BC Healthy Living Alliance Submission to the 2015 Budget Consultation

The BC Healthy Living Alliance (BCHLA) is pleased to make our submission to the Select Standing Committee on Finance and Government Services again this year. We kindly ask members of this committee to consider a range of proposals that have the ability to reduce chronic disease by addressing risk factors common to numerous chronic conditions. Prioritizing investment in disease prevention measures today can improve the health and wellness of British Columbians and thereby reduce demand for healthcare services in the long-term.

In addition to the human cost, chronic diseases are costly to our healthcare system. Excess weight costs $612M, smoking costs $670M and inactivity costs $335M in direct healthcare costs.i Overall, the 34% of British Columbians diagnosed with chronic conditions consume approximately 80% of the combined Medical Services Plan, PharmaCare and acute care budgets. Yet much of the disease burden could be avoided since many chronic diseases are preventable, including approximately 50% of cancer and type-2 diabetes as well as 80% of premature heart disease and stroke.ii

British Columbians who live in our poorest communities are between 24% and 91% more likely to die early from cancer (24%), respiratory diseases (53%), circulatory diseases (65%) and diabetes (91%)iii. These socio-economic inequities in health are estimated to increase healthcare costs by 20%.iv Improving living standards for disadvantaged citizens and communities will improve not just health outcomes but will also have a positive effect on productivity and the economy.

The potential of health promotion and disease prevention to bend the health cost curve and create a sustainable healthcare system cannot be underestimated. According to provincial health officer Dr. Perry Kendall, a strengthened provincial strategy and investment in prevention can improve the health of British Columbians and potentially avoid up to $2 billion in yearly healthcare costs. Other evaluations have shown that health promotion interventions have the potential to save 90% more lives and reduce costs by 30% within a decade.v

Future projections for chronic disease underscore the need to make prevention a priority. Projections show that if nothing changes there could be over 768,000 British Columbians with Type 2 Diabetes by 2032 and in the next ten years the number of new cancer cases is expected to rise by 75%.

With these figures in mind, the BC Healthy Living Alliance urges members of this committee to consider the evidence-informed policy proposals below, many of which have been supported or advanced by academics and other health, business and civil society organizations in BC and other jurisdictions.

Summary of BCHLA Recommendations

  1. The budget allocated for public health be doubled in order to achieve the objectives, goals and measures as outlined in ‘BC’s Guiding Framework for Public Health’ and the ‘Healthy Families BC Policy Framework’.
  2. Resources be allocated to a cross-ministerial Poverty Reduction Plan with clear targets and timelines and oversight by a designated Minister.
  3. The Ministry of Finance together with the Ministry of Health, Ministry of Agriculture and the Ministry of Natural Gas Development (Responsible for Housing) work collectively with BC Housing to support food security initiatives in social housing.
  4. The Ministry of Finance together with the Ministry of Education and Ministry of Children and Family Development work towards a universal childcare system starting with improved availability and lower costs for communities and populations with higher levels of childhood vulnerability.
  5. The Ministry of Finance continue to increase tobacco taxes per carton (200 cigarettes) to a level on par with other provincial leaders in this area.
  6. The Ministry of Health work with the Ministry of Finance to introduce an excise tax of at least 20% on all sugar sweetened beverages.
  7. The Ministry of Finance together with the Ministry of Public Safety and Solicitor General shift alcohol taxes so that they are based on the percentage of absolute alcohol in a standard drink.
  8. The Ministries responsible for film policy, the Ministry of Community, Sport and Cultural Development and the Ministry of Jobs, Tourism and Employment, make youth related films, TV and digital media that include tobacco imagery ineligible for provincial film subsidies and tax credits.
  9. The Ministry of Finance work together with the Ministry of Health, the Ministry of Community Sport and Cultural Development and the Ministry of Transportation to renew funding sources available to local governments for healthier built environments and active transportation infrastructure.

1) BCHLA recommends that the budget allocated for public health be doubled in order to achieve the objectives, goals and measures as outlined in ‘BC’s Guiding Framework for Public Health’ and the ‘Healthy Families BC Policy Framework’.

  • In 2013, after significant consultation with stakeholders, the Ministry of Health released ‘Promote, Protect, Prevent: Our Health Begins Here. BC’s Guiding Framework for Public Health’ which articulates a long-term vision for the public health system in addition to more short term actions and performance measures.
  • In 2014, the Ministry of Health released ‘Healthy Families BC Policy Framework: A Focused Approach to Chronic Disease and Injury Prevention’ which builds on earlier work in chronic disease prevention and operationalizes four goals in the Guiding Framework for Public Health.
  • Given the pressures on the health budget from preventable chronic disease, the considerable research and resources invested in these planning documents and the ability they have to “improve the health of British Columbians, reduce inequities in health and contribute to the financial sustainability of our healthcare system,” BCHLA recommends that the budget be doubled to achieve the goals and objectives of these frameworks.

2) BCHLA recommends that resources be allocated to a cross-ministerial Poverty Reduction Plan with clear targets and timelines and oversight by a designated Minister.

  • Income security is a serious concern to BCHLA because it is a strong predictor of health outcomes. In BC, those in the lowest income quintile have twice the risk for heart disease and diabetes.vi, vii, viii, ix
  • In BC, it is estimated that the government pays from $2.2 to $2.3 billion on the direct cost of poverty. However, the cost of inaction is higher and British Columbians currently pay between $8.1 and $9.2 billion to maintain the status quo.x
    British Columbia remains as one of only two jurisdictions in Canada without a provincial or territorial poverty reduction strategy.
  • As a member of the Poverty Reduction Coalition of BC, BCHLA along with 439 other organizations have recommended the following actions:
    1. Provide adequate and accessible income support for the non-employed, and remove policy barriers so that recipients can build and maintain assets.
    2. Improve the earnings and working conditions of those in the low-wage workforce.
    3. Improve food security for low-income individuals and families.
    4. Address homelessness and adopt a comprehensive affordable housing and supportive housing plan.
    5. Provide universal publicly-funded childcare.
    6. Enhance support for training and education for low-income people.
    7. Enhance community mental health and home support services, and expand integrated approaches to prevention and health promotion services.

We recognize that governments would be challenged to advance all of these actions. However, it is important to make a start on each even if that means introducing more targeted approaches to assist those who can benefit most from increased support. The example below demonstrates how a targeted program reduced poverty by 10% in the target population and how the program was cost-effective when compared just to the cost of treating depression resulting from poverty.

  • The National Collaborating Centre on Healthy Public Policy conducted detailed studies on policies that improve health for those on the low end of the socio-economic spectrum – they found that the Self Sufficiency Project – an expired BC program helped single parents to transition to work and become more self-sufficient.xi
  • Evaluation of the Sufficiency Project (1992-2001) which aimed to verify whether an income supplement could help single parents move off of social assistance (British Columbia and New Brunswick) demonstrated reductions in poverty (-10%), increase in full-time employment (+15%) and saw their monthly income increase by $121. The parents in the experimental group also saw a 19% reduction in the incidence of mental health problems which led the researchers to “conclude that income supplements cost less than treating depression.”xi

3) BCHLA recommends that the Ministry of Finance together with the Ministry of Health, Ministry of Agriculture and the Ministry of Natural Gas Development (Responsible for Housing) work collectively with BC Housing to support food security initiatives in social housing.

  • The availability and affordability of healthy foods determine the relative food security of households and communities. This can have a tremendous impact on health as food insecurity is associated with elevated risk for diet-related chronic diseases such as type 2 diabetes, hypertension and heart disease.
  • Within BC, food insecurity is especially acute in low income households. According to a Metro Vancouver Housing survey, 66% of the respondents living in social housing indicated that they had experienced food insecurity in the past year.xii
  • An initiative based within social housing sites provides a way to reach and address food security issues within households that are vulnerable to hunger and that are otherwise difficult to reach.
  • Food security pilot projects in social housing have included community kitchens and gardens, mobile produce markets and buying clubs as well as food skills classes. Although these have only been available in a few sites, a BC Housing report found that where food programs were offered on‐site, the participation rate was up to 50% of the tenant population.xii
  • Based on research that has been done on food security in social housing, program evaluations, studies on the benefits of food security for vulnerable populations, and the frontline experiences of and observations from housing providers, the outcomes from increased levels of food security benefit both tenants and housing providers.
    • Outcomes for tenants include: better physical and mental health; increased feelings of security, self‐determination, and autonomy; decreased behavioural issues; decreased hospitalization; strengthened capacity to focus on other aspects of their lives; and improved child development and adolescent well‐being. xii
  • Given the success of food security pilot projects in reaching populations at risk of hunger and the proven health benefits to adults and children, BCHLA recommends that funding be provided to expand food security initiatives in social housing across the province.
  • There is growing interest in this topic as evidenced by the BC Non Profit Housing Association special symposium on food security in social housing as part of their annual conference in 2013. Building on this growing interest, modest seed funding could be used initially to connect building managers and housing providers with existing food security programs delivered by health authority staff and community agencies.

4) BCHLA recommends that the Ministry of Finance together with the Ministry of Education and Ministry of Children and Family Development work towards a universal childcare system starting with improved availability and lower costs for communities and populations with higher levels of childhood vulnerability.

  • “Positive conditions during childhood not only support child health but have long lasting effects on health and the development of disease during adulthood.”xiii
  • Longitudinal studies have also demonstrated that disadvantaged children who participate in quality early childhood development programs have significantly better outcomes.xiv
  • University of Montreal economics professor Pierre Fortin’s analysis of Quebecʹs universal childcare system found that due to increased income and consumption tax revenue, Quebec taxpayers get back $1.49 for every $1.00 spent.xv
  • The economic case for quality childcare has led it to be advanced by a range of economists and organizations including: the Provincial Health Officer, Perry Kendall, Nobel Prize winner, James Heckman; the Vancouver Board of Trade and the BC Business Council as well as many social service organizations and academics.
  • According to UBC’s Human Early Learning Partnership, in BC there are only childcare spaces for 5% of children under the age of three and just over one third for children between the ages of three and five.xvi,xvii
  • Both the Human Early Learning Partnership and the Coalition of Child Care Advocates of BC have recommended a universal early childhood education program with accessible childcare service fees of $10/day and no fees for families earning less than $40,000/year.
  • BCHLA recognizes that implementing universal childcare may not be feasible immediately; however, we would encourage government to work towards this goal, starting with the expansion of childcare resources in communities and neighbourhoods with high measures of child vulnerability.
  • The Early Development Instrument is a tool that is already in use across BC and would be appropriate for assessing areas in the province where expanded early childhood development programs are needed in response to the number of children with higher levels vulnerability. http://earlylearning.ubc.ca/edi/

5) BCHLA recommends that the Ministry of Finance continue to increase tobacco taxes per carton (200 cigarettes) to a level on par with other provincial leaders in this area.

  • Increasing the price of tobacco is a proven method for encouraging smokers to quit and reducing tobacco use. It is particularly effective among youth who are even more price sensitive.
  • Studies demonstrate that a 10% increase in the per package cost of cigarettes reduces smoking between three and five percent.
  • While BC made progress in this area by raising tobacco taxes this past April. Under current taxation levels the total cost of a carton of 200 cigarettes in BC is $104.96 which places BC below most other provinces and territories. The majority tax at a higher rate than BC creating a strong deterrent:
    • Manitoba (Total cost of carton = $125.80)
    • Northwest Territories, (Total cost of carton = $117.86)
    • Nova Scotia (Total cost of carton = $112.03)
    • Saskatchewan (Total cost of carton = $108.40)
    • Newfoundland and Labrador (Total cost of carton = $110.22)
    • Prince Edward Island (Total cost of carton = $107.32)

6) BCHLA recommends that the Ministry of Health work with the Ministry of Finance to introduce an excise tax of at least 20% on all sugar sweetened beverages.

  • The direct and indirect costs of obesity are projected to cost British Columbia $1.1 billion in 2016.xviii
  • “[M]ore than for any category of foods, rigorous scientific studies have shown that consumption of soft drinks is associated with poor diet, increasing rates of obesity, and risk for diabetes.”xix
  • The Institute of Medicine of the National Academies has suggested that a tax on non‐nutritional foods such as sugary drinks is one of the most promising tools available to governments for addressing unhealthy weights.xx
  • One study found consumption dropped by 16% with the introduction of a 35% tax. Another study found that the biggest consumers of sugary drinks were also the most price sensitive. Their consumption dropped by 44% with a 27% price increase and dropped much more compared to moderate consumers.xxii
  • The BC Provincial Health Officer and the 2011 Budget Consultation Report have recommended that the province look for ways to “reduce the consumption of sugar sweetened beverages, such as pop, fruit drinks, energy drinks and vitamin waters.”
  • Algeria, France, Hungary, Mexico and the US all have some type of tax on sugary drinks specifically or junk foods generally.
    • In 2012, France brought in an excise tax of 7.16 euros per 100 litres.
    • In Hungary, the revenues from the so-called “hamburger tax” projected at $100 million, are to be invested in prevention. The Hungarian excise tax on food and beverages rich in fat, sugar, salt and caffeine will include charges of approximately 3¢ per litre on soft drinks and $1.25 per litre on energy drinks.
    • In January of this year, Mexico introduced a one peso per litre tax on sugar sweetened beverages with the hope of curbing consumption in a population that leads the world in both obesity levels (32.8%) and in the quantity of sugary drinks consumed annually (163 litres per year).
    • There are presently 33 states in the US where sugar sweetened beverages are additionally taxed; however, the majority of the taxes are too small to shift behaviour.
  • Research has shown that taxes included in the shelf price have a greater impact on consumption than taxes applied at the register.xxiii
  • BCHLA supports an excise tax of at least 20% on sugar sweetened beverages as this would relate to portion size, remove the incentive for discounted super‐size servings and would be significant enough to have an impact on consumption.

7) BCHLA recommends that the Ministry of Finance together with the Ministry of Public Safety and Solicitor General shift alcohol taxes so that they are based on the percentage of absolute alcohol in a standard drink.

  • BCHLA, along with agencies such as the World Health Organization and the Public Health Agency of Canada , have included hazardous consumption of alcohol as a key risk factor for chronic disease, because of the overwhelming national and international evidence.xxv
  • The potential population burden of alcohol on chronic disease will be equal or greater than that of tobacco as rates of smoking decline due to health promotion measures which have included taxation, regulation and education.xxvi
  • The conclusions from the current evidence are that the net benefits of alcohol use are outweighed by the negatives.xxvii Even consumption lower than ‘problem drinking’ levels – just one to two standard drinks per day over a long period – can increase risk for some chronic diseases.xxvii
  • Between 85-90% of younger people who drink are consuming alcohol in excess of recommended guidelines set to reduce health harms.xxix
  • The evidence shows that increased access to alcohol (whether through pricing, increased hours of operation or number of locations) leads to public health impacts. Studies have shown that a 10% increase in price correlates to a 5% reduction in drinking, including for problem drinkers, but pricing is especially effective with youth.xxxi
  • Shifting the method of the Provincial liquor mark-up so that it is based on the percentage of alcohol in the product can achieve two things: it can reduce consumption by price‐sensitive consumers (such as youth) while also discouraging producers from creating higher alcohol products marketed to young adults.

8) BCHLA recommends that the Ministries responsible for film policy, the Ministry of Community, Sport and Cultural Development and the Ministry of Jobs, Tourism and Employment, make youth related films, TV and digital media that include tobacco imagery ineligible for provincial film subsidies and tax credits.

  • It is estimated that 30‐50% of teenaged smokers are influenced to start smoking as a result of exposure to smoking imagery in films.xxxii
  • “[E]xposure to on‐screen smoking is estimated to cause 43,000 premature deaths among current Canadian smokers aged 15‐19”.xxxii
  • Youth represent the single largest group of consumers of movies.
  • Tobacco companies have been aggressively marketing tobacco to youth through creative avenues such as product placement in popular media since being pushed out of traditional advertising channels.
  • It has been calculated that every dollar of film subsidy given to movies with smoking costs Canadians an additional $1.70 in tobacco related healthcare costs and productivity losses.xxxii
  • Removing subsidies to youth related films with tobacco imagery together with making tobacco imagery a criteria for 18A classification removes the incentive for film and digital media producers to include tobacco marketing and placement of tobacco products in media for youth audiences.

9) The Ministry of Finance work together with the Ministry of Health, the Ministry of Community Sport and Cultural Development and the Ministry of Transportation to renew funding sources available to local governments for healthier built environments and active transportation infrastructure.

  • Community planning and infrastructure exerts a powerful influence over citizen’s access to healthy foods and ability to be physically active in their daily routines. “Research is increasingly demonstrating links between the built environment and eating and physical activity behaviours.”xxxiii
  • Dr. Larry Frank, found that adults are 2.5 times more likely to engage in active transportation when living in compact and well connected neighbourhoods. They are also more likely to get the recommended amounts of daily physical activity.xxxiv
  • A report by the Provincial Health Services Authority found that “there is a growing consensus among public health experts that supporting more physically active modes of transportation and better access to recreational opportunities offer the most effective ways to increase activity levels across the population, particularly among people who are overweight and/or inactive.”xxxv
  • The Canadian Fitness and Lifestyle Research Institute found in a survey of Canadian Municipalities that “three in five communities report that an increase in the amount of walking, bicycling and multi‐purpose trails was the most pressing infrastructure need in their community to increase physical activity levels among citizens.”xxxvi
  • An injection of $175M to LocalMotion and Cycling Infrastructure Partnerships Programs could be used to expedite change on the ground and boost BC’s physical activity rates.
    • BCHLA supports the BC Cycling Coalition’s recommendation for an investment of $175M to enable BC communities to build active transportation networks.
    • This figure is based on postulation that BC could build a first rate cycling network following the funding formula of the Netherlands, who are widely recognized as global leaders in cycling and who spend approximately $40 per person, per year on cycling.
    • High quality cycling facilities that are attractive to a significant portion of the population such as bicycle paths and separated bicycle lanes can cost from $1 million to $4 million per km (1/6 the cost of one km of road network for motorized vehicles).
  • In this submission we have highlighted a selection of budget measures which could be taken to reduce the prevalence of risk factors for chronic disease and improve the health outcomes of British Columbians. Population health evidence tells us that we need action on behavioural risk factors such as encouraging physical activity, reducing consumption of drinks high in sugar or alcohol and preventing youth smoking while also addressing the social elements of health by promoting income security and early childhood development to bridge the gap between disease and wellness.
  • It is also important to recognize the linkages between good physical and mental well-being and ensure that policies and programs address the holistic needs of individuals and communities.
  • There are many other areas where government can take measures to improve health in BC. Within the healthcare system, there is a growing consensus that to address the current and foreseeable chronic disease burden, it will be necessary to improve access to primary care which should be incorporating comprehensive health promotion and disease prevention.
  • Finally, BCHLA has long urged government to take a whole of society, whole of government and whole of person approach in addressing the prevention of chronic diseases. Only when we break down the silos within and between government and other sectors, will we be successful in truly achieving a healthy society.

Submitted by BCHLA:

Who We Are

Established in 2003, BCHLA represents the largest health promotion team in BC history. Our Vision is “a healthy British Columbia” and our Mission is: “To improve the health of British Columbians through leadership and collaboration to address the risk factors and health inequities that contribute significantly to chronic disease.”

Voting Members:

Scott McDonald, BCHLA Chair and CEO, BC Lung Association
Stephanie Stevenson, Executive Director, BC Pediatric Society
Suzanne Allard Strutt, CEO, BC Recreation and Parks Association
Barbara Kaminsky, CEO, Canadian Cancer Society, BC and Yukon Division
Sue Taylor, Regional Director, Western Canada, Canadian Diabetes Association, Pacific
Sonya Kupka, Regional Executive Director, Dietitians of Canada, BC Region
Adrienne Bakker, CEO, Heart and Stroke Foundation of Canada, BC & Yukon
Dr. John Millar, Director, Public Health Association of BC
Marie Crawford, Associate Executive Director, Union of BC Municipalities

Non-Voting members:

First Nations Health Authority
Fraser Health Authority
Health Officers Council of BC
Interior Health Authority
Island Health
Ministry of Health
Northern Health
Provincial Health Services Authority
Public Health Agency of Canada BC/Yukon Region
Vancouver Coastal Health

References:

[i] H. Krueger & Associates Inc. “The Economic Benefits of Risk Factor Reduction in British Columbia: Tobacco Smoking, Excess Weight and Physical Activity”, July 2013. www.krueger.ca

[ii] British Columbia. Office of the Provincial Health Officer. Investing in prevention: improving health and creating sustainability: the Provincial Health Officer’s special report., August, 2010 http://www.health.gov.bc.ca/library/publications/year/2010/Investing_in_prevention_improving_health_and_creating_sustainability.pdf

[iii]Tjepkema M, Wilkins, R, Long A, Cause-specific mortality by income adequacy in Canada: A 16-year follow-up study Health Reports 2013 Vol. 24 no.7 pp. 14-22

[iv ] Federal Provincial Territorial Advisory Committee on Population Health and Health Security. Reducing Health Disparities – Roles of the Health Sector: Recommended Policy Directions and Activities. Public Health Agency of Canada. ISBN: 0‐662‐69312‐4., 2005.

[v] Milstein, B. H. (2011). Why behavioural and environmental interventions are needed to improve health at lower cost. Health Affairs, 30(5), 823-832.

[ix] Statistics Canada Canadian Community Health Survey Cycle 3.1 Share File (2005).

[xi] National Collaborating Centre for Healthy Public Policy. Thirteen Public Interventions in Canada that have Contributed to a Reduction in Health Inequalities. (February 2010) http://www.ncchpp.ca/docs/13interventions_Inequalities_EN_sansISBN_FINAL.pdf

[xii] Vancouver Coastal Health. Food Security in Social Housing Action Framework and Resource Guide (2013) http://www.vch.ca/your_health/population-health/food-security/social-housing/ Accessed 13-10-08

[xiii] Raphael, D. and T. Bryant. (2006). Maintaining population health in a period of welfare state decline: political economy as the missing dimension in health promotion theory and practice. Promotion and Education. 13:236‐242.

[xiv] HighScope. (2005). Lifetime effects: The HighScope Perry Preschool Study Through Age 40. www.Highscope.org/Content.asp?ContentID=219 Accessed August 30, 2010.

[xv] Fortin, P. Godbout, L & St-Cerny, S. Impact of Quebec`s Universal Low fee Child Care Program on Female Labour Force Participation, Domestic Income and Government Budgets http://www.oise.utoronto.ca/atkinson/UserFiles/File/News/Fortin-Godbout-St_Cerny_eng.pdf Accessed 13-10-8

[xvi] Goelman H., L. Anderson, P. Kershaw and J. Mort. (2008). Expanding Early Childhood Education and Care Programming: Highlights of a Literature Review, and Public Policy Implications for British Columbia. Place Published: Human Early Learning Partnership, University of British Columbia.

[xvii] Kershaw, P., L. Anderson, B. Warburton and C. Hertzman. (2009). 15 by 15: A Comprehensive Policy Framework for Early Human Capital Investment in BC.

[xviii] Centres for Public & Population Health & Provincial Health Services Authority Recommendations for an Obesity Reduction Strategy for BC http://www.phsa.ca/NR/rdonlyres/2E9592B9-C3EE-4F47-A723 4DB330553E87/57542/ORS_RecommendationsAug112010.pdf

[xix] Rudd Center for Food Policy and Obesity. (2009). Soft Drink Taxes: A Policy Brief.

[xx] Lynn Parker, Annina Catherine Burns, and Eduardo Sanchez, Editors; Committee on Childhood Obesity Prevention Actions for Local Governments; Institute of Medicine; National Research Council, Local Government Actions to Prevent Childhood Obesity, 2009, 140 pages. http://www.nap.edu/catalog/12674.html

[xxi] Block JP, Chandra A, McManus KD, Willett WC. Point of purchase price and education intervention to reduce consumption of sugary soft drinks. Am J Public Health. August 2010, Vol 100, No. 8 | American Journal of Public Health 1427‐1433

[xxii] Gustavsen G. Public Policies and the Demand for Carbonated Soft Drinks: A Censored Quantile Regression Approach. 2005 International Congress, August 23‐27, 2005, Copenhagen, Denmark. European Association of Agricultural Economists

[xxiii] Fletcher, J., D. Frisvold and N. Tefft. (2010). Taxing Soft Drinks and Restricting Access to Vending Machines to Curb Child Obesity. Health Affairs. May 2010, 29:5.

[xxiv] Public Health Agency of Canada. Risk Factor Atlas http://www.phac‐aspc.gc.ca/cd‐mc/atlas/index‐eng.php

[xxv]WHO, 2011http://www.who.int/substance_abuse/publications/global_alcohol_report/msbgsruprofiles.pdf; WHO, 2009, and Rehm J, Mathers, C.et al, “Alcohol and Global Health 1: Global burden of disease and injury and economic cost attributable to alcohol use and alcohol‐use disorders,” The Lancet 373: 2223‐33, 2009.

[xxvi] Rehm et al. 2006 cited in the CPHA Position Statement on Alcohol (draft paper presented at CPHA 2011 conference in Montreal)

[xxvii] Butt, et al, in press; Rehm, et al., 2010.

[xxviii] Schutze, M. et al. Alcohol attributable burden of incidence of cancer in eight European countries based on results from prospective cohort study,” British Medical Journal 2011;342:d1584.

[xxix] British Columbia. Promote, Protect, Prevent: Our Health Begins Here [electronic resource] : BC’s Guiding Framework for Public Health. (2013) http://www.health.gov.bc.ca/library/publications/year/2013/BC-guiding-framework-for-public-health.pdf

[xxx] Stockwell et al, 2011, Stockwell et al 2009. Babor et al 2010.

[xxxi] British Columbia. Office of the Provincial Health Officer. Public health approach to alcohol policy: an updated report from the Provincial Health Officer, December 2008 http://www.health.gov.bc.ca/library/publications/year/2008/alcoholpolicyreview.pdf

[xxxii] Physicians for a Smoke‐Free Canada. (2010) Tobacco Vector: How American movies, Canadian film subsidies and provincial rating practices will kill 43,000 Canadian teens alive today – and what Canadian governments can do about it. http://www.smoke‐free.ca/pdf_1/2010/Tobaccovector.pdf Accessed September2011

[xxxii] Adapted from the Federal Provincial Territorial Advisory Committee on Population Health and Health Security. Reducing Health Disparities. Public Health Agency of Canada.,2007.

[xxxii] Johansen, H. Living with Heart Disease: The Working Age Population. Statistics Canada: Health Reports. 10,1, 1999.

[xxxii] James R. et. al. The health of Canadians with diabetes. Health Reports. 9(3). 1997.

[xxxii] Ivanova, I., The Cost of Poverty in BC (2011) Co-published by the CCPA – BC Office, the Public Health Association of BC, and the Social Planning and Research Council of BC http://www.policyalternatives.ca/sites/default/files/uploads/publications/BC%20Office/2011/07/CCPA_BC_cost_of_poverty_full_report.pdf

[xxxiii] Healthy Eating Active Living Convergence Partnership. (2008). Strategies for Enhancing the Built Environment to Support Healthy Eating and Active Living.

[xxxiv] BC Recreation and Parks Association. (2009). Physical Activity and Transportation Benefits of Walkable Approaches to Community Design in British Columbia. Available at http://www.bcrpa.bc.ca/recreation_parks/active_communities/documents/BCRPA_Transportation_Study_2009.pdf

[xxxv] Provincial Health Services Authority. (2007). Creating a Healthier Built Environment in British Columbia

[xxxvi] Canadian Fitness and Lifestyle Research Institute (2004) A municipal perspective on opportunities for physical activity: Trends from 2000–2004. Available at http://www.cflri.ca/eng/statistics/surveys/capacity2004.php