Health Canada's 2023 drug survey shows very high rates of youth vaping and smoking. Why is no one talking about it?

On December 27th, during the lull between Christmas and New Year, Health Canada quietly released the results of the Canadian Substance Use Survey. The material produced for this release includes a data sheet summary, a description of the methodology, and a very useful interactive data tool. 

Notably missing from these communications products was a press release or any official statement about the context or impact of these results in the department's view. Also absent over the intervening 6 weeks is any comment or reaction from the federal Minister responsible for addressing the harms of substance use, the Hon. Ya'ara Saks.

This silence is all the more concerning, given the picture this survey provides of harmful substance use among young Canadians, with indicators of early dependence. Among teenagers aged 15-19, 17% vape daily, 12% use cannabis every day or nearly every day and one-in-twenty (5%) already meets the criteria for alcohol dependence. 

This post reports on the findings of this survey with respect to tobacco and nicotine use.

Canadian Substance Use Survey (CSUS) 2023 estimates for cigarette and vaping prevalence

As shown in the figures above, the CSUS estimates that almost as many Canadians were using vaping products as smoking cigarettes:  10% were past month vapers and vs 13% were past-month smokers. They found 1 in 20 Canadians vapes daily (5%), compared with 1 in 12 who smokes cigarettes daily (8%).

When it comes to young Canadians (aged 15 to 24), past month cigarette smoking rates are similar to those in the general population (14% vs 13%). However, vaping rates are significantly higher: in the past month 1 in 3 teenagers (31%) and 1 in 4 young adults (26%) used a vaping device, compared with 1 in 14 adults over 25 (7%).

With respect to daily use of these products, CSUS found that in comparison with adults over 25, young people are much less likely to smoke daily  (3% for 15-19 year olds, 4% for 20 to 24 year olds and 9% for those over 25), but much more likely to vape on a daily basis. About 1 in 6 (17%) teenagers aged 15-19 vapes daily, as do 1 in 7 (15%) young adults,  compared with 1 in 25 adults over 25.

The figures shown above were extracted from the CSUS data tables. It should be noted that, unlike many other government surveys, CSUS includes in their estimate of daily cigarette use those who have smoked fewer than 100 cigarettes in their lifetime.  

The CSUS estimates for overall smoking rates use are aligned with those from other government surveys .... but....

When comparing the estimates of overall population prevalence of cigarette smoking from this survey with those produced by other government surveys, the rates of cigarette use are largely consistent. The wave of the Canadian Community Health Survey (CCHS) conducted in 2023 identified 11.4% Canadians as "current smokers". The CSUS identified 11.8% who met the same criteria.  

The results for other smoking variables were also aligned. CSUS estimates of those who had ever smoked 1 cigarette or who had smoked 100 cigarettes or more, or who had smoked in the past 30 days were very close to those produced by the CCHS (50% vs 52%; 37% vs 41%, 13% vs 12%). CCHS has historically covered the population of people over 12 years of age, but in 2023 was changed to cover only those 18 years and older.

The trend-line produced by CCHS, CSUS and two other Health Canada surveys of smoking are shown below. They do not suggest that there has been a substantial decrease in the rates of cigarette use over the past 4 years.  

...CSUS estimates for smoking rates among youth and young adults are higher than indicated by previous surveys.

For young people, the CSUS produces higher estimates of current and daily smoking than did Health Canada's previous surveys (the Canadian Tobacco Alcohol and Drug Survey, CTADS, and the Canadian Tobacco and Nicotine Survey, CTNS).

The CTNS in 2022 estimated that 4% of youth aged 15-19 were current smokers, and 1% were daily smokers. The CSUS estimates in the following year were 8% and 3% respectively. For young adults aged 20 to 24 the 2022 CTNS estimates were  8% (current) and 3% (daily), which contrasts with the 2023 CSUS estimates of 10% and 4%. Estimates for those aged over 25 were substantially the same.  

The CSUS estimates for vaping in Canada are the highest recorded to date.

Health Canada surveys which monitor vaping began in 2013 (the Canadian Tobacco Alcohol and Drug Survey), and were redesigned in 2019 (The Canadian Tobacco and Nicotine Survey) and then subsumed into other surveys in 2023, including CSUS (15+), the CCHS (18+) and the Canadian Health Survey on Children and Youth (CHSCY, not yet released).  

The rates for ever use, past-month use and daily use of vaping products from available federal government surveys are shown below. Of theses, the CSUS has produced the highest estimates of  youth use:

• half of youth (47%) and young adults (52%) have used an e-cigarette at least once
• one-third of youth (31%) and one-quarter of young adults (26%) have used them in the past month
• one-sixth of youth (17%) and one-seventh of young adults (15%) use them daily. 
• for every three young Canadians who experiment with vaping devices, one has become a daily user.

Differences among surveys:  CSUS vs. CCHS vs. CTNS vs CTADS vs .....

The methods used by the CSUS are not identical to those used in the previous surveys commissioned by Health Canada to assess substance use. 

Because of these differences, the results from one instrument is not not intended to be used to evaluate changes over time in the behaviour. In the information attached to the CSUS release, Health Canada makes this clear:  "The changes to the sampling methodology in 2023 may have impacted estimates of substance use. ... cell phone recruitment and oversampling of youth and young adults with the knowledge that the survey would be asking about substance use, may have resulted in an overestimation of substance use ... we recommend using CSUS 2023 data without comparison to previous iterations."

On this basis, we cannot infer that vaping rates have risen dramatically between 2022 and 2023. But can we infer that are problems with one or other survey sampling methods? 

Of the four surveys identified above, CSUS is the only one which was not conducted by Statistics Canada. The work was contracted to Advanis, the public opinion firm which also manages the Health Canada's cannabis survey (The Canadian Cannabis Survey). This private sector research firm appears to have followed similar recruitment and selection methods in both surveys. 

In the technical notes which accompany these Advanis surveys, a rationale is provided for the decision to supplement traditional telephone recruitment with outreach to young people who participate in on-line panels and also for providing some financial incentives for certain youth respondents. This approach has not been included in the surveys conducted for Health Canada by Statistics Canada.

It seems evident that these sampling methods produced very different results for measuring youth substance use. What is less clear is how to interpret the results.

Implications for public health

Such dramatic differences in the measurements commissioned by Health Canada warrant reflection and action.

If the problem of youth vaping and other substance use is greater than previously thought, there is even more reason for the department to (finally!) step off the brakes and implement measures to stop manufacturers from inducing young people to use harmful and addictive products.

If the Minister and the department do not wish adjust their policies and programs in response to this new information, then they should explain this decision. 

At the very least, there should be greater transparency and openness about how the federal government views the results and methods of its own surveys.

Feds pocket $74+ million from kids' vaping

As reported here earlier, the federal Public Accounts that were tabled on the last day Parliament sat before Christmas provide details on the excise taxes collected by various federal agencies. This blog reports on the evolving role of vaping taxes as a source of federal revenues and the disproportionate amount provided by young people.

Tobacco tax revenues are down, but new vaping taxes have mostly made up the difference

In the 2023-2024 fiscal period, federal revenues from tobacco were $2.6 billion, down from $3 billion the year before. The introduction of a federal vaping taxes in the fall of 2022  however has helped the federal government to maintain its revenues from nicotine use. Vaping tax revenue grew from $184 million in its first half-year of implementation to $486 million last year. 

The combined federal revenues on nicotine products was just over $3 billion, only a little lower than in recent years.

Kids are paying 15% of federal vaping taxes

The youthfulness of Canadian vapers is documented in federal surveys of smoking and vaping behaviour, such as the last Canadian Tobacco and Nicotine Survey which was conducted into January 2023. 

For every 20 Canadians who vape, 8 are under 25 and 3 are under 19 years of age. This proportion holds with respect to both daily and occasional use, as shown in the table below. By contrast, in the general population, 9 out of 10 Canadians are over 25 years of age. 

In the absence of better data, we can use the age distribution of the vaping population to estimate the share of vaping taxes (and vaping product sales!) that are made by each age group. 

• Children aged 15 to 19 provided $74.302 million in federal vape tax revenues (15.3%)
• Young adults aged 20 to 24 provided $123.7 million (25.5%)
• Adults over age 25 provided $287.9 million. (59.2%)

This crude method likely underestimates the amount of tax paid by children. Children under 15 were not included in the CTNS survey, but some are known to vape, therefor the actual proportion of children who vape will be larger than the survey estimates. Also, the vaping tax is not equally assessed on all vaping products, with a higher rate is placed on those products (pods, disposables) that are favoured by young people.

Vape taxes can be a health intervention only if they affect affordability 

Taxes on harmful products are understood to be an effective and an efficient way of reducing consumption, which is why they are strongly supported by health experts. Tobacco taxes have a convincing history of  helping reduce smoking rates. But it is not the taxes, per se, which impact product use, but rather the resulting increase in product prices that they produce. Tobacco companies have generally increased their prices in response to new taxes, although they sometimes blunt their impact by absorbing some of the tax for a period of time. The belief and expectation that taxes will be passed on to the consumer is one reason that many health economists have not seen it necessary to include price controls with tobacco taxes. 

With vaping taxes, the expectation that prices would proportionately increase has not been met. Since taxes were introduced in Canada, the companies have been able to modify their production costs or product designs in ways that the price of vaping has fallen DESPITE the introduction of new taxes. For this reason, vaping taxes without price controls may prove to be ineffective as a health measure, although effective as a source of government revenue.

The image below displays the tax and price for one mg of deliverable nicotine sold by Imperial Tobacco in Ontario in January 2025.  From a package of 20 cigarettes that costs $14.69, a single cigarette costs $0.73 cents of which $0.37 is tax. This cigarette contains 2.4 mg of deliverable nicotine giving a tax of $0.15 and a price to consumer of $0.31 per mg of deliverable nicotine.

The nicotine in the different VUSE products made by the same company are subject to somewhat different vaping taxes, depending on volume of liquid they contain. The price of a mg of deliverable nicotine in the package of older-fashioned VUSE epods (containing 76 mg of nicotine and subject to $2.24 in taxes) is not so different than its cigarette equivalent. VUSE Pods are taxed at $0.06 cents per mg of nicotine, with a cost to the consumer of $0.26 per mg, which is about ten cents more per mg of nicotine than it was before the vaping tax was introduced. 

The nicotine in the nicotine devices introduced to the market since the federal tax came into force is less than half the price of the Vuse e-pod. The Vuse GO 8000 was introduced this past summer. It contains 300 mg of nicotine and is now subject to $13.44 in taxes. The tax per mg of nicotine  is $0.045 cents and the consumer price per mg is $0.12 cents.

In short, manufacturers were able to overcome the impact of the vaping tax by redesigning their products to deliver nicotine in a less costly way. The first generation of VUSE disposables has been withdrawn from vaping shops, to be replaced by products which have defeated the health benefit of the vape tax.

Fact checking the "Swedish Experience"

This post responds to recurring efforts by tobacco companies and their allies to promote the "Swedish Experience" as template for harm reduction based on oral nicotine delivery. 

Data from reliable sources are used fact check the industry's claims. They show that for most indicators Sweden has not out-performed Canada with respect to reducing smoking prevalence or reducing tobacco-related disease. The Swedish experience is one where twice as many people use nicotine... and smoking is not being phased out more quickly.

Pouch promoters say Sweden is a tobacco control success story

Tobacco companies promote Sweden's permissive approach to snus as a way to keep smokers happy (with nicotine), keep investors happy (with high sales and profits) and keep health regulators happy (with low levels of disease).  

From BAT Presentation, 2024

Examples of this sales pitch can be found in investor presentations (such as those earlier this spring by British American Tobacco and Philip Morris International), in messaging from allied agencies (such as Smokefree Sweden), in industry-friendly media and on social media.

These pro-pouch arguments boil down to two claims:

* Widespread snus use in Sweden has led to lower smoking rates

* Widespread snus use in Sweden has led to low rates of tobacco-caused disease 

This is not the first time that the Swedish Experience has been trotted out by industry and others to encourage a permissive approach for oral nicotine. The current reprise is being delivered in the context of concerns in the US about the rapid increase in the sales of Zyn, and among European initiatives to regulate the introduction of nicotine pouches and Canada's Health Minister's plans to restrict how these products are marketed. 

(Nor is it the first time that tobacco control agencies have pushed back against these efforts. The data provided below is an update to our 2007 analysis.)

FACT CHECK: IN RECENT DECADES, THE "SWEDISH EXPERIENCE" HAS PRODUCED WORSE OUTCOMES THAN CANADIAN TOBACCO CONTROL. 

(Although the situation in Sweden was better in the last century).

As detailed below:

Widespread snus use in Sweden has NOT led to lower smoking rates

• Estimates of smoking rates in Sweden are generally not lower than those in Canada. 
• Smoking rates in Sweden have fallen, but not at a faster rate than in Canada 
• Twice as many Swedes use tobacco-industry nicotine products as do Canadians (30% vs 15%).

Widespread snus use in Sweden has NOT led to low rates of tobacco-caused disease 

• Lung cancer death rates among men are lower in Sweden than Canada, but the situation for other major tobacco-related diseases is not better.
• Tobacco-related deaths have fallen faster in Canada than in Sweden
• Sweden's lower lung cancer rates are rooted in lower tobacco use in the last century (not an outcome of current snus use)

Smoking rates in Sweden are not lower than in Canada

For decades, the OECD has tracked daily smoking rates among men and women in its high-income member states. The OCED provides access to this data, and also presents it in  data visualizations.  

OECD Countries identified as having lower daily cigarette smoking rates in 2021 than Sweden (9.7%) include New Zealand (9.4%), the United States (8.8%), Canada (8.7%), Mexico (8.6%), Norway (8%), Costa Rica (7.8%) and Iceland (7%). The World Health Organizations' report on tobacco smoking rates similarly shows Sweden behind Canada (12.6% vs 12%, Table A1.2), although rates of smoking manufactured cigarettes are slightly higher in Canada (where roll-your-own tobacco is no longer common).

Smoking rates in Sweden have fallen, but not at a faster rate than in Canada 

The Global Burden of Disease group and the Institute for Health Metrics and Evaluation provide historic smoking prevalence data which has been age-standardized to allow comparisons among countries and across time periods.(The data are available here). 

Their data shows that Sweden has done well (ranking 12th among 204 countries)  - but that other countries, including Canada (ranked 9th) and Australia (ranked 7th) have done better. The country with the greatest progress was Brazil, where the rate of oral tobacco use is very low and e-cigarettes are not legal for sale.  

Twice as many Swedes use tobacco-industry nicotine products as do Canadians 

There are 4 main categories of nicotine products sold by tobacco companies:  cigarettes and cigarette tobacco, electronic cigarettes/vaping products, heated tobacco products and nicotine pouches. 

There are currently  no global databases with information on the overall use of nicotine through these products, but national surveys can be used for this purpose. 

• Information for Sweden in 2022 can be found in a report on the use of cigarettes, snus and e-cigarettes among Swedes produced by the Swedish Council for Information on Alcohol and Other Drugs. The report uses a representative survey of 18,000 Swedes aged 17 to 84 and identifies past-month use of these products. Sweden's health authorities do not report on heated tobacco use, suggesting that its use is perceived to be very low.
• Information for Canada in 2022 can be found in the Canadian Tobacco and Nicotine Survey,(CTNS), which surveyed 12,000 Canadians who were older than 15. This survey asked about several forms of tobacco use, but did not inquire about heated tobacco products, suggesting that the use of this product category is perceived to be very low.

Results from these two surveys show similar rates for past month use of cigarettes (12% in Sweden, 11% in Canada), and not very different rates for vaping (4% in Sweden to 6% in Canada). One in 5 Swedes used either snus or non-tobacco nicotine pouches (20%) compared with fewer than 1% of Canadians. Because of snus use, twice as many Swedes use nicotine as do Canadians (30% vs. 15%).

(A data sheet with the information presented below as well as for men and women can be downloaded here).

Lung cancer rates among men are lower in Sweden than in Canada, but the situation for other major tobacco-related diseases is no better.

The World Health Organization provides information on the number and rate of deaths from specific diseases, and also provides data files which make age-adjustments to this data to allow for comparison between countries. 

Using only countries for which WHO signals the data is robust enough for comparison, Sweden is in the second-best quintile for overall deaths from lung cancer and Canada is in the worst. 

For lung cancer rates among men, Sweden is in the second-best quintile for men, but in the second-worst for women. Canada is in the middle quintile for men but the worst for women. 

The 20 countries for which comparable data is available and which have lower age-standardized lung-cancer rates than Sweden for the whole population are (in decreasing order):  Jamaica,  Venezuela, Kyrgyzstan, Philippines, Brazil, Chile, Trinidad-Tobacco, Belize, Grenada, Mauritius, Colombia, Saint Lucia, Barbados, Kuwait, Panama, Mexico, Antigua-Barbuda, Nicaragua, St Vincent and the Grenadines and Costa Rica.

(A data sheet with lung cancer rates extracted from WHO's files can be downloaded here). 

For deaths from other major tobacco-related diseases (e.g. Ischaemic Heart Disease and COPD), Sweden does worse or not much better than Canada. 

The same age-standardized World Health Organization data allow for comparisons with the number of deaths from other tobacco-caused diseases in Sweden and other countries.

With respect to heart disease, Swedish men and women both experience higher death rates than in Canada. In 2019, there were an estimated 6 more deaths from heart disease in Sweden for every 100,000 people than there were in Canada. For Chronic Obstructive Pulmonary Disease, Canada's rates for men are slightly higher than those for Sweden, and those for women are slightly lower: overall Canada had one more death from COPD for 100,000 people than Sweden. Public health agencies in Sweden have also pointed out that tobacco mortality in Sweden is not the lowest in Europe.

The data shown below is available on a downloadable data sheet; Data visualizations are available on Our World in Data. 

Tobacco-related deaths have fallen faster in Canada than in Sweden

The Global Burden of Disease Project has published estimates of the proportion of global deaths caused by tobacco use and other risk factors, and provided the data for individual countries in supplementary tables. 

Their estimates for Canada and Sweden (downloadable here) show similar results: 1 in 5.6 deaths in Canada is due tobacco, compared with 1 in 6.6 deaths in Sweden. When comparing progress in age-standardized deaths from tobacco between 1990 and 2021, Canada was in a somewhat better condition than Sweden:  the overall rate of deaths from tobacco-caused deaths fell by 15.6% in Canada, compared with 12.3% in Sweden. 

 

Sweden's lower lung cancer rates are rooted in lower tobacco use in the 20th century - not today's nicotine pouches

Lung cancer can occur many decades after tobacco use, and current lung-cancer rates are an indicator of tobacco use in previous periods. One likely reason that Sweden has lower rates of lung cancer now than Canada does is because much less tobacco was smoked in the last century.

Reports on historic tobacco sales produced by PN Lee and colleagues show that over the past century per capita tobacco sales (including cigarettes, cigars, pipe and snus) remained constant in Sweden. By contrasts, per capita consumption in Canada rose dramatically in the middle of the past century (to more than double the rate in Sweden) before falling.

Grams of tobacco consumed per day per adult.
From P.N. Lee, International Smoking Statistics
for Sweden and Canada 

In living memory, most of the tobacco consumed in Canada has been in the form of manufactured or roll-your-own cigarettes. By contrast, snus has been the predominant product in Sweden for 30 years. 

There are many reasons other than the presence of snus that may explain why cigarette smoking never emerged with the ferocity in Sweden as it did in Canada and other European countries. Among these are differing experiences with returning soldiers (Sweden was a neutral country during World War Two), control of the tobacco market by a government-owned company,  and the absence of television advertising in Sweden. Although Sweden is not now looked on as a leader in tobacco control, during the 1970s and 1980s it pioneered several tobacco control measures, including advertising restrictions (1979) and rotating health warnings (1987). 

Are e-cigarettes safer than regular cigarettes? 107 studies are compiled to provide a disturbing answer.

This post reports on a new study which calculates the risks of using e-cigarettes in comparison with those of using cigarettes alone, or using both e-cigarettes and cigarettes, or using neither. The study was published today in the digital journal NEJM Evidence: Population-Based Disease Odds for E-Cigarettes and Dual Use versus Cigarettes.

The lead author of this systematic review and meta-analysis is Dr. Stan Glantz, who is well known for his pioneering tobacco control research. Co-authors are Dr. Nhung Nguyen, an epidemiologist specializing in substance use and Dr. Andre Luiz Oliveira da Silva, whose experience in tobacco regulatory science includes work with the Brazilian government health agency ANVISA. (Dr. Glantz provides more information on the study here.)

Their review looked for all population epidemiological studies published between January 2005 and October 1 2023 that reported on experience of disease in the general population by e-cigarette users. In that sense, this paper is the contribution of the authors of 107 studies aimed at building the epidemiological evidence base on e-cigarettes.

The results published today are in stark contrast to previously published estimates of relative risk (see below) and call into question the view of the government of Canada and others whose policy objective is to achieve population level health benefits by encouraging smokers to switch to e-cigarettes.

The meta-analysis was restricted to disease categories for which at least 5 previous papers had been published. There were six such conditions: cardiovascular disease, stroke, metabolic dysfunction asthma, COPD and oral disease. Other diseases (including cancer) did not meet this criteria.

The results of this study: 

* do not support the conclusion that smokers who switch completely to e-cigarettes are less likely to experience cardiovascular disease, stroke and metabolic dysfunction.

* support the conclusion that vapers who do not smoke are more likely to experience cardiovascular disease, metabolic dysfunction, asthma, COPD and oral disease than are those who neither smoke nor vape.

* support the conclusion that dual users (those who smoke and vape) have 20-40% higher odds of experiencing cardiovascular disease, stroke, metabolic dysfunction, asthma, COPD and oral disease than if they only smoked. 

The importance of this paper to tobacco control

This paper challenges previous conclusions that e-cigarettes produce meaningfully lower risks to the user than cigarettes, and counters beliefs that encouraging smokers to switch to e-cigarettes reduce population-level harm.

It suggests that the relative risks associated with vaping have been seriously understated:

* In 2015,  British researchers recommended that governments consider e-cigarettes to be "95% less harmful" than combustible cigarettes. This assessment was not based on data, but on the opinion of a small group of researchers, some of whom were associated with the vaping industry. 

* In 2023, American health economists assumed that the risk of dying from vaping is 15% that of smoking when building a simulation model for health outcomes. 
* In 2022, New Zealand researchers used studies on biomarkers to estimate that "vaping could be a third as harmful to health as smoking", although they rescinded (corrected) that conclusion a year later with the admission that "data limitations with the selected studies and the assumptions involved in our method, are too problematic to allow for a valid quantitative assessment."

The implications for health policy in Canada

In 2018 Health Canada adopted a harm reduction approach to tobacco centred on smokers' switching to e-cigarettes. Six years later, their stated intention remained to "increase the number of people who transition away from smoking (to vaping)".  

Official statements by the Government of Canada on the risks of vaping are mostly vague with respect to diseases other than addiction, with an overarching message that they are "not completely harmless". Not only do federal government communications fail to specify any diseases likely caused by e-cigarettes, they further blunt their warnings by simultaneously recommending that smokers switch to e-cigarettes.

Health Canada's advice on the risks of vaping

The department has acknowledged that this approach was developed with "limited scientific evidence and much uncertainty" and that that "this lack of evidence persists". (It has recently provided $1.2 million to CAMH to conduct an evidence review). 

Uncertainty should no longer be used as a cover for Canada's harm reduction strategy.  Canada's health policies should no longer assume that smokers who switch to e-cigarettes are likely to improve their health, given the greater likelihood that they will become dual users. The government should abandon its "balanced" approach which tolerates exposing young people and non-smokers to inducements to try vaping in the (unsupported) hopes that such marketing will result in substantial population health benefits.

Applying the disease odds published today to the situation in Canada suggests that vaping policies in this country have not reduced harm, but have instead increased it. Only a small proportion of e-cigarette users in Canada are former smokers (27%), with a much larger share being dual users (34%) or never smokers (40%). (CTNS 2023).

An appropriate response to the evidence published today would be for Canadian governments to move quickly to ban inducements to vape (flavours, package designs, promotions and pricing incentives), to increase risk communication (mass media, warning labels), to curb supply and to hold manufacturers responsible for the harms their products are causing.   

Updates on smoking behaviours from the Canadian Community Health Survey 2022

This post provides information on data collected by the Canadian Community Health Survey (CCHS) during 2022. The 5 figures presented below use data made public on Statistics Canada web-site (Health Characteristics annual estimates), Health Canada's website and the Data Dictionary for the survey which was provided to us by Statistics Canada. A downloadable data sheet  which relates to some of the figures is available.

Background: Canada's national surveys on smoking behaviour

With 65,300 participants, the Canadian Community Health Survey is the largest health survey in Canada, but it is not the only one. 

The Canadian Community Health Survey has been conducted for over 20 years, although several changes have been made over those years. The questions on smoking behaviour were redrafted in 2022 and questions on vaping behaviour were added. Major changes to the way information is collected were made in 2015 (when in-person interviews were reduced), in 2020 (when they were abandoned) and in 2022 (when on-line interviews were added to telephone interviews). As reported here earlier, the method by which data is collected seems connected to peoples' willingness to self-identify as a smoker: people who responded face-to-face were more likely to say they smoked. 

On behalf of Health Canada, since late 2019 Statistics Canada also conducts the Canadian Tobacco and Nicotine Survey, (CTNS) which now also includes questions on cannabis and alcohol use. 12,100 Canadians participated in that survey in 2022, and data from that wave were released by Health Canada this past September. The CTNS was preceded by the Canadian Tobacco Use Monitoring Survey (CTUMS, 1999-2012) and the Canadian Tobacco Alcohol and Drug Survey (2013-2017).  The CTNS collects information on-line, and the previous surveys used telephone interviews.

Figure 1: the gaps between survey estimates are closing

For many years there was a sizeable gap in the estimates of smoking rates produced by the CCHS and CTUMS/CTADS, with the larger survey identifying a million more smokers than the smaller telephone surveys. 

There was very little difference in the estimates for 2022. The CTNS collected in winter 2022-23 found 10.9% of Canadians over 15 years of age smoked daily or on occasion (10.9%), close to the CCHS estimate of 11.6% for Canadians over 12 years of age. 

There was also no difference in the estimates of past-month vaping use between both surveys. Both estimated past-month e-cigarette use at 5.8%. 

Figure 2 : More provincial variation in smoking rates than in vaping rates

With five times as many Canadians participating, the CCHS is better able to provide comparisons of substance use among Canada's smaller provinces than is the smaller CTNS. 

As tested by Statistics Canada, smoking rates are statistically higher than the rest of the country in Newfoundland, Nova Scotia, Saskatchewan and lower in Ontario and British Columbia. Vaping rates are statistically higher in Alberta and lower in Ontario. 

Figures 3a and 3b: Prevention can take the credit for driving smoking rates down.

From 2001 to 2022, the CCHS survey population grew by 7.2 million, the number of smokers fell by 2.8 million, the number of former smokers grew by 1.14 million,  (to on to 33 million), the number of experimenters grew by 0.7 million and the number of Canadians who reported they had never smoked a whole cigarette grew by 8.6 million.

The population growth in Canada during that period reflects the net impact of 1.8 million births, 1.5 million deaths, the net arrival of 1.6 million immigrants and 0.6 million non-permanent residents and the net departure of 0.16 million emigrants. 

The survey results suggest the key role that population turnover is playing in estimates of smoking prevalence. Since 2018, there was a decline both in the number of smokers and the number of former smokers, with a growth in lifetime abstainers that was more than twice as large as the loss of ever smokers.

Figure 4: Cannabis now rivals tobacco for number of users

When considering the total population, the CCHS estimates that many more Canadians have used cannabis in the past month than have smoked cigarettes (4.6 million vs. 3.8 million), with a somewhat smaller difference reported by the CTNS (3.4 million vs. 2.6 million). 

When it comes to daily use, however, cigarettes are more commonly used than cannabis (3 million vs. 2 million Canadians) or vaping (3 million vs. 1 million Canadians).

 

Figure 5: January is a key month for quitting.

In previous years, the CCHS only asked recent quitters about the month in which they quit smoking. In 2022 the information was asked of all former smokers. 

January was most frequently cited as the month in which a smoker quit (19%) followed by June (11%) and September (9%).

Delays and missing details from the 4th wave of the Canadian Tobacco and Nicotine Survey.

 Today Statistics Canada released a few results of the fourth wave of the Canadian Tobacco and Nicotine Survey. This release confirms that without any new constraints on vaping marketing the youth vaping problem continues. 

What we know

The patterns of nicotine use are stable over the past 4 years. As shown in Statistics Canada's Infographic from the release, over the past 4 years, nicotine continues to capture new cohorts of teenagers. As these teenagers age into their twenties, young adult vaping continues to climb while smoking rates fall. Once blended into the larger population of Canadians, however, the use both products has not diminished. 

Overall, an additional 1% of Canadians are using vaping products in early 2023 than in late 2019 and 1% fewer Canadians reported smoking over the same period. 

The impact of policy change is imposed on youth. This survey was implemented after the federal government legalized the vaping market with the intention of providing adult smokers with access to vaping products while protecting youth from vaping.

When compared with data from the period before the change of law in May 2018, the failure to achieve those goals is made clearer. Over the 5 years period, adult use of vaping products has changed little, but youth use rose quickly and has stabilized at a high level.

More than 1 in 5 teenagers who tries a vaping product ends up using them every day. The probability of becoming a daily user of vaping products is high. One fifth of young people who had ever tried vaping products were doing so daily at the time of survey. Even among adults over 25, one-seventh of ever-vapers were vaping daily. 

Sexual orientation is associated with higher vaping rates. Vaping rates are twice as high among non-heterosexual Canadians as among those who identify as heterosexual (11.5% vs 5.5%). The pattern for cigarettes is less pronounced (12.4% vs 10.8%). 

What we still don't know

Frustratingly, very few results from the CTNS were released today. The survey questionnaire covers a wide range of issues related to tobacco and nicotine use. 

Among the data from the survey which is not yet available is that which will allow us to know:

• the smoking status of Canadian vapers (e.g. how many are former smokers?)
• rates of use of other tobacco products (e.g. chewing tobacco) and cannabis
• patterns of co-use of tobacco, vaping and cannabis, and progression of use (e.g. which products are used first?)
• relationship of indigeneity and other racial identity to the use of these products (e.g. which groups appear more vulnerable?).
• use of flavourings in vaping products (e.g. who is using candy and fruit flavourings and why?)
• source of supply of vaping and tobacco products (e.g. where do young people get their nicotine products from?)
• the reasons that Canadians say they use vaping products (e.g. are these to help stop smoking, to reduce stress or to satisfy curiosity?)  
• changes in the use of these substances in different regions of Canada. (e.g. are people in provinces with taxes or flavour restrictions or retail constraints less likely to use these products?)
• the use of stop-smoking aids (e.g. what products are smokers using in their quit attempts - and which are associated with success?)
• beliefs about the  harmfulness of e-cigarettes (e.g. do these beliefs seem to influence use?)

This information will only be available once results of an analysis are made available by federal government agencies, or once the data is made available to independent researchers.

Delaying data release

An important story from today's release is that it took so long to receive so little information. This survey should and could have been released in the spring, as it was in previous years.  By arranging for a delay of the data release, Health Canada was able to defer this bad news story. 

In 2020 and 2021 - despite the pressures of COVID - Statistics Canada released the data in March and made the PUMF file available at the same time. In 2022, the data was released in May, with the PUMF made available August. 

In each of those years, Health Canada made its analysis available many months later.  But because the raw data was available to researchers and other levels of government, the impact of this delay was lessened.

The Health Ministry appears to have objected to Statistics Canada's decision to make the data available to the public in advance of that department. In a memo to the Minister in July 2020, Health Canada officials complained "The Tobacco Control Directorate (TCD) was not aware that the data set was being made available to the public by Statistics Canada until after the fact." 

It appears that this year the intention was for both government departments to release information on the same date. In response to inquiries on the release, Statistics Canada officials informed us this summer that: "The CTNS master file release date for the 2022 reference year is currently planned for September 11, 2023. This is when the data become available to the public. This differs from previous cycles of CTNS, whose master files were released in the spring. Additionally, Health Canada will be releasing web summary tables on September 11. The PUMF for CTNS 2022 is tentatively planned to be released later in October." (emphasis added)

As it turns out, Health Canada does not seem have met this deadline. The last line in today's release notes that "Health Canada will also be releasing a detailed report from the latest cycle of the CTNS in September 2023."

Six take-aways from Canada's student smoking survey

This past week Health Canada released the results of the most recent Canadian Student, Alcohol and Tobacco Survey, with data collected in selected schools across Canada (except New Brunswick) during the 2021-2022 school year. 

This is the most recent version of the school-based smoking and drug survey which has been conducted periodically since 1994. In recent years the survey covers students in grades 7 to 12. To focus on the health status of these young Canadians as they complete their public school years, many of the results discussed below are limited to those for the senior grades 10 to 12. An excel chart with the tables shown below can be downloaded here. 

CBC News coverage

Health Canada provides a useful summary of topline results - and the media has reported on the concerns raised about the continuing high rate of vaping that was produced by the survey.  

This post identifies 6 important take-away messages from these results.

1. Health Canada has not undone the damage of its 2018 policy change.

In May 2018, the federal government implemented a major policy change and allowed vaping products to be sold with few regulatory restrictions. The impact of those policies was immediate: past month e-cigarette use among senior high school students doubled between 2016-2017 and 2018-2019 (from 14.6% to 29.4%).

Beginning in 2020, the federal government began to restrict the market freedoms which it had initially extended to vaping companies. Most promotions were banned in the fall of 2020, nicotine concentration was capped at 20 mg/ml the following summer. Starting in 2019, provincial governments began to increase their own restrictions on the marketing of e-cigarettes (a summary of measures can be viewed here).

The student survey taken after these changes were in place shows a flattening of the curve, but there is no evidence that the harms caused by the 2018 policy change are being reversed. Past-month vaping by students in grade 10 to 12 has been reduced from 29.4% to 23.6%, and the frequency of daily vaping in this age group has remained at more than 1 in 10 students (11.8% in 2020-21, compared with 11.6 in 2018-19 and 2.2% in  2016-17).

The continuing high rate of vaping is particularly worrisome in the context of Health Canada's failure to implement other marketing restrictions. In June 2021, the government announced plans to restrict flavours in vaping products, but has seemingly walked away from that intention. In April 2021 it announced plans to curtail youth-friendly product designs, but abandoned these the following year. 

2. Many Canadian students think there are few risks to smoking or vaping

During last year's survey, more than 1 in 20 Canadian students (6.3%) perceive no risk of harm from smoking cigarettes on a regular basis -- twice as many as held that view in 2014-15. Roughly the same percentage hold this view about e-cigarettes (6.6%). In this case, the number who think regular vaping causes no risk has fallen in half, from 11.9% in 2014.

A large proportion (almost half) of students perceive little or no risk to using cigarettes or e-cigarettes once in a while. 

3. E-cigarettes seem to addict more quickly than cigarettes 

A much higher proportion of young people who ever try vaping become daily users before they leave school.

Among the senior high school students surveyed, the path from experimental to regular use appears faster or deeper for vaping products than for cigarettes. Over the past 8 cycles, an average of 1 in 10 senior high school students who ever tried cigarettes was using them daily at the time of the survey (from a low of 5% in 2018-19 to a high of 14% in 2008-09). This “conversion factor” can be calculated by dividing the number of daily users by the number of ever users and expressing the result as a percentage.

The rate of conversion to regular use of vaping products was much higher in the 3 cycles in which data that allows for this calculation to be made, growing from 5% in 2016-2017 to 29% in 2021-22.

4. Health Canada has now missed one of its three  tobacco control targets, but has not said how it will address this failing.

The federal government sets policy targets for its programs, and - as shown on Treasury Board's InfoBase - three such targets are set for Canada's Tobacco Strategy:

* smoking prevalence no greater than 5% by 2035 (as measured by CCHS) 

* past-month tobacco use by children in grades 7 to 12 no greater than 5% by March 2023 (as measured by CSTADS)

* past month e-cigarette use by children in grades 7 to 12 no greater than 5% by March 2023 (as measured by CSTADS). 

Because Health Canada delayed CSTADS by one year, there will be no measure of tobacco or e-cigarette use among students in March 2023. The data released for 2022 however show that the target for e-cigarettes has been exceeded by 1 in 20 children (16% instead of 10%).

Health Canada has not established a target for overall nicotine use by young people and surprisingly does not release an estimate of the number of students who use nicotine through either tobacco or vaping products. 

5. The steady decline in cigarette smoking pre-dates the availability of e-cigarettes.

Senior high school students (grades 10 to 12) were included in the survey for the first time in 2006-2007. Since then, the proportion of senior high school students who have never smoked a single cigarette has increased from one-half (52%) to more than three-quarters (78% in 2021-2022). During the same period, the number of students who were smoking each day or on an occasional basis fell by more than two-thirds (from 11.4% to 3.1%).

The label "current smoker" is applied only to those who have smoked more than 100 cigarettes (4 to 5 packs) in their lifetime. If those who have smoked in the past month but have not yet reached that amount are included, the percentage of senior students who are currently using tobacco increases to 6%. (3.1% who had moved past the experimental phase and were smoking on a daily or occasional basis and 2.9% who had smoked fewer than 100 cigarettes in their lifetime but had smoked in the past month). (CSTADS definitions are available here). 

6. Provincial flavour restrictions are not preventing youth from using flavoured e-cigarettes. 

Three Canadian provinces had flavour bans in place at the time of this survey: Prince Edward Island, Nova Scotia and New Brunswick. (New Brunswick did not participate in the survey). Three other provinces had restrictions which prohibited flavoured vaping liquids from being sold other than in specialty shops where young people are not allowed to enter.

The reported choices of students shows that these restrictions were not sufficient to prevent young people from having access to flavoured products. Among those who reported having a usual flavour, three quarters (75%) said they used a fruit flavour: this was only marginally lower in the provinces where such flavours were not permitted for sale. The second most frequently identified flavour category was mint-menthol (14% nationally). 

Nova Scotia, where only tobacco-flavoured liquids are permitted for sale, was the only province with a reportable number of students who said they usually used tobacco flavourings - fewer than 1 in 20 (4%).

The growing population of never-smoking vapers

The students who spent an hour of classroom time answering the CSTADS survey last year are the first generation of Canadians who entered high school after e-cigarettes were legalized in Canada. From this new cohort alone, there are 360,000 school children who are vaping, and 174,000 who already do so every day. By the time the next school surveys are taken, many of these children will no longer be included - although they will be captured by surveys like the Canadian Tobacco and Nicotine Survey (CTNS), which will describe them as the "young adults" that they have grown into -- allowing policy makers and tobacco-nicotine companies to suggest that such nicotine use reflects a choice made after the duty of the state and manufacturer to protect young people from these products has ended.  

The effect of the aging-out of youth vapers is already apparent in the CTNS surveys. The results to winter 2021 are shown below, with the winter 2022 results likely to be released this summer.

We should acknowledge that each successive cohort of children recruited into vaping adds to the number of Canadians injured by the policy decision to allow tobacco companies to promote and supply vaping products as consumer goods. These young people (and as the adults they will soon be) are the collateral damage in a poorly designed harm reduction approach. The damage will grow until the policy is changed. 

Bans on flavourings and youth-friendly designs are urgently required, as are meaningful barriers to youth access. Equally important is the need for Canada to re-think its approach to managing nicotine supply. The CSTADs results are another indication that Canada's tobacco harm reduction approach is not working.  

New survey results show no decrease (and some areas of increase) in tobacco use and vaping

 On May 5, Statistics Canada released results of the third wave of the Canadian Tobacco and Nicotine Survey., in which almost 10,000 Canadians reported their use of tobacco and vaping products. (Top-level results of prior waves, with smaller samples, are available on Health Canada's web-site, and other analysis was reported here earlier). 

This blog presents graphs showing the results of this survey in the context of previous versions of Health Canada's tobacco use surveys.

Very little change overall

Statistics Canada reported very little overall change in vaping behaviour among Canadians as a whole, with mostly unchanged proportions of Canadians who had ever tried a vaping device, who were using one in the past month or who were using one daily. The one significant change they highlighted was the growing proportion of current vapers who were using daily -- up from 44% to 55% between 2020 and 2021.

No change in teen-vaping, but an increase in vaping among young adults.

The good news is that the increase in youth vaping observed after the market was legally opened 4 years ago has stalled. Over the past 2 years, this survey has not observed a statistically significant increase in vaping among teenagers or adults over 25

Vaping rates among young adults, however, have increased. Many of those who were in this age group this year would have surveyed as a teenagers when this survey began. Whether these are the same young people who would have been teenagers in previous surveys or whether they are Canadians who start to vape as young adults will not be known until the survey's full data set is released and analyzed. 

No decrease in smoking for any age group.

The CTNS did not observe a reduction (or increase) in cigarette smoking overall, nor for any age group.

Increased overall nicotine use among younger Canadians

The introduction of e-cigarettes in 2018 complicated the picture of Canada's progress against tobacco use. The age group which has most reduced smoking (adults over 25) is the group with the least use of e-cigarettes. For younger age groups, overall nicotine use has returned to levels higher than they were in 2018. 

Sources for data above:

CTUMS. Canadian Tobacco Use Monitoring Survey, 1999-2012:

CTADS. Canadian Tobacco Alcohol and Drug Survey, 2013, 2015, 2017. 

CTNS. Canadian Tobacco and Nicotine Survey, 2019-2020; and 2021.