GHEI Module 4C: Fundamentals of Public Health Practice

1. GHEI Module 4C:Fundamentals of Public Health Practice • Charles Gardner, MD, CCFP, MHSc, FRCPC • Medical Officer of Health, • Simcoe Muskoka District Health Unit • September 3, 2013

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

3. Objectives: • Understand health promotion approaches to public health practice • Understand the difference between primary, secondary and tertiary prevention strategies • Become familiar with the current challenges and opportunities for global tobacco control efforts, drawing upon the history of tobacco control in Canada and Ontario, with reflections on transferable lessons regarding other health hazards.

4. Health Promotion • Health: “A state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity.” (WHO 1948) • Health for all: “The attainment by all the people of the world of a level of health that will permit them to lead a socially and economically productive life.” (WHO 1984) • Health promotion: “The process of enabling people to increase control over their health and its determinants, and thereby improve their health.” (Ottawa Charter 1986) World Health Organization(WHO). Health Promotion Glossary. Geneva: 1998. WHO/HPR/HEP/98.1.

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

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

7. Bangkok Charter (2005) • Critical issues: Globalization as a source of challenges and opportunities; Need for policy coherence • Key Commitments to make the promotion of health: • central to the global development agenda • a core responsibility for all of government • a key focus of communities and civil society • a requirement for good corporate practice. Bangkok Charter for Health Promotion in a Globalized World. 6thGlobal Conference on Health Promotion. Bangkok: 2005.

8. Theory in Health Promotion Using theory can guide the selection of the best health promotion interventions for a given problem HP theories and models explain health behaviour and change at the level of: Individuals Communities Communication strategies Organizations Healthy public policy processes Poole J. So what about health promotion? The history, the ideas, the projects. July 2006.

9. Stages of Change Model Prochaskaand DiClementein NutbeamDand Harris E. Theory in a nutshell: A practical guide to health promotion theories. 2ndEd. McGraw-Hill Australia: 2004.

10. Diffusion of Innovation Theory

11. The Social Marketing Approach • Uses commercial marketing techniques to benefit individuals / society • Consumer-driven, with defined subgroups • 4 P’s of an effective “marketing mix”: • Product: behaviour/social change + its benefits • Price: barriers / costs (e.g. $, time) • Place: making behaviour change easy and convenient • Promotion: delivering the message to the target audience National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice, 2ndEd. US Department of Health and Human Services. 2005: 36-7.

12. The Advocacy Approach Advocacy: “A combination of individual and social actions designed to gain political commitment, policy support, social acceptance and systems support for a particular health goal or programme.” Public health media advocacy: “The strategic use of news media to advance a public policy initiative.” World Health Organization(WHO). Health Promotion Glossary. Geneva: 1998. WHO/HPR/HEP/98.1. Chapman S. Advocacy for public health :a primer. J EpidemiolCommunity Health 2004; 58: 361-5.

13. Primary Prevention of Disease • Goal: To protect healthy people from developing a disease or experiencing an injury in the first place. • Examples: • Health education and behavioural change • Immunization • Social benefits guidance • Community development GillamS. The practice of public health in primary care. In Pencheonet al. Oxford Handbook of Public Health. Oxford UP: 2006. 286.

14. Secondary Prevention Goal: To halt or slow the progress of disease (if possible) in its earliest stages; in the case of injury, goals include limiting long-term disability and preventing re-injury. Examples: Reduce risk of future ill-health (e.g. screen for HTN, treat with meds, reduce CVD and CVA risk) Give information (e.g. screen pregnant woman for trisomy21) GillamS. The practice of public health in primary care. In Pencheonet al. Oxford Handbook of Public Health. Oxford UP: 2006. 286.

15. Tertiary Prevention Goal: To prevent further physical deterioration and maximize quality of life. Examples: cardiac or stroke rehabilitation programs chronic pain management programs patient support groups GillamS. The practice of public health in primary care. In Pencheonet al. Oxford Handbook of Public Health. Oxford UP: 2006. 286.

16. Non-communicable Diseases (NCD) • Leading cause of death globally • 80% of NCD deaths occur in low-middle income countries: • Cardiovascular disease • Cancer • Diabetes • Chronic lung disease WHO. 2010. Global Status Report on NCDs.

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

18. 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.

19. TOBACCOLessons from the Battles of a Half Century

20. Acknowledgements • Insights and background materials from discussions with the following: • Robert Kyle, MOH Durham Region, former TSAG member • David Butler-Jones, Chief Public Health Officer of Canada • John Garcia, Assoc. Prof. and Dir., School of Public Health, U of Waterloo; former Dir. of the Health Promotion Branch, ON. Min of Health • Kate Manson-Smith, ADM of Health Promotion Division, MOHLTC • Michael Perley, E.D., OCAT • Richard Schabas, MOH, HPEHU; former CMOH ON.

21. One-Billion Deaths… • …may occur globally in the 21st century from tobacco use (WHO, 2008) • 100 million deaths in the 20th century • “Cigarettes are the only legal product that, when used as intended, are lethal” • Despite this, things have really changed in Canada since 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

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

23. Health Impacts of Tobacco THE leading preventable cause of death in the world. Causes 1 in 10 adult deaths worldwide Kills up to 50% of all users Nearly 80% of the world's one billion smokers live in low- and middle-income countries. http://www.who.int/features/factfiles/tobacco/en/index.html

24. Health Impacts of Tobacco • Tobacco use is responsible for: • 10% of all deaths from cardiovascular disease • 22% of all cancer deaths • 71% of all lung cancer deaths • 36% of all deaths from the respiratory system • 42% of all COPD deaths WHO. 2012. WHO Global Report: Mortality Attributable to Tobacco.

25. The rise and fall of tobacco use and disease

26. Stages of the Tobacco Epidemic Internationally Tobacco Control, 1994; 3, 242-247

27. 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

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

29. Some key questions re tobacco and its history • How did we get here? • Understanding the basic dynamics of an industry-driven epidemic • Where do we go from here? • Understanding the political challenges of implementing effective practices • What lessons can be applied to other leading preventable cause(s) of death? • Identifying transferable lessons regarding other prominent causes of chronic disease

30. 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

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

32. Research: The Evidence Gathers • 1947 – Norman Delarus (Canadian), case (50) control study re lung cancer. • 1950 – Evart Graham (USA), JAMA, case (605) control study re lung cancer (author quit smoking after study, but died of lung cancer in 1957). • 1950 – Bradford Hill, Richard Doll, BMJ, 20 British hospitals, case control study, lung cancer. • 1951 – Richard Doll et al. Commencement of a 50-year-long cohort study on male physicians in the UK

33. Surgeon General Reports on Tobacco • 29 reports in all – latest one in 2012 • 1964 landmark first report • Based on 7,000 articles relating to smoking and disease • Very guarded language • Citation of antecedent work • Dramatic increase in tobacco use and lung cancer (from 3T in 1930 to 41T in 1962) over past century • No relationship with education – urban more than rural • Cancer of lungs, etc., probably COPD, heart disease, LBW babies, fires • “Habituation”, not addiction

34. Surgeon General Reports: Progression • 1979 • Much more strident language • “The largest preventable cause of death” • An addiction • Reductions in use • 1986 • “Involuntary smoking” hazards • ETS restrictions in 40 states and in DC • “96 percent of businesses have adopted smoking policies” • Restrictions may reduce tobacco use – evaluation needed

35. Research / Analysis • Ontario Council on Health Report, Smoking and Health in Ontario: A Need for Balance,1982 • USEPA, 1992 • Australian National Health and Medical Research Council in 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

36. The Industry’s Response • Some historic milestones • Macdonald Tobacco established in Montreal in 1858 • Cigarette rolling machine in 1881; safe matches in 1890s • “Ability of T. industry to remain healthy while its customers get sick “one of the most amazing marketing feats of all times” – Jake Epp, 1996 • Tremendous wealth • £ 19.7 billion in duty paid in 2010 in the Americas (BAT – “Managing the Challenges in the Americas”) • Present companies in Canada • Imperial Tobacco • Rothmans, Benson & Hedges Inc. • JTI-MacDonald Corp James Albert Bonsack's cigarette rolling machine, invented in 1880 and patented in 1881. (Wikipedia)

37. The Industry’s Response Deliberate deception Public declaration of responsibility as a ruse Sponsorship of scientific opposition Denial of the health impacts Personal responsibility arguments Marketing to youth (and denying it) Marketing to recruit new smokers (and denying it) Policy manipulation Political involvement – prominent politicians as tobacco executives Voluntary code re marketing as a means of forestalling legislation (effective in the 1970’s) Threatened withdrawal of sponsorship as means of coercion Contraband tobacco Undermining price as a control measure Legal challenges Supreme Court re the Tobacco Products Control Act

38. Knowledge Exchange and Grass-roots Advocacy in Canada / Ontario • Canadian Cancer Society • newsletter in 1951 citing the emerging evidence • Canadian Public Health Association • Advocacy positions in 1959, 1988, and 2011 • Seeking elimination (under 1%) by 2035 • Canadian Medical Association • concluded in 1961 smoking causes lung cancer • Non‐Smokers’ Rights Association, and the Canadian Council on Smoking and Health, (now the Canadian Council for Tobacco Control) founded in 1974 • Physicians for a Smoke-Free Canada formed in 1985 • Ontario Campaign for Action on Tobacco (OCAT), 1992 • Ontario Tobacco Research Unit, 1993 • Ontario Medical Association: advocacy paper for smoke-free legislation (2003), cars and children (2004)

39. History of TC and Public Health in Ontario • No tobacco control in the Mandatory Health Programs and Services Guidelines until 1989 – 25 years after the Surgeon General’s report • The first CMOH Report, 1991, was on tobacco control • Mandatory Health Programs and Services Guidelines • Guidelines in 1989, and 1998 • Structure: Outcome objectives re smoking rate reductions, smoke-free homes, tobacco vendor compliance (re Tobacco Control Act) • Actions: consistent with today’s local tobacco control mandate Liaison, school curriculum, smoke-free policies in workplaces, cessation, regulatory efforts re secondhand smoke • Ontario Public Health Standards 2008 – “Chronic Disease Prevention” • Structure: broad process outcomes, Societal and Board Objectives – details in protocols

40. Historic Government Roles Tobacco promotion Agricultural R&D, subsidies Provision (military) Tobacco control Regulation of manufacturing (such as the 2005 cigarette ignition propensity regulations) Sales (age, vendors / vending) restrictions Marketing / advertising / packaging (plain) / warnings (graphic) Taxation Research Cessation supports Location of use restrictions Litigation Partnerships Public awareness and de-normalization (Prohibition)

41. Government Response: Federal • For 80 years (between 1908 to 1988) the Federal Government did not pass tobacco control legislation – despite more than 20 private members’ bills in the 1960s • Resolution to ban tobacco, 1903 and 1904 – second reading only • Legislation: • 1908 Tobacco Restraint Act - prohibited sales under 16 • 1988 Non-Smokers’ Health Act (private members bill) and Tobacco Products Control Act - prohibited advertising; charter challenge with sections ruled unconstitutional • 1993 Tobacco Sales to Young Persons Act – prohibited sales under 18 • 1997 Tobacco Act – still in effect; disclose product content, prohibited sale to youth, prohibited mail-order and vending machines, warning labels, restricted advertising • Taxation increases in 1980’s, reduction in 1994 • 40,000 additional deaths • Graphic packaging in 2000 and 2012 • Tobacco farms quota buyout in 2008 • More than doubled Ontario’s crop

42. Government Response: Provincial (Ontario and others) • For 98 years (1892 to 1990) the provincial government of Ontario did not pass tobacco control legislation • Legislation: • Prohibition of sale to minors – BC in 1891, ON (age 18) and NS in 1892, NB in 1893, NWT in 1896 • 1990Smoking in the Workplace Act - minimum areas for nonsmoking (not enclosed and separately ventilated) • 1994Tobacco 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

43. Smoke-Free Ontario Act and Strategy, 2006 • Comprehensive, multi-level and intensive strategy: training, mass media, planning infrastructure (such as TCANs), local programs, research and evaluation • programming and 40% of SFO funding for local public health (previously only cost-shared funding) • Banning smoking in enclosed public places and workplaces • Banning the display of tobacco products at the point of purchase (i.e. powerwalls) • Strengthening restrictions on selling tobacco products to young people • Expanded services and infrastructure to help smokers quit • Created and funded programs, including a peer-to-peer infrastructure, to prevent youth from starting to smoke • Funded extensive awareness and social marketing initiatives • Funded research capacity and training supports for health system workers

44. Ontario since 2009 • Banned smoking in vehicles when children under 16 are present • Passed legislation to allow the government to to sue tobacco companies to recover past and ongoing healthcare costs due to tobacco-related illness • Passed legislation to address the supply of flavoured cigarillos to young people • MOHLTC Action Plan, 2012 – to have the lowest tobacco use in the country • According to 2006 Health Canada figures, legal sales of cigarettes in Ontario fell by 31.8 percent, or by approximately 4.6 billion cigarettes, since 2003

45. Local Public Health and NGO Advocacy in the 1990s / 2000s • Toronto: • Bylaw in 1979 prohibiting smoking in retail stores, elevators, escalators, service lineups • Bylaw in 1993 requiring workplace smoking policies • Bylaw in 1997 – enclosed, separately ventilated DSAs – rescinded • Smoke-free bylaws in 2000 / 2002: Waterloo Region, Toronto, Ottawa • Other municipalities – such as Simcoe County, District of Muskoka; Cornwall a noted success in eastern Ontario • Most of the provincial population covered by smoke-free bylaws in early 2000s - Set the stage for the SFOA • Much leadership, partnership and support from NGOs – OCAT in particular working closely with local public health

46. The Impact of Government Decisions Past-Year Smoking, by grades 7-12, Ontario, 1977-2011 Source: 2012 Smoke-Free Ontario Strategy Evaluation Report, Ontario Tobacco Research Unit: http://otru.org/2012-smoke-free-ontario-strategy-evaluation-report-full-report/

47. OTRU Report 2012 • Progress, however change too slow to achieve government’s & TSAG’s goals • Protects most Ontarians most of the time from ETS in indoor public places • Changing social climate and reducing use among youth • YSS report 1/3 youth remain susceptible • However, no reduction in adult smoking in 5 years – took 10 years to reduce by 5% • Protection: • Reduction in ETS exposure over 5 years • 26% still exposed at work, and 32% still on restaurant patios • 11% of aged 12 to 19 still exposed in homes – (not tracked in multiunit dwellings & likely much higher)

48. 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/

49. 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

50. 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