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."

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

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.

Rights4Vapers surfaced in the spring of 2019. It identifies as a "vaper consumers rights movement", "an organization of vaping advocates dedicated to the advancement of Canadian-based research on vaping" and "an informal collection of committed volunteers".

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.

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!

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

Link to Leger Report "Endgame Measures and Harm Reduction".
Survey conducted among Canadians.