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)