Quebec and the High Cost of Smoking

In the waning light of a brisk October evening in Quebec City, patrons flock to a bar in a yuppie neighbourhood near the Plains of Abraham. Inside, Sarah McLachlan's sensual voice spills out of the sound system. As Quebec's version of happy hour - cinq à sept - gathers momentum, a haze of smoke thickens over the tables. At the bar, Jocelyn Frenette hauls intermittently on a cigarette while chatting with a friend. Frenette, 47, began SMOKING as a 20-year-old. A pack-a-day smoker, he says it's a habit rather than something he particularly enjoys. He quit twice - once for three years and another time for 18 months - but resumed during periods of stress. Even his mother's diagnosis with lung CANCER hasn't dissuaded Frenette, a shipping manager. Nor does he worry about his health. "I've known people who died who had cancer," says Frenette, "and they'd never smoked in their life."

That carefree attitude, still common in Quebec, frustrates the efforts of health officials to make a dent in the highest smoking rate - and lung cancer mortality rate - among all the provinces. Data prepared by Statistics Canada and the Canadian Institute for Health Information for this edition of the Maclean's Health Report show the Quebec City region's overall death rate for cancer in 1996 as the highest among 17 major communities. The region around the Quebec capital stands out for its dismal lung and colorectal cancer death rates - and mortality rates among its men. Its males expire from cancer at higher rates than anywhere else. Specifically their death rate from lung cancer, at 95.1 per 100,000 population, compares with a national number of 67.5. Second worst are Montreal's men, dying of lung cancer at a rate of 81.5 per 100,000.

While not the nation's worst, the cancer mortality rates for women in the two Quebec regions are above average. And Montrealers in general fare only slightly better than Quebec City residents, posting the fourth-highest overall cancer death rates. The disturbing statistics come as no surprise to provincial health officials. Last year, Quebec's health ministry published a strategy document showing that as early as 1991, the province's cancer mortality rate was the highest in Canada and above that in 15 other industrialized countries. And a Statistics Canada study released last year showed Quebec men had the leading cancer death rate among the provinces between 1991 to 1993, largely attributed to lung cancer.

Unlike many jurisdictions where smokers have been chased out of public places, Quebecers still practise the habit without shame. Cigarette smoke is hard to avoid in shopping malls, cafés, many offices and occasionally even on the escalators leading out of Montreal's smoke-free metro system. But, finally, life is about to get more difficult for Quebec's puffers. Regulations that take effect in December will restrict smoking in public places and the workplace. The law's passage last year closely followed the government's announcement of a new plan for a more co-ordinated fight against cancer.

In the suburban grey stone building that houses Quebec City's public health department, Dr. Guy Roy cautions against reading too much into annual mortality rates that will fluctuate from year to year. Still, the department co-ordinator concedes that cancer rates are a challenge for the region - and the province. "The problem," says Roy, "is essentially one of smoking." At Quebec's ministry of health, Dr. Luc Deschênes, director general of medical and university affairs, puts the problem in perspective. If lung cancer is eliminated from Quebec's numbers, he says, "the mortality rate for the other types of cancers is about the same as the rest of Canada." Roy notes that the province is now seeing the toll from smoking habits dating back 15 to 30 years. Health officials attribute at least 85 per cent of lung cancer cases and roughly 30 per cent of all cancer deaths to smoking. Tobacco use is also linked to an estimated 30 per cent of cardiac deaths and other respiratory deaths. That statistical trail leads straight to Quebec City and Montreal, which also posted the two highest death rates for bronchitis, emphysema and asthma in the Maclean's survey.

Among Canadians, Quebecers' attachment to smoking is rivalled only in some Atlantic provinces. Quebec and Prince Edward Island lead the pack with the greatest percentage of smokers - 32 per cent of the population aged 12 and over - followed closely by Newfoundland and Nova Scotia. (New Brunswick matches the national average with 28 per cent of its population considered smokers.) Among Quebec health advocates, theories about the causes of the high rate abound. Some touch on cultural characteristics ranging from Quebecers' Latin nature to a view of smoking as more of a recreational activity. Some note that three out of Canada's four tobacco companies are based in the province. Anti-smoking activist Louis Gauvin says one study shows far more francophones across Canada smoke than their anglophone counterparts: on average 36 per cent compared with 26 per cent. "Francophones start to smoke younger, they smoke more cigarettes in a day and they smoke stronger, more damaging cigarettes," says Gauvin, adding that more research is needed to understand why.

Smokers like Frenette say they encounter little opposition from non-smokers. A hitchhiker recently nixed his offer for a ride upon discovering he smoked, he says, but no one has ever asked him to butt out. "Non-smokers used to be smokers," says Frenette matter-of-factly. "There's still tolerance." And, in fact, Maclean's annual year-end polls consistently rank Quebecers as the most tolerant Canadians, willing to accept behaviour in others even if they disapprove of it in themselves. Dr. Mary Delafield, a Quebec City family physician and the medical director of Laval Hospital's smoking cessation clinic, believes attitudes among Quebec's non-smokers differ sharply from elsewhere in North America. "People tend to still regard smoking here more as a right," says Delafield. "The non-smoker's rights are beginning to take precedence, but it's slow. We're 10 years behind British Columbia and California."

One cancer advocacy group says prevention messages often fall on deaf ears. "Quebecers don't really listen," says Nicole Mireault, spokesman for the Quebec branch of the Canadian Cancer Society. "The mentality among smokers is, 'We all have to die someday.' " But others say the problem is that any attempts to address the smoking issue so far have been ineffective. "Restaurants will tell you they have a no-smoking section," says Dr. Richard Margolese, director of oncology at Montreal's Jewish General Hospital and professor of surgery at McGill University. "But that just means that table A is non-smoking. Table B is smoking."

Anti-smoking advocates find comfort in the new legislation, which provides fines for smoking in the workplace or public areas, and restricts tobacco company sponsorship of sporting and cultural events. Dr. Marcel Boulanger, president of a provincial smoking prevention group, is impressed by the cultural change that the law represents. "It wasn't that long ago that Quebec had a premier who was a veritable chimney," says Boulanger, referring to the late René Lévesque, a chain-smoker whose Parti Québécois government was in power from 1976 to 1985. "Now, we have a national assembly that votes unanimously in favour of a law that could almost be considered avant-garde. It just goes to show how far we've come."

There's still a lot of ground to cover. Roy and his colleagues in Quebec City lament the sharp increase across the country this decade in smoking among the young, especially among girls. Preventing young people from taking up the habit, says Roy, is "the No. 1 challenge in public health." In her family practice in Quebec City, Delafield bemoans the number of young women smokers among her patients. "So many of them say, 'I don't smoke very much, only half a pack a day,' " says Delafield. "They just seem to deny the importance of it. I find that discouraging and I don't see it changing."

But while lung cancer draws the bulk of attention over cancer mortality rates, Quebec has other challenges as well. Colorectal cancer appears to be a problem - Quebec City, followed by Montreal, posted the highest death rates from that cause in the 17 communities. While there is no definitive explanation, genetics and dietary factors may play a role, according to the doctors at Quebec City's public health department. While Quebecers' diet historically has been rich in animal fat, Roy maintains that eating habits have improved. "Fortunately, it's less bad," says Roy with a laugh. "But it's obvious there are still gains to be made on that level."

Quebec, meanwhile, has taken its own unique approach to the disease. While other provinces have dedicated resources specifically to a cancer program, Quebec has integrated cancer within its total health-care program. "I guess the jury is out on which is the better approach," says Dr. Barbara Whylie, director of medical affairs and cancer control with the National Cancer Institute of Canada and the Canadian Cancer Society. The province lagged behind others by several years in setting up a formal breast cancer screening program only last June. While insisting that Quebecers receive very good cancer treatment, Deschênes concedes cancer control starts with the promotion of good health habits. "And this," he says, "is probably lacking in our province." But Quebec is already implementing a new approach to cancer, beefing up facilities in communities and building a team approach to the disease - from cancer prevention right through to palliative care.

Even as that strategy goes into effect, Quebec faces a serious crunch on the treatment front. In June, it began sending patients to the United States for radiation therapy because of bloated waiting lists due to staff and equipment shortages. The situation isn't improving, according to Dr. Carolyn Freeman, chief of radio-oncology at the McGill University Health Centre. "There are hundreds of patients waiting between four and eight weeks and these are patients that should not be waiting," laments Freeman. A wait of six to eight weeks for patients with brain tumors, lymphomas, and head and neck cancers is "not that uncommon," she says. "I think the situation is very critical."

While that treatment conundrum drags on, other health officials will focus their efforts on lung cancer and smoking. Some people have gotten the message. At the Quebec City bar, retired justice of the peace Denis Demers, 56, stands near a few smokers but abstains. He vividly remembers how gruelling it was to quit his three-pack-a-day smoking habit in the mid-1980s. "I was aggressive, I ate a lot," says Demers, who searched in vain for medical help to get through the process. Recently, while at a doctor's office, he noticed a poster offering help to smokers wanting to quit. "I thought it was good that doctors or hospitals can help those who want to stop," he says. But for health officials eager to slash cancer deaths, reaching smokers disinclined to butt out is the more daunting challenge.

Lethal Cancer

Deaths from all types of cancer, per 100,000 population in health regions in 1996. (In all cases except Toronto, health regions referred to in this report include areas outside the city.)

1. Quebec City 225.4

2. Halifax 223.1

3. Sudbury 220.9

4. Montreal 218.5

5. Winnipeg 205.7

6. St. John's 205.5

7. Hamilton 202.5

- CANADA 199.6

8. London 199.1

9. Ottawa 189.4

10. Fredericton 187.6

11. Regina 187.3

12. Calgary 187

13. Edmonton 186.5

14. Toronto 180.4

15. Victoria 180.4

16. Saskatoon 176.1

17. Vancouver 161.2

Source: Statistics Canada

Maclean's October 25, 1999