Return on investment of Canadian tobacco control policies implemented between 2001 and 2016.

OBJECTIVES: To determine the return on investment (ROI) associated with tobacco control policies implemented between 2001 and 2016 in Canada. METHODS: Canadian expenditures on tobacco policies were collected from government sources. The economic benefits considered in our analyses (decrease in healthcare costs, productivity costs and monetised life years lost, as well as tax revenues) were based on the changes in smoking prevalence and attributable deaths derived from the SimSmoke simulation model for the period 2001-2016. The net economic benefit (monetised benefits minus expenditures) and ROI associated with these policies were determined from the government and societal perspectives. Sensitivity analyses were conducted to check the robustness of the result. Costs were expressed in 2019 Canadian dollars. RESULTS: The total of provincial and federal expenditures associated with the implementation of tobacco control policies in Canada from 2001 through 2016 was estimated at $2.4 billion. Total economic benefits from these policies during that time were calculated at $49.2 billion from the government perspective and at $54.2 billion from the societal perspective. The corresponding ROIs were $19.8 and $21.9 for every dollar invested. Sensitivity analyses yielded ROI values ranging from $16.3 to $28.3 for every dollar invested depending on the analyses and perspective. CONCLUSIONS: This analysis has found that the costs to implement the Canadian tobacco policies between 2001 and 2016 were far outweighed by the monetised value associated with the benefits of these policies, making a powerful case for the investment in tobacco control policies.

Impact of Canada's menthol cigarette ban on quitting among menthol smokers: pooled analysis of pre-post evaluation from the ITC Project and the Ontario Menthol Ban Study and projections of impact in the USA.

INTRODUCTION: Between 2015 and 2018, Canada banned menthol cigarettes. This study pooled data from two pre-post cohort studies (the Ontario Menthol Ban Study, and the International Tobacco Control Policy Evaluation (ITC) Canada Survey, conducted in seven provinces) to derive more precise estimates of the impact of Canada's menthol ban on quitting and to apply these estimates to project the impact of a menthol ban in the USA. METHODS: Weighted multivariable logistic analyses compared post-ban quit success of menthol smokers with non-menthol smokers (for daily smokers and for all (daily + non-daily) smokers), controlling for sex, age, ethnicity, education, baseline smoking status, baseline cigarettes per day and study regions. Projections to the USA were created by multiplying the effect size of the Canadian menthol ban on quitting (percentage of increased quitting among menthol smokers) by the number of menthol smokers overall and among African Americans, from the 2019 National Survey on Drug Use and Health. RESULTS: After the menthol cigarette ban, menthol smokers were more likely than non-menthol smokers to have quit smoking among daily smokers (difference=8.0%; 95% CI: 2.4% to 13.7%,p=0.005) and all (daily+non-daily) smokers (difference=7.3%; 95% CI: 2.1% to 12.5%,p=0.006). The projected number of smokers who would quit after a US menthol ban would be 789 724 daily smokers (including 199 732 African Americans) and 1 337 988 daily+non-daily smokers (including 381 272 African Americans). CONCLUSIONS: This pooled analysis of Canada's menthol cigarette ban provides the foundation for estimating the impact of menthol bans in the USA and other countries. Projections suggest that a US menthol cigarette ban would have a substantial impact on increasing quitting.

Taking global leadership in banning menthol and other flavours in tobacco: Canada's experience.

Measures to ban or restrict menthol and other flavours in tobacco products are under consideration or newly implemented in an increasing number of jurisdictions across the world. As one of the world leaders, Canada's experience in successfully developing and implementing such measures can be instructive for other jurisdictions. This paper explores the history of how Canada was able to implement tobacco flavour bans including menthol, examines some of the challenges and presents lessons learnt for other jurisdictions. The crucial motivation for these bans emerged from surveillance data showing high rates of flavoured tobacco use by youth, including menthol cigarette smoking, that was publicised by non-governmental organisations. Further data showed that early legislation in 2009 contained loopholes (cigar size exemptions and menthol exemptions) that limited the benefits of the legislation. Leadership by the provinces created an environment in which the federal ban on menthol ingredients in 2017 was a clear and obvious step to ensure implementation across the country. The Canadian measures have been successful at reducing the use of flavoured tobacco including menthol cigarettes and facilitating smoking cessation. Lessons learnt include the downsides of exemptions, the lack of a contraband issue (despite an existing supply in Canada), the benefits of availability of youth flavour prevalence data and the success of subnational regulations to advance national regulation.

Trends in the Prevalence of Current, Daily, and Nondaily Cigarette Smoking and Quit Ratios by Depression Status in the U.S.: 2005-2017.

INTRODUCTION: Cigarette smoking remains more common among individuals with depression. This study investigates whether cigarette quit ratios and cigarette use prevalence have changed differentially by depression status during the past decade. METHODS: National Survey on Drug Use and Health data (2005-2017) were analyzed in 2019. Respondents aged ≥12 years were included in analyses of smoking prevalence (n=728,691) and respondents aged ≥26 years were included in analyses of quit ratio (n=131,412). Time trends in smoking prevalence (current, daily, and nondaily) and quit ratio (former/lifetime smokers) were estimated, stratified by past-year depression. Adjusted analyses controlled for demographics. RESULTS: Smoking prevalence was consistently higher among those with depression than those without depression. From 2005 to 2017, nondaily smoking did not significantly change among individuals with depression (9.25% to 9.40%; AOR=0.995, 95% CI=0.986, 1.005), whereas it decreased from 7.02% to 5.85% among those without depression (AOR=0.986, 95% CI=0.981, 0.990). By contrast, daily smoking declined among individuals with (25.21% to 15.11%; AOR=0.953, 95% CI=0.945, 0.962) and without depression (14.94% to 9.76%; AOR=0.970, 95% CI=0.967, 0.973). The quit ratio increased among individuals with (28.61% to 39.75%; AOR=1.036, 95% CI=1.021, 1.052) and without depression (47.65% to 53.09%; AOR=1.013, 95% CI=1.009, 1.017), yet quit ratios were consistently lower for those with depression than those without depression. CONCLUSIONS: Quit ratios are increasing and smoking prevalence is decreasing overall, yet disparities by depression status remain significant. Disparities in quit ratio may be one contributing factor to the elevated prevalence of smoking among those with depression. Innovative tobacco control approaches for people with depression appear long overdue.

Ban on menthol-flavoured tobacco products predicts cigarette cessation at 1 year: a population cohort study.

OBJECTIVES: The province of Ontario, Canada, banned the use of menthol-flavoured tobacco products as of 1 January 2017. The long-term impact of a menthol ban on smoking behaviour has not been previously evaluated. METHODS: Population cohort study with baseline survey conducted September-December 2016 and follow-up January-August 2018 among residents of Ontario, Canada, 16 years old and over who reported current smoking (past 30 days) at baseline survey and completed follow-up (n=913) including 187 reporting smoking menthol cigarettes daily, 420 reported smoking menthol cigarettes occasionally, and 306 were non-menthol cigarette smokers. Relative rates of making a quit attempt and being a non-smoker at follow-up were estimated with Poisson regression controlling for smoking and demographic characteristics at baseline. RESULTS: At follow-up, 63% of daily menthol smokers reported making a quit attempt since the ban compared with 62% of occasional menthol smokers and 43% of non-menthol smokers (adjusted relative rate (ARR) for daily menthol smokers compared with non-menthol smokers: 1.25; 95% CI 1.03 to 1.50). At follow-up, 24% of daily menthol smokers reported making a quit since the ban compared with 20% of occasional menthol smokers and 14% of non-menthol smokers (ARR for daily menthol smokers compared with non-menthol smokers: 1.62; 95% CI 1.08 to 2.42). CONCLUSIONS: The study found higher rates of quitting among daily and occasional menthol smokers in Ontario 1 year after the implementation of a menthol ban compared with non-menthol smokers. Our findings suggest that restrictions on menthol may lead to substantial improvements in public health.

Association of flavoured cigar regulations with wholesale tobacco volumes in Canada: an interrupted time series analysis.

INTRODUCTION: This study examines the association of Federal Canadian regulations passed in 2009 addressing flavours (excluding menthol) in small cigars with changes in cigar sales. METHODS: Quarterly wholesale unit data as reported to Health Canada from 2001 through 2016 were analysed using interrupted time series analysis. Changes in sales of cigars with and without flavour descriptors were estimated. Analyses were seasonally adjusted. Changes in the flavour types were assessed over time. RESULTS: The Federal flavour regulations were associated with a reduction in the sales of flavoured cigars by 59 million units (95% CI -86.0 to -32.4). Increases in sales of cigars with descriptors other than flavours (eg, colour or other ambiguous terms) were observed (9.6 million increase (95% CI -1.3 to 20.5), but the overall level (decline of 49.6 million units (95% CI -73.5 to -25.8) and trend of sales of cigars (6.9 million units per quarter (95% CI -8.1 to -5.7)) declined following the ban. Sensitivity analysis showed that there was no substantial difference in effect over time comparing Ontario and British Columbia, suggesting that other provincial tobacco control legislation was not associated with the changes in levels. Analyses suggested that the level change was sensitive to the specification of the date. CONCLUSION: This study demonstrates that flavour regulations have the potential to substantially impact tobacco sales. However, exemptions for certain flavours and product types may have reduced the effectiveness of the ban, indicating the need for comprehensive, well-designed regulations.

Tobacco retail availability and risk of relapse among smokers who make a quit attempt: a population-based cohort study.

INTRODUCTION: The availability of tobacco is thought to influence smoking behaviour, but there are few longitudinal studies examining if the location and number of tobacco outlets has a prospective impact on smoking cessation. METHODS: The Ontario Tobacco Survey, a population-representative sample of Ontario adult smokers who were followed every 6 months for up to 3 years, was linked with tobacco outlet location data from the Ontario Ministry of Health. Proximity (distance), threshold (at least one outlet within 500 m) and density (number of outlets within 500 m) with respect to a smokers' home were calculated among urban and suburban current smokers (n=2414). Quit attempts and risk of relapse were assessed using logistic regression and survival analysis, adjusted for neighbourhood effects and individual characteristics. RESULTS: Increased density of tobacco outlets was associated with decreased odds of making a quit attempt (OR: 0.54; 95% CI 0.35 to 0.85) in high-income neighbourhoods, but not in lower income ones. There was an increased risk of relapse among those who had at least one store within 500 m (HR: 1.41 (95% CI 1.06 to 1.88). Otherwise, there was no association of proximity with quit attempts or relapse. CONCLUSIONS: The existence of a tobacco retail outlet within walking distance from home was associated with difficulty in succeeding in a quit attempt, while the increased density of stores was associated with decreased attempts in higher income neighbourhoods. The availability of tobacco may influence tobacco use through multiple mechanisms.

Health professional advice, use of medications and smoking cessation: A population-based prospective cohort study.

INTRODUCTION: The mediating role of cessation medications in the association between health professional advice and quitting behaviors is unclear. METHODS: Data were from the Ontario Tobacco Survey longitudinal study, collected between July 2005 and June 2011 in Ontario, Canada. The analytic sample included 3437 baseline smokers who were seen by health professionals during follow-up. Logistic regression with generalized estimating equations and mediation analysis techniques were used to examine the impact of advice and medications on quitting outcomes (making a quit attempt, short-term quitting 1-6months and long-term quitting>6months). RESULTS: Those who received advice to quit smoking were more likely to use cessation medications than those who did not receive advice (21% vs. 13%, P<0.001). Receiving advice was associated with making a quit attempt (adjusted odds ratio (OR) 1.25, 95% confidence interval (CI) 1.10-1.41) and long-term quitting (adjusted OR 1.49, 95% CI 1.10-2.02), but not with short-term quitting. Use of cessation medications was associated with making a quit attempt (adjusted OR 11.83, 95% CI 9.93-14.08), short-term quitting (adjusted OR 3.69, 95% CI 2.90-4.68), and long-term quitting (adjusted OR 2.73, 95% CI 1.95-3.82). Using prescription medications was associated with a higher likelihood of quitting short-term (adjusted OR 2.43, 95% CI 2.59-3.74) and long-term (adjusted OR 2.27, 95% CI 1.23-4.17) than using NRT. Use of cessation medications was a significant mediator in the pathway from receiving advice to quitting. CONCLUSION: Health professionals should advise smokers to quit and encourage them to use cessation medications, especially prescription medications when trying to quit.

Tobacco retail outlets and vulnerable populations in Ontario, Canada.

Interest has been increasing in regulating the location and number of tobacco vendors as part of a comprehensive tobacco control program. The objective of this paper is to examine the distribution of tobacco outlets in a large jurisdiction, to assess: (1) whether tobacco outlets are more likely to be located in vulnerable areas; and (2) what proportion of tobacco outlets are located close to schools. Retail locations across the Province of Ontario from Ministry of Health Promotion data were linked to 2006 Census data at the neighbourhood level. There was one tobacco retail outlet for every 1,000 people over age 15 in Ontario. Density of outlets varied by public health unit, and was associated with the number of smokers. Tobacco outlets were more likely to be located in areas that had high neighbourhood deprivation, in both rural and urban areas. Outlets were less likely to be located in areas with high immigrant populations in urban areas, with the reverse being true for rural areas. Overall, 65% of tobacco retailers were located within 500 m of a school. The sale of tobacco products is ubiquitous, however, neighbourhoods with lower socio-economic status are more likely to have easier availability of tobacco products and most retailers are located within walking distance of a school. The results suggest the importance of policies to regulate the location of tobacco retail outlets.

Do components of current 'hardcore smoker' definitions predict quitting behaviour?

AIMS: It has been hypothesized that the smoking population is represented by an increasingly 'hardcore' group of smokers who are resistant to quitting. Many definitions of 'hardcore smokers' have been used, but their predictive validity is unknown. To evaluate whether 'hardcore smoker' definition components predict quitting behaviours and which combinations of 'hardcore' components are most predictive. DESIGN, SETTING AND PARTICIPANTS: Longitudinal, random telephone survey of a representative sample of adult smokers in Ontario, Canada (n = 4130, recruited 2005-08 and followed for 1 year). MEASUREMENTS: Multiple logistic regression models were compared to evaluate the predictive ability of 'hardcore' components (high daily cigarette consumption, high nicotine dependence, being a daily smoker, history of long-term smoking, no quit intention and no life-time quit attempt) on three outcomes [continued smoking, not attempting to quit and having unsuccessful quit attempt(s)]. FINDINGS: All 'hardcore' components predicted having no quit attempt and continued smoking during follow-up (P < 0.05), except for history of long-term smoking and no life-time quit attempt (for continued smoking). Among respondents who made 1 + quit attempts during follow-up, only high nicotine dependence, high daily cigarette consumption and being a daily smoker were predictive of quitting failure (P < 0.01). The best combination of components depended on the outcome. CONCLUSIONS: Measures of 'hardcore' include a mixture of motivational, dependence and behavioural variables. As found previously, motivational and behavioural measures, such as intention to quit, predict failure to make quit attempts. However, dependence components best predicted continued smoking and thus would be best for further exploring the hardening hypothesis.

Taking stock a bibliometric analysis of the focus of tobacco research from the 1980s to the 2000s.

BACKGROUND: Little is known about the body of tobacco research as a whole. PURPOSE: This paper examines the changes in literature focus (1980s to 2000s) and identifies areas in need of increased attention. METHODS: Tobacco articles randomly selected from searches of the MEDLINE and Web of Science databases were coded according to (1) epidemiologic framework component; (2) study focus; and (3) form of tobacco. Frequencies, cross-tabulations, and tests of proportions were conducted. The analysis was conducted in 2009. RESULTS: From the 1980s to the 2000s, there was a significant decrease in tobacco-related articles focusing on the "agent" and an increase in articles focusing on the "host." Few articles in either decade focused on the "environment" or on the "vector" (<10%). The percentage of study foci addressing health effects decreased, whereas prevalence/use and cessation foci increased. Approximately two thirds of articles focused on the cigarette. CONCLUSIONS: The nature of tobacco research has shifted from examining the links between cigarettes and disease to understanding why people smoke and how to help them quit. Proportionately more research could focus on the environment and vector components of the epidemiologic framework, to expand strategies for reducing tobacco-related disease.

"Hardcore" definitions and their application to a population-based sample of smokers.

INTRODUCTION: As smoking prevalence declines, some suggest that so-called "hardcore" smokers will come to represent a growing and irreducible proportion of current smokers ("hardening hypothesis"). Different definitions of a "hardcore" smoker have been used in the literature. This paper describes population-based definitions of "hardcore" smokers and compares estimates of the prevalence of "hardcore" smokers derived using these definitions. METHODS: Definitions identified in a comprehensive literature search were reduced to their component constructs. We estimated the prevalence of "hardcore" smokers as a proportion of all current adult smokers in Ontario, Canada, using data from the Ontario Tobacco Survey (2005-2008; N = 4,130). Definition concordance was examined using bivariate cross-tabulations. RESULTS: Six definitions were identified in the literature. Five definitions included constructs of quit intentions and quit attempts, four included nicotine dependence, three included long-term use, and one included a measure of smoker knowledge about smoking hazards and confronting substantial societal disapprobation of smoking. Estimates of "hardcore" smoker prevalence in Ontario based on these definitions ranged from 0.03% to 13.77%. CONCLUSIONS: Estimates of the prevalence of "hardcore" smokers in Ontario varied considerably between the six definitions of the "hardcore" smokers found in the population-based literature. This study underscores the need for consensus on the best definition of "hardcore" smoker.

A systematic review of longitudinal studies on the association between depression and smoking in adolescents.

BACKGROUND: It is well-established that smoking and depression are associated in adolescents, but the temporal ordering of the association is subject to debate. METHODS: Longitudinal studies in English language which reported the onset of smoking on depression in non clinical populations (age 13-19) published between January 1990 and July 2008 were selected from PubMed, OVID, and PsychInfo databases. Study characteristics were extracted. Meta-analytic pooling procedures with random effects were used. RESULTS: Fifteen studies were retained for analysis. The pooled estimate for smoking predicting depression in 6 studies was 1.73 (95% CI: 1.32, 2.40; p < 0.001). The pooled estimate for depression predicting smoking in 12 studies was 1.41 (95% CI: 1.21, 1.63; p < 0.001). Studies that used clinical measures of depression were more likely to report a bidirectional effect, with a stronger effect of depression predicting smoking. CONCLUSION: Evidence from longitudinal studies suggests that the association between smoking and depression is bidirectional. To better estimate these effects, future research should consider the potential utility of: (a) shorter intervals between surveys with longer follow-up time, (b) more accurate measurement of depression, and (c) adequate control of confounding.

Population health and the hardcore smoker: Geoffrey Rose revisited.

The "hardening hypothesis" suggests that as smoking prevalence decreases, lighter smokers will quit first, leaving more "hardcore" smokers in the population. At a population level, however, the weight of evidence suggests that no hardening is occurring. By understanding the lessons from Geoffrey Rose's model of population-level risk factor change, we argue that the hardening of the smoking population is not inevitable. The Rose model predicts that the effect of policy interventions, and changes in social norms, can shift the population-level risk distribution for continuing to be a smoker, making it more likely that all smokers will quit. This analysis also suggests that further reductions in smoking prevalence will not come without further changes in the underlying--and largely cultural--root causes of smoking in a population.

Environment modifies the association between depression symptoms and smoking among adolescents.

Previous studies have shown a strong correlation between depression and smoking, but the mechanism underlying the relationship is not well understood. This study examined whether the prevalence of smoking in schools influences the relationship between smoking and depression symptoms at the individual level. Information on demographics, tobacco use, and depression symptoms for 3,382 students in Grades 7-12 from 126 schools in Ontario, Canada, was obtained from the 2003 Ontario Student Drug Use Survey (E. Adlaf & A. Paglia, 2003). The effect of school-level smoking was strongly negative (coefficient = -1.05, p = .01), suggesting that depression and smoking at the individual level were strongly related in schools with a lower smoking prevalence but that this relationship diminished as the prevalence of smoking increased. Contextual effects may be important to understanding the link between smoking and depression in adolescents.

The Heaviness of Smoking Index as a predictor of smoking cessation in Canada.

Nicotine addiction is believed to be a major impediment for many people in quitting smoking, but measures of nicotine dependence such as the Heaviness of Smoking Index (HSI) have had mixed success in predicting cessation. Using the National Population Health Survey, the relationship between HSI at baseline in cycle 2 (1996-1997) and successful smoking cessation at cycle 3 (1998-1999) and cycle 4 (2000-2001) was examined in 2938 Canadian adult smokers. A logistic regression model was developed for HSI as a predictor of smoking cessation, and then tested for interaction and confounding. The odds ratio of not smoking in cycle 3 was 2.08 (95% CI: 1.51, 2.86; p<0.001) for low HSI (<2) compared to medium HSI. When the period of follow-up was extended, individuals with both high (>4) HSI scores (OR 2.16; 95% CI: 1.11, 4.21; p=0.02) and low scores (OR 2.22; 95% CI: 1.41, 3.49) had higher odds of not smoking at both cycle 3 and cycle 4 than those with medium HSI scores. The likelihood of reporting cessation was higher than expected in the Canadian population among highly dependent smokers, particularly among older smokers, those with middle or greater income adequacy, and those with no intention to quit smoking. There were no substantial changes to the results when those lost-to-follow-up were treated as continuing smokers. These findings indicate that nicotine dependence is only one factor in succeeding at a quit attempt. Individual and population strategies for smoking cessation may need to consider other influences such as cognitive, affective and environmental factors.

Smoker preference for "elastic cigarettes" in the Canadian cigarette market.

Elastic cigarettes are characterized by yields of constituents that increase proportionally faster than smoke volume as cigarettes are smoked more intensely. Elasticity may function to overcome physical limitations in increasing puff volume during nicotine-seeking behaviour. The purpose of this study was to determine if there are elastic cigarettes in the Canadian cigarette market and to determine smoker preference for elastic cigarettes. Elasticity was calculated for 115 brands in the Canadian filtered cigarette market for puff volumes of 44 and 56 ml. Puff volumes, nicotine and tar deliveries were obtained from earlier published documents. Sales data were used as a proxy for smoker preference. Ordinary least squares regression was used to determine the association of sales and elasticity in the Canadian cigarette market. The cigarette brands ranged from a mean elasticity value of 1.21 to 0.67. Of the 115 Canadian cigarette brands tested, 23 brands had a mean elasticity value significantly over 1.00, making them elastic. After adjusting for brand, the average elastic cigarette sold an average of 361 million cigarettes while an inelastic cigarette sold 89.5 million cigarettes (p<0.0001). The difference in sales between elastic and inelastic cigarettes was independent of tar yield and filter type. Elasticity was not associated with tar yield (p=0.2734). There are elastic cigarettes in the Canadian cigarette market and the results suggest a possible smoker preference for elastic cigarettes. Utilizing elasticity may be valuable in the development of future harm reduction strategies.