Wednesday 29 December 2021

Year-end Quiz: Tobacco Control in 2021

Before 2021 fades completely, here is a quiz to test your knowledge of tobacco control events over the past 12 months. The answers can be found at the bottom of this post. No peeking!

1. In 2021, one of Canada's major pension funds announced that it would divest its tobacco shares. Which one was it?

2. In 2021, which two provinces banned all flavours in vaping liquids other than tobacco flavour?  

3. In 2021, Health Canada reported that over the past year it had inspected more than 300 Instagram accounts managed by vaping manufacturers or retailers. How many were found NOT to be following the law?  (Bonus points -- for what percentage of infractions were charges laid?)

4. In 2021, in which province did smokers face a $10 per carton increase in tobacco taxes?

5. In 2021, which vaping product made by a multinational tobacco company was removed from the Canadian market (and which one was introduced)?

6. In 2021, tobacco companies' insolvency protection entered its third year, and the companies were authorized to continue "business as usual" while they tried to reach a settlement with the provinces to resolve the lawsuits against them. Which province stated that its objective was to end "business as usual" for tobacco companies in Canada?

7. In 2021, the Quebec Court of Appeal ruled on a constitutional challenge to that province's Tobacco Control Act filed by the Canadian and Quebec Vaping Associations. On how many issues did the Court side with the vape store owners?

8. In 2021, Statistics Canada released the second cycle of the Canadian Tobacco and Nicotine Survey. Among Canadians who reported using a vaping device over the past month, what proportion said they were former smokers?

9. For the fiscal year ending March 31, 2021 - and to the nearest $ billion, how much revenues did Canadian governments report they had received in tobacco taxes? 

10. In December 2021, New Zealand announced its strategy to achieve Smokefree Aotearoa by 2025. Which of the following were not included in its strategy:

a) Ensuring Indigenous leadership and decision-making across all levels of the action plan. 
b) Increasing stop smoking services
c) Lowering the amount of nicotine in tobacco products
d) Examine how best to restrict filters
e) Forbidding tobacco sales or supply to people born 2007.
f) Suing tobacco companies

11. Match the slogan to the company

A) Philip Morris International
B) British American Tobacco
C) Altia

1. "Moving beyond smoking"
2. "A better tomorrow"
3. "Delivering a Smoke-Free Future"

12. In 2021, Canadian tobacco companies filed financial reports with the Ontario court as part of their efforts to maintain insolvency protection while they negotiate a settlement with provincial governments and other Canadians who are suing them. From these reports, what proportion of their expenses are related to purchasing tobacco leaf (to the nearest 10%)?

13: What is their profit margin (retained earnings as a percentage of total revenues, excluding tobacco taxes) to the nearest 10%?    

14. The Canadian Student Tobacco Alcohol and Drug Survey (CSTADS) measured tobacco and e-cigarette use among high school students in 2008-2009, 2010-2011, 2012-2013, 2014-2015, 2016-2017 and 2018-2019. In 2018-19, 19% of students in grades 7 to 12 (approximately 402,000 young Canadians) had ever tried smoking a cigarette, and 34% had ever tried an e-cigarette. What change was seen in these behaviours in the 2020-2021 cycle of the biennial survey?

15. In answer to Health Canada's 2021 Canadian Cannabis Survey, which of the following substances did the fewest Canadians think were associated with moderate or great risk to the user?

A. Drinking alcohol on a regular basis
B. Smoking tobacco on a regular basis
C. Using an e-cigarette with nicotine on a regular basis
D. Smoking cannabis on a regular basis
E. Vaporizing cannabis on a regular basis
F. Eating cannabis on a regular basis.

16. Which of the following Canadian-based companies and products were in development in 2021

A. PODA. A heated-nicotine product that saturates tea pellets with synthetic nicotine (and is therefore not subject to current federal laws).
B. TAAT.  A nicotine-free hemp cigarette that is engineered to mimic a tobacco cigarette (but without the nicotine).
C. TPJ. The former "Punk Juice" company is expanding to make 36 million non-tobacco nicotine pouches per month. 
D. DITCH. A programmable e-cigarette designed to wean smokers off nicotine.  

17. Which Canadian legislature set new precedents by adopting a law to ban smoking in all publicly-funded rental housing as well as banning price-promotions aimed at tobacco retailers? 

18. What tobacco-related commitments were included in the platforms of federal political parties during the election for Canada's 44th Parliament?

19. During the 2021 federal election, which vaping organization registered with Elections Canada as a third party, and who was their financial agent?

20. As of December 11, 21 months have passed since the World Health Organization declared COVID-19 to be a pandemic. How long is it since the WHO identified smoking as a pandemic?

21. In 2021, did COVID surpass tobacco as the leading cause of preventable death in Canada? 

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Answers

1. Quebec's Caisse de dépot announced in January that it had signed the Tobacco-Free Finance Pledge . The "Caisse" was established by the Quebec government to manage several public and parapublic pension plans in Quebec, including the Quebec Pension Plan. Other large public pension funds in Canada which do not invest in tobacco include Ontario's Teachers Pension Plan, OMERS, and Alberta's AIMCo.  The Canadian Pension Plan Investment Board has not adopted this responsible investment policy.

2. These flavour restrictions came into force in Prince Edward Island in March, and in New Brunswick in September. 

3. Health Canada found non-compliance on 53% of the accounts.  No charges were laid, although warning letters were sent. 

4. Cigarette taxes went up by $10 per carton in British Columbia: $4 as a result of federal tax increases and $6 following a provincial tax increase. Tobacco taxes are now highest in B.C., although sales tax differences make the total price higher in some Atlantic provinces. 

5. In August 2021, Japan Tobacco International withdrew its Logic Compact device from the Canadian Market. In September 2021, Philip Morris International began selling VEEV vaping products in Ontario.

6. In 2021, none of the provinces made any public comments about the lawsuits. To date, none has identified any non-monetary objectives.

7. Zero. The Appeal Court upheld the Quebec law in its entirety. 

8. One-third (33%). Of the estimated 1.46 million Canadians who had used a vaping device in the past month, 485,100 were former smokers, 438,500 were never smokers and 532,400 were current smokers (smoked cigarettes in the past month). 

9. $7.53 billion. Of that amount, $4.46 billion was received by provincial governments, $54 million by territorial governments and $3.1 billion by the federal government. 

10. The only measure not included in New Zealand's plan is suing tobacco companies.

11. Their recently-trademarked slogans reflect their transformation goals: PMI is "delivering a Smoke-Free Future", BAT has "A Better Tomorrow", Altria is "Moving beyond smoking."

12: Two of the companies provided information on how much they spent on tobacco - 4% and 2% of their operating costs respectively.

13: The profit margin exceeded 50%. During the period reported, the annual combined net (after tax) cash retained by the companies is about $1.7 billion dollars. This is about one-half of the $3.3 billion they collectively received through sales and other activities (after excise, sales and income taxes are discounted). 

14. The formerly biennial CSTADS survey did not take place in 2020-2021. The contract for the next cycle was not signed until December 2020, with work commissioned for the 2021-2022 school year. 

15. F. The 2021 Canadian Cannabis Survey found that the percentage of Canadians who thought people have moderate or great risk of harming themselves with regular use was as follows:

A. Drinking alcohol on a regular basis - 75%
B. Smoking tobacco on a regular basis - 95%
C. Using an e-cigarette with nicotine on a regular basis - 89%
D. Smoking cannabis on a regular basis - 74%
E. Vaporizing cannabis on a regular basis - 75%
F. Eating cannabis on a regular basis - 63%

16. They all are. 

17. Nunavut adopted a new Tobacco and Smoking Act in spring 2021. The law has not yet come into force.

18. The platform commitments were as follows:

19. Rights4Vapers registered with Elections Canada as an official third party, and the chairman of the Vaping Industry Trade Association was listed as their financial agent. 

20. More than 35 years. In its 1986 resolution (WHA39.14), the World Health Organization called for action on the "pandemic of smoking and other forms of tobacco use, which results in the loss of the lives of at least one million human beings every year and in illness and suffering for many more."

21. No. Between January 1, 2021 and December 25, 2021 there were 14,400 confirmed COVID deaths. (Other estimates of excess deaths from COVID in 2021 are not yet available, although they are for 2020). Annual deaths from smoking in Canada are currently estimated at 51,700.


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Thursday 16 December 2021

Tobacco tax revenues are (almost) keeping pace with inflation, despite declining sales

This week the federal government released the Public Accounts for the fiscal year ending March 31, 2021. Contained within them was information on the amount of excise tax and duties collected by Revenue Canada that related to tobacco (and other goods). 

This post reports on these revenues and those of the other 13 Canadian jurisdictions that assess taxes on tobacco products. Further information is available on the following fact sheets:

Adjusted for inflation, combined tobacco tax revenues are the lowest they have been in 20 years. 

In fiscal 2020-2021, federal and provincial-territorial governments collected $7.528 billion in specific taxes levied on cigarettes, cigars, manufactured tobacco and other tobacco categories. This is down from the highest amount reported 5 years ago ($8.43 billion in 2016-2017).

Once inflation is taken into consideration, the collective revenues from tobacco taxes of Canadian governments have remained relatively stable over the past 20 years.


Tax increases have (mostly) overcome the impact of falling cigarette sales. 

Over the past 20 years, the number of cigarettes legally sold in Canada has fallen, and the decline has been more rapid in recent years. 

Nominally, taxes collected in 2019-2020 were slightly more than they had been in 2003 ($7.6 billion vs. $7.1 billion), even though the number of cigarettes sold had fallen by about one-third (from 36 billion to 23 billion). Once inflation is taken into consideration, the value of the tax revenues had fallen by about one-fifth.



Tobacco taxes represent a small fraction of government revenues

In Canada, tobacco tax revenues generally account for about 1% of government revenues. This proportion has been stable in recent years. In the low-tax provinces of Quebec and Ontario, the contribution to government revenues is under 1%, and in no jurisdiction is it greater than 2%. 



The amount of taxes provided by an "average" smoker has grown slightly

An estimate of the average amount of tobacco taxes paid by Canadian smokers can be calculated by dividing tobacco tax revenues by the number of smokers in each jurisdiction. Differences between provinces will reflect variances in the tax rates between provinces and also in the proportion of the market which is untaxed (eg. contraband). 

By this method, smokers in the Atlantic provinces currently pay the most in provincial taxes - more than $1,800 per year in Nova Scotia and Newfoundland. Smokers in Quebec pay less than half that amount ($733 per year). On average, across the country a smoker payd about $5.00 per day in tobacco taxes to provincial and federal governments, or $1,800 per year.

Although per-smoker revenues have grown over the past two decades, the growth in value is only marginally larger than the inflationary increase. In 2003 the average  annual revenue per smoker across the country was $1,257. Although it had grown to $1,800 by 2020, the value of that revenue was only marginally higher ($1,346 if stated in equivalent 2003 dollars).

Note: Statistics Canada cautions that data from the Canadian Community Health Survey for 2020 should be used with caution because of methodological changes imposed by the pandemic. These methodological issues may contribute to the apparent sharp increase in 2020 in some provinces.  







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Monday 6 December 2021

Will flavour restrictions cause vapers to turn to cigarettes? A look at the evidence.

'Thousands of Canadians will start smoking again.' The threat of increasing smoking rates has emerged as a key argument used in campaigns to defeat Health Canada' proposed restrictions on the flavouring ingredients that will be permitted in vaping liquids. This message has been pushed in advocacy advertisements in the Hill Times, in demonstrations before Parliament, in regulatory submissions, and in other public communication.


Is there evidence to support  or refute this claim? Will many vapers who have stopped using cigarettes return to tobacco if they can only access menthol and tobacco-flavoured liquids? 

There are very few published studies that help predict how vapers will respond to a ban on flavours. Many studies (including consumer research in Canada) have looked at the role of flavours in inducing trial and in maintaining use, but few have yet been published that look at how vapers responded when flavours were taken off the market. More than a year has passed since vaping e-liquid flavour bans came into effect in four New England states, and a summary of research on the experience in those jurisdictions is discussed below.

With little available research on the observed effects of such a regulation, governments are offered consumer research on the potential effects. This blog looks at two newly-published independent studies prepared by research teams which have to date been supportive of e-cigarettes. In both studies the researchers concluded that their studies did not support a prediction that vapers would revert to smoking if flavours were banned. Other relevant research conclusions and recorded experiences with state and provincial flavour bans are also presented. 

1. The ITC research group found a majority of vapers are opposed to flavour restrictions but only a few of those who are not already smoking say they would return to tobacco.

The ITC Consortium surveys smokers and vapers on at least an annual basis. In February last year, they surveyed their panel of smokers and former smokers in the United Kingdom, the United States and Canada and asked those who vaped non-tobacco flavours what they would do if a ban on flavours other than tobacco and menthol came into effect. 

The question was relevant to only a very small fraction of the smokers and vapers in the Canadian ITC panel. Of the 3,688 Canadians on the Canadian ITC panel who are already using nicotine, 250 were included because they were never-smoking regular vapers who were not using menthol or tobacco flavours. Of these 250 Canadians, only one-fifth (21.5%) were not already smoking at the time of the survey, giving a small sample size of Canadians around 55 people.

More exclusive vapers would stop vaping than would start smoking
Country-specific results were not provided, but for the 3 countries only 10.1% of this smaller group said they would move from vaping to smoking if flavours were banned. A larger number of those who do not smoke (14.5%) said they would give up vaping.

Among dual users, 1 in twenty would stop smoking and vaping, 3 in 10 would give up vaping
Of those who were currently using both tobacco and vaping products, one-third said they would stop vaping if flavours were restricted, including 5.4% who said they would give up both smoking and vaping.

Annotated Figure 4 from Gravely et al, 2021


The 19 authors of this study did not predict that a ban on vaping flavours would result in net public health harm. They concluded: "At this time, it is not clear what net population-level consequences would occur if non-tobacco flavored NVPs were prohibited. While a majority of vapers in this study opposed this policy, and many vapers would not be willing to switch to available flavors, there was considerable variability in predicted behavioral responses."

This research team did not map their results onto the Canadian market.  This can be done if 5 assumptions are accepted: 

1) that this cohort represented Canadians at large, 
2) that vapers' actual actions will reflect their stated intentions, 
3) that the Canadian Tobacco and Nicotine Survey gives an accurate representation of vaping and smoking patterns, 
4) that dual use is more harmful than only smoking and only vaping, and 
5) that vaping is less harmful than smoking. 

If these assumptions hold, a ban on flavours other than mint-menthol and tobacco would result in 16,000 more Canadians exposed to the harms of tobacco and 159,000 fewer exposed to the harms of vaping. 
  • 17,900 fewer smokers (5.4% of 337,500 dual users whose usual flavour is not tobacco, mint-menthol or flavourless and who will stop smoking and vaping)
  • 34,400 additional smokers (10.1% of 337,00 former smokers whose usual flavour is not tobacco, mint-menthol or flavourless and who will stop vaping and start smoking instead.
  • 92,100 fewer dual users (27.5% of 331,500 dual users whose usual flavour is not tobacco, mint-menthol or flavourless and who will stop vaping)
  • 49,000 fewer vapers (14.5% of 337,00 former smokers whose usual flavour is not tobacco, mint-menthol or flavourless and who will stop vaping and not re-start smoking)
These results are in addition to any impact on the one-third of Canadian vapers who have never smoked cigarettes, and whose opinions were not included in the ITC survey.

2. An experiment with U.K. smokers found that those who were moved to a flavourless e-cigarette were no more likely to want to smoke cigarettes than those who used flavoured liquids.

Researchers at the Universities of Bristol and Cardiff and the U.K. government agency Public Health England recruited daily smokers who were not thinking about or trying to quit smoking. Smokers were randomly assigned to using an e-cigarette with a fruit flavour or using one with no flavour at all, and asked to refrain from smoking for a period of one week (which 85% were able to do). 

The researchers found no differences in cravings or ability to remain abstinent for one week. "Contrary to our hypothesis ... We did  not find evidence to indicate an effect of e-liquid flavouring on smoking lapse occurrence (during the study week), enjoyment of the e-cigarette, ease of transitioning from smoking to using an e-cigarette, intentions to continue using an e-cigarette, intentions to quit smoking, motivation to quit smoking (after study week) and return to smoking and continuation of e-cigarette use (1 week follow up).These findings suggest that, during an initial switch from smoking to using e-cigarettes, there may be little impact of using unflavoured e-liquids on cigarette craving if fruit/sweet-flavoured e-liquids are restricted."

They did find that those who were assigned to flavoured liquids used their products almost twice as long during the week (101 vs. 55 minutes).

3. California vape-shop customers who did not use tobacco-flavours were not more likely to say they would switch to combustible cigarettes if other flavours were banned. 

Researchers at the University of Southern California looked at differences in response to flavour bans by level of e-cigarette dependence, flavour preference, and perception of harm. They recruited 276 participants for their survey at vape shops. While their main focus was impact on purchasing vaping liquids, they also analyzed whether vapers said they would return to e-cigarettes. They found that "flavour preference was not related to intention to switch to combustible tobacco products in the case of a flavour ban (p=0.71, results not shown), suggesting that flavour bans could deter users with flavour preference from using combustible products."

Generally, they concluded that a flavour-ban would provide public health benefit: "Customers who preferred flavours were less likely to intend to continue vaping in the case of a flavour ban, suggesting that flavour bans could reduce vaping among experimental tobacco users, without preventing highly nicotine-dependent users from switching from cigarettes to e-cigarettes for harm reduction."


4. Even without flavour restrictions, a large portion of Canadian former smokers who vape  relapse to smoking.

As reported here earlier, this fall Health Canada released the third of a series of reports prepared by Environics which follow a group of Canadian vapers every 12 months. After one year, Environics found that 26% of former smokers had returned to cigarettes at the end of the first year. In the next wave of the survey, almost a third of those who had remained non-smokers for the first year had relapsed to smoking (6% of 20%).


The study also found that tobacco flavour is increasingly preferred by this cohort over time - with almost half of vapers who used to smoke identifying this as their preferred flavour . "Compared to previous waves of the study, preference for tobacco flavoured vaping liquids has increased, overtaking fruit flavours as the most common choice among Regular Vapers. Tobacco flavour preference is especially high among former smokers who still vape (46%), suggesting that many of these users have replaced smoking with vaping products to give an experience that more closely resembles smoking."


Other recent research has identified that long-time former smokers who take up vaping are twice as likely to relapse to smoking as former smokers who do not vape.

 
5. Jurisdictions which have banned vaping flavours have not seen a significant increase in cigarette sales.

Only a small number of  jurisdictions have implemented bans on e-cigarette flavours. In North America these include Massachusetts (November 2019), New York (May 2020), Rhode Island (March 2020), New Jersey (April 2020), Nova Scotia (April 2020), and New Brunswick (September 2021). 


To date there have been no reports of large increases to cigarette sales following these bans. Because the few jurisdictions that introduced flavour bans did so immediately prior or during the COVID-19 pandemic, conclusions about the impact of the ban on tobacco sales need to consider this additional important event. Another complexity for analysis is the likelihood that sub-national flavour bans have little real effect on vapers because they continue to be able to purchase products from out-of-province/state online retailers.
Data provided by Health Canada, 2021


6. Other studies produce mixed results

A few other research findings are helpful to understanding the potential response to a flavour ban. 
  • Several years ago, John Buckell and his Yale University colleagues conducted a discrete choice experiment with American smokers and vapers, asking them to respond to removal of flavours in cigarettes and e-cigarettes. With these options, participants reacted to proposals to ban flavours in e-cigarettes, but allow menthol in cigarettes, by saying they would turn to cigarettes. To proposals to remove menthol from cigarettes, but allow flavours in vaping products, they said they would turn to vaping products. To proposals to only allow tobacco-flavoured in both, their response was mixed: on average, there would be a drop-off of 1 in 20 users, with 8% fewer coming from those who vaped counter-balanced by 3% who would smoke. None of these conditions reflect Health Canada's proposals to allow menthol in e-cigarettes, but to continue the long-standing ban on menthol in cigarettes.

  • Researchers in Washington D.C. used results from a longitudinal survey of young adults (aged 18 to 34) in selected U.S. urban centres. Unlike the ITC study reported above, this survey included people who used nicotine and those who did not. Like the ITC study reported above, this survey asked participants about their support for flavour restrictions and vapers were asked how they would respond if flavour bans were put in place. Overall, support for a flavour ban was neutral, with e-cigarette users opposing and non-users supporting. Like the ITC study, some vaper participants reported that they would quit entirely, some reported that they would use cigarettes. 

    The researchers reported that their findings had mixed implications: "Current findings regarding young adults’ perceptions of sales restrictions on flavored vape products and on all vape products indicate that such policies may not only have a positive impact (ie, reduced e-cigarette use prevalence) but also underscore the potential for no impact (ie, continued e-cigarette use) or negative impact (ie, switch to cigarettes or dual use). Those most likely to perceive positive outcomes of such policies being implemented were less frequent users, never smokers, and those with greater e-cigarette-related health concerns. Moreover, nonusers reported mixed support for such policies, with e-cigarette users indicating low levels of support. This research is timely given the movement toward implementing e-cigarette sales restrictions and can inform future tobacco control initiatives."

Article at: Heather Posner, MPH, Katelyn F Romm, PhD, Lisa Henriksen, PhD, Debra Bernat, PhD, Carla J Berg, PhD, MBA, Reactions to Sales Restrictions on Flavored Vape Products or All Vape Products Among Young Adults in the United States, Nicotine & Tobacco Research, 2021, ntab154,

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Sunday 28 November 2021

Targetting high prevalence populations.

Last week Canada's new Ministers of Health and Mental Health, the Hon. Jean-Yves Duclos and the Hon. Carolyn Bennett, issued a joint statement on tobacco.  

In this statement the Ministers introduced a two new elements to the federal plan: the intention to follow a "people-centred approach" and an adjustment to priority populations to include  "those suffering with mood or anxiety disorders, as well as people living in poverty." 

This post looks at the higher -prevalence populations identified by Health Canada in recent years and how reducing smoking in these groups will contribute to achieving lower overall smoking.


New priority populations 

Health Canada's focus on higher-smoking populations continues to evolve. When Canada's Tobacco Strategy was announced in May 2018) the communities of concern identified were Indigenous peoples, LGBTQ+ persons, young adult males and workers in certain industries. Later departmental communications dropped workers from the group and listed only "LGBTQ+, young adults and Indigenous Peoples". Last week the Ministers statement made no reference to young adults, when adding mental health and poverty to the list of priority concerns.

It is possible to estimate number of Canadians who are included in this new focus using data from Statistics Canada's Canadian Community Health Survey, for which the most recently-available public file is for 2017-2018. One of the limitations to this survey is that it does not include people who live on Reserves or aboriginal settlements, where about one-half of Indigenous Canadians reside.) 

The data discussed below is presented on a downloadable data sheet. 

A wide target

Most Canadian smokers (81%) would be included in one of the groups identified by Health Canada since 2018. 

  • 2021 Target:
    Those in any of the following circumstances: Indigenous populations, LGBTQ populations, those suffering with mood or anxiety disorders, as well as people living in poverty
    41% of the population, 53% of smokers are affected by one or more of these conditions.
  • 2018 Target (1):
    Those in any of the following circumstances: Indigenous peoples, LGBTQ+ persons, young adult males and workers in certain industries
    33% of the population, 47% of smokers are affected by one or more of these conditions.
  • 2018 Target (2):
    Those in any of the following circumstances: Indigenous peoples, LGBTQ+ persons, young adult males
    13% of the population, 22% of smokers are affected by one or more of these conditions

  • All of the groups identified as priorities since 2018:
    Those in any of the following circumstances: Indigenous peoples, LGBTQ+ persons, young adult males, workers in certain industries, people living in poverty, those suffering with mood or anxiety disorders.
    66% of the population, 81% of smokers are affected by one or more of these conditions. 

The prevalence gaps and the benefits of closing them  

All of the sub-populations identified as targets by Health Canada since 2018 have considerably higher rates of tobacco use than do their counterparts -- Indigenous Canadians are twice as likely to be smokers as non-Indigenous Canadians, and those with mental health issues are similarly at double the risk. 

The difference between the smoking rates can be characterized as the "prevalence gap". The prevalence gap between those living in the poorest 30% and upper 70% of household incomes is 6 percentage points (20% vs 14%), that between Indigenous Canadians living off reserve and non-Indigenous Canadians is 17 percentage points (32% vs 15%) and the gap between those who are affected by any of the six conditions identified by Health Canada and those who are not is 12 percentage points (21% vs 9%).


These gaps are especially important to population-health outcomes when the affected population is large. One quarter of Canadian smokers identify as having an anxiety or mood disorder, compared with less than one-tenth for those who identify as Indigenous or not heterosexual. Among the six conditions identified by Health Canada the largest number of smokers are found among blue-collar workers and those living in relative poverty. 


Differences in population size mean that interventions targeted at some populations will have a larger or smaller impact on the overall health of Canadians than will others. Among the groups identified by Health Canada since 2018, for example, closing the prevalence gap for those in the poorest 30% of households or for those who work in blue-collar jobs would have the largest impact on overall smoking rates. If the gap were closed for all groups, overall smoking prevalence would fall by 41%. In 2017-18 that would have brought Canadian smoking prevalence down to 9.4%. 



More on smoking and health inequaliaties in Canada

The circumstances associated with higher smoking prevalence by Health Canada are a partial list of other factors that are associated with large smoking prevalence gaps. A previous review  found large disparities associated with alcohol abuse and cannabis use, tenancy, education, marital status and home ownership.  In some cases, the health inequalities ran in a different direction than typical health inequalities: Canadians who were immigrants or visible minorities are less likely to smoke.

Figure from:
Mind the Gap: Disparities in Cigarette Smoking in Canada 

Closing the prevalence gaps

The published literature on effective population-level interventions to close prevalence gaps is not large, and these have been mostly confined to the gap associated with socioeconomic disparities. The most recent published review of studies concluded that "Price increases and targeted population-level cessation support are the only interventions where there is consistent evidence of a greater effect among low-SES smokers."


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Sunday 14 November 2021

Doctors' group calls on new Health Ministers to revamp Canada's Tobacco Control Strategy

In advance of the beginning of Canada's 44th parliament, Physicians for a Smoke-Free Canada (PSC) has written the new Minister and Associate Minister of Health to recommend priority actions to reduce tobacco use. The letter can be read here.

The health charity urges the ministers to address two key weaknesses in the federal approach to tobacco control: a) the commercialization of tobacco harm reduction and b) the absence of a plan to phase out the supply and demand for tobacco and nicotine.

PSC's president, Dr. Atul Kapur noted that tobacco industry products continue to be responsible for more deaths in Canada than any other preventable risk. "Because previous ministers of health decided to delay putting adequate regulatory controls on the tobacco industry, more than 50,000 Canadians died from tobacco use this year -- greatly more than deaths from COVID-19 and opioids combined."

Dr. Kapur noted that while past and current efforts to reduce smoking have had good effect, they have failed to prevent the continued epidemic of tobacco in Canada. "Decades after the federal government acknowledged the harms of smoking, there are no laws to forbid tobacco companies from recruiting new users. One-third of Canadians who smoke today -- over 1 million younger adults -- began doing so in this century, after core measures like graphic health warnings, higher taxes and smoke-free places were in effect."

PSC notes that other health agencies and researchers have recently identified deficiencies in Health Canada's tobacco strategy, calling it "incremental, erratic and reactive" and having "no coherent plan to reduce tobacco use ... no milestones, benchmarks or tangible national plans beyond optimistic guidance documents." [1]

In its letter, PSC asks Ministers Duclos and Bennett to engage outside experts, civil society and in the preparation of the review they are obliged by law to provide to Parliament by next spring, and identifies its own priorities for reform. These are:
  1. Preventing future addiction by adopting the policy goal of ending commercial nicotine and tobacco use.
  2. Aligning the supply of tobacco with public health goals by reforming retail distribution, removing commercial incentives for suppliers to recruit new users and requiring manufacturers to meet public health targets, possibly through the use of production caps or other supply controls now used in environmental regulation.
  3. Expanding current demand-reduction measures by fully implementing and scaling up the measures required by the Framework Convention on Tobacco Control, improving the delivery of supports to vulnerable populations,  and developing new and innovative demand-reduction approaches. 
"This government has committed to ending the sale of combustion engines in passenger cars by 2035 - but remarkably has no plan in sight to end the same of combustible cigarettes." PSC's president, Dr. Atul Kapur pointed out. "The 'way'  to end the tobacco pandemic is there - what is needed is the 'will' of ministers of health to make it happen."

Priority measures to reduce addiction and disease caused by commercial tobacco and nicotine products


1. PREVENT FUTURE ADDICTION

Commit to end the harms from commercial tobacco and nicotine.
The federal government should adopt as a policy goal the end of commercial nicotine and tobacco use, [as Finland has done](https://www.finlex.fi/en/laki/kaannokset/2016/en20160549_20161374.pdf). In coordination with other levels of government and civil society, Health Canada should establish a timeframe with specific interim and long-term targets to ensure that new generations are not recruited to commercial tobacco or nicotine use.

2. REFORM TOBACCO SUPPLY

Align the supply of commercial tobacco and nicotine with public health goals.
Currently tobacco and nicotine manufacturers, retailers and other suppliers are motivated and rewarded to maximize economic returns, with many of their business practices guided by economic pressure and corporate law. Key reforms needed are:
  • De-commercialization of harm reduction.
  • Reforming retail distribution and ensuring that tobacco and nicotine products are not sold outside of adult-only specialty stores or by individuals trained and motivated to support cessation.
  • Requiring tobacco companies to contribute to winding down tobacco use and nicotine addiction, for example by obliging them to meet public health targets for production and consumption. Examples of mechanisms that can assist this are found in the federal Climate Action Plan.

3. EXPAND EFFECTIVE EXISTING MEASURES

Maximize the potential for demand-reduction measures
There is an international consensus around a set of demand-side interventions that are embraced by the Framework Convention on Tobacco Control. Canada’s implementation of these measures has not yet optimized their impact. Canada should intensify, scale up or develop innovative approaches to meaures such as the following:
  • End all promotions for consumer (non-therapeutic) tobacco and nicotine products, including  those delivered in bars, through social media or direct-mail, and ban incentive programs and other promotions directed at retailers.
  • Eliminate flavourings in all consumer (non-therapeutic) tobacco and non-tobacco flavourings from nicotine products products,
  • Regulate the market introduction of new tobacco/nicotine products by establishing notification and authorization processes.
  • Raise the legal minimum age to 21 and phase in a smoke-free generation policy.
  • Apply equally stringent regulations to non-therapeutic nicotine products and tobacco.
  • Enhance programming and develop tailored approaches for more vulnerable communities.
  • Increase tobacco prices substantially through tax increases and price regulation (preferably standardized pricing).
  • Accelerate regulation-making and remove structural barriers to timely policy-implementation for tobacco control.
  • Provide international leadership (including financial support for global efforts).
  • Apply the polluter-pay principle, recovering the cost of related Canadian public health interventions from the tobacco and nicotine industries

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Monday 8 November 2021

Guess who's behind Canada's vapers' protest movement?

European journalists recently investigated the relationship between public opposition to e-cigarette regulation and tobacco companies and other corporate interests. Last week their findings were published in the French newspaper of record, Le Monde: VAPING: The real dollars behind fake consumer organisations.

While their focus was mostly on activities in Europe, the report also spotlighted connections between the Canadian Rights4Vapers group and tobacco and other business interests. With additional information from Canadian government agencies it now seems clear that this group is far from independent of the vested interests of tobacco companies.

Follow the money .... 

The investigative team set out to trace the backers for activities organized by the World Vaping Association (including a bus touring across Europe to rallying opposition to e-cigarette regulations) and for other pro-vaping actions - such as those described here a few weeks ago.  

They demonstrated that these activities were executed with the participation of anti-regulatory think tanks like the Consumer Choice Centre, Students for Liberty and the Taxpayers Protection Alliance. And they dug up the financial connection between tobacco companies and the libertarian Koch funders to these think tanks and non-profits. (The figure below is from the Le Monde article).

This media report elaborated on the connections between tobacco companies and the Atlast network of pro-business think tanks that had been documented previously by a research team at Simon Fraser University,

The Canadian operations  ....

The Le Monde investigation noted the parallels with the Canadian pro-vaping rallies of this summer managed by Rights4Vapers.


L-R: Maria Papiannoy, Christina Xydous, Yolanda Watson
Although Rights4Vapers does not pro-actively disclose their budget or source of revenue, it is clear that they have money to spend. This summer (with their Quebec wing, la Coalition des droits des vapoteurs du Québec), they brought a publicity tour through southern Ontario and Quebec. The campaign costs would have been substantial, in addition to travel costs and campaign material, they worked with PR handlers for some events, engaged a videographer and wrapped their campaign bus. 

Rights4Vapers activities are directed by vaping store owners. Those who conducted the protest tour may have volunteered their efforts, but they were not consumer volunteers. The three leaders, shown in their twitter post, are vape store owners and staff (Maria Papiannoy of EcigFlavourium; Christina Xydous of La Vapote and Yolanda Watson of 705 E-liquids). 

The Rights4Vapers Team has additional connections to vaping, tobacco and foreign business interests. As shown in the figure below, the leadership identified on Rights4Vapers website includes several links to tobacco industry funded and associated agencies, including representatives of two foreign lobby bodies.

* Dr. Gopal Bhatnagar founded the 180Smokes chain (with more than 30 vape stores).
* Ian Irvine, as described earlier, has completed contracts funded by Philip Morris International. 
* Michael Landl heads the Consumer Choice Center-associated World Vapers Alliance
* David Williams is the head of the U.S.-based Taxpayers Protection Alliance, which is lpart of the Atlas network of tobacco-friendly advocacy groups.

The financial agent for Rights4Vapers is the head of the Vaping Industry Trade Association. Protesting federal regulations during an election period required Rights4Vapers to register with Elections Canada as a third party. In doing so, they revealed that their financial agent was Michael Meathrel, owner of Dvine laboratories and chairman of the Vaping Industry Trade Association.  

The Vaping Industry Trade Association (VITA) represents the interests of multinational tobacco-nicotine companies as well as domestic vaping producers. When it was established in 2019, three of the four founding directors lead the government-public relations operations of the multinational tobacco and nicotine companies. (Two of these companies have since left the organization, one citing policy differences.)


Déja vu all over again

Rights4Vapers is not the first  attempt by corporations to try to influence Canadian health policy by setting up and funding smokers' rights organizations and other fake grass-roots ('astroturf') groups. 

There was the 'Alliance for Sponsorship Freedom" and "Coalition 51" (opposing advertising restrictions), the Smokers' Freedom Society (challenging science on health impact), "My Choice" and the "Fair Air Association" (fighting restrictions on smoking in public place), and "The National Coalition Against Contraband Tobacco" (fighting against regulation and taxes). Usually evidence that these events were established and directed by tobacco companies was only made solid long after the policy-decisions had been made. (Five years ago a BAT document was leaked which showed how they manipulated retailers and municipalities to fuel fears of contraband cigarettes in order to avoid taxes and health regulations.)

The cost of inaction

Rights4Vapers illustrates the weakness of Canada's implementation of Article 5.3 of the Framework Convention on Tobacco Control - the obligation to protect public health policies "from commercial and other vested interests of the tobacco industry."

The Global Center for Good Governance in Tobacco Control recently assessed nations on their efforts to address tobacco industry interference, and this year ranked Canada 28th among 80 countries.

Five years ago, Canadian health groups recommended a number of specific actions to Health Canada to reduce the ability of tobacco companies to reach policy makers through front groups. Despite assurances from then Minister of Health Jane Philpott that Health Canada was looking to develop "domestic policy guidelines on Article 5.3 in collaboration with federal, provincial/territorial and civil society tobacco control partners," no such guidelines were developed. Based on Canada's 2020 report to the FCTC secretariat, this intention has been abandoned.

Greater transparency would allow parliamentarians and other policy makers to distinguish between authentic consumer concerns and industry lobbying. It would allow Elections Canada greater confidence that the prohibitions in Canada's Elections Act on foreign agencies (like the Taxpayers Protection Alliance) participating in third party activities during federal elections, and on foreign funding (like contributions from the Consumer Choice Center) paying for these  election-period activities. It would allow the Commissioner of Lobbying greater confidence that companies are not doing a run-around their obligations to document meetings with policy-makers.


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Tuesday 2 November 2021

Health Canada study following vapers over 2 years found no reduction in tobacco smoking.

Last week the federal government released its most recent consumer research report on Canadian vaping behaviour. The results show that among a group of Canadian vapers, there was no overall decrease in smoking behaviour over the past two-years.

The Vapers Online Survey to Measure Attitudes and Behaviours Regarding Vaping Over Time (2019 to 2021) is a quasi-longitudinal ("return to sample") study conducted by Environics Research. This is the only Canadian government survey to follow the same group of individuals who are using vaping products over time. The baseline report was made available in the fall of 2019 (POR 047-17), with the first and second year results published 12 and 24 months later (POR 098-19, POR 113-20). 

There are a number of limitations to how this survey can guide our understanding of whether or not the legalization of the vaping market is reducing population-level harm or whether it is contributing to it. 
  • Because the study participants are drawn from a panel, the results cannot be interpreted as representative of the whole population. (This is a limitation shared by many other behaviour studies).
  • The survey has a very low response rate (25% last year, and 17% this year). 
  • The behaviour is self-reported, and there is no way of confirming whether respondents are under- or over-reporting their smoking and vaping experiences.
  • The survey only follows the behaviour of selected Canadians who were vaping in 2019 -- it does not look at the behaviour of those who entered the vaping market after early 2019.
  • The results have been analyzed at the aggregate level, and there is no attempt to link individual behaviours over time. No conclusions, for example, are offered on whether those vapers who used certain flavours were more or less likely to quit. 
  • The data is not made available to independent researchers for subsequent analysis
Nonetheless, this is the only (and consequently the best) quasi-longitudinal study of adult vaping in Canada. 

Smoking rates have gone up each year.

The results of this report are in the same direction as those of studies published in the peer-reviewed literature: in real-life situations smokers who use vaping products do not show greater (or any) success in quitting smoking.

Among this group of Canadians, there were more smokers at the end of two years than there were at the beginning.  In 2019, 58% of the vapers were also smoking cigarettes (dual users). By 2021, 62% were either dual users or had stopped vaping and only used tobacco products.

Many of these Canadians changed their vaping or smoking behaviour -- half in the first year and one-third in the second. But there were more who relapsed or took up smoking than there were successful quitters. Over the two year period the number of vapers dropped by one third (33%), but the number of smokers increased (by 4%). 

This lack of progress was not because smokers who vaped did not want to quit. Environics reported that "The vast majority of Dual Users are either planning to quit, or already trying to quit smoking; most of those who plan to quit intend to do so within the next six months."


Among those vapers who had never smoked in 2019, more than one-third had done so by 2021.

Among the 337 panelists who agreed to the follow-up study, about one-quarter (24%) had never smoked a cigarette in 2019, but only about 16% were counted as neither a smoker or former-smoker two years later (Report, Table 44). This implies that one-third (8% of 24%) had moved from vaping to smoking at some point over the 24 months.

In last year's report, with results from almost 1,000 panelists, Environics was able to provide sufficient information on the transitions to allow a Sankey illustration of the transitions change over the first year of the study. The smaller sample this year (337) did not allow for such data release. 


Tobacco flavour is the preference of vapers who used to smoke.

Almost one-half (46%) of former smokers who still vape prefer tobacco flavoured vaping products. Overall, tobacco and fruit flavours are equally preferred. Canadian vapers continue to cite a preference for flavours which are not legal for sale in Canada (candy, dessert, cannabis, energy, etc). 




Vapers want to quit

Two-thirds (66%) of those who are vaping are planning to quit, and one-quarter (26%) are currently trying to do so. Most (74%) are turning to some form of cessation-aid, with NRT, cannabis and stop-smoking medications like Zyban most often identified as the method being used.


And more! 

In addition to the web-based survey of panelists, Environics recruited 46 to share their experience and views on vaping and smoking, using this qualitative data to contextualize and amplify their conclusions. The wide range of experiences and views - including some related to the role of flavours and COVID-19 - are best enjoyed by reading pages 40-45 of the report!

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Monday 1 November 2021

New poll shows support for a course correction to Health Canada’s tobacco strategy

Press Release - November 1, 2021


(Ottawa and Montreal) - A poll conducted for Physicians for a Smoke-Free Canada and the Quebec Tobacco Control Coalition shows key elements of Health Canada’s approach to reducing smoking are out of line with public opinion.

“A few years ago the federal government shifted its focus away from regulating tobacco products and towards a vaping market where smokers were encouraged to switch to vaping products but young people were to be discouraged from both smoking and vaping,” explained Cynthia Callard, executive director of Physicians for a Smoke-Free Canada. “The results from this poll show that Canadians want government to not only roll back the vaping market but to beef up controls on tobacco products.”

The poll was conducted by Leger between September 29th and October 11th, 2021 among a sample of 2,400 Canadians aged 18 and over. Survey participants were asked about their perspectives on tobacco harm reduction policies. They were also asked to choose from a list of tobacco control measures which they thought would be most and least effective at reducing smoking.

When asked their views on harm reduction approaches, the majority of Canadians surveyed (79%) – including a majority of smokers (75%) – did not support Health Canada policies that are aimed at making e-cigarettes attractive to and widely available for smokers.

The strongest support (79%) was for governments to not focus on getting smokers to switch to vaping products, but to focus instead on helping smokers quit smoking and nicotine use altogether. A clear majority (69%) felt that vaping products should not be sold in attractive flavours even if this resulted in smokers only having access to flavourless or tobacco-flavoured products. In fact, close to a third of adult vapers (29%) favours allowing only tobacco and flavourless e-liquids in order to protect youth. Additionally, a small majority of Canadians (55%) would favour vaping products being removed from convenience stores and vape shops and sold only in pharmacies or smoking cessation clinics.

“The consensus is that Canadians want to reduce the presence of products with nicotine, especially to avoid new young users,” concluded Leger.



Survey respondents were also asked to choose the most and least effective policies from a set of five new regulatory approaches to tobacco products. The policies Canadians thought would have the greatest impact were requiring tobacco companies to make cigarettes less addictive by reducing the amount of nicotine in them and banning the sale of tobacco and nicotine products except in specialty shops where young people may not enter. Interestingly, the policy of raising the minimum legal age to buy tobacco to 21 years was overwhelmingly considered to be least effective of the options offered.

“The measures presented in this survey are among those proposed to governments five years ago when the Canadian tobacco control community met to develop an “Endgame” approach to reducing tobacco use in Canada,” explained Flory Doucas, co-director and spokesperson for the Quebec Tobacco Control Coalition.

“Although all of these suggestions were excluded from the 2018 revision to Health Canada’s tobacco strategy, this poll suggests that the public understands that greater controls on the tobacco industry are needed if smoking rates are to fall. These results should motivate governments and the health community to work for a tighter framework governing which tobacco and nicotine products are allowed for sale as well as where they can be sold.”



Last June, Health Canada tabled draft regulations to restrict flavourings in vaping products, while allowing menthol and mint flavours to be sold even though these are very popular flavours with young Canadians. “The results of this poll should prompt federal and provincial health ministries to ensure a comprehensive ban on all flavours other than tobacco, similar to those already in place in Nova Scotia, Prince Edward Island and New Brunswick,” said Ms. Doucas.

Tobacco use remains the leading preventable cause of death in Canada. In 2019, one in five Canadian deaths (18%, or 51,700 deaths) were a result of using tobacco industry products.

Contact:


Cynthia Callard 613 600 5794
Flory Doucas 514 515 6780


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