titis B vaccination programs for intravenous drug users and people who have recently contracted a sexually transmitted disease (two groups considered at high risk for hepatitis B) have shown poor acceptance of and - in those who do accept - low compliance with the proposed vaccination schedule.2 Therefore, we maintain our that universal vaccinaconclusion [The CPS responds.] tion is the best way to control Although we agree with Dr. Cim- hepatitis B in Canada. olai that the epidemiologic data concerning hepatitis B in Canada Victor Marchessault, MD, FRCPC vice-president are limited and that further Executive Canadian Paediatric Society studies should be carried out, we Ottawa, Ont. believe that there is sufficient evidence to support our recommen- References dation of universal vaccination. First, there has clearly not 1. Alter MJ, Hadler SC, Margolis HS et al: The changing epidemiology of hepatitis been any noticeable decrease in B in the United States: need for alternathe reported rates of hepatitis B in tive vaccination strategies. JAMA 1990; Canada since the licensure of an 263: 1218-1222 effective vaccine. If the recom- 2. Successful strategies in adult immunization. MMWR 1991; 40: 700-712 mended strategy of vaccine use had been effective we would have expected a major decrease. Second, in the sentinel county surveillance study carried out in Catch them young the United States a major impact of vaccine use on the incidence of In "Education, not prohibition, is the way to stop people acute hepatitis B was observed from smoking" (Can Med workers.' only in health care J 1992; 146: 248, 250) Dr. Assoc the Where it has been studied, Napke criticized recent Edward epidemiologic features of hepatitis in the fight to reduce the activities B in Canada are similar to those of tobacco-caused illness epidemic in the United States. FurtherEvidently, he was one in Canada. more, patterns of vaccine use in the two countries have been sim- of the pioneers in the movement ilar (most of the vaccine has been to establish effective bylaws in Murray D. Krahn, MD, MSc, FRCPC given to health care workers). Ottawa to protect the public from Division of Clinical Decision Making Therefore, it can be expected that environmental tobacco smoke. Department of Medicine use has had little impact Because of his excellent work and vaccine Tufts University School of Medicine on the incidence of disease in our that of others Ottawa has some of Boston, Mass. the most progressive municipal Allan S. Detsky,MMD, PhD, FRCPC country. Director legislation in North America. with all of patients Third, Division of General Internal Medicine There are two aspects of the acute hepatitis B seen in the Monand Clinical Epidemiology tobacco problem that governtreal area in 1990 one-third had The Toronto Hospital a legitimate interest have ments Toronto, Ont. no known risk factors for acquisithe public from the in: protecting simtion of the infection. This is of tobacco smoke chemicals toxic References in made ilar to the observation from bechildren and preventing the US sentinel county study.' 1. Centers for Disease Control: Hepatitis These patients cannot be reached coming dependent on one of the Surveillance Report No. Si, US Dept of addictive and dangerous Health and Human Services, Atlanta, by a selective vaccination strategy. most known.' I find it very substances hepaof studies pilot Fourth, 1987
grants who have come from areas where hepatitis B is endemic. Given the wide geographic variation in disease incidence Cimolai's suggestion of regional programs seems interesting and worth exploring. However, Canada's adoption of a universal program does not preclude further research to determine if the program is worth while. With respect to Cimolai's second argument, our analysis, to be published in Medical Decision Making (in press), is not a hymn to the virtues of universal vaccination; rather, it is a critical appraisal of all the potential costs and benefits of such a program. We consider, of course, the ancillary costs of vaccination, such as the cost of administering the vaccine, of concomitant screening programs and of performing follow-up serologic studies (in infants born to carriers only) etc. To reiterate our conclusions, a universal vaccination strategy appears to be comparable in economic attractiveness to existing health care interventions, with two provisos: the cost of the vaccine must be reduced, and the long-term effectiveness of the vaccine must be demonstrated. If the cost remains high, and especially if booster doses are required for the maintenance of long-term immunity, the economic attractiveness of universal vaccination will be substantially decreased.
16
CAN MED ASSOC J 1992; 147 (1)
2. Hepatitis B in Canada: surveillance summary, 1980-1989. Can Dis Wkly Rep 1991; 17: 166-171 3. Alter MJ, Mares A, Hadler SC et al: The effect of underreporting on the apparent incidence and epidemiology of acute viral hepatitis. Am J Epidemiol 1987; 125: 133-139 4. Alter MJ, Hadler SC, Margolis HS et al: The changing epidemiology of hepatitis B in the United States: need for alternative vaccination strategies. JAMA 1990; 263: 1218-1222
LE ter JUILLET 1992
curious that Napke readily embraces the former and completely rejects the latter. He seems to believe that education is insufficient to persuade tobacco addicts not to subject those around them to dangerous chemicals but sufficient to prevent children from starting to smoke. I know of no one in Canada who advocates the prohibition of tobacco use. In a country of at least 5 million addicts2 this wquld be ineffective and cruel. It is not correct to equate tax increases with prohibition. The reason that tax increases are advocated by those of us in the pro-health field is that price increases are very effective at preventing children from starting to smoke:3 it has been estimated that for every 10% increase in tobacco prices there is a 14% decrease in the number of teenagers who smoke.4 Children are sensitive to price increases, and many will choose to spend their money on other things when the price of cigarettes goes up. Napke is correct when he points to the great success in protecting the public from environmental tobacco smoke. Most of us can now live our lives free of tobacco smoke, provided that we stay out of restaurants and bars. However, Napke is badly misinformed on the issue of Canada becoming a smoke-free society. The tragedy of tobacco-caused disease will be with us for some time to come. Children are starting to smoke at frighteningly high rates. A study by the Nova Scotia Council on Smoking and Health found that 25% of 15-year-old female students were smoking every day, along with 22% of male students.5 It is naive to believe that this situation can be changed solely through education. Since the mid-60s children have been inundated with information on the harmful effects of smoking. The survey in Nova Scotia found that most teenagers were well aware of JULY 1, 1992
the health effects of smoking, but this did nothing to prevent them from starting.5 Many experts in the field concede that there are serious limits to what education alone can accomplish.6 Retired physicians speaking to teenaged students about the dangers of smoking are highly unlikely to have much of an impact. Napke also seems to believe that the current federal legislation banning tobacco advertising should be abandoned in favour of an extensive countercampaign advertising the harmful effects of tobacco. Before the ban the tobacco industry spent about $100 million annually on advertising.7 I am curious to know where Napke thinks we will get the money to produce the truthful advertisements. One interesting funding source would be a dedicated tax on tobacco to go directly to counteradvertising.8 The promotion of a lifestyle and the subtle use of body image in the death industry's advertisements (especially those directed at women) may be more effective at promoting smoking than are dying people at
discouraging smoking. The increase in tobacco smuggling is certainly a concern, but the appropriate way to manage this is to tax tobacco products on the way out of Canada (since the vast majority end up back here anyway) and to convince our US friends of the public health advantages of tobacco tax increases. A critical component of smoking-prevention campaigns is effective legislation to prevent the sale of tobacco to minors. The Tobacco Restraint Act (1 908)9 is nothing more than a farce. Other important activities in the fight to prevent children from smoking are generic packaging and prominent, truthful health warnings. These eliminate the attractiveness of the packages and prevent the manufacturers from using packaging as a marketing tool.
The war on tobacco will be won by preventing children from starting to smoke while allowing adult addicts to continue to use tobacco in settings in which they are not imposing smoke on others. As in most areas of public health, education is useful but rarely successful by itself in causing major changes in behaviour. Mark C. Taylor, MD, FRCSC President Physicians for a Smoke-Free Canada Ottawa, Ont.
References 1. Benowitz NL: Pharmacologic aspects of cigarette smoking and nicotine addiction. N Engl J Med 1988; 319: 13181330 2. Millar WJ: The Smoking Behaviour of Canadians - 1986, Dept of National Health and Welfare, Ottawa, 1988: 2 3. Ferrence RG, Garcia JM, Sykora K et al: Effects of Pricing on Cigarette Use Among Teenagers and Adults in Canada, 1980-1989, Addiction Research Foundation, Toronto, 1991: 6 4. Lewit EM, Coate D: The potential for using excise taxes to reduce smoking. JHealthEcon 1982; 1: 121-145 5. Freeman A, Mills T, Purcell J et al: The 1990 Nova Scotia Council on Smoking and Health Survey, NS Min of Health, Halifax, 1991: 7 6. Kozlowski LT, Coambs RB, Ferrence RG et al: Preventing smoking and other drug use: let the buyers beware and the interventions be apt. Can J Public Health 1989; 80: 452-456 7. Sutter S: Tobacco ad ban goes up in smoke. Marketing 1991; Aug 5: 21 8. Warner KE: Selling Smoke: Cigarette Advertising and Public Health (APHA Public Health Policy ser), Am Public Health Assoc, Washington, 1986: 93-95 9. Tobacco Restraint Act, RSO 1908, c T-9, s 1
[The author responds.] My thanks to Dr. Taylor for his contribution toward combatting this legalized, lethal addiction. Excessive taxation on any product is a form of prohibition and - whenA that product is as addictive as cigarettes - may create the setting for crime, including violence.
The Ottawa police have noticed an alarming increase over the past year in the proportion of CAN MED ASSOC J 1992; 147 (1)
17
grants who have come from areas where hepatitis B is endemic. Given the wide geographic variation in disease incidence Cimolai's suggestion of regional programs seems interesting and worth exploring. However, Canada's adoption of a universal program does not preclude further research to determine if the program is worth while. With respect to Cimolai's second argument, our analysis, to be published in Medical Decision Making (in press), is not a hymn to the virtues of universal vaccination; rather, it is a critical appraisal of all the potential costs and benefits of such a program. We consider, of course, the ancillary costs of vaccination, such as the cost of administering the vaccine, of concomitant screening programs and of performing follow-up serologic studies (in infants born to carriers only) etc. To reiterate our conclusions, a universal vaccination strategy appears to be comparable in economic attractiveness to existing health care interventions, with two provisos: the cost of the vaccine must be reduced, and the long-term effectiveness of the vaccine must be demonstrated. If the cost remains high, and especially if booster doses are required for the maintenance of long-term immunity, the economic attractiveness of universal vaccination will be substantially decreased.
16
CAN MED ASSOC J 1992; 147 (1)
2. Hepatitis B in Canada: surveillance summary, 1980-1989. Can Dis Wkly Rep 1991; 17: 166-171 3. Alter MJ, Mares A, Hadler SC et al: The effect of underreporting on the apparent incidence and epidemiology of acute viral hepatitis. Am J Epidemiol 1987; 125: 133-139 4. Alter MJ, Hadler SC, Margolis HS et al: The changing epidemiology of hepatitis B in the United States: need for alternative vaccination strategies. JAMA 1990; 263: 1218-1222
LE ter JUILLET 1992
curious that Napke readily embraces the former and completely rejects the latter. He seems to believe that education is insufficient to persuade tobacco addicts not to subject those around them to dangerous chemicals but sufficient to prevent children from starting to smoke. I know of no one in Canada who advocates the prohibition of tobacco use. In a country of at least 5 million addicts2 this wquld be ineffective and cruel. It is not correct to equate tax increases with prohibition. The reason that tax increases are advocated by those of us in the pro-health field is that price increases are very effective at preventing children from starting to smoke:3 it has been estimated that for every 10% increase in tobacco prices there is a 14% decrease in the number of teenagers who smoke.4 Children are sensitive to price increases, and many will choose to spend their money on other things when the price of cigarettes goes up. Napke is correct when he points to the great success in protecting the public from environmental tobacco smoke. Most of us can now live our lives free of tobacco smoke, provided that we stay out of restaurants and bars. However, Napke is badly misinformed on the issue of Canada becoming a smoke-free society. The tragedy of tobacco-caused disease will be with us for some time to come. Children are starting to smoke at frighteningly high rates. A study by the Nova Scotia Council on Smoking and Health found that 25% of 15-year-old female students were smoking every day, along with 22% of male students.5 It is naive to believe that this situation can be changed solely through education. Since the mid-60s children have been inundated with information on the harmful effects of smoking. The survey in Nova Scotia found that most teenagers were well aware of JULY 1, 1992
the health effects of smoking, but this did nothing to prevent them from starting.5 Many experts in the field concede that there are serious limits to what education alone can accomplish.6 Retired physicians speaking to teenaged students about the dangers of smoking are highly unlikely to have much of an impact. Napke also seems to believe that the current federal legislation banning tobacco advertising should be abandoned in favour of an extensive countercampaign advertising the harmful effects of tobacco. Before the ban the tobacco industry spent about $100 million annually on advertising.7 I am curious to know where Napke thinks we will get the money to produce the truthful advertisements. One interesting funding source would be a dedicated tax on tobacco to go directly to counteradvertising.8 The promotion of a lifestyle and the subtle use of body image in the death industry's advertisements (especially those directed at women) may be more effective at promoting smoking than are dying people at
discouraging smoking. The increase in tobacco smuggling is certainly a concern, but the appropriate way to manage this is to tax tobacco products on the way out of Canada (since the vast majority end up back here anyway) and to convince our US friends of the public health advantages of tobacco tax increases. A critical component of smoking-prevention campaigns is effective legislation to prevent the sale of tobacco to minors. The Tobacco Restraint Act (1 908)9 is nothing more than a farce. Other important activities in the fight to prevent children from smoking are generic packaging and prominent, truthful health warnings. These eliminate the attractiveness of the packages and prevent the manufacturers from using packaging as a marketing tool.
The war on tobacco will be won by preventing children from starting to smoke while allowing adult addicts to continue to use tobacco in settings in which they are not imposing smoke on others. As in most areas of public health, education is useful but rarely successful by itself in causing major changes in behaviour. Mark C. Taylor, MD, FRCSC President Physicians for a Smoke-Free Canada Ottawa, Ont.
References 1. Benowitz NL: Pharmacologic aspects of cigarette smoking and nicotine addiction. N Engl J Med 1988; 319: 13181330 2. Millar WJ: The Smoking Behaviour of Canadians - 1986, Dept of National Health and Welfare, Ottawa, 1988: 2 3. Ferrence RG, Garcia JM, Sykora K et al: Effects of Pricing on Cigarette Use Among Teenagers and Adults in Canada, 1980-1989, Addiction Research Foundation, Toronto, 1991: 6 4. Lewit EM, Coate D: The potential for using excise taxes to reduce smoking. JHealthEcon 1982; 1: 121-145 5. Freeman A, Mills T, Purcell J et al: The 1990 Nova Scotia Council on Smoking and Health Survey, NS Min of Health, Halifax, 1991: 7 6. Kozlowski LT, Coambs RB, Ferrence RG et al: Preventing smoking and other drug use: let the buyers beware and the interventions be apt. Can J Public Health 1989; 80: 452-456 7. Sutter S: Tobacco ad ban goes up in smoke. Marketing 1991; Aug 5: 21 8. Warner KE: Selling Smoke: Cigarette Advertising and Public Health (APHA Public Health Policy ser), Am Public Health Assoc, Washington, 1986: 93-95 9. Tobacco Restraint Act, RSO 1908, c T-9, s 1
[The author responds.] My thanks to Dr. Taylor for his contribution toward combatting this legalized, lethal addiction. Excessive taxation on any product is a form of prohibition and - whenA that product is as addictive as cigarettes - may create the setting for crime, including violence.
The Ottawa police have noticed an alarming increase over the past year in the proportion of CAN MED ASSOC J 1992; 147 (1)
17
