National forum on the future of tobacco control in Canada: What we heard

1. Preamble

This report provides an overview of comments received at the National Forum on the Future of Tobacco Control in Canada, held in Ottawa on March 1-2, 2017. Forum participants were asked for their views on how to reduce tobacco use in Canada to less than 5% by 2035. The report summarizes the discussions held on site, in the different rooms, as well as online. Note that the content of this report does not necessarily reflect the views of the Government of Canada.

2. Purpose and format of the National Forum

Purpose of the National Forum

The National Forum on the Future of Tobacco Control in Canada (the "Forum"), held in Ottawa on March 1-2, 2017, forms part of the consultative approach that the Government of Canada took towards charting a new course to help Canadians lead healthier, tobacco-free lives. The Forum, along with other consultations, allowed the Government to take stock of the accomplishments of the past to set out a bold new federal approach driven by an aggressive target: to reduce tobacco use in Canada to less than 5% by 2035.

The Forum engaged 150 stakeholders from the tobacco control community including academia; non-governmental organizations (NGOs); public health professionals; provincial and territorial governments; health care providers; health professional associations; youth; representatives from Indigenous organizations and communities; and other tobacco control experts. The intent of the Forum was to provide an opportunity for broad discussion on issues pertinent to the development of a new federal tobacco control strategy.

Two members from Health Canada's Youth Leadership Team (YLT) introduced the Honourable Jane Philpott, Minister of Health, who opened the Forum by describing the impact of tobacco use on the lives of Canadians and the need for continued action on a national and international scale. Minister Philpott emphasized that smoking is still the leading preventable cause of premature death in Canada and noted that the extent of tobacco use varies considerably across different segments of the population, with some segments being disproportionately affected. For example, smoking rates in some First Nations and Inuit communities are as much as four times higher than among the general Canadian population. She called for innovative ideas, perspectives, feedback, adjustments, and effective mechanisms to reduce the rate of tobacco use in Canada to less than 5% by 2035.

Format of the National Forum

The Forum provided novel approaches to engagement to maximize participation and outcomes: a main workshop space, a dialogue space, a youth-led innovation lounge, and a forum for virtual participation.

Each workshop was launched by short presentations that were intended to initiate the discussion. Participants then discussed each topic in small groups. The small groups reported back to the larger group and main points from the discussion were captured on large posters for each topic. Simultaneous English/French interpretation was provided for the presentations and large group discussion.

The dialogue space was intended to be a safe, unstructured space where participants could determine the topic of discussion. This space provided an alternative to the structured workshop format. It operated at the same time as the workshops, in a separate room. A graphic recorder captured the dialogue space discussion.

The youth-led innovation lounge was facilitated by the Students Commission of Canada and the YLT. It was intended to be a place to exchange innovative ideas between the YLT and forum attendees. The YLT created and illustrated the types of digital interactions that they believe are effective for engaging youth, and also provided a youth perspective on the issue of tobacco control.

The forum for virtual participation mirrored the workshop space. Participants were able to participate via WebEx and the government conference line. They could see and hear the main speakers in the workshop space, and then were able to participate in a separate, facilitated online discussion in both official languages.

The workshop and virtual space were organized into a series of sessions on themes drawn from Health Canada's consultation document. The themes addressed in the Forum included:

• Tobacco: a complex issue
• Exploring the goal of less than "5 by 35"
• Protecting youth and those who do not smoke
• Helping Canadians who use tobacco
• Tobacco use, social and health inequities
• Building capacity

During the final session of the Forum there was an opportunity for all participants to see the work that had been developed in each of the spaces and to identify emerging themes from across the different streams.

Mr. Simon Kennedy, federal Deputy Minister of Health, provided closing remarks to the Forum. He noted the considerable changes in the tobacco control landscape over the last few years, including partners having implemented their own strategies, the emergence of new technologies such as electronic cigarettes (e-cigarettes) and the impending legalization and regulation of cannabis. "The expiry of the current Federal Tobacco Control Strategy in March 2018 presents an opportunity to modernize the federal approach, reduce the burden of tobacco use on all Canadians and strengthen Canada's role as a world leader in public health," he added. He expressed his gratitude that the members of the tobacco control community "could engage in a substantive discussion with a divergence of views in a respectful manner."

3. Formal presentations during the Forum

Tobacco in Canada: a complex issue

Ms. Clara Morin Dal Col, Health Minister for the Métis National Council and British Columbia President for the Métis National Council, discussed the Métis experience with smoking and tobacco control. She highlighted challenges for Canada's Indigenous groups including a much higher rate of smoking and a lack of research and data on smoking in Canada's Indigenous communities. She also cited the problem that the most recent research on Métis smoking rates is now 10 years old. She recommended directly engaging Métis and Indigenous communities in any tobacco control strategy.

Dr. Diane Finegood, Professor of Biomedical Physiology and Kinesiology at Simon Fraser University, framed tobacco as a complex issue with many interdependencies. Addressing complex problems through approaches that focus on structural elements tends to be the least effective. She noted it is important not to become trapped in discussions about how to attribute blame for the problem, as this often blocks discussion about real solutions. Individuals working in a complex system need to know the role they can play within their area of action. Dr. Finegood introduced a causal map of the United States tobacco control system prepared by the National Cancer Institute as a starting point to explore the Canadian tobacco control context.

Exploring the goal

Dr. Elizabeth Eisenhauer, Head of Queen's University Department of Oncology, provided an overview of the Tobacco Endgame Summit's (September 30 to October 1, 2016) recommendation of a goal of less than 5% tobacco use in Canada by 2035. Tobacco use is the most important risk factor for cancer worldwide. The lag time from the first cigarette an individual smokes to the time when they may suffer tobacco-related cancer or illness means that the burden of illness and death from tobacco is expected to continue to rise for another 20 years. In her presentation, Dr. Eisenhauer stressed the need to take bold risks and go beyond tobacco control to consider a tobacco-free future.

Protecting youth and non-smokers

Mr. Bill Hogarth, Director of Education at York Regional District School Board for 16 years, spoke about some unintended consequences of tobacco control programs using the example of schools in York Region. For example, it was easier to identify and engage students who were using tobacco when they were smoking on the school property in designated smoking areas. However, moving them 20 meters away from school property meant they were no longer the responsibility of the school administration; it became a community issue. Common themes among these students included a desire to "belong" and a high degree of stress. He closed by asking how adults can protect youth in the age of social media and legalized cannabis.

Dr. Steven Hoffman, Scientific Director at the Institute of Population and Public Health of the Canadian Institutes of Health Research, described examples of targeted marketing of tobacco products that has occurred on some university campuses outside Canada, including leveraging youth to market to peers, and the proximity of some vaping stores to elementary schools. He noted that public health organizations need to take targeted marketing by the tobacco industry and its retailers very seriously and address it. Youth are not a homogeneous group. The tobacco industry knows this and targets particular youth subgroups to sell their products. Tobacco control approaches aimed at youth, in response, must be both universally accessible and personalized, and use effective methods to reach them such as peer-to-peer education.

Helping Canadians who use tobacco

Dr. Milan Khara, a physician at Vancouver Coastal Health Addictions Services, characterized the problem of tobacco use as a chronic, relapsing, addictive disorder. In the efforts to eliminate tobacco, those who are 'left behind' can become unintentionally marginalized (e.g. in smoke-free hospitals, tobacco users are literally left on the periphery of the grounds). He highlighted existing smoking cessation programs and activities in British Columbia as an example of the range of smoking cessation strategies that should be supported more broadly to reach remaining smokers. Dr. Khara also noted that harm reduction may also have a role. The Canadian tobacco control community will have to do more of what they are doing, do it better, as well as innovate in order to reach the less than 5% tobacco use by 2035 goal.

Dr. Ross MacKenzie, a Health Studies lecturer in the Department of Psychology at Macquarie University in Sydney, Australia, stated that between two thirds and three quarters of ex-smokers successfully quit smoking without the use of nicotine replacement therapies (NRTs), other pharmaceutical products, or counselling. While assisted cessation (i.e. pharmacotherapy, quitlines, counselling, etc.) shows good results in clinical trials, these results do not replicate in real world settings. Dr. MacKenzie suggested that the tobacco control community should be telling people who are looking to quit that smoking cessation can be a prolonged process, that failed quit attempts are a part of that process, and that the majority of former smokers stopped smoking without NRTs or other forms of cessation assistance.

Dr. David Hammond, Associate Professor and Chair in Applied Public Health at the University of Waterloo, discussed tobacco harm reduction in the form of e-cigarettes. He summarized the literature and fundamental arguments that frame the public health debate on e-cigarettes: e-cigarettes can help some people to quit smoking; they may also sustain smoking especially in cases of dual use of cigarettes and e-cigarettes; and they may promote smoking initiation and uptake in youth. Dr. Hammond noted that all these arguments are true to some extent and that it ultimately depends on who is using the product and for what reason. Similarly, he argued that e-cigarettes and other harm reduction products could have positive or negative public health impacts. Dr. Hammond added that the impact can be influenced by tobacco control policy and regulations, which should include considerations that relate to minimum age restrictions, flavours restrictions, marketing restrictions, product standards, the communication of relative risks of products and the extent to which the regulatory framework can be adapted to emerging products.

Tobacco use, social and health inequities

Ms. Elizabeth Hydesmith, Program Specialist, Tobacco Reduction at the Winnipeg Regional Health Authority (WHRA), described how the WRHA moved to an equity-based approach to address inner city smoking among Indigenous people that has fundamentally changed how the WRHA approaches this issue, and the way they have developed and delivered programs and resources. The health equity lens includes: a cultural/spiritual element; recognition of the impacts of poverty on individuals and communities; education; and, a movement for smoke-free homes.

Dr. John Millar, Clinical Professor Emeritus at the School of Population and Public Health, University of British Columbia, highlighted increasing levels of inequity in the United States and Canada and its impact on health. In populations where people are experiencing a lot of stress and pain they will often turn to tobacco, alcohol, food, etc. This affects us all by driving up the cost of health care and affecting the entire economy. Dr. Millar cited specific economic remedies for commercial tobacco use in the current context, notably raising the minimum wage to a living wage and raising taxes on tobacco. He called for a change in corporate culture so that tobacco companies and other companies that cause harm are not able to simply externalize these costs. He called for increased funding for research, program delivery and policy development.

Building capacity

Dr. Robert Schwartz, Principal Investigator and Executive Director at the Ontario Tobacco Research Unit (OTRU), University of Toronto, recommended that tobacco control employ a strong 'learning system' including research, surveillance, evaluation and monitoring elements. He noted that the current federal strategy lacks such a system. There is a lack of dedicated research funding, and current surveillance tools hamper the Canadian government's ability to ask specific questions, get timely results and course-correct over time. Canada can learn from recent international experience in building surveillance systems that provide frequent, flexible, timely longitudinal data. Improving the tobacco control learning system will require funding which could be levied from the tobacco industry.

Dr. John Garcia, Professor at the University of Waterloo School of Public Health & Health Systems, described the American Stop Smoking Intervention Study for Cancer Prevention (ASSIST) program of the US National Cancer Institute. ASSIST engaged civil society to build state-level tobacco control strategies and is readily transferable to Canada (already employed in Ontario and Alberta). Important structural elements include a national coordinating centre, civil society-inspired committees, national conferences, training, consultation services and communities of practice.

4. Synthesis of discussions and cross-cutting themes

This section collates the main themes discussed at the National Forum from across the various streams of participation.

Understanding the problem

• Holistic and comprehensive way of understanding the problem: Tobacco control was presented as a complex problem. Paradigm changes in complex issues require discussions about deeply held beliefs and an understanding of how specific strategies can work together. More reflection and discussion is needed to consider how to deal with tobacco from a variety of perspectives.
• Reframing the issue through a context-dependent and health equity lens: Current initiatives predominantly view tobacco control as an individual addiction issue and target interventions at the general population. Participants noted that the issue needs to be reframed as a context-dependent, complex issue with more multi-faceted interventions. Tobacco use exacerbates health issues more acutely among groups that experience social stigma, poverty and marginalization. The fact that tobacco use is more prevalent among certain sub-populations (e.g. Indigenous people, low socio-economic status, LGBTI) makes it important to view the issue through a "lens" that is relevant for those groups and to develop strategies appropriately. Many comments dealt with the need to understand the root causes of tobacco use and the necessity to recognize individual behavior and the strong link to social conditions: Why do people start smoking? What makes them continue? What need does smoking fulfill for them? Understanding the answers to these questions can support the development of improved strategies to help people find appropriate ways to quit smoking - or to avoid taking it up in the first place - that are relevant to their specific needs. It was discussed that Health Canada and its partners need to demonstrate an understanding and ability to apply a health-equity approach to tobacco control from policy development and resource allocation through to program and service delivery. The issue is bigger than tobacco use, thus it requires a bigger solution.
• Indigenous communities: Many Indigenous communities have a long relationship with tobacco that is quite different from non-Indigenous communities. For some, tobacco is sacred and used for spiritual and ceremonial purposes. For communities to be successful in reducing commercial tobacco use, a tobacco control strategy must recognize this history and perspective. Colonialism and reconciliation are other important considerations that need to be taken into account.
• Need to change public perception about the problem: Many participants noted a strong feeling in the general public that tobacco is no longer a significant or urgent problem in Canada. As long as this is the perception, it will be difficult to get the attention and the resources required to deal with the issue.

Understanding the target

• How to get to less than 5% by 2035: The tobacco control problem today is substantially different from what it was 20 years ago. There have been significant reductions in tobacco use among certain populations; however, prevalence remains high among certain groups. Those involved in the tobacco control system have a responsibility to ensure that these groups are not left behind. To reach the target, research is required to understand the problem as it exists now, and pilot and implement strategies that are comprehensive and appropriate for the populations it serves, with suitable levels of resources. It may also be useful to develop sub-goals that may be more specific and have shorter timelines or milestones as a way of supporting the effort to achieve the main goal.
• Ending vs. controlling tobacco: There was some conflicting discussion related to eliminating commercial tobacco use (prohibition) versus controlling tobacco. Some participants felt strongly that the eradication of commercial tobacco use is the appropriate goal and that the tobacco industry has no place in Canada.

Approaches to address the problem and reach the target

"Whole of government" approach

• At present there is a perception that different federal departments are working at cross-purposes when it comes to tobacco control (e.g. some see tobacco as an agricultural production or economic development opportunity). Many recommended that a consistent "whole of government" approach to the issue be taken.

Cannabis - challenge and opportunity

• The issue of cannabis legalization and regulation generated much discussion. Some viewed it as a strong challenge to tobacco control, especially if there was a difference in the approach of how/where it would be sold and used (e.g. measures related to age of access). Others saw an opportunity to pilot different approaches that could serve to inform a new approach to tobacco control.

Preventing new smokers

• Youth: There was a great deal of interest in ensuring that the exposure of youth to tobacco is delayed for as long as possible. The youth-led Innovation Space demonstrated the potential of using different engagement and social media strategies to actively engage youth.
• Raising minimum age for sale: There was discussion of the proposal to raise the federal minimum age for legal sale of tobacco to 21 years of age, which had some strong support. Challenges concerning enforcement and other considerations were discussed.
• Creating a 'smoke-free generation': There was some discussion of trying to create a 'smoke-free generation' (i.e. not selling tobacco products to anyone born after a given date as a move towards an eventual ban). Enforcement was also seen to be a challenge for this strategy.

Helping current smokers

• Cessation support: Some participants recommended better availability of cessation supports, such as NRTs or counselling. Some commented that quit supports should be just as accessible as tobacco products.
• Incentives and contests: It was mentioned that incentives and contests were successful in some jurisdictions.
• A clinical vs. a population approach: Those working one-on-one with people who smoke reiterated that it is important not to leave behind those who are unable to quit. Some expressed concern that there may be unintended consequences for regulations that too strictly control or ban tobacco. Others supported using stronger population-level policy approaches (e.g. price and taxation policies) instead of a clinical focus (e.g. one-on-one counselling).

Addressing heterogeneous populations

• First Nations communities: There is a difference between the sacred use of tobacco and the use of commercial tobacco products that needs to be understood when working in tobacco control in a First Nations context. It was also discussed that many Indigenous youth today don't understand the difference between the sacred and commercial use of tobacco. Important work is being done with youth in many First Nations communities to increase awareness and understanding of the sacred role of tobacco and to distinguish it from commercial tobacco. The need to consider the singularities of various communities and to avoid making assumptions was also raised.
• Inuit perspective: From an Inuit perspective, tobacco does not have the same cultural or spiritual association as it does for First Nations; rather tobacco was introduced by "outsiders" and was quickly adopted. Current prevalence rates for Inuit are among the highest of sub-populations in the world.
• Social inequity/marginalization: The issues of how specific communities were disproportionately affected by tobacco were prominent in participants' comments. In addition to Indigenous communities, the LGBTI community, those with mental health issues and members of the military were discussed. Many participants expressed the need for tobacco control approaches that are sub-population specific, and the need to take into consideration social inequities, marginalization and other issues pertinent to these communities. The need to consider addiction as a symptom of social inequity was highlighted. People who smoke may do so as a coping mechanism and this should be a consideration for tobacco control to support alternative coping skills and other forms of assistance to support cessation.
• Community engagement: It was felt that a segmented approach is required to address populations with high prevalence rates. It is important to develop tobacco control strategies with communities, and to support communities to increase their capacity (with adequate resources and program flexibility) to address tobacco within their unique contexts. There were many comments throughout the Forum that reinforced the need for the communities or groups experiencing the highest levels of prevalence (e.g. Indigenous peoples or youth) to be actively engaged in the development of new strategies. These strategies should be designed in such a way as to be respectful and consistent with cultural beliefs and approaches. Communities should be in control of their implementation, and supported with adequate resources to do so.
• Family/school/social strategies: Commenters suggested there is a need to better understand the reasons why youth smoke (e.g. what is behind the phrase "I just felt like it"). Social norming is important and therefore the creation of tobacco-free environments (e.g. smoke-free campuses) is important. It was suggested that tobacco education should be intensified for youth (and their parents). A focus on young adult social identities through programming was proposed. Youth and young adults should be involved in all levels of planning, implementation and evaluation for smoking cessation programs.
• Biases among healthcare providers: It was noted that there are often biases against disadvantaged communities where smoking remains a problem among health care and other professionals, as well as among people who smoke. There can often be a dependency relationship created with clients that focuses on clinician needs and not the clients'; in contrast, the focus should be on creating an empowering environment. The self-efficacy of dealing with an addiction can be tremendously empowering. From a policy perspective, there is a need to ensure that low income individuals and the working poor have equal access to cessation supports.

Decreasing demand

• Taxation and accountability for taxation revenues: Some suggested not prioritizing less effective, targeted programmatic measures at the expense of tax/pricing policy. Price has historically been one of the most effective measures to reduce tobacco use, particularly by youth. There was considerable discussion about how the tobacco industry is taxed, and how these resources could be redistributed to support tobacco control. Some participants called for a dedicated tax strategy driven by population health objectives. Participants wanted to see more mechanisms that would ensure the industry pays for more of the costs of the damage they inflict, possibly including a levy for damages instead of a tax.
• Marketing: A number of marketing and advertising focused measures were proposed, including: banning all tobacco advertising/promotion; prohibiting tobacco companies from providing incentives to retailers; moving forward with plain and standardized packaging; considering product regulation to reduce attractiveness; and, creating a national social marketing campaign for youth. Participants also felt that cessation rates could be bolstered by sustained marketing campaigns (including social marketing). The First Nations Health Authority initiatives, initiatives run by the Nunatsiavut government and programs of the US Centres for Disease Control and Prevention were all cited as good examples of powerful media campaigns. It was recommended that tobacco control partners adopt the tobacco industry's strategy of targeting "market segments" in a highly sophisticated way.

Decreasing supply

• Sales/retail strategies: It was suggested that the availability of tobacco products be decreased through measures such as restrictions on where the products can be sold in retail outlets. Some recommended that tobacco not be available 24/7 and that sales be regulated so that it could not be sold in school zones. One proposed strategy was to limit retail sales of tobacco to pharmacies only.
• Supply interventions: Trade restriction measures, licensing, crop substitution and cap-and-trade measures were all discussed. Addressing the contraband problem and disrupting the trade of illegal tobacco products is also necessary.
• Illicit tobacco: The contraband market of tobacco products continues to be a challenge in Canada. A need for more reliable data on the evolution of the market was identified as a means to better evaluate and address the issue and to dispel claims that certain tobacco control measures drive the demand for contraband tobacco.

Mitigating risks of new products and innovations

• Greater regulation was recommended for new products such as vaping products and tobacco heat-not-burn products. There was concern about how vaping and new tobacco products might relate to or potentially undermine tobacco control measures. Due to their potential for renormalizing smoking behaviour, it was suggested that new products should be controlled or restricted, at least in the short term.

Partnerships and collective action

• International capacity: Tobacco is a global problem and the tobacco industry operates internationally. Several participants called for recognition of the World Health Organization Framework Convention on Tobacco Control (FCTC) and recommended that Canada move further in implementing its tenets. Canada was also advised to develop significant, long-term strategic bilateral partnerships with other countries to mutually advance tobacco control on an international scale. Participants also recommended that Canada resume a leadership role in the FCTC with long-term, sustained assistance to NGOs and governments in developing countries.
• Funding and provincial/territorial relationships: The federal government was encouraged to tie provincial transfer payments to the less than 5% by 2035 goal as part of its national health care funding. It was also suggested that sustained base funding be continued to existing cessation programs such as the national Quitline and that investments be made in a social marketing strategy and targeted programming to sub-populations where smoking prevalence is high.
• National strategy/collaboration: Participants recommended that the government develop a new national tobacco control strategy, led by the federal government with buy-in and collaboration amongst all levels of government, NGOs, researchers and public health officials. There are many levels at which capacities can be developed in other sectors (e.g. education, social services, justice, health care workers) and with all ages within communities. Indigenous communities and existing networks of community-based workers (e.g. health care workers) should be included in capacity-building efforts.
• Long-term accountability: In terms of accountability at the federal government level, there was a call for benchmarks and reporting by the federal government. It was also noted that changes in government can affect the continuity of long-term goals like 'less than 5% by 2035'. It was stressed that the government needs to properly fund capacity to get closer to the tobacco control goal.

Building capacity

• Adequate resources: Many participants noted that for the strategy to be successful going forward, adequate resources will be crucial. A number of suggestions were made regarding how this funding should be provided, including through some form of tax or levy on the tobacco industry.
• Apply complexity and systems thinking in planning: As a complex problem, a target like less than 5% by 2035 may be less effective than functional goals that articulate what specifically needs to change.
• Knowledge exchange/hub: Meaningful, ongoing, integrated knowledge exchange by dedicating resources to smaller meetings of researchers, NGOs, policymakers and practitioners is needed. The creation of an independent research centre (or centres) was encouraged.
• Building capacity in surveillance, monitoring and evaluation: Participants encouraged the government to do in-depth surveillance and to provide ongoing data in a timely fashion, including data on equity issues. It was recommended that consistent methodologies be followed and that evaluation be built into programs from the start. The importance of having individual and community-level data was also raised.
• Coordination of the strategy: Coordination and adequate resourcing of the various parts of the tobacco control strategy - research, surveillance, program delivery, monitoring and evaluation - were seen to be critical to continued progress. Some participants suggested that this coordination would be best managed through an independent, non-governmental body. The Alcohol, Smoking and Substance Involvement Screening Test model was cited as one approach that could be translated to a Canadian context.
• Fostering innovation: The current tobacco control strategy and activities continue to contribute to declines in tobacco use in Canada. However, the current landscape is now quite different and not all traditional tools are tailored to the new reality. Participants felt that there is a need to consider innovative ideas for a modernized strategy going forward. The necessity to find the levers that can help to create the right environment that could be more effective at achieving desired change was also raised.

Dialogue space

The Dialogue Space was an unstructured space for participants to have challenging conversations on the topics they decided to discuss. A graphic recorder captured the main ideas of the discussions as it unfolded on a large 4 X 8 foot canvas, through words, images and links. Most discussions were captured on a single canvas. The last discussion, which was on Indigenous perspectives, was captured on a separate canvas at the request of the participants. Key topics discussed in the dialogue space included:

• Possibilities and opportunities for reframing tobacco control in Canada, such as taking a health equity approach and encouraging concerted actions by all sectors;
• The economics of tobacco control, how the tobacco industry is taxed, and how these resources could be redistributed to support tobacco control;
• The pros and cons of increasing price and tax of tobacco products;
• Considerations that relate to the inclusion of a harm reduction approach;
• Ways to support and engage youth, as well as sub-populations with high tobacco use prevalence rates; and,
• The cultural significance of tobacco for various Indigenous communities and the distinction from commercial tobacco use, as well as the use of commercial tobacco by Indigenous people and how to engage and work with them to address this particular form of tobacco use.

Youth-led Innovation Lounge

At the Innovation Lounge, the YLT illustrated the types of digital interactions that they believe are most effective for engaging youth and offered a youth perspective on the issue of tobacco control. Much of the conversation focussed on the different ways youth use tobacco products and vaping products, and the central role of social media for engaging them. One of the key recommendations for engaging youth in tobacco control was the need to use a personalized perspective that takes into account the diversity of the youth population. The need to use aspirational messages with emotional value was also raised.

Virtual participation

Discussions held through the virtual participation stream focused mainly on topics similar to those discussed in the main workshop space, and have been incorporated in the precedent text.

5. Conclusion

The expiry of the current Federal Tobacco Control Strategy (FTCS) in March 2018 presents an opportunity to modernize the federal approach, reduce the burden of tobacco use on all Canadians and strengthen Canada's role as a world leader in public health.

The tobacco control landscape has changed significantly over the last number of years. Since the FTCS was launched in 2001, partners have implemented their own strategies, new technologies such as vaping products have emerged, and work has begun to legalize, strictly regulate and restrict access to cannabis.

Health Canada has set the aggressive target of less than 5% tobacco use by 2035 and now needs to develop a strategy to make that target a reality and make a real difference in the future health of Canadians.

Health Canada thanks all participants for sharing their insight and feedback. This feedback, along with comments received as part of other related consultation activities, will be invaluable as a new strategy for tobacco control in Canada is developed.

Health Canada will continue to engage stakeholders as we work towards our common goal of significantly reducing the unacceptable burden inflicted by tobacco use on our society.