In "Balancing Act: An All-of-Society Approach to Substance Use and Harms", Ontario's Chief Medical Officer of Health, Dr. Kieran Moore, focuses on Ontario's experience with substance use. He provides specific recommendations on four categories of substances: tobacco-vaping products, cannabis, alcohol and opioids.
The analysis and recommendations in this 81-page report do not reflect the policy of the current Government of Ontario. Ontario's Chief Medical Officer of Health has a duty to provide the legislature with an independent annual "on the state of public health in Ontario." In recent years these reports have focused on specific public health issues - last year's report focused on pandemic preparedness.
Dr. Moore's 2024 report provides a comprehensive review of the impact of both legal drugs (nicotine, cannabis, alcohol) and illicit drugs (opioids), and addresses upstream and downstream factors which influence use and harmful use.
As the title "Balancing Act" suggests, the report identifies the forces and tensions which influence public policy in these areas -- respect for individual autonomy with respect to substance use, community protection, economic benefits and harms, reducing harm without increasing use, etc.
The recommendations which flow from this analysis challenge many current policies and practices of both the Ontario and Federal government. (Not only did the Ontario government quickly distance itself from his recommendations, it chose to release the report on the Friday afternoon of a long weekend.)
With respect to tobacco and nicotine - an area largely abandoned by Ontario's Conservative government after its election in 2019 - Dr. Moore offers little support for federal government's harm reduction approach. Dr. Moore casts doubt on the potential for vaping products to assist with smoking cessation when sold as consumer products: "Studies comparing nicotine e-cigarettes to usual care/no treatment suggest only a small benefit, and the long term (i.e. longer than two years) benefits and harms of e-cigarette use are largely unknown due to short follow-up of current studies. The World Health Organization (WHO) recommends that “any government pursuing a smoking cessation strategy utilizing e-cigarettes should control the conditions under which the products are accessed to ensure appropriate clinical conditions and regulate the products as medicines."
For example, Dr. Moore's report casts doubt on the potential for vaping products to assist with smoking cessation when sold as consumer products: "Studies comparing nicotine e-cigarettes to usual care/no treatment suggest only a small benefit, and the long term (i.e. longer than two years) benefits and harms of e-cigarette use are largely unknown due to short follow-up of current studies. The World Health Organization (WHO) recommends that “any government pursuing a smoking cessation strategy utilizing e-cigarettes should control the conditions under which the products are accessed to ensure appropriate clinical conditions and regulate the products as medicines."
Instead, Dr. Moore uses the report to call for stronger controls on nicotine products (including nicotine pouches): "Ontario still falls short of many of the World Health Organization recommendations to protect children, including banning flavours as well as any features that could appeal to youth." His specific recommendations for tobacco-and nicotine policies and programs are listed verbatim below.
Dr. Moore's advice is good for Ontario, and would be good for the rest of the country too.
Canada's national approach to tobacco control was abandoned in 2001 when the federal government stepped away and established its own approach. The Federal Tobacco Control Strategy (FTCS) modified the NSTRTU framework (Prevention, Protection, Cessation, Denormalization) to drop Denormalization and to replace it with the goal of Harm Reduction. Some provincial governments have subsequently adopted their own strategies, but most of these have languished without renewal in recent years. None have formally adopted harm reduction as a tobacco control objective.
Dr. Moore's report offers a sensible plan to protect public health from tobacco industry products. It will however take a major change in approach by either the Ontario and Federal government for these measures to be put in place.
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Recommendations from "Balancing Act: An All-of-Society Approach to Substance Use and Harms" related to Tobacco and Nicotine
Reinvigorate the Smoke-Free Ontario Strategy, focusing on populations and regions with high rates of
tobacco use. Expand the strategy to create a comprehensive, coherent public health-oriented framework for
regulating vaping and all nicotine-containing products.
Targets
• Adopt Health Canada’s target of less than 5% tobacco use by 2035
• Develop aggressive targets to prevent the use of vaping products by youth and people who do not smoke
Health Promotion
• Continue to raise awareness among Ontarians, particularly youth, of the risks associated with tobacco
and vaping products
Regulatory Measures
Minimum legal age of purchase
• Increase the minimum legal age to purchase tobacco and vaping products from 19 to 21 years old
• Consider progressively increasing the minimum legal age to purchase these products over time as a way
to ban the purchase of these products by future generations
Product Controls
• Ban flavours for all tobacco and vaping products
• Expand restrictions on where people can smoke or vape (i.e. not in social housing, near building
entrances, exits and air intakes, in all outdoor spectator stands, beaches, and specified parts of provincial
parks)
• Require apartment landlords and condominium boards to have a smoking/vaping policy
• Ban the use of water pipes in all places where smoking is banned
• Expand the current regulatory framework to include specified non-tobacco nicotine products, such as
nicotine pouches, and prevent their sale and promotion to youth and people who do not smoke
• Ban the sale of disposable vaping products
• Establish product controls to prevent the evolving risk of vaping devices being used to deliver other drugs,
such as cannabis, fentanyl, and crystal methamphetamine.
Availability
• Restrict physical store locations where tobacco and vaping products can be sold, including prohibiting any
new stores within 200 metres of an elementary or secondary school or an existing tobacco/vaping retail
outlet, and capping the total number of retail locations in a municipality/region (i.e. retail density)
• Impose a licensing fee for retailers of tobacco and vaping products
• Explore measures to reduce illegal, untaxed tobacco sales outside of First Nations communities
• Work with the federal government to ban online retail sales of tobacco and vaping products without in person age verification at delivery
Pricing and Taxation
• Increase the provincial sales tax on tobacco products and increase the tax each year to keep pace with
inflation
• Maintain provincial sales tax on vaping, and increase annually to keep pace with inflation
Promotion
• Work with the federal government to restrict:
o online and social media advertising of tobacco and vaping products
o the design, appearance, and branding of e-cigarettes to reduce their appeal to youth
• Reduce or eliminate the number of price signs allowed in tobacco and vaping retail settings visible to
youth
• Prohibit manufacturers from offering incentives to retailers (e.g. bonuses for reaching sales volume
targets, chances to win vacations or entertainment tickets, lower prices based on volumes purchased),
and prohibit retailers from passing incentives on to consumers
Enforcement
• Issue time-limited suspensions for retail outlets that repeatedly sell vaping products to minors, as is done
for tobacco
• Enforce the current limitations on nicotine concentration in vaping products (20 mg/ml), determine
whether companies are using product strategies to undermine the 20 mg/ml standard, and restrict the
capacity of tanks, pods and refill containers
Treatment
• Increase access, including free products, to evidence-based smoking cessation therapies and supports,
such as the Ottawa Model for Smoking Cessation
• Increase research and training on vaping cessation therapies and supports for youth and adults
Monitoring and Reporting
• Establish key performance indicators for public health inspectors and others involved in enforcing tobacco
and vaping policies designed to protect minors and non-smokers
• Work with Public Health Ontario and with federal, provincial, territorial and Indigenous partners to
continue to:
o Monitor the impact of tobacco and vaping on health
o Review new evidence on vaping and other non-tobacco nicotine use
o Assess the impact/effectiveness of tobacco and vaping policies
o Issue regular public reports on Ontario’s progress (key performance indicators) in reducing harms
associated with tobacco and vaping use
