ITC Canada National Report FINDINGS FROM THE WAVE 1 TO 8 SURVEYS ( ) NOVEMBER 2013

Transcription

1 The International Tobacco Control Policy Evaluation Project ITC Canada National Report FINDINGS FROM THE WAVE 1 TO 8 SURVEYS ( ) NOVEMBER 2013 Promoting Evidence-Based Strategies to Fight the Global Tobacco Epidemic

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3 Findings from the ITC Canada Wave 1 to 8 Surveys ITC Canada National Report Suggested Report Citation ITC Project (November, 2013), ITC Canada National Report. Findings from the Wave 1 to 8 Surveys ( ). University of Waterloo, Waterloo, Ontario Canada.

4 Message Created in 2000, the Canadian Institutes of Health Research (CIHR) is the Government of Canada s health research investment agency, providing leadership and support for research to improve health and health care for Canadians and of the global community. The Institute of Population and Public Health has a specific mission within CIHR to improve the health of populations and promote health equity in Canada and globally through research and its application to policies, programs, and practice in public health and other sectors. There is increasing recognition of the threat that non-communicable diseases (NCDs) poses for the health of Canadians and people throughout the world. The United Nations recently convened a high-level meeting on NCDs, only the second time in its history it has convened such a meeting on a public health issue; the first was on HIV/AIDS. Tobacco use is the greatest single contributor to the onset of NCDs and is the one for which populationbased interventions (notably in the form of tobacco control policies) exist and where there exists an international mechanism (the WHO Framework Convention on Tobacco Control) for implementing such interventions. The International Tobacco Control Policy Evaluation Project and its international collaboration of more than 100 researchers across 22 countries, covering over half of the world s population, is a world-leading research program that focuses on evaluating the impact of FCTC policies. Over the past decade, the ITC Project has become a leading authority on what works and what doesn t work in the implementation of tobacco control policies in Canada and throughout the world. CIHR is pleased to have been one of the earliest supporters of the ITC Project, in 2002 support that continues today. We have also recognized the ITC Project s unique efforts at dissemination exemplified by their many national reports, including this Canadian report. The findings of the ITC Canada Wave 1 to 8 National Report are sure to have a powerful impact in advancing tobacco control policies in Canada and shaping the global tobacco regulation agenda. Canada has long been seen as a global leader in tobacco control and continues to make great progress. This report provides the first comprehensive assessment to guide the future of tobacco control policies in Canada. The findings provide several important messages for Canada and other countries. The pictorial health warnings that Canada had on cigarette packs between 2001 and 2012 were an inspiration to other countries. To strengthen this intervention, ITC findings document the need for frequent updating of pictorial health warnings as recommended in the FCTC Article 11 Guidelines. The report also identifies the need for educational campaigns on the importance of extending smoke-free policies to outdoor environments. In addition, it highlights the need for ongoing evaluation and refinement of policies that regulate tobacco products and product advertising to curb the tobacco industry s evolving tactics to attract a new generation of tobacco users. We congratulate Professor Fong and his colleagues in preparing this comprehensive evaluation of Canada s efforts to fight the number one cause of premature death and disease. Sincerely, i Nancy Edwards, Ph.D. Scientific Director, Institute of Population and Public Health Canadian Institutes of Health Research

5 Message In Canada, smoking causes 30% of all cancer deaths and about 85% of all lung cancer cases. And although there have been significant reductions in smoking rates in Canada, as in most high-income countries, smoking still remains by far the single most important preventable cause of cancer and premature death in Canada. And so any efforts to prevent cancer in Canada and throughout the world must include tobacco control. Because population-based interventions such as policies offer the greatest promise in reducing tobacco use, there is a need for measuring the impact of policies such as pictorial warnings, smokefree laws, bans on advertising, promotion, and sponsorship, higher taxes to increase price of tobacco products, and measures to reduce illicit trade. In the same way that methods for treating cancer must be continually and rigorously evaluated in order to increase their effectiveness, methods for preventing cancer must also be subjected to rigorous evaluation. What works and what doesn t? How can we increase the effectiveness of our policies designed to reduce tobacco use? The International Tobacco Control Policy Evaluation Project (the ITC Project) is the world s most extensive research effort to measure and understand the impact of tobacco control policies it is the first ever international longitudinal study of tobacco use, and its focus on measuring the impact of policies has led to major contributions to the evidence base on the effectiveness of tobacco control policies. In Canada, the ITC Project has followed a large cohort of Canadian smokers over eight waves across nearly a decade ( ) to evaluate Canada s implementation of the WHO Framework Convention on Tobacco Control, the world s first health treaty, which obligates over 170 countries, including Canada, to the above-mentioned tobacco control policies, among others. In addition, the ITC Project conducts surveys in more than 20 other countries which allows for cross-country comparisons to identify policy implementation strengths and weaknesses at a global level. A major objective of the ITC Project is to engage in effective dissemination and knowledge transfer activities to provide policymakers and other health stakeholders with research evidence from the ITC Project to promote strong evidence-based action to reduce smoking. The Canadian Cancer Society is supporting these dissemination efforts through a Prevention Scientist Award provided to Professor Fong; this report is one of the key outcomes that we have supported. We thank Professor Fong and the ITC Project team for this important report which will assist in guiding strong tobacco control policies in Canada and internationally. Sincerely, Pamela C. Fralick, ICD.D President and CEO Canadian Cancer Society ii

6 Message The Non-Smokers Rights Association (NSRA) has been at the forefront of tobacco control efforts in Canada for four decades. Professional, dynamic advocacy based on solid research and critical thinking has been the hallmark of the NSRA since its inception. The availability of robust data on the effectiveness of tobacco control policies is critical to our ongoing efforts to influence decision-makers to implement stronger tobacco control policies both in Canada and around the world. The ITC Project has collected data from a cohort of Canadian smokers over ten years ( ) to evaluate Canada s implementation of the WHO Framework Convention on Tobacco Control. This ITC Wave 1 to 8 National Report is a comprehensive document which identifies the strengths and weaknesses in Canada s implementation of the WHO Framework Convention on Tobacco Control across a broad range of policy domains. The findings provide evidence of Canada s leadership in tobacco control, including significant declines in the percentage of smokers who noticed smoking in indoor workplaces, restaurants, and bars/pubs between 2005 and Bans on retail displays of tobacco products at point of sale (POS) have led to a significant reduction in smokers noticing cigarette packs in the retail environment. The findings also provide guidance on areas where we need to advocate for stronger policies, including stronger measures to control tobacco price incentives and the promotion of smoking in the entertainment media. The report identifies the need for sustained funding for campaigns to raise awareness of the harms of second-hand smoke and the need to expand smoke-free policies to outdoor public places. The findings also confirm that Canada s delay in implementing new pictorial health warnings resulted in the declining effectiveness of the warnings as a tool to educate smokers and promote behaviours that lead to quitting. We are encouraged by the findings that the majority of smokers are supportive of stronger tobacco control policies. For example, more than two-thirds of smokers support a law that would ban additives and flavourings that make cigarettes seem less harsh. We are pleased that the ITC Project has recognized the importance of disseminating scientific findings to stakeholder groups who are instrumental in influencing policy change. This Report will serve as a useful evidence-based guidance document not only for NSRA s work to strengthen tobacco control in Canada, but also for civil society and tobacco control advocates around the world. Sincerely, Melodie Tilson Director of Policy Non-Smokers Rights Association Member, Board of Directors Framework Convention Alliance iii

7 Message The Framework Convention Alliance (FCA) is an international civil society alliance of over 350 NGOs across more than 100 countries which co-ordinates policy activities in support of strong action in tobacco control throughout the world. We advocate for further development and the strongest possible implementation of the WHO Framework Convention on Tobacco Control (FCTC), the first modern-day public health treaty, which almost all countries in the world have accepted as legally binding. The International Tobacco Control Policy Evaluation Project is the only research effort to focus on evaluating this seminal international health policy initiative. The ITC Canada Wave 1 to 8 National Report provides a comprehensive, evidence-based evaluation of Canada s efforts to implement the FCTC based on over a decade of survey data in Canada. Scientific studies of policy impact take on special importance in the domain of tobacco control given the tobacco industry s well-documented history of distorting facts, inventing facts, and attempting to create doubt in the minds of governments and the public through their well-funded public relations campaigns and through researchers and front groups paid to espouse pro-tobacco positions. The ITC Project s rigorous research design, as well as its attention to identifying gaps in the implementation of the FCTC and uncovering tobacco industry tactics to hinder these efforts, make this report a unique and influential basis for guiding comprehensive strategies for implementation of the FCTC. The ITC Canada Wave 1 to 8 National Report is a superb example of the importance of scientific research in the fight against the global tobacco epidemic, which threatens to kill up to one billion people in the world in the 21st Century. This timely resource will surely support civil society and decision-makers in mobilizing stronger implementation of the FCTC in Canada. And because of Canada s prominence as a leader of tobacco control policies, the ITC Canada National Report will be certain to be important and influential throughout the world. Sincerely, Francis Thompson Director of Policy and Advocacy, Framework Convention Alliance iv

8 The findings of the ITC Canada Wave 1 to 8 National Report are sure to have a powerful impact in advancing tobacco control policies in Canada and shaping the global tobacco regulation agenda. Canada has long been seen as a global leader in tobacco control and continues to make great progress. This report provides the first comprehensive assessment to guide the future of tobacco control policies in Canada. Nancy Edwards, Ph.D. Scientific Director, Institute of Population and Public Health Canadian Institutes of Health Research

9 Table of Contents i Preface letters vii List of Tables and Figures xii ITC Policy Evaluation Project 1 Background 5 Executive Summary 9 The Tobacco Landscape in Canada 29 Methods 35 Findings 35 Tobacco Use and Cessation 48 Smoke-free Public Places and Workplaces 65 Health Warning Labels 72 Tobacco Price and Taxation 83 Education, Communication, and Public Awareness 89 Tobacco Advertising, Promotion, and Sponsorship 100 Conclusions and Implication of the Findings 104 ITC Survey Project Contacts 105 References vi

10 List of Tables and Figures Table 1 Smoke-free policies in indoor workplaces and public places in Canada 18 << Figures Table 2 Smoking bans in private motor vehicles with children in Canada 18 Table 3 Smoking bans on outdoor patios in Canada 19 Table 4 Municipal smoking bans on outdoor playgrounds, parks, other outdoor places, and beaches in Canada (as of May 2012) 20 Table 5 Tobacco advertising, promotion, and sponsorship bans in Canada 24 Table 6 Implementation of restrictions on the display of tobacco products at point of sale (POS) in Canada 25 Table 7 Subsidized smoking cessation aids by province/territory (as of November 2012) 27 Table 8 Smoker quitlines in Canadian provinces and territories 28 Table 9 Summary of characteristics of the ITC Canada Wave 2 to 8 Surveys 30 Table 10 Total respondents interviewed in the ITC Canada Wave 1 to 8 Surveys, by wave 31 Table 11 Demographic characteristics of the ITC Canada Wave 1 to 8 Survey samples 32 Figure 1 Canada s tobacco control policy timeline in relation to the ITC Canada Surveys 3 Figure 2 Canada s first set of pictorial health warnings ( ) 10 Figure 3 Canada s current pictorial health warnings on cigarette packs ( present) + 2 warnings on little cigar packs 11 Figure 4 Average number of cigarettes smoked per day among daily smokers, by region, by wave 35 Figure 5 Percentage of smokers who report using roll-your-own cigarettes, by region, by wave 36 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Percentage of smokers who have ever heard of electronic cigarettes, by region, Wave 8 (Jul 10 Jun 11) 37 Percentage of smokers who have ever tried electronic cigarettes, by region, Wave 8 (Jul 10 Jun 11) 37 Percentage of smokers who think that electronic cigarettes are less harmful than regular cigarettes among those who have heard of electronic cigarettes, by region, Wave 8 (Jul 10 Jun 11) 38 Percentage of smokers who would support or strongly support a law that banned all additives from cigarettes, by region, Wave 8 (Jul 10 Jun 11) 38 Percentage of smokers who would support or strongly support a law that banned additives and flavourings that make cigarettes seem less harsh, by region, by wave 39 Percentage of smokers who agree or strongly agree that if they had to do it over again, they would not have started smoking, by region, Wave 8 (Jul 10 Jun 11) 39 Percentage of smokers who agree or strongly agree that society disapproves of smoking, by region, Wave 8 (Jul 10 Jun 11) 40 Percentage of smokers who plan to quit smoking within the next six months, by region, Wave 8 (Jul 10 Jun 11) 40 vii

11 List of Tables and Figures << Figures Figure 14 Figure 15 Figure 16 Figure 17 Figure 18 Various reasons that led smokers to think about quitting smoking somewhat or very much in the last six months, by wave 41 Percentage of smokers who reported that the effect of smoke on non-smokers led them to think about quitting smoking somewhat or very much in the last six months, by region, Wave 8 (Jul 10 - Jun 11) 42 Percentage of smokers who reported that the price of cigarettes led them to think about quitting smoking somewhat or very much in the last six months, by region, Wave 8 (Jul 10 Jun 11) 42 Percentage of smokers who reported that smoking restrictions at work led them to think about quitting smoking somewhat or very much in the last six months, by region, Wave 8 (Jul 10 Jun 11) 42 Percentage of smokers who reported that close friends and family disapproval of their smoking led them to think about quitting smoking somewhat or very much in the last six months, by region, Wave 8 (Jul 10 Jun 11) 42 Figure 19 Percentage of smokers who received various forms of support for cessation, by wave 43 Figure 20 Figure 21 Figure 22 Percentage of smokers who received various forms of support for cessation from a physician, by region, Wave 8 (Jul 10 Jun 11) 44 Percentage of smokers who agree or strongly agree that the government should do more to tackle the harm done by smoking, by region, Wave 8 (Jul 10 Jun 11) 45 Percentage of smokers who would support or strongly support a law that banned tobacco products completely, by region, Wave 8 (Jul 10 Jun 11) 45 Figure 23 Timeline of Canada s indoor smoke-free policies in relation to the ITC Canada Surveys 47 Figure 24 Percentage of smokers who are employed outside their home who reported having a complete indoor smoking ban at their workplace, by wave 49 Figure 25 Percentage of smokers who noticed people smoking indoors at various venues, by wave 50 Figure 26 Percentage of smokers who are employed outside their home who noticed people smoking indoors at their workplace in the last month, by region, by wave 51 Figure 27 Percentage of smokers who support complete smoking bans in various venues, by wave 52 Figure 28 Figure 29 Figure 30 Figure 31 Figure 32 Figure 33 Percentage of smokers who support a complete smoking ban in all indoor workplaces, by region, by wave 53 Percentage of smokers who report having a complete smoking ban in restaurants/cafés, by wave 53 Percentage of smokers who noticed people smoking in a restaurant/café on last visit, by region, by wave 54 Percentage of smokers who support a complete smoking ban in restaurants/cafés, by region, by wave 55 Percentage of smokers who report having a complete smoking ban in bars and pubs, by wave 56 Percentage of smokers who noticed people smoking in a bar/pub on last visit, by region, by wave 57 viii

12 List of Tables and Figures << Figures Figure 34 Figure 35 Figure 36 Figure 37 Percentage of smokers who support complete smoking bans in bars/pubs, by region, by wave 58 Percentage of smokers who never allow smoking anywhere in their homes and who never smoke inside their car when non-smokers are present, by wave 59 Percentage of smokers who never allow smoking anywhere in their homes, by region, by wave 60 Percentage of smokers who reported that they never smoke inside their car when non-smokers are present, by wave 60 Figure 38 Timeline of Canada s smoking bans in private motor vehicles with children 61 Figure 39 Figure 40 Figure 41 Percentage of smokers who support a law that bans smoking in cars carrying children, by wave 62 Percentage of smokers who support smoking bans in outdoor areas of hospitality venues, by wave 63 Impact of health warnings on smokers perceptions and behaviours in the last month, by wave 66 Figure 42 8 of the 16 Round 1 pictorial warnings evaluated in the ITC Canada Survey 67 Figure 43 Figure 44 Figure 45 Percentage of smokers who are aware that smoking causes various health conditions or outcomes, by wave 68 Percentage of smokers who are aware of the presence of toxic chemicals in second-hand smoke, by wave 69 Percentage of smokers who agree or strongly agree that cigarettes should be sold in plain packages, by region, by wave 70 Figure 46 Australia s cigarette plain packaging 71 Figure 47 Smokers opinions and behaviours related to the price of cigarettes, by wave 72 Figure 48 Figure 49 Percentage of smokers who agree or strongly agree that they spend too much money on cigarettes, by region, by wave 73 Percentage of smokers who reported that they spent money on cigarettes that would have been better spent on household essentials such as food, by region, by wave 74 Figure 50 Affordability of cigarettes and change in affordability per year in 17 countries 75 Figure 51 Figure 52 Figure 53 Figure 54 Figure 55 Percentage of smokers who reported that price was a reason for brand selection among those who have smoked their current brand for less than one year, by region, by wave 77 Reasons for brand selection among those who have smoked their current brand for less than one year, by wave 78 Percentage of smokers who made a special effort to buy less expensive cigarettes, by region, by wave 78 Percentage of smokers who made an effort to purchase less expensive cigarettes and who purchased cigarettes from a First Nations reserve, by wave 79 Percentage of smokers who reported purchasing cigarettes from a First Nations reserve within the last six months, by region, by wave 80 ix

13 List of Tables and Figures << Figures Figure 56 Figure 57 Figure 58 Figure 59 Figure 60 Figure 61 Figure 62 Figure 63 Figure 64 Figure 65 Figure 66 Figure 67 Figure 68 Figure 69 Figure 70 Figure 71 Figure 72 Figure 73 Percentage of smokers who reported purchasing cigarettes from a First Nations reserve many times or all the time within the last six months, by region, by wave 80 Percentage of smokers reporting purchasing cigarettes from various tax avoiding sources at last purchase, by country 81 Percentage of smokers who support or strongly support restricting the number of places where cigarettes can be purchased, by region, Wave 7 (Oct 08 Jul 09) and Wave 8 (Jul 10 Jun 11) 82 Percentage of smokers who noticed advertising or information often or very often in the last six months that talks about the dangers of smoking or encourages quitting, by wave 83 Percentage of smokers who noticed advertising or information often or very often in the last six months that talks about the dangers of smoking or encourages quitting, by region, by wave 84 Various media and venues where smokers noticed anti-smoking messages in the last six months, by wave 84 Percentage of smokers who noticed anti-smoking messages on television and on store windows or inside stores in the last six months, by region, Wave 8 (Jul 10 Jun 11) 85 Percentage of smokers who are aware that smoking causes various health conditions or outcomes, by region, Wave 8 (Jul 10 Jun 11) 86 Percentage of smokers who are aware of the presence of toxic chemicals in second-hand smoke, by region, Wave 8 (Jul 10 Jun 11) 87 Percentage of smokers who noticed cigarettes or tobacco products being advertised in various venues and media in the last six months, by wave 90 Percentage of smokers who noticed people smoking in entertainment media often or very often in the last six months, by wave 91 Percentage of smokers who were exposed to various forms of cigarette or tobacco product promotion that used strategies to increase exposure to cigarettes or tobacco products in the last six months, by wave 92 Percentage of smokers who noticed clothing or other items with cigarette brands or logos, or competitions linked to cigarettes in the last six months, by wave 93 Percentage of smokers who have seen or heard about various forms of cigarette or tobacco sponsorship in the last six months, by wave 94 Percentage of smokers who noticed special price offers, free gifts or special discount offers, or free samples in the last six months, by wave 95 Percentage of smokers who noticed cigarette packages displayed inside shops or stores in the last month, by region, by wave 96 Percentage of smokers who noticed tobacco advertising on store windows or inside stores where tobacco products are sold in the last six months, by region, by wave 97 Percentage of smokers who support complete bans on cigarette advertising and cigarette displays inside shops and stores, by wave 98 x

14 The ITC Canada Wave 1 to 8 National Report is a superb example of the importance of scientific research in the fight against the global tobacco epidemic, which threatens to kill up to one billion people in the world in the 21 st Century. This timely resource will surely support civil society and decision-makers in mobilizing stronger implementation of the FCTC in Canada and throughout the world. Francis Thompson Director of Policy and Advocacy Framework Convention Alliance

15 ITC Policy Evaluation Project The International Tobacco Control Policy Evaluation Project (the ITC Project) is a multi-country prospective cohort study designed to measure the psychosocial and behavioural impact of key policies of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in more than 20 countries. In 2002, researchers in Canada (University of Waterloo) formed a collaboration with an international team of researchers in Australia (The Cancer Council of Victoria), the United Kingdom (University of Strathclyde), and the United States (Roswell Park Cancer Institute and University of Illinois at Chicago) to create the ITC Four Country Project. Over the years, a number of other organizations and investigators have been involved in the ITC Four Country Project including University of Stirling, The Open University, State University of New York at Buffalo, Medical University of South Carolina, University of Nottingham, St. Andrews University, and King s College London. The ITC Four Country Project conducts nationally representative longitudinal cohort surveys of adult smokers in Canada, Australia, the United Kingdom, and the United States. The ITC Canada Wave 1 to 8 Surveys were conducted approximately annually between 2002 to ITC Four Country Survey Investigators Dr. Geoffrey T. Fong* University of Waterloo, Canada Dr. Mary E. Thompson University of Waterloo, Canada Dr. Christian Boudreau University of Waterloo, Canada Dr. David Hammond University of Waterloo, Canada Dr. K. Michael Cummings* Medical University of South Carolina, United States Dr. Andrew Hyland Roswell Park Cancer Institute, United States Dr. Richard J. O Connor Roswell Park Cancer Institute, United States Dr. James F. Thrasher University of South Carolina, United States Dr. Frank J. Chaloupka University of Illinois at Chicago, United States Dr. Ron Borland* The Cancer Council Victoria, Australia Dr. Hua-Hie Yong The Cancer Council Victoria, Australia Dr. Melanie Wakefield The Cancer Council Victoria, Australia Dr. Gerard Hastings* University of Stirling and The Open University, United Kingdom Dr. Ann McNeill* King`s College London, United Kingdom Dr. Louise Hassan Bangor University, United Kingdom Dr. Fiona Harris The Open University, United Kingdom *Principal Investigators ITC Canada Project Management Mary McNally, Lead Project Manager (Waves 5 and 6) Janine Ouimet, Lead Project Manager (Waves 7 and 8) Amanda Duncan, Lead Project Manager (Wave 8) Ruth Loewen, Survey Manager (Waves 1 to 8) Funding for the ITC Canada Project Canadian Institutes of Health Research (CIHR) (57897, 79551, ) U.S. National Cancer Institute (NCI) (P50 CA (Roswell Park Transdisciplinary Tobacco Use Center), RO1 CA100362, P01 CA138389) Robert Wood Johnson Foundation (045734) Canadian Tobacco Control Research Initiative (014578) Propel Centre for Population Health Impact (formerly Centre for Behavioural Research and Program Evaluation (CBRPE) at the University of Waterloo) Ontario Institute for Cancer Research (OICR) (Senior Investigator Award to Geoffrey T. Fong) Support for the preparation of this Report was provided by the Canadian Cancer Society Research Institute through a Prevention Scientist Award to Geoffrey T. Fong. Acknowledgements This report was prepared by a team of collaborators at the University of Waterloo: Dr. Janet Chung-Hall (lead author), Lorraine Craig (project management), Pete Driezen (data analysis), and Megan Tait (data visualization and contributor to Methods chapter). Peer review was provided by Melodie Tilson of the Non-Smokers Rights Association (Tobacco Landscape and Findings chapters), Dr. Geoffrey T. Fong (reviewer and contributor to recommendations), Dr. Anne C.K. Quah (editing), Dr. G. Emmanuel Canada Guindon of the Université de Montréal (Tobacco Price and Taxation chapter), and Dr. David Hammond of the University of Waterloo (Health Warning Labels chapter). We would like to acknowledge the efforts of Dr. Tara Elton-Marshall and Taryn Sendzik who provided project management support from to 2004 (Dr. Tara Elton-Marshall) and 2005 to 2006 (Taryn Sendzik). Graphic design and layout provided by Sonya Lyon of Sentrik Graphic Solutions Inc. xii

16 BACKGROUND The ITC Project Surveys The International Tobacco Control Policy Evaluation Project (the ITC Project) is the first-ever international cohort study of tobacco use. Its overall objective is to measure the psychosocial and behavioural impact of key national level policies of the WHO Framework Convention on Tobacco Control (FCTC). The ITC Project is a collaborative effort with international health organizations, researchers, and policymakers in more than 20 countries (see back cover) so far, inhabited by more than 50% of the world s population, 60% of the world s smokers, and 70% of the world s tobacco users. In each country, the ITC Project is conducting longitudinal cohort surveys to assess the impact and identify the determinants of effective tobacco control policies in each of the following areas: Health warning labels and pack descriptors Pricing and taxation of tobacco products Tobacco advertising and promotion Smoke-free legislation Education and support for cessation All ITC surveys are developed using the same conceptual framework and methods, and the survey questions, which include more than 150 questions directly relating to policy impact, are designed to be identical or functionally equivalent across all ITC countries in order to allow strong cross-country comparisons. The ITC Project aims to provide an evidence base to guide policies enacted under the FCTC, and to systematically evaluate the effectiveness of these legislative efforts. The ITC Canada Survey In 2002, researchers in Canada (University of Waterloo) partnered with an international team of researchers in Australia (The Cancer Council of Victoria), the United Kingdom (University of Strathclyde), and the United States (Roswell Park Cancer Institute and University of Illinois at Chicago) to create the ITC Four Country Project. The ITC Four Country Project conducts nationally-representative longitudinal cohort surveys of adult smokers in Canada, Australia, the United Kingdom, and the United States. The main objectives of the ITC Canada Survey are: 1) To examine patterns of smoking behaviour and opinions associated with smoking among adults in Canada. The ITC Survey collects detailed information on adult smokers quitting behaviour, consumption patterns, and other important aspects of smoking behaviour. 2) To examine the impact of specific tobacco control policies implemented in Canada. The ITC Survey includes several sections that are designed to evaluate the impact of specific FCTC policies (e.g., health warning labels on cigarette packs, smoke-free laws, mass media campaigns, and price/taxation increases) on smokingrelated behaviours, beliefs, and attitudes. 3) To compare the behaviour of smokers and the impact of policies between Canada and other ITC countries. The ITC Survey is being administered in more than 20 countries. ITC Survey questions are identical or very similar across all ITC countries which allows for comparison of smoking patterns and the impact of policies in Canada with those in other ITC countries. The ITC Canada Survey is a prospective longitudinal study of adult smokers aged 18 years or older. Data for Waves 1 to 6 were collected using computer-assisted telephone interviewing (CATI) software. Data for Waves 7 and 8 were collected using online web-based surveys, with respondents who did not complete the web survey within a set time frame being re-routed back into the telephone calling queue to complete the survey by CATI. 1

17 This report presents findings from the ITC Canada Wave 1 to 8 Surveys ( ). The sample size was initially around 2000 at each wave, with replenishment sampling from the same sampling frame to maintain sample size across waves (with a slightly reduced sample in Waves 7 and 8). The sample sizes and composition of the sample at each wave are summarized in the Methods section. The ITC Canada Wave 1 Survey (2002) was conducted after the implementation of the first round of pictorial warning labels in Canada (July 2001). The ITC Canada Wave 2 to 8 Surveys ( ) were conducted during the implementation of several other major tobacco control policies, including a ban on tobacco advertising in all domestic print media (October 2009), a comprehensive ban on smoking in indoor workplaces and public places (in 9 provinces and 1 territory as of January 2010), a full ban on retail displays of tobacco products at all point of sale locations (in all 10 provinces and 3 territories as of January 2010), a ban on smoking in private motor vehicles carrying children (in 6 provinces and 1 territory as of January 2010), and a comprehensive ban on smoking on all outdoor patios (in 3 provinces and 1 territory of as of January 2010). An overview of the ITC Canada Survey dates in relation to the implementation of tobacco control policies in Canada is provided in Figure 1. The ITC Project aims to provide an evidence base to guide policies enacted under the FCTC, and to systematically evaluate the effectiveness of these legislative efforts. This report provides a detailed picture of the tobacco control landscape in Canada and an evaluation of Canada s implementation of the FCTC based on ITC Canada Wave 1 to 8 findings. 2

18 Figure 1. Canada s tobacco control policy timeline in relation to the ITC Canada Surveys June rotating pictorial health warnings required to cover 50% of the front and back of the pack - one side must be English, the other French Oct 2003 Tobacco advertising and promotion restrictions of 1997 federal Tobacco Act expanded to include promotion of tobacco company sponsorships Nov 2004 FCTC ratification Oct 2005 Cigarette ignition propensity regulations implemented Feb 2007 Agreement with 9 manufacturers to ban misleading descriptors to settle complaint filed with federal Competition Bureau Wave 1 Oct Dec 2002 Smoker N=2,214 Wave 3 Jun Dec 2004 Smoker N=2,108 Wave 5 Oct 2006 Feb 2007 Smoker N=2,022 3 Wave 2 May Sep 2003 Smoker N=2,196 Wave 4 Oct 2005 Jan 2006 Smoker N=2,029 Wave 6 Sept 2007 Feb 2008 Smoker N=2,015

19 May 2008 Full bans on retail displays of cigarettes in stores in NU, PEI, NS, ON, QC Oct 2009 Ban on tobacco advertising in all print media (with exceptions) Jan Full bans on POS retail displays in 7 provinces and 2 territories - Restrictions on POS retail displays (bans only apply to premises that are accessible to minors) in 3 provinces and 1 territory - Comprehensive ban on smoking in indoor workplaces and public places in 9 provinces and 1 territory April 2010 Cigarette, little cigars, and blunt wraps packages must contain at least 20 sticks July 2010 Ban on flavours (except menthol) in cigarettes, cigarillos weighing 1.4 grams or less and having a filter, and blunt wraps July All 10 provinces and 1 territory had implemented a comprehensive smoking ban in indoor workplaces and public places (see Figure 23) - 8 provinces and 1 territory had prohibited smoking in vehicles carrying children (see Figure 38) Sept 2011 No longer obligated to list numerical values for toxic emissions. Ban on light/mild descriptors in the promotion of tobacco products and accessories Some 100% smoke-free multi-unit dwellings - Almost all federally regulated public modes of transportation are smoke-free, designated smoking rooms in some airports March 21, new picture-based health warnings - Warning covers 75% front and back of package - 8 new picture-based messages inside the package - Quit line number and web address added to health warnings Wave 7 Oct 2008 Feb 2009 Smoker N=1,846 Wave 9 Anticipated Aug 2013 May 2014 Smoker N=1,500 Wave 8 July 2010 June 2011 Smoker N=1,581 4

20 Executive Summary Canada has long been recognized as a world leader in tobacco control being the first country to require pictorial health warnings in 2001, and more recently, the first country to ban all flavours (except menthol) in cigarettes and some little cigars. Canada was one of the first 40 countries to ratify the WHO Framework Convention on Tobacco Control (WHO FCTC), the world s first health treaty, on November 26, The treaty requires Member Parties to implement a variety of evidence-based measures to reduce tobacco use and exposure to second-hand smoke. The International Tobacco Control Policy Evaluation Project is the first-ever international cohort study of tobacco use. Its overall objective is to measure the psychosocial and behavioural impact of key national level policies of the FCTC. The ITC Canada Survey was launched in 2002 in an effort to evaluate Canada s progress in implementing the FCTC, to evaluate the impact of policies on patterns of the smoking behaviour and opinions of adult smokers in Canada, and to compare findings with smokers in more than 20 ITC countries. The ITC Canada Survey is conducted as part of the ITC Four Country Project which conducts approximately annual cohort surveys of adult smokers in Canada, the United State, the United Kingdom, and Australia. Eight survey waves have been conducted between 2002 and 2011 among a sample of approximately 1500 randomly selected smokers with replenishment to replace those who are lost to follow up. The surveys are conducted using computer-assisted telephone surveys and web-based surveys. Evidence from the Wave 1 to 8 Surveys indicate that Canada has made great progress in implementing effective tobacco control policies, even before the ratification of the FCTC, however findings highlight the importance of ongoing monitoring of policy impact and periodic updating of policies, in order to maintain their effectiveness. The main study findings are highlighted below: Tobacco Use and Cessation The majority of Canadian smokers use cigarettes on a daily basis. In 2011, the vast majority of smokers used factory-made cigarettes exclusively, and only a small minority used smoked tobacco products other than cigarettes or smokeless tobacco products. The reported use of menthol cigarettes was low (4%) and more than two-thirds (66%) of smokers said they would support or strongly support a law that banned additives and flavourings that make cigarettes seem less harsh. Overall, there was low use of tobacco products other than cigarettes in Canada. Although 39% of smokers were aware of e-cigarettes, only 11% of these smokers (4% of all smokers) had ever used them. Among smokers who were aware of e-cigarettes, 89% believed that they were less harmful than regular cigarettes. More than 86% of smokers in 2011 reported that they had ever tried to quit smoking. Between 2002 and 2011, more than 2 out of 5 smokers identified the following as the most important reasons that led them to think about quitting: wanting to set an example for their children (41% to 48%), and concern for personal health (45% to 51%). Although Canadian smokers have a high degree of readiness to quit smoking, overall support for helping them to take steps towards quitting successfully remains low. 5

21 For example, 31% to 43% of smokers who had visited a doctor in were advised to quit, but less than 25% received other forms of support for cessation including pamphlets or brochures on how to quit, a prescription for stop smoking medications, or a referral to a cessation service. Smokers support stronger actions by the Canadian government to provide cessation assistance. More than half of smokers (57% to 64%) in agreed or strongly agreed that the government should to do more to tackle the harm done by smoking. In addition, 34% of smokers in said that they would support or strongly support a law that banned tobacco products completely. Smoke-free Policies With the implementation of smoke-free policies at the provincial and territorial level between 2002 and 2011, support for indoor smoke-free laws among smokers has increased over time. In 2011, approximately three-quarters (78%) of Canadian smokers supported complete bans on smoking in workplaces, restaurants, and cafés, while just over half (58%) supported smoke-free bars or pubs. Smoke-free laws have been very effective in reducing exposure to second-hand smoke in indoor public places and workplaces. Between 2005 and 2011, there were significant reductions in the percentage of smokers who noticed smoking in indoor areas of workplaces (from 28% to 11%), restaurants (from 20% to 1%) and bars or pubs (from 45% to 2%). The percentage of smokers who have smoke-free homes increased from about a quarter (27%) in 2002 to almost a half (43%) in In 2011, the majority of Canadians (80%) reported that smoking is never allowed in any car when children are present, and 83% expressed strong support for banning smoking in cars carrying children. In 2011, less than a quarter of smokers supported a complete ban on smoking in outdoor eating areas of restaurants and cafés and fewer supported smoke-free patios at bars and pubs. Warning Labels The ITC Wave 1 to 8 Surveys evaluated the effectiveness of Canada s first round of pictorial warning labels beginning two years after they were implemented up until the time they were replaced with new images after being on packs for more than ten years. There was strong evidence of a decline or levelling off in warning label effectiveness over time across all measures. There was a significant decline between 2002 and 2011 in the percentage of smokers who noticed the labels (from 55% to 39%), who read or looked closely at them (from 27% to 17%), who reported that the labels stopped them from having a cigarette (19% to 14%). The findings also provide evidence of a lack of awareness that smoking causes breast cancer, bladder cancer, and blindness. In 2011, support for plain packaging ranged from 32% of smokers in British Columbia to 55% of smokers in Quebec. Example of pictorial warnings from evaluated in this Report 6

22 Price and Taxation Cigarettes have become more affordable in Canada between 2002 and First Nations reserves are a primary source for the purchase of low or untaxed cigarettes. The percentage of smokers who reported last purchasing cigarettes for themselves on a First Nations reserve increased between late 2002 and , and has since levelled off or decreased. The percentage of smokers who reported purchasing cigarettes from a First Nations reserve in the last six months was highest in Ontario and had increased significantly from 2005 to Cigarette brand choice was driven by price among smokers who recently switched brands, the vast majority (73% to 80%) stated that price was the reason for their current brand choice. Education, Communication, and Public Awareness Anti-tobacco campaigns have become less visible over time. There was a significant decrease in the percentage of smokers who often or very often noticed advertising or information in the last six months either on the dangers of smoking or that encouraged quitting, from 52% in 2002 to 21% in In the absence of mass media public education campaigns, pictorial warnings continued to be a major source of information on the dangers of smoking and benefits of quitting. Between 2002 and 2011, the vast majority of smokers (70% to 82%) said that they noticed anti-smoking messages on cigarette packs. Tobacco Advertising, Promotion, and Sponsorship (TAPS) Federal and provincial bans on TAPS have significantly reduced the overall visibility of traditional forms of tobacco marketing including on store windows or inside stores where tobacco products are sold, on posters or billboards, in newspapers or magazines, and on television. Bans on retail displays of tobacco products at point of sale led to a near total elimination of this form of tobacco advertising. In 2011, only 6% of smokers noticed cigarette packages being displayed inside shops or stores where tobacco products are sold, which represents a significant reduction from 76% in There was also increasing support among smokers for tobacco advertising bans in retail locations, with nearly half of smokers in reporting that they would support complete bans on tobacco advertising inside shops and stores (47%), as well as complete bans on displays of cigarettes inside shops and stores (48%). However, smokers continue to be exposed to tobacco promotion through venues not currently covered by TAPS bans. For example, between 2002 and 2007, 18% to 21% of smokers reported seeing people smoking in the entertainment media often or very often in the last six months. The high prevalence (22%) of smokers reporting noticing special price offers for cigarettes suggests the need for further measures to control price and price promotions, including reducing the availability of cheaper brands. 7

23 Recommendations 1. Increase training for health professionals to enable them to provide cessation advice and support. Canadian smokers have a high degree of readiness to quit smoking, but the rate of physician advice to quit and providing links to cessation assistance and support remains low. 2. Implement a ban on menthol and other flavourings in tobacco products. Two-thirds of adult smokers in Canada support or strongly support a law that would ban additives and flavourings. 3. The vast majority of smokers in Canada who have heard of e-cigarettes (89%) believe that they are less harmful than regular cigarettes, and evidence so far supports these beliefs. Because of the extraordinary harmfulness of cigarettes, e-cigarettes offer potential for reducing harm. And thus, Health Canada should update their current legislation with respect to the production and sale of e-cigarettes. But at the same time, it will be critically important to examine how e-cigarettes are being used among smokers, former smokers, and especially among youth and young people. Do e-cigarettes promote quitting? Do they promote dual use rather than quitting smoking altogether? Is there evidence that they may act as a gateway product? The answers to these questions are essential to inform regulations and/or legislation that could lead to reduction of health harm at the level of the individual as well as for public health. 4. Slow progress in the implementation of smoke-free outdoor laws at the provincial level and low support for smoking bans in outdoor hospitality areas among smokers suggests the need for increased public education on the harms of second-hand smoke and dissemination of success stories in the implementation of outdoor smoke-free policies. 5. Evidence of wear-out effects associated with the Round 1 pictorial health warnings that appeared on cigarette packs for more than ten years and emerging evidence of the substantial impact that large pictorial warnings can have on smoking prevalence suggest that the Canadian government should follow FCTC Article 11 Guidelines that recommend rotation and refreshing of warnings every two to three years. 6. With the growing importance of the pack to the tobacco industry as a means of attracting consumers, and emerging studies showing the effectiveness of plain packaging in Australia, the Canadian government should move forward to implement legislation for plain and standardized tobacco packaging. 7. In order to harness the strong impact that price and taxation measures can have on lowering smoking prevalence, the Canadian government should continue to reduce the affordability of cigarettes by increasing prices and taxes, particularly in Ontario and Quebec, where average tobacco prices and total taxes are much lower than in other provinces/territories. While the evidence shows that the purchase of contraband cigarettes has levelled off recently, stronger measures are required to eliminate the availability of contraband tobacco products. 8. Declining awareness of anti-tobacco campaigns and gaps in knowledge of important health effects such as breast cancer, bladder cancer, and blindness suggest the need for sustained funding for campaigns on the health effects of tobacco use and the expansion of the content of pictorial health warnings to cover less well-known harms of smoking. 9. Point of sale display ban legislation in British Columbia, Manitoba, Saskatchewan, and the Northwest Territories should be strengthened by removing the exemption for venues that are not accessible by minors. Nearly one-quarter (22%) of smokers noticed special price offers for cigarettes, which highlights the need for further measures to control price and price promotions, including reducing the availability of cheaper brands. 10. There is a need to regulate smoking in movies and television programming by implementing strategies outlined in the Guidelines for Article 13 including requiring certification that no benefits have been received for tobacco depictions, prohibiting the use of identifiable tobacco brands or imagery, and requiring anti-tobacco advertisements and implementing a ratings or classification system that takes tobacco depictions into account. 8

24 THE TOBACCO LANDSCAPE IN CANADA This section provides an overview of tobacco use and tobacco control policies in Canada at the time of the Wave 1 to Wave 8 Surveys ( ). The WHO Framework Convention on Tobacco Control (FCTC), the world s first public health treaty, addresses the global tobacco epidemic through a variety of measures to reduce tobacco demand and supply, including price and taxation (Article 6), smoke-free policies (Article 8), packaging and labelling of tobacco products (Article 11), tobacco advertising and sponsorship (Article 13), cessation and treatment (Article 14), illicit trade (Article 15), and sales to minors (Article 16). 1 With 177 member Parties as of September 2013, the FCTC is one of the most successful treaties ever established. Canada is known as a world leader in tobacco control and on November 26, 2004 became one of the first 40 countries to ratify the treaty. Prevalence of Tobacco Use Tobacco Use among Adults and Youth Overall smoking prevalence among Canadian adults (aged 15 and older) decreased steadily from about 50% in 1965 to less than 20% in 2011, with a levelling off in this decline in the most recent years. 2 In 2011, the Canadian Tobacco Use Monitoring Survey (CTUMS) 3 found that smoking prevalence among adults (aged 15 and older) in Canada was 17.3%, with a higher prevalence of smoking among males (19.7%) than females (15.0%). Rates of smoking were highest among young adults aged 25 to 34 years (23.8%) and 20 to 24 years (21.5%), and lowest among youth aged 15 to 19 years (12.0%). Smoking prevalence was also significantly lower among adults with a university education (8.9%) in comparison to adults with a college education (19.1%). Prevalence of smoking also varied by province, ranging from 14.2% in British Columbia to 19.8% in Quebec. In 2011, daily smokers reported an average cigarette consumption of 14.4 cigarettes per day (CPD), with a significantly higher average daily cigarette consumption among males (15.2 CPD) than females (13.3 CPD). 2 Between 1999 and 2011, average cigarette consumption among daily smokers decreased across all provinces, and ranged from 13.6 CPD in Ontario to 16.3 CPD in New Brunswick in ,3 In Canada, the use of tobacco products other than cigarettes is overall very low. In 2011, less than 3.0% of Canadians reported using cigarillos, cigars, and waterpipe in the past 30 days, and less than 0.5% of Canadians reported using pipe or chewing tobacco/pinch/snuff in the past 30 days. For all of these tobacco products, rates of use were significantly higher among males than females, and among youth and young adults aged 15 to 24 years than adults aged 25 years and older. Prevalence of use of cigarillos/cigars ranged from 4.3% in Quebec to 2.2% in Prince Edward Island. 2 The Youth Smoking Survey (YSS) 3 showed that smoking prevalence among students in grades six to nine was 2.2% (2.2% for males, and 2.1% for females). The YSS also found that 15.5% of students had tried smoking. Existing studies have shown that flavoured tobacco products may be especially appealing to youth, and that the tobacco industry targets the marketing of these products to this demographic. 4, 5, 6 In 2011, 7.8% of Canadian students in grades six to nine reported ever using flavoured tobacco products including cigarillos, cigars, smokes tobacco, and waterpipe. 3 9