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.

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 naïve 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."

Take-away

• 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.

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:

• Provincial Smoking Behaviour 2000 to 2019: CCHS (6 indicators)
• Provincial Smoking Behaviour 2000 to 2017-2018: CCHS (4 indicators) - age and sex 
• Quitting history 2000 to 2017-2018

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.