Transcript Position Enhancement Summary

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:
1. Understand health promotion approaches to public
health practice
2. Understand the difference between primary,
secondary and tertiary prevention strategies
3. 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 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:
1.
Cardiovascular disease
2.
Cancer
3.
Diabetes
4.
Chronic lung disease
WHO. 2010. Global Status Report on NCDs.
WHO. 2010. Global Status Report on NCDs.
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
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.
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
The Breadth of Health Impacts of Tobacco:
Surgeon General’s Report 2010
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.
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
The Rise and Fall of Tobacco Use and Disease
Male Lung Cancer Mortality
Female Lung Cancer Mortality
2006
Smoke-Free Ontario Act
prohibited smoking in all
workplaces and enclosed
public spaces.
1914-1918
WWI: Cigarettes sent overseas to
soldiers as an act of patriotism
1964
1984
US Surgeon General
Report on Smoking
Major tax increases
on tobacco products
2000
Series of health warnings
appear on cigarette packages
Data Source: Holowaty E, Chin Cheong S, Di Cori S, Garcia J, Luk R, Lyons C, Thériault ME. 2002. Tobacco or health in
Ontario: Tobacco-attributed cancers and deaths over the past 50 years... and the next 50. Division of Preventive Oncology,
Cancer Care Ontario; May 2002
http://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=14456
Stages of the Tobacco Epidemic
Internationally
Tobacco Control, 1994; 3, 242-247
Progress: Tobacco mortality in
Ontario 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
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
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
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
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
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
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
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)
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
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)
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
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)
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
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
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
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
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
Source: 2012 Smoke-Free Ontario Strategy Evaluation Report, Ontario Tobacco Research Unit: http://otru.org/2012-smoke-free-ontario-strategyevaluation-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)
OTRU Report 2012
Prevention:
• 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/
Ontario and other provinces
Current Smoking (Past 30 Days), by Jurisdiction, Ages 12+, 2010
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
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
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 smokefree 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
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 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)
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
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 (movies and internet –
Cannes award for creativity)
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
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
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.”
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
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
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
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
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
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
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
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