Six Insights from the Canadian Tobacco and Nicotine Survey.

Earlier this week, Statistics Canada made available the public use microfile for the second wave of the Canadian Tobacco and Nicotine Survey. The agency has further modernized its data release methods, and the file is easily accessible to the public. This post looks at some key findings from this survey - more detail and data tables are available on a downloadable fact sheet.

Background on The Canadian Tobacco and Nicotine Survey (CTNS)

The CTNS was put in place in late 2019, following a decision to terminate the biennial Canadian Tobacco, Alcohol and Drug Survey (CTADS) after 2017. The first wave of the CTNS was conducted in October to December 2019, with the second wave repeated in December 2020 to January 2021. The first results of the CNTS 2020 were released by Statistics Canada on March 17, 2021. 

This survey asked questions of  8,112 Canadians, although only 41% of those who were asked to participate agreed to do so. Four times as many Canadians participated in CTADS, and the Canadian Community Health Survey gathers information from more than 10 times as many people. 

The small sample size of the CTNS severely limits the usefulness of the survey to assess differences between provinces or over time. A survey of this size does not provide for monitoring of the impact of regulatory change. For example, Nova Scotia's ban on flavoured vaping products had been in effect for more than 8 months before the survey was taken, but the sample size for Nova Scotia (404) was too small to produce enough vapers to meet Statistics Canada's quality standards for release. 

As a result, we are not permitted to report that the CTNS found that most Nova Scotia vapers were continuing to access flavours in that province, even though the sale of those flavours had been prohibited for several months. Had the sample size been larger, we could likely have provided this evidence that public health measures have been undermined.

1. Vaping rates have stabilized in Canada between 2019 and 2020.

There is little difference in the estimated proportion of Canadians who have used e-cigarettes in the past month between late 2019 and late 2020. 

2. Four in 10 Canadian vapers are under 25 years of age. Three in 10 have never smoked cigarettes.

The CTNS survey results show that although Canadian youth and young adults (aged 15 to 24) make up only 15% of the surveyed population, they represented 40% of those who vape. This survey estimates there are 425,000 teenage vapers in Canada, 314,100 of whom have never smoked a cigarette. Of the estimated 274,000 young adult vapers (aged 20-24), 113,000 have never smoked cigarettes. Among the 760,400 vapers older than 25, slightly more than a third (279,600) are former smokers, almost half (372,000) continue to smoke cigarettes and one-seventh (108,000) have never smoked.

In the fall-winter of 2020-2021 there were about 1.46 million Canadians who had vaped in the past month. Of these, one-third (485,100) were "former smokers." The remainder were "never smokers"(438,500, 30%) or "current smokers" (532,400 dual users, 38%).

 

3. For every 100 people who have tried vaping, 14 became daily users

One indicator of becoming addicted to a substance is regular use. The CTNS explored the use of 3 inhalable drugs: vaping liquids, tobacco smoke and cannabis. For all three of these substances, between one-tenth and one-fifth of Canadians who reporting having used the drug even once in their lifetime were daily users at the time of the survey.

The highest proportion was for cigarettes --- with daily use by 17 of 100 lifetime users. For e-cigarettes, the number was slightly lower, with daily use by 14 of 10 lifetime users. The proportion of ever users of cannabis was 10%.

4. Four in 10 smokers made a quit attempt over the past year. One in 3 of those would-be quitters used a cessation aid.

Two-fifths (42%) of smokers and recent quitters said they had made a quit attempt in the year prior to being surveyed -- and almost one-third (30%) tried two or more times.

When asked whether they had tried to quit using specific approaches, the majority (62%) said they had tried to quit on their own. Almost one half (47%) said they had reduced the number of cigarettes they smoked, one-quarter (26%) said they had switched to vaping, slightly more (30%) said they had used nicotine replacement and one-quarter (27%) said they had used an internet or "other" method. Because prescription medication was not identified on the questionnaire, treatments like varenicline may be included under "other". These answers were not exclusive, and smokers may have tried more than one method during the year or even used several concurrently.

The number of smokers who reported using a Quitline or Smokers Helpline or using a smart phone app was so small that the survey result is unreportable.

5. Most smokers were not successful in their quit attempts – despite the quit method they used.

The vast majority (85%) of smokers who reported making a quit attempt in the past year were still smoking at the time of the survey. Of the estimated 1.6 million Canadians who quit for one day or more over the past year, only 242,000 were still not smoking at the time of the survey (15%). 

Differences in the outcomes for those using different cessation approaches were not tested for statistical significance but are presented below. The largest number of successful quitters were those who identified as using no quit method.

6. Tobacco-flavour is the only vaping flavour not attracting young people or recreational users to vape.

The CTNS survey asked respondents who had vaped in the past month which flavours of vaping liquid they vaped most often. Eight options were offered: tobacco, fruit, candy, dessert, mint, or menthol, flavourless, and no usual flavour. Of these, only tobacco, mint, menthol and flavourless will be permitted by Health Canada's proposed restrictions on vaping flavours.

Tobacco flavour is most often chosen by older Canadians and by those who are using e-cigarettes to try to reduce or stop smoking. So few teenagers reported preferring tobacco flavour that the number is not reportable.  

The survey also enquired about vapers’ main reason for vaping. Because of the limited size of the survey, these choices cannot be looked at individually with respect to flavour choices, but must be grouped.

Of the eight options, three can be categorized as not being related to trying to reduce smoking. These were the reasons given by almost one-half (46%) of current vapers:

• Curiosity, you just wanted to try it
• Because you enjoy it 
• To reduce stress or calm you down

Four optional reasons were given that were related to reducing tobacco use, and these were chosen by two-fifths of smokers (43%) . 

• To quit smoking cigarettes
• To cut down on smoking cigarettes
• To use when you cannot/are not allowed to smoke cigarettes
• To avoid returning to smoking cigarettes

The eighth option was an unclassifiable “other” reason, chosen by one-tenth (11%) of vapers.

 

Tobacco flavour is most often chosen by older Canadians and by those who are using e-cigarettes to try to reduce or stop smoking. So few teenagers reported preferring tobacco flavour that the number is not reportable.

Lessons for tobacco control from climate-change action plans

Last week, Royal Assent was given to the Canadian Net-Zero Emissions Accountability Act. This new law, as the Library of Parliament describes it,  "requires the Government of Canada to set national targets for reducing greenhouse gas (GHG) emissions and establishes a planning, reporting and assessment process with the aim of achieving net-zero emissions by 2050."

On the day the bill became law, the government announced new elements of its plan to reduce greenhouse gas emissions: From 2035, all cars and passenger trucks sold in Canada must be zero-emissions.

This post explores the parallels between Canada's targets for greenhouse gas and tobacco use reductions, and whether the measures being put in place to address climate change might also benefit public health if applied to tobacco use.

The parallels 

Canada's strategies to control tobacco and to address climate change share a number of common characteristics. They both:

• primarily address the negative consequences of combustion
• involve the shared jurisdiction of federal, provincial and territorial governments
• seek to modify the behaviour of consumers and producers
• are challenged by the interests of those with vested commercial interests 
• are the subject of international framework conventions
• are embracing technological solutions, suchy as renewable energy or alternative nicotine

The federal goals 

Over the past 30 years, the federal government has set several domestic and international goals to reduce tobacco use and to reduce greenhouse gas (GHG) emissions. Environmental goals are generally expressed as a percentage reduction in emissions equivalent to mega-tonnes of carbon monoxide (MT CO2 eq). Tobacco use goals are generally expressed as achieving a reduced level of smoking or tobacco use prevalence (generally interpreted as those who have smoked cigarettes in the past month).

Climate change: Canada's first international commitment to reduce GHG emissions was in 1992, at the United Nations Conference on Environment and Development in Rio at which the United Nations Framework Convention on Climate Change (UNFCCC) was signed. Subsequent targets were agreed to at Conferences of the Parties to this convention, including the Kyoto Protocol (2005), the Copenhagen Accord (2010) and the Paris Agreement (2015). At the most recent conference (2019), Canada committed to "a net-zero-by-2050 goal".

Smoking: The federal government has adopted tobacco control strategies since 1963, but quantified targets for general prevalence were first adopted in 2001, when the aim was to reach 20% prevalence in 2006 and reduce cigarette consumption by 30%. The goal of 12% was subsequently set for 2012, and in 2017 Health Canada adopted the goal of "less than 5% tobacco use by 2035".  In 2013, as part of the World Health Organization's Global NCD Action Plan, Canada participates in the goal of reducing smoking prevalence between 2010 and 2025 by 30% (from 20.8% to 14.6%). 

These goals are shown in the figure below, together with data on annual levels between 1990 and 2019. To illustrate the rates of progress of both goals on the same graph, prevalence targets have been converted into the approximately equivalent absolute level of cigarette consumption. (Data and sources can be downloaded here).

Provincial targets to reduce tobacco use

Six provincial governments have also set targets for tobacco reduction.

• New Brunswick has aligned its target with the federal objective of less than 5% by 2035.
• Quebec, Ontario and British Columbia have set a target of 10% prevalence, aiming to achieve this in 2023 (ON, BC) and 2025 (QC).
• Alberta set a target for 12% prevalence for 2022.
• Newfoundland and Labrador aims to reduce smoking to 18.1% by 2025.

The other 7 provinces and territories do not have quantified targets for tobacco use reduction. Most provinces and territories have not updated their tobacco strategies since 2015. The exceptions are Quebec (2020), Ontario (2018), New Brunswick (2019), and Prince Edward Island (2017). More information on these goals and the strategies behind them is provided on a downloadable fact sheet.

International alignment for a 5% prevalence target.

Several other national governments have adopted an "endgame", "smokefree" or other tobacco reduction goal that is formally interpreted as aiming for under 5% prevalence. Some have identified it as smoking prevalence (e.g. New Zealand), some as tobacco-use prevalence (e.g. Canada) and some as nicotine or tobacco use (e.g. Finland). Among these countries, two are aiming to achieve this objective by 2025. These goals, illustrated below, are described in a backgrounder which can be downloaded here.

Other potential lessons from climate change

Legal accountability is only one tool that the climate change strategies are using that tobacco control has not yet embraced. Others include:

• An integrated federal-provincial planLessons from climate change
  The Pan-Canadian Framework on Clean Growth and Climate Change  is a national framework plan that includes commitments by federal, provincial and territorial governments. A federal-provincial approach for tobacco control formerly existed as the National Strategy To Reduce Tobacco Use (NSTRTU), which was on place from the mid 1980s to the late 1990s: this inter-jurisdictional approach was disbanded shortly after its last strategy was agreed to in 1999.

• Equitable pricing protection across Canada 
  As a component of the pan-Canadian framework, provincial governments are free to set their own carbon pricing systems but the federal government will act unilaterally if provincial carbon pricing measures do not meet the national benchmark. The Greenhouse Gas Pollution Pricing Act ensures minimal use of pricing to reduce GHG.
  
  A similar challenge exists for tobacco, where provincial taxes vary considerably across provinces. Provincial taxes in Quebec, for example, result in cigarettes in that province being markedly cheaper than in most other provinces. (They are also very cheap in Ontario). The federal government could close that gap, as it does for carbon, by applying a higher federal tax in Ontario and Quebec than it does in provinces which meet the internationally recommended level of 70% of purchase price. We have previously recommended that the federal government use its tax power to ensure a minimum $0.45 tax per cigarette.

• Accountability
  The new Canadian Net-Zero Emissions Accountability Act initiates several measures in support of the attainment of Canada's climate change goals. These include requirements for the Ministers of Environment and Finance to prepare and make public reports on progress, structured systems for public engagement and expert advice, and requirements for independent oversight. Should climate change targets not be met, the law requires governments to provide details on how they will get back on track. (This concept was first introduced to Parliament in 2007, and was twice defeated before its adoption this spring). 

• A phase-out plan for the most harmful products, and incentives to help make it happen 
  The climate change strategy includes the intention to phase out certain combustible products, including coal-fired energy and cars and passenger trucks. Federal regulations are being used to phase out coal-fired energy generators by 2030. Almost a decade ago, the federal phased out incandescent light bulbs because they were too energy inefficient.
  
  The recent announcement that conventional cars and passenger trucks could not be legally sold after 2035 identifies that economic incentives will be employed to achieve the target. The same carrots-and-sticks approach could be used to phase out combustible cigarettes, or to relocate tobacco sales to age-gated specialty shops could simlarly