in today's complex world, and it will not do in as complex an issue as tobacco.

Senator Adams: You mentioned that cigarettes are the cheapest in Ontario and Quebec. I live in Nunavut. The taxes go up every year for cigarettes. In Rankin Inlet right now, it is close to $9 for a package of cigarettes, and a carton is over $60. People are still buying them. No matter what the cost, people will buy. It is the same thing with alcohol. Many people in the community say we will have a dry community, but then other people come along, the bootleggers and so on, and sell alcohol for over $100 per bottle. It is difficult to address this issue.

I do find the commercial where the woman is speaking with the little machine very effective. I used to be a smoker, and I quite over 30 years ago, but if I still smoked, I would quit after seeing that. Senator Kenny spoke about money being allocated to anti-smoking messages. As soon as a law is passed, every community should be working on it. Once a bill is passed, it takes time to get used to it. Queen's Park started a few years ago to restrict smoking areas, and now we see that in other places. When I came to the Senate in 1977, people were still smoking in committee rooms, and now you cannot smoke anywhere in a government building. Even right now, young people as young as 13 years old are having children and at the same time they are smoking. I should like to see more advertising like the sticker. How does that work?

Dr. Cushman: I actually have the French copy with me, but it basically says, "Will you please make your establishment smoke free?" This is what we are distributing.

Having spent a winter up North, I know somewhat of what you are saying. Your point is interesting, because in the North, it is almost like the smoking started later and, therefore, will end later. That reinforces Senator Kenny's earlier point about how each community needs to tailor its approach to its particular needs.

Senator Cochrane: I have been educated this evening in regard to the illnesses that you have told us about caused by cigarette smoking. I had no idea that osteoporosis, cataracts or even diabetes were conditions of smoking. How did you come up with the research on diabetes being caused by smoking?

Dr. Ferrence: This is based not on my own research but on research that has been carried out in North America and in other countries. Smoking is not the only cause of these diseases, but it is a contributing factor to a number of conditions, including diabetes. It is a likely contributing factor at this point. We do know that people with diabetes have much higher rates of heart disease and all kinds of other circulatory problems, and the smoking exacerbates that and makes all the associated conditions much worse. I did not bring all that research with me tonight, but there is documented evidence based on various medical studies that have been done for this.

Senator Cochrane: You were saying that the lowest prices for cigarettes are in Ontario and Quebec. Have you had an opportunity to review other provinces? Is the number of children who smoke increasing because the prices are lower than in other provinces where the prices are higher?

Dr. Ferrence: That is not as easy to answer as one might think, because the economic models are very strong. However, they all specify "other things being equal" and of course, in the real world, other things are not equal. Thus, we had differential amounts of smuggling in different provinces. Ontario, for example, has a fairly active tobacco control strategy, but there are a lot of differences. Research is being done. One of the difficulties is that we have not had a good surveillance system in place to provide month-to-month data that would make it easier to measure this.

There were no national surveys by the federal government from 1991 to after the tax cut in 1994. We have been at a real disadvantage, so various studies are being done using different methodologies to try to get that data. It has been very difficult. However, we do see clear effects. During the 1980s, when the price increased, we saw a 60 per cent reduction in smoking by youth.

There is an entire history of economic literature going back 50 years that shows strong effects.

One of the real problems with tobacco is that it is too cheap. You can buy one cigarette for 35 cents even in Nunavut. Where else can you get a hit from a drug for 35 cents? You cannot even get a cup of coffee for that price. Tobacco is far too cheap. We would have to raise the cost many, many times to reduce levels of smoking comparable to those in countries where people really cannot afford it. Those people might smoke two or three cigarettes per day because they cannot afford more. Whereas Canadians feel very hard-pressed if they have to reduce their smoking from 20 to 15 cigarettes per day because the price goes up. We do not have the appropriate perspective on this at all.

The Chair: Your presentation was very informative. I wonder if you could leave some of the material you brought, for example, those stickers. We would appreciate that.

Our next witnesses are Dr. Esdaile and Dr. Kuling.

Dr. Peter Kuling, Chair, Tobacco Steering Committee, Canadian Medical Association: Honourable senators, thank you for inviting me here tonight.

I am a Saskatchewan born and raised physician and I practised in Prince Albert, Saskatchewan, for approximately 20 years. I have just moved to the Ottawa area. I practice family medicine in Orleans, emergency medicine in Perth and Smiths Falls, and I am an assistant professor of family medicine at the University of Ottawa, teaching the new students of medicine.

On behalf of the Canadian Medical Association, I want to thank the committee for inviting the association to participate in the hearings on Bill S-20, the Tobacco Youth Protection Act.

As the national voice of Canadian physicians, the CMA's mission is to provide leadership for physicians and to promote the highest standard of health and health care for Canadians. On behalf of its members, and the Canadian public, the CMA performs a wide variety of functions, including advocacy for policies and strategies that will promote health and prevent disease and injury.

I come before you today representing the Canadian Medical Association in my capacity as the chairman of the tobacco steering committee. Equally important, I come before you as a physician who treats patients suffering from the effects of prolonged addiction to tobacco. I witness first-hand the devastation that this extremely hazardous substance wreaks on many Canadians and their families.

Since our first public warning on the hazards of tobacco use back in 1954, the Canadian Medical Association and Canada's physicians have spoken out repeatedly against its use, warning of its dangers, and recommending a variety of tobacco control measures. Besides our members' daily work in advising and assisting patients to stop smoking, the CMA has been involved in projects to provide resources for physicians to help them counsel their patients against smoking. This activity is mirrored by our provincial and territorial medical associations.

For example, since 1990, the B.C. Doctors' Stop-Smoking Program has provided physicians in British Columbia with materials to help them intervene with patients who smoke. Manitoba's doctors are spearheading a campaign for a bylaw to ban smoking in public places in Winnipeg. In the Northwest Territories, the medical association is also working on a similar public health strategy.

The doctors of Nova Scotia are involved in a Millennium project to encourage smokers to talk to their family physicians about their smoking. Prince Edward Island has a very effective program where physicians volunteer their time annually to speak to every grade 6 class about the dangers of tobacco use.

Our medical associations in Newfoundland, Labrador, Ontario, Saskatchewan, and Alberta are all partners in tobacco reduction coalitions in their provinces.

In its advocacy efforts against tobacco use, the CMA has worked and continues to work closely with all provincial associations, as well as other medical associations and groups, some of whom you have already heard from. In addition, the CMA has worked over the years with individual parliamentarians, including Senator Kenny, on the issue of tobacco use.

The CMA has closely followed and supported the work of Senator Kenny in his efforts to introduce legislation aimed at reducing tobacco product use among the youth of Canada. In fact the CMA supported the senator's previous proposed legislation in this area, Bill S-13, the Tobacco Industry Responsibility Act.

The CMA supports the legislative initiative of Bill S-20 as a necessary means of implementing sustained and substantially funded programs to reduce tobacco use, especially among our youth. The CMA also endorses the intent of this bill to impose a levy on the tobacco industry for the purpose of funding tobacco control programs. In 1999, the CMA also recommended, at its annual general meeting, a similar scheme to designate 0.6 cents per cigarette sold to a fund to defray the cost of tobacco intervention programs involving Canadian physicians, such as those that I have already mentioned.

Why does the CMA endorse such a move, and therefore the proposed legislation? Every day, Canadian physicians such as myself see the damage caused by tobacco use. I can walk you through the hospital on my daily rounds and go through every ward and show you where tobacco is involved. You enter the hospital and you see the emergency ward.

You would see the children with asthma aggravated by second-hand smoke, or the person with chronic, end-stage pulmonary disease who is having difficulty breathing. I could take you to the obstetrics ward, where you would see mothers delivering infants with very low birth weight who are having difficulty starting out in life.

I could take you to the intensive care unit, where the person has had a fresh myocardial infarction resulting from tobacco use, and is fighting for his life. I could take you to the surgical floor, where I am dealing with a person with lung cancer who is facing surgery and an end to his life.

It goes on. I could show you, every step of the way in my daily work, where tobacco is involved in everything I do.

For some, the issues surrounding tobacco have become complex. However, for me it is clear and simple -- tobacco kills. In fact tobacco kills over 45,000 Canadians a year. One out of every two smokers in this country dies prematurely as a direct result of his or her habit. Many people with tobacco-related diseases do not die of that disease, therefore mortality statistics greatly underestimate the actual burden of suffering in Canada caused by tobacco.

The list of diseases associated with tobacco is long and growing. We have known for nearly 50 years that smoking causes lung cancer. We now know it is associated with cancers of the mouth, the gums, the bladder, and the head and neck. Research also suggests linkages to cancers of the colon and cervix.

Smoking is a leading cause of heart disease. We know that. It is also a leading cause of many respiratory diseases, including emphysema. Scientists are continually uncovering links between tobacco and ill health. Studies have linked smoking to Buerger's disease, an unfortunate disease in young men that causes gangrene and leads to amputation of the fingers and toes. We know of linkages to premature aging and impotence.

One does not have to be a smoker to suffer from tobacco's harmful effects. As I have stated, children born to mothers who have smoked during their pregnancies are at greater risk of low birth weight. Second-hand smoke has also been associated with heart and lung disease. The risk of respiratory infections and asthma in children is aggravated by second-hand smoke.

Smoking is also responsible -- and I see this in the emergency ward -- for 25 per cent of deaths and an uncalculated number of injuries from household fires. We seem to forget those statistics.

The burden of tobacco carries a high price tag. It is estimated that it costs Canada $3 billion a year in direct health expenses, and an additional $8 billion in indirect expenses such as disability and absenteeism.

The National Cancer Institute of Canada predicts that between now and the year 2015, the total number of new cancer cases will grow by 70 per cent, straining Canada's already-threatened public health system.

Most worrying is that despite our national efforts, the number of young people smoking has increased. In 1997, 29 per cent of Canadian teens smoked, compared to 21 per cent in 1990. That statistic translates into thousands of young Canadians who have put themselves at risk of serious illness and premature death.

Consequently, in addition to supporting Bill S-20, the CMA also supports a comprehensive range of measures to discourage tobacco use in this country. Such measures include further restrictions on advertising and marketing of products, enforcement of the ban on sales to minors, and reduction of toxic ingredients in tobacco.

The CMA supports and applauds recent federal measures to control tobacco, including the recent proposals by Health Canada to print graphic health warnings on cigarette packages; the strengthening of reporting requirements of the tobacco industry; and high tobacco prices and taxes. In fact, high cigarette prices are considered a powerful deterrent to youth smoking.

The burden of tobacco use is more than lists and statistics for physicians. We see the people behind the data. We see the physical and mental suffering that these diseases bring to patients and families. The physicians of Canada, not the members of the tobacco industry, must face Canadians and tell them that they will die.

Physicians and other health professionals play an important role in helping smokers break the habit. Evidence shows that a brief encounter with a physician leads to an increased chance of smoking cessation. Canadians generally see their physician at least once a year, and consider their family doctor to be a credible source of information on how to lead a healthy lifestyle.

I have outlined some of the programs in which physicians are involved to counsel both existing and potential smokers. However, funding for many of these programs is not on a sustainable basis, and therefore many successful programs may soon expire. The CMA believes that we need to ensure the viability of such programs through long-term, sustainable funding. The CMA would be the first to admit that this would require generous and sustained support.

The American Centers for Disease Control recommends a minimum of U.S. $5 per capita be spent on comprehensive tobacco control programs. That would translate into $200 million annually in Canada. For a population the size of Canada, it has been recommended that we spend between $9 and $24 per capita on tobacco use prevention. Currently, Canada spends .66 of one cent per capita. Clearly, we can do better.

In 1997, the Liberal Party promised to double funding for tobacco control programs, from $50 million to $100 million over five years. These additional funds were to be invested in smoking prevention and cessation programs for young people.

The CMA has already expressed its desire to see this amount formally committed. However, we believe that a truly effective program for prevention and cessation of tobacco use requires a larger and more permanent funding commitment.

The levy of 0.75 cents per cigarette proposed in Bill S-20 would bring in a total of $360 million annually for a comprehensive range of programs to discourage young people from smoking. While this amount takes us within the range recommended by the CDC, it is only a small fraction of the $3 billion that I alluded to earlier that tobacco use costs our health care system.

Statistics do indicate that strong tobacco control programs produce results. The states of Florida, California, and Massachusetts have implemented strong and well-funded youth smoking prevention campaigns. Surveys report that while teen rates in the U.S. have either risen or remained static in recent years, in Florida they declined significantly between 1988 and 1999. It is the largest annual decline reported since 1980. Similar results have been reported in California and Massachusetts.

The CMA would like to see a similar decline among Canadian teens, and a corresponding decline in tobacco-related illness and death. Tobacco truly is the number one cause of preventable disease and death in Canada. The CMA urges the Government of Canada to deal with tobacco in proportion to the burden it imposes on the citizens of this country.

Dr. David Esdaile, Vice-President, Physicians for a Smoke Free Canada: I am a family physician working in Ottawa. The sole aim and purpose of our group is to reduce and prevent the terrible health and death tolls caused by tobacco.

On a more personal level, I have a 14- and a 16-year-old. I have an interest in keeping my children separated from this stuff that we are discussing.

You have heard the huge numbers here. I want to be brief and to keep the detail limited: 45,000 deaths is probably a minimum; 17,700 from cancer; 17,500 from heart or cardiovascular; and just under 10,000 from lung disease.

You have heard that deaths among women from lung cancer now far exceed deaths from breast cancer. This is a tragedy, the proportions of which we are just beginning to see. Lung cancer deaths in men now exceed cancers of the prostate, colon, pancreas, and stomach together.

As a family physician, I too have the unfortunate "opportunity" of seeing these numbers translated into real people. Their tears are real. Their anxieties are real. Otherwise, these individuals are the same as you and me. Their only problem is that they were hooked on tobacco and nicotine when they were children, in virtually every case. Most of them were unable to quit. Some of them were able to quit, but perhaps more sadly, too late.

I have been in practice now for 25 years. When I started thinking about this, I realized there was a blur in my head -- perhaps that is the memory bank -- of the faces and names of those who, over those years, have succumbed to this product's damage, from heart disease and cancer. Some memories are worse than others -- a disease of shorter duration or worse pain towards the end.

There are many varieties of cancer -- of the throat, the gall bladder, certain leukemias, and now we think breast cancer can also be related to second-hand smoke. I no longer work in the emergency department. When I did, I saw seven people in one year between the ages of 27 and 37 who had suffered heart attacks. Two of those people were having their second heart attack, and for all of them, their only risk factor was smoking. They did not smoke more than only else; they just smoked.

I work in a breast cancer clinic as well as in general practice. I remember one woman well. We diagnosed -- if one can use this term -- a "favourable" breast cancer in her when she was 30. It was 5 millimetres, which is less than a quarter-inch. Everything pointed to long-term survival, in excess of 95 per cent probability.

Throughout the time I followed her, I pushed her to do one thing, namely, give up the habit. She could not give it up. Ten years later, she died of lung cancer at 40. It was completely unrelated to her breast cancer diagnosed at age 30.

We face this on a daily basis. Half of all smokers will die from their habit. That is the World Health Organization's accepted number. What has not been stated is that one-half of those will die in middle age. The average loss of life expectancy per patient is 23 years. That is an average; therefore, if one patient loses 13 years of expected life, then another is losing 33 years.

About a month ago, I saw a woman who was a little older, again with a positive diagnosis of lung cancer. As with many cases of lung cancer, she has an inoperable disease. There is no surgical cure. This patient will go on to what I consider the "miseries" of chemotherapy. I hate to say that, but it would be difficult for anyone to say otherwise. She will die relatively quickly from her disease. In her case, the irony is that she quit smoking 10 years ago. Nonetheless, she has a smoker's disease.

This message needs to hit home. The cancer process in this case does not stop just because smoking stops. The malignant and genetic changes that cause cancer often continue. Emphysema and chronic lung problems often progress. Although you stop smoking, once the diseases are established, they only get worse. Even though cardiac risk can be improved, the heart damage is not reversed anywhere near 100 per cent by quitting.

The people we are talking about have to go home to speak to their spouses and their families. Especially with lung cancer, they must tell them that the game is up. They had plans for the future; those are over. They had dreams; those dreams are on the back burner. Perhaps they were thinking that they had worked hard and they would have that little time to enjoy life. They will not have that time.

Our message is that these are real people. These are your neighbours and mine. They are in my family and they are probably in yours.

As far back as 1971, the federal government was looking, in Bill C-248, at cutting back promotion and putting warnings on cigarette packs. As has happened so often with tobacco issues, that bill was allowed to die.

We have seen the classic industry delays in changes to voluntary codes. Governments have changed. Bills have suffered under political pressure, as we have heard from Senator Kenny. All of this is happening on an issue that we must agree is non-partisan.

We all agree that children should not smoke. Surely then, knowing what we know today, we should do all that we can to prevent our children from smoking. Even the tobacco industry has publicly acknowledged agreement on this particular issue.

What we have done to date -- and this is the most important message -- has not worked, or at the very least, it has worked imperfectly.

I read recently in a magazine that if you always do what you have done, then you will always get what you have. If what you are doing is not working, do something else.

It is clear, and easy to say, that what we have been doing has not been working. We have allowed history to repeat itself again and again in terms of hooking generation after generation on tobacco. These 30 to 40 years' worth of danger signs are saying that this is a dangerous product.

Bill S-20 is that something else that we need. It is not new, in that much of its core has been tried, and has succeeded, in California. It is new for us in Canada. It allows us to take tobacco out of the area of partisan politics, where it is fair to say it does not belong. This bill allows us to give tobacco the priority it so badly deserves.

The bill is extremely well thought out and organized. It removes tobacco usage from partisan politics, where it has thrived for the last 30 years. The tobacco industry is doing extremely well in Canada. The limitations on overhead are excellent. The money put aside for evaluation is absolutely essential, and the fact that reports will be reviewed by the Auditor General and presented to Parliament regularly is critical.

Acknowledging the safeguards, the bill puts a level of resources into the protection of our youth that begins to reach, essentially, the lower level recommended by the Centers for Disease Control. The greatest strength of the proposed system in this bill is that it has been tried in California and has been a resounding success.

California has one of the lowest smoking rates for children in North America, at 10 or 11 per cent, whereas we are talking about 29 per cent in Canada. Dr. Cushman suggested that the numbers are actually much worse. From a medical perspective, I urge you to support this bill.

Senator Kenny: This is a question for both of you. You have both described your experiences as physicians and how you have had to deal with patients face to face. You have both described this as being the major preventable cause of a disease that touches virtually every family in Canada. Given the grief and trauma that people go through when they are struck with a tobacco-related disease, why is there not more reaction from your patients? Why is it, in your opinion, that we do not see more people coming before Parliament to speak about the issue? Why is it so far down on the list of political priorities?

Dr. Esdaile: I do not know if there is an easy answer. I guess I would start out with the obvious thing, namely, that not many people want to appear in front of such an august committee.

There are issues on tobacco that have been touched on already, not the least of which is the distinct temporal separation between the act of starting to smoke and the eventual demise of the smoker. Sometimes that is not so long; often it is. Often, as I have pointed out, the person who dies is no longer a smoker. It is often not so clear that smoking is the cause. There is no question that as physicians, we accept entirely that this is a paediatric disease and addiction. Children become addicted to this product and remain addicted for the rest of their lives. Once they become adults, people do not tell them that they were addicted as children. People say, "Look at your bad lungs. Look at your bad circulation. Why haven't you quit?" There is a huge sense of guilt today from all we hear around us and in the press. You must smoke outside, and you know that it is bad for you, but you are still doing it despite your kids. There is guilt. The smokers who get the disease really do not want to come forward; they feel that they have paid the ultimate price.

I am reminded of a real person here. Often, people who smoke are surrounded by people who smoke. Senator Adams spoke about his people. Approximately 72 per cent of Inuit people smoke. The numbers are absolutely critical cultural issues. If one person smokes, the other person smokes. The industry spends three times as much per capita on smoking promotion in Quebec as in any other province. If you smoke in Quebec, there is a good chance your friends and family do too. That goes on and on. If you are a 60-year-old professional physician, chances are you do not smoke, and neither do your friends.

Shortly after I moved to Ottawa, I was on call and was called to see a woman who was not my patient. She was probably 65 and was dying of lung cancer, with bone metastases. She was not having a good time. She was in a lot of pain and was on a morphine pump. Late one evening, her family called me in to see if something could be done. I did not know her and I did not know them. They did not see this, but when I walked in, all the boys were sitting around the TV watching the hockey game, and they were all smoking. Here was mom, dying in the back room from a smoking-related illness. That connection was not made.

It is not one little ditty on a children's channel -- and I am in favour of that -- that will get to these people. You need repetition. We do not need to reach the people who do not smoke. We need to reach the people who are hard to reach. They are the people with cultural identities, the people who are no longer in school, and the people who are out of jobs. You need funds and specific programs to reach these people.

The answer is, there is time and there is guilt. People just do not see the connection. Even if they do, they will not step forward. Most of the time, once you contract many of the tobacco diseases -- other than chronic emphysema -- they kill you quite quickly. If you have a heart attack, or a second heart attack, or lung cancer that is not operable, chances are you will not do a lot of work against tobacco.

Dr. Kuling: I agree with my colleague. By the time the tobacco-related illness hits you and has ravaged you, you are apathetic. That lifestyle choice and that addiction go back so far, and people are so busy dealing with what they have to deal with then that they do not become advocates for changing the addiction process in the young.

That is an interesting question, Senator Kenny. There must be more family members who have witnessed this disease and devastation in their families who should be coming forward to speak on it. For some reason, there is apathy, in that they have succumbed to this addiction and they are now paying the price. They are trying to get any kind of quality of life at the end stage.

The Chair: A very famous person in the United States who has had cancer -- and I do not know whether it was from smoking -- is the leveraged buy-out king.

Senator Adams: It seems that no matter how many people die or get sick, smokers do not seem to be convinced that cigarettes are bad for them. When I smoked, I was not a heavy smoker. I used to have a cigarette when I was hunting or when I was having hot tea. It is a lot different smoking outside than inside a building. A lot of people in the North are drinking, too. Often, they want to have a drink and a smoke at the same time. Have you looked at the effect of alcohol on nicotine?Some people do not drink and they hardly smoke. Many people like to sit in front of the television with a beer to watch a hockey game and they like to smoke at the same time.

When I was young, we were very bored. However, we did not even have cigarettes. We had tobacco that you had to cut with your knife and soften before you could roll it in the paper to smoke it. Usually, people smoked pipes. Today, however, you can buy cigarettes everywhere. They have cut down on smoking in aircraft now. I used to hate it when someone would light up behind me and I would get second-hand smoke.

We need to be reminded that 45,000 people are dying every year from cigarette-related illnesses. Earlier, I asked Dr. Cushman how we can get the message out. How will we increase advertising to stop more people from smoking? In the old days, newspapers and magazines carried cigarette advertising. Today, however, that is not permitted in Canada.

Dr. Esdaile: You touched on just about everything that involves tobacco in a very brief period. You pointed out that you associate smoking, or did associate smoking, with hunting, maybe with alcohol, or just sort of a social get-together. That, of course, is how tobacco companies sell their products. You cannot sell tobacco for what it is. It is addictive. It stinks. If you are not yet hooked, it makes you feel sick, and then it does make you sick, and it eventually kills half the people who use it. You cannot sell that, so you have to sell it by association. This has not been lost on the tobacco industry. They do this extremely well. They tell us they are not advertising now, that it is only sponsorship, but as we heard earlier, very young children recognize today's sponsorship. It largely goes to the sort of things you are looking at: association with risk taking, with sports, with lifestyle, out on a cruise boat. That is how they are selling their product.

I am not an addiction expert, although there was one here earlier. I do not think there is any question that people who are hooked on one product are more likely to be hooked on the other. Perhaps the greater issue is that if you have quit smoking, you are much more likely to break down, lose that inhibition, and go back to smoking.

As to how you prevent risk taking, I think you never will. It is only by repetition, by changing your style, and by speaking to children in their own language, not yours, that you will reach them. My poor kids hear this every day. This is not the only place I talk; I practice on them. Last year my 14-year-old son had a spinal fracture from snow boarding, a wrist fracture from snow boarding, and he ripped his ankle apart from mountain biking down a hill. All of those injuries will heal, and he can talk about them years from now courageously. So far, and hopefully on an ongoing basis, he is not a smoker, because once he takes that risk, he will carry it with him for a very long time.

You mentioned access to the product. That is one of the biggest problems. It is easy, easy, easy. If they cannot buy it themselves, they get it through their friends. There is no question that the incredible availability of tobacco is one of the biggest problems.

Dr. Kuling: Senator Adams, when you were speaking, could not help but think of my practice in Prince Albert. Certainly 60 per cent of my practice involved aboriginals. The worst victims of the tobacco industry are the children. I mentioned earlier the low birth weight infant born to an aboriginal family in which the housing is poor, let alone the fact that everyone in the house is smoking. When we see those children in emergency, I literally must hospitalize them to remove them from that smoking environment and help with their pneumonia. They already have broncho-spasms, the beginnings of asthma. We have to use high-dose steroids. We are talking about children that are 5, 10, 15 pounds in total body weight. You get them to a point where you can send them home, only to have them bounce back again. It is well known that aboriginal people already have a predisposition to lung disease, and the effects of tobacco on that are horrendous.

I plead with you that these are innocent victims of second-hand smoke. If you think these are just mild inconveniences, they are not. They are devastating effects. Think of little children weighing 10 or 15 pounds, with an intravenous, having steroids pumped into them to relieve a spasm in their airways, and having masks over their faces and giving them ventilin to try to open up these airways so that they can get oxygen to their brain cells. It is horrendous. I wish more people could actually see these situations. They would feel the torment themselves so that they had to do something about this. They have to become advocates. They have to take a tough stand. That is probably is one of the things that led me to your table tonight.

Senator Adams: Do you have any type of brochure with information on the effects of the various diseases? Do you think if something like that were sent to every household, that that would help a little? Often I receive junk mail from people advertising for the local store, but something like a non-smoking pamphlet should be sent to every household.

Dr. Esdaile: It would be unfair to people not to show them what tobacco causes. That is what the recommended package warnings, the graphic warnings, are all about.

I would argue that children will find it disgusting, but as with so many other things in life, they will get over that, particularly if they are already hooked. That comes back to the multi-pronged attack. That is one prong, and it is both appropriate and good. It is telling people what is happening. Why do we say it is a cause of cardiomyopathy? What in God's name is that? Show them the picture. The picture is worth a thousand words.

What succeeded in California, and the thing that made the biggest difference, is that they "denormalized", which means that they took the tobacco industry and said, these people are not good people. Yes, they are good businessmen and businesswomen, but they are promoting an incredibly dangerous product with full knowledge of what they are doing. They pointed the finger very cleverly in very catchy ads that made a lot of people, including kids, feel like they were being had. If there is one thing kids do not like, they do not like to be had.

Dr. Kuling: Certainly I think children need the information. One of the most successful programs in Prince Edward Island is where the physicians volunteer their time to speak to every Grade 6 class about the dangerous effects of smoking. I have some personal friends who are physicians there, and they tell me that one of the things that has the biggest impact is showing pathological specimens of human lungs, a pink one from a non-smoker, and a black one from a smoker. That has such an enormous effect on those children that they talk about it, and they take up the cause themselves.

Here is the crux of what we are discussing tonight. We need to reach our children and to educate them. What Dr. Esdaile has done with his children, we should be doing with every family across the country, be it the schools or the parents with their children. That is where we can stop the problem. That is why I think Senator Kenny's bill will have the right effect and will make a difference.

The Chair: You mentioned Grade 6. Do you feel that is the optimum age? When children are approaching adolescence, they become more cool and cynical, but smaller children are more susceptible to looking at a situation and deciding that it is not good. They get a lot of satisfaction out of doing something. I wonder if you have any thoughts about whether one should start before Grade 6?

Dr. Kuling: I think that Grade 6 was just the place where Prince Edward Island physicians felt they could intervene. I am not sure of all the reasons why, but I agree with you. I think that we must push that age down and denormalize smoking with children so that they see this as an abnormal and inappropriate thing to do.

I think of it in another realm. The subject of contraception used to be talked about at certain ages, and now that age is getting younger and younger. Certainly with smoking, I do not think that Grade 6 is the optimal time; I think it should be much earlier. I agree with you.

The Chair: We appreciate your testimony today.

Our next panel includes, from the Canadian Cancer Society, Dr. Bonham; from the Heart and Stroke Foundation, Mr. Tholl; and from Coalition Québecoise pour le contrôle du tabac, Mr. Lépine.

Dr. Gerry Bonham, Health Consultant, Canadian Cancer Society: Madam Chair, and members of the committee, it is a great honour to be asked to participate in this exercise. I can assure you this is a labour of love on my part.

Much of the good stuff has come out in the questions, so I will not repeat any of that material, except where I think it deserves emphasis. I will concentrate on the voluntary agency -- the Canadian Cancer Society -- with which I have been very active over the last 10 years. I will make the point later on that, with this burden solved by Bill S-20, perhaps we can proceed to other important matters.

There is an opportunity cost, in this situation, where we have had the rightful burden of addressing the tobacco issue, but this is not the only cause of cancer. I will go into that perhaps a little bit more. First, I should share with you that I have had a life-long interest in the subject of tobacco. My first positive act was to declare my own workplace of 70 people smoke-free back in 1964 -- the year of the Surgeon General's famous report. I do not think anyone had a smoke-free place in Canada prior to that time, and I feel proud of having achieved that.

My entire life in the tobacco world has been partly an atonement for my parents. My parents did everything wrong. They surrounded me with smoke, and I spent all my childhood years wheezing away and missing a lot of school. It was not all that pleasant. To top it all off, my parents, who lived on the outer edges of Winnipeg, were neighbourhood "pushers" -- they actually had a cigarette vending machine in their living room. My friends used to comment on this: "No wonder you are crazy about this tobacco issue, you were embarrassed by what your parents were doing back in Winnipeg in the 1930s." The Depression was on, of course, and there were all kinds of people going door-to-door to make a buck by installing these cigarette dispensers. I remember they were 10 for a dime or 25 for a quarter. It is a vivid childhood memory.

In my career, I have been Medical Officer of Health in Calgary and Vancouver. I have worked with the University of Toronto to set up a teaching health unit in East York. I have also worked in Prince George and on Vancouver Island. Everywhere I worked, every place I turned, the tobacco issue was front and centre for a public health officer like me -- unavoidable -- and I had to deal with it.

I can remember presenting a report card to the citizens of Calgary every year in which I actually listed the problems in order of importance. Of course, tobacco-related disease was always number one because it stood out as a preventable burden to which everyone should pay attention.

I have been more involved latterly with municipal bylaws, and particularly the issue that the Workers Compensation Board of British Columbia has been wrestling with in terms of totally smoke-free workplaces. I will answer your earlier question, Senator Adams, about alcohol and tobacco, because some fascinating things emerge from that subject.

The Canadian Cancer Society has 350,000 volunteers. It is Canada's largest health agency and an enormous amount of work is done in patient support, fundraising, and getting money for research. These are the big-end things. Some time ago, the Canadian Cancer Society set up a public issues office in Ottawa, separate from the head office in Toronto. Then there was a fan-out, and we all sent representatives from the various provinces to this national committee. I have been part of that for about 15 years, and it has been an important part of my work. Even after my so-called "retirement" from public health practice, this has been an unavoidable involvement for me because of its importance.

When you travel to other places, you realize that the Canadian Cancer Society is doing really solid work -- their efforts to help people avoid sunburn and the resulting melanoma and cancers show. Other people are paying attention to air pollution and its connection with cancer. The issue of diet and cancer has not been very seriously addressed. Our organization has been somewhat paralyzed by this huge, overriding issue that is hopefully going to be addressed by Bill S-20, and supported.

Personal issues have been brought out more than once in this session. I lost a very close friend last year, who started smoking when he was 12. I saw him die by inches, and it was a horrible experience for me. My wife lost her best friend, who was addicted at 12 and died at 40 from lung cancer. I am sure that we have all had these experiences. The physicians on the last panel referred to the ubiquity of this problem. It is everywhere, and it is up to everyone to address it.

I want to convey one thing about the epidemiology of cancer from smoking. When you succeed in lowering the rates of smoking, you see a reduction in lung cancer 20 years or 30 years later. British Columbia has the lowest overall rate of cancer in Canada, and the lowest rate of lung cancer in males, because 20 and 30 years ago, there was a more adequate embracing of anti-smoking.

The public health system and the voluntary health agencies were more seriously on top of this issue, and it paid off. Of course, now we will see the reverse happening with this recruitment of teenagers into the tobacco habit. We will see a bulge in 20 years or 30 years.

This should not surprise us. After World War II, when it had been your patriotic duty to send cigarettes to the servicemen at the front, we saw in the 1960s a real bulge of fatal illness among that group.

Bill S-20 is important now because we have lost ground. Others have described that. We need to win that ground back and create a bulge going the other way, to create a plateau 20 or 30 years down the road. One of the problems in taking tobacco seriously is that delay.

Another problem is that some people who are currently more committed to lifestyle issues do not like to admit that they have an unhealthy habit. They feel somewhat guilty about it. One of my colleagues told me the other day that he did not care how he died as long as it was not from a preventable disease. He said that he would hate to leave that legacy. He made a solid point.

It has been mentioned that the Inuit have a 72 per cent smoking rate and that among the First Nations it is 56 per cent. The $360 million provided for in Bill S-20 may not be adequate. Canada has a national government, ten provincial legislatures and three territorial governments, regions, regional centres, local communities, school communities, and many other groupings that make for a difficult job ahead. That $360 million will not be excessive for the degree of difficulty in the work ahead.

Some of my colleagues in the cancer society and in other voluntary health agencies have said that this may be overkill. I do not believe that. We need this desperately.

We need to look at the politics of this. We have had claw-backs of assigned money. It is unconscionable to actually give a small amount of money and then claw it back. That has happened in recent years. We have had insensitive political processes.

We also have the power of the tobacco industry itself. They have recruited members of Parliament, senators, a former prime minister, and a then sitting prime minister's wife to contribute their enormous power, plus money, with which to back up sponsorship and buy friends. It just burns me up to see a bunch of Boy Scouts showing up at a community meeting looking for tobacco sponsorship money for some recreational event they are trying to organize. This permeates our entire society, from the Boy Scouts up to the most senior politicians of the land.

We must not allow any claw-backs. They should not be allowed to turn this venture down.

The arm's-length feature of Bill S-20 is so incredibly important. I went to Australia to visit a centre that has an arm's-length organization. It works well. They have been able to kill all the tobacco sponsorship.

Incidentally, they find the arrangement a bargain, because half the money for the tobacco sponsorship goes to promoting their logo. It does not go to the event. They told me that they have money left over from the sponsorship kitty that they anticipated spending. It depoliticizes the process.

I heard the other day that a state governor in the U.S., where the arrangements were not-arm's length, spent his evenings revising television ads to make them politically acceptable. We do not want that. We do not want a health minister spending his evenings doing that type of work. The only way to avoid that situation is to have this arm's-length arrangement.

In a book called Cancer Wars, the author said that the failure to control the world's most deadly cause of cancer will one day be looked upon as the biggest mistake of 20th century health policy. He was right. This is the "one day" to which he was referring. The time is now, and the cause is absolutely correct. He had an accurate reading on this one issue.

Mr. William G. Tholl, Executive Director, Heart and Stroke Foundation of Canada: It is a pleasure to be here before this committee, and it is wonderful to hear the enthusiasm expressed by Dr. Bonham and others about the opportunities that are presenting themselves. If you do not mind, I will read from my short presentation.

I believe the clerk has been advised that we intend to show a short video about two-thirds of the way through my presentation, if that is acceptable to you.

[Translation]

Our mission is to encourage the study, prevention and reduction of disability and death caused by stroke and heart disease. We carry out this mission through research, education, and promotion of healthy lifestyles.

[English]

In recent years, the foundation has taken a leadership role in advocating for a heart healthy policy. An important aspect of that role is the foundation's focus on anti-tobacco work. The Heart and Stroke Foundation commends Senator Kenny and Senator Nolin for their second, and we trust successful, effort to move forward on the tobacco front. We are very pleased to appear before your committee today.

Today, we know that tobacco, the number one risk factor for heart disease and stroke, has no place in heart healthy lifestyles. That makes Bill S-20 important to the Heart and Stroke Foundation of Canada.

I would like to speak briefly to three issues: the need for expeditious passage of the bill, the importance of consulting with the voluntary sector through the proposed oversight committee, and the need to enhance and sustain the capacity of the voluntary sector to deliver frontline anti-tobacco programs.

Madam Chair, the cardiovascular committee believes that it is crucial that the utmost be done to reduce the most influential and avoidable risk factor for cardio-vascular disease -- tobacco smoking. Smoking kills 45,000 Canadians annually. It prematurely kills three times more Canadians than car accidents, suicides, alcohol, murder, and AIDS combined. It costs Canadian society about $15 billion annually.

Smoking is known to substantially increase the incidence of all forms of heart disease and stroke. Of the premature deaths caused by smoking-related disease in 1996 in Canada, cardiovascular disease accounted for almost 39 per cent, for a total of almost 18,000 deaths. However, we all know that the moment you stop smoking, and this in many respects distinguishes our perspective from other perspectives, your cardiovascular health starts to improve immediately. In fact, within 24 hours of quitting smoking your chance of having a heart attack decreases. Within one year, the risk of heart disease is diminished by one-half compared to smokers.

Madame Chair, we also know that $20 million annually is currently spent on tobacco control by the federal government. While significant, it is vastly insufficient, given the scope of the tobacco problem in Canada.

This is another reason for our support of this bill and why it inspires so much hope within our community.

We believe that Bill S-20 could serve as an important vehicle to change the attitude of Canadians toward tobacco products and the tobacco industry. This aspect is important, in that it reveals to youth the nature of the so-called "lifestyle" advertising and promotional initiatives of the tobacco industry. We know that preventing smoking among our youth is especially worthwhile, given that we also know that once teenagers begin smoking, they are typically on that consumption pattern for at least 20 years.

Special urgency is warranted when you consider that teen smoking has been growing since 1990 and is increasingly becoming a young person's habit. I noticed a question earlier on about what may be going on in terms of reduction in smoking, increased smoking, and other risk factors. We have done some work in that area in the context of a baby boomer survey a few years ago. I may comment on that later if there is sufficient time.

Clearly, nipping the tobacco habit in the bud among youth can significantly advance long-term public health in Canada. In this respect I had the pleasure of participating in the selection process for Minister Rock's youth advisory council, and in that connection support clause 18 of this bill. For those of you who are sometimes troubled by whose hands our future is in, let me tell you that, based on the 120 young adults whom I had an opportunity to either meet or review their CV's, we are in safe hands. They are committed young Canadians. I was pleased to see the appointment of 18 of them to the youth advisory council. The thinking is that if you want to hire a qualified bus driver, who better to ask about the driver than the kids who are to be driven around.

That part of the bill particularly is something we strongly support, and we would strongly support the more active involvement of children in deciding what kinds of programs may or may not work.

It is also crucial that the voluntary sector stay involved and be involved on an early, ongoing and meaningful way in this process of developing an anti-tobacco strategy for Canada. To this end, we look forward to Minister Robillard's announcement later this week regarding joint efforts to enhance the relationship between the voluntary sector and the public sector. In this spirit, we believe it is important that the voluntary sector is consulted by the oversight committee as proposed by Bill S-20, the committee that will oversee the distribution of project funding. This is extremely critical to success. It is only by consulting with the voluntary organizations that deliver the front line programs that we stand a chance of being truly effective.

Honourable senators, this bill would provide the dollars to bolster our fight against tobacco and its effects on youth. Contrary to some critics, we know how to make good use of these funds. For example, at the provincial level we are extraordinarily proud of the anti-tobacco mass media campaign recently implemented by the Heart and Stroke Foundation of Ontario, in conjunction and collaboration with colleagues at the cancer society, and supported by a grant from the Government of Ontario. This 16-week, $3.2 million campaign, aims to change tobacco use by portraying it as socially unacceptable. It targets those Ontarians who are not smokers, but who have been or are being harmed by tobacco -- these so-called "libertarians" who continue to accept that it is okay to be smoked around, the 28 or 29 per cent.

The ads are now appearing on television, radio, and in newspapers across the province. You may have seen some of these commercials recently in Ottawa. We have received many positive comments from the public about this campaign, and I ask your permission at this time to show two short clips.

(Video Presentation)

Mr. Tholl: I believe the committee will agree that this is a new way of trying to get through to Canadians indirectly rather than directly. As I say, the reaction so far has been tremendously positive.

I point out to those who would argue that we do not know how to make use of significant sums of money, that the annual cost of this campaign alone in Ontario would exceed $10 million. If successful in Ontario, we would obviously want to try to adopt a similar program across Canada. The cost of such a campaign would be roughly $30 million annually. This is just one, and we like to think very effective, way of going about it.

I stress again that this is the power of collaboration. You have a provincial government and two voluntary agencies working hand in hand, not head to head, to try to achieve a common objective. This is but one example of what we think are successful programs that are only held back due to lack of funding. We have recently again collaborated with a number of other agencies, including the Canadian Medical Association, on a series of modules that are located in 5,000 general practitioner offices across the country. One of those modules deals with smoking and heart disease and contains material readily available, up to date, and developed by an expert committee. Once these are all distributed by those 5,000 physicians' offices, that information will be updated every six months and available on an interactive Internet site.

Another, similar program -- again working through physicians' offices and with physicians -- is "A Guide to Patients and a Smoke-free Future." This has been translated into four different languages for smoking cessation programs; most recently into Spanish for Chile. Again, the limitation is money for translation costs in many cases.

Approximately one-third of those youth advisory committee appointees whose CV's I had an opportunity to look at were graduates of what we call our "Fly Higher Program," one of our most successful in-school programs aimed at children aged 6 to 12.

Those are the kinds of programs, and again, the cost to get them out into the community is not inconsequential. We would like to think that there are considerable opportunities to look at what is tried and what is true, to get through to the communities, if only we had the resources to do so.

This problem has been escalated in recent times by the cutbacks in government. That is a subject for another day, but as the federal government shovels snow under provincial governments, provincial governments under regional governments, much of that snow ends up at the driveway of the health charities, who are expected to step in where governments have stepped out. Therefore, our inability to get these programs out is amplified and exacerbated by that.

Madam Chair, we have learned the lessons of the tobacco demand reduction strategy. That is to say, we must ensure that we are effective in what we do and that we have the ability to prove that what we are doing is effective. It is all about making a difference. We recognize that monitoring and evaluation are important components of any good program. For this reason, we are especially pleased to see that Bill S-20 provides for and requires that each and every project allocate 10 per cent of its funding toward evaluation.

Before I conclude, I will step away from my text. I just returned from a World Health Assembly, where I was a member of the delegation representing the Government of Canada. I have never been quite so proud as when I was in Geneva and we actually saw the adoption of a resolution toward adopting the tobacco framework convention. There is no question that the world is looking to Canada for leadership in the entire arena of tobacco and tobacco management reduction strategy. Bill S-20 would be an incredible addition to that overall arsenal of programs. The world is watching this, other bills, and other initiatives that Canada is taking. Literally, a hush came over a group of 192 countries when Canada began to speak to the need for an international convention on tobacco control.

In conclusion, we urge the Senate to expedite the passage of Bill S-20. Heart and Stroke Canada is confident that once implemented, Bill S-20 will serve within the context of a comprehensive tobacco strategy to effectively combat tobacco consumption among Canadian youth. We are also absolutely committed to doing our part to ensure that this bill is passed by the other place expeditiously.

[Translation]

Mr. Gilles Lépine, Coalition québécoise pour le contrôle du tabac, Alliance pour la lutte au tabagisme de Québec et de Chaudière-Appalaches: I am very pleased to be here today. I want to congratulate Senator Kenny and Senator Nolin on their work and determination. We support them in their work to prevent smoking among young Canadians.

I am the executive director of Sport étudiant in the Québec--Chaudière-Appalaches region; I represent the Alliance pour la lutte au tabagisme de Québec et de Chaudière-Appalaches, as well as the Coalition québécoise pour le contrôle du tabac.

I had prepared a multimedia Power Point presentation for you. In your kits you will find the print presentation, in colour. Although you will not have any sound, you will have the images.

The Coalition québécoise pour le contrôle du tabac, which I am representing today, brings together over 730 organizations and is thus the world's second largest coalition; that is appreciable. The Coalition's mission is to protect the public from sidestream smoke, to prevent young persons from starting smoking, to control tobacco marketing, to support smokers who want to quit, and to introduce measures to support the legislation. These purposes are current among, and have been endorsed by, the Coalition's 730 members.

As part of the anti-smoking campaign, the Coalition has called for a number of measures, including funding for promotion and for research on the causes of smoking.

The next page refers to a smoke-free age, and our regional alliance in the Québec--Chaudière-Appalaches region. The Alliance brings together a number of stakeholders working the fields of health and education. Smoking is often thought of as a health issue, but it is also an education issue.

Next, Sport étudiant, an organization in the Québec-- Chaudière-Appalaches region of which I am the executive director, covers 340 elementary schools, 80 secondary schools, 12 colleges, and Université Laval, thus reaching 220,000 students.

I have worked with young persons for 21 years. For the past six years, we have been responsible for campaigning against smoking in our region. My job is to introduce young persons to a healthy lifestyle and to encourage them to practice sports. When we have 35 per cent or 40 per cent of our young persons doing sports in the schools, we are satisfied. Unfortunately for me, at present the most popular form of recreation in the schools is smoking, practised by 38 per cent of students.

Here you see some images shown in the schools. For example, when we say that smoking kills, we mean that it kills 12,000 persons every year in Quebec; 33 persons every day; more than one every hour. That is a lot of people. Since we began our discussion today, three persons in Quebec have died from smoking.

The next image, also presented in graph form, shows that smoking causes more deaths than traffic accidents, AIDS, drugs, suicide and homicide. Think about the present publicity on AIDS alone. Then look at the proportion of deaths caused by AIDS, as compared with the proportion of deaths caused by smoking. The graph is crystal clear. On the next page, you have an image we show a great deal in the schools that shows students how many toxins tobacco smoke contains. This picture is worth 1,000 words. It shows what tobacco smoke contains. Tobacco produces very harmful smoke but, unfortunately, is a legal product.

The next image is a good picture of young persons, down at the corner, lighting up to look older and to acquire that sophistication people are so proud to project on our movie and television screens. Nicotine is a ''harder'' drug than heroin, and is as addictive as cocaine. Imagine how adding cocaine to Big Mac's best sauce would boost sales!

Young persons are smoking more. In Quebec alone, this fact has been much discussed. Repeatedly, after taxes have been lowered, smoking among young persons has doubled: a victory for the tobacco industry. Tobacco companies have managed to increase the percentage of young smokers from 18 per cent to 38 per cent. While we may congratulate the skill of their marketing departments, ultimately this triumph will mean more smoking-related deaths.

Young persons are smoking more. This image, too, is disturbing but real. In Quebec, 13 per cent of 11- and 12-year-olds smoke. Unfortunately, as we say in our region, you have to reach them by the summer they are 11 because, if you wait until they are 13, you have lost them. It is too late after 10 cigarettes: by then, young persons are hooked. And the tobacco industry knows that.

I also want to make the following important points about Bill S-20. We are talking about tobacco money. If you consider that young persons smoke -- and you have repeatedly been told that they do -- that means some $280 million in cigarette sales to minors every year: young persons 18 years of age and younger buy $280 million worth of tobacco products. Consider that the federal government collects over $80 million in taxes on these illegal sales; that more than 50 per cent of corner stores sell cigarettes to young persons; and that our society tolerate this practice. As a government, we pocket the taxes from young persons who are not allowed to buy this product.

In my view, advertising and sponsorship are the most important aspects of Bill S-20. In recent years, advertising has changed to sponsorship, which is just as influential if not more so. Tobacco companies are buying a corporate image: it's a marketing move. You can see advertising on the left, and sponsorship on the right: they are simply two sides of the same coin. In Quebec alone, advertising and sponsorship combined are a $90 million industry. That $90 million covers 7 million persons. That means $13 per person, including young persons, newborn babies, and senior citizens.

Other figures we have discussed are the per capita amounts invested to reduce smoking in other jurisdictions, in comparison with the 65 cents Canada invests. If we spend only 65 cents per capita, we can expect to reap what we have sown, particularly in Quebec, where 38 per cent of young persons are smokers.

I really like this image of Jacques Villeneuve. I go into battle every day to fight smoking, but I am armed with only a pea shooter against a bazooka. I have the equivalent of $70 per school -- 20 cents per young person -- and hope that will be enough to pay for a social conscience. Meanwhile, the tobacco industry is spending $13 per person. They have 1,300 cents; I have 20 cents. Do you imagine a society's consciousness can be raised with so little money? That is what Bill S-20 is all about: fighting fire with fire! Either we attack with a near-professional marketing approach; or we keep on preaching good intentions, with zero results.

Let me give you an example. We carried out a survey among 3,995 10- to 12-year-olds in elementary schools.

These young persons were asked what sports their favourite stars played. Hockey, of course, came first. Hockey is a religion in Canada and Quebec. Basketball, with well-known star Michael Jordan, came third. Every school has a basketball team, and young people play basketball on every street.

In second place, ahead of Michael Jackson, came auto sport. Let me tell you, in 21 years as a sports manager, I have never organized a Formula One league. No immediate role model or neighbour practises auto sport, but there is an extremely strong media message that penetrates every home in Canada. Jacques Villeneuve is a real magnet for young persons. On his helmet you can read that Rothmans' is a good smoke.

Some steps have already been taken to fight smoking. Personally, and because I am all for athleticism, I like what the Australians have done. They have led a counterattack by introducing the Quit program, which I find very interesting. Imagine Jacques Villeneuve saying, "Milk tastes better,'' or "Milk is a great drink,'' that would be a big step forward. And, if I had enough money to convince Céline Dion to say that people should stop smoking, that would do a pretty good job of competing with Jacques Villeneuve.

There are other example of steps that can be taken. I really like the striking boldness of ''in your face'' advertising; it counteracts the Joe Camel image and goes for tobacco executives' jugulars.

Parody is an extremely powerful tool. With only a tiny investment, I can destroy Joe Camel's image and, along with it, the image of companies that spend millions pushing tobacco.

In your kits, you can see an image that looks a lot like a Pokémon card. We simply took a leaf from Pokémon's book and distributed 250,000 of these cards in our region, where they took the place of Pokémon cards. Like Nintendo, Pokémon is a phenomenon. Millions of dollars are invested in cross-marketing, a pervasive selling technique.

As an example, I manufacture cards, create comic strips, produce films for television, take out newspaper advertising, develop video programs: I do everything I can to attract the target audience of young persons. We have paid sociologists and psychologists millions of dollars to learn what really attracts young persons, what ''grabs'' them.

That is what the tobacco industry is doing. The message from educators and physicians is too nice and too health-oriented to attract as many young persons. Millions of Pokémon cards are sold, not because they convey an educational message, but because that seller has pinpointed young persons' awareness and tastes.

We have to attack tobacco sales in a professional manner and stop acting like amateurs. To do that, we need money. We created a multimedia show that combined rock music and theatre. It was shown to 2,000 young university students. The theme, against a background of exciting music, was how cancer developed in a young woman smoker's lungs. In many cases, the message hit home; many professors joined the fight against smoking.

We have weaknesses, but we also have strengths. One of our strengths is the fact that we have permission to go into the schools. Usually, the teachers and the physicians are on our side, and so we can give the message straight to young persons, something tobacco companies envy us. We can enter the educational institutions and deliver an effective message at low cost.

In addition to Australia's Quit program, Florida has a Truth program, and we now have on the drawing board a Libre program. Regardless of a program's name or source, it is vitally important to have a Canadian trademark that will attract people, rally them to the cause, and strike a blow against smoking once and for all.

We created used a great many images, and used humour as well. Quebec residents love a good show and a good laugh. Usually these ideas are effective, but I am still using a pea shooter.

I want to leave you with a statement that I really liked; I heard it at an international conference. It was said, rightly, that smoking is the only epidemic, the only disease, that is sponsored. Do not forget that some people are making a lot of money; they have a stake in having more people start smoking and get sick.

[English]

Senator Kenny: My first question is to Mr. Lépine. Can you tell the committee what the following events have in common and what affect they have on you: Just for Laughs, tennis tournaments, a golf championship, Formula One racing, the jazz festival, and the fireworks competition?

[Translation]

Mr. Lépine: These events allow tobacco companies to make their products appear to be part of normal life and to raise their profile. What do tobacco companies have in common? They strike the imagination; they make something that is not normal appear to be part of normal life; they make smoking prestigious. They have not invested $90 million for no reason. They have communications experts advising them. Although the effects are considered to be aimed at adults, they vividly affect young persons' imaginations.

[English]

Senator Kenny: All of these events take place in Montreal between June and September?

[Translation]

Mr. Lépine: Yes, indeed. People associate vacations with pleasure.

[English]

Senator Kenny: What leverage does this give to tobacco companies in the province of Quebec?

[Translation]

Mr. Lépine: As I said earlier, it allows them to acquire a healthy corporate image. They look like benefactors, people who help us have fun and make our lives more pleasant. They associate sports, culture, and humour with their product, which is tobacco. People then tend to believe that tobacco companies are people who help us make our cities more attractive. Ultimately, all tobacco companies want to do is spread their message. People watch the Benson & Hedges fireworks, but all they remember is the cigarette brand name. Tobacco companies are doing a very good job of buying a corporate image for themselves.

[English]

Senator Kenny: Do these events have any political impact, in your view?

[Translation]

Mr. Lépine: They certainly do. When changes were proposed to the sponsorship for Canada's Grand Prix, a wave of protest swept Quebec, along the lines of, ''Don't touch the sponsorship or the Grand Prix might go elsewhere.'' The tobacco companies were holding a trump card in their hand. Their threats carried a great deal of weight with the event, because their sponsorship remained unchanged.

[English]

Senator Kenny: Dr. Bonham, could you describe to the committee how the volunteers and how the Canadian Cancer Society would be different if Bill S-20 were passed?

Dr. Bonham: I said it in a fairly general way. There has been a lot of what some might call internal strife at our national public issues committee because we have had no opportunity to address any of the other big areas for prevention in the field of cancer. If Bill S-20 were passed, as a voluntary agency we would collaborate with the heart and stroke and lung agencies to develop programs, but that would be at the service level. I am referring to the advocacy level. If the job were getting done, via a variety of measures, we could then pay due attention to other advocacy issues, which I think are terribly important. However, understandably, we are stymied by the enormity of the tobacco issue. It is overwhelming. We cannot just park it over here and say, "It has had a good run for a couple of years; now we will do something else." We cannot do that.

We would find ourselves in more adequately funded, if collaborative, programming, in the many ways that have come out of the session today. As an agency that has formalized, perhaps, a little more than others its advocacy function, we see this as very important to sustain. We are just not able to get around to these other important issues at all.

Senator Kenny: Mr. Tholl, in terms of the funding of the Heart and Stroke Foundation, you commented on other funding, in particular the grant you received from the Province of Ontario for the ad. For the benefit of the committee, could you review once again what you think the Heart and Stroke Foundation could do if it had adequate funding.

Mr. Tholl: To build on Dr. Bonham's comments, the urgent consistently crowds out the important. Just about the time we go to look at other things that are important to cardiovascular health, such as nutrition -- and the Canadian Cancer Society just collaborated with the Heart and Stroke Foundation on a 5- to 10-a-day campaign that was award-winning -- we look back and see these startling statistics. For example, between 1991 and now there has been a 33.3 per cent increase in the number of teenagers smoking. You think you have that under control so that instead of looking at individual risk modification -- tobacco, nutrition, lifestyle and stress -- you can begin to look at the interaction among those risk factors. Therein lies the longer-term answer.

There is increased research done by Dr. Marks at Queen's, and others, which suggests that each one of us has our own internal maximum risk threshold. Part of it is because you choose your parents carefully. Some 50 per cent of cardiovascular disease is still determined by genetic makeup. The other 50 per cent is a complicated risk calculus that each of us has, depending on what we have experienced in our life, such as one of our friends dying earlier than they should have. Somehow, that affects one's risk calculus. Hence, if you reduce risk in one area -- tobacco -- it is like a balloon, it tends to pop out in other areas, such as increased stress and increased weight gain.

How would this bill help us? It would help us to better understand how to modify individual risk factors. It would also allow us to turn our attention to multiple risk factor reduction, which is a complicated but important business that we need to examine.

Dr. Bonham: With regard to the risk issue raised by Dr. Esdaile, I go to France about every second year. I must say that they have converted a high risk to a low risk, or an absolutely safe movement, by converting all their cigarette vending machines to condom dispensers.

Senator Wilson: I am interested in the international dimension you hinted at, Mr. Tholl. You mentioned the fact that there was some consideration, probably in the seminal stages, for a framework for an international tobacco convention. Can you say a little bit more about that?

Mr. Tholl: As I say, Canada took a leadership role. We moved the resolution and it was seconded by Norway. There was a lot of preparatory work prior to this. There is a consensus resolution that we will proceed with a negotiating team toward developing a convention that would apply internationally to things such as warnings on packages, et cetera.

What surprised me a little bit is that amid all this good progress was the resistance to involving non-governmental agencies and organizations in such endeavours. When you start to ask, why would you not want an NGO, such as a world heart association, or a world heart federation, or an umbrella organization at the table, you get funny answers. You get answers like, "Well, if we put you at the table, that would diminish our voice," says the United States, "because we only have one voice, despite all the money we put in."

There are some interesting impediments. That is why I emphasized in our brief the need for early, ongoing and meaningful involvement. Not to involve the NGOs with their 250,000 members is like cutting off the head from the hands and legs. That is the point we tried to make with the Americans in Geneva.

Another legitimate concern is that some of our organizations, not the Heart and Stroke Foundation of Canada or most of the other organizations to whom we relate, continue to take money from the tobacco industry on the pretence that they will be using it for anti-tobacco efforts. It just goes to show you that desperate people in desperate organizations do desperate things when they do not have the money to carry out their mission.

Senator Wilson: Is that under the auspices of the World Health Organization?

Mr. Tholl: Under the World Health Organization, which is Geneva-based.

Senator Wilson: Is it envisaged as other conventions are, where countries sign on to it and then ratify it?

Mr. Tholl: That is correct. It is like the land mines convention.

Senator Wilson: That is why they are afraid of the NGOs.

Senator Adams: Dr. Bonham, you said that about 72 per cent of Inuit smoke cigarettes. At what age do they start? I am over 65 now and I no longer smoke.

Dr. Bonham: That was not too clear, senator. I meant to follow up the source of information to clarify what is meant. It could not be a percentage of the whole population because they do have children below smoking age. Thus, 72 would imply a universality, which I do not think is true.

Someone raised cultural differences. Quite often, in various programs, we have encountered the issue of tobacco use being predominantly a male thing, with smoking rates as high as 90 per cent in some societies, which carries over from immigration into Canada. We have pockets of the same thing. I was in China a while ago. The female smoking rate there is 10 per cent, while the rate for males is 90 per cent. The difference among those who have immigrated to Canada would be very great, too.

Senator Adams: I guess we need more studies in our communities. Many of the young people have nothing to do. The daylight hours may affect the numbers. We now have 24 hours of daylight, while in the winter we only have three or four hours of daylight. Would that have anything to do with the smoking rate? People sit at home and watch TV. They stay at home with nothing to do. They have to have a smoke.

Dr. Bonham: I had a study leave in Finland, which is pretty far north. They have the lowest smoking rates for children that I have encountered. I never saw one child smoking in the time I was there. I did not get into the true north of Finland; but, certainly, they are faced with very long daylight hours and very long night-time hours, depending on the season.

Senator Adams: I am sure it is similar to where we live in the Arctic.

Mr. Bonham: Your first comment may be the more valid one. The organization of activity for children has a lot to do with it. There is a lot of intriguing evidence of physical activation programs being associated with much lower smoking rates and enhanced school performance.

It is one of these win-win situations.

When I was up in Prince George, they actually closed the school down for two afternoons a week. A team of teachers and parents would take the kids out cross-country skiing or whatever. They did not miss the two half-days.

Senator Adams: Every time I go up North, every second week or so, we have a radio bingo every second night. Everyone would like to win $3,000 and they say, "Have another cigarette." It is different from the rest of Canada. Far more people smoke up there. I do not know what causes it. I do hope that we pass Bill S-20 and there will be some help to find the causes.

Meanwhile, you mentioned in your script that the advertising costs about $10 million?

Mr. Tholl: That is right, senator, it would cost about $10 million annually. If it were to go across Canada, about $30 million annually.

Senator Adams: And how can it be programmed? How many minutes would it be shown per hour? There are some commercials that are repeated often during regular shows. How does that system work?

Mr. Tholl: They are rotated. Every other month, it reverts from the Heart and Stroke Foundation to the Canadian Cancer Society. There are two or three similar types of messages, and the messages rotate.

Senator Adams: Do you have a time limit per year for the commercials you show? I would like to know how it works. We have local stations up North.

Mr. Tholl: This is a six-month pilot program only being shown in Ontario. It will be evaluated to determine whether it is having the intended effect. If it does, we will look to see whether it can be broadened in Ontario and see if we can borrow from it and create something similar that could be suitable for use across Canada. Right now, it is an Ontario pilot project.

Senator Adams: Mr. Lépin, your report was very interesting. My French is not very good. Can we have this translated into English?

The Chair: Yes, it will be done soon.

[Translation]

The Chair: Mr. Lépine, thank you very much for being with us this evening. I was very much impressed by your presentation.

[English]

Thank you all for attending here. We have benefited greatly from your testimony. We are grateful to you.

The committee adjourned.