Saturday 31 December 2022

The New Year and quitting smoking: what the data tell us.

For millenia the New Year has brought with it an expectation of personal improvement, and for many smokers that means trying (often again!) to quit smoking. This post looks at newly-available data from the Canadian Community Health Survey (CCHS) which sheds some light on the quitting behaviour of Canadian smokers. 

(The charts shown below and the data on which they are based can be downloaded here.)

One in seven Canadians who say they recently quit smoking report they did so in January.

Smokers appear more likely to quit in January than any other month. 

When gathering information for the Canadian Community Health Survey, Statistics Canada asks each participant about their smoking status. Those who say they are former smokers are asked how long ago they quit and those who say they have quit in the past year are then asked in which month that quit happened. 

The results of these questions over the past 7 cycles of this survey show a clear pattern: the month with the most reported quits is January (15% of quits). The months with the least reported quitting are the spring months of April to June, in which fewer than half as many successful quits are reported as in January.

Because the survey does not include questions about when non-successful quit attempts took place, it is not clear the  extent to which the cyclical pattern of successful quitting relates to differences in quit attempts, differences in success rates or just the timing of the interview. (Statistics Canada normally conducts the Canadian Community Health Survey throughout the year, with roughly even numbers of Canadians interviewed in each month.) Other information that is not provided in the survey is the month in which smokers start (or relapse): we know little about the seasonal patterns of smoking initiation and relapse behaviour.

The number of Canadians who quit smoking each year is equivalent to the population of Halifax.

Over the past 6 years, Statistics Canada has estimated that an average of 400,000 Canadians are former smokers who quit over the past 12 months.

But the number of Canadians who remain former smokers each year is only one-sixth as large (equivalent to the population of Prince George).

Over the last 6 years, the number of former smokers grew by only 400,000 (7.9 million in 2021, up from 7.5 million in 2023).  The average annual growth in the number of former smokers in that period is about 66,000 Canadians. 

The six-fold discrepancy between the number of new past-year quitters and the increase in the population of former smokers reflects a combination of factors, including  population changes (such as former smokers dying), and also the frequency with which past-year quitters / other former smokers resume smoking.

Quitting rates in Canada appear stable over time, but many fewer Canadian smokers are quitting.

Over the past two decades, the relationship of recent-quitters to remaining smokers has fluctuated from 8% to 11%. 

Half as many Canadians are identified as past-year quits in recent years as previously: from 680,000 in 2003 to 314,500 in 2021). This decline reflects a reduction in the number of smokers available to quit (6 million in 2003 compared with 3.8 million in 2021). 

Relative to the population, there are fewer former smokers now than 20 years ago.

Over the past two decades, the number of  former smokers has grown by 1 million - from 6.9 million in 2003 to 7.9 million in 2021. During the same period, however, the population of Canadians over 12 years of age grew by over 7 million (from 25.8 million to 32.5 million). 

The proportion of Canadians who are former smokers has declined slightly - from 26% in 2003 to 24% in 2021. 

Smoking prevalence is falling mostly because more people are not starting smoking (and not because there are more former smokers).

Statistics Canada estimates that since 2015:
  • The number of current smokers fell by 1.5 million  and the prevalence of current smoking fell from 18% to 12% 
  • The number of former smokers increased by 399,000. The prevalence of former smokers in the population fell from 25% to 24%. 
  • The number of former “experimenters” (non-smoking Canadians who had smoked between 1 and 100 cigarettes) fell by 154,000. The prevalence of “experimenters” fell from 13% to 11%.
  • The number of never-smokers (people who had never smoked one whole cigarette) increased by 3.5 million. The prevalence of never smoking increased from 45% to 52%.

During this period, the number of Canadians aged 12 or over grew by 2 million people. If, in a counterfactual scenario, smoking behaviour had been stable during that period of population growth, there would now be:
  • almost 400,000 more smokers instead of a decline of 1.5 million
  • an increase in never smokers of only 1 million instead of the observed increase of 3.5 million
  • an increase in former smokers of 556,000 instead of the observed increase of only 399,000
  • an increase in experimenters of 288,000 instead of the observed decrease of 154,000.
From this counterfactual scenario we can conclude that the decline in smoking rates in Canada during involved 6 in 100 fewer Canadians smoking. This resulted from the net difference between 8 in 100 more Canadians never smoking and 2 in 100 fewer Canadians who had once smoked a cigarette no longer doing so.

The actual population change is shown in the waterfall graph below.

Are these estimates plausible? Where did the 1.2 million ever-smokers go?

The data outlined above suggest that between 2015 and 2021, the Canadian population lost 1.2 million people who had ever smoked a cigarette (From 16.7 million to 15.5 million). 

The number of deaths in Canada reported by Statistics Canada for the 7 year period 2015 to 2020 and for 2021 total 2 million. A contribution to the population loss of  1.2 million ever smokers would be the high ever smoking rates among the older Canadians who made up most of those deaths. The CCHS reported that in 2017-2018, three-quarters of Canadians then over 60 years of age had smoked at least one cigarette.

Tuesday 6 December 2022

Tidbits from Health Canada's new Smoker and Vaper Panels

Over the last week, two major surveys on smoking and vaping commissioned by Health Canada were disclosed.  Both were conducted by Environics Research and managed under the framework of Government of Canada Public Opinion Research. Reports on these surveys are available from the Library of Canada at the following links:

Both panels were designed to permit "return-to-sample" (RTS) reviews in which the same individuals are asked in future years about changes to their and/or vaping behaviours.  

This is the second such RTS approach for vaping: the results of the panel in place between 2019 and 2021, reported here a year ago, found significant changes in vaping and smoking over the two year period. (Among the participants in this first panel, contrary to the results in the general public, smoking rates went up over the two years). The federal government currently has no longitudinal population surveys which include vaping or smoking behaviour. 

Between them, these two new Environics studies cost over $450,000 and involved the recruitment of 4,815 vapers (Canadians over aged 15 who had vaped at least once a week over the past month) and 7,248 smokers (Canadians over aged 15 who had used cigarettes in the past month). The recruitment was conducted to allow for additional young people and communities of concern (indigenous, visible minority, LGBTQ2+) Over half a million Canadians were invited to take the survey and the participation rate was 14% (vaping) and 13% (smoking). 

Both of the new survey reports (and the additional data on "banner tables") contribute to our collective understanding of the perspectives of individuals who use these products and are therefore worthy of a careful read by the tobacco control community. 

This post identifies some of the unique or surprising findings in these reviews. Environics' summaries from both reports are pasted at the bottom of this post. 

1) Most smokers -- and especially young smokers -- do not find smoking unaffordable.

Smokers were asked "how affordable are the cigarettes you buy?" Only 1 in 5 Canadians said that cigarettes were unaffordable, and one-third reported they were affordable. As expected, smokers who lived in provinces where taxes are higher were more likely to report that cigarettes were unaffordable, as were smokers who had a smaller family income. 

Large differences were seen in the perception of affordability by age. Only 1 in 10 teenage smokers and 1 in 5 young adults found cigarettes were unaffordable - compared with 2 in 5 adults . 

2) One-third of young vapers and former smokers say that throughout the day they vape "continuously" 

There are large differences in the frequency with which vapers report they use their devices. The highest frequency of use is reported by two mostly exclusive groups: teenagers and former smokers.

3) Many young smokers think that the dangers of tobacco are exaggerated.

Two in five teenage smokers agree with the statement "the medical evidence that smoking is harmful is exaggerated".  Among the general smoker population, one in five shares this view, but about half say that the dangers are not exaggerated.

Beliefs among Indigenous smokers are also different than the general population, with more than one-quarter (28%) saying that the dangers are exaggerated, and fewer than one-third (30%) say they are not. A similar pattern was found with other equity groups identified in this survey. 

4) Smokers and vapers report similar patterns of first nicotine dose of the day.

For the most part, similar proportions of smokers and vapers say they use nicotine within 5 minutes of waking (the survey acknowledges that many smokers are vapers, but does not provide information on how soon after waking a cigarette OR a vaping product is used).  Almost half of teenagers who smoke or vape do so within 30 minutes of waking. 

Surprisingly, perhaps, no vapers identified "addiction" as one of the three main reasons they vape (QC2). 

5) Dual users vape to overcome smoking restrictions on average more than 7 times a day.

Over half of the vapers in this panel also use cigarettes (58%), with fewer than 1 in 5 being people who have transitioned from smoking to vaping (former smokers = 18%). One quarter (24%) have never been regular smokers, including the almost 1 in 5 (18%) who have never smoked a whole cigarette.

Dual users smoke an average of 8 cigarettes per day -- almost all of which they identify as using to overcome barriers to smoking. 

6) Vapers who have quit smoking are LESS LIKELY to say they have received advice from vape stores or health professionals.  

Vapers who had previously smoked or who continue to smoke were asked with whom they had spoken about using vaping to quit or reduce cigarette use (results shown below).  Those who had successfully quit smoking were more likely to report they had spoken with no one than were those who continued tdo smoke (37% vs 16%), and were less likely to report they had talked with vape store staff (20% vs 34%) or health care professionals (16% vs 29%). The most commonly reported discussions on vaping to quit were from friends and family. 

A similar question was asked of those on the smoker panel who also vaped. Those results are shown on page 41 of Environic's smoker panel report. 

7) One quarter of those who currently smoke have formerly made a "successful" quit attempt.

Among the Smokers' Panel, one-quarter (25%) had previously quit for more than six months: 18% of smokers had quit for more than one year before relapsing, and 7% had quit for six months to one year. Six months is the benchmark for a successful quit used in many studies on efficacy of stop-smoking approaches, and one-year is often used to define long-term quitter.

8) When dependency is assessed on the same basis for vaping and tobacco, "high dependency" is more often observed for vaping.

Environics used the "Heavy Smoking Index" parameters to assess how many Canadian smokers in their panel had moderate or high dependence on smoking. The index assigns a score based on how many cigaretets were smoked each day and how soon after waking the first cigarette was consumed. These researchers established a Heaviness of Vaping Index, which similarly identified high dependence for those who vaped with nicotine more than 21 times per day and within 5 minutes or waking, or 31 or more vapes a day and vaped within 30 minutes of waking.

Under their parameters, vapers were  more likely to be defined as having high dependence. 

Implications for public health

Health Canada continues to heavily fund and to rely on consumer research studies to inform its approach to tobacco and vaping. As reported  here earlier, these reports are available to the public. 

Nonetheless, this data on the Canadian experience with and use of nicotine products has not been translated into publications in peer-reviewed journals, and it remains on the 'grey literature' shelf. This hinders translating the Canadian experience into more generalizable conclusions, through systematic reviews or other knowledge development activities. A system to translate these reports into scientific publications could increase their value and use. 

A limitation of the "panel" approach is that it is a closed system -- looking only at the behaviour of the individuals initially selected. The first Environics vaping panel, for example, identified how many vapers moved from vaping to dual use or being nicotine-free, but was not structured to include those who moved from smoking to vaping. Half of the vapers included in the second vaping panel started vaping regularly over the past two years -- at least one year after the first panel was struck. 

Even with the new two-panel approach, the behaviour and beliefs of those who return to smoking or vaping (relapse) or who start smoking or vaping (initiation) will not be assessed. If the panel system proves effective, there may be some use in extending it to monitor behaviour changes among former smoker/vapers and never smoker/vapers too.

Monday 28 November 2022

A new global treaty on plastics -- and why it is important for tobacco regulation

Earlier this year, the United Nations Environmental Programme (UNEP) began the process to develop a global treaty on plastics. This week formal negotiations are underway in Punta del Este (Uruguay). This post provides background to this meeting and what it could contribute to reducing tobacco use in Canada.

A framework convention on plastics

The first session of the International Negotiating Committee is focused on laying the ground work for the treaty, using procedures agreed to this past summer. These sessions are being closely observed by industry, NGOs and researchers, whose participation in the event included a structured interaction with delegates which took place this weekend.

Three dozen countries have grouped themselves in the High Ambition Coalition to End Plastic Pollution of which Canada is a founding member. The stated vision of this group of nations is to end plastic pollution by 2040. Among their deliverable goals is the elimination of problematic plastics, including by bans and restrictions. As of thsi date, however, none of these countries includes cigarette filters in their restrictions on single-use plastics.

The treaty that emerges from these negotiations could end the human and environmental damage caused by cigarette filters. Or it might not. The difference may well come down to the extent that the tobacco industry is allowed to influence decision-making at the treaty and the extent to which governments like Canada's work to stop that happening. Notably, Canada has not yet responded to calls to protect this process from tobacco industry interference.

Photo courtesy of

Canada has recently accelerated efforts to reduce plastic pollution ...

Federal efforts to address plastic pollution have accelerated in recent years and in June federal regulations to ban six single use plastics were finalized. By the end of next year, plastic checkout bags, cutlery, foodservice ware, stir sticks and most straws will no longer be permitted for sale in Canada. (The government is also developing recycled content regulations and rules for recycling and composting.)

... but has not yet developed a plan to address plastic waste from tobacco products

Cigarette filters were exempted from Canada's federal bans on single-use plastics, even though the federal government had been advised to include them by Parliamentarians, the Zero Waste Coalition, environmental organizations and the public. In the background statement to the regulations, the government acknowledged that cigarette filters were a problem, that they were among the top 10 most commonly littered items in Canada, and that two-thirds of Canadians polled thought they should be included in a plastics ban. Decisions on cigarettes were postponee: "Currently, cigarette filters are being assessed by the Department to determine whether they are plastic pollutants of concern, and the result of this assessment could be reflected in future Government action."

There are 21 billion reasons for Canada to ban cigarette filters in order to protect the environment...

Most cigarettes are made with acetate (plastic) filters, which are non-biodegradable. The microplastics and tobacco-toxins which leach into the environment from discarded cigarette filters are harmful to plants and aquatic animals.

The United Nations Environment Programme estimates that world-wide, cigarette filters result in 766.6 million kilograms of toxic trash each year. This will include the portion of the 21 billion cigarettes smoked in Canada last year that were tossed away instead of being disposed of safely. Municipal litter audits and shore-line cleanups continue to report cigarette butts are a leading source of discarded waste.

The recent marketing of inexpensive cartridge-based and disposable electronic cigarettes has added to the complexity and burden of tobacco industry waste. (With toxic liquids and lithium batteries, this toxic e-waste is another pressing challenge.).

... and to reduce the harm to individual smokers and to public health

Cigarette filters were introduced by the tobacco industry as a harm-reduction product, and the "less harmful" messaging was heavily promoted. One legacy of these campaigns is that many consumers and regulators wrongly continue to think that filters offer some health benefit.

In fact, as the World Health Organization confirms "despite tobacco industry marketing, there is no evidence that filters have any proven health benefits.”

Instead, filters add to the harms of combustible cigarettes. Because they make cigarettes more attractive and diminish concerns about the health consequences of smoking, filters help the tobacco industry recruit and addict new customers. Because the ventilation holes in them facilitate deep inhalation, they increase the risk of one type of lung cancer (adenocarcinoma).

No country has yet implemented an fully effective strategy to address tobacco and vaping waste...

In recent years Canada and countries in Europe have advanced restrictions on the use of single-use plastics. In addition to prohibiting certain items, these policies also require manufacturers to accept the financial or physical responsibility to dispose of waste (Extended Producer Responsibility, EPR).

A very few countries have imposed specific measures to address cigarette waste. Examples of these include mandatory labelling of cigarettes as acontaining plastic (in all EU countries), requiring cigarette manufacturers to pay for waste management (France), and a municipal levy on retailers to recover abatement costs (San Francisco). France's experience in applying EPR to cigarette waste exposed a vulnerability of this approach, as the industry used its "responsibility" for the solution as a lever to influence public and regulator attitudes to tobacco use.

Other measures to address cigarette waste have been proposed but not yet implemented. These include bans on filters or requirements for biodegradable filters, deposit-return systems and greater deterrence for littering.

Some jurisdictions have taken action to address waste from vaping products. California supports public education efforts and the United States Environmental Protection Agency categorizes them as toxic waste. Caledonia bans disposable e-cigarettes, as other governments are considering doing. The French Senate recently proposed a surtax on disposable e-cigarettes of €6 per ml of liquid.

Tobacco companies use greenwashing to avoid meaningful change

Knowing that a filter ban will cause fewer people to start smoking and will help smokers stop, the tobacco industry will encourage governments to adopt less powerful measures to address plastic filter waste. They want the issue to be seen as the result of consumer behaviour, not product design.

Around the world, tobacco companies are using greenwashing public relations campaigns to achieve this.

In Canada, they provide environmental groups with small amounts of money to mobilize volunteers to clean cigarette butts from beaches and other environmentally sensitive areas. These efforts portray smokers as the villains, clean-up crews as the heroes and the industry on the side of the heroes.

Another industry PR effort for false solutions is the encouragement and support for the installation of public ashtrays, and promoting the unrealistic view that filters can be recycled.

The "Sustainability Report" issued this August by Rothmans, Benson and Hedges (the Canadian subsidiary of Philip Morris International) exposes the cynical use of these campaigns.

  • The company provided a total of $75,000 (one twelve-thousandth of its annual net income of $900,000,000)
  • 600,000 volunteers were engaged in clean up (one for every 7 Canadian smokers).
  • These volunteers collected three-quarters of a million cigarette butts (one for every 27,000 cigarettes sold in Canada, or one for every 9,000 cigarettes manufactured by Rothmans, Benson and Hedges.)
In short, for less than the salary of a sales person, the company was able to engage volunteer work by more than a half million Canadians to clean up its garbage. Even then, only a slight fraction of cigarette waste was recovered.

France's experience in applying EPR to cigarette waste exposed a vulnerability of this approach, as the industry used its "responsibility" for the solution as a lever to influence public and regulator attitudes to tobacco use.

There is an emerging consensus that a ban on cigarette filters is needed.

Although decades have passed since concerns about the health harm of filters were raised, health authorities have generally avoided developing regulations in this area of cigarette design (other than recommending controls on filter ventilation).

Growing concerns about the environmental impact have recently strengthened the call for an end to the use of filters altogether. This year the World Health Organization set the environment as the theme for World No Tobacco Day. In doing so, it called on governments to “treat cigarette filters the same as any other single-use plastic, and consider banning them, to protect public health and the environment."

Banning cigarette filters was a policy recommendation already supported by a number of Canadian organizations and individuals, including Greenpeace Canada, 15,600 Canadian petitioners, Surfrider, the House of Commons Standing Committee on Environment and Sustainable Development and theNational Zero Waste Council.

From a series of interviews with members of the tobacco control community in Canada, it appears that banning cigarette filters is considered the best option -- but that getting this accomplished will require thought and resources.

FCTC Article 5.3 is a key issue for negotiations in the plastics treaty.

An important rule for the negotiation process will be measures to prevent the tobacco industry from influencing governments.

This may involve a shift in thinking for some delegations. Policy development in the environmental sector often involves multi-party consultations, with business and civil society given equal voice. There is no strong equivalent to FCTC Article 5.3, where there is understood to be a "fundamental and irreconcilable" conflict of interest between the commercial interests of tobacco companies and public health.

Tobacco control interests will be represented at the Plastics Treaty negotiations by the Stop Tobacco Pollution Alliance. You can follow the negotiations through a blog posted by one of the founders of this alliance, the US group ASH.ORG.

And you can show your support by joining this group.

More information:

World Health Organization

2022 report "Poisoning our Planet"

Environment and Climate Change Canada

Plastic waste and pollution reduction

NGO positions

Stop Tobacco Pollution Alliance: Key Messages: Tobacco Control in Plastics Policies
Stop Tobacco Pollution Alliance: Plastics Treaty Process and National Policies: A Backgrounder
Stop Tobacco Pollution Alliance: Tobacco in Plastics Policies Tobacco in Plastics Policies
Take Action
Global Center for Good Governance in Tobacco Control, Tobacco's Toxic Plastics: A Global Outlook
ASH Scotland Briefing - E-cigarette waste; Disposables, a new problem

Tuesday 22 November 2022

The updated Cochrane review of e-cigarettes -- and what it should mean for Canada.

Last week, the UK based health charity, Cochrane, released its sixth report on the evidence on the use of e-cigarettes for smoking cessation

This post reflects on how this and other Cochrane conclusions could serve Canadian efforts to reduce smoking at the population and individual levels. In brief:
  • Cochrane establishes that in clinical trials, E-cigarettes fail 10 times more often than they succeed (roughly the same as NRT). Other reviews have shown that in real life they are even less successful.
  • The products used in the studies reviewed by Cochrane are different than those on the market in Canada. The U.S. Surgeon General recommends that because of the wide variation in products and usage it is not prudent to draw generalized conclusions about their efficacy as stop-smoking medications
  • Cochrane reviews show that other stop-smoking medications do better in clinical trials. (The ones that, unlike e-cigarettes, have been assessed and authorized on the basis of their safety, efficacy and quality.)
  • Any advice to a smoker to use e-cigarettes to quit smoking (or to reduce the harms from continued nicotine use) should be tailored to individual circumstances and be individually delivered in a therapeutic context. Population-level encouragements for smokers to use e-cigarettes are imprudent. To date these have back-fired in Canada, resulting in more new nicotine addicts than former smokers. 

Next version, much the same as the first...

The Cochrane review on e-cigarettes that was published last week has the same central messages as the versions published in September 2021, the one published in April 2021, and the one published in October 2020. A major difference with earlier versions is the number of studies they accepted for their analysis: three that compared NRT to e-cigarettes were included in 2020, four in 2021 and six this year.

This study was released with considerable fanfare and extensive public relations efforts. Cochrane publishes several reports on tobacco issues (described at the end of this post) - few seem to get the same PR effort. 

The press releases that accompanied the release of the report were clearly designed to encourage e-cigarette use by smokers. The lead author's statement suggested  that e-cigarettes were a highly effective stop smoking medication: "For the first time, this has given us high-certainty evidence that e-cigarettes are even more effective at helping people to quit smoking than traditional nicotine replacement therapies, like patches or gums."

Another PR effort was a linked and coordinated release sent by other British enthusiasts. Professor John Britton was one endorser, and unequivocally presented e-cigarettes as a panacea for smoking cessation: "All smokers should therefore try vaping as a means to end their dependency on smoking tobacco."   (The release made no mention that Dr. Britton has been engaged by  Canadian commercial vaping interests to oppose flavour restrictions in New Brunswick. )

There are many reasons to disagree with these views.

Cochrane has confirmed that in clinical trials, e-cigarettes are NOT very effective at helping smokers quit.

The reviewers memorably present their conclusions in a plain language summary"For every 100 people using nicotine e‐cigarettes to stop smoking, 9 to 14 might successfully stop, compared with only 6 of 100 people using nicotine‐replacement therapy, 7 of 100 using e‐cigarettes without nicotine, or 4 of 100 people having no support or behavioural support only."

Rather than confirm the superiority of e-cigarettes, these numbers confirm the inadequacy of both vaping products and NRT - even under the best of supervised therapeutic circumstances. 

The Cochrane report on e-cigarettes concluded in effect that 90 of 100 smokers who use e-cigarettes to quit smoking will be smoking again within 6 months, compared with 94 failures for every 100 who use NRT. 

The relative risk for success between E-cigarettes and NRT is 1.63 (10 vs 6 successes per 100 tries). The relative risk for failure between NRT and E-cigarettes is 1.04 (94 vs 90 failures per 100 tries) 

(Simon Chapman provides a good discussion of the high rate of failure in his blog "Would you take a drug that failed with 90% of users? New Cochrane data on vaping “success”)

Cochrane has confirmed that in clinical trials, other stop-smoking medications available in Canada do better than e-cigarettes.

Other Cochrane reviews have assessed the effectiveness of pharmacotherapies for smoking cessation. These include the stop-smoking medications that have been approved by Health Canada following a review of their safety, efficacy and quality. (The safety, efficacy and quality of e-cigarettes is not examined by Health Canada before they are permitted for sale).

Among these medications are prescription medications Varenicline and Bupropion. These drugs do not replace nicotine from tobacco, but instead help the smoker end nicotine addiction by altering the brain's response to it. Varenicline reduces nicotine withdrawal symptoms and diminishes the rewarding effects of cigarettes. Through a different mechanism, Bupropion also decreases nicotine withdrawal symptoms and may diminish the rewarding effects of cigarettes. Other over-the-counter stop-smoking medications authorized for sale  include the natural health product Cytisine and the prescription anti-depressant Nortriptyline.

A 2020 review by Cochrane looked at the effectiveness of some pharmacotherapies, using similar analytic methods to thsoe used in the review on e-cigarettes. This review pharmacotherapies concluded that for every 100 people who tried to quit smoking:

  • 17 to 20 were successful at quitting for at least 6 months if they used Bupropion alone (80 to 83 failed). 
  • 17 to 28 were successful if they used Bupropion and NRT (72 to 83 failed). 
  • 21 were successful if they used Varenicline alone (79 failed). 
  • 20 to 33 were successful if they used Varenicline and Bupropion (67 to 80 failed).

Randomized Clinical Trials are designed for therapeutic medication and are not the right yardstick to assess consumer product use.

In developing its assessment of the effectiveness of e-cigarettes as cessation devices, the Cochrane reviewers considered only clinical trials that used randomized control trials (RCT). This may be the gold standard for assessing medications before granting licensing approval, but it does not reflect the reality of most smokers' quit attempts. 

In RCT's, smokers are engaged and participating in a therapeutic cessation attempt, often using a specified e-cigarette product. In the real world, most try to quit without any external structure or support and use a variety of products. 

This Cochrane review is out of step with other scientific assessments of the usefulness of e-cigarettes as quitting aids.

The Cochrane reviewers are only one of several research groups conducting systematic reviews of e-cigarettes efficacy for smoking cessation. Even among reviews that, like Cochrane, considered only Randomized Control Trials, other scientists have concluded that even on the narrow question of whether e-cigarettes are superior to NRTs, the evidence is not there. 

Reviewers of RCT's on e-cigarettes who came to different conclusions include:

  • An Australian review of RCT's found limited evidence that in the clinical setting freebase nicotine e-cigarettes are efficacious as an aid to smoking, and that they double the likelihood of relapse to resuming smoking, strong evidence that e-cigarettes increase combustible smoking uptake in non-smokers, and insufficient evidence that nicotine e-cigarettes are efficacious outside the clinical setting. (Banks et al, 2022)
  • An Irish review of RCT's found "no clear evidence of a difference of effect" between e-cigarettes and NRT. (Quigley et al. 2021)
  • A review for the US Preventive Services Task Force found "inconsistent" results in RCT's and did not conclude that e-cigarettes were effective as a therapeutic product for smoking cessation. (Patnode et al, 2021)
  • The U.S. Surgeon General found that there was too much variation in the products sold and the way they were used to make generalizations about whether or not they were effective for smoking cessation. (U.S. Surgeon General, 2020).
Reviewers who considered both RCTs and longitudinal or observational studies have found no benefit to quitting with e-cigarettes.
  • Swedish review of RCT's and longitudinal studies found no net benefit to the use of e-cigarettes for quitting smoking was found. (Hedman et al, 2021)
  • American researchers looking at RCT's and observational studies found that although e-cigarettes were found to be effective when used as therapeutic interventions in clinical settings, this was not the case when they were sold as consumer products in the general population. (Wang et al, 2021). 
  • Analysis of American smokers over time found no evidence that higher nicotine e-cigarettes (or lower nicotine cigarettes) improved successful quitting or prevented relapse (Chen et al, 2022)
  • Another study using the same longitudinal study found that dual users were less likely to quit. (Osibogun et al, 2022)
  • * A study conducted by Environics for Health Canada, which followed vapers over a two-year period finding no net reduction in smoking (Environics POR 113-20
Outside of the United Kingdom, very few medical bodies recommend e-cigarettes for smoking cessation. Those which advise doctors to refrain from recommending e-cigarettes to smokers include the College of Family Physicians of Canada and U.S. Preventive Services Task Force.  Leading Canadian smoking cessation  specialists Peter Selby and Laurie Zawertailo published a Clinical Practice review on Tobacco Addiction in the New England Journal of Medicine this summer, concluding that even though nicotine e-cigarettes may be more effective than nicotine-replacement therapy "We would recommend against the use of e-cigarettes for smoking cessation given insufficient evidence to support their use."

This Cochrane review did not address the non-clinical (public health) consequences of e-cigarette use

There are a number of aspects of e-cigarette use that were not included in the Cochrane assessment, and harms which were not accepted as "adverse consequences". These include:

  • the increased health risks incurred by smokers who try e-cigarettes, but continue to smoke (dual users), thereby inhaling the different harmful chemicals in each type of product. 
  • the increased health risks incurred by smokers who successfully quit with e-cigarettes, but who continue to use them. (The Hajek research found that those who successfully quit using NRT are half as likely to continue using nicotine as those who used e-cigarettes).
  • the initiation into nicotine use by young people who are influenced by messaging that encourages e-cigarette use.
  • the role of the tobacco industry in designing and supplying both cigarettes and e-cigarettes, and the commercial pressure that encourages them to market these in ways which maintain sales.
In the full (pay-walled) version of their report, the reviewers acknowledge this limitation of their study: "Reviews of ECs for policymaking are often broader in scope than our review, which focuses exclusively on their role in supporting smoking cessation in people who smoke. Outside of smoking cessation, there remain unanswered questions about the impact of EC availability and use on young people; we will be evaluating this in a separate review."

There is no evidence that encouraging smokers to use e-cigarettes has benefitted health in Canada.

The federal policy decision in 2016 to liberalize the sale of vaping products as consumer goods remains controversial. Four years have passed since this policy became law with the 2018 Tobacco and Vaping Products Act)

The impact of this policy change is reflected in federal surveys, which show that the uptake of these products was largely among young people, and not among adult smokers.

Although smoking rates continue to decline, Federal surveys show that this is chiefly due to the growing population of never smokers, and that the quitting rates in Canada have not increased since e-cigarettes were legalized.

Currently in Canada, two-thirds of e-cigarette users either continue to smoke cigarettes (36%) or have never smoked (33%).

Thursday 17 November 2022

An update on flavoured vaping liquids.

In June 2021 Health Canada said it intended to restrict vaping flavours, and circulated draft regulations which banned sweeteners and flavourings other than tobacco and mint-menthol.  The 75-day consultation period on this proposal ended 14 months ago. 

The absence of signals from the department or Minister about their current intentions were identified in a post last August, as were the activities of vaping industry lobbyists to defeat flavour restrictions in Canada and developments elsewhere. 

Today's post covers provides an update on related events.

1) Industry Actions

In Canada, tobacco and vaping interests continue to gain access to officials and consumers

In the late summer and early fall, Philip Morris' Canadian subsidiary (Rothmans, Benson and Hedges, RBH) was granted meetings with the Prime Minister's office (August 11) and with the chair of the House of Commons Standing Committee on Health (Sept 26). (RBH sells two flavoured vaping systems in Canada.) 

Other multinationals also met with decision-makers. Representatives of JUUL met with the office of the Minister of Mental Health and Addiction, MPS from the New Democratic and Conservative parties and a Senators. (JUUL does not market flavours other than mint and menthol in Canada). 

The possibility of flavour restrictions did not deter BAT-Imperial Tobacco from investing in the disposable vaping market in Canada, as reported here last month.Seven of the 9 flavours would be disallowed under the proposed flavour restrictions.

In November, Rights4Vapers launched its second road tour to "share the facts" about vaping. They characterize flavour bans as  'experimental measures' that are a 'threat to public health'.  Appearances in cities in Quebec and Ontario were scheduled between November 16 and 29.

2) Regulatory Actions

Californians vote for a flavour ban.

During last week's mid-term elections, California voters were also asked to vote on whether flavours shoudl be banned in tobacco products (including e-cigarettes). The 2-to-1 decision was in favour of maintaining the ban that had been adopted by the Legislature 2020. The referendum was the result of an industry-led petitioned to force a plebiscite on the question. Immediately following their referendum loss, RJ Reynolds launched a court challenge to the law, seeking an injunction to delay implementation. (RJ Reynolds is the U.S. branch of British American Tobacco and sells menthol cigarettes and VUSE branded e-cigarettes). 

European Commission bans flavours in heated tobacco. 

On November 3rd, the European Commission published a "delegated directive" which expanded the regional ban on flavourings in tobacco products to include heated tobacco (e.g. IQOS), and to waterpipe tobacco. (Commission Delegated Directive (EU) 2022/2100 of 29 June 2022 amending Directive 2014/40/EU of the European Parliament and of the Council as regards the withdrawal of certain exemptions in respect of heated tobacco products)

The flavouring ban was applied to cigarettes in EU countries in May 2020. The Commission cited the growing use of heated products as a reason for the new regulation. 

Netherlands narrows its list of permitted flavourings to 16. 

Through the EU Technical Regulation Information System (TRIS), this summer the Netherlands circulated a draft Order which set down the 16 flavouring additives it proposed to allow for e-cigarettes.

The comment period for the Netherlands' regulation ended on October 20 - the objections of 22 vaping industry organizations are available as 'contributions' on the EU's TRIS system. 

With 16 authorized chemicals, the Netherlands has the smallest "whitelist" of the three countries that are using the approach of restricting ingredients instead of regulating the "characterizing" flavour that results from the ingredient use. The two other countries are Canada (which proposes to allow more than 80 chemicals), and China, which now allows around 100. There are small differences in how chemicals are categorized between Canada and the Netherlands. 

A comparison of the whitelist of permitted ingredients among China, Canada and the Netherlands can be downloaded here: 

The U.S. FDA finds no public health benefit to menthol flavoured product.

As discussed here earlier nother significant event last week was the announcement by the U.S. Food and Drug Administration that it would not allow the sale of menthol-flavoured Logic vapes. (The Logic device was marketed in Canada, but withdrawn in the summer of 2021 after Canada imposed restrictions on nicotine concentration.)

This was the first decision by the FDA regarding menthol flavourings. Under U.S. law, since September 2020, each product has been separately evaluated before being authorized for sale (although unauthorized products remain widely available). Authorization can only be issued if evidence is provided to the FDA that the product will protect public health - in effect that it will support smoking cessation and will not increase youth use.

Estonia and Latvia identify need for regional cooperation.

Health ministeres in the Baltic are working to cooperate in regulating the vaping market, where restrictions on vaping flavours are a key regulatory concern. Legislation is advancing in Estonia and Latvia. The Latvian legislature is looking at a proposal to ban on all flavours but tobacco. Concerns in Estonia focus on regaining control of a market in which there has been significant illicit sales of flavoured liquids, with a proposed bill that would allow more flavours by only banning sweet and soft-drink flavours. Lithuania has a ban on flavours in place.  

3) Research

Research on the impact of e-liquid flavourings continues to grow. 

This month the journal Tobacco Control published a Supplement edition containing 15 articles on the "Impact of Flavour Restricting Policies on Non-Cigarette Tobacco Products". Among the diverse research findings reported in this supplement are:

* flavour restrictions implemented at the state level are undermined because of non-compliance with regulations, for both youth and adults

* many e-cigarette users are willing to purchase flavoured products from illegal sources. 

* commercial producers adapt to flavour restrictions through social media posts, product design and product modification - and DIY flavours can make e-cigarettes as harmful as commercially flavoured products.     

* the number of chemicals used as flavourants is increasing.

* the FDA restrictions on flavours in pod-style products resulted in "few changes in smoking and vaping behaviours" among adults, although there was significant switching among products used.

* adults using e-cigarettes to quit smoking who lived in jurisdictions where flavors were restricted did not differ in their quitting outcomes than those who did not. 

Monday 7 November 2022

An update on tobacco sales and tax revenues in Canada

This post provides updated information on cigarette sales and tobacco taxes in Canada. Links to Fact sheets with the data reflected in the figures below are provided at the bottom of the post.

1) Total tobacco tax revenues in Canada continue to fall - and more quickly than predicted by tax officials.

Overall, tobacco tax revenues across Canada fell by 6% in 2021-2022 compared with the previous fiscal year.

All of the provinces experienced a decline in tobacco tax revenues, from a provincial total of $4.46 billion in 2020-21 to $3.95 billion in 2021-2022. The drop was greatest in Newfoundland (-21%), New Brunswick (-20%), Alberta (-18%), and Ontario (-16%). It was smallest in British Columbia (-0.4%), Quebec (-5%) and Prince Edward island (-7%).

This was offset by a modest increase in federal tobacco tax revenues (3%), resulting from a $4 per carton tax increase included in the 2021 budget. At that time, Finance Canada predicted that this would increase revenues by $415 million -- but the real increase was just over one-quarter of that prediction.

Almost all (94%) of the federal tobacco tax is collected on manufactured cigarettes, with taxes on cigars and loose tobacco totalling less than $203 million. Provincial governments do not provide detail on revenues from different types of tobacco.

2) Industry revenues from cigarettes continue to climb, even though sales continue to fall.

Tobacco manufacturers are required to report to Health Canada the number cigarettes they sell, and also to report on their wholesale revenues (including federal taxes) from these sales. This data is released by Health Canada in an aggregate form for each calendar year.

From this data a comparison with the revenues to manufacturers and the federal government from cigarette sales during the calendar year can be made. Since 2014, industry revenue has increased by $1.5 billion a year (54%), while federal tax revenues on the same sales have fallen by $190 million (-6%).

3) The average Canadian smoker provided governments with $1,862 in tobacco-specific taxes in 2021

Excise taxes on tobacco products are applied by all provincial and territorial governments, as well as by the federal government. The rate of tax varies across the provinces, as does the practice of applying additional sales taxes to these products.

In 2022, the federal government applied a tax of $29.79 to each carton of cigarettes. Provincial excise taxes ranged from $29.80 per carton (Quebec) to $65.00 (British Columbia and Newfoundland). The Northwest Territories applies the highest tax ($68.80 per carton). Almost two-thirds (64%) of Canada’s smokers live in Quebec and Ontario, where where tobacco taxes are lowest.

In 2021-2022, these taxes resulted in an average of $1,862 in government revenues from tobacco sales to each of Canada’s 3.8 million smokers. The federal government reported $830 in tobacco tax revenue per smoker and provincial governments reported revenues between $627 and $1,862 per smoker. This works out to a total of about $5.10 in tobacco tax per smoker per day.

4) Fifteen cigarettes were reported sold each day for each Canadian smoker in 2021

Across Canada, the number of cigarettes reported sold per smoker ranges from 13 per day in British Columbia to 18 per day in Manitoba and Nova Scotia, with a national average of 15 per day (5,458 per year). If the sale of fine-cut (roll-your-own) is included, the number of cigarettes and hand-rolled cigarettes sold increases by less than 3 cigarettes per smoker per week.

5) Tobacco taxes represent less than 1 cent for every dollar of Canadian tax revenue.

In Canada, tobacco tax revenues generally account for less than 1% of government revenues. The proportion is the lowest in Ontario (0.5%) and highest in Nova Scotia and Newfoundland and Labrador (1.3%).

6) Shifts in reported cigarette sales and tax revenues help assess estimates of contraband and smoking prevalence

Discrepancies between the changes to the number of cigarettes sold and changes to the number of smokers could result from a number of factors, including:

changing patterns of nicotine use (e.g. shifting to or away from e-cigarettes)
variance in the estimates of smoking behaviours
changes in the proportion of the market which is illicit/unreported.
incomplete reporting by manufacturers

Between 2020 and 2021, for example, the change in the number of cigarettes sold and the change in the number of smokers was roughly comparable (-10% and -8%), as shown in the figure below. During the previous year, at the beginning of the COVID pandemic, there was a greater drop in the estimated number of smokers than in reported cigarette sales (-11% vs -3%). This suggests that factors such as the COVID-related changes to survey methods or the decreased availability of contraband may contribute to this discrepancy.

Over the past year there were notable discrepancies in the patterns of cigarette sales and reported smokers in some provinces. In Manitoba, for example, the estimate of the number of smokers fell by a quarter (-28%), while cigarette sales grew by one-tenth (8%). In British Columbia, the number of smokes fell slightly (-3%) in comparison with a large drop in cigarette sales (-12%). (See Fact Sheet for provincial figures).

Downloadable Fact Sheets