ICYMI: Tobacco control developments in Canada - Summer 2023

For those distracted by wildfires, day-camp schedules, beach days or other seasonal events, this post provides a summary of notable tobacco-control developments since the summer kick-off on July 1st.

Health Canada

New hands at the helm: A late July cabinet shuffle appointed new cabinet responsibilities for health. Both Mark Holland (Minister of Health) and Ya'ara Saks (Associate Minister of Health/Minister of Mental Health and Addiction) are newcomers to cabinet. Their priorities for the file are still not known: neither has yet made public comments related to tobacco issues, and the mandate letters from the Prime Minister's office are not yet public.

A plan without timelines:  In mid-July, Health Canada published its Forward Regulatory Plan, forecasting 3 regulatory changes: (1) updates to the Tobacco Reporting Regulations; (2) restrictions on flavourings, and (3) rules for age-gating e-sales of tobacco and vaping products. As discussed here earlier, no timeframe is given for either flavour restrictions or age-gating - nor are these identified in this year's departmental workplan.  

A green-light for BAT's pouches: As previously reported, Health Canada authorized British American Tobacco to sell Zonnic-brand nicotine pouches as stop-smoking medications. These products do not yet appear to be on the market, although trademarks are being put in place to support marketing.

Young people unimpressed by vape-to-quit messages: Health Canada paid for on-line focus group tests with young people to assess their reaction to potential advertisements which encouraged smokers to switch to vaping products. (The advertisement is not in use at this time).

The results of this opinion research were released this summer (POR 031-22). The ads got a thumbs down from this group: "Many participants, particularly the older ones, expressed the opinion that the ad communicated that vaping is a preferable alternative to smoking (although not necessarily healthier); a few even thinking that the ad was “promoting” vaping. Many participants expressed their view that they felt this was not a good message to communicate, with a few participants questioning the appropriateness of the Government of Canada logo at the end."

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Provincial actions

Flavour restrictions. On August 2nd, the Quebec government finalized its regulatory prohibition on the sale of vaping liquids which had a taste other than tobacco-flavour. The measure was first proposed in April and will take effect on October 31, 2023.

Of Canada’s 13 provincial and territorial governments, 6 have adopted legislation or regulations to ban the sale of any e-cigarette liquid other than tobacco flavour: Nova Scotia, Prince Edward Island, New Brunswick, Northwest Territories, Nunavut and Quebec. (See updated fact sheets on E-cigarette flavour bans and provincial regulations on vaping products).

Tightening promotional rules.  The Saskatchewan government launched a public consultation on proposed changes to its  Tobacco and Vapour Products Control Act. In addition to raising the minimum age from 18 to 19, the government would strengthen restrictions on advertising with new legal definitions for advertising and promotion. 

Litigation talks poised to drag on. At the end of July, representatives for Imperial Tobacco Canada indicated that they would be seeking a further extension for their protection from lawsuits. A hearing is scheduled for September 27. If allowed, this would extend litigation protection to all tobacco companies past the 54 month mark.   

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Selected publications on tobacco and vaping - Summer 2023

Cole AG, Gohari MR, Leatherdale ST. Evaluating the One-Year Impact of School e-Cigarette Use Interventions among Current Youth e-Cigarette Users in the COMPASS Study, 2017/18-2018/19. Int J Environ Res Public Health. 2023 Jul 13;20(14):6353. 

This study used survey results from 90 schools in the Canadian longitudinal school study (COMPASS) to assess whether school-based prevention and cessation programs had an impact on the vaping behaviour of children who were already using e-cigarettes one year later. They didn't.

Reiter A, Hébert-Losier A, Mylocopos G, Filion KB, Windle SB, O'Loughlin JL, Grad R, Eisenberg MJ. Regulatory Strategies for Preventing and Reducing Nicotine Vaping Among Youth: A Systematic Review. Am J Prev Med. 2023 Aug 6:S0749-3797(23)00313-6.

These researchers systematically reviewed 30 studies on the impact of regulations on youth vaping. They found "insufficient evidence to recommend age restrictions (n=16), restrictions on location of use (n=1), and mixed/combined regulations (n=3). Flavor bans (n=4), sales licenses (n=2), and taxation (n=2) were generally shown to be associated with decreased rates of youth vaping. Warning labels (n=2) were associated with a decreased desire to initiate vaping." 

Simonavičius E, East K, Taylor E, Nottage M, Reid JL, Arnott D, Bunce L, McNeill A, Hammond D. Impact of e-liquid packaging on vaping product perceptions among youth in England, Canada, and the United States; a randomised online experiment. Nicotine Tob Res. 2023 Aug 5

This on-line study provided young people with different pictures of vaping liquid packaging and asked them about their interest in trying such products and their views on the health harms of using them. Young people were less likely to say they wanted to try liquids that were displayed in plain packaging.

Levy DT, Cadham CJ, Yuan Z, Li Y, Gravely S, Cummings KM. Comparison of smoking prevalence in Canada before and after nicotine vaping product access using the SimSmoke model. Can J Public Health. 2023 Aug 4. doi: 10.17269/s41997-023-00792-3. 

This paper compared earlier predictions of smoking patterns in Canada derived from the SIMSMOKE model with the actual changes in behaviour. "Smoking prevalence in Canada, especially among younger adults, declined more rapidly once NVPs became readily available. The emergence of NVPs into the Canadian marketplace has not slowed the decline in smoking." 

(NB: a similar study was undertaken by the same author under contract with Health Canada, but has not yet been released).

Bandara NA, Zhou XR, Alhamam A, Black PC, St-Laurent MP. The genitourinary impacts of electronic cigarette use: a systematic review of the literature. World J Urol. 2023 Jul 31. doi: 10.1007/s00345-023-04546-1. 

These Vancouver-based researchers reviewed 28 research articles which looked at the impact of e-cigarettes on bladder cancer and other genitourinary conditions. While identifying the need for more research, they concluded "E-cig use was associated with an increased risk of bladder cancer, increased exposure to carcinogenic compounds, mixed evidence on CKD, increased risk of reproductive disorders and burns to the GU system." 

Struik L, Christianson K, Khan S, Yang Y, Werstuik ST, Dow-Fleisner S, Ben-David S. Factors that influence decision-making among youth who vape and youth who don't vape. Addict Behav Rep. 2023 Jul 17;18:100509. 

These researchers interviewed 25 young British Columbians and assessed their approaches to e-cigarette use against a theoretical framework. They found that young peoples' decisions to vape are based on multiple and intersecting factors, and that the school environment encourages vaping in many different ways.

Block AC, Schneller LM, Leigh NJ, Heo J, Goniewicz ML, O'Connor RJ. Heavy metals in ENDS: a comparison of open versus closed systems purchased from the USA, England, Canada and Australia. Tob Control. 2023 Jul 12:tc-2023-057932. 

This analysis of certain heavy metals in vaping liquids purchased in Canada in 2017-18 found measurable amounts of Nickel in JUUL products.

Courtemanche Y, Poliakova N, Muckle G, Bélanger RE. Smoking cessation attempts and successes among Nunavimmiut. Can J Public Health. 2023 Jul 6. 

This article reports on the results of a survey of smoking cessation among  Nunavimmiut (Inuit community at Ungava bay) 

Bitar S, Collonnaz M, O'Loughlin J, Kestens Y, Ricci L, Martini H, Agrinier N, Minary L. A systematic review of qualitative studies on factors associated with smoking cessation among adolescents and young adults. Nicotine Tob Res. 2023 Aug 30

This study reviewed 20 years of qualitative research on adolescent smoking cessation, identifying both environmental factors and individual attributes which influence behaviour.

Watson LK, Weldon I, Lin GO, Nanyangwe-Moyo T, Hoffman SJ, Poirier MJP. Beyond MPOWER: a systematic review of population-level factors that affect European tobacco smoking rates. Eur J Public Health. 2023 Jul 27

This Canadian research team looked at studies of European smoking outcomes to assess both MPOWER and other interventions on population-level smoking. Tobacco interventions that are not identified in the MPOWER framework (like levels of expenditure) and other public policies (like gender equality) were also found to have a positive impact on smoking reduction.

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Resources

Public Health Ontario has captured information on youth vaping in an infographic. 

It has also compiled a  summary of Ontario Tobacco, Vaping & Cannabis By-laws. 

Updated estimates of the costs of substance use in Canada (including tobacco)

In early spring this year updated calculations on the costs of substance use were released by the Canadian Centre on Substance Use and Addiction (CCSA)  and the Canadian Institute for Substance Use Research (CISUR). 

This post highlights key findings on tobacco-related costs from their report "Canadian Substance Use Costs and Harms 2007-2020". 

1. Tobacco is responsible for almost one-quarter (22.7%) of the measured costs of substance use in Canada.

In 2020, the health care, lost productivity and other measured costs from tobacco use were estimated to be $11.2 billion. The total for all substance use was estimated to be $49 billion. The only substance with greater overall costs than tobacco was alcohol ($19.7 billion). Opioids came third, with total costs of  $7.1 billion.

Virtually all of the costs of tobacco use were related to healthcare costs ($5.4 billion in 2020), made up of costs for physician time (36%), prescription drugs (34%) and hospitalization (24%).  Premature death was responsible for half of the $5.25 billion costs of lost productivity associated with tobacco.  

Healthcare and lost productivity costs include both costs incurred by the individual and those paid by government. 

2. Tobacco control efforts have reduced the economic burden of tobacco.

This analysis found that the total  (inflation-adjusted) costs of tobacco use are trending down. The per-capita costs had fallen by one-fifth (20%) between 2007 and 2020 - from $365 per person in 2007 to $294 per person in 2020. This reduction was attributed to fewer hospitalizations and deaths. 

By contrast, the total costs associated with alcohol increased during this period by one fifth (21%). The analysts attribute the difference to the success of tobacco control policies and programs. "The diverging costs of alcohol and tobacco use may be explained by the presence of strong public health policies designed to curb tobacco use. Examples include package warning labels, increased taxation and advertising restrictions. Fewer equivalent, recently updated policies exist for alcohol." 

3. Tobacco causes most substance-related deaths

This analysis estimates that 73,994 deaths from substance use occurred in Canada in 2020. Nearly two in three of these deaths were caused by tobacco products (46,366 or 63%), one-quarter by alcohol (17,098 or 23%) and under one-tenth by opioids (6491 or 9%). Only 336 deaths were attributed to cannabis.

Estimates for overall mortality from tobacco has not varied much over the period of this study, while deaths from alcohol, opioids, cocaine and other CNS stimulants have increased.  

Although the total deaths from tobacco have remained steady over this period, evidence of the impact of tobacco control policy can be seen in the death rates from tobacco, which have fallen significantly. According to the data made available from this study, the actual death rate from tobacco use in Canada has fallen from 144 deaths per 100,000 people in 2007 to 123 in 2020. Eliminating the impact of an aging population by standardizing the death rates shows a decline from 89 to 57 deaths per 100,000 people over the same period of time.

4. Because they cause younger deaths, alcohol and opioids cause a greater loss of productive life-years than tobacco.

The success of tobacco control and reduced smoking rates is reflected in the steadily decreasing quantity of life-years lost as a result of early death.  This study based its measure of potential years of productive life lost (PYPLL) on the number of deaths occurring up to 65 years of age. (This indicator "is an explicit way of weighting deaths occurring at younger ages which may be preventable"). One-third of substance use deaths (24,346) occurred before the age of 65, resulting in 345,091 PYPLLs. 

Following the  methods used in this study, opioids have recently surpassed alcohol as the substance causing the greatest potential years of productive life lost. Early deaths from the use of these substances was estimated to result in the loss of 104 million years of potential productive life lost for alcohol and 112 million for opioids. For tobacco the estimate was the third greatest loss at 53 million years.

5. Provincial estimates are available

Data from the report is online in an interactive form at  https://csuch.ca/explore-the-data/. From this source, estimates for total provincial costs for healthcare and lost productivity are shown to range from $12.7 million (Yukon) to $4 billion (Ontario). Importantly, the analysts were unable to provide estimates for in-patient hospitalizations, day surgeries, emergency department visits or paramedic services in Quebec, which results in a known underestimation of costs for that province. 

Provincial-level estimates of tobacco-caused deaths show, as expected, that most populous provinces have the greatest number of deaths. However, the death rate per 100,000 individuals varied across the country- with the highest rate in Newfoundland (193 deaths per 100,000 people) and the lowest in Alberta (100 deaths per 100,000). 

When standardized for age, death rates were lowest in British Columbia and Ontario (51 and 53 deaths per 100,000) and highest in the territories (168 in Nunavut and 127 in Northwest Territories per 100,000).

The Canadian Centre on Substance Use and Addiction provides extensive information on the methods they used as well as data tables on request. 

Canada performs well, but has not yet reached podium status in WHO's ranking of global tobacco control efforts

This week the World Health Organization and Bloomberg Philanthropies issued their biennial report card on progress towards the MPOWER tobacco-control goals. 

This post highlights findings from the 248-page report that are of particular relevance to Canada.

The MPOWER measures

The MPOWER model was implemented by WHO and the Bloomberg Philanthropies as a way to track the global tobacco epidemic and the impact of measures intended to address it. 

The first report was made public in 2008, with subsequent reports in 2009, 2011, 2013, 2015, 2017, 2019 and 2021

MPOWER focuses on core tobacco control measures that are complementary to, but a subset of, the obligations in the Framework Convention on Tobacco Control. They are:

M - MONITOR tobacco use and prevention policies
P  -  PROTECT people from tobacco smoke
O -  OFFER help to quit tobacco  
W -  WARN about the dangers of tobacco (assessed for pack warnings and mass media)
E -  ENFORCE bans on tobacco advertising, promotion and sponsorship
R -  RAISE taxes on tobacco.

Canada has a high level of achievement in 3½ of the MPOWER measures

The World Health Organization ranks Canada among the countries with highest level of  implementation for:

• M Monitoring tobacco use (along with 73 other countries)
• P Smoke-free environments  (along with 73 other countries)
• O cessation programs (along with 31 other countries)
• W pack warnings (with 102 other countries). 

Canada was considered to be at the second implementation level for the other objectives:

• W mass media (36 countries do better)
• E  advertising bans (65 countries do better)
• R taxation (41 countries do better)

Four countries were ranked with highest level achievement in all six measures (Brazil, Turkiye, Netherlands, Mauritius). Other countries with higher overall levels of implementation than Canada are Ethiopia, Iran, Ireland, Jordan, Madagascar, Mexico, New Zealand and Spain.

This year's report also provided information on related measures. Canada was identified among the 58 countries with highest-level achievement in implementing a national level tobacco control program and among the 87 countries which have regulated electronic nicotine delivery systems (ENDS or e-cigarettes). 

Canada's progress towards the MPOWER goals appears to have stalled over the past 15 years. Compiling score from all nine reports shows that Canada has increased its level of achievement in only one area (mass media) in the past decade, and has failed to implement policies on taxation or public education at the MPOWER standard. Nonetheless, age-standardized adult prevalence as measured by WHO has continued to fall.

Canada's taxes on tobacco are lower than in most other OECD countries.

The World Health Organization recommends that 75% of the purchase price of tobacco products be composed of taxes. Its assessment of tobacco taxes in Canada took note of the varying tax rates across the country, but found that overall taxes represented only 63.3% of purchase price. 

Among the 38 countries with developed economies that are members of the OECD, 23 countries exceeded this target. Canada did not. Canada ranked sixth from the bottom among these countries. (see our Figure using WHO data below)

Canada's daily smoking rate is lower than in most OECD countries

To compare smoking rates across countries, the WHO team made adjustments to account for differences in age distribution and survey methods. 

Traditionally, Canada measures smoking rates by considering only cigarette smoking (and not cigars, pipes, hookah or other forms of smoked tobacco. Smoking rates in Canada are usually stated as 'current smoking', meaning people who smoke on a daily or occasional basis. 

The WHO team found that the age-standardized daily tobacco smoking prevalence in 2022 among people aged 15 or older for Canada was 9%. By way of comparison, Statistics Canada estimates are very similar, suggesting 8.4% of Canadians over 12 years of age smoked cigarettes daily in 2021. 

Among the 38 OECD countries, Canada had the fifth lowest smoking rate - as shown below.

Canada has implemented many - but not all - of the measures WHO recommends for regulating e-cigarettes.

The World Health Organization is increasingly concerned about the marketing of electronic nicotine devices (ENDS) to children, an issue not foreseen when the MPOWER model and the FCTC were first developed. 

In this year's report, for example, the WHO warns that "ENDS are addictive and harmful, particularly for young people", and that "ENDS undermine tobacco control progress and threaten smoke-free environments. The report notes that 121 countries have adopted measures to address these products, with 34 banning the sale of ENDS and 87 countries permitting a regulated market. 

 

From MPOWER report 2023
Measures to Regulate ENDS 2022

Some of the ENDS regulations recommended by the WHO have been implemented in Canada - including bans on using them in public indoor places, workplaces and public transport, requirements for warning labels, bans on sale to minors and taxation. One WHO recommendation that has not yet been implemented across Canada is a ban on flavours.