1. TOBACCO Lessons from the Battles of a Half Century Charles Gardner, MD, CCFP, MHSc, FRCPC Simcoe Muskoka District Health Unit October, 2014

2. Acknowledgements Insights and background materials from discussions with the following:  Robert Kyle, MOH Durham Region, former TSAG member  David Butler-Jones, Former 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, former ADM of Health Promotion Division, MOHLTC  Michael Perley, E.D., OCAT  Richard Schabas, MOH, HPEHU; former CMOH ON.

3. Learning Objectives With regard to tobacco and its history:  To understand the basic dynamics of an industry-driven epidemic of chronic disease  To understand the political and societal challenges to implementing effective practices  To understand the challenges and the roles of local public health  To identify transferable lessons regarding other prominent causes of chronic disease

4. One-Billion Deaths… …may occur globally in the 21st century from tobacco use (WHO, 2008)  100 million deaths in the 20 th century  “Cigarettes are the only legal product that, when used as intended, are lethal”  Despite this, things have really changed 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

5. The Breadth of Health Impacts of Tobacco: Surgeon General’s Report 2010

6. The rise and fall of tobacco use and disease

7. Progress: Tobacco mortality has declined relative to other risk factors 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

8. 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

9. Some key questions re tobacco and its history 1.How did we get here? Understanding the basic dynamics of an industry-driven epidemic 2.Where do we go from here?  Understanding the political challenges of implementing effective practices 3.What lessons can be applied to other leading preventable cause(s) of death? Identifying transferable lessons regarding other prominent causes of chronic disease

10. 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? 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

11. 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

12. 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

13. 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 on Tobacco

14. 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

15. 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

16. James Albert Bonsack's cigarette rolling machine, invented in 1880 and patented in 1881. (Wikipedia) 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

17. 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

18. 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)

19. 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

20. 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)

21. 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

22. 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

23. Government Response: Provincial (Ontario and others)  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

24. 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

25. 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

26.  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 Local Public Health and NGO Advocacy in the 1990s / 2000s

27. The Impact of Government Decisions Source: 2014 Smoke Free Ontario Strategy Evaluation Report. The Ontario Tobacco Research Unit. January 2014 Past-Year Smoking, by grades 7-12, Ontario, 1977-2011

28. Bylaw advocacy: A local public health experience, 2001-2003, Leeds, Grenville Lanark (LGL)

29. The Tobacco Bylaw Campaign 2002  February 2002 – presentation of the survey results to the Board of Health as a launch of the campaign Board endorsed the campaign, provided that we seek to have a common bylaw for all 24 municipalities  Mailed position paper to municipal councils, partner agencies, physicians, and businesses calling for their support in our campaign

30. LGL Campaign 2002  From March to July we presented to all 24 municipal councils  We also attended a number of public meetings, and meetings with local Chambers of Commerce  Most municipal councils were openly opposed or even hostile to our message  Public meetings were very emotional and difficult, with personal verbal attacks – PUBCO involvement  Support came at surprising times and from surprising sources – Brockville Chamber of Commerce

31. We engendered support…  Local hospital boards (five), CHC’s and medical advisory committees communicated their support  Many other groups communicated their support in writing or at public presentations Canadian Cancer Society, Heart and Stroke Foundation, Cancer Care Ontario, Health Care Network of SEO, LLG Health Forum, Brockville YMCA The DHC of SEO did not support our campaign

32. A campaign management question  Our first presentation was to the Smiths Falls Council. Within a month Council prepared a motion that it is the decision of private business to determine smoking restrictions. It takes a two thirds majority for Council to overturn previous passed motions If you were the MOH what would you do?

33. Issues of Opposition  A common issue raised by the Councils was the potential cost of enforcement. If you were the MOH how would you address this?

34. Spring 2003  In July 2003 Brockville Council passed a new bylaw as follows: Phasing out smoking in restaurants, bowling alleys by July 2004 DSR’s for legions, bingo halls No restrictions on smoking in bars The other municipalities made no or minimal changes to their bylaws.

35. Expert Advice for 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 (490,000 fewer users) 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% MOHLTC target – Ontario to have lowest rate of smoking in Canada

36. Tobacco Control System Committee

37. Smoke Free Ontario Strategy: Tobacco Control System Committee

38. OTRU 2014 Report: Smoking rates over time in Ontario Source: 2014 Smoke-Free Ontario Strategy Monitoring Report. The Ontario Tobacco Research Unit. January 2014

39. Ontario and other provinces Source: 2014 Smoke-Free Ontario Strategy Monitoring Report. The Ontario Tobacco Research Unit. January 2014

40. Priority Populations Source: 2014 Smoke-Free Ontario Strategy Monitoring Report. The Ontario Tobacco Research Unit. January 2014

41. Priority Populations Source: 2014 Smoke Free Ontario Strategy Evaluation Report. The Ontario Tobacco Research Unit. January 2014.

42. The Impact of Smoke-Free Public / Work Places (and the need for smoke- free patios)

43. Contraband Tobacco 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.

44. TSAG Implementation Highlights of Strategies Commenced:  Whole of government approach Ministry of Health Action Plan: to have the lowest smoking rate in the country Min of Finance re contraband - engagement of first nations re contraband  Tobacco growing: Raw leaf regulation commenced in January, 2015 – posted for comment  Cessation: Need to double annual quit rate from 1.6% in order to achieve TSAG target of 5% reduction over 5 years (OTRU 2013 report) Coordinated tobacco cessation services –hospital-based and workplace-based smoking cessation demonstration grants –increased access to counseling and pharmacotherapy through primary care –Provincial cessation supports reaching 5% of smokers (OTRU 2013 report) ODB coverage for prescription cessation products

45. TSAG Implementation Strategies commenced:  Research 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 (“Stop the Denial” - movies and internet re social smoking – Cannes award for creativity) TCANs – regional social marketing events (ex. CE – social supply awareness videos – “Bad Ways to be Nice”) OPHEA school-based tobacco prevention pilot

46. TSAG Implementation Strategies commenced: Youth Smoking Prevention Act if reintroduced, would:  Products: prohibit new products (ban flavored tobacco products targeted at youth), restrict water pipes (enhanced testing for tobacco content)  Prohibit smoking on playgrounds, sport fields, and restaurant and bar patios (local public health action re bylaws – 75+ outdoor smoking amendments)  Prohibit tobacco sales on post-secondary education campuses and specified provincial government properties Federal Budget 2014:  Price: Increase price / tax ( $4 per carton)

47. 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: plain packaging  Price: Anti-contraband public education  Promotion: Adult ratings for movies and video games with tobacco imagery (local public health advocacy)

48. TSAG Implementation Strategies awaiting commencement / uncertain status:  Tobacco Growing: Work with partners to reduce tobacco production over time (licenses, acreage, ceilings)  Protection 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

49. OTRU Report 2013  Protection: Reduction in ETS exposure over 5 years No reduction in ETS for blue collar workers 31% exposed on restaurant / bar patios 8 % of aged 12 to 19 still exposed in homes – declining MUD’s, patios, outdoors and social exposures continuing  Prevention: Reduction in youth smoking – has slowed recently Initiation among young adults (18% for females and 28% for males aged 20 to 24) – evidence needed on targeted programs Need to focus on high-risk schools / youth who also have a high prevalence of other risk behaviors

50. OTRU Report 2013 Cessation: Need to more than double the quit rate (1.6% annually) to achieve 5% reduction over 5 years Need to increase taxes – Ontario’s prices among the lowest in Canada Need to increase social marketing (“Quit the Denial” re social smoking) Need to have more sustained, funded campaign for cessation – 5% attempt, with limited awareness of supports (Smokers’ Helpline, the STOP program, the Ottawa model, and the Ontario Drug Benefit program) fund considerable efforts to train health professionals in providing cessation support through TEACH, RNAO, and PTCC. Evidence from TEACH and RNAO Source: OTRU review, http://otru.org/2014-smoke-free-ontario-strategy-evaluation-report-full-report/http://otru.org/2014-smoke-free-ontario-strategy-evaluation-report-full-report/

51. International trends (from the industry) Source: Passport The Future of Tobacco. Euromonitor. September 2011 “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.”

52. 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

53. Australia’s Success Among people aged 14 and older, daily smoking declined significantly between 2010 and 2013 (from 15.1% to 12.8%). Source: Authoritative information and statistics to promote better health and wellbeing (AIHW), Australian Institute of Health and Wellness, 2013

54. Australia’s Success Big Tobacco's smoke and mirrors won't work this time The Drum By Simon ChapmanSimon Chapman Updated Wed 23 Jul 2014, 8:18am AEST Photo: Big Tobacco won't admit it, but smoking rates have plummeted. (ABC News: Nic MacBean)

55. 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.

56. What next? What is our end-game? Provincially? Internationally? How should local public health be positioned in this?

57. 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 Emerging issues and surprises (such as e-cigarettes and water- pipes) Know that the industry still has enormous resources and influence – but also that the peak and decline in tobacco internationally will come

58. What are the transferable lessons? 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

59. 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

60. 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

61. 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