Today, tobacco smoking remains the leading preventable cause of death and disease worldwide. Smoking kills half of its regular users, and, for those whom it doesn’t kill, it robs them of a decade of their life on average. In light of the well-documented negative effects, many countries are campaigning to reduce the use of tobacco, and the University of Waterloo’s own Professor Geoffrey Fong is playing a key part in supporting them. I sat down with Professor Fong to talk about his work: what he does, how he got here, and why he continues to do it.
Who is Geoffrey Fong?
Fong is a professor of Psychology and Public Health Sciences at the University of Waterloo. He is also a senior investigator at the Ontario Institute for Cancer Research. Fong is also the founder of the International Tobacco Control Policy Evaluation Project (the ITC Project), where he currently conducts most of his research.
Over the course of his career, Fong has received a number of honours. Among many others, Fong was elected as a Fellow of the Canadian Academy of Health Sciences in 2015, he was awarded the 2019 Medal of Honour from the Health Research Foundation (whose first recipient in 1945 was Sir Alexander Fleming, the discoverer of penicillin). Fong and two ITC colleagues at Waterloo (Professors David Hammond and Mary Thompson) received the 2021 Governor General’s Innovation Award. Most recently, in December 2021, Fong was appointed as an Officer of the Order of Canada.
Through it all, Fong told me that the success of the ITC Project over the past 20 years has only been possible through the dedication and cooperation of the ITC research team of over 150 experts across 31 counties, whose research collectively covers over half of the world’s population and over two-thirds of the world’s tobacco users.
The designations may paint a picture of a stuffy, serious scholar, but Fong was quite the opposite in our conversation. Bright and vibrant, he’s able to discuss his work in detail without being bogged down by technical jargon. He smiles often as he speaks. At one point, he brought out a cigarette package he had on hand to show me the graphic warning labels Canada currently uses. The overall impression was that of a man who is truly passionate about his work.
Getting the Ball Rolling
Two decades of research with the ITC Project marks the recent history of Fong’s work, but he’s been collecting information about public health for even longer. At an earlier project, when he was a professor at Princeton University, Fong conducted research into the effects of varying approaches to sex education on the rate of sexually transmitted infections among youth.
The research was timely, as the US had passed a bill mandating abstinence-only models of sex education shortly before Fong and his team published their findings regarding abstinence education in the Journal of the American Medical Association—at the time, one of the first scientific inquiries into the efficacy of that approach.
Fong was struck by the US government’s politically driven pursuit of an abstinence-only approach in the absence of evidence. “I was appalled by the fact that they were spending all this money—430 million US dollars—on a program without any evidence one way or another.” Fong says of his response to the bill. “It just didn’t make any sense to me.”
As you may not be surprised to hear, governments have continued to make far-reaching decisions without sufficient scientific justification since then. The next time Fong encountered such a case, it would grab his attention forcefully enough to compel him to build a career on it.
Picking Up Smoking
That encounter came the next year, in 1999, when Roy Cameron, a faculty colleague in Health Studies, told Fong about Canada’s impending decision to implement graphic warning labels on cigarette packaging.
“Roy says to me during lunch, ‘Canada is going to be putting these new warning labels on cigarette packs’ and I said ‘oh, what do they look like’. And he showed me the mock-ups of these extraordinary packages.” Fong told me. “I was shocked because, as a social psychologist, I’ve learned about fear appeals in graduate school, and here it is staring me in the face, and these are going to be introduced to all of Canada. And I said, ‘This is incredible. We need to find out if these graphic warnings work.’”
From there, Fong’s interest in studying the effectiveness of tobacco control policies was born, beginning with examining the effects of graphic health warnings on packaging. Fong received a literature review from Cameron that day containing 47 articles on the subject, reading through them all that same night. What he came to see was that there was a lack of critical research into the effectiveness of these policies. Aside from one study conducted in Australia, there had been no widespread scientific examination of how warning labels affected populations.
What was needed—and still is—Fong explained to me, was a broad-reaching inquiry into the way that individuals are affected by policies. “You’ve got to start from the people who are actually doing the behaviour—in this case, the people who are living and dying of smoking.” Fong said of his approach. “If policies work, they work because, ultimately, they are changing the behaviour of individuals. So to get at evaluating policies, you have to start with individuals. That was the beginning of the ITC Project.”
Using his background in social psychology, Fong was able to create a research program using a survey that was built to understand the behaviour of tobacco users at the individual level, including features that would allow it to rigorously evaluate tobacco control policies. This would become the ITC Project’s main tool for collecting information: the longitudinal cohort survey. These surveys are able to measure and track changes in beliefs, attitudes, and reported behaviours relating to tobacco use over time.
The Difficulties of Wrangling Cats Internationally
The work of the ITC Project is not without its challenges. While Fong and his collaborators continue to demonstrate the effectiveness of various tobacco control policies, many countries are still failing to implement them. Even more frustrating is the fact that many of those abstainers are among the 181 countries currently party to the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), an international treaty whose members have pledged to implement policies designed to reduce both supply and demand for tobacco. The FCTC calls for policies such as graphic warnings on packaging, banning smoking in key public places, significantly increasing tobacco taxes, banning tobacco marketing, and supporting cessation. Despite a landmark article led by the ITC Project and WHO collaborators showing that implementation of the treaty’s policies results in very strong reductions in smoking rates, very few countries have enacted even half of them.
The hesitation, Fong believes, is caused by a variety of factors. “Part of it has to do with tobacco industry influence,” Fong told me, “but part of it is just structural. There are few resources for tobacco control in most countries, especially low- and middle-income countries, and you really need resources. If you’re doing a smoke free law, you’ve got to have enforcement. If you’re doing product regulation—like the menthol bans that Canada has—you’ve got to be able to test tobacco products. It takes a lot of money to implement and enforce policies.”
The infrastructure to support tobacco control, then, is not immaterial. The money that has to be fronted to enforce these policies can be an unattractive or even impossible proposition for many governments. Even so, the money that these governments are spending through inaction is even greater. While costly initially, countries that act against tobacco smoking actually stand to recoup money over time, as they curb the tremendous losses smoking incurs in increased healthcare and lost productivity—not to mention regaining the value of the millions of human lives which stand to be extended or outright saved by reduced tobacco smoking.
Optimisms in an Emergency
Uptake of tobacco control legislation may be lagging, but Professor Fong remains hopeful for the future. “The science talks,” he told me, “and governments are listening, and courts are listening.”
And it seems to be true. The ITC Project has created a virtuous cycle whereby evidence supporting the effectiveness of tobacco control policies motivates countries to implement them, which in turn provides even more evidence of their effectiveness to help sway countries who are still on the fence.
One such landmark case was that of Ireland, which went smoke-free in 2004 and saw dramatic reductions in overall tobacco usage. Smoking in pubs plummeted from 97 to 5 per cent, with declines in other settings like restaurants and workplaces occurring as well. Furthermore, Fong and his team’s research suggests that the decrease in public smoking did not result in a corresponding increase of smoking in the home.
The ITC Project was careful to document these effects, surveying the population of Ireland before and after the legislation was enacted. Fong was invited to present the ITC findings at a 2005 meeting involving a number of European health ministers and parliamentarians. The result was that several other countries throughout Europe and the world implemented their own smoke-free policies over the next few years, all of which resulted in declines of second-hand smoke in key public areas.
The impact of the Irish precedent was even felt right here, in Canada, when Alberta enacted a similar smoke free law a few years later. Professor Fong was invited to present the ITC Project’s findings in an Edmonton meeting, after which the Health Minister of Alberta told him that the data was “exactly the evidence [they] need” to move forward with similar legislation.
Wisdom
The fight against tobacco use continues and will likely stretch into future generations. Among the pantheon of global issues which students will go on to address after their education, from climate change to inequality to growing political dissension, it seems that tobacco control will be a prominent member. To this end, I asked Professor Fong’s advice for students at the University of Waterloo.
His response was simple: “Get involved in what professors and researchers at Waterloo actually do. University is not just harder high school. There are so many extraordinary opportunities to get involved in cutting-edge research in so many fields. In my case, my early involvement in psychology research as an undergraduate shaped the rest of my life.”
To Professor Fong, getting started is not something resigned to the distant future. Whatever you’re passionate about, beginning to make a difference and finding your way is as easy as looking around at where you are now, at what you have now, and always remaining open to the future it might make for you.
