1. TOBACCO Lessons from the Battles of a Half Century Charles Gardner, MOH, Simcoe Muskoka District Health Unit Vito Chiefari, Manager of Health Protection Division, York Region, Co-Chair of provincial Tobacco Control System Committee

2. 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 Mason-Smith, ADM of Health Promotion Division, MOHLTC  Michael Perley, E.D., OCAT  Richard Schabas, MOH, HPEHU; former CMOH ON.

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

4. One-Billion Deaths… …may occur globally in the 21 st century from tobacco use.  “Cigarettes are the only legal product that, when used as intended, are lethal”  Despite this, things have really changed since 1964 (or even 1984) Majority of adult males (including physicians) were smokers Smoking at board of health meetings … and at Ministry / MOH meetings Smoking in all indoor public places No real restrictions on tobacco marketing activities

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

7. Progress: Tobacco is no longer “the number one preventable cause of death” Source: SEVEN MORE YEARS: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario. Institute for Clinical Evaluative Sciences, Public Health Ontario

8. Taking stock of the present status of tobacco control in Ontario Research, surveillance and KE Strategies – Prevention, Protection, Cessation National, provincial and municipal legislation Litigation Public health programs NGO advocacy / public education Health care system supports for cessation Public support for the above But … ongoing dedicated opposition from the industry… and thus despite 60 years of evidence supporting action, 1 / 5 adults still smoke; 13,000 deaths annually in Ontario

9. Some key questions 1.How did we get here? 2.Where do we go from here? 3.What lessons can be applied to the other “number one preventable cause(s) of death”?

10. Phases of the Tobacco Epidemic P HASE I: 1884-1914 Consolidation of the Cigarette Industry and Early Controversies P HASE II:1914-1950 Era of Good Feeling; Cigarettes Promoted by Governments P HASE III:1950-1964 The Gathering Storm of Health Concerns P HASE IV: 1964-1984 Regulatory Hesitancy P HASE V: 1984-2008 Tobacco as Social Menace P HASE VI: The Future Neoprohibitionism versus harm reduction? Source: Local Tobacco Control Coalitions in the United States and Canada: Contagion Across the Border? Stephanie J. Frisbee, PhD, and Donley T. Studlar, PhD. Presented at: 11th Annual Conference of the Canadian Political Science Association May 16 ‐ 18, 2011, Wilfrid Laurier University, Waterloo, ON

11. Research: Early Concerns Early health (and moral) concerns:  “loathsome to the eye, hatefull to the nose, and harmefulle to the braine”, King James I, 17th century Scientific reports as early as 1912 re lung cancer Concerns in the 1920’s to 40’s  Reader’s Digest in 1924; Science in 1938 (Johns Hopkins biostats study – reduced longevity); small study in Germany in 1939 re increased lung cancer with smoking; Departments of Pensions and National Health in 1940

12. Research: The Evidence Gathers 1947 – Norman Delarus (Canadian), case (50) control study re lung cancer. 1950 – Evart Graham (USA), JAMA, case (605) control study re lung cancer (author quit smoking after study, but died of lung cancer in 1957). 1950 – Bradford Hill, Richard Doll, BMJ, 20 British hospitals, case control study, lung cancer.

13. 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

14. Surgeon General’s Report, 1964

15. Surgeon General Reports: Progression 1979 Much more strident language “The largest preventable cause of death” An addiction Reductions in use

16. Surgeon General Reports: Progression 1986 “Involuntary smoking” hazards ETS restrictions in 40 states and in DC “96 per cent of businesses have adopted smoking policies” Restrictions may reduce tobacco use – evaluation needed

17. Research / Analysis Ontario Council on Health report, Smoking and Health in Ontario: A Need for Balance,1982 USEPA in 1992 Australian National Health and Medical Research Council in 1997 California EPA in 1997 United Kingdom Scientific Committee on Tobacco and Health in 1998 WHO 1999 US National Toxicology Program in 2000 Protection from second-hand tobacco smoke in Ontario, OTRU, 2001 Evidence to Guide Action, PHO, 2010 The Tobacco Strategy Advisory Committee (TSAG) report and recommendations, 2010

18. Research Methods and Foci Topics Disease in users Disease with ETS Use patterns over time (gender, SES) Effectiveness of interventions Activities of the industry Political dynamics Methods Case control, cohort, RCT, environmental metrics, review of historical / industry documents, interviews, media coverage

19. The Industry’s Response Some historic milestones Macdonald Tobacco established in Montreal in 1858 Cigarette rolling machine in 1881; safe matches in 1890’s 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 Philip Morris International Japan Tobacco International-Macdonald James Albert Bonsack's cigarette rolling machine, invented in 1880 and patented in 1881. (Wikipedia)

20. 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

21. 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 ‐ Smoker’s 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  OMA: advocacy paper for smoke-free legislation (2003), cars and children (2004)

22. History of TC and Public Health in Ontario  Mandatory Health Programs and Services Guidelines 1984 – no tobacco control (only “Nutrition” re chronic disease prevention) 1989 – “Tobacco Use Prevention” –Objectives: 85% of adults (90% of teens) non-use of tobacco by 2000; 70% homes smoke-free –Actions: Liaison, school curriculum, smoke- free policies in workplaces, cessation, regulatory efforts re second-hand smoke  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.

23. History of TC and Public Health in Ontario  Mandatory Health Programs and Services Guidelines 1998 – “Chronic Diseases and Injuries” –Objectives: similar but targeting 2005; 90% tobacco vendor compliance –Actions: Similar, plus TCA enforcement  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

24. Historic government roles Tobacco promotion  Agricultural R&D, subsidies  Provision (military) Tobacco control  Sales (age, venders / vending) restrictions  Marketing / advertising / packaging (plain) / warnings (graphic)  Taxation  Research  Cessation supports  Location of use restrictions  Litigation  Partnerships  Public awareness and de-normalization  (Prohibition)

25. Government response: Federal  Resolution to ban tobacco, 1903 and 1904 – second reading only  Tobacco Restraint Act, 1908 Prohibited sales under 16  Judy LaMarsh, Minister of Health and Welfare, acknowledged the harmfulness of smoking in 1963  More than 20 private members bills in the 1960’s  National Tobacco Control Strategy commenced in 1986  Non-Smokers Health Act, 1988 Smoke-free federal workplaces; designated smoking areas on planes, trains, ships; prohibited advertising (Hazardous Products Act); health warnings on packaging

26. Government Response: Federal  Tobacco Products Control Act, 1988 Required to list additives Prohibited advertising – sections rule unconstitutional by the Supreme Court of Canada  Tobacco Sales to Young Persons Act, 1993 Prohibited sales under 18; vending machines in bars only  Tobacco Act 1997 – still in effect Product content, prohibited sale to youth, prohibited mail-order and vending machines, warning labels, restricted advertising  Tobacco taxation increase in the 1980’s – cut in 1994 (50%) resulted in 40,000 additional deaths  Federal tobacco graphic packaging – 2000; updated in 2012  Tobacco farms: quota buyout (replaced with manufacturer- controlled contract system) in 2008 increase in Ontario crop from 22 M pounds in 2009 to 50 M in 2010

27. Government response: Provincial (Ontario and others)  Prohibition of sale to minors – BC in 1891, ON (age 18) and NS in 1892, NB in 1893, NWT in 1896  Smoking in the Workplace Act, 1990 Minimum areas for nonsmoking (not enclosed and separately ventilated)  Tobacco Control Act, 1994 Ontario’s first general tobacco control statute Prohibition of sale in pharmacies and vending machines, to minors, allowed municipal bylaws for smoke-free spaces Smoking or holding lighted tobacco was prohibited in health care facilities, pharmacies, schools and colleges and in other retail and institutional settings

28. Government response: Provincial (Ontario and others)  “Actions will Speak Louder Than Words” policy document in 1999  Tobacco program funding: $4 M in 1995, $10M in 1999, to $60 M by 2006, to $45 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

29. Smoke-Free Ontario Act and Strategy, 2006  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 to quit;  Created and funded programs, including a peer-to-peer infrastructure, to prevent youth from starting to smoke;  Built partnerships with tobacco control stakeholders and supported their advocacy efforts at all levels of government;  Funded extensive awareness and social marketing initiatives;  Funded research capacity and training supports for health system workers. Dedicated SFO funding and programming for local public health Local, regional and provincial infrastructure (such as the Tobacco Control Area Networks – TCAN)

30. Ontario since 2009  Banned smoking in vehicles when children under 16 are present;  Passed legislation to allow the government to sue tobacco companies to recover past and ongoing health care costs due to tobacco-related illness; and  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 per cent, or by approximately 4.6 billion cigarettes, since 2003.

31. Municipal Bylaw Advocacy: Local Public Health and NGO Advocacy in the 1990’s / 2000’s  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 DSA’s – 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 2000’s - Set the stage for the SFOA  Much leadership, partnership and support from NGOs – OCAT in particular working closely with local public health

32. The Impact of Government Decisions Source: Smoke-Free Ontario Strategy Evaluation Report, Ontario Tobacco Research Unit: http://otru.org/2011-smoke- free-ontario-strategy-evaluation-report-full-reporthttp://otru.org/2011-smoke- free-ontario-strategy-evaluation-report-full-report

33. Effectiveness of indoor public space ETS prohibition California’s smoke-free legislation:  20% reduction in tobacco use (2X national rate of reduction)  Lung cancer reduction in men 1.5X national rate  Lung cancer reduction in women 4.8%, when increased by 13.2% in other states - (JAMA, Dec 2000)  CVD mortality reduction 2.93 deaths per 100,000 per year greater than the rate of reduction in the USA overall (NEJM Dec 2000) Toronto’s smoke-free bylaw:  admission to hospital because of cardiovascular conditions decreased by 39% (95% CI 38%–40%)  admissions because of respiratory conditions decreased by 33% (95 % CI 32%–34%). (CMAJ May 18, 2010 vol.)

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

35. 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

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

37. 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

38. 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?

39. 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?

40. 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.

41. What is the impact of SFO? OTRU Report 2011  Protects most Ontarians from ETS in the workplace and public places  Reduction in use, including youth  However, stalled reduction in low SES and in some health units  Protection: Reduction in ETS exposure 28% still exposed at work, and 31% still on restaurant patios Still some exposure in home / car (reduction over time) Source: OTRU review, http://otru.org/2011-smoke-free- ontario-strategy-evaluation-report-full-report/http://otru.org/2011-smoke-free- ontario-strategy-evaluation-report-full-report/

42. What is the impact of SFO? OTRU Report 2011 Prevention: Reduction in youth smoking Still over 20% youth / young adults smoke Less then half receive in-class discussion on tobacco Widespread contraband undermining progress Cessation: Only 1% reduction in smokers from 2007 to 2009 Intention to quit not increasing Provincial cessation supports only reaching 5% of smokers Need to double annual quit rate from 1.2% to 2.4% Source:OTRU review, http://otru.org/2011-smoke-free-ontario-strategy-evaluation-report- full-report/http://otru.org/2011-smoke-free-ontario-strategy-evaluation-report- full-report/

43. Ontario and other provinces Source: Smoke Free Ontario Strategy Evaluation Report. The Ontario Tobacco Research Unit. October 2011

44. Priority Populations

45. Source: Smoke Free Ontario Strategy Evaluation Report. The Ontario Tobacco Research Unit. October 2011 Priority Populations

46. 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.

47. Contraband Tobacco Source: Evidence to Guide Action: Comprehensive Tobacco Control in Ontario. Smoke Free Scientific Advisory Committee 2010. OAHPP

48. 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%

49. TSAG Implementation Strategies commenced:  Whole of government approach (e.g. Min of Revenue re contraband)  Price Premiers stated commitment to double enforcement re contraband Ministry of Revenue legislation review on enforcement, and engaging First Nations  Promotion: Refresh package warnings (done by federal government) 1-800 number

50. TSAG Implementation Strategies commenced:  Tobacco growing: Increase restrictions beyond federal government requirements – legislation review to regulate raw tobacco  Prevention: Peer to peer youth work, school policy development (provincial support for local public health work)  Cessation: Coordinated tobacco cessation services ODB coverage for cessation products Target high risk groups (some local initiatives) BCI guidelines Telephone-based support

51. 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 Campaigns to increase awareness of health effects, social influences, the perception of the industry, motivate to quit, counter messages in movies and games, end demand for contraband (provincial support for local public health work)

52. TSAG Implementation Strategies awaiting commencement / uncertain status:  Sufficient resources presently maintained at $3.29 per capita or $42.8 million, reduced from $60 million in the 2008/09 fiscal year (at least $100 M would be within the CDC recommendations)  Divestment of investments  Prevent industry interference in government policy (WHO guidelines)  Quick response teams to industry activities  Products: Prohibit flavoured smokeless tobacco Prohibit smokeless tobacco within 5 years Plain packaging Prohibit new tobacco products

53. TSAG Implementation Strategies awaiting commencement / uncertain status:  Price Minimum product price Increase price / tax Provincial marking for taxed tobacco Anti-contraband public education  Placement Designated retail outlets (like alcohol control) – further restrict locations Industry requirement to annually reduce youth uptake

54. TSAG Implementation Strategies awaiting commencement / uncertain status:  Promotion: Close advertising exemptions – packaging, accessories, movies Adult rates for movies and video games with tobacco imagery  Tobacco Growing: Work with partners to reduce tobacco produced over time (licenses, acreage, ceilings) Tobacco farm in Norfolk County, summer 2012 Wikipedia

55. TSAG Implementation Strategies awaiting commencement / uncertain status:  Cessation: Accountability mechanisms for providers re smoking cessation Accessible in all locations Engage insurance industry Address labeling issues and misinformation Available at retail level

56. TSAG Implementation Strategies awaiting commencement / uncertain status:  Reduce disparities Incorporate equity considerations broadly  Protection Amend SFO to eliminate smoking in patios, hotels, doorways, playgrounds (local public health action re bylaws) Restrict water-pipes  Increase fines  Amend Residential Tenancies Act to allow smoke-free MUDs a material term of leases (local municipal initiatives)  Tax credits for smoke- free affordable housing

57. TSAG Implementation Strategies awaiting commencement / uncertain status:  Funding adequacy Dedicated funding from tobacco taxes to tobacco control Financial penalties for the industry not meeting reduction targets to be directed to tobacco control Public health funding from tobacco settlements

58. 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

59. 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 commences plain packaging in 2012

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

61. What are the transferable lessons? 1.What are the take-away lessons from our half century struggle with tobacco? 2.Industry-driven health threats: What are other examples today? 3.What lessons from tobacco are transferable to other public health issues?

62. 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 may be transferable insights regarding other industry-driven challenges to public health.