Do telephone interviews undercount smokers?

Earlier this month, Statistics Canada released the most recent results from its long-standing and impressive Canadian Community Health Survey (CCHS). The results were very encouraging for those who work to reduce tobacco use -- smoking rates had declined to 13% -  the lowest rate in our lifetime. Earlier in the year, another Statistics Canada survey (the Canadian Tobacco and Nicotine Survey, CTNS) had estimated that smoking rates had fallen even further -- to 10%. 

This is not a trivial difference in measurement of this major health issue: one study finds more than a half million more smokers than another. Nor is it the first time that the CCHS provided higher estimates than other surveys conducted for Health Canada. 

For two decades there has been a gap of about 2 to 4 percentage points between the 'official' estimates produced by government surveys and used as indicators to track and assess programming and policy.

This post investigates whether different technologies used by these surveys contribute to the differences in these estimates, and also whether recent changes to CCHS methods may contribute to some of the decline.

Statistics Canada has reduced the number of in-person visits to collect information about the health of Canadians. 

Data for the smoking surveys sponsored by Health Canada, including the Canadian Tobacco Use Monitoring Survey (CTUMS), the Canadian Tobacco, Alcohol and Drugs Survey (CTADS) and the Canadian Tobacco and Nicotine Survey CTNS) are collected through telephone interviews conducted from Statistics Canada's call centre based in Ottawa. 

This call centre is also used to conduct the majority of the interviews for the Canadian Community Health Survey. This survey also has a parallel data collection process conducted by Statistics Canada's field interviewers, who are based across the country. These interviewers are trained to make personal contact with the dwelling that has been randomly selected and to conduct the interview in person (often at a at respondent's home). If that is not possible, they then attempt to make contact by telephone. 

During the revamping of the CCHS in 2015, the number of interviews conducted by regional staff was reduced, from about 50% to 30%. During the same period, the share of these interviews that were conducted in person also fell - from about three-quarters in 2007-2008 to less than two-thirds a decade later. Statistics Canada recently reported that all in-person interviews were terminated after March 2020 and no information is yet available for 2019.

The diminishing share of person interviews to CCHS results for 2005 to 2017-2018 is  shown below. 

More people will say they smoke when they are speaking in person to a surveyor

Compared with telephone interviews, in person discussions appear more likely to result in Canadians identifying themselves as smokers. 

In 2017 and 2018, for example, across all ages and both sexes those who were asked "At the present time, do you smoke cigarettes every day, occasionally or not at all?" were more likely to say they smoked if the interviewer could see them than if they were being interviewed on the telephone.

The difference was substantial: in 2017-2018 smoking prevalence estimates resulting from face-to-face discussions for men and women were about 50% higher (27% vs 18% for men and 19% vs 12% for women).

This survey mode effect appears to have grown over time

The gap between smoking rates estimated by in person interviews and telephone interviews has appeared in all of the CCHS waves over the past 15 years, but appears to have grown in recent years. 

In 2005, there was a 1 percentage point gap between the estimate of smoking prevalence produced by 47,500 in person interviews and those produced by 84,800 phone interviews (22.4% vs 21.4%). A decade later , in 2015-2016, the difference had grown to 9 percentage points (25% estimated 19,600 in person interviews vs. 16.1% estimated by 90,000 telephone interviews). 

Notably, the number of interviews conducted in person for CCHS (19,600 in 2017-2018) is greater than the number of interviews conducted for the CTNS (8,614 in 2019) or CTADS (16,349 in 2017). 

The impact of survey mode on smoking prevalence estimates has been identified before.

Early in the development of the CCHS, Statistics Canada tested for differences in responses received from their regional surveyors (CAPI) and those received by their call centres (CATI). They did not look specifically at the 60% of CAPI interviews that were conducted in person, but nonetheless found large and statistically significant different estimates of smoking prevalence of people in their 20s  (38% vs. 28%). They also found more Canadians self-reported other health conditions to regional staff, including obesity, drunk driving, and visiting a doctor.

Similar differences have been noted by American researchers, where estimates of smoking prevalence resulting from in person surveys were 3 percentage points higher than telephone surveys, and where it was found that some people are less likely to admit that smoking is permitted in their home when they are being interviewed face-to-face.

However, other studies have validated that self-reported smoking prevalence from CCHS is consistent with blood cotinine levels collected as part of the  Canadian Health Measures Survey (CHMS). This study was conducted with data collected in 2012-2013.

Statistics Canada has put other disclaimers on the 2020 CCHS results.

The diminished contribution of in-person interviews is only one reason why the 2020 estimates for smoking prevalence may be downwardly biased.

Last week, when releasing the 2020 results, Statistics Canada also signalled concerns to readers about  a higher non-response rate and a shortened collection period. "Users are advised to use the CCHS 2020 data with caution, especially when creating estimates for small sub-populations or when comparing to other CCHS years."

In particular, they noted that population groups which generally have higher smoking rates were under-represented in this survey period: "respondents interviewed during the pandemic (September to December 2020) appear to have slightly higher educational attainment and they were slightly more likely to own their place of residence compared to previous cycles." 

Implications for public health:

* Canadians should be cautious in interpreting the 2020 CCHS results for smoking behaviour as an indication that smoking has declined significantly during the COVID crisis.

* A review of the impact of survey modes on estimates of smoking behaviour is warranted.

A data sheet with CCHS estimates of smoking behaviour produced by telephone and in person interviews between 2005 and 2017-2018 is downloadable here. 

What they did in their summer vacation

It's that time of year again. The days are growing shorter, and parents are scurrying to find school outfits for children who have suddenly grown taller. Soon, teachers will be assigning their charges with the ritual essay "how I spent my summer vacation", and using the results to build their lesson plans for the coming year.

This post reviews actions of the tobacco industry over the summer months  -- and points the way to issues that health regulators may want to turn their attention to.

Yet more nicotine products on the horizon

1) Canadian-made PODA pods

A new entry in the "what nicotine product will they think of next" category is being promoted to investors this week. Vancouver-based Poda Lifestyles has developed a heat-not-burn nicotine device that replaces tobacco with synthetic nicotine and tea leaf pellets. They tell investors that this product is "outside the scope of existing tobacco regulations and duties". The team which is guiding this initiative includes alumni from Philip Morris and JUUL.

It would appear that Heat-not-burn nicotine-tea devices may fall outside Canada's federal tobacco laws? Because they are not made of tobacco and if don't produce an aerosol, they are likely not captured by the current definitions in the Tobacco and Vaping Products Act.

2) TJP and Canadian-made nicotine pouches

An Ontario factory is planning to manufacture 36 million nicotine pouches per month starting early next year. TJP announced last month that it had recruited investments to permit production out of Pickering, a short distance from Toronto. This privately-held company began as the maker of "The Juice Punk" e-liquids.

Nicotine pouches are not currently legal for sale in Canada, as they fall under the Food and Drugs Act and thus require authorization. Last year Health Canada issued an advisory that they were "unauthorized" and demanded that some be pulled from the market.

In recent years they have become energetically marketed in other countries as a harm-reduction product.

Big Tobacco drifts towards Big Pharma

Philip Morris International is the owner of Rothmans, Benson and Hedges, a company which sells about  4 in 10 of the cigarettes legally sold in Canada. Both the international company and its Canadian operation have ramped up their efforts to "transform" their operations to sell an enhanced range of nicotine and non-nicotine products, redeem their reputations and regain influence over public policy. 

This summer PMI made headlines as it attempts to acquire Vectura, a manufacturer of inhaled delivery systems for asthma and chronic lung disease medications manufactured by other pharmaceutical firms. Its ownership by a tobacco company has raised concern and alarm among U.KI. health charities. 

PMI has recently acquired other pharmaceutical companies, including OtiTopic (which makes medications for heart disease) and Fertin (which makes gums and other oral delivery systems, including NRT and cannabis). 

PMI now has a foothold in 2 Canadian pharmaceutical operations. It will soon own 100% of Fertin's Canadian operation, Nordiccan (which currently markets cannabinoid pouches in Canada) and 40% ownership of Medicago (which controversially received federal funding to work on a COVID vaccine).

Philip Morris International tries steer Endgame thinking

In July, the new CEO of Philip Morris International (Jacek Olczak) made headlines by calling on the U.K. government to ban cigarettes within the next 10 years. The United Kingdom is currently developing a new (post-Brexit) tobacco plan. In 2019, the government called on the industry "to make smoked tobacco obsolete", but few established tobacco control leaders in that country are calling for legal controls to make that happen. 

Rothmans, Benson and Hedges gets citizen volunteers to clean up its commercial waste

Cigarette filters are a single-use plastic that is one of the most frequent forms of litter and a source of pollutants, which is why there is increasing pressure for regulations that impose producer responsibility on the industry. In an apparent effort to head regulations off at the pass, Philip Morris' Canadian operation is trying to gain a leading position in the Canadian response to cigarette waste. 

This summer it ramped up these efforts on two fronts. 

1. Through a partnership with Terracycle, Rothmans, Benson and Hedges is funding community groups to sign up to collect cigarette butts (either through sweep-up operations or public ashtrays) and remit them in return for gifts or cash. Each pound of waste is worth $1. This summer a "sweepstake" contest offered incentives to newly recruited locations and individuals.

2. This summer, RBH offered grants of up to $5,000 to non-profit organizations to support litter cleanup projects (the activities were not restricted to tobacco waste). Eligible expenses were restricted to organizing, hosting and promoting -- groups would receive money for the equipment required to conduct the cleanup, but were expected to provide volunteer labour. This summer $75,000 in grants were provided: the predominant  recipients seem to be ATV clubs.  

More grants were offered at the end of the summer for projects in education, environment and community development. (Notwithstanding the FCTC recommendations that government "denormalize and, to the extent possible, regulate activities" like these, the Canadian government has remained silent on this RBH initiative).

Japan Tobacco has withdrawn its e-cigarettes from Canada

This spring JTI notified consumers that it would be pulling out of the Canadian market in August, and did so by mid-month. Despite Canada being one of the world's six largest vaping markets, two major tobacco companies have decided to abandon efforts to market their e-cigarettes here. Imperial Brands pulled its myBlu e-cigarettes in July 2020, citing Canada's packaging and labelling requirements. JTI did not acknowledge whether the regulations to cap nicotine were a factor in its decision to quit Canada, although it remains active in other markets where nicotine levels are similarly controlled.   

Imperial Tobacco Canada is looking to expand into non-nicotine products

In late spring, Imperial Tobacco Canada (which is owned by British American Tobacco) launched a new strategy for its operations in Canada. Their press release highlighted their recent acquisitions in cannabis production and their intention to extend their marketing beyond tobacco and nicotine ("For our consumers, we want to offer a range of enjoyable and responsibly marketed products in tobacco, nicotine and beyond.")

Some vaping liquid manufacturers have found a work-around Canada's 20 mg/ml nicotine cap.

On July 23rd, new federal regulations banned the sale of vaping liquids that contained more than 20 mg/ml of nicotine. The very next day, one of Canada's older vaping producers (Theravape) informed consumers that the new ISO methods required by Health Canada meant that products that were previously sold as 34 mg/ml could now be considered 20 mg/ml. They were able to lower the amount by consideringly the nicotine molecules in a nicotine-salt compound.

Theravape's clients were reassured: "A new 20mg/mL salt nic ejuice will now be as strong as an old 36mg/mL."

Health Canada adopted the ISO standard that results in this down-grading after being encouraged to do so by vaping manufacturers. The World Health Organization has also recognized the ISO standard. 

 

 Rothmans revamps its retailer contracts

Tobacco companies give rebates to retailers in return for promotional concessions. This summer, RBH revamped its retail contracts to offer rebates of $4.50, $5.50 or $6.50 on each carton of cigarettes. To get the lowest rebate, retailers must participate in on-line 'training' sessions that inform them how to promote brands, gather data for the company and accept minimum shipments of some products. Higher discounts are given to retailers which sell IQOS, and higher yet to those who are trained to encourage smokes to use IQOS. 

Someone is investing heavily to mobilize against flavour bans

Most major tobacco control reforms have been met with well-organized opposition efforts that are framed as citizen's movements. For decades, tobacco companies created the "Smokers' Freedom Society", PUBCO and restaurant associations, the Alliance for Sponsorship Freedom, and other organizations as a seemingly human shield against public health regulations. 

The is summer Rights4Vapers has all the hallmarks of an industry-funded ersatz-grassroots effort. With a large RV with a specialty skin, a handful of campaigners are working their way through a 26 day tour of Ontario and Quebec to mobilize opposition to regulations on vaping products. 

The printed placards, t-shirts, and the social-media presence suggest a well-funded and professionally organized effort. The only thing missing so far has been a crowd to mobilize. 

Their kick-off rally in Ottawa, billed as drawing 500 to 600 protesters, was attended by about 100 people, many of whom appeared to be vaping store owners who were thanked at the end of the small demonstration for coming to Ottawa from across Ontario to participate. 

JUUL recruits medical journal to publish a volume of pro-vaping studies

In early summer, the American Journal of Health Behaviour published a supplemental volume with 11 studies funded or authored by JUUL which promote the health benefits of their products. It was later revealed that JUUL had paid the journal US$51,000 for the publication. The publication prompted criticism from researchers, public health bodies and politicians. 

New trademarks show how flavour descriptors are used as branding

Each of the companies has filed trademarks in Canada this summer which point to potential new  marketing activities.

Only weeks after Health Canada published a proposal to restrict flavours other than tobacco, mint, menthol and combinations of those three flavours, BAT's e-cigarette branch trademarked new mint brand descriptors for its VUSE e-cigarettes: River Mint and Forest Mint. It also registered a brand name for cannabis-vaping liquids (CBD Mix) and for a new specialty store Vusionry  BAT also registered a new design for its NRT, ZONNIC, which is manufactured by BAT-owned Niconovum and currently marketed in the United States.  

 

This summer, Philip Morris International filed almost two-dozen trademarks for vaping products and heated tobacco products with unusual and evocative names: Yugen, Noor, Apricity, Terea Turquose, Tidal Pearl, and others.