Hon Eric Hoskins Minister of Health and Long-Term Care 10th Floor, Hepburn Block 80 Grosvenor Street Toronto, Ontario M7A 2C4

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1 2 Carlton Street, Suite 1306 Toronto, Ontario M5B 1J3 Tel: (416) Fax: (416) alpha s members are the public health units in Ontario. alpha Sections: Boards of Health Section Council of Ontario Medical Officers of Health (COMOH) Affiliate Organizations: ANDSOOHA - Public Health Nursing Management Association of Ontario Public Health Business Administrators Association of Public Health Epidemiologists in Ontario Association of Supervisors of Public Health Inspectors of Ontario Health Promotion Ontario Ontario Association of Public Health Dentistry Ontario Society of Nutrition Professionals in Public Health August 27, 2014 Hon Eric Hoskins Minister of Health and Long-Term Care 10th Floor, Hepburn Block 80 Grosvenor Street Toronto, Ontario M7A 2C4 Dear Minister Hoskins, Re: 2014 alpha Resolutions On behalf of member Medical Officers of Health, Boards of Health and Affiliate organizations of the Association of Local Public Health Agencies (alpha), I am writing today to introduce six Resolutions that were passed by the Association at its June 2014 Annual General Meeting for your support and action. A Provision of Population Data from Administrative Sources and Changes in Practice Related to the National Household Survey As you are no doubt aware, the Government of Canada has replaced the mandatory long-form census with a National Household Survey (NHS). Although Statistics Canada has determined that the data generated is likely reliable at the national, provincial, territorial levels, it has also warned that non-response has affected the usefulness of data for the analysis of smaller or identifiable populations. This is a major disadvantage for our member health units as they assess the needs of their communities in an effort to provide the most effective public health programs and services. We are asking you to support our call on the Government of Canada to reinstate the mandatory long-form census and in the interim expedite access to supplemental data sources to support healthy public policy and planning at the community level. A Regulating the Manufacture, Sale, Promotion, Display, and Use of E- Cigarettes E-cigarettes are tobacco- and smoke-free devices designed to deliver nicotine vapour to users. Their popularity is growing but there is little clarity about their risks and benefits in the current body of evidence. We do recognize the important potential for these devices to be effective smoking-cessation aids, but at the same time, we are concerned about the possible negative health impacts of long-term use as well as the setbacks to our efforts to denormalize the use of tobacco and its associated products. We are therefore calling on the Ontario Ministry of Health and Long-Term Care among others to take the measures to protect the health of Ontario residents by ensuring manufacturing consistency for these devices, supporting research on their long-term health effects and regulating their promotion, sale and use. Page 1 of 3 Providing Leadership in Public Health Management

2 Hon Eric Hoskins Page 2 of 3 August 27, 2014 A Designating Provincially and Municipally Funded Multi-Unit Dwellings Smoke-Free Tobacco use remains the leading cause of preventable illness and death in Ontario and its health effects are not limited to smokers. Evidence has clearly shown the dangers of second-hand smoke (SHS), and protecting Ontarians from it is the foundation of the strict prohibitions on smoking in enclosed public spaces in the Smoke-Free Ontario Act. Public demand for further prohibitions is on the rise, and this includes support for regulation of private spaces within multi-unit dwellings. Second-hand smoke easily drifts among individual units via spaces, cracks and shared air circulation systems, resulting in significant exposure of non-smokers to SHS in their own homes. We are therefore calling on your Ministry to partner with the Ministry of Municipal Affairs and Housing to further protect the health of Ontarians by ensuring that new provincially- and municipally-funded multi-unit dwellings are designated smoke-free and that such designation be made prerequisite for eligibility for any future provincial funding for housing. A A Provincial Approach to Community Water Fluoridation The relationship among poor oral health, poor overall health, developmental issues and social risks is very well established. Equally well-established is the greater burden of poor oral health in marginalized populations, which are also less likely to be able to afford the out-of-pocket expense of most preventive and restorative oral health services in Ontario. We know that there is a marked decline in the rates of tooth decay where fluoride has been added to municipal water supplies, the benefits of which are realized without regard to age, education, socio-economic status or access to other preventive measures. Despite the designation of community water fluoridation by the US Centers for Disease Control as one of the ten great public health achievements of the 20 th Century, our members are experiencing formidable challenges to maintaining the practice in their communities. We are therefore calling on you to amend regulations of the Safe Drinking Water Act to require community water fluoridation for all municipal water systems where appropriate and to provide the required funding and technical support to municipalities. A Enactment of Legislation to Enforce the International Code of Marketing of Breast-Milk Substitutes (the Code) Breastfeeding is known to provide the ideal food for infants, to promote both maternal and child health and to contribute to the reduction of chronic health conditions later in life. On this basis, the Government of Canada has endorsed the International Code of Marketing of Breast-Milk Substitutes which outlines the minimum requirements necessary to promote and protect breastfeeding by restricting the marketing of these products. Given the numerous and ongoing violations of the Code by manufacturers and marketers of Breast-Milk substitutes in Canada, we are calling on your Ministry to enact, support and enforce legislation as appropriate in order to ensure implementation of all provisions of the International Code of Marketing of Breast-Milk Substitutes and its subsequent relevant World Health Assembly Resolutions.

3 Hon Eric Hoskins Page 3 of 3 August 27, 2014 A Maintaining Preventive Dental Services in the Ontario Public Health Standards (PSO) Prevention is the foundation of all public health activities, which include important programs and services in oral health. The Government of Ontario clearly recognizes this, as it has mandated preventive oral health services for vulnerable children and youth as part of the Ontario Public Health Standards (OPHS), in order to reduce the prevalence of dental disease. It has also made addressing oral health a key action item in its Ontario Poverty Reduction Strategy. With the current restructuring of Ontario s publicly-funded oral health programs, we believe that it is imperative to maintain focus on preventive oral health services by ensuring that the existing mandate remains part of the OPHS. We are therefore calling on you to ensure that preventive dental services continue to be a clearly mandated activity in the OPHS so that all vulnerable Ontario children can continue to access this public health service. We look forward to working with the Government of Ontario to resolve these issues, which will contribute to the improvement of health and wellbeing for all Ontarians. Sincerely, Linda Stewart, Executive Director COPY: Hon. Dipika Damerla, Associate Minister of Health and Long-Term Care (Long-Term Care and Wellbeing) Dr. Graham Pollett, Chief Medical Officer of Health (Acting) Roselle Martino, Executive Director, Public Health Division Olah Dobush, Assistant Deputy Minister, Health Promotion (Acting) Dr. George Pasut, Interim President & CEO, Public Health Ontario (Resolution A14-1) Hon. Kathleen Wynne, Premier of Ontario (Resolution A14-2, A14-3) Pegeen Walsh, Executive Director, Ontario Public Health Association (Resolutions A14-1,2,3) Pat Vanini, Executive Director, Association of Municipalities of Ontario (Resolution A14-3) Enclosures The Association of Local Public Health Agencies (alpha) is a non-profit organization that provides leadership to Ontario s boards of health and public health units. The Association works with governments and other health organizations, to advocate for a strong and effective public health system in the province, as well as public health policies, programs and services that benefit all Ontarians.

4 alpha RESOLUTION A14-1 TITLE: SPONSOR: Request for Provision of Population Data from Administrative Sources and Changes in Practice Related to the National Household Survey Association of Public Health Epidemiologists in Ontario (APHEO) the National Household Survey (NHS) is intended to provide data for small geographic areas and small population groups; and the 2011 NHS was conducted as a voluntary national population survey; and non-response to the NHS has increased compared to the mandatory long form Census as result of the voluntary nature of the survey; and Statistics Canada supports the general reliability of the data at the national, provincial, territorial levels; and despite this support, Statistics Canada has identified possible effects of non-response in aboriginal identity, ethnic origin, education, income, mobility, language, and housing; and the risk of bias of such measures increases for small areas and smaller populations, the groups for which the NHS is intended to provide estimates; and the NHS surveys a different population than the long form census did: those living in communal settings and abroad are excluded; and the possible bias due to non-response and the change in population has made it difficult if not impossible to compare measures such as income with previous censuses or other sources; and no alternate information sources are readily available to inform decisions or validate NHS estimates based on aboriginal identity, ethnic origin, education, income, mobility, language, and housing at the health unit level; and supplemental data such as those derived from the annual tax file provided by the Canada Revenue Agency or citizenship and immigration statistics from Citizenship and Immigration Canada are available under the Data Liberation Initiative; and only institutional networks of Canadian postsecondary institutions participating in the Data Liberation Initiative currently have access to such data; NOW THEREFORE BE IT RESOLVED that the Association of Local Public Health Agencies request Statistics Canada to make available and/or expedite access to supplemental information or their derivative products in the areas aboriginal identity, ethnic origin, education, income, mobility, language, and housing to support decision makers in small areas and smaller populations. This request will be copied to the Prime Minister s office, Minister of Industry (as the originator of the Order in Council that altered the census), the Minister of Health, and the leaders of the opposition parties and their critics for these two ministries; Page 1 of 2

5 alpha RESOLUTION A14-1 continued Page 2 of 2 AND FURTHER that Statistics Canada and those who may influence decisions made by Statistics Canada be asked to reinstate a mandatory long form census and otherwise gather and make available information from administrative databases such data that may be influenced by non-response to the NHS at a small area or small population level; AND FURTHER that the Association of Local Public Health Agencies encourage other stakeholder agencies such as the Ministry of Health and Long Term Care, Public Health Ontario, Ontario Public Health Association, etc. to support this resolution. ACTION FROM CONFERENCE: Resolution CARRIED

6 alpha RESOLUTION A14-2 TITLE: SPONSOR: Regulating the Manufacture, Sale, Promotion, Display, and Use of E-Cigarettes Board of Health, Peterborough County-City Health Unit an e-cigarette is a device designed to mimic the appearance and feel of a regular cigarette, pipe or cigar, but with one critical difference they do not contain tobacco; and there has been a huge increase in the growth and popularity of e-cigarettes in recent years; and in one study on the prevalence of use among youth and young adults, results indicate that ⅓ of Canadian smokers and 6% of non-smokers had ever tried e-cigarettes. Of those, 14% of smokers and 1% of non-smokers indicate being current e-cigarette users; and e-cigarettes are available from a wide variety of locations including convenience stores, gas stations, pharmacies, specialty e-cigarette stores, and the internet; and e-cigarettes do not contain tobacco, they are not covered under the Tobacco Act or the Smoke-Free Ontario Act; and e-cigarettes that contain nicotine and/or with health claims require pre-market authorization by Health Canada before they can be sold in Canada; and there are no long-term studies on the health effects of using e-cigarettes, they pose a substantially lower health risk compared to cigarettes, and there has been little evidence of harm from e-cigarettes; and the long term risk of inhaling propylene glycol (one of the main ingredients) is still unknown and lack of manufacturing standards means there is significant variation in nicotine and other chemical content, which poses a health risk to the user; and e-cigarettes have tremendous potential to help smokers reduce their cigarette consumption and to quit smoking altogether; and current available smoking cessation aids have limited effectiveness and e-cigarettes have the potential to help smokers reduce their health risks; and using an e-cigarette in indoor environments, may involuntarily expose nonusers to nicotine from second hand vapour but not to toxic tobacco-specific combustion products; and e-cigarettes, both with and without nicotine, have the potential: to undermine current smoke-free regulations; complicate enforcement; re-normalize smoking thus making the habit more attractive, especially among youth and young adults; and lead to an increase in dual use (e-cigarettes and traditional cigarettes); and more research is needed to determine the health risks of exposure to second-hand vapour; Page 1 of 2

7 alpha RESOLUTION A14-2 continued Page 2 of 2 NOW THEREFORE BE IT RESOLVED that the Association of Local Public Health Agencies request Health Canada, the Ontario Ministry of Health and Long-Term Care and its stakeholders to provide for the public health, safety, and welfare of all Ontario residents by: ensuring manufacturing consistency of e-cigarettes; conducting research on the long-term health effects of e-cigarettes and exposure to second hand vapour; and regulating the promotion, sale and use of e-cigarettes in Ontario. AND FURTHER that the Premier of Ontario, the Chief Medical Officer of Health, Ontario Public Health Association, Prime Minister of Canada, Chief Public Health Officer of Canada, federal Minister of Health, and Ontario s Minister of Health and Long-Term Care be so advised. ACTION FROM CONFERENCE: Resolution CARRIED

8 alpha RESOLUTION A14-3 TITLE: SPONSOR: Designating Provincially and Municipally Funded Multi-Unit Dwellings Smoke-Free Board of Health, Peterborough County-City Health Unit tobacco use remains the leading cause of preventable illness and death in Ontario; and there are more than 4000 chemicals found in second-hand-smoke (SHS), of which at least 250 are regulated toxins, and 69 are known carcinogens, or cancer causing agents; and there is no safe level of exposure to SHS; and in adults, SHS exposure can cause serious cardiovascular and respiratory diseases including lung cancer and coronary heart disease; in children, it can cause Sudden Infant Death Syndrome (SIDS), asthma, ear infections, bronchitis and pneumonia, ; and eliminating smoking in indoor spaces is the only way to fully protect nonsmokers from SHS exposure; cleaning the air and ventilating buildings cannot eliminate SHS; and now that most Ontarians are protected under the Smoke-Free Ontario Act (SFOA) in public places and workplaces such as bars and restaurants, hospital entrances, casinos, the common areas of multi-unit dwellings, as well as in cars with children under 16, demand for other smoke-free environments is on the rise, particularly in multi-unit dwellings (MUDs); and under the SFOA smoking is prohibited only in common areas and not inside individual units in shared housing; and residents who live in social units, especially children, the elderly and persons with preexisting health conditions, continue to be negatively affected by second-hand smoke exposure; and there is a growing need for smoke-free housing options as evident in a recent Ipsos Reid survey, where one-third of respondents indicated being regularly exposed to SHS in their homes and 80% would choose to live in a smoke-free building if given their preference; and smoke-free policies in multi-unit dwellings are legal, enforceable and non-discriminatory; NOW THEREFORE BE IT RESOLVED that the Association of Local Public Health Agencies request the Ministry of Municipal Affairs and Housing, the Ontario Ministry of Health and Long-Term Care and its stakeholders: to provide for the public health, safety, and welfare of all Ontario residents by ensuring that new provincially and municipally funded multi-unit dwellings are designated smoke-free; and, that any future provincial funding for housing require as a criteria for eligibility, that any new units be designated as smoke-free. AND FURTHER that the Premier of Ontario, the Chief Medical Officer of Health, the Ontario Public Health Association and the Association of Municipalities of Ontario be so advised. ACTION FROM CONFERENCE: Resolution CARRIED Page 1 of 1

9 alpha RESOLUTION A14-4 TITLE: SPONSOR: A Provincial Approach to Community Water Fluoridation Simcoe Muskoka District Health Unit the relationship between poor oral health and poor overall health is well established; and the relationship between poor oral health and social risks including speech development, ability to thrive and readiness to learn in children, and self-respect and employability in adults is also well established; and the burden of poor oral health is greater for marginalized populations; and most preventive and restorative oral health services in Ontario are out-of-pocket expenses that favour those with the ability to pay; and there has been a documented marked decline in the rates of tooth decay where fluoride has been added to municipal water supplies; and these health benefits extend to all residents in a community regardless of age, education, socio-economic status or access to other preventive measures; and it is estimated that every $1 invested in community water fluoridation yields an estimated $38 in avoided costs for dental treatment; and the current evidence supports that fluoridation based on a maximum allowable concentration (MAC) of 1.5 mg/l is safe; and these health benefits extend to all residents in a community regardless of age, education, socio-economic status or access to other preventive measures; and boards of health experience formidable challenges to the ongoing fluoridation of municipal drinking water and defending such challenges is taxing, consuming limited public health resources; and despite the best efforts of boards of health, municipalities in Ontario have discontinued community water fluoridation, over the last five years effecting almost half a million people, or almost 4% of Ontario's population; and jurisdictions that have legislated fluoridation at the state, provincial, territorial or national level of government have succeeded in increasing the percentage of their population receiving fluoridated water. Page 1 of 2

10 alpha RESOLUTION A14-4 continued Page 2 of 2 NOW THEREFORE BE IT RESOLVED that the Association of Local Public Health Agencies call for the Province of Ontario to amend regulations of the Safe Drinking Water Act to require community water fluoridation for all municipal water systems (when source-water levels are below the Health Canada-recommended level of 0.7 mg/l) to prevent dental caries; AND FURTHER that the Province provides the funding and technical support to municipalities required for community water fluoridation. ACTION FROM CONFERENCE: Resolution CARRIED

11 alpha RESOLUTION A14-7 TITLE: SPONSOR: Enactment of Legislation to Enforce the International Code of Marketing of Breast-Milk Substitutes (the Code) Haliburton, Kawartha, Pine Ridge District Health Unit breastfeeding is known to provide the ideal food for infants and is recommended by Health Canada for all healthy full-term infants; and breastfeeding promotes both maternal and child health and contributes to the reduction of chronic health conditions, obesity and health inequalities; and interventions to improve breastfeeding are cost-effective with high cost-benefit ratios compared to curative interventions; and the Government of Canada endorsed the International Code of Marketing of Breast-Milk Substitutes which outlines the minimum requirements necessary to promote and protect breastfeeding by restricting the marketing of breast-milk substitutes; and the government of Canada has not enacted legislation making all aspects of the Code enforceable by law; and numerous violations of the Code have been and continue to be reported on an ongoing basis since 1981 when the Code was adopted voluntarily by the Canadian Government; and the suppliers of breast-milk substitutes, a $25 billion dollar industry world-wide, have unparalleled marketing abilities; and compliance with the Code leads to improved breastfeeding initiation, duration and exclusivity rates; and the Ontario Public Health Association (OPHA) outlined in their 2010 position paper their support and ongoing efforts to advocate at the federal level for legislation to support the Code including the ability to enforce this legislation; and the Peterborough County-City Health Unit has taken action at the federal level, asking the Canadian government to honour its commitment to maternal and child health by advocating for legislation of the Code in Canada; and the Health and Social Services Committee of Durham Regional Council, the Board of Health for the Grey Bruce Health Unit, the Board of Health for the North Parry Sound Health Unit and the Board of Health for the Haliburton Kawartha Pine Ridge District Health Unit have all endorsed Peterborough County-City Health Unit s position to urge the Federal government to enact legislation; Page 1 of 2

12 alpha RESOLUTION A14-7 continued Page 2 or 2 NOW THEREFORE BE IT RESOLVED that the Association of Local Public Health Agencies strongly recommends and urgently requests the Prime Minister of Canada, the federal Minister of Agriculture and Agri-Food, Ontario Minister of Children and Youth Services, Ontario Minister of Education, the federal Minister of Health, and Ontario Minister of Health and Long-Term Care to enact legislation implementing all provisions of the International Code of Marketing of Breast-Milk Substitutes and its subsequent relevant World Health Assembly Resolutions; AND FURTHER the Association of Local Public Health Agencies strongly recommends and urgently requests the Prime Minister of Canada, the federal Minister of Agriculture and Agri-Food, Ontario Minister of Children and Youth Services, Ontario Minister of Education, the federal Minister of Health, and Ontario Minister of Health and Long-Term Care to establish a sustainable enforcement program to allow for monitoring and addressing non-compliance with the legislation. ACTION FROM CONFERENCE: Resolution CARRIED AS AMENDED

13 alpha RESOLUTION A14-8 TITLE: SPONSOR: Maintaining Preventive Dental Services in the Ontario Public Health Standards (PSO) Simcoe Muskoka District Health Unit the relationship between poor oral health and poor overall health is well established; and there exists a relationship between poor oral health and social risks including poor speech development, inability to thrive and challenges to learn in children; and the burden of poor oral health is greater for marginalized child populations; and school based pit and fissure sealant programs and fluoride varnish applications in schools have been shown to be highly effective clinical preventive interventions; and most preventive oral health services in Ontario are out-of-pocket expenses that families of children cannot always afford; and in the Ontario Public Health Standards (OPHS), an objective of the Child Health programs is to reduce the prevalence of dental disease in children and youth; and the OPHS have mandated that all children in need of preventive oral health services receive essential clinical preventive services; and Requirement 13, regarding the Preventive Oral Health Services Protocol, will be removed from the Ontario Public Health Standards upon implementation of the new integrated Healthy Smiles Ontario Program; and only children of families that meet the financial eligibility criteria will be eligible for public health preventive oral health services, resulting in the exclusion of a significant population of vulnerable children. NOW THEREFORE BE IT RESOLVED that the Association of Local Public Health Agencies write to the Minister of Health and Long-Term Care calling for the Province of Ontario to maintain the preventive dental services in the Ontario Public Health Standards so that all Ontario children who qualify clinically and are from families who cannot afford this care at a fee for service clinic will be offered this public health service. ACTION FROM CONFERENCE: Resolution CARRIED Page 1 of 1