GHEI Module 4C: Fundamentals of Public Health Practice Charles Gardner, MD, CCFP, MHSc, FRCPC Medical Officer of Health, Simcoe Muskoka District Health Unit September 3, 2013

Acknowledgement Dr. Liane Macdonald, BA MD MSc(PH) FRCPC Dr. Natalie Bocking, MD MIPH CCFP

Objectives:   Understand health promotion approaches to public health practice Understand the difference between primary, secondary and tertiary prevention strategies Become familiar with the current challenges and opportunities for global tobacco control efforts, drawing upon the history of tobacco control in Canada and Ontario, with reflections on transferable lessons regarding other health hazards.

Health Promotion Health: “A state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity.” (WHO 1948) Health for all: “The attainment by all the people of the world of a level of health that will permit them to lead a socially and economically productive life.” (WHO 1984) Health promotion: “The process of enabling people to increase control over their health and its determinants, and thereby improve their health.” (Ottawa Charter 1986) World Health Organization(WHO). Health Promotion Glossary. Geneva: 1998. WHO/HPR/HEP/98.1.

Lalonde. A New Perspective on the Health of Canadians. 1974. Lalonde Report (1974) Lalonde. A New Perspective on the Health of Canadians. 1974.

Ottawa Charter for Health Promotion (1986) Ottawa Charter for Health Promotion. WHO, Geneva: 1986. WHO/HPR/HEP/95.1/

Bangkok Charter (2005) Critical issues: Globalization as a source of challenges and opportunities; Need for policy coherence Key Commitments to make the promotion of health: central to the global development agenda a core responsibility for all of government a key focus of communities and civil society a requirement for good corporate practice. Bangkok Charter for Health Promotion in a Globalized World. 6thGlobal Conference on Health Promotion. Bangkok: 2005.

Theory in Health Promotion Using theory can guide the selection of the best health promotion interventions for a given problem HP theories and models explain health behaviour and change at the level of: Individuals Communities Communication strategies Organizations Healthy public policy processes Poole J. So what about health promotion? The history, the ideas, the projects. July 2006.

Stages of Change Model Prochaskaand DiClementein NutbeamDand Harris E. Theory in a nutshell: A practical guide to health promotion theories. 2ndEd. McGraw-Hill Australia: 2004.

Diffusion of Innovation Theory

The Social Marketing Approach Uses commercial marketing techniques to benefit individuals / society Consumer-driven, with defined subgroups 4 P’s of an effective “marketing mix”: Product: behaviour/social change + its benefits Price: barriers / costs (e.g. $, time) Place: making behaviour change easy and convenient Promotion: delivering the message to the target audience National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice, 2ndEd. US Department of Health and Human Services. 2005: 36-7.

The Advocacy Approach Advocacy: “A combination of individual and social actions designed to gain political commitment, policy support, social acceptance and systems support for a particular health goal or programme.” Public health media advocacy: “The strategic use of news media to advance a public policy initiative.” World Health Organization(WHO). Health Promotion Glossary. Geneva: 1998. WHO/HPR/HEP/98.1. Chapman S. Advocacy for public health :a primer. J EpidemiolCommunity Health 2004; 58: 361-5.

Primary Prevention of Disease Goal: To protect healthy people from developing a disease or experiencing an injury in the first place. Examples: Health education and behavioural change Immunization Social benefits guidance Community development GillamS. The practice of public health in primary care. In Pencheonet al. Oxford Handbook of Public Health. Oxford UP: 2006. 286.

Secondary Prevention Goal: To halt or slow the progress of disease (if possible) in its earliest stages; in the case of injury, goals include limiting long-term disability and preventing re-injury. Examples: Reduce risk of future ill-health (e.g. screen for HTN, treat with meds, reduce CVD and CVA risk) Give information (e.g. screen pregnant woman for trisomy21) GillamS. The practice of public health in primary care. In Pencheonet al. Oxford Handbook of Public Health. Oxford UP: 2006. 286.

Tertiary Prevention Goal: To prevent further physical deterioration and maximize quality of life. Examples: cardiac or stroke rehabilitation programs chronic pain management programs patient support groups GillamS. The practice of public health in primary care. In Pencheonet al. Oxford Handbook of Public Health. Oxford UP: 2006. 286.

Non-communicable Diseases (NCD) Leading cause of death globally 80% of NCD deaths occur in low-middle income countries: Cardiovascular disease Cancer Diabetes Chronic lung disease WHO. 2010. Global Status Report on NCDs.

WHO. 2010. Global Status Report on NCDs.

WHO. 2010. Global Status Report on NCDs. Caused by 4 behavioural risk factors: Tobacco use Unhealthy diet Insufficient physical activity Harmful use of alcohol WHO. 2010. Global Status Report on NCDs.

TOBACCO Lessons from the Battles of a Half Century Anatomy of a Half Century Recommended Reading Material   Report from the Tobacco Strategy Advisory Group to the Minister of Health Promotion and Sport: Building On Our Gains, Taking Action Now: Ontario’s Tobacco Control Strategy for 2011 – 2016. October 18, 2010. www.mhp.gov.on.ca/en/smoke-free/TSAG%20Report.pdf   A report of the Smoke-Free Ontario – Scientific Advisory Committee. Evidence to Guide Action: Comprehensive Tobacco Control in Ontario. 2010. http://www.oahpp.ca/services/evidence-to-guide-action-ctc-in-ontario.html Optional Reading Material Kennedy A., et al. Strong tobacco control program requirements and secure funding are not enough: lessons from Florida. Am J Public Health. 2012 May;102(5):807-17. http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2011.300459 Brandt, A. Inventing Conflicts of Interest: A History of Tobacco Industry Tactics. Am J Public Health. 2012 Jan, Vol. 102, No. 1, pp. 63-71. http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2011.300292

Acknowledgements Insights and background materials from discussions with the following: Robert Kyle, MOH Durham Region, former TSAG member David Butler-Jones, Chief Public Health Officer of Canada John Garcia, Assoc. Prof. and Dir., School of Public Health, U of Waterloo; former Dir. of the Health Promotion Branch, ON. Min of Health Kate Manson-Smith, ADM of Health Promotion Division, MOHLTC Michael Perley, E.D., OCAT Richard Schabas, MOH, HPEHU; former CMOH ON. Robert Kyle is a member of the Cessation Task Force for the Tobacco Control System Committee Bob Laramy also provide input – Ministry of Revenue ADM, Strategic Partnership and Policy Division Compliance Programs Division  John Andersen, Assistant Deputy Minister, Ministry of Finance George Pasut, VP of Public Health and Science, PHO Andrea Fuller, member of the Prevention Task Force for the Tobacco Control System Committee David McKeown, MOH, Toronto Public Health ADM of Health Promotion Division, Kate Manson Smith – co-chair of the Tobacco Control System Committee Vito Chiefari – York Region, formerly with Ministry of Health Promo (and with SMDHU) – co-chair of the Tobacco Control System Committee

One-Billion Deaths… …may occur globally in the 21st century from tobacco use (WHO, 2008) 100 million deaths in the 20th century “Cigarettes are the only legal product that, when used as intended, are lethal” Despite this, things have really changed in Canada since 1964 (or even 1984) Majority of adult males (including physicians) were smokers Smoking at board of health meetings … and at Ministry / MOH meetings Smoking in all indoor public places No real restrictions on tobacco marketing activities 100 million deaths in the 20th century 6 trillion cigarettes per year internationally Surgeon General’s Report, 1964: At the 12th grade level between 40 to 55 percent of children have been found to be smokers. By age 25, estimates of smoking prevalence run as high as 60 percent of men and 36 percent of women. There is a further increase up to 35 and 40 years after which a drop is observed.

The Breadth of Health Impacts of Tobacco: Surgeon General’s Report 2010 Smoking’s very widespread impacts on health – well documented

Health Impacts of Tobacco THE leading preventable cause of death in the world. Causes 1 in 10 adult deaths worldwide Kills up to 50% of all users Nearly 80% of the world's one billion smokers live in low- and middle-income countries. - Tobacco kills nearly six million people each year, of whom more than 5 million are users and ex users and more than 600 000 are nonsmokers exposed to second-hand smoke. Unless urgent action is taken, the annual death toll could rise to more than eight million by 2030. - Consumption of tobacco products is increasing globally, though it is decreasing in some high-income and upper middle-income countries. http://www.who.int/features/factfiles/tobacco/en/index.html

Health Impacts of Tobacco Tobacco use is responsible for: 10% of all deaths from cardiovascular disease 22% of all cancer deaths 71% of all lung cancer deaths 36% of all deaths from the respiratory system 42% of all COPD deaths WHO. 2012. WHO Global Report: Mortality Attributable to Tobacco.

The rise and fall of tobacco use and disease Tobacco’s rise and fall has been largely the result of government policy over the years During the world wars the Red Cross and the YMAC helped send cigarettes to soldiers. World War I and continued until the 1975, the U.S. military distributed cigarettes as part of rations for military personnel (formal military Tobacco Control Coalitions in Canada & the USA [4] tobacco control efforts did not begin until 1986). (Smith & Malone, "Everywhere the soldier will be": wartime tobacco promotion in the US military, 2009) Peak % of population smoking in 1975 Peak sales in 1980 100 fold increase over 60 period of time

Stages of the Tobacco Epidemic Internationally Tobacco Control, 1994; 3, 242-247

Progress: Tobacco mortality in Ontario has declined relative to other risk factors Tobacco is the single most important health issue – though due to our success with tobacco control its use has declined such that its population health impact is now comparable to diet, physical inactivity and alcohol in Ontario Smoking reduces the life expectancy of users by over 10 years – but due to the prevalence of use it reduces the life expectancy of the population in Ontario by 3 years Source: SEVEN MORE YEARS: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario. Institute for Clinical Evaluative Sciences, Public Health Ontario

Taking stock of the present status of tobacco control in Ontario Research, surveillance and KE Strategies – Prevention, Protection, Cessation National, provincial and municipal legislation Litigation Local public health programs (Ministry funded) NGO advocacy / public education Healthcare system supports for cessation Public support for the above But … ongoing dedicated opposition from the industry… and thus despite 60 years of evidence supporting action, 1/5 adults still smoke; 13,000 deaths annually in Ontario We now have a comprehensive set of control measures and supports in place for tobacco control in Ontario – and yet 1/5 of adults still smoke, speaking to the power of the tobacco industry

Some key questions re tobacco and its history How did we get here? Understanding the basic dynamics of an industry-driven epidemic Where do we go from here? Understanding the political challenges of implementing effective practices What lessons can be applied to other leading preventable cause(s) of death? Identifying transferable lessons regarding other prominent causes of chronic disease Reflective questions – will try to address in my presentation

Phases of the Tobacco Epidemic PHASE I: 1884-1914 Consolidation of the Cigarette Industry and Early Controversies PHASE II: 1914-1950 Era of Good Feeling; Cigarettes Promoted by Governments PHASE III: 1950-1964 The Gathering Storm of Health Concerns PHASE IV: 1964-1984 Regulatory Hesitancy PHASE V: 1984-2008 Tobacco as Social Menace PHASE VI: The Future Neoprohibitionism versus harm reduction? Frisbee and Studlar presentation at Wilfred Laurier University in 2011 Source: Local Tobacco Control Coalitions in the United States and Canada: Contagion Across the Border? Stephanie J. Frisbee, PhD, and Donley T. Studlar, PhD. Presented at: 11th Annual Conference of the Canadian Political Science Association May 16‐18, 2011, Wilfrid Laurier University, Waterloo, ON Early controversies – tobacco opposition on morality grounds The Feel Good Era – I Love Lucy was owned by Phillip Morris who openly marketed tobacco on it. Future “harm reduction” – not sure on this – perhaps e-cigarettes re the Globe article: http://www.theglobeandmail.com/life/health-and-fitness/health/could-e-cigarettes-save-smokers-lives-some-health-advocates-think-so/article11583353/ Source: Local Tobacco Control Coalitions in the United States and Canada: Contagion Across the Border? Stephanie J. Frisbee, PhD, and Donley T. Studlar, PhD. Presented at: 11th Annual Conference of the Canadian Political Science Association May 16‐18, 2011, Wilfrid Laurier University, Waterloo, ON

Research: Early Concerns Early health (and moral) concerns: “loathsome to the eye, hatefull to the nose, and harmefulle to the braine”, King James I, 17th century Scientific reports as early as 1912 re lung cancer Concerns in the 1920s to 1940s Reader’s Digest in 1924; Science in 1938 (Johns Hopkins biostats study – reduced longevity); small study in Germany in 1939 re increased lung cancer with smoking; Departments of Pensions and National Health in 1940 King James found smoking “loathsome” but then discovered how lucrative it was to tax it People suspected that inhaling smoke was harmful to health, but did not have the evidence to prove it.

Research: The Evidence Gathers 1947 – Norman Delarus (Canadian), case (50) control study re lung cancer. 1950 – Evart Graham (USA), JAMA, case (605) control study re lung cancer (author quit smoking after study, but died of lung cancer in 1957). 1950 – Bradford Hill, Richard Doll, BMJ, 20 British hospitals, case control study, lung cancer. 1951 – Richard Doll et al. Commencement of a 50-year-long cohort study on male physicians in the UK Familiar names in the history of epidemiology research methods – such as the Bradford Hill criteria of causation Early clarity of action – in 1962 the Royal College of Physicians of London recommended most of the basic elements of tobacco control that we now pursue Mortality in relation to smoking: 50 years' observations on male British doctors Richard Doll, emeritus professor of medicine,1 Richard Peto, professor of medical statistics and epidemiology,1 Jillian Boreham, senior research fellow,1 and Isabelle Sutherland, research assistant1 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC437139/ Mortality from smoking was greater for those starting in the early 20th century than in the 19th century (possibly due to earlier commencement) and took 50 years to fully document the impact of lifelong tobacco use – 10 year loss of life expectancy, killing half of all long-term users

Surgeon General Reports on Tobacco 29 reports in all – latest one in 2012 1964 landmark first report Based on 7,000 articles relating to smoking and disease Very guarded language Citation of antecedent work Dramatic increase in tobacco use and lung cancer (from 3T in 1930 to 41T in 1962) over past century No relationship with education – urban more than rural Cancer of lungs, etc., probably COPD, heart disease, LBW babies, fires “Habituation”, not addiction

Surgeon General Reports: Progression 1979 Much more strident language “The largest preventable cause of death” An addiction Reductions in use 1986 “Involuntary smoking” hazards ETS restrictions in 40 states and in DC “96 percent of businesses have adopted smoking policies” Restrictions may reduce tobacco use – evaluation needed

Research / Analysis Ontario Council on Health Report, Smoking and Health in Ontario: A Need for Balance,1982 USEPA, 1992 Australian National Health and Medical Research Council in 1997 California EPA, 1997 United Kingdom Scientific Committee on Tobacco and Health, 1998 WHO, 1999 Actions will Speak Louder than Words,1999 US National Toxicology Program, 2000 Protection from secondhand tobacco smoke in Ontario, OTRU, 2001 Evidence to Guide Action, PHO, 2010 The Tobacco Strategy Advisory Committee (TSAG) report and recommendations, 2010 Ontario Council on Health report, Smoking and Health in Ontario: A Need for Balance,1982 Mary Jane Ashley, Bob Spazoff were members Basic elements of tobacco control but still very guarded Included nonsmoking sections in hospitals and work places, and exploration for harm reduction strategies Protection from second-hand tobacco smoke in Ontario, OTRU, 2001 Most of these studies were cited during the OCAT campaigns in 2000’s Evidence to Guide Action and TSAG now our present guides “Actions will Speak Louder than Words”; report of the Ontario Minister of Health and Long-term Care’s Expert Advisory Committee on Tobacco (1999); this report led to the renewal of the Ontario Tobacco Strategy in 2000/ 2001. http://otru.org/wp-content/uploads/2012/06/special_actions_eng.pdf

The Industry’s Response Some historic milestones Macdonald Tobacco established in Montreal in 1858 Cigarette rolling machine in 1881; safe matches in 1890s “Ability of T. industry to remain healthy while its customers get sick “one of the most amazing marketing feats of all times” – Jake Epp, 1996 Tremendous wealth £ 19.7 billion in duty paid in 2010 in the Americas (BAT – “Managing the Challenges in the Americas”) Present companies in Canada Imperial Tobacco Rothmans, Benson & Hedges Inc. JTI-MacDonald Corp James Albert Bonsack's cigarette rolling machine, invented in 1880 and patented in 1881. (Wikipedia) Canada has three main cigarette companies: Imperial Tobacco Canada Ltd. (Imperial Tobacco), Rothmans, Benson & Hedges Inc. (Rothmans), and JTI-MacDonald Corp. (JTI) Imperial Tobacco has the highest market volume share (53%), followed by RBH (34%) and JTI (8%).126 OTRU 2012 review on SFO

The Industry’s Response Deliberate deception Public declaration of responsibility as a ruse Sponsorship of scientific opposition Denial of the health impacts Personal responsibility arguments Marketing to youth (and denying it) Marketing to recruit new smokers (and denying it) Policy manipulation Political involvement – prominent politicians as tobacco executives Voluntary code re marketing as a means of forestalling legislation (effective in the 1970’s) Threatened withdrawal of sponsorship as means of coercion Contraband tobacco Undermining price as a control measure Legal challenges Supreme Court re the Tobacco Products Control Act The activities of the tobacco industry have been extensively documented in large part due to the document disclosure requirements of the Master Settlement Agreement (the suit in the USA). Past politicians on tobacco boards / executives: Paul Martin Louis St. Laurent Michael Kirby The Tobacco Industry Research Committee (TIRC), a group that would be carefully shaped by Hill & Knowlton to serve the industry’s collective interests, would be central to the explicit goal of controlling the scientific discourse about smoking and Health. The public announcement of the formation of the committee came in a full-page advertisement run in more than 400 newspapers across the country, soon known as the ‘‘frank statement.’’ - Brandt, A. Inventing Conflicts of Interest: A History of Tobacco Industry Tactics. Am J Public Health. 2012 Jan, Vol. 102, No. 1, pp. 63-71. http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2011.300292

Knowledge Exchange and Grass-roots Advocacy in Canada / Ontario Canadian Cancer Society newsletter in 1951 citing the emerging evidence Canadian Public Health Association Advocacy positions in 1959, 1988, and 2011 Seeking elimination (under 1%) by 2035 Canadian Medical Association concluded in 1961 smoking causes lung cancer Non‐Smokers’ Rights Association, and the Canadian Council on Smoking and Health, (now the Canadian Council for Tobacco Control) founded in 1974 Physicians for a Smoke-Free Canada formed in 1985 Ontario Campaign for Action on Tobacco (OCAT), 1992 Ontario Tobacco Research Unit, 1993 Ontario Medical Association: advocacy paper for smoke-free legislation (2003), cars and children (2004) The public health community started early re advocacy (but late re Mandatory Programs) Familiar names over the years: Gar Mahood (Non‐Smoker’s Rights Association) Andrew Pipe (Physicians for a Smoke-Free Canada) Michael Perley (Ontario Campaign for Action on Tobacco) John Garcia with the Canadian Cancer Society and then Director of the Public Health Division of the Ministry of Health Roberta Ferrence (OTRU) Ted Boadway (OMA)

History of TC and Public Health in Ontario No tobacco control in the Mandatory Health Programs and Services Guidelines until 1989 – 25 years after the Surgeon General’s report The first CMOH Report, 1991, was on tobacco control Mandatory Health Programs and Services Guidelines Guidelines in 1989, and 1998 Structure: Outcome objectives re smoking rate reductions, smoke-free homes, tobacco vendor compliance (re Tobacco Control Act) Actions: consistent with today’s local tobacco control mandate Liaison, school curriculum, smoke-free policies in workplaces, cessation, regulatory efforts re secondhand smoke Ontario Public Health Standards 2008 – “Chronic Disease Prevention” Structure: broad process outcomes, Societal and Board Objectives – details in protocols Public health late (25 years after the Surgeon General’s report) to include tobacco in Mandatory Programs Richard Schabas led inclusion of tobacco in Mandatory Programs in 1989 and with the first CMOH report (which was on tobacco) The first CMOH Report, 1991 Burden of illness – trends, progress – but still 20% of deaths and long way to go to goal of 10% of use by 2000 Ontario Public Health Standards 2008 – “Chronic Disease Prevention” Objectives (Societal and Board): surveillance, increased healthy environments, skills and behaviours preventing chronic disease; policy makers, public aware / have information, priority populations smoke free, vendors comply with SFOA Actions: broad requirements, Tobacco Compliance Protocol re enforcement of SFOA, Comprehensive Tobacco Control Guidance Document Surveillance, Prevention, Protection, Cessation

Historic Government Roles Tobacco promotion Agricultural R&D, subsidies Provision (military) Tobacco control Regulation of manufacturing (such as the 2005 cigarette ignition propensity regulations) Sales (age, vendors / vending) restrictions Marketing / advertising / packaging (plain) / warnings (graphic) Taxation Research Cessation supports Location of use restrictions Litigation Partnerships Public awareness and de-normalization (Prohibition) Often more public money for tobacco promotion than for tobacco control historically Bhutan is the only control to have prohibited the use of tobacco (Canada considered it in 1903) National Tobacco Control Strategy - 1986 Four Goals: 1. Prevention: Preventing tobacco use among young people. 2. Cessation: Persuading and helping smokers to stop using tobacco products. 3. Protection: Protecting Canadians by eliminating exposure to second‐hand smoke. 4. Denormalization: Educating Canadians about the marketing strategies and tactics of the tobacco industry and the effects the industry's products have on the health of Canadians in order that social attitudes are consistent with the hazardous, addictive nature of tobacco and industry products Five Strategies: 1. Policy and Legislation: To ensure coordination of tobacco policy across sectors, and implementation of organizational policies and legislation across sectors that support reducing tobacco use. 2. Public Education: To make available and accessible information, services and programs about tobacco and tobacco related issues, which address prevention, cessation, protection and denormalization. 3. Industry Accountability and Product Control: To regulate the manufacturing, marketing, and sale of tobacco products to reduce addiction and disease. 4. Research: To increase knowledge of tobacco and tobacco use, the tobacco industry, effective interventions for tobacco control and health and socioeconomic impacts of tobacco use. Building and Supporting Capacity for Action: To increase the ability of individuals, health intermediaries and communities at the national, provincial/territorial and local levels to take action. From: (Health Canada, 2005)

Government Response: Federal For 80 years (between 1908 to 1988) the Federal Government did not pass tobacco control legislation – despite more than 20 private members’ bills in the 1960s Resolution to ban tobacco, 1903 and 1904 – second reading only Legislation: 1908 Tobacco Restraint Act - prohibited sales under 16 1988 Non-Smokers’ Health Act (private members bill) and Tobacco Products Control Act - prohibited advertising; charter challenge with sections ruled unconstitutional 1993 Tobacco Sales to Young Persons Act – prohibited sales under 18 1997 Tobacco Act – still in effect; disclose product content, prohibited sale to youth, prohibited mail-order and vending machines, warning labels, restricted advertising Taxation increases in 1980’s, reduction in 1994 40,000 additional deaths Graphic packaging in 2000 and 2012 Tobacco farms quota buyout in 2008 More than doubled Ontario’s crop Often more public money for tobacco promotion than for tobacco control historically Bhutan is the only control to have prohibited the use of tobacco (Canada considered it in 1903) National Tobacco Control Strategy - 1986 Four Goals: 1. Prevention: Preventing tobacco use among young people. 2. Cessation: Persuading and helping smokers to stop using tobacco products. 3. Protection: Protecting Canadians by eliminating exposure to second‐hand smoke. 4. Denormalization: Educating Canadians about the marketing strategies and tactics of the tobacco industry and the effects the industry's products have on the health of Canadians in order that social attitudes are consistent with the hazardous, addictive nature of tobacco and industry products Five Strategies: 1. Policy and Legislation: To ensure coordination of tobacco policy across sectors, and implementation of organizational policies and legislation across sectors that support reducing tobacco use. 2. Public Education: To make available and accessible information, services and programs about tobacco and tobacco related issues, which address prevention, cessation, protection and denormalization. 3. Industry Accountability and Product Control: To regulate the manufacturing, marketing, and sale of tobacco products to reduce addiction and disease. 4. Research: To increase knowledge of tobacco and tobacco use, the tobacco industry, effective interventions for tobacco control and health and socioeconomic impacts of tobacco use. Building and Supporting Capacity for Action: To increase the ability of individuals, health intermediaries and communities at the national, provincial/territorial and local levels to take action. From: (Health Canada, 2005)

Government Response: Provincial (Ontario and others) For 98 years (1892 to 1990) the provincial government of Ontario did not pass tobacco control legislation Legislation: Prohibition of sale to minors – BC in 1891, ON (age 18) and NS in 1892, NB in 1893, NWT in 1896 1990 Smoking in the Workplace Act - minimum areas for nonsmoking (not enclosed and separately ventilated) 1994 Tobacco Control Act - Ontario’s first general tobacco control statute prohibition of sale in pharmacies and vending machines, to minors, allowed municipal bylaws for smoke-free spaces prohibited in healthcare facilities, pharmacies, schools and colleges and in other retail and institutional settings Tobacco program funding: $4 M in 1995, $10M in 1999, to $60 M by 2006, to $47.8 M by 2011 Provincial government suits BC in 2004, Supreme Court support Manitoba, Sask. Que., PEI, NS, NB have launched suits Enabling legislation in Ontario and Alberta For 98 years the provincial government of Ontario did not pass tobacco control legislation Shoppers Drug Mart was owned by Imasco Federal tobacco tax cut 1994 (50%). Increased again in 2004-06. Health Canada estimates 40,000 additional deaths (The Impact of the Cigarette Price Rollback on the Future Health of Canadian Adolescents" Health Canada, Bureau of Chronic Disease Epidemiology, Laboratory Centre for Disease Control. Draft. 1994) Developing the partnerships – OCAT, OTRU, NSRA http://www.cbc.ca/news/health/story/2011/07/29/f-smoking-laws-timeline.html

Smoke-Free Ontario Act and Strategy, 2006 Comprehensive, multi-level and intensive strategy: training, mass media, planning infrastructure (such as TCANs), local programs, research and evaluation programming and 40% of SFO funding for local public health (previously only cost-shared funding) Banning smoking in enclosed public places and workplaces Banning the display of tobacco products at the point of purchase (i.e. powerwalls) Strengthening restrictions on selling tobacco products to young people Expanded services and infrastructure to help smokers quit Created and funded programs, including a peer-to-peer infrastructure, to prevent youth from starting to smoke Funded extensive awareness and social marketing initiatives Funded research capacity and training supports for health system workers 90% of population was covered by smoke-free indoor public space bylaws at the time that SFOA commenced

Ontario since 2009 Banned smoking in vehicles when children under 16 are present Passed legislation to allow the government to to sue tobacco companies to recover past and ongoing healthcare costs due to tobacco-related illness Passed legislation to address the supply of flavoured cigarillos to young people MOHLTC Action Plan, 2012 – to have the lowest tobacco use in the country According to 2006 Health Canada figures, legal sales of cigarettes in Ontario fell by 31.8 percent, or by approximately 4.6 billion cigarettes, since 2003 Source: TSAG report Banning smoking in vehicles followed OMA advocacy MOHLTC Action Plan – government’s announced renewal of the SFO Strategy in Spring 2011; $5M reinvestment; emphasis on smoking cessation and contraband reduction strategy

Local Public Health and NGO Advocacy in the 1990s / 2000s Toronto: Bylaw in 1979 prohibiting smoking in retail stores, elevators, escalators, service lineups Bylaw in 1993 requiring workplace smoking policies Bylaw in 1997 – enclosed, separately ventilated DSAs – rescinded Smoke-free bylaws in 2000 / 2002: Waterloo Region, Toronto, Ottawa Other municipalities – such as Simcoe County, District of Muskoka; Cornwall a noted success in eastern Ontario Most of the provincial population covered by smoke-free bylaws in early 2000s - Set the stage for the SFOA Much leadership, partnership and support from NGOs – OCAT in particular working closely with local public health

The Impact of Government Decisions Past-Year Smoking, by grades 7-12, Ontario, 1977-2011 Falling with government tobacco control legislation: reduced consumption with increased taxation in the 1980’s. Increasing consumption with smuggling and price reduction, 40,000 deaths with price reduction of 1994 Falling consumption with increased taxation, smoke-free bylaws and SFOA in the 2000’s Source: 2012 Smoke-Free Ontario Strategy Evaluation Report, Ontario Tobacco Research Unit: http://otru.org/2012-smoke-free-ontario-strategy-evaluation-report-full-report/

OTRU Report 2012 Progress, however change too slow to achieve government’s & TSAG’s goals Protects most Ontarians most of the time from ETS in indoor public places Changing social climate and reducing use among youth YSS report 1/3 youth remain susceptible However, no reduction in adult smoking in 5 years – took 10 years to reduce by 5% Protection: Reduction in ETS exposure over 5 years 26% still exposed at work, and 32% still on restaurant patios 11% of aged 12 to 19 still exposed in homes – (not tracked in multiunit dwellings & likely much higher) YSS is the Youth Smoking Study Impact of SFOA on smoking in restaurants and bars is evident – with no reduction in smoking on patios (see OTRU SFOA 2012 review, figure 12): http://otru.org/2012-smoke-free-ontario-strategy-evaluation-report-full-report/ Also shows reduction in smoke exposure in homes for all ages, but lower for adults than children

OTRU Report 2012 Prevention: Cessation: Reduction in youth smoking (1/2 reduction over 6 years) Still 25% aged 20 to 24 smoke Need to focus on high-risk schools / youth who also have a high prevalence of other risk behaviors Cessation: In recent years no change in the proportion of smokers intending to quit, or in the number of cigarettes smoked daily Train health professionals in providing cessation support through TEACH, RNAO and PTCC Intention to quit not increasing Provincial cessation supports only reaching 5% of smokers Need to double annual quit rate from 1.3% in order to achieve TSAG target of 5% reduction over 5 years Need the multiple strategies in TSAG to achieve the provincial goal of the lowest smoking in Canada Source: OTRU review, http://otru.org/2012-smoke-free-ontario-strategy-evaluation-report-full-report/ Also, current quit rate would need to double in order for the province to be the lowest prevalence jurisdiction in Canada; this translates into 490,000 fewer smokers. This will require a population-based strategy which includes renewed policy and educational efforts at multiple levels; cessation services alone will not be enough. Current cessation services based on OTRU estimates reach only 5% of smokers. This point was made by John Garcia at this past week’s SFO System Committee meeting. Marked increase in population reach in cessation supports (5% total), but despite this, cessation rate not changed. Certain states in the USA (eg, New York) have a much higher reach.

Ontario and other provinces Current Smoking (Past 30 Days), by Jurisdiction, Ages 12+, 2010 Ontario has the slipped to have the third lowest rate of use in the country – stayed the same as in 2009 (reported in the 2011 report), and Manitoba dropped from 19% to 17 % use – BC increased from 15% to 16% Note: Vertical lines represent 95% confidence intervals. Source: Canadian Community Health Survey 2010. Source: 2012 Smoke Free Ontario Strategy Evaluation Report. The Ontario Tobacco Research Unit. November 2012

Priority Populations Current Smoking (Past 30 Days), by Education, Ages 18+, Ontario, 2001 to 2011 Stall in reduction for the lowest education level Source: 2012 Smoke Free Ontario Strategy Evaluation Report. The Ontario Tobacco Research Unit. November 2012

Priority Populations Current Smoking (Past 30 Days), by Occupation, Ages 15 to 75, Ontario, 2009/10 Trades much higher tobacco use than social science sector Note: Vertical lines represent 95% confidence intervals. Source: Canadian Community Health Survey 2009/10. Source: 2012 Smoke Free Ontario Strategy Evaluation Report. The Ontario Tobacco Research Unit. November 2012

The Impact of Smoke-Free Public / Work Places (and the need for smoke-free patios) Christine, please include Figure 12: Exposure to SHS at Restaurants or Bars, Ages 15+, Ontario, 2005 to 2010 from 2012 Smoke Free Ontario Strategy Evaluation Report. The Ontario Tobacco Research Unit. November 2012

Contraband Tobacco 14% to 42% of all cigarettes bought by adult smokers in Ontario may be contraband.10,11 – OTRU 2012 SFO Strategy review Quebec has historically had the lowest tax rate Ontario is unable to raise its tax rate because contraband is high and will increase Reflects locations of first nations communities – also in the 1990’s reflected proximity to NY state with low taxation at that time (sources of contraband – though the tobacco had actually been produced in Ontario) TSAG A legal carton of 200 cigarettes in Ontario now costs $80.16, compared to a baggie of 200 contraband cigarettes that could cost as little as $6.00. Contraband tobacco represents the supply of cheap cigarettes, accounting for approximately 30%, and perhaps more, of the cigarettes smoked in Ontario — not just by adults, but also increasingly by young people. The low price of contraband makes cigarettes affordable, especially to young people. There is plenty of evidence that proves the demand for tobacco products falls by three to four percent for every 10% increase in price. Because contraband cigarettes are sold without all applicable taxes, they undermine government efforts to increase prices and reduce tobacco use though higher taxes. There are essentially three sources of unregulated tobacco products in Ontario: 􀂃 products legally manufactured for sale only in First Nations communities to status First Nations people, but sold outside those communities; 􀂃 products manufactured in the United States that are smuggled into Canada via Kahnawake, Tyendinaga, Six Nations, and Akwesasne, which straddles the border between Canada and the United States; and 􀂃 counterfeit products (primarily shipped from China). Figure 4 Source: The Canadian Tobacco Market Place. Estimating the volume of Contraband Sales of Tobacco in Canada; Updated – April 2010. Physicians for a Smoke-Free Canada.

Moving Forward in Ontario: Tobacco Strategy Advisory Group (TSAG) BUILDING ON OUR GAINS, TAKING ACTION NOW: ONTARIO’S TOBACCO CONTROL STRATEGY FOR 2011 – 2016 Based on EVIDENCE TO GUIDE ACTION – PHO Advice to government: Tobacco Control System Committee to advise the province on SFO renewal implementation Targets to be achieved by 2016 5% reduction in tobacco use Reduce ETS – ban smoking on restaurant and bar patios, and allow smoke-free leases in the Residential Tenancies Act Increase quitting rates and reduce reuptake rates Ban new tobacco products Reduce tobacco disease by 6.5% TSAG takes us back to specific outcome targets (unlike the OPHS, but like the old Mandatory Programs)

TSAG Implementation Numerous Recommendations Whole of government approach Supply strategies Price, promotion, new product prohibition, reduced production, divestment Demand strategies Prevention, cessation, protection (MUDs), social marketing Research, address disparities, prevent government interference, dedicated adequate funding, litigation Strategies commenced: 16 Strategies awaiting commencement / uncertain status: 32 (though 3 are being addressed by local public health, municipal government or the federal government) Mr. Gardner.   Further to your additional query I have the below noted information to provide. Please let me know if you need anything further. Addressing illegal tobacco is a priority for thes government. Enforcing tobacco tax laws complements the Smoke-Free Ontario strategy.  Raw leaf tobacco oversight is just one of the ways the government is moving to strengthen enforcement against illegal tobacco products.  Over the past year, Ontario introduced a number of important compliance activities to curtail the availability of illegal tobacco, including: Effective January 1, 2014, only packages of cigarettes and fine cut tobacco marked with an Ontario-adapted federal stamp (replacing the peach-coloured federal stamp) will be allowed for sale to consumers required to pay tobacco tax. The Ministry of Finance and the Alcohol and Gaming Commission of Ontario have signed an information-sharing agreement where retailers selling illegal tobacco could have their lottery licences suspended. During the 2013 growing season, Ministry of Finance Inspectors will provide assistance to the Ontario Flue-Cured Tobacco Growers’ Marketing Board with their inspection visits. Additional details about the Ministry of Finance’s raw leaf tobacco program are to be set out in a supporting regulation. Once that regulation is filed, the Ministry of Finance will provide details on the registration and reporting requirements of the program. When filed, the regulation is expected to provide details, including: the criteria for obtaining a registration certificate additional grounds for suspending or cancelling a registration certificate the information that must be provided to the Ministry of Finance The Ministry of Finance continues to work closely with various law enforcement agencies to combat illegal tobacco.  We actively work with our key partners to address illegal tobacco by participating in various joint force initiatives, including the RCMP-led Cornwall Regional Task Force, and by sharing intelligence information with our partners to strengthen the enforcement of tobacco tax laws. Since 2008, more than 223 million illegal cigarettes, 2.5 million untaxed cigars and 74 million grams of untaxed fine cut or other tobacco products have been seized by ministry investigators and inspectors John Andersen Assistant Deputy Minister Ministry of Finance Compliance Programs Division Mr. Gardner Further to your request for information I wish to provide you with the following. The Tobacco Tax Act (Act) was amended by the Supporting Smoke-Free Ontario by Reducing Contraband Tobacco Act, 2011 (Bill 186) to include provisions for Ministry of Finance (ministry) oversight of raw leaf tobacco. This change was originally to be effective as of October 1, 2012. On March 22, 2013, a regulation became effective which provides a temporary exemption (exemption period) from the requirement to register with the ministry before engaging in raw leaf tobacco activities until  January 1, 2014 During the exemption period, persons who are regulated by the Ontario Flue-Cured Tobacco Growers’ Marketing Board must follow the Board’s regulations. During the 2013 growing season, Ministry of Finance Inspectors will provide assistance to the Ontario Flue-Cured Tobacco Growers’ Marketing Board with their inspection visits Effective January 1, 2014, every person who deals with or handles raw leaf tobacco in Ontario will need to register with the ministry.  This includes producers (growers), dealers, processors, importers, exporters and anyone who transports raw leaf tobacco into or out of Ontario and who is not  registered with the ministry as an interjurisdictional transporter under the Tobacco Tax Act. After the exemption period ends, conducting raw leaf tobacco activities without the appropriate registration certificate under the Tobacco Tax Act can result in seizure, fines and penalties. Additional details about the Ministry of Finance’s raw leaf tobacco program, including reporting requirements, are to be provided for by regulation at a later date. “Raw leaf tobacco” includes:  all varieties of raw leaf tobacco grown in or imported into Ontario, including dark-fired/dark-cured (also known as black), burley and flue-cured tobacco, and all states of the raw leaf tobacco being grown (other than seedlings) or that has grown, regardless of the extent to which the raw leaf tobacco is processed.  This includes the tobacco plant in the ground and cured leaves that have been partially processed. For more information, please visit the ministry’s website: http://www.fin.gov.on.ca/en/tax/tt/rawleaf.html If you need anything further please let me know. Compliance Programs Division  |  Tel.:  905 837-5236 1550 Bayly Street                      |  Fax:  905 837-5252 Pickering ON  L1W 3W1             |  Email:  John.Andersen@ontario.ca

TSAG Implementation Highlights of Strategies Commenced: Whole of government approach (e.g. Min of Finance re contraband) engagement of first nations re contraband Tobacco growing: Raw leaf regulation commencing in January, 2014 Cessation: Coordinated tobacco cessation services hospital-based and workplace-based smoking cessation demonstration grants increased access to counseling and pharmacotherapy through primary care ODB coverage for cessation products Mr. Gardner.   Further to your additional query I have the below noted information to provide. Please let me know if you need anything further. Addressing illegal tobacco is a priority for thes government. Enforcing tobacco tax laws complements the Smoke-Free Ontario strategy.  Raw leaf tobacco oversight is just one of the ways the government is moving to strengthen enforcement against illegal tobacco products.  Over the past year, Ontario introduced a number of important compliance activities to curtail the availability of illegal tobacco, including: Effective January 1, 2014, only packages of cigarettes and fine cut tobacco marked with an Ontario-adapted federal stamp (replacing the peach-coloured federal stamp) will be allowed for sale to consumers required to pay tobacco tax. The Ministry of Finance and the Alcohol and Gaming Commission of Ontario have signed an information-sharing agreement where retailers selling illegal tobacco could have their lottery licences suspended. During the 2013 growing season, Ministry of Finance Inspectors will provide assistance to the Ontario Flue-Cured Tobacco Growers’ Marketing Board with their inspection visits. Additional details about the Ministry of Finance’s raw leaf tobacco program are to be set out in a supporting regulation. Once that regulation is filed, the Ministry of Finance will provide details on the registration and reporting requirements of the program. When filed, the regulation is expected to provide details, including: the criteria for obtaining a registration certificate additional grounds for suspending or cancelling a registration certificate the information that must be provided to the Ministry of Finance The Ministry of Finance continues to work closely with various law enforcement agencies to combat illegal tobacco.  We actively work with our key partners to address illegal tobacco by participating in various joint force initiatives, including the RCMP-led Cornwall Regional Task Force, and by sharing intelligence information with our partners to strengthen the enforcement of tobacco tax laws. Since 2008, more than 223 million illegal cigarettes, 2.5 million untaxed cigars and 74 million grams of untaxed fine cut or other tobacco products have been seized by ministry investigators and inspectors John Andersen Assistant Deputy Minister Ministry of Finance Compliance Programs Division Mr. Gardner Further to your request for information I wish to provide you with the following. The Tobacco Tax Act (Act) was amended by the Supporting Smoke-Free Ontario by Reducing Contraband Tobacco Act, 2011 (Bill 186) to include provisions for Ministry of Finance (ministry) oversight of raw leaf tobacco. This change was originally to be effective as of October 1, 2012. On March 22, 2013, a regulation became effective which provides a temporary exemption (exemption period) from the requirement to register with the ministry before engaging in raw leaf tobacco activities until  January 1, 2014 During the exemption period, persons who are regulated by the Ontario Flue-Cured Tobacco Growers’ Marketing Board must follow the Board’s regulations. During the 2013 growing season, Ministry of Finance Inspectors will provide assistance to the Ontario Flue-Cured Tobacco Growers’ Marketing Board with their inspection visits Effective January 1, 2014, every person who deals with or handles raw leaf tobacco in Ontario will need to register with the ministry.  This includes producers (growers), dealers, processors, importers, exporters and anyone who transports raw leaf tobacco into or out of Ontario and who is not  registered with the ministry as an interjurisdictional transporter under the Tobacco Tax Act. After the exemption period ends, conducting raw leaf tobacco activities without the appropriate registration certificate under the Tobacco Tax Act can result in seizure, fines and penalties. Additional details about the Ministry of Finance’s raw leaf tobacco program, including reporting requirements, are to be provided for by regulation at a later date. “Raw leaf tobacco” includes:  all varieties of raw leaf tobacco grown in or imported into Ontario, including dark-fired/dark-cured (also known as black), burley and flue-cured tobacco, and all states of the raw leaf tobacco being grown (other than seedlings) or that has grown, regardless of the extent to which the raw leaf tobacco is processed.  This includes the tobacco plant in the ground and cured leaves that have been partially processed. For more information, please visit the ministry’s website: http://www.fin.gov.on.ca/en/tax/tt/rawleaf.html If you need anything further please let me know. Compliance Programs Division  |  Tel.:  905 837-5236 1550 Bayly Street                      |  Fax:  905 837-5252 Pickering ON  L1W 3W1             |  Email:  John.Andersen@ontario.ca

TSAG Implementation Strategies commenced: Research Reduce disparities Provincial and local research, surveillance and monitoring – re initiatives, programs, policies, disparities, youth and young adult prevention Reduce disparities Engage First Nations (Min of Finance) Social marketing Social smoking provincial commercial (movies and internet – Cannes award for creativity) Research – PHO Heather Manson Engage first nations – Bob Laramy Social marketting – Task Force of the Tobacco Control System Committee Social Picking / Farting

TSAG Implementation Strategies awaiting commencement / uncertain status: Sufficient resources (at least $100 M would be within the CDC recommendations) Current strategy funding is $47.8 million (this includes the $5M enhancement in 2011) Dedicated funding from tobacco taxes to tobacco control Public health funding from tobacco settlements Divestment of investments Products: prohibit new products, plain packaging, restrict water pipes Price: Increase price / tax; Anti-contraband public education Promotion: Adult rates for movies and video games with tobacco imagery OMERS invested in Phillip Morris – alPHa advocacy to divest

TSAG Implementation Strategies awaiting commencement / uncertain status: Tobacco Growing: Work with partners to reduce tobacco production over time (licenses, acreage, ceilings) Protection Amend SFO to eliminate smoking in patios, hotels, doorways, playgrounds (local public health action re bylaws – 75+ outdoor smoking amendments) Smoke-free Multiunit Dwellings: Amend Residential Tenancies Act to allow smoke-free MUDs a material term of leases (local municipal initiatives – now 75 + smoke-free community housing buildings in Ontario) Tax credits for smoke-free affordable housing SMDHU staff and Board of Health Chair and Barrie City Councilor, Barry Ward re establishing a smoke-free community housing building

International trends (from the industry) “Although China will pay lip service to tobacco control, population growth is forecast to mitigate any fall in smoking prevalence, even in the long term.” Large population of smokers in China is critical to the ongoing success of the tobacco industry internationally From: Passport The Future of Tobacco. Euromonitor. September 2011

Tobacco in China http://www.who.int/tobacco/mpower/graphs/en/index.html.

Tobacco Use in the Caribbean At least 20% of the general population of the Caribbean has consumed tobacco at some point during their life More than a 10% of the population of the English-speaking Caribbean are current consumers, meaning they have consumed tobacco during the last month. A 2010 comparative analysis of student drug use in 12 Caribbean countries - Lifetime prevalence rates of tobacco use indicates that : - Grenada has the highest reported rate - 34.53% - Suriname - 33.06% - Dominica - 30.69% - T&T - 28.86% World Drug Report 2010 Courtesy of Jeffrey Edwards MD, Doctorate of Public Health candidate, University of the West Indies

Words from the industry “Euromonitor International’s view is that widely implemented plain packaging legislation would be the most damaging tobacco control measure ever introduced, because at least 50% of cigarettes pricing strength resides in the branding.” Australia commenced plain packaging in 2012 Chilling to hear the industry’s perspective of “damaging tobacco control”

Some observations from tobacco’s history The power of industry: An industry capable of making great profits at the expense of 10 years of the life expectancy for most of the population for most of a century Once established, has enormous influence, delaying effective government action for decades Foresight is possible, but action has been delayed: The solutions can be logically deduced (but delayed in implementation). Some identified early (the 1960s) the range of tobacco-control strategies required Research is the beginning – determination, the end Research is the essential starting point to turning things around – but is not enough. The courage and determination of many people in and out of the public health community over many years has been critical for change Early clarity of action – in 1962 the Royal College of Physicians of London recommended most of the basic elements of tobacco control that we now pursue

What next? What is our end-game? Provincially? Internationally? How should local public health be positioned in this? We have achieved much – and much remains to be achieved TSAG recommendations are excellent – but much remains to be implemented Expect many years of dedicated work to come Expect (and work to overcome) setbacks and delays Know that the industry still has enormous resources and influence – but also that the peak and decline in tobacco internationally will come We need to continue on with the full range of recommendations in TSAG.

What are the transferable lessons? There are parallels with other “unhealthy commodities”. Unhealthy foods Inadequate physical activity Unsafe alcohol consumption Vinyl chloride, asbestos, cars Underlying common strategies of unhealthy commodity industries: Seek to bias research findings Co-opt policy makers and health professionals Lobby politicians and public officials to oppose public regulation Encourage voters to oppose public health regulation To deflect criticism - promote actions outside their areas of expertise Conclusion - there is little objective evidence that public–private partnerships deliver health benefits Sources: Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Rob Moodie et al, on behalf of The Lancet NCD Action Group - Lancet 2013; 381: 670–79. Why corporate power is a public health priority. Gerard Hastings. BMJ August 2012:345 There are industries that drive these other public health issues: climate change denial is another example (Canada’s Food Guide; Low Risk Drinking Guidelines) In industrial epidemics, the vectors of spread are not biological agents, but transnational corporations. Unlike infectious disease epidemics, however, these corporate disease vectors implement sophisticated cam paigns to undermine public health interventions. To minimise the harmful eff ects of unhealthy commodity industries on NCD prevention, we call for a substantially scaled up response from governments, public health organisations, and civil society to regulate the harmful activities of these industries. Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries Rob Moodie, David Stuckler, Carlos Monteiro, Nick Sheron, Bruce Neal, Thaksaphon Thamarangsi, Paul Lincoln, Sally Casswell, on behalf of The Lancet NCD Action Group - Lancet 2013; 381: 670–79 Center for Alcohol Policies, an organisation established and funded by large global alcohol producers, commissioned reports from scientists that resemble WHO documents. These reports were “incomplete, not subject to traditional peer review, and either supportive of industry positions or emphasizing high levels of disagreement among scientists”.56 Industry strategies: The first strategy is to bias research findings. The second strategy is to co-opt policy makers and health professionals. SAB Miller and the International Center for Alcohol Policies have assisted the Lesotho, Malawi, Uganda, and Bostwana Governments to write their national alcohol control policies. The third strategy is to lobby politicians and public officials to oppose public regulation. According to US Senate records, the largest alcohol companies spent US$150 million lobbying compared with $40 million for tobacco between 1999 and 2011. In another example, the Sugar Association threatened WHO that it would lobby the US Government to withdraw its funding because WHO strategy on diet, physical activity, and health highlighted a strong link between sugar and NCD risk. The fourth strategy is to encourage voters to oppose public health regulation. For example, the tobacco industry has, and continues to campaign for, a restricted role of government, and against taxation and regulation. Their campaigns emphasise that tobacco use is an individual responsibility and raise arguments against so called nanny state governments. As an alter native to regulatory measures, alcohol and food indus tries promote ineff ective individually-targeted infor mation and educational approaches,49,68–72 and sometimes employ counter-productive covert marketing.17,49,72–75 From the denial of tobacco addiction as late as 199476 to the obstruction of traffi c-light labelling of unhealthy food77 and the recent detraction of alcoholic drinks from EU labelling legislation,78 the tobacco, alcohol, and food industries have all tried to block access to objective health information and to manipulate channels of communication.56,72,73 To deflect criticism, corporations promote actions outside their areas of expertise. For example, tobacco corporations promote the prevention of violence against women79 and ultra-processed food and drink corporations emphasise physical inactivity.3 Tobacco and alcohol producers also highlight illegal distribution and smuggling to deter policy makers from introducing regulation that will curtail their own activity.80 histories of joint ownership—eg, Philip Morris owned both Kraft and Miller Brewing;81 Altria is a lead shareholder in tobacco and food companies that have shared directorships;50 SAB Miller Board includes at least fi ve past or present tobacco company executives and board members;40 and the Diageo Executive Director, responsible for public aff airs, spent 17 years in a similar However, there is little objective evidence that public–private partnerships deliver health benefits, and many in the public health fi eld argue that they are just a delaying tactic of the unhealthy commodity industries. 10,91–

What are the transferable lessons? There are transferable strategies. Healthy Kids Panel recommendations (re healthy weights in children) National Alcohol Strategy recommendations Commonly recommended strategies Whole of government approach Government outreach and funding to partners Safe / healthy consumption standards Restrictions on marketing / product placement / outlet density (eg. maintain the LCBO) Product content disclosure / signage Public awareness raising School programs Surveillance and public reporting Healthcare interventions Protection of vulnerable populations / poverty reduction / youth Legislation enforcement Ongoing research There are industries that drive these other public health issues: climate change denial is another example (Canada’s Food Guide; Low Risk Drinking Guidelines) In industrial epidemics, the vectors of spread are not biological agents, but transnational corporations. Unlike infectious disease epidemics, however, these corporate disease vectors implement sophisticated cam paigns to undermine public health interventions. To minimise the harmful eff ects of unhealthy commodity industries on NCD prevention, we call for a substantially scaled up response from governments, public health organisations, and civil society to regulate the harmful activities of these industries. Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries Rob Moodie, David Stuckler, Carlos Monteiro, Nick Sheron, Bruce Neal, Thaksaphon Thamarangsi, Paul Lincoln, Sally Casswell, on behalf of The Lancet NCD Action Group - Lancet 2013; 381: 670–79 Center for Alcohol Policies, an organisation established and funded by large global alcohol producers, commissioned reports from scientists that resemble WHO documents. These reports were “incomplete, not subject to traditional peer review, and either supportive of industry positions or emphasizing high levels of disagreement among scientists”.56 Industry strategies: The first strategy is to bias research findings. The second strategy is to co-opt policy makers and health professionals. SAB Miller and the International Center for Alcohol Policies have assisted the Lesotho, Malawi, Uganda, and Bostwana Governments to write their national alcohol control policies. The third strategy is to lobby politicians and public officials to oppose public regulation. According to US Senate records, the largest alcohol companies spent US$150 million lobbying compared with $40 million for tobacco between 1999 and 2011. In another example, the Sugar Association threatened WHO that it would lobby the US Government to withdraw its funding because WHO strategy on diet, physical activity, and health highlighted a strong link between sugar and NCD risk. The fourth strategy is to encourage voters to oppose public health regulation. For example, the tobacco industry has, and continues to campaign for, a restricted role of government, and against taxation and regulation. Their campaigns emphasise that tobacco use is an individual responsibility and raise arguments against so called nanny state governments. As an alter native to regulatory measures, alcohol and food indus tries promote ineff ective individually-targeted infor mation and educational approaches,49,68–72 and sometimes employ counter-productive covert marketing.17,49,72–75 From the denial of tobacco addiction as late as 199476 to the obstruction of traffi c-light labelling of unhealthy food77 and the recent detraction of alcoholic drinks from EU labelling legislation,78 the tobacco, alcohol, and food industries have all tried to block access to objective health information and to manipulate channels of communication.56,72,73 To deflect criticism, corporations promote actions outside their areas of expertise. For example, tobacco corporations promote the prevention of violence against women79 and ultra-processed food and drink corporations emphasise physical inactivity.3 Tobacco and alcohol producers also highlight illegal distribution and smuggling to deter policy makers from introducing regulation that will curtail their own activity.80 histories of joint ownership—eg, Philip Morris owned both Kraft and Miller Brewing;81 Altria is a lead shareholder in tobacco and food companies that have shared directorships;50 SAB Miller Board includes at least fi ve past or present tobacco company executives and board members;40 and the Diageo Executive Director, responsible for public aff airs, spent 17 years in a similar However, there is little objective evidence that public–private partnerships deliver health benefi ts, and many in the public health fi eld argue that they are just a delaying tactic of the unhealthy commodity industries. 10,91–

Final Thoughts Tobacco is the industry-driven cause of the greatest loss of life in modern history We have made very difficult and slow progress – but indeed we have progressed Much remains to be achieved in Ontario Things will get worse before they get better internationally There are transferable insights regarding other industry-driven challenges to public health Tribute to Heather Crowe, lung cancer victim of ETS in the workplace, and advocate for smoke-free legislation