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David Moore
View David Moore Profile
David Moore
2019-04-11 15:40
Thank you, Madam Chair.
On behalf of the BC Centre for Excellence in HIV/AIDS and our Executive Director, Dr. Julio Montaner, I would like to thank the committee for the opportunity to speak today. My name is David Moore. I'm a Research Scientist at the BC-CfE in Vancouver and a professor in the Faculty of Medicine at UBC.
I'd like to start by acknowledging that I am presenting from the unceded traditional territory of the Musqueam, Squamish and Tsleil-Waututh first nations.
The BC-CfE is a provincial agency dedicated to improving the health of British Columbians living with HIV and AIDS. The BC-CfE works in partnership with the B.C. Ministry of Health, health authorities, municipalities and community groups in B.C. to promote evidence-based programs and policies to improve the quality of life for those living with HIV and to protect people from acquiring the virus.
As you've already heard, gay, bisexual and other men who have sex with men—hereafter referred to as “gbMSM”—are disproportionately affected by HIV and other sexually transmitted and blood-borne infections in Canada. Despite great advances in our scientific knowledge, gbMSM continue to experience the largest number of new HIV diagnoses each year amongst all populations at risk. In 2016 they accounted for 48% of new HIV diagnoses in Canada, despite comprising only 3% to 5% of the adult male population. Nationally, the number of new diagnoses amongst gbMSM has remained largely unchanged over the last 10 years. HIV remains a fundamental threat to the health of gbMSM and results in significant costs to the Canadian health care system.
However, recent advances in HIV treatment and prevention have generated great optimism for the potential elimination of HIV as a public health threat among gbMSM. The BC-CfE was at the forefront of developing modern HIV treatment as a highly effective means of preventing the development of AIDS and premature death amongst people living with HIV. More recently, research has shown that effective HIV treatment is 100% effective in preventing HIV transmission. As such, the close to 90% of gbMSM in metropolitan Vancouver who are receiving HIV treatment and have achieved virologic suppression can now be assured that they will have near-normal life expectancy; equally important, they will not transmit HIV to their sexual partners.
The B.C. experience has shown that facilitated access to HIV testing and immediate access to free treatment amongst people living with HIV, or treatment as prevention, known as “TasP”, is the key to controlling the epidemic. TasP has now been adopted globally as part of the BC-CfE's proposed 90-90-90 targets for the global rollout of antiretroviral therapy. These targets propose that by 2020, at least 90% of people living with HIV will have been diagnosed, at least 90% of these will be receiving HIV treatment, and 90% of these will have achieved virologic suppression. It's estimated that meeting the 90-90-90 targets will lead to a 90% decrease in AIDS mortality by 2020 and a decrease in HIV infections of 90% by 2030. The 90-90-90 targets have now been formally adopted by the United Nations and by the Government of Canada, yet the implementation of TasP in Canada has been uneven. There is a growing concern that we will fail to meet the 90-90-90 targets on time.
More recently, it has been shown that taking a combination of two antiretroviral medications, or HIV pre-exposure prophylaxis, which is known as “PrEP”, is at nearly 90% effective in preventing HIV acquisition amongst gbMSM at high risk of infection. However, PrEP access across Canada remains suboptimal. Since January 2018 in B.C., PrEP has been available free of charge through BC-CfE for B.C. residents at high risk of acquiring HIV. Since full public funding for PrEP began in B.C., uptake has been very high, with more than 4,000 individuals, of whom 98% are gbMSM, initiating PrEP through the program as of the end of March 2019. As a result, B.C. is currently experiencing the lowest rates of new HIV diagnoses since the mid-1990s. We therefore call on the federal government to secure equitable and effective access to HIV testing and prevention programs, with support for and access to TasP and PrEP at no charge for people living with HIV or those at risk of HIV infection.
While the issues above highlight the great optimism felt about the control of the HIV epidemic, this is not the case for other sexually transmitted infections, blood-borne infections, or STBBIs. As we've heard from Dr. Gilbert, diagnosis rates of hepatitis C, syphilis, gonorrhea, and chlamydia continue to grow each year across the country, and again, gbMSM are heavily overrepresented in these epidemics. Therefore, we support the development and implementation of the government's STBBI action plan, coupled with significant new funding for programming, monitoring, evaluation and research. Without additional funding, our efforts will be diluted and will result in very limited impact for affected communities.
As mentioned by Dr. Gilbert, it's now understood that the syndemics of mental health and substance use disorders play a large role in increasing the vulnerability to STBBIs amongst gbMSM. Public policies developed over the last decades have likely reduced some of the stigma and discrimination faced by gbMSM in Canada. However, frequent and pervasive exposure to stigma and discrimination within the school, home, community and online environments due to one's sexual and/or gender minority status are still common and result in what has been termed “minority stress”. This minority stress is then reflected in much higher rates of substance use and mental health disorders. Compared with heterosexual men, sexual minority men are four times more likely to attempt suicide, two to three times more likely to develop depression and anxiety, and are twice as likely to develop drug dependencies. In order to have a sustainable impact on minority stress experienced by gbMSM, additional attention must be paid towards implementing evidence-based mental health and substance-use disorder services at the community level. We therefore recommend that the federal government work with provincial, territorial and indigenous partners to bridge the gaps in mental health and substance use services for gbMSM.
Another factor that has likely contributed to the continuing stigmatization of HIV, and by extension gbMSM, has been the over-criminalization of HIV exposure in Canada. While steps were taken federally to address this issue in late 2018, these had limited impact across the country. Therefore, we recommend that legislation be put forward to eliminate the over-criminalization of HIV exposure in Canada. We also recommend that the federal government unequivocally endorse the notion that undetectable equals untransmittable as it relates to the transmission of HIV.
As we've also heard, many gbMSM also use substances to cope with mental health challenges related to persistent societal stigma and discrimination. While cigarette smoking and hazardous alcohol use have not received as much attention in the press as illicit substances, they are highly prevalent amongst gbMSM, thus gbMSM are at greater risk of developing a host of illnesses related to tobacco and alcohol use, including cardiovascular disease, cancers, respiratory, kidney and liver diseases. Access to evidence-based smoking and alcohol cessation programming by gbMSM is quite low across the country and needs to be improved. The burden of smoking and hazardous alcohol use and the risks for developing diseases associated with these conditions are multiplied for HIV-positive gbMSM. Therefore, we support the inclusion of LGBTQ+ people as a key population in the federal tobacco control strategy, but recommend that additional funding for that strategy be secured to support community-based approaches to smoking prevention and cessation among LGBTQ+ people.
As well, the use of methamphetamine and other stimulants is highly prevalent among gbMSM. Among participants in our cohort study in Vancouver, 44% of HIV-positive and 10% of HIV-negative gbMSM report methamphetamine use in the previous six months. Participants who reported recent methamphetamine use were more likely to have been diagnosed with an anxiety disorder or depression and scored higher for symptoms for both anxiety and depression in comparison with individuals who did not report recent use. Therefore, we also recommend that additional funding be secured to support research and evidence-based programming to provide treatment and support for gbMSM who are affected by substance use disorders, particularly methamphetamine use and hazardous alcohol use.
In summary, in order to improve the health of gay, bisexual and other men who have sex with men in Canada, we recommend that the federal government take steps to realize the potential for HIV elimination among gbMSM in Canada and better control of other STBBIs. However, we must also work with provincial, territorial and indigenous partners to ensure that we are also addressing the syndemic problems of mental health and substance use disorders, which are important drivers of these epidemics.
Thank you.
Rob Cunningham
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Rob Cunningham
2018-05-01 15:46
Thank you very much, Chair.
Thank you for giving me the opportunity to testify today.
The focus of my testimony will be part 2 of the bill, clauses 47 to 67, implementing a $1-per-carton increase in tobacco taxes and modifying the inflation indexing for tobacco taxes from every five years to every year. We applaud these measures and urge all committee members to support these provisions. Tobacco products remain the leading cause of preventable disease and death in Canada, killing 45,000 Canadians annually and causing about 30% of all cancer deaths.
We also strongly support the federal budget provisions that provide increased investment in the federal tobacco control strategy. This is essential as part of the efforts to meet the objective of reducing tobacco use to under 5% by 2035. There are still more than five million Canadians who smoke. There are teenagers starting to smoke every month. We have made considerable progress, but enormous work remains.
The budget measures regarding tobacco taxes and funding of the strategy are complemented by Bill S-5, adopted at third reading by the House of Commons last week, and by pending regulations for plain and standardized packaging. Plain packaging, a key measure to protect youth and curb the package as a means of promotion, has already been adopted by eight countries.
Increasing tobacco taxes is the most effective strategy to reduce tobacco use, especially among youth who have less disposable income. They're more price sensitive. That tobacco taxes decrease consumption is recognized by the World Bank, the World Health Organization, a vast number of studies in Canada and worldwide, provincial and territorial governments across Canada, and successive federal governments. Tobacco tax increases are a win-win, benefiting both public health and public revenue. The budget projects increased revenue of $375 million in this fiscal year alone as a result of the tobacco tax changes.
Inflation indexing of the tobacco tax was initiated in the 2014 federal budget, with indexing to occur every five years. The first inflation adjustment was to have occurred in 2019. Indexation ensures that tobacco tax rates are in effect kept the same on an after-inflation basis. In its pre-budget submission, Imperial Tobacco Canada recommended annual indexation instead of every five years as part of its recommendations to this committee.
Federal tobacco taxes are better than provincial tobacco taxes from a contraband perspective, because they apply on reserves. There's no difference between on-reserve and off-reserve tax rates. The level of contraband on which federal tobacco taxes are not paid is far lower than the contraband level on which provincial tobacco taxes are not paid.
I would invite committee members to turn to the background material that was circulated to you. The first graph shows comparative provincial and territorial tobacco tax rates. We see that Ontario and Quebec have the lowest tax rates in Canada but the highest contraband. That's counterintuitive to what we hear from the tobacco industry. They say higher tobacco taxes increase contraband. We see that in western Canada they have far higher rates of tobacco taxes but much lower levels of contraband.
Why is contraband higher in Ontario and Quebec? It's proximity to the illegal factories and sources of supply, but we can see that higher tobacco taxes have been sustained in the west and the Atlantic.
The next graph shows the trend in federal and provincial tobacco tax revenue. We see that even with reduced smoking rates, tobacco tax revenue continues to increase despite the lower smoking prevalence. In fiscal year 2017, the amount of $8.4 billion was collected, with even more of an increase if GST, HST, and PST on tobacco products were factored in.
The next graph shows the long-term trend in smoking prevalence in Canada. In 1965 it was 50% for Canadians aged 15 plus. In 2016 that was down to 17%. Over recent years we've seen a continuing decline. That's very positive, but it's also relevant when we see that tobacco tax revenue continues to increase. So tobacco taxes do benefit public revenue.
The next graph shows trends among teenagers, the 15- to 19-year-olds. We see a continuing decline in smoking prevalence among youth. That's very good. Tobacco taxes and other measures have contributed to that, but we want to keep driving this down further. The recently announced measures will help do that.
We thank the federal government for the new tobacco control measures that have been brought forward, and we appreciate the support from all parties. We look forward to continuing progress.
Thank you.
View Michael McLeod Profile
Lib. (NT)
Thank you, Mr. Chair, and thank you to all the presenters here today.
I'm especially happy to see the Canadian Cancer Society here, talking about some of the concerns we have around smoking. In our country, we still have large populations in different regions where there are a lot of smokers. Wherever there are a lot of smokers, there are high rates of lung cancer. In the Northwest Territories, Nunavut, Yukon, and all areas of the north, we still have a high number of smokers. I've raised the concern on the floor of the House of Commons about this issue and asked what can we do about it. We really have to get it under control. I've sat through presentations in my riding with people from health, with the charts on the wall. Smoking and lung cancer is double or triple what everything else is that is a cause of cancer.
It was interesting to hear that you are looking at the issue of raising the cost of cigarettes as a detriment to smoking. I'm not sure if I totally agree with that, so maybe you could explain it to me, because, as I said, I'm from the Northwest Territories where a carton of cigarettes is $161.20 today. I don't see anyone quitting smoking because of that. Maybe you could just tell me what information you have, what research shows that this works.
Rob Cunningham
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Rob Cunningham
2018-05-01 16:40
There are extensive studies that show that higher prices decrease consumption. I think the prices in Northwest Territories vary by community. In some cases, they may be lower than that. Your health minister recently stated in the legislative assembly that he wants Northwest Territories to have the highest tobacco taxes in Canada. That used to be the case. Manitoba is the current leader. He's going to urge the minister of finance to try to ameliorate that.
Teenagers are especially price sensitive because they have less money, and they're not yet addicted, and it would go down more if we didn't have nicotine addiction. However, it clearly works, and we have seen some decrease in smoking among indigenous youth, especially off reserve, but it's still way too high. In Northwest Territories there is not the same lower tax rate on reserves that we see in provinces.
It is a tremendous concern. Had the tax rates not been there, smoking rates would be even higher.
View Greg Fergus Profile
Lib. (QC)
View Greg Fergus Profile
2018-05-01 17:01
Thank you very much.
I have just a very quick question.
Mr. Cunningham, thank you very much for your presentation and taking a look at the smoking rates. I was particularly taken with your analysis as to what the federal excise tax means in terms of places where there are higher numbers of contraband cigarettes.
At the very end, where you talk about the youth smoking rates based on age, has your organization disaggregated that data to look at what the smoking rate is among young women as opposed to young men, among 15- to 19-year-olds?
Rob Cunningham
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Rob Cunningham
2018-05-01 17:02
Yes. It's going down among both boys and girls, so the news is good. It's also going down among young adults, both male and female. However, we need to keep at it.
Rob Cunningham
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Rob Cunningham
2018-05-01 17:02
In recent years, there isn't. If we go back a couple of decades, there has been a change. It was going down among boys but not among girls. In more and more recent years, we've made progress among girls. It was very frustrating previously.
View Dave Van Kesteren Profile
CPC (ON)
You're absolutely right.
We all had mothers. My mother is gone now, but I'll testify that she was probably one of the wisest of women. She never smoked, but we would talk about smoking, and obviously with a large family, there were some who smoked. She would say that people need their vices. I can't imagine being in a prison when you're stripped of all those things. I think you described perfectly what that is—a stress reliever—and we have no idea of the types of stress.
Do you think it's a human right for them to smoke in prison?
Anne Cattral
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Anne Cattral
2017-11-02 10:12
It's so hard. I'm an ex-smoker myself. My son is in there. He's a non-smoker and he's so happy that nobody is allowed to smoke, but I would suggest that to expect somebody who maybe has smoked since they were 12 or 13 years old, maybe 20-some years, to stop cold turkey would be very difficult.
Again, I would say, along with Irene, that if there were an outside smoking lodge or whatever that they could go to and have cigarettes legally in there—they're illegal—as well as other harm reduction techniques that they need to introduce into the prison in terms of any other addictions they have.... It's an addiction.
Daniel Krewski
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Daniel Krewski
2016-11-22 17:02
I like the question. I want to make a couple of quick points. One is what the scope of CEPA is whether we're talking about environmental tobacco smoke or active smoking.
Certainly, active smoking is the predominant cause of lung cancer, responsible for some 90% of all lung cancers in this country, but among the other causes, and this is my second point, close on the list would be radon in your homes, which is responsible for about 10%. The vast majority of the radon-related lung cancer cases, however, occur in smokers because of the synergism between the two agents. If you got rid of smoking, you'd also solve the radon problem.
This point came up in the “next generation of risk” science project we did, in which you might have a particular statute that focuses on an environmental agent such as radon, while a lifestyle factor such as smoking is outside the scope, but because those two interact, maybe at a cross-agency or cross-statute nexus there might be some public health interventions you could design that would serve multiple purposes. That's what we call the population health approach to risk assessment.
Gabriel Miller
View Gabriel Miller Profile
Gabriel Miller
2016-10-21 11:08
Thank you, Mr. Chair, for the opportunity to be here.
Most of the time, I will speak English. However, if you put questions to me in French, I will do my best to answer in that language.
It's my privilege to be here on behalf of the Cancer Society, which is the country's largest national health charity. We have 140,000 volunteers across the country and millions of supporters.
Today I want to summarize the three recommendations in our brief. Most importantly, I want to suggest to you very strongly that there are practical, affordable steps the federal government can take in this budget not only to improve health care but also to get better value for our health care dollars. Good health care and good health are the foundations of everything we value, including our economy. We face no greater health challenge than cancer, our leading cause of death. Building a more productive health care system, one that achieves more value for the money we put into it, will not only relieve suffering and pain; it will save lives, it will save money, and it will benefit every household and business in this country.
Achieving better value for the money we invest will ease the burden on taxpayers in a country where we invest more than $150 billion each year through government in health care, making it by far the largest piece of provincial budgets. Achieving better outcomes in prevention and treatment will reduce the costs of sickness and disability. It will help more Canadians remain active participants in the labour force for longer periods of time. In our submission, we highlight three areas where the federal government can take practical, affordable action. Let me say a couple of words about each.
Concerning tobacco control, despite the progress we've made over the last 30 years, tobacco remains the single largest preventable cause of cancer in Canada. Tobacco use remains responsible for 30,000 deaths a year in this country. Somehow, however, we've allowed federal investments in tobacco control to erode. Today we invest 1¢ of every dollar the federal government collects in tobacco taxes in programs to help people stop smoking. It's time we renew our federal tobacco strategy—it expires next year—and renew it with funding appropriate to what was envisioned when the strategy was first introduced in the early 2000s, an annual investment in excess of $100 million a year.
Second, I want to say a word about health research. While federal health care transfers have increased at 6% a year for more than a decade, federal investments in health research have become stagnant. They have essentially flatlined since 2008. This is madness. Surely as our health challenges grow, and our investments grow with them, we want a smarter, more evidence-based suite of policies to draw on. It's essential that, at the very least, our investments in health research keep pace with our investments in health care.
Finally, I'll say a word about the new national health accord. We strongly support the priority areas the federal government has outlined, especially home care and drug affordability.
In conclusion, I really want to draw your attention to the most important opportunity that the government has this year and a recommendation that I think this committee could make that would have a real impact. We recommend that the government dedicate as much as possible of the $3 billion it has committed to home care to improving palliative care across the country in homes and communities. This investment targeted at palliative care has the power to transform that type of care in this country. Spread too wide, that investment will have its impact diluted. By focusing on palliative care, we can come very close to closing the gap for people, especially at the end of life in the last 30 days. Here in Ontario it's estimated that care in the last 30 days of life is 10 times more expensive to provide in an acute-care hospital than it is to provide at home, and at least two or three times more expensive than it would be in a hospice or a community setting. This is an enormously powerful opportunity to make life better for families, to relieve unnecessary pain and suffering, and to transform one of the most broken parts of our health care system.
I think there are practical, affordable steps we can take together. The Cancer Society is anxious to work with you to realize them.
I want to thank you very much for the opportunity today.
View Raj Grewal Profile
Ind. (ON)
View Raj Grewal Profile
2016-10-21 11:40
When it was $100 million a year, what was the impact on the Canadian population for a decrease in Canadians' smoking?
Gabriel Miller
View Gabriel Miller Profile
Gabriel Miller
2016-10-21 11:40
It's a bit tricky separating all of the factors and attributing to any one of them, but I can tell you that Canada began a historic turnaround in smoking rates about 30 years ago. The federal government's commitment to that strategy also accompanied actions on a number of fronts.
Gabriel Miller
View Gabriel Miller Profile
Gabriel Miller
2016-10-21 11:40
Federal leadership has been key.
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