1. 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

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

3. 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.

4. 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 )
World Health Organization(WHO). Health Promotion Glossary. Geneva: WHO/HPR/HEP/98.1.

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

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

7. 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.

8. 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.

9. 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.

10. Diffusion of Innovation Theory

11. 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.

12. 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: WHO/HPR/HEP/98.1.
Chapman S. Advocacy for public health :a primer. J EpidemiolCommunity Health 2004; 58:

13. 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:

14. 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:

15. 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:

16. 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 Global Status Report on NCDs.

17. WHO. 2010. Global Status Report on NCDs.

18. 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 Global Status Report on NCDs.

19. 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 – October 18,  
A report of the Smoke-Free Ontario – Scientific Advisory Committee. Evidence to Guide Action: Comprehensive Tobacco Control in Ontario
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 May;102(5):
Brandt, A. Inventing Conflicts of Interest: A History of Tobacco Industry Tactics. Am J Public Health Jan, Vol. 102, No. 1, pp

20. 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

21. 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 (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.

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

23. 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 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.

24. 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 WHO Global Report: Mortality Attributable to Tobacco.

25. 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

26. Stages of the Tobacco Epidemic Internationally
Tobacco Control, 1994; 3,

27. 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

28. 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, 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

29. 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

30. Phases of the Tobacco Epidemic
PHASE I: Consolidation of the Cigarette Industry and Early Controversies PHASE II: Era of Good Feeling; Cigarettes Promoted by Governments PHASE III: The Gathering Storm of Health Concerns PHASE IV: Regulatory Hesitancy PHASE V: 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:
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

31. 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 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.

32. 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
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

33. 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

34. 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

35. 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
California EPA, 1997
United Kingdom Scientific Committee on Tobacco and Health,
WHO, 1999
Actions will Speak Louder than Words,1999
US National Toxicology Program, 2000
Protection from secondhand tobacco smoke in Ontario, OTRU,
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/

36. 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 (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

37. 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 Jan, Vol. 102, No. 1, pp

38. 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)

39. 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

40. 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
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)

41. 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
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)

42. 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 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

43. 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

44. 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 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

45. 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

46. The Impact of Government Decisions
Past-Year Smoking, by grades 7-12, Ontario,
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:

47. 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): Also shows reduction in smoke exposure in homes for all ages, but lower for adults than children

48. 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,
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.

49. 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

50. 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

51. 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

52. 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

53. 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 Physicians for a Smoke-Free Canada.

54. Moving Forward in Ontario: Tobacco Strategy Advisory Group (TSAG)
BUILDING ON OUR GAINS, TAKING ACTION NOW: ONTARIO’S TOBACCO CONTROL STRATEGY FOR 2011 –
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)

55. 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, 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:
If you need anything further please let me know.
Compliance Programs Division  |  Tel.: 
1550 Bayly Street                      |  Fax: 
Pickering ON  L1W 3W1             |   

56. 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, 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:
If you need anything further please let me know.
Compliance Programs Division  |  Tel.: 
1550 Bayly Street                      |  Fax: 
Pickering ON  L1W 3W1             |   

57. 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

58. 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

59. 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

60. 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

61. Tobacco in China

62. 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 %
- Suriname %
- Dominica %
- T&T %
World Drug Report 2010
Courtesy of Jeffrey Edwards MD, Doctorate of Public Health candidate, University of the West Indies

63. 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”

64. 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

65. 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.

66. 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 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 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–

67. 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 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 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–

68. 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