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.

Sunday 27 September 2020

Smoking and Income: Insights from the Canadian Community Health Survey

Earlier this summer, Statistics Canada released data files for the 2017-2018 Canadian Community Health Survey. This post is one of an occasional series which reviews this data for information on smoking patterns in Canada. Today's post is the first to look at the relationship between income and smoking behaviour. 

Inequities in income and smoking behaviour continue

In recent decades the relationship between economic disadvantage and smoking has been well established. A clear demonstration of this is in the smoking rates of each household income quintile (one-fifth of households). Those in the poorest households are 1.8 times as likely to smoke as those in the wealthiest: only 12% of Canadians in the highest group say they smoke cigarettes compared with 22% in the poorest.

The CCHS has reported on income quintiles since 2005. Although smoking rates have fallen in all household income groups over this period, the differences among them have not. In 2005, there was an 8 percentage point difference in smoking rates between lowest and highest income quintiles (27% vs 19%), while in 2017-2018, the gap was 9 percentage points (21% vs. 12%).  

Those in Canada's poorest one-fifth of families are 70% more likely to smoke than are those in Canada's one-fifth richest (RR=1.7).

This is is not because poorer Canadians are more likely to experiment with or become smokers. Canadians in all income levels are generally equally likely to have never smoked (this is less true for younger Canadians). Smokers in higher-income households, however, are more likely to quit than are those in poorer homes. For every 100 Canadians who have ever smoked more than 100 cigarettes, 70 in the highest income quintile will have quit, while only 57 in the lowest quintile will have done so.

Most smokers live in households with incomes over $60,000.

Although smoking rates are higher among poorer Canadians, it is not true that most smokers are poor. 

Statistics Canada provides information on household income brackets in increments of $20,000, with the highest category being "$80,000 or more". More than half (55%) of Canadian smokers live in families with household income over $60,000.

Families dealing with food insecurity are also affected by nicotine addiction. However, most smokers are not facing food insecurity. 

One signal that families are in economic distress is when they experience difficulties in obtaining enough food. The CCHS indicates when families have some difficulties accessing food ('marginal'), when they sometimes compromise quality or quantity of food consumed ('moderate') and when they have not had enough to eat regularly ('severe').

Slightly more than 1 in 10 Canadians (13%) live in families experiencing food insecurity, while more than 1 in 5 smokers (22%) do.

Canadians who are food secure smoke at half to one-third the rate of those who are facing moderate or severe food insecurity (14% vs 28% and 41%). Of the 2.5 million Canadians who live with moderate or severe food insecurity, one-third are  are smokers. 

Canadians living on social assistance are much more likely to smoke. However, the large majority of smokers are in the workforce.

In 2017-2018, the CCHS identified that the main source of income for three-quarters of survey participants (76%), were wages and earnings; that 15% relied on retirement benefits and that fewer than one in five (3%) were dependent on social assistance payments like employment insurance, welfare or workers compensation. Smoking rates in that last category were more than double those of the general population (38% vs 16%). Almost one in ten (8%) of smokers are in receipt of social assistance. 

About the CCHS

The Canadian Community Health Survey is an annual survey conducted by Statistics Canada. Every two years, the Public Use Micro File is made available with information based on surveys of the health behaviours and status of about 100,000 Canadians over the age of 12.

Links to data referred to in this post:

Wednesday 16 September 2020

Vaping stores launch another constitutional challenge to provincial regulations

This week the CBC reported that earlier this month the Nova Scotia government has been served with a notice from local vaping merchants that they are asking that province's courts to strike down certain vaping regulations. The argument they will present to the court is that sections of the Tobacco Access Act violate the human rights of vapers.

This lawsuit was no surprise. Since late winter, GOFUNDME campaigns had been underway to raise money for this endeavour. The first campaign raised $38,000, and the second raised $107,000

Nor is this the first constitutional challenge to provincial restrictions on vaping products. 

In the spring of 2016, the Quebec government faced similar challenges from the Quebec Vaping Association (L'association Québécoise des vapoteries) and the Canadian Vaping Association. Those groups claimed that sections of the Quebec Tobacco Control Act, which had been adopted in November 2015, were in conflict with rights protected under the Quebec and Canadian Charters of Rights.

And it may not be the last! British Columbia's strict regulations, some of which come into force this week, have also been accused of being contrary to Canada's Charter. 

This post presents a brief overview of these legal claims, and of the court decisions to date.


The regulations

In 2020, Nova Scotia put in place three major changes to its vaping controls:

Cloud Factory
Dartmouth Location

The legal challenge

Notice of the legal challenge to these measures was filed on September 8, 2020 by Halifax lawyer Michael Scott of Patterson Law on behalf of the Cloud Factory Vape Shop and its part-owner Edward MacEachern. This store does not appear to be a large commercial undertaking, with a small number of outlets located in strip malls in Dartmouth and Fall River, Nova Scotia.  

This document advises the government that the court will be asked to:

  • strike down those sections of the Tobacco Access Act which ban the sale of flavoured e-cigaretets (s. 3(e), 3(ba) and 7)
  • strike down those sections of the Smoke-Free Places Act which ban using vaping products in retail stores (s. 5(a)(j)).
  • strike down those sections of the Revenue Act which impose a tax on vaping liquids (s. 46C-E)
The vape store owner claims that these restrictions run against his right, outlined in section. 7 of Canada's Charter of Rights and Freedoms, to "life, liberty and security of the person."  (The application did not claim that limits on nicotine concentration were unconstitutional.)

Although the details are sketchy (there are only 14 substantive paragraphs in the legal document), some of the arguments that will be made in support of this claim are outlined. These include the claim that bans on flavours  "unreasonably deprive adults of an important part of their smoking cessation method (flavoured vaping liquid)," that the ban on trying vaping products in stores does not protect youth but arbitrarily infringes the rights of adult vapers, and that the tax on vaping products infringes on rights "held by those who legitimately rely on vaping as part of their smoking cessation strategy." 

This will be a two-step legal process. In the first hearing (identified in the documents as being on November 30th), they will be asking for an immediate injunction striking down those sections of the law until their case can be fully heard. For the main trial, which they they could be ready for within a year, they have identified  4 categories of expert witness, and estimate that a 5-day hearing will be required.


The regulations

Quebec substantially amended its Tobacco Control Act in November 2015 to bring electronic cigarettes and vaping products under many of the same restrictions that were applied to combustible and other tobacco products. As exceptions to the rules for tobacco, these revisions allowed e-cigarettes to be displayed in specialty stores (but not sampled), and allowed e-cigarettes to be sold in flavours. 

The legal challenge

In March and April 2016, both the Association Québécoise des vapoteries  and the Canadian Vaping Association filed separate legal challenges to some of these new measures. These two cases were combined, and an 11-day hearing took place in December 2018. 

The main issues considered by the court were:

  • Does Quebec have a right to legislate in this area when the federal government has adopted different measures?
  • Do restrictions on advertising vaping products infringe the right to security of the person and right to expression provided for in the Canadian and Quebec Charter of Rights and Freedoms?
  • Do prohibitions on trying vaping products in specialty stores infringe the right to security of the person provided for in the Canadian and Quebec Charters?

In May 2019, Justice Dumais of the Quebec Superior Court issued a ruling (2019qccs1644) in which he decided that:
  • The federal Tobacco and Vaping Products Act does not preclude Quebec from passing its own  restrictions in vaping marketing, and the two laws are not incompatible with each other. 
  • Most aspects of the Quebec law do not infringe Charter rights to the security of the person.
  • The restriction on allowing people to try the product in stores did limit the rights of vapers to security of the person and there was no justification for this infringement. (Justice Dumais struck down  s. 2(1) and 2(12) of the Tobacco Control Act)
  • Those provisions of the Quebec law which prohibited advertising vaping products to smokers as a cessation device were also an infringement of expression rights under the Charters, and the infringement was not justified. (He struck down s. 24(4, 8, 9 and paragraph 3 of the Tobacco Control Act and s 6.4(2) of regulations under that act). 
The Quebec government filed an appeal of that ruling in June, 2019, claiming that the judge had made 'palpable and overriding errors'. Among these errors were the judge's view that vaping products were sold as cessation products for smokers only and that they were not also consumer goods targeting the broader population. The appeal also considers that the judge erred in the way he minimized the health risks associated with vaping.

A hearing date for this appeal has apparently not yet been scheduled. The Canadian Cancer Society has been granted intervenor status in the appeal.  

The Quebec government has not modified its law in response to the ruling, nor has it materially strengthened its restrictions on vaping marketing as other provinces have done. Last November, it commissioned a group of experts to provide advice on measures to address vaping, but their report (which was due in April) has not yet been made public. The 5-year review of the Quebec law is due to be submitted to the legislature in November 2020.

Will there be more?

Other provinces have recently introduced restrictions on vaping marketing. This week, for example, British Columbia's restrictions on nicotine levels, packaging and flavours also came into effect. Prince Edward Island has banned flavours in vaping products, effective March 1, 2021. 

These measures may be the subject of additional lawsuits --- or there may be some already filed that have not been made public. Governments are under no obligation to disclose whether their health regulations are being challenged.

Notably absent from the Nova Scotia and Quebec challenges are the multinational tobacco companies, which have historically spearheaded constitutional challenges to health regulations, and which generally sell through convenience stores, not specialty vape shops.