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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