Application to use Health Canada's health related messages for tobacco products

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All fields marked by an asterisk (*) must be completed

1. Applicant Information

• (*) Complete Name: Title (Mr., Mrs., Ms., Dr.), First Name and Last Name
• Organisation (if applicable)
• (*) Address
  • City / Town
  • Province / State
  • Postal / Zip Code
  • Country (if not Canada)
  • (*) Telephone No.
  • Facsimile No.
  • (*) E-mail Address
• Web Site Address (if applicable)
• (*) If permission is granted, person/organization in whose name permission is to be issued.
  • Individual named above
  • Organization named above
  • Other

2. Information on the Applicant's Work

• (*) Intent of use of the graphic health warnings messages (context in which it will be used).
• (*) Title of the Work
• (*) Format(s) in which the work will be produced
  • Paper
  • Internet
  • CD-ROM
  • Video / Film
  • DVD
  • Diskette
  • Other:
• (*) Number of copies to be printed / produced OR specific URL(s) for Web page(s) where your work will be published
• (*) End Use / Utilisation finale
  • Commercial
  • Non-Commercial
  • Educational / Education
  • Free Distribution
  • Advertising / Promotion
  • Other (please specify)
  • Tobacco product packaging (other countries)
• (*) Commercial sale price to end-users (if applicable) OR Price to end-users for works produced on a cost-recovery basis
• (*) Target Audience
  • General Public
  • Health Professional
  • Students
  • Other (please specify)
    • Elementary
    • High School
    • Collegiate / University
• (*) Territory where your work will be distributed
  • Canada
  • World-wide
  • Other (please specify)

3. Title of Health Canada Work

• Appendix A for Health Warning Messages for cigarettes (2000 Series)
• Appendix B for Health Warning Messages for cigarettes (2011 Series)
• Appendix C for Health Warning Messages for little cigars (2011 Series)
• Appendix D for Health Information Messages (2011 Series)
• Appendix E for Toxic Emission Statements (2011 Series)

4. Response

I would appreciate receiving a response by Month/Day/Year

5. Other

Have you previously received approval to use Health Canada's graphic health warning messages, health information messages or toxic emission statements for tobacco products?

• Yes
• No

If yes, provide previous approval date and name of licensee (if available).

• Date
• Name of licensee

(*) A copy of your work must be submitted to Health Canada once it has been produced to:

Tobacco Products Regulatory Office
Regulations Division
Controlled Substances and Tobacco Directorate
Ground, Main Stats Building, 1605
150, Tunney's Pasture Driveway, Tunney's Pasture
Ottawa, Ontario
K1A 0K9

Please address all correspondence by fax or by e-mail to:

Tobacco Products Regulatory Office
Regulations Division
Controlled Substances and Tobacco Directorate
Health Canada
Fax: (613) 948-8495
E-mail: pregs@hc-sc.gc.ca

Appendix A - Health Warning Messages for cigarettes (2000 Series)

(*) Selection of pictures to be used:

• Don't poison us
  (Image: 2 boys)
• Tobacco smoke hurts babies
  (Image: baby in incubator)
• Each year, the equivalent of a small city dies from tobacco use
  (Image: statistics)
• Cigarettes leave you breathless
  (Image: man coughing)
• Cigarettes are highly addictive
  (Image: ashtray)
• Cigarettes cause lung cancer
  (Image: man on respirator)
• Idle but deadly
  (Image: ashtray)
• Where there's smoke there's hydrogen cyanide
  (Image: smoke background)
• You're not the only one smoking this cigarette
  (Image: standing cigarette)
• Children see, children do
  (Image: mother & daughter)
• Cigarettes hurt babies
  (Image: pregnant woman)
• Tobacco use can make you impotent
  (Image: bent cigarette)

I am interested in:

• Image only
• Text only
• Both - image & text

N.B. Please note that Health Canada does not own the copyright to the images of the following four graphic health warning messages not listed above: Cigarettes cause stroke, Cigarettes cause lung cancer (Image: lung), Cigarettes are a heartbreaker and Cigarettes cause mouth diseases. You can contact pregs@hc-sc.gc.ca to obtain information regarding the use of these images.

Appendix B - Health Warning Messages for cigarettes (2011 Series)

(*) Selection of pictures to be used:

• "I wish I had never started smoking."
  (Image: Leroy)
• "Just breathing is torture."
  (Image: Lena)
• Tobacco smoke hurts everyone.
  (Image: empty crib)
• Cigarettes cause bladder cancer.
  (Image: toilet)
• Smoking in the car hurts more than just you.
  (Image: girl in car)
• A single stroke can leave you helpless.
  (Image: man in wheelchair)
• Your kids are sick of your smoking.
  (Image: asthma boy)
• Another premature death.
  (Image: morgue)
• Tobacco smoke: No thanks.
  (Image: pregnant woman)

I am interested in:

• Image only
• Text only
• Both - image & text

N.B. Please note that Health Canada does not own the copyright to the images of the following seven graphic health warning messages not listed above: Oral cancer, Cigarettes are a major cause of heart disease, Cigarette addiction affects generations, When you smoke it shows, Risk of blindness, This is what dying of lung cancer looks like and Look at the power of the cigarette... You can contact pregs@hc-sc.gc.ca to obtain information regarding the use of these images.

Appendix C - Health Warning Messages for little cigars (2011 Series)

(*) Selection of pictures to be used:

• A single stroke can leave you helpless.
  (Image: man in wheelchair)
• Chronic Bronchitis
  (Image: woman leaning on wall)
• Throat cancer. It's tough to swallow.
  (Image: man with blue tube)
• Tobacco smoke hurts everyone.
  (Image: empty crib)
• Tobacco is addictive, even for casual smokers.
  (Image: woman looking at cigarette)
• Another premature death...
  (Image: morgue)
• Smoking in the car hurts more than just you.
  (Image: girl in car)
• Tobacco smoke: No thanks.
  (Image: pregnant woman)
• Your kids are sick of your smoking.
  (Image: asthma boy)
• Bladder cancer.
  (Image: toilet)

I am interested in:

• Image only
• Text only
• Both - image & text

N.B. Please note that Health Canada does not own the copyright to the images of the following seven graphic health warning messages not listed above: Oral cancer, Cigarettes are a major cause of heart disease, Cigarette addiction affects generations, Risk of blindness, Lung cancer. You can contact pregs@hc-sc.gc.ca to obtain information regarding the use of these images.

Appendix D - Health Information Messages (2011 Series)

(*) Selection of pictures to be used:

• It's never too late...
  (Image: man and woman)
• Morning cough?
  (Image: blue lungs)
• Never quit trying to quit.
  (Image: red calendar)
• "I had enough of feeling guilty..."
  (Image: Susan)
• They only last an average of a few minutes...
  (Image: clock)
• Thinking of having a baby?
  (Image: pregnant woman)
• Quitting... What's in it for me?
  (Image: soccer player & saxophone player)
• How can the quitline help me?
  (Image: headset)

I am interested in:

• Image only
• Text only
• Both - image & text

Appendix E - Toxic Emission Statements (2011 Series)

(*) Selection of pictures to be used:

• Tobacco smoke contains more than 70 chemicals that can cause cancer.
• Tobacco smoke contains hydrogen cyanide, a poisonous gas.
• Tobacco smoke contains benzene, a chemical that causes cancer.
• Tobacco smoke contains fine particles that can damage the respiratory system.