Transcript Position Enhancement Summary

TOBACCO
Lessons from the Battles
of a Half Century
Charles Gardner, MD, CCFP, MHSc, FRCPC
Simcoe Muskoka District Health Unit
October, 2014
Acknowledgements
Insights and background materials from discussions with
the following:
 Robert Kyle, MOH Durham Region, former TSAG member
 David Butler-Jones, Former Chief Public Health Officer of Canada
 John Garcia, Assoc. Prof. and Dir., School of Public Health, U of Waterloo;
former Dir. of the Health Promotion Branch, ON. Min of Health
 Kate Manson-Smith, former ADM of Health Promotion Division, MOHLTC
 Michael Perley, E.D., OCAT
 Richard Schabas, MOH, HPEHU; former CMOH ON.
Learning Objectives
With regard to tobacco and its history:
 To understand the basic dynamics of an industry-driven
epidemic of chronic disease
 To understand the political and societal challenges to
implementing effective practices
 To understand the challenges and the roles of local public
health
 To identify transferable lessons regarding other prominent
causes of chronic disease
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 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
The rise and fall of tobacco use and
The Rise and Fall of Tobacco Use and Disease
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
Progress: Tobacco mortality has
declined relative to other risk factors
Source: SEVEN MORE YEARS: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in
Ontario. Institute for Clinical Evaluative Sciences, Public Health Ontario
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
Government Response: Provincial
(Ontario and others)
 Tobacco program funding:
• $4 M in 1995, $10M in 1999, to $60 M by 2006, to $47.8 M by
2011
 Provincial government suits
• BC in 2004, Supreme Court support
• Manitoba, Sask. Que., PEI, NS, NB have launched suits
• Enabling legislation in Ontario and Alberta
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 smokefree 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: 2014 Smoke Free Ontario Strategy Evaluation Report. The Ontario Tobacco Research Unit. January 2014
Bylaw advocacy: A local public health
experience, 2001-2003, Leeds,
Grenville Lanark (LGL)
The Tobacco Bylaw Campaign 2002

February 2002 – presentation of the survey results to the
Board of Health as a launch of the campaign
• Board endorsed the campaign, provided that we seek to
have a common bylaw for all 24 municipalities

Mailed position paper to municipal councils, partner
agencies, physicians, and businesses calling for their support
in our campaign
LGL Campaign 2002




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From March to July we presented to all 24 municipal councils
We also attended a number of public meetings, and meetings
with local Chambers of Commerce
Most municipal councils were openly opposed or even hostile to
our message
Public meetings were very emotional and difficult, with personal
verbal attacks – PUBCO involvement
Support came at surprising times and from surprising sources –
Brockville Chamber of Commerce
We engendered support…


Local hospital boards (five), CHC’s and medical advisory
committees communicated their support
Many other groups communicated their support in writing or at
public presentations
•
•
Canadian Cancer Society, Heart and Stroke Foundation, Cancer
Care Ontario, Health Care Network of SEO, LLG Health Forum,
Brockville YMCA
The DHC of SEO did not support our campaign
A campaign management question

Our first presentation was to the Smiths Falls Council. Within
a month Council prepared a motion that it is the decision of
private business to determine smoking restrictions.
•
It takes a two thirds majority for Council to overturn previous passed
motions
If you were the MOH what would you do?
Issues of Opposition

A common issue raised by the Councils was the potential cost
of enforcement.
If you were the MOH how would you address this?
Spring 2003

In July 2003 Brockville Council passed a new bylaw as follows:
•
•
•
•
Phasing out smoking in restaurants, bowling alleys by July 2004
DSR’s for legions, bingo halls
No restrictions on smoking in bars
The other municipalities made no or minimal changes to their
bylaws.
Expert Advice for Ontario:
Tobacco Strategy Advisory Group (TSAG)
 BUILDING ON OUR GAINS, TAKING ACTION NOW: ONTARIO’S
TOBACCO CONTROL STRATEGY FOR 2011 – 2016
 Based on EVIDENCE TO GUIDE ACTION – PHO
 Advice to government:
• Tobacco Control System Committee to advise the province on SFO
renewal implementation
 Targets to be achieved by 2016
• 5% reduction in tobacco use (490,000 fewer users)
• Reduce ETS – ban smoking on restaurant and bar patios, and allow
smoke-free leases in the Residential Tenancies Act
• Increase quitting rates and reduce reuptake rates
• Ban new tobacco products
• Reduce tobacco disease by 6.5%
• MOHLTC target – Ontario to have lowest rate of smoking in Canada
Tobacco Control System Committee
Smoke Free Ontario Strategy:
Tobacco Control System Committee
OTRU 2014 Report:
Smoking rates over time in Ontario
Source: 2014 Smoke-Free Ontario Strategy Monitoring Report. The Ontario Tobacco Research Unit. January 2014
Ontario and other provinces
Source: 2014 Smoke-Free Ontario Strategy Monitoring Report. The Ontario Tobacco Research Unit. January 2014
Priority Populations
Source: 2014 Smoke-Free Ontario Strategy Monitoring Report. The Ontario Tobacco Research Unit. January 2014
Priority Populations
.
Source: 2014 Smoke Free Ontario Strategy Evaluation Report. The Ontario Tobacco Research Unit. January 2014
The Impact of Smoke-Free Public /
Work Places (and the need for smokefree patios)
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.
TSAG Implementation
Highlights of Strategies Commenced:
 Whole of government approach
• Ministry of Health Action Plan: to have the lowest smoking rate in
the country
• Min of Finance re contraband - engagement of first nations re
contraband
 Tobacco growing:
• Raw leaf regulation commenced in January, 2015 – posted for
comment
 Cessation:
• Need to double annual quit rate from 1.6% in order to achieve TSAG
target of 5% reduction over 5 years (OTRU 2013 report)
• Coordinated tobacco cessation services
– hospital-based and workplace-based smoking cessation demonstration
grants
– increased access to counseling and pharmacotherapy through primary
care
– Provincial cessation supports reaching 5% of smokers (OTRU 2013
report)
• ODB coverage for prescription cessation products
TSAG Implementation
Strategies commenced:
 Research
• Provincial and local research, surveillance and monitoring – re
initiatives, programs, policies, disparities, youth and young adult
prevention
 Reduce disparities
• Engage First Nations (Min of Finance)
 Social marketing
• Social smoking provincial commercial (“Stop the Denial” - movies
and internet re social smoking – Cannes award for creativity)
• TCANs – regional social marketing events (ex. CE – social supply
awareness videos – “Bad Ways to be Nice”)
• OPHEA school-based tobacco prevention pilot
TSAG Implementation
Strategies commenced:
Youth Smoking Prevention Act if reintroduced, would:
 Products: prohibit new products (ban flavored tobacco products
targeted at youth), restrict water pipes (enhanced testing for
tobacco content)
 Prohibit smoking on playgrounds, sport fields, and restaurant and
bar patios (local public health action re bylaws – 75+ outdoor
smoking amendments)
 Prohibit tobacco sales on post-secondary education campuses
and specified provincial government properties
Federal Budget 2014:
 Price: Increase price / tax ( $4 per carton)
TSAG Implementation
Strategies awaiting commencement / uncertain status:
 Sufficient resources (at least $100 M would be within the CDC
recommendations)
• Current strategy funding is $47.8 million (this includes the $5M
enhancement in 2011)
• Dedicated funding from tobacco taxes to tobacco control
• Public health funding from tobacco settlements
 Divestment of investments
 Products: plain packaging
 Price: Anti-contraband public education
 Promotion: Adult ratings for movies and video games with
tobacco imagery (local public health
advocacy)
TSAG Implementation
Strategies awaiting commencement / uncertain status:
 Tobacco Growing: Work with partners to reduce tobacco
production over time (licenses, acreage, ceilings)
 Protection
• Smoke-free Multiunit Dwellings:
– Amend Residential Tenancies Act to allow smoke-free MUDs a
material term of leases (local municipal initiatives – now 75 +
smoke-free community housing
buildings in Ontario)
– Tax credits for smoke-free
affordable housing
OTRU Report 2013
 Protection:
•
•
•
•
•
Reduction in ETS exposure over 5 years
No reduction in ETS for blue collar workers
31% exposed on restaurant / bar patios
8 % of aged 12 to 19 still exposed in homes – declining
MUD’s, patios, outdoors and social exposures continuing
 Prevention:
• Reduction in youth smoking – has slowed recently
• Initiation among young adults (18% for females and 28% for
males aged 20 to 24) – evidence needed on targeted
programs
• Need to focus on high-risk schools / youth who also have a
high prevalence of other risk behaviors
OTRU Report 2013
Cessation:
• Need to more than double the quit rate (1.6% annually) to
achieve 5% reduction over 5 years
• Need to increase taxes – Ontario’s prices among the lowest in
Canada
• Need to increase social marketing (“Quit the Denial” re social
smoking)
• Need to have more sustained, funded campaign for cessation –
5% attempt, with limited awareness of supports (Smokers’
Helpline, the STOP program, the Ottawa model, and the
Ontario Drug Benefit program)
• fund considerable efforts to train health professionals in
providing cessation support through TEACH, RNAO, and
PTCC. Evidence from TEACH and RNAO
Source: OTRU review, http://otru.org/2014-smoke-free-ontario-strategy-evaluation-report-full-report/
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.”
Source: Passport The Future of Tobacco. Euromonitor. September 2011
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
Australia’s Success
• Among people aged 14 and older, daily smoking declined
significantly between 2010 and 2013 (from 15.1% to 12.8%).
Source: Authoritative information and statistics to promote better health and wellbeing
(AIHW), Australian Institute of Health and Wellness, 2013
Australia’s Success
Big Tobacco's smoke and mirrors won't work this time
The Drum
By Simon Chapman
Updated Wed 23 Jul 2014, 8:18am AEST
Photo: Big Tobacco won't admit it, but smoking rates
have plummeted. (ABC News: Nic MacBean)
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?
What next?
What is our end-game? Provincially? Internationally?
How should local public health be positioned in this?
• We have achieved much – and much remains to be achieved
• TSAG recommendations are excellent – but much remains to
be implemented
• Expect many years of dedicated work to come
• Expect (and work to overcome) setbacks and delays
• Emerging issues and surprises (such as e-cigarettes and waterpipes)
• 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?
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 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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•
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•
•
•
•
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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