Tuesday 15 December 2020

Tobacco companies make an average of $2.50 per day from Canadian smokers

Earlier this month, Health Canada released new data on the average wholesale unit price of manufactured cigarettes sold in each Canadian province over the past 16 years. This data allows us to compare the revenue generated by cigarette manufacturers in each province during that period, including on a per-smoker basis and in comparison with revenues from tobacco taxes in each jurisdiction.

The "average" price says little about what an individual smoker pays, but says a lot about what the companies earn.

From the purchaser's perspective, the "average" wholesale price is not a helpful indicator. For the most part, few people pay the "average" price for a pack of cigarettes. Some brands cost more than others, some stores charge more than others, and some provinces charge more tax than others. 

From a corporate income perspective, however, the "average" price is a core indicator. And when combined with public data on volume of cigarettes sold in each province, it allows us to calculate the dollar value of smokers to the companies' overall bottom line.

The average wholesale price of cigarettes in Canadian provinces has increased by 75% to 123% over the past five years

After more than a decade of stable pricing, tobacco companies began to sharply increase their wholesale prices over the past 5 years, from a national average of $0.095 per cigarette in 2014 to $0.176 in 2019, providing them an additional 85% per cigarette sold. In some provinces the average price was higher, as was the rate of increase. This may be because smokers in some provinces purchase more expensive brands, or it may be because manufacturers charge higher prices or offer fewer price discounts to retailers in some provinces. Because of inflation, the adjusted value of these increases is somewhat less, but still significant, as shown below.

Tobacco companies make $300 more per year from smokers than they did 5 years ago

Nation-wide, the amount of revenue generated by the industry for each Canadian smoker rose from $517 in 2014 to $898 in 2019.

Differences between the provinces can be attributed to differences in the amount of cigarettes purchased (some may smoke more or may purchase contraband) as well as differences in the brands chosen or wholesale prices charged. In 2019, the companies made the most revenue from smokers in the three most western provinces (about $1,100 per year per smoker) and the least in Quebec ($750 per smoker). Their revenue from each smoker has increased by an average of 74% since 2014 - ranging from 53% in Alberta to 100% in Nova Scotia.


Tobacco companies earn about $2.50 per day from Canadian smokers

On a daily basis, smokers in Canada provide from $2.05 (Quebec) to $3.06 (British Columbia) in revenue to cigarette manufacturers. The companies earned $1.04 more per day from the 4.7 million smokers in 2019 than they did from than 5.4 million smokers of 2014 ($2.46 vs $1.42). In some provinces the increase was almost a double: in British Columbia the average smoker paid $3.06 in 2019, compared with $1.51 in 2014.   

Tobacco companies' wholesale revenue is increasing faster than provincial tobacco taxes.

Earlier this month we showed how federal tax revenue was lower and falling relative to wholesale prices. This new data allows us to see that across Canada, while provincial tax revenues are generally higher than industry revenues they are also falling behind. (Ontario collects less in tax revenue than the industry earns from sales in that province) The examples of the province with the highest excise taxes (Manitoba) and the lowest (Quebec) are shown below, with links to data for all provinces provided below. Tobacco taxes are reported for a financial year ending in March, while corporate revenue is provided for the calendar year. 

The take-away
  • The business data Health Canada requires tobacco companies to report provides insight into their evolving pricing practices. These companies are generating significantly more revenue in recent years than historically.

Downloadable fact sheets

Tuesday 8 December 2020

E-cigarettes and respiratory disease: from "no available evidence" to "significant concern".

Do e-cigarettes cause respiratory diseases (other than EVALI)?

Almost three years have passed since the National Academies on Sciences Engineering and Medicine (NASEM) answered that question with a "we don't know" in their landmark review of the "Public Health Consequences of E-Cigarettes".

The panel of scientists charged with this review looked only at published research that was available before the end of August, 2017. At that time, there were few researchers engaged: of the 17 studies on e-cigarette users the NASEM panel looked at, six were conducted by the same (now somewhat controversial) research team.

With little to go on, the panel found "limited evidence" that on the one hand, e-cigarettes reduced some lung diseases for smokers that switched and, on the other, that it increased lung diseases for non-smokers that vaped. Generally, they concluded that not much was known: "Conclusion 11-1: There is no available evidence whether or not e-cigarettes cause respiratory diseases in humans."

Among their recommendations were a call for the U.S. Food and Drug Administration and others to give priority to funding research into respiratory effects of e-cigarettes. With additional research funding and interest, much more evidence of the impact of e-cigarettes on lung health is available. This post reports on the troubling results of two recently published studies.

Longitudinal study of smokers found e-cigarette users are 30% to 70% more likely to develop respiratory disease

Wubin Xie of Boston University followed 21,000 adults who were participating in the American longitudinal Population Assessment of Tobacco and Health (PATH) study. None of the individuals included in their review reported any respiratory disease at the outset of their participation.

Only a few years later, however, a large percentage of those using e-cigarettes reported respiratory conditions, including COPD, emphysema, chronic bronchitis, and asthma. After adjusting for all possible other factors, the research team found that e-cigarette use was associated with a 30% increase in the risks of chronic bronchitis and asthma, a 60% increase in the risk of chronic obstructive pulmonary disease (COPD), and a 70% increase in the risk of emphysema. They tested for reverse causation and found it not to be an explanatory factor. They repeated the analysis, restricting the analysis to those who had never smoked cigarettes. The results did not change substantially. While cigarette smoking is a known risk factor for respiratory diseases, this study shows that e-cigarette use is an additional independent risk factor for respiratory diseases.

Study: Wubin Xie and colleagues. Association of electronic cigarette use with incident respiratory conditions among US adults from 2013 to 2018.

A review and meta-analyses of the relationship of e-cigarette use and respiratory diseases finds e-cigarette users have a 40% increase in the risk of asthma and 50% increase in the risk of COPD

While Wubin Xie and colleagues were conducting their research in Boston, another group of researchers, Thomas Wills and colleagues were independently researching the same subject from their base in Hawaii, using very different methods. They reviewed past epidemiological studies and conducted meta-analyses of the association of e-cigarette use with asthma and COPD, controlling for cigarette use and other covariates. There were 15 studies in the asthma meta-analysis and 9 studies in the COPD meta-analysis. (Four of the papers they looked at were included in the NASEM review, the others did not meet their selection criteria).

The results of this systematic review were remarkably similar to those posted by Wubin Xie and colleagues: there was a 40% increase in the risk of asthma and a 50% increase in the risk of COPD. The researchers tested competing explanations including possible self-report bias, the possible "ill-worker-effect" and possible reverse causality. None of these alternative explanations stood up to their scrutiny, giving them confidence that the meta-analyses results reflect real relationships.

Dr. Wills and colleagues also provided an updated review of laboratory studies and found that e-cigarette vapours cause biological changes that can lead to respiratory diseases. These adverse biological changes were observed in cell cultures, animal studies and human studies.

The team also assessed their findings against the established criteria for inferring causal relationships, and found that they met the criteria of consistency, strength of effect, temporality, biological plausibility and, in some cases, dose-response gradient. They conclude that "E-cigarette use has consequences for asthma and COPD, which is of significant concern for respirology and public health." 

Growing global concerns

Three years after the NASEM report a much larger body of evidence from independent researchers is available for review, and additional scientific panels have been commissioned by international organizations and national governments to consider the evidence. These reviews have been broader in scope, covering other health effects, not just respiratory diseases, and generally conclude that e-cigarettes are not safe.

These reviews include reports by or for the World Health Organization, the European Union, the Irish Government, the Government of the Netherlands, the Australian Government, and the Spanish Government.

In February 2020, the World Health Organization concluded "ENDS [electronic nicotine delivery systems] on their own are associated with increased risk of cardiovascular diseases and lung disorders and adverse effects on the development of the fetus during pregnancy. ENDS are undoubtedly harmful, should be strictly regulated, and, most importantly, must be kept away from children."

In September 2020, based on evidence available up to April 2019, European Union's Scientific Committee on Health, Environmental and Emerging Risks (SCHEER) concluded that:
  • for users of electronic cigarettes the overall weight of evidence for risks of local irritative damage to the respiratory tract is:
    • moderate for heavy users of electronic cigarette due to the cumulative exposure to polyols, aldehydes and nicotine, and
    • not to be excluded for average and light users. However, the overall reported incidence is low.
In June 2020, after reviewing 67 recent pertinent studies, the Irish Health Research Board concluded that e-cigarette use was responsible for "probable harms" due to respiratory diseases.

In April 2020, the Trimbos Institute reported to the Dutch government that "Newer studies provide more and more indications that the use of an e-cigarette could lead to damage to the respiratory tract and the cardiovascular system."

The Australian government website states categorically that e-cigarettes are not safe. The web-site goes on to state "many scientists are concerned that using e-cigarettes could increase risk of lung disease, heart disease and cancer."

A 2020 Spanish Health Department report states that the adverse short-term effects on the respiratory system are similar to those of cigarette smoking.

There is a growing global scientific consensus that e-cigarette use leads to increased risk of respiratory diseases.

Wednesday 2 December 2020

Canadian government revenues from tobacco taxes fell by more than 8% in 2019-2020.

Earlier this week, the federal government tabled in parliament its annual report on public accounts. Together with similar reports from provincial governments (or budget statements where the public accounts are not yet ready), we now have a picture of the amount of taxes collected by Canadian governments on tobacco products over the past fiscal year - April 1, 2019 to March 31, 2020.

In all but one province (Manitoba), tobacco tax revenues were down. Last year a total of $7.64 billion were collected by territorial, provincial and federal governments in excise taxes imposed on cigarettes, cigars, smokeless, rawleaf, manufactured and other forms of tobacco. The previous year, the amount collected had totalled $8.29 billion. Links to tables of historic tax revenues and other data are provided below.  

Federal and provincial tobacco tax revenues are declining slowly, once adjusted for inflation.

Despite periodic increases in some provinces, tobacco tax revenues have been essentially flat (with a recent downward trend) for more than a decade, once inflation is taken into consideration. 

Several factors contribute to the amount of tobacco tax received by governments: the tax rate, the number of smokers and the volume of cigarettes smoked on which taxes have been avoided (illicit sales). Other than cigars (which account for less than 2% of federal tobacco tax revenue), tobacco products are taxed on a per-unit or per-weight basis and changes to retail prices have no impact on government revenues.

The average smoker provides more than twice as much tax revenue in some provinces than others.

Tobacco tax rates and the sale of untaxed tobacco vary significantly across Canadian provinces, and so too does the amount of tax received per average cigarette smoker. Ontario, which has the second-lowest cigarette tax rate and is believed to have the highest contraband rate, received the least revenue on a per-smoker basis ($650). Quebec, with the lowest tax-rate recieved slightly more ($775). Per-smoker revenue for the other provinces ranged from $1,200 to $1,625. In addition, federal tax revenues on tobacco products were about $650 per smoker. 

The impression that revenues per smoker have grown over the past 15 years is corrected once the revenues are adjusted for inflation. Both adjusted and unadjusted amounts are shown in the figures below.

(These figures are approximations only, as the Canadian Community Health Survey only provides estimates of the number of cigarette smokers and most public accounts only provide total combined revenues for all types of tobacco products. About 95% of the value of the wholesale tobacco market is for manufactured cigarettes.)

Tobacco industry revenues are increasing while tax revenues aren't.

Not all tobacco-related revenues are stagnant. Data released earlier this year by Health Canada (based on calendar, not fiscal years) show that although federal tax revenues have been stagnant, the revenue received through wholesale shipments has continued to climb.

From the information reported to and by Health Canada,  between 2009 and 2019 the volume of cigarette sales has fallen by 17% (from 28.6 to 23.9 billion), wholesale revenues on cigarette sales have climbed by 55% (from $2.7 billion to $4.2 billion) and cigarette taxes remitted to the federal government have increased by 25% (from $2.4 billion to $3 billion).

Related data sheets:

Tuesday 24 November 2020

Innovative proposals for regulating tobacco retail.

This post highlights two recent and innovative government proposals to address tobacco retailing - including a home grown solution for northern Canada!

Curbing retailer incentive programs

Tobacco companies
motivate retailers
with prizes and rewards.
One of the more recent marketing strategies of tobacco companies is to offer incentive programs to convenience store owners and sales clerks. In return for selling more product, participating in sales training or otherwise helping promote tobacco products, these workers can earn points which they can redeem for travel, gift items or other benefits. They can also vie for the right to buy tobacco products more cheaply than their competitors.

This is a problem for public health because it puts additional pressure on retailers to sell cigarettes -- lots of them. It drives the price of cigarettes down because those who do not get special prices are pressured to lower their in order to compete with those who do. It gives store employees a personal incentive to sell more products, irrespective of the benefit to their employer. 

To date, Quebec is the only province to have amended its law to address these new promotional programs. In 2015 it amended its Tobacco Control Act to prohibit tobacco companies from "offering rebates, gratuities or any other form of benefit related to the sale or the retail price of a tobacco product to operators of tobacco retail outlets, including their employees." This measure has ended some of these marketing ploys, but has not stopped the companies from rewarding or punishing retailers by adjusting the wholesale prices.

Nunavut is the first Canadian jurisdiction to introduce legislation to directly address the preferential pricing practices and their health impact. Last month, its legislature gave second reading to Bill 57, a proposed new Tobacco and Smoking Act.   This bill contains many important measures and sets a new high standard for Canadian tobacco control laws. Among its innovations are a clear direction to shut down promotions that encourage retailers to sell more tobacco and "smoking" products (including electronic cigarettes).

The proposed measures include:

  • an end to incentives offered to retailers by manufacturers or wholesalers
  • an end to incentives offered to customers by retailers 
  • an end to price signs at retail (price lists can be shown to customers)
  • an end to price reductions for higher volume sales (like bundled packages)
  • an end to price discrimination (offering retailers or customers a better price than to others)
  • the power to regulate prices 
Reducing the density of tobacco retailers

Over the decades, provincial governments have reduced the number of places where tobacco can be sold. Cigarettes can no longer be sold in pharmacies (except in B.C.), in health care settings (except in New Brunswick). Some provinces have also banned sales in restaurants and bars, amusement parks, and through the internet. 

These restrictions have helped drive down the number of tobacco retailers in Canada from over 40,000 in 2000 to about 28,000 today. But to date no Canadian government has set a target to reduce the density or quantity of tobacco retail outlets.

Last week, Netherlands Health Minister Paul Blockhuis outlined his plan to do so for that country. With a long-term goal of restricting tobacco sales to age-restricted stores, his initial 5-year plan will reduce that country's tobacco outlets from 16,000 to about 6,000 after 2024 by ending sales in vending machines, one line and in supermarkets. A review will begin next year on how to transition to tobacco only stores after 2030. 

The Netherlands has roughly half the population of Canada. After 2024 it will have fewer tobacco outlets per capita (34 for 100,000 people) than any other European Country. By way of comparison, Canada currently has 71 tobacco retail outlets per 100,000 people and 26 gas stations or pharmacies for the same population.

This Dutch approach is supported by an economic review and modelling of the impact in which several options were consieered, such as capping density and using licensing conditions. The government estimates that moving towards tobacco-only stores as they are doing will reduce the number of Dutch smokers by 120,000.

Sunday 15 November 2020

An update on evidence linking teen vaping to cigarette smoking

Earlier this spring, we provided a review of studies into the relationship between young people using e-cigarettes and their subsequent use of tobacco. This post reports on four more large studies which support the general conclusion that young e-cigarette users are three to four times more likely to become tobacco cigarette smokers 

All four studies provide systematic reviews of previous evidence. The most recently published of these studies provides a a new analysis of longitudinal data from the Population Assessment of Tobacco and Health (PATH) survey in the United States. Two others are meta-analyses commissioned by government health agencies – one from Ireland and Australia. One other, from the European Union, reviewed previous studies, meta-analyses, and e-cigarette components particularly attractive to young people.

Evidence from an analysis of longitudinal data from the PATH survey

Smoking Intention and Progression From E-Cigarette Use to Cigarette Smoking was published in the journal Paediatrics in November 2020. Olusegun Owotomo and his colleagues at the University of Texas used data from the Population Assessment of Tobacco and Health (PATH) study to look at changes in adolescent behaviour from 2014-15 to 2015-16. They used a US nationally representative population of adolescents who were 12 to 17 years old at the beginning of the study period to find out whether the teenager's  stated intention to smoke cigarettes or their use of e-cigarettes predicted actual cigarette smoking one year later. There were four previous analyses of PATH data that examined the relationship between e-cigarette use and subsequent smoking, but this was the first to also examine the effect of intention to smoke.  References to these previous studies can be found in the Australian study by Olivia Baenziger and her colleagues.

It turned out that both intention to smoke and e-cigarette use predicted later smoking.. "Among adolescents who had expressed intention to smoke conventional cigarettes at baseline, e-cigarette use did not predict cigarette smoking at follow-up. However, among adolescents without previous intention to smoke conventional cigarettes, e-cigarette use predicted cigarette smoking." 

If teens said they intended to smoke, they were three times more likely to actually become cigarette smokers. Children who smoked e-cigarettes in 2014-15 were 4.6 times more likely to become cigarette smokers by 2015-16, even if they earlier had no intention of becoming cigarette smokers. This latter finding is very much in line with most other studies of same phenomenon, as we shall see in the following sections.

Evidence from meta-analyses performed by the Irish Health Research Board

Electronic cigarette use and tobacco cigarette smoking initiation in adolescents: An evidence review was made public by the Irish Health Research Board in October. It was prepared to respond to Ireland's Department of Health's request for an answer to the question "Does e-cigarette use by adolescents who are cigarette na├»ve at baseline lead to subsequent cigarette smoking?"

This review predated the Owotomo study discussed above, so the latter was not included among the papers analyzed.
The Irish HRB review included 21 studies, up from the 17 included in the meta-analysis reported by Jasmine Kouja and her colleagues a few months earlier. Of these, 15 longitudinal studies reported adjusted odds ratios. The HRB concluded: "We found a four-fold association between ever using e-cigarettes and initiating smoking tobacco cigarettes in adolescents in a combined analysis of nine cohort studies conducted with follow-up periods between 4 and 24 months"

The analysis considered this relationship using different theoretical constructs. "We identified three theories that attempt to explain the move from using e-cigarette use to smoking tobacco cigarettes, and these are: the gateway theory, the common liability theory, and the catalyst model." The HRB recommends that further studies be designed to test these theories.

Evidence from umbrella review and meta analyses of gateway effect and relapse undertaken researchers in Australia 

With support from the Australian Government Department of Health, Olivia Baenziger and her colleagues prepared a report on E-cigarette use and combustible tobacco cigarette smoking uptake among non-smokers, including relapse in former smokers: umbrella review, systematic review and meta-analysis. It was made available in September ahead of peer-review. 

This study included several components. First, they reviewed three previous meta-analyses, "an umbrella review" and noted that all three had similar findings, that young e-cigarette users were 3-4 times more likely to later become cigarette smokers. Secondly, they identified 25 studies as methodologically suitable for inclusion in their own meta-analysis of the the relationship between e-cigarette use and subsequent cigarette smoking. When all were combined in the meta-analysis, it was estimated that e-cigarette users were 3.25 times more likely to become cigarette smokers.

Thirdly, the researchers found three studies that studied whether former smokers who took up e-cigarettes would relapse to cigarettes smoking. This is the first systematic review to consider the relationship of e-cigarette use to smoking relapse. It found former smokers were 2.4 times more likely to relapse to cigarette smoking if they took up e-cigarette use. 

"Our umbrella and systematic review, along with an updated meta-analysis using data from primary studies, shows strong and consistent evidence that never smokers who have "used e-cigarettes are more likely than those who have not used e-cigarettes to try smoking conventional cigarettes and to transition to become regular tobacco smokers."

Evidence reviewed by the European Commission

Another scientific assessment of the role of e-cigarettes in the initiation of smoking was conducted by the European Commission's Scientific Committee on Health, Environmental and Emerging Risks (SCHEER). In February 2019, the Commission requested SCHEER to review the health effects, cessation impact and also "their role as a gateway to smoking." The SCHEER released its Preliminary  opinion on electronic cigarettes in late September and will make public its final version after reviewing comments that were submitted in response. 

In this paper, the SCHEER reported that "Regarding the role of electronic cigarettes as a gateway to smoking/the initiation of smoking, particularly for young people, the SCHEER concludes that there is strong evidence that electronic cigarettes are a gateway to smoking for young people. There is also strong evidence that nicotine in e-liquids is implicated in the development of addiction and that flavours have a relevant contribution for attractiveness of use of electronic cigarette and initiation." (emphasis in original)

The question of causality and the gateway effect

The reviews discussed above took different approaches and applied different models when considering whether smoking is causally related to e-cigarette use. 

* The Health Research Board reported that its study design "does not allow us to say there is a definitive causal relationship, but it does allow us to say that the findings builds a case towards a causal relationship as the findings are consistent across all studies included in the meta-analysis." It recommended further studies to establish "what drives the relationship between e-cigarette and tobacco cigarette use."

* The EU SCHEER committee considered both the gateway hypothesis and the renormalisation hypothesis to explain the relationship between e-cigarette use and later smoking by adolescents. They concluded "that there is strong evidence that electronic cigarettes are a gateway to smoking for young people."

* The Australian team found that the similarity of results in many places suggested a causal link ("... the consistency of findings across multiple studies and settings supports the likelihood of a causal relationship"), but that the cross-sectional observational design of most studies meant they could not yet rule out "the possibility of residual confounding."

* The longitudinal design of the U.S. study (which was not included in the other reviews) adds further evidence to support a causal relationship. The authors' conclusion implies that the results should be treated as support for a causal connection. "Abstinence from e-cigarette use should be framed as an adolescent smoking prevention strategy."

  • Multiple studies and multiple meta-analyses from many countries show remarkably consistent results.  Young people who take up using e-cigarettes are 3-4 times more likely to progress to becoming cigarettes smokers than their peers who do not use e-cigarettes. 
  • This risk of becoming a smoker also applies to those young e-cigarette users who declare they have have no intention of becoming smokers.  Despite their intentions, they are over four times more likely to become cigarette smokers.
  • Former smokers who take up e-cigarettes are over twice as likely to relapse to cigarette smoking.

Monday 9 November 2020

Which Canadian province is doing the best at reducing smoking?

In Canada, tobacco control is an area of shared jurisdiction: both federal and provincial governments have wide authority to regulate the manufacture, promotion, distribution and sale of tobacco products. Although Canada's constitution generally gives provinces control over commercial activities, the Supreme Court long ago recognized the authority of the federal government to also regulate cigarette promotions and products. 

Despite differences in emphasis and intensity, the tobacco control regulations and programs in each province are largely similar. A province that might be "leading the pack" in one aspect (eg flavour restrictions) may not be so far ahead with others (eg taxes). Added to these differences are also demographic and cultural differences across Canada's wide geography.

This post looks at data on smoking behaviour in Canada's provinces, based on 9 cycles of the Canadian Community Health Survey (CCHS) spanning almost 2 decades. The information presented below is for the general population, sex and age disaggregated information is also available on the following interactive tables:

Smoking rates have fallen across the country

Smoking rates across the country have fallen by almost one-half (a 40% reduction) between the first cycle of CCHS (in 2000) and the period for which complete indicators have been released (2017-2018). 

That is to say that each year over the past 2 decades, for each group of 200 Canadians, every year there has been one less person who smokes every day or on occasion. This pattern holds true in most provinces.

The standings between the provinces have not changed greatly in 20 years. The provinces with the lowest smoking rates in 2017-2018 are essentially the same as those with the lowest rates 18 years earlier - British Columbia and Ontario. Although smoking rates have dropped by a greater proportion in some other provinces, they have not yet caught up.

The reduction has been greatest with respect to daily smoking. Since 2000, the percentage of Canadians who smoke daily has fallen by more than 11 percentage points (11 people in 100). The provinces with the largest declines in daily smoking are Quebec and Prince Edward Island (13.5 percentage points). 

There has been very little change in occasional smoking. There are more occasional smokers in 2017-2018 than in 2000 (1.5 million to 1.1 million). The increase in the rate of occasional smoking is slight but statistically significant (from 4.5% to 4.8%). During this period, the overall population grew by over 5 million people. The profile of occasional smokers (and the number who were once daily smokers) will be explored in a future post.

The greatest drop in smoking has been among the youngest Canadians

Current smoking among teenagers has fallen by two-thirds since 2000. Those born in the 1980s were 3 times more likely to smoke as teenagers than those born in the first decade of this century (19% vs 6%). Comparisons among all provinces have become more difficult, as surveyors are unable to find enough young smokers to provide a reliable estimate for the smaller jurisdictions. Among the larger provinces, Quebec rates for teen smoking (age 12 to 19) have fallen from 27% to 8%, compared with Ontario's from 17% to 6%, Alberta's from 18% to 6% and British Coumbia's from 12% to 5%. 

Fewer and fewer Canadians ever try smoking...

As we observed earlier for Canada as a whole, it is the "never smoking" population that is likely driving reductions in smoking. 

This is especially true in some provinces. For example, British Columbia nad Ontario are also the provinces where people are most likely to have never smoked a single cigarette. In Ontario and B.C., one-half of all citizens and 6 in 10 people in their 20's have never smoked a single cigarette (compared with 5 in 10 in the other provinces). 

Ontario and Quebec provide an example of this. Although Ontario has a lower smoking rate than Quebec (15% vs 18%), the percentage of Quebec smokers who have quit is no lower: the Quit Ratio of former to current smokers is 1.42 in Ontario and .1.59 in Quebec. Ontario's relative success can be attributed to fewer people having begun smoking. One-half (51%) of Ontarians have never smoked one cigarette, compared 40% of Quebeckers.

... and more smokers have quit.

Overall, the proportion of Canadians who have smoked and then quit has grown slowly, although progress has been uneven across the Country.

British Columbia is also in the lead for this indicator: in that province there are 4 former smokers for every 2 smokers, compared with a national average of 3 former smokers for every 2 smokers. All provinces are doing much better than they were in 2000 - with greater improvements in New Brunswick, Prince Edward Island and New Brunswick. The prairie provinces are doing least well at moving smokers to former smokers. One contributing factor is the relative youthfulness of prairie populations, and the greater likelihood that older smokers will have quit: the median age in the prairies (36) is a full 5 years younger than in B.C. (41).


(Although fewer smokers are quitting every year)

Since 2003, this survey has asked former smokers how long ago they quit. From this we know that the number of Canadian smokers who have quit in the past year has fallen from almost 700,000 in 2003 to 414,000 in 2017-2018. 

This is not unexpected, given that with a falling smoking rate there are fewer remaining smokers year on year. Nonetheless, even as a proportion of remaining smokers, the number of "recent quitters" is not growing. It would appear that in most provinces, smokers are no more likely to quit in 2017-2018 than they were 20 years ago.  

As a result, most former smokers are long-term quitters. Two-thirds of former smokers in Canada quit more than a decade ago, with very few differences across the country.

In fact, death is more responsible for reducing the number of Canadian smokers than quitting. The CCHS shows that for every 10 fewer Canadian smokers in 2018 than there were a decade earlier, there were only 4 more former smokers. The other 6 smokers had disappeared from the CCHS population, mostly likely through death. (During that period, there were 1 million fewer smokers, but only 429,000 more former smokers). 

The takeaway:
  • Individual and community efforts to reduce smoking have succeeded in Canada at a steady if slow pace for the past 20 years.
  • British Columbia has maintained its lead for two decades. Other provinces are generally keeping pace with B.C., and some have made relatively greater progress on some indicators (eg. youth smoking). 
  • Falling smoking rates reflect reduced number of people who start to smoke and increased number of smokers who successfully quit. Some provinces are doing relatively better than others at protecting youth from smoking and from achieving successful population cessation.
  • Demographic differences between the provinces may be responsible for some differences between provincial smoking, starting and quitting rates. 

Friday 23 October 2020

Post-consumer tobacco waste -- more harmful than plastic straws and stir sticks.

Earlier this month, Jonathan Wilkinson, the minister of Enviornment and Climate Change Canada announced Canada's plans to achieve zero plastic waste within the next decade.  Included in this plan was a ban on 6 categories of single-use plastic items: plastic checkout bags, straws, stir sticks, six-pack rings, cutlery, and food ware made from hard-to-recycle plastics.

While the federal government plans to reduce the use of these plastic products (and eventually also to reduce the use of other food services packages and drink cups), its intentions for tobacco waste are limited to increasing the frequency that these products are recycled or recovered.

The exclusion of tobacco-waste from the proposed ban on single-use plastics is surprising in some ways:

Continued exceptionalism for the tobacco industry?

It has long been observed that tobacco manufacturers are  frequently exempted from regulations that are applied to other industries. In the case of the federal plastics strategy, Environment and Climate Change Canada has made clear the reasons it is exempting cigarette filters from its ban on single use plastics.

The department established 3 criteria to decide which single-use plastics to ban: 1) whether they were found in the environment, 2) whether they were often not recycled and 3) whether they have readily available alternatives. 

It was the department's determination that there are no alternatives to cigarette filters that seems to underpin their decision to implement measures to mitigate the problems caused by post-consumer tobacco and vaping waste, but not to end the use of these harmful plastics. 

The world is moving to banning single use plastics, and the tobacco industry is trying to avoid that impact.

Measures to curb the use of single use plastics are under development in many countries. Last year, the European Union adopted a directive requiring its member states to pass legislation by July 2021 to require tobacco manufacturers to cover the costs of awareness-raising, litter clean-up, data gathering and reporting and waste collection, and also to require waste-related markings on tobacco product packaging. 

Not surprising then, that tobacco companies have accelerated cross-border activities to frame the issue and to influence public policy in ways that would minimize the impact on their business. They focus attention away from their producer responsibilities and instead present tobacco waste as a problem related to smoker behaviour. They frame tobacco waste as a problem caused by user non-compliance, and not the result of manufacturing practices and product design.

Philip Morris International says its objective is to "Prevent littering of our products by promoting appropriate behaviour among adult consumers.”  This year its subsidiary, Rothmans, Benson and Hedges, provided grants to 17 clean-up operations in Canada -- leveraging the work of volunteers to clean up the waste it caused.

British American Tobacco, and its Canadian subsidiary Imperial Tobacco Canada Ltd also promotes measures addressed at consumers, not producers. "BAT acknowledges that cigarette filters provide a waste issue for regulators. However, it believes that the most appropriate solution is promoting the proper disposal of butts so that they don’t pollute the environment." 

These corporate initiatives of the companies are worrisome. Good implementation of the Framework Convention on Tobacco Control would not permit Corporate Social Responsibility initiatives, like RBH's grants to clean-up squads, nor tobacco industry partnerships, like Imperial Tobacco's former sponsorship of municipal ashtray programs.  

The federal government has to date given no signal that it will protect its single use plastics plan from tobacco industry influence. (In its recent roundtable on the topic, the U.K. environment ministry acknowledged these responsibilities.)

Public education is not enough. There are better options to choose from

A number of options for managing tobacco and vaping product waste have been developed by independent researchers and civil society. 

In addition to amplifying existing measures (like smoke-free laws, public education and product labelling), these include:

Considerations for public health regulators

The way in which post-consumer tobacco waste is managed can have an impact on public health. Dr. Stuart Kreisman in Vancouver has pointed out that:

The widespread presence of ashtrays imply tacit government consent, acceptance and even approval of widespread smoking in public. They strengthen the impression that smoking is common, and create smoking zones in public places. Such re-normalization of smoking is directly aligned with the strongest interests of the tobacco industry.

Governmental responsibilities to address tobacco use include environmental objectives AND the obligation to protect these from tobacco industry interference. 

By engaging in the development of federal, provincial and municipal approaches to single-use plastics, health agencies can ensure that these policies support public health objectives. One way to do this is to respond to federal proposals, which are open for comments until December 9, 2020.

A briefing note to assist this process can be found here.

Thursday 15 October 2020

New longitudinal studies find little support for e-cigarettes as an effective tool for population-level smoking cessation

 About the PATH survey

In May 2020, we reported on a number of studies that analyzed data from the PATH survey. To recap, since 2013, there has been a remarkable survey operating in the United States that has deepened our understanding of tobacco and e-cigarettes use and consequences. It is the Population Assessment of Tobacco and Health Survey (PATH) - a longitudinal, nationally representative survey of 46000 Americans. This survey generates information on tobacco and e-cigarette use behaviours, and with its longitudinal design it interviews the same individuals every year. It is planned that the survey will continue at least until 2024.

Since May, more longitudinal analyses have been published using PATH survey data. Three of these explore the relationship between smoking cessation and e-cigarette use and merit a closer look.

July 2020:
PATH study finds e-cigarettes no more effective at helping smokers quit (but keeps more people using nicotine).

The first of these was published by Rufeng Chen and colleagues in June 2020. They followed a subsample of 2,535 people who were smokers in 2014-15, and who had tried at least once to quit smoking by 2015-16. Their success at quitting smoking was assessed at 2016-17. They found that, among those who used e-cigarettes to help them quit, about 13% were successful. However, this success rate was not significantly different from that achieved by smokers who used other methods to quit smoking. Importantly, two-thirds of successful quitters who used e-cigarettes were still using e-cigarettes by the time of the 2016-17 PATH survey. The authors conclude:

These results suggest e-cigarettes may not be an effective cessation aid for adult smokers and, instead, may contribute to continuing nicotine dependence.

August 2020:
Another PATH study finds quitting is no more likely with e-cigarettes.

Many of the same authors of the paper by Rufeng Chen and colleagues also collaborated on an August 2020 paper by John Pierce and colleagues. Pierce and colleagues used similar methods to those used by Chen and colleagues, but studied a slightly different time period, from 2013 to 2016 instead of 2014 to 2017. Use of e-cigarettes, use of approved pharmacotherapy or use of no product, all resulted in a smoking cessation rate of about 10% 1-2 years later. However, over half of e-cigarette users who successfully quit smoking were still using e-cigarettes at the end of the study period.

The authors concluded:

We found no evidence to support our first hypothesis that ENDS [electronic nicotine delivery systems] would be associated with increased abstinence duration from either cigarette or any tobacco. Twelve-month cigarette abstinence was ~10% and comparable across all methods used to quit, and the finding was robust to sensitivity analyses. Over half of those who used e-cigarettes to try to quit were still using e-cigarettes at the W3 follow-up.

Similarly our results did not support our second hypothesis that daily use of ENDS would be associated with increased cigarette abstinence. 

September 2020:
PATH study finds frequent e-cigarette use helps smokers quit.
Alison Glasser and colleagues analyzed three waves of PATH data from 2013 to 2016. They concluded:

This study suggests that consistent and frequent e-cigarette use over time is associated with cigarette smoking cessation among adults in the US.

At first blush, this conclusion seems at odds with the previous PATH studies, but closer inspection shows the results are the same.

In this study, the authors reported only on the frequency and consistency of e-cigarette use with later quitting success. They did not report on the the relationship between all e-cigarette use and smoking cessation, although that relative risk can be calculated from the data presented in the paper. As it turns out, the RR = 1.0, indicating no relationship between all e-cigarette use and 12 months or more of smoking cessation.

Still, there would be encouraging news for e-cigarettes as a possible smoking cessation method if there were a great many "consistent and frequent" users of e-cigarettes. Regrettably this is not the case. Out of 5894 study participants who were e-cigarettes users at the beginning, only 78, just 1%, were "consistent and frequent" users of e-cigarettes. For that 1% of users, quitting with e-cigarettes was more successful.

One might ask how many e-cigarette users who were trying to quit smoking successfully quit both smoking and e-cigarette use by the end of the study period in 2016? Glasser and colleagues do not provide that datum. However, Pierce and colleagues who analyzed the same PATH data sets over the same time period do provide the information. Here is the answer

None in the daily e-cigarette use group (n=56) and 45% (95% CL, 36.8-53.5%) of the no e-cigarette group (n=162) were abstinent from all tobacco [including e-cigarettes] for 12+ months at W3.

In other words, not a single e-cigarette user who was using e-cigarettes to quit was able to quit both combustible cigarette and e-cigarettes after three years.

In general, the PATH analyses show that, at the population level, e-cigarettes are not helpful in smoking cessation and even e-cigarette users who successfully quit smoking will still be addicted to nicotine in their e-cigarettes.

Would the same findings be true in Canada?

There is no ongoing longitudinal monitoring of nicotine use behaviour in Canada that is comparable to the US PATH survey for detail, size and quality. Nevertheless there is some Canadian information available that does offer some limited comparison.

Health Canada has commissioned a return-to-sample (semi-longitudinal) survey of Canadian vapers. Despite its limitations (non-representative sample, 25% response rate at T2, 992 usable responses), this survey has the merit of following the vaping behaviour of the same group of vapers over a one-year period, from 2019 to 2020. The report found that although 11% of vapers had smoked in 2019 but quit using cigarettes by 2020, a larger number (13%) were non-smokers in 2019 but in 2020 were smoking cigarettes.

In other words, the modest amount of quitting behaviour among vapers was more than offset by uptake of smoking in the same population. And one-half of vapers who had never smoked cigarettes at the beginning of the survey were doing so one year later.

So far, the Canadian evidence, like that in the USA, does not support the conclusion that vaping is an effective population-based smoking cessation method. 

Data from Environics Canada.
Vapers Online Survey to Measure Attitudes and Behaviours
Regarding Vaping Over Time (2019 to 2020).
POR 098-19.

Thursday 8 October 2020

Another look at quitting rates: Insights from the Canadian Community Health Survey

Shortly after Statistics Canada released data from the 2017-2018 Canadian Community Health Survey (CCHS), we reported on the relatively small contribution of quitting to the progress against tobacco use, focusing on population growth and turn-over (deaths) over the past decade. 

This post takes a second look at changes in quitting behaviour over the past 20 years for Canadian men and women at different stages of life. It identifies some of the challenges in using quitting rates or quit ratios as indicators for tobacco control.  

The percentage of Canadians who are former smokers has barely changed since the beginning of the century....

Although the proportion of Canadians who smoke has fallen from one-quarter (26%) in 2000 to one-sixth (16%) in 2018, the share of the population who are former smokers has barely budged - hovering around 25%. As discussed earlier this summer, and shown below it is the growth in "never smokers" that has driven overall smoking rates down. 

Between 2000 and 20018, the number of smokers fell by 1.7 million, but the number of former smokers grew by only 1.2 million. The number of people who had never smoked one cigarette grew by 5 million.

But among Canadian who have ever smoked, a greater proportion have quit 

The slow growth in the number of former smokers can mask progress in the proportion of smokers (instead of the proportion of the whole community) that have stopped smoking.

Looking at the number of Canadians who have quit smoking as a proportion of those who have ever smoked shows that there has been overall growth in quitting. 

The daily smoker Quit Ratio (ratio of former daily smokers to ever daily smokers) has grown from half (51%) in 2000 to two-thirds (66%) in 2018 (shown below). The current smoker Quit Ratio, which includes those who continue to smoke on an occasional basis, has grown somewhat less (from 49% to 61%). The figure is available on the downloadable Excel sheet, linked below. 

Success in quitting comes with age...

Although virtually all smokers start before they are in their early 20s, successful quitting happens at all ages and accumulates as people age. This is illustrated in the chart below, which shows the percentage of ever smokers who have quit in 5 age groups over 2000 to 2018, the years of available CCHS data. 

The proportion of former smokers is particularly high for those over 65, in part because of the early death of smokers.  Those in the numerator live longer than those in the denominator!  (The median age of dying of a tobacco-related disease is in the early 70s.)

... which means an aging population will have more successful quitters

The increased proportion of smokers who have quit may be the result of the natural aging of Canada's population. Canada's population is aging: the median age of Canadians grew from 36.8 to 40.8 between 2000 and 2018. The proportion of Canadians participating in the CCHS who were 45 years or older grew from two-fifths in 2000 (42%) to one-half in 2018 (51%).   


When talking about smoking, we frequently divide Canadians into three groups: those who smoke on a daily or occasional basis ('current smokers'), those who used smoke but who don't any more ('former smokers') and those who have never smoked ('never smokers'). The CCHS is such a large survey (around 100,000 respondents) that it allows for more distinctions to be made: 

  • Current smokers includes:
    • Daily smokers - people who smoke on a daily basis.
    • Occasional smokers - people who report that they smoke, but not every day. 
  • Former smokers:
    • Former daily smokers are those who no longer smoke but who used to smoke every day.
    • Former occasional smokers are those who used to smoke (but not daily) and who no longer do. 
    • Sometimes, this term has been used to include those non-smokers who have never smoked daily and who smoked very little (from 1 to 100 cigarettes in their life).
  • Experimenters is the term now used to describe those who have smoked one cigarette in their life, but have never smoked more than 100 cigarettes and who do not smoke now.
  • Never smokers (or abstainers) are those who have never smoked one whole cigarette.

Download the data!

Excel files for the tables presented above:
Previously released Excel tables:

Tuesday 6 October 2020

Active and passive smoking increase the risk of breast cancer: Women need to be warned

In 2009, a Canadian expert panel concluded that the relationship between breast cancer and active and passive smoking was "consistent with causality."  Since then the evidence that smoking and passive smoking cause breast cancer has grown stronger.

Breast cancer death and disease from tobacco smoke

In Europe in 2017 3,354 breast cancer deaths could have been avoided if women had not smoked nor been exposed to passive smoking, according to May, 2020 report that tallied these death tolls for all 28 countries of the European Union.

The toll breast cancer disease (but not deaths) takes related to smoking and passive smoking has been estimated for Canada for the year 2015.  In that year, active  smoking was responsible for 1,129 cases of breast cancer and passive smoking for 311 cases.  These two risk factors accounted for 4.6% and 1.3%, respectively, of all breast cancer cases in Canada.

Recent solid science underlies these estimates

In 2015, a respected group of researchers in Lyon, France combined the results of 86 studies on breast cancer and tobacco smoke to demonstrate that active smoking was related to a 9% increase in risk for breast cancer and that passive smoking resulted in a 20% increase in risk.   Information from the Lyon study was then used to produce the estimates of breast cancer death and disease in the European Union and Canada.

The Lyon researchers concluded:

As time passes, the evidence accumulates for considering that active tobacco smoking is associated with a modest, but real increase in the risk of breast cancer. The consistency of findings, the low heterogeneity of results of prospective studies, the dose–response found in prospective studies, the permanent higher risk since the first studies done on the topic, and the absence of influence of major confounders on associations are all indicating that the relationship would be causal. For passive smoking also, the evidence for a modest but real association with breast cancer strengthens with the accumulation of data. In this respect, public health policies should inform women about the risk of breast cancer associated with both active and passive smoking.

Implications for industrial practice and government policy

Two studies that estimated population attributable risk for breast cancer due to active and passive smoking used  different estimates of relative risk and different consequences of breast cancer as their endpoints.  No matter how you slice it, however, both investigative teams agree that breast cancer disease and death are in some measure (2.6% - 5.9%) attributable to active and passive smoking. 

A recent court decision in Quebec has clearly established that tobacco manufacturers have a duty to warn of dangers from using their product and that, according to Quebec law, they cannot omit telling consumers important facts.  That 2 to 6 percent of breast cancer is attributable to active and passive smoking would qualify as an important fact that tobacco companies omit telling consumers.

As shown below (with more illustrations at the end of this post, some governments already require warnings about breast cancer on cigarette packages. Canada is not yet among them.

Over the decades, Health Canada has gradually broadened the scope of health impacts that are communicated through health warning labels on tobacco packaging. Given the evidence reviewed here, one might expect breast cancer to be included in a future revision of regulated health warning labels.

Whatever governments might do or not do about this issue does not negate the tobacco industry's duty to warn.  This is made explicit in Section 16 of the Tobacco and Vaping Products Act

For greater certainty, this Part does not affect any obligation of a manufacturer or retailer at law or under an Act of Parliament or of the legislature of a province to warn consumers of the health hazards and health effects arising from the use of tobacco products or vaping products and from their emissions.
Tobacco companies should be warning women about the risks of breast cancer from active and passive smoking and they should be doing it now.

(photos courtesy of Rob Cunningham)

Wednesday 30 September 2020

The economic rewards for driving smoking rates down to 5% by 2035.

The federal government has set the goal of reducing smoking rates in Canada to less than 5% by 2035. But are we on track to getting there? And are there economic benefits to governments and citizens if we do?

This summer, the Quebec Coalition for Tobacco Control and Physicians for a Smoke-Free Canada commissioned Dr. Hans Krueger to answer these questions. Dr. Krueger is a Canadian health economist who specializes in measuring the economic impact of health behaviours.

Dr. Krueger focused his efforts on Canada's two largest provinces, Ontario and Quebec. He found that if current trends continue, neither province would reduce smoking to 5% by 2035. Smoking rates are set to be twice as high -- 12.9% in Quebec and 11.5% in Ontario in 2035. 

Should these provinces achieve a 5% prevalence rate by accelerating the current rate of decline there would be significant economic benefits. Dr. Krueger estimates that doing so would save Quebecers $22.2 billion and would save Ontarians $26.1 billion.

Current trends in smoking predict high future health care costs

Dr. Krueger used the Canadian Community Health Survey to analyze trends in smoking rates and intensity of smoking between 2000 and 2018. From these, he projected the current trends until 2035.  As an alternative scenario, he estimated how many smokers there would be if these provinces were on track to reduce smoking to 5% by 2035. He calculated that reaching this national target would result in 990,000 fewer smokers in Ontario and 641,000 in Quebec. 

Fewer smokers would reduce both the direct costs of treating smoking-caused disease and the indirect costs that result from earlier deaths and disability. Dr. Krueger calculated how much lower these costs would be each year if the '5% Trend' were in place, and how much the savings would add up to by 2035, factoring in inflation. The combined benefit was close to $50 billion, of which one-third would be in the health care costs mostly covered by provincial healthcare programs.

By providing a forecast of future costs, Dr. Krueger's study complements recent reports on the economic burden of smoking, such as that released this year by the Canadian Centre on Substance Use and Addiction and the University of Victoria.  It supports conclusions of other researchers that current measures are not sufficient to reach the 5% target

Dr. Krueger's report "The Economic Benefits of Reducing the Prevalence of Tobacco Smoking in Quebec and Ontario" is available here.