For years, we have been gradually tightening the noose on smokers with public-health measures, such as restricting smoking in the workplace, hiking tobacco taxes, introducing graphic warnings on cigarette packages, ending tobacco-company sponsorship of sporting and artistic events, outlawing advertising, eliminating flavoured products that target children, banishing tobacco products from pharmacies and hiding them out of sight in corner stores, and banning smoking in bars, restaurants, patios, parks, beaches and so on.
These measures have been relatively effective. Since 1980, Canada has cut the percentage of women and men who smoke by half. But progress has been slow and gradual.
There are still about 4.7 million regular smokers, or 16 per cent of adults in Canada. More than 40,000 Canadians die annually of tobacco-related illnesses, principally cancer, cardiovascular disease and chronic obstructive pulmonary disease (COPD).
Tobacco remains a legal product, one that is widely used and quite profitable, despite the fact that it is lethal.
Are we going to content ourselves with quietly encouraging smokers to quit and passively hoping young people will not begin smoking and expecting that the problem will resolve itself somehow, some day in the distant future?
Or are we going to set hard targets for the elimination of tobacco?
After decades of short-term, largely local measures, it's time to embrace some bold national initiatives.
The endgame needs to be clear: To eradicate the use of tobacco products and the diseases they cause in the near future. That means there needs to be a hard deadline, say, 2025 for Canada, and 2040 for the rest of the world. (Most countries define being "tobacco-free" as having fewer than 5 per cent of adults who smoke.)
So how do you get there? There are a number of possible strategies.
Prohibition: Tobacco is a toxic addictive substance with little or no redeeming value that creates a great health and economic burden. Banning it outright would be justifiable but probably ineffective. We have to bear in mind, too, that governments have both tolerated and profited from tobacco for a long time, and punishing nicotine addicts would be cruel.
Tobacco-free generation: There is a proposal in Singapore for a line-in-the-sand approach – to bar anyone born after 2000 from buying or consuming tobacco products, with the aim of gradually phasing out its sale and use. A novel idea, but probably difficult to enforce in most countries.
Shrinking supply: You take a base year of tobacco sales, and then reduce supply by 10 per cent a year and, in a decade, there is no more tobacco sold. New Zealand is taking this tack, but it can only work in a country that is relatively isolated and can strictly control imports.
A regulated market: Make the government solely responsible for the marketing and distribution of tobacco (similar to the LCBO monopoly over alcohol in Ontario) then gradually choke off supply. A number of countries have state-run tobacco production and sales – notably China, home to one-third of the world's smokers – but they have little incentive to reduce sales sharply.
Prescription-only tobacco: Make tobacco a controlled substance and limit access to those with an addiction. With this approach, you limit access to new smokers, but don't punish long-time smokers. However, there likely would be a vigorous black market, as there is for other prescription drugs.
Nicotine-reduction legislation: Strictly regulate the amount of nicotine in cigarettes, and force manufacturers to reduce it over time, so that smokers are tapered off their addiction, and tobacco becomes less addictive. The U.S. Food and Drug Administration is considering this approach.
Ultimately, the solution likely will be a combination of some of these measures as well as the more traditional public-health and harm-reduction approaches.
There also needs to be much more serious effort invested in smoking cessation, in helping people who want to quit (which is most) actually quit.
And, of course, there will be new challenges that crop up along the way, like e-cigarettes. They create a conundrum because they have the potential to eliminate the most damaging aspect of smoking (the smoke and other byproducts of combustion are what cause disease and death, not nicotine), but can also undermine anti-smoking efforts by normalizing the act of smoking (or vaping) anew.
With 1.2 billion smokers worldwide, and more than five million smoking-related deaths a year, we cannot underestimate the challenge.
Traditional, cautious tobacco-control measures will take forever to have a lasting impact, and deaths will pile up by the millions.
The carnage inflicted by smoking has gone on far too long. Surely, the time for half measures has passed. Some urgency is in order in the quest for a tobacco-free world.