Reducing the economic burden of chronic disease requires major investment in public health/Des investissements de grande envergure en sante publique pour reduire le poids economique des maladies chroniques.

Raine, Kim D.

This issue includes an illuminating paper entitled "Variation across Canada in the economic burden attributable to excess weight, tobacco smoking, and physical inactivity". (1) The research used innovative economic modeling to estimate the economic burden of each of these three risk factors based on population attributable risk. The results and conclusions have important implications for public health practice and policy.

The first conclusion is that there has been a major shift in the distribution of economic burden by risk factor, with the economic burden attributable to smoking decreasing, while the burdens attributable to both excess weight and physical inactivity are increasing. A large part of this change is related to prevalence; smoking prevalence in Canada is now down to 17.5%, while 46.1% of Canadians have excess weight and 43.6% are inactive. (1) While there is still work to do in tobacco control, two questions arise: 1) what can we learn from the successes of tobacco control in decreasing prevalence of smoking in Canada that can be applied to obesity and physical inactivity? and 2) what type of investment will Canada need to make to catalyze a similar reduction in prevalence in excess weight and inactivity?

The second conclusion of the study is that there are geographic differences in the prevalence of risk factors across Canada. Specifically, due to the lower prevalence of smoking, excess weight and inactivity in British Columbia (BC), the economic burden per capita is lower than in any other province. Why do those living in BC smoke less, take part in more physical activity and have less excess weight? Specifically: 1) what characteristics of the social and physical environments create conditions that offer some protection to people living in BC? and 2) what public health investments have contributed to those protective environments?

Lessons from tobacco control: Investing in social change

While diseases associated with tobacco use are still of significant economic burden to Canadians, the paper by Krueger et al. clearly demonstrates that as smoking prevalence decreases, the economic burden is lessened. (1) In 1965, 49.5% of Canadians over the age of 15 smoked. The Government of Canada has been funding tobacco control interventions since the 1960s. First, public education was introduced. More comprehensive social marketing programming dominated the 1980s and 1990s. Predominantly voluntary restrictions on some of tobacco companies' marketing activities began briefly in the early 1970s under the threat of proposed legislation. However, concerted policy development combining legislation, regulation and health promotion began in the early 1980s, and the Tobacco Products Control Act was enacted in 1988, by which time smoking rates had dropped to 32%. In 2001, the federal government invested $560 million over five years to the Federal Tobacco Control Strategy (FTCS). Although intervention efforts had already seen an almost 50% decline in smoking rates (in those 15 years and older) to 25%, the commitment to tobacco control was clearly on the agenda, and the FTCS was a comprehensive, coordinated strategy including mass media, enforcement of regulations, surveillance and local projects. The investment was significant; the goal of reducing smoking rates to 20% in the first five years was achieved. (2) Changing social norms is not easy; it requires significant effort and investment. The federal, provincial and territorial governments made a clear decision to invest in tobacco control. That investment has paid off in reduced health care and indirect costs. (1)

With respect to physical inactivity and excess weight, Canada appears to be at the stage now where it was with tobacco control in the 1970s. Focus on individual behaviour change through public education and social marketing dominates. Campaigns to promote physical activity, such as ParticipACTION, have been successful in raising public consciousness of physical activity. (3) With respect to control of advertising of unhealthy foods and beverages in attempts to curb childhood obesity, the current norm is voluntary measures controlled by industry, which have been largely ineffective in curbing children's exposures. (4) The exception is Quebec, where the Quebec Consumer Protection Act (QCPA) has prohibited all commercial marketing to children since 1980. This legislation has been shown to be more protective of Francophone children, who are less likely to be exposed to cross-border media from English Canada. (5) School environments, an ideal site for protecting children, have made some progress. All provinces have adopted guidelines for healthy school food, yet only Ontario, BC, New Brunswick, Newfoundland and Nova Scotia have made them mandatory (6) (school boards and municipalities within provinces have opted to adopt stronger measures in some cases, although compliance is uncertain as monitoring is often not mandated). Similarly, some provinces have adopted mandatory daily physical activity (DPA) policies, yet implementation is spotty, possibly due to low resources. (7) In other words, Canada has a patchwork of policies with respect to improving food and physical activity environments, but no strong legislation to date. What is missing is a coordinated and well-resourced investment, including the resolve to take on industry (e.g., Big Food), who invest billions in marketing their products. (8) This is where we can learn from tobacco control. We need collective environmental action for individual responsibility to take full effect and for comprehensive measures to be most effective. Action (with evaluation) is warranted before all of the evidence of intervention effectiveness has been established. (9) Concerted policy development combining legislation, regulation and health promotion is needed to reverse the epidemics of physical inactivity and excess weight.

There is certainly no shortage of ideas as to potential environmental and policy approaches to addressing physical inactivity and excess weight. Even in (formerly) conservative Alberta, decision-makers support policy action to address physical inactivity, healthy eating and obesity, although the highest levels of support align with individually-focused policies such as public education. (10) Federally and provincially, no Canadian jurisdiction has made a financial investment in chronic disease prevention that parallels the magnitude of the initial FTCS, despite the political rhetoric of reports and strategies that extoll the virtues of commitment to prevention. Lack of coordination means missed or misplaced opportunities and unrealized return on investment.

Public health investments: Lessons on creating supportive environments

But what of the regional variations in risk factor prevalence and associated costs? What characteristics of the social and physical environments create conditions that offer some protection to people living in BC? As the paper (1) points out, favourable weather patterns may play some role in BC's higher physical activity levels, although the other Canadian jurisdiction with a higher than the Canadian average proportion of adults considered active in 2013 was Yukon! (11) Perhaps a western culture promotes physical activity over weather for hardy Canadians. The most relevant insight is the significant investment in ActNow BC, a whole-of-government approach with the expressed goal of improving the health of the population, including a $25 million infusion for addressing risk conditions and risk factors for chronic disease. However, political and financial support for ActNow has waned. Others have suggested that to build on the momentum, ActNow BC could be strengthened through legislation, learning from Quebec's Public Heath Law, allowing for accountability to long-term population health goals. (12)

Returning to another lesson from tobacco control, it is worth noting that "complacency that past actions will serve well in the future may retard future progress" (9) (p. 899). Complacency is a huge risk to public health. Progress in changing policy and environments to reduce chronic disease risk requires significant investment, both politically and financially. Clearly, a return on investment can be realized as risk prevalence drops. (1) The economic argument is one more tool in advocating for healthy public policy. It's time for a well-resourced, legislated federal commitment and investment in reducing inactivity, improving healthy eating and reducing excess weight, working in parallel with tobacco (and alcohol) control so we can learn and build together. Canadians, and the sustainability of our health care system, are worth it.

Kim D. Raine, PhD, RD, FCAHS

Centre for Health Promotion Studies, School of Public Health, University of Alberta, Edmonton, AB

doi: 10.17269/CJPH.106.5214

REFERENCES

(1.) Krueger H, Krueger J, Koot J. Variation across Canada in the economic burden attributable to excess weight, tobacco smoking and physical inactivity. Can J Public Health 2015;106(4):e171-77.

(2.) Health Canada. Federal Tobacco Control Strategy: 2001-2011 Horizontal

Evaluation: Final Report 2012. Ottawa, ON: Health Canada, 2012. Available at: http://www.hc-sc.gc.ca/ahc-asc/alt_formats/pdf/performance/eval/ftcs evaluation-sflt-eng.pdf (Accessed June 30, 2015).

(3.) Bauman A, Cavill N, Brawley L. ParticipACTION: The future challenges for physical activity promotion in Canada. Int J Behav Nutr Phys Act 2009;6:89. PMID: 19995460. doi: 10.1186/1479-5868-6-89.

(4.) Potvin Kent M, Dubois L, Wanless A. Self-regulation by industry of food marketing is having little impact during children's preferred television. Int J Pediatr Obes 2011;6(5-6):401-8. PMID: 21838571. doi: 10.3109/17477166.2011. 606321.

(5.) Potvin Kent M, Dubois L, Wanless A. A nutritional comparison of foods and beverages marketed to children in two advertising policy environments. Obesity 2012;20(9):1829-37. PMID: 21720425. doi: 10.1038/oby.2011.161.

(6.) Canadian Partnership Against Cancer. Prevention Policies Directory. Available at: http://www.cancerview.ca/cv/portal/Home/PreventionAndScreening/ PSProfessionals/PSPrevention/PreventionPoliciesDirectory/ (Accessed July 2, 2015).

(7.) Olstad DL, Campbell EJ, Raine KD, Nykiforuk CIJ. A multiple case history and systematic review of adoption, diffusion, implementation and impact of provincial daily physical activity policies in Canadian schools. BMC Public Health 2015;15:385. PMID: 25885026. doi: 10.1186/s12889-015-1669-6.

(8.) Brownell KD, Warner KE. The perils of ignoring history: Big tobacco played dirty and millions died. How similar is big food? Milbank Q 2009;87:259-94. PMID: 19298423. doi: 10.1111/j.1468-0009.2009.00555.x.

(9.) Yach D, McKee M, Lopez AD, Novotny T. Improving diet and physical activity: 12 lessons from controlling tobacco smoking. BMJ 2005;330 (7496):898-900. PMID: 15831879. doi: 10.1136/bmj.330.7496.898.

(10.) Raine KD, Nykiforuk CI, Vu-Nguyen K, Nieuwendyk LM, VanSpronsen E, Reed S, et al. Understanding key influencers' attitudes and beliefs about healthy public policy change for obesity prevention. Obesity 2014;22(11): 2426-33. PMID: 25131938. doi: 10.1002/oby.20860.

(11.) Canadian Fitness and Lifestyle Research Institute. Physical Activity Level of Canadians. Ottawa: CFLRI, 2015. Available at: http://www.cflri.ca/sites/ default/files/node/1374/files/CFLRI_Bulletin%201_PAM%202014-2015.pdf (Accessed July 2, 2015).

(12.) Anderson I, Beak C, Ling T, O'Reilly C, Roberts C. Building on the Momentum of ActNow BC. Vancouver, BC: Simon Fraser University, 2010. Available at: https://www.academia.edu/330294/Building_on_the_Momentum_of_ ActNow_BC (Accessed June 30, 2015).

Le present numero traite d' un article fort instructif intitule << Variation across Canada in the economic burden attributable to excess weight, tobacco smoking, and physical inactivity >> (1). La recherche s'appuie sur un modele novateur pour estimer le fardeau economique que representent les trois facteurs de risque que sont l' exces de poids, le tabagisme et l' inactivite physique en fonction de leur fraction etiologique du risque dans la population. Les resultats et conclusions ont d'importantes consequences sur les pratiques et les politiques en matiere de sante publique.

Comme premiere conclusion, on peut lire qu'il y a eu une transformation importante dans la distribution du fardeau economique par facteur de risque, celui attribuable au tabagisme diminuant et ceux attribuables a l'exces de poids et a l'inactivite physique augmentant. Cette transformation s' explique en grande partie par l'evolution de la prevalence, laquelle a decline a 17,5% au Canada pour le tabagisme tandis que la proportion de Canadiens qui presentent un exces de poids et qui sont inactifs atteint respectivement 46,1% et 43,6% (1). Il reste certes du travail a faire du cote du tabagisme, mais deux questions emergent. Premierement, quelles lecons peut-on tirer de l'efficacite des mesures de lutte contre le tabagisme a diminuer la prevalence du tabagisme au Canada et comment peut-on les appliquer a l' obesite et a l' inactivite physique? Deuxiemement, quel type d'investissement le Canada doit-il faire pour entrainer une reduction similaire de la prevalence de l'obesite et de l'inactivite?

La deuxieme conclusion de l'etude porte sur les differences geographiques de la prevalence des facteurs de risque au Canada. Le cas de la Colombie-Britannique est particulierement informatif: la prevalence du tabagisme, de l'exces de poids et de l' inactivite y entraine un fardeau economique moindre par habitant que dans toute autre province. Pourquoi les Britanno-Colombiens fument-ils moins, sont-ils plus actifs et souffrent-ils moins d'obesite? De maniere plus detaillee, quelles caracteristiques du milieu social et naturel creent les conditions propices a une certaine protection des Britanno-Colombiens? Quels investissements en sante publique ont contribue a creer un tel contexte favorable?

Tirer des lecons de la lutte contre le tabagisme: investir dans les changements sociaux

Meme si les maladies associees au tabagisme constituent encore un fardeau economique considerable pour les Canadiens, l'article montre clairement que la prevalence du tabagisme est en baisse et fait donc diminuer le fardeau economique qui y est associe1. En 1965, 49,5% des Canadiens de plus de 15 ans fumaient. Le gouvernement du Canada finance les mesures de lutte contre le tabagisme depuis les annees 1960. Il y a d' abord eu des campagnes educatives, suivies de programmes globaux de marketing social qui ont domine pendant les annees 1980 et 1990. Les producteurs de cigarettes et tabac ont ete nombreux a restreindre volontairement certaines de leurs activites promotionnelles au debut des annees 1970 devant la menace de la loi proposee. Cependant, la combinaison de legislation, de reglementation et de promotion de la sante a favorise la creation concertee de politiques au debut des annees 1980, puis la Loi reglementant les produits du tabac a ete adoptee en 1988 a un moment oU le taux de tabagisme avait deja baisse a 32%. En 2001, le gouvernement federal a investi 560 millions de dollars sur cinq ans pour la Strategie federale de lutte contre le tabagisme (SFLT). Meme si les mesures de lutte avaient deja entrainer une diminution du taux de tabagisme de pres de la moitie, se situant alors a 25% chez ceux ages de 15 ans ou plus, la lutte au tabagisme restait clairement une priorite: la SFLT etait une strategie globale et coordonnee faisant appel aux medias de masse, a la mise en application de la reglementation, a la surveillance et a des projets locaux. L'investissement etait colossal, et on a reussi a faire encore baisser le taux de tabagisme a 20% au cours des cinq premieres annees (2). Changer les normes sociales n'est pas chose facile: il faut beaucoup d'efforts et d'argent. Les gouvernements federal, provinciaux et territoriaux ont clairement decide d'investir dans la lutte contre le tabac. L'investissement a permis de reduire les couts indirects ainsi que les couts des soins de sante1 associes a l'usage du tabac.

En ce qui concerne l'inactivite physique et l'exces de poids, le Canada semble en etre la ou il en etait avec le tabagisme au cours des annees 1970. On vise les changements comportementaux individuels par la sensibilisation et le marketing social. Les campagnes de promotion de l' activite physique comme ParticipACTION ont reussi a sensibiliser les citoyens a l'importance de l'activite physique (3). Pour ce qui est de la lutte contre la promotion de boissons et d'aliments malsains pour contrer l'obesite infantile, il est de convention de laisser les entreprises prendre des mesures volontaires, mais trop peu de resultats ont ete atteints (4). Cependant, le Quebec fait exception avec la Loi sur la protection du consommateur du Quebec interdisant la publicite destinee aux enfants depuis 1980. Cette loi s' est revelee efficace a proteger les enfants francophones qui sont moins a risque d'etre exposes aux medias anglo-canadiens (5). Il y a aussi eu des progres dans les milieux scolaires, ideaux pour la protection des enfants. L'ensemble des provinces ont adopte des directives pour que les ecoles offrent de la nourriture saine, mais seules l'Ontario, le Nouveau-Brunswick, Terre-Neuve-et-Labrador et la Nouvelle-Ecosse les ont rendues obligatoires (6) (les conseils scolaires et les municipalites des provinces ont adopte des mesures plus contraignantes dans certains cas, mais il est difficile de savoir si on les respecte, car on n'effectue pas la surveillance necessaire). De la meme facon, dans certaines provinces, on a adopte des politiques d'activite physique obligatoire chaque jour, mais leur mise en aeuvre est fragmentaire, probablement en raison du manque de ressources (7). Autrement dit, le Canada compte sur un reseau plus ou moins disparate de politiques sur la saine alimentation et l'activite physique, mais aucune loi solide a cet effet. Il faut nettement investir d'importantes sommes de maniere coordonnee et cibler les entreprises comme les geants de l'agroalimentaire qui investissent des milliards de dollars pour faire la promotion de leurs produits (8). C'est la oU les lecons de la lutte contre le tabagisme pourront etre utiles. Il faut agir de maniere collective sur les milieux de vie pour que la responsabilite individuelle prenne tout son sens et que les mesures globales mises de l'avant rapportent. Il est justifie d'agir (et d'evaluer les actions) avant que soient recueillies toutes les preuves de l' efficacite d' une intervention (9). L'elaboration concertee de politiques combinant legislation, reglementation et promotion de la sante est necessaire si on veut endiguer l'epidemie d'inactivite physique et d' obesite.

Ce ne sont certainement pas les idees qui manquent quant aux methodes et aux milieux a viser pour contrecarrer l'inactivite physique et l'exces de poids. Meme dans l'Alberta (autrefois) conservatrice, les decideurs sont d' accord avec les mesures politiques pour contrer l'inactivite physique, la mauvaise alimentation et l' obesite, meme si on est plus dispose a accepter des politiques centrees sur les citoyens, notamment des programmes de sensibilisation publique (10). Ni le gouvernement federal ni les provinces n'ont fait d'investissement dans la prevention des maladies chroniques de la meme ampleur que la SFLT malgre les grands discours sur les rapports produits et les strategies elaborees oU on louange les vertus de la prevention. Sans coordination, on risque de manquer des occasions ou d' agir au mauvais moment et ainsi de gaspiller l' argent investi.

Investissements en sante publique: des lecons pour creer un contexte favorable

Qu'en est-il des variations regionales dans la prevalence des facteurs de risque et des couts associes? Quelles caracteristiques du milieu social et naturel creent les conditions propices a une certaine protection chez les Britanno-Colombiens? Comme le mentionne l' article (1), la meteo favorable peut jouer un certain role dans le taux superieur d' activite physique en ColombieBritannique, bien que le deuxieme endroit au Canada oU la proportion moyenne d' adultes consideres comme actifs ayant depasse la moyenne en 2013 soit le Yukon (11)! C'est peut-etre plus la culture de l'ouest du pays qui favorise l'activite physique que la meteo dans ce cas-ci. La piste la plus interessante demeure cependant l'investissement colossal effectue dans ActNow BC, une approche pangouvernementale ayant pour but d' ameliorer la sante de la population et prevoyant 25 millions de dollars pour etudier les conditions et facteurs de risque des maladies chroniques. Cependant, le soutien politique et financier pour ActNow s'est estompe. D'autres specialistes ont suggere qu' il fallait profiter de l'occasion pour creer un cadre legislatif pour ActNow BC un peu a l'image de la Loi sur la sante publique du Quebec de maniere a obliger la reddition de compte sur les objectifs a long terme en matiere de sante de la population (12).

Il y a aussi une autre lecon a retenir de la lutte contre le tabac: << se contenter des actions passees en se disant qu'elles auront des bienfaits a l'avenir peut retarder les progres >> (9) (p. 899) [traduction libre]. Une telle attitude complaisante constitue un enorme risque pour la sante publique. Il faut beaucoup d'argent et de volonte politique pour realiser des progres dans la transformation de la reglementation et des milieux de vie pour reduire les risques de maladies chroniques. Il ne fait aucun doute qu'on peut retirer des benefices nets si l' investissement fait baisser la prevalence des risques (1). L'argument economique est un autre outil pour revendiquer des politiques publiques promotrices de sante. Le gouvernement federal doit des maintenant s'engager a investir d'importantes sommes pour reduire l'inactivite, ameliorer l'alimentation et combattre l' obesite en imitant ce qui se fait dans la lutte contre le tabac (et l'alcool) pour que nous puissions tous apprendre l'un de l'autre et avancer ensemble. La population canadienne ainsi que la viabilite de notre systeme de sante en valent la peine.

REFERENCES BIBLIOGRAPHIQUES

(1.) Krueger H, Krueger J, Koot J. Variation across Canada in the economic burden attributable to excess weight, tobacco smoking and physical inactivity. Rev can sante publique 2015;106(4):e171-77.

(2.) Sante Canada. Strategie federale de lutte contre le tabagisme 2001-2011 Evaluation horizontale. Ottawa, ON: Sante Canada, 2012. Sur Internet: http://www.hc-sc.gc.ca/ahc-asc/performance/eval/ftcs-evaluation-sflt-fra.php (consulte le 30 juin 2015).

(3.) Bauman A, Cavill N, Brawley L. ParticipACTION: The future challenges for physical activity promotion in Canada. Int J Behav Nutr Phys Act 2009; 6:89. PMID: 19995460. doi: 10.1186/1479-5868-6-89.

(4.) Potvin Kent M, Dubois L, Wanless A. Self-regulation by industry of food marketing is having little impact during children's preferred television. Int J Pediatr Obes 2011;6(5-6):401-8. PMID: 21838571. doi: 10.3109/17477166.2011. 606321.

(5.) Potvin Kent M, Dubois L, Wanless A. A nutritional comparison of foods and beverages marketed to children in two advertising policy environments. Obesity 2012;20(9):1829-37. PMID: 21720425. doi: 10.1038/oby.2011.161.

(6.) Canadian Partnership Against Cancer. Prevention Policies Directory. Sur Internet: http://www.cancerview.ca/cv/portal/Home/PreventionAndScreening/ PSProfessionals/PSPrevention/PreventionPoliciesDirectory/ (consulte le 2 juillet 2015).

(7.) Olstad DL, Campbell EJ, Raine KD, Nykiforuk CIJ. A multiple case history and systematic review of adoption, diffusion, implementation and impact of provincial daily physical activity policies in Canadian schools. BMC Public Health 2015;15:385. PMID: 25885026. doi: 10.1186/s12889-015-1669-6.

(8.) Brownell KD, Warner KE. The perils of ignoring history: Big tobacco played dirty and millions died. How similar is big food? Milbank Q 2009;87:259-94. PMID: 19298423. doi: 10.1111/j.1468-0009.2009.00555.x.

(9.) Yach D, McKee M, Lopez AD, Novotny T. Improving diet and physical activity: 12 lessons from controlling tobacco smoking. BMJ 2005;330(7496): 898-900. PMID: 15831879. doi: 10.1136/bmj.330.7496.898.

(10.) Raine KD, Nykiforuk CI, Vu-Nguyen K, Nieuwendyk LM, VanSpronsen E, Reed S, et al. Understanding key influencers' attitudes and beliefs about healthy public policy change for obesity prevention. Obesity 2014;22(11): 2426-33. PMID: 25131938. doi: 10.1002/oby.20860.

(11.) Institut canadien de la recherche sur la condition physique et le mode de vie. Physical Activity Level of Canadians. Ottawa, ON: CFLRI, 2015. Sur Internet: http://www.cflri.ca/sites/default/files/node/1374/files/CFLRI_Bulletin%201_ PAM%202014-2015.pdf (consulte le 2 juillet 2015).

(12.) Anderson I, Beak C, Ling T, O'Reilly C, Roberts C. Building on the Momentum of ActNow BC. Vancouver, BC: Simon Fraser University, 2010. Sur Internet: https://www.academia.edu/330294/Building_on_the_Momentum_of_ ActNow_BC (consulte le 30 juin 2015).