1. TOBACCO Lessons from the Battles of a Half Century
Charles Gardner, MD, CCFP, MHSc, FRCPC MOH, Simcoe Muskoka District Health Unit May, 2013

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 understanding the actions that local public health departments have taken to lessen the burden of tobacco- attributed disease
To identify transferable lessons regarding other prominent causes of chronic disease

4. One-Billion Deaths…
…may occur globally in the 21st century from tobacco use (WHO, 2008).
“Cigarettes are the only legal product that, when used as intended, are lethal”
Despite this, things have really changed since 1964 (or even )
Majority of adult males (including physicians) were smokers
Smoking at board of health meetings … and at Ministry / MOH meetings
Smoking in all indoor public places
No real restrictions on tobacco marketing activities

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

6. The rise and fall of tobacco use and disease

7. Progress: Tobacco mortality has declined relative to other risk factors
Source: SEVEN MORE YEARS: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario. Institute for Clinical Evaluative Sciences, Public Health Ontario

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

9. Some key questions How did we get here? Where do we go from here?
What lessons can be applied to other leading preventable cause(s) of death?

10. Tobacco — Part of “the Columbian Exchange”
Tobacco’s origin in the Americas:
Nicotiana rustica, N. tobacum
Spread rapidly as a practice and a crop
Jamestown V., southern US, Caribbean, China – “1,000% return on investment”
Local impacts on agricultural development
Soil depletion, displacement of food crops
Sources:1493: Uncovering the New World Columbus Created. Charles Mann, Smoke and Mirrors. The Canadian Tobacco War. Rob Cunningham, 1996.

11. 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?
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

12. 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 40s
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

13. 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

14. 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

15. Surgeon General’s Report, 1964

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

17. Surgeon General Reports: Progression
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

18. 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
WHO 1999
US National Toxicology Program in 2000
Actions will Speak Louder than Words (1999)
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

19. Research Methods and Foci
Tobacco is one of the most well researched areas of public health practice
Topics
Disease in users
Disease with ETS
Use patterns over time (gender, SES)
Effectiveness of interventions / essential program components (including state-wide programs)
Activities of the industry
Political dynamics
Methods
Case control, cohort, RCT, pathophysiology, environmental metrics, review of historical / industry documents, interviews, media coverage

20. 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)

21. 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

22. 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)

23. 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 secondhand 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.

24. 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

25. 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)

26. 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
Tobacco Restraint Act, 1908
Prohibited sales under 16
Judy LaMarsh, Minister of Health and Welfare, acknowledged the harmfulness of smoking in 1963
National Tobacco Control Strategy commenced in 1986

27. Government Response: Federal
1988 – smoke-free (federal) workplaces and designated smoking areas on planes, trains, ships (Non-Smokers’ Health Act); prohibited advertising (Hazardous Products Act and Tobacco Products Control Act – sections ruled unconstitutional by Supreme Court);
Prohibited sales under 18; vending machines in bars only (Tobacco Sales to Young Persons Act )
1997, still in effect - Tobacco Act
Disclose product content, prohibited sale to youth, prohibited mail- order and vending machines, warning labels, restricted advertising
Tobacco taxation increase in the 1980s – 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

28. Government Response: Provincial (Ontario and others)
For 98 years (1892 to 1990) the provincial government of Ontario did not pass tobacco control legislation
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 healthcare facilities, pharmacies, schools and colleges and in other retail and institutional settings
Enabled municipal smoking bylaws

29. 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

30. 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 to 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

31. 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, 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 percent, or by approximately billion cigarettes, since 2003
Government announced renewal of SFO in 2011 – $5 M reinvestment. Emphasis on cessation and contraband reduction

32. 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

33. Effectiveness of indoor public space ETS prohibition
California’s tobacco control program – including 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 % 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 )
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. The Impact of Government Decisions
Past-Year Smoking, by grades 7-12, Ontario,
Source: 2012 Smoke-Free Ontario Strategy Evaluation Report, Ontario Tobacco Research Unit:

35. 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 – 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)

36. 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,

37. 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

38. 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

39. 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

40. 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.

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

42. 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%

43. 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
Tobacco growing:
Increase restrictions beyond federal government requirements – legislation review to regulate raw tobacco

44. TSAG Implementation Strategies commenced: Prevention: Cessation:
Peer-to-peer youth work, school policy development (provincial support for local public health work)
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
Target high-risk groups (some local initiatives)
BCI guidelines
Telephone-based support

45. 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
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)

46. TSAG Implementation
Strategies awaiting commencement / uncertain status:
Sufficient resources
Current strategy funding is 47.8 million (this includes the $5M enhancement in 2011)
Reported in TSAG report (2010) 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
Restrict waterpipes (2 municipal bylaws)

47. TSAG Implementation
Strategies awaiting commencement / uncertain status:
Price
Minimum product price
Increase price / tax
However, federal government closed tax loophole on roll- your-own tobacco
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

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

49. 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
Reduce disparities
Incorporate equity considerations broadly

50. TSAG Implementation
Strategies awaiting commencement / uncertain status:
Protection
Amend SFO to eliminate smoking in patios, hotels, doorways, playgrounds (local public health action re bylaws – 75+ outdoor smoking amendments)
Restrict water-pipes
Increase fines
Amend Residential Tenancies Act to allow smoke-free MUDs a material term of leases (local municipal initiatives – now smoke-free community housing buildings in Ontario)
Tax credits for smoke-free affordable housing

51. 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

52. 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

53. 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

54. 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 (if 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

55. 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

56. What are the transferable lessons?
There are parallels with other major public health issues.
Unhealthy foods
Inadequate physical activity
Unsafe alcohol consumption
There are transferable strategies.
Healthy Kids Panel recommendations
National Alcohol Strategy recommendations
Whole of government approach
Restrictions on marketing / product placement / outlet density
Product content disclosure / signage
Public awareness raising
School programs
Surveillance
Healthcare interventions
Vulnerable populations / poverty reduction
Ongoing research

57. 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