Comparison of indicators of dependence for vaping and smoking: Trends between 2017 and 2022 among youth in Canada, England and the United States.

INTRODUCTION: The current study sought to examine trends in indicators of dependence for youth vaping and smoking during a period of rapid evolution in the e-cigarette market. METHODS: Data are from repeat cross-sectional online surveys conducted between 2017 and 2022 among youth aged 16-19 in Canada, England, and the USA. Participants were 23,145 respondents who vaped and/or smoked in the past 30 days. Four dependence indicators were assessed for smoking and vaping (perceived addiction, frequent strong urges, time to first use after waking, days used in past month) and two for vaping only (use events per day, E-cigarette Dependence Scale). Regression models examined differences by survey wave and country, adjusting for sex, age, race, and exclusive/dual use. RESULTS: All six indicators of dependence increased between 2017 and 2022 among youth who vaped in the past 30 days (p<.001 for all). For example, more youth reported strong urges to vape at least most days in 2022 than in 2017 (Canada: 26.5% to 53.4%; England: 25.5% to 45.4%; USA: 31.6% to 50.3%). In 2017, indicators of vaping dependence were substantially lower than for smoking; however, by 2022, youth vaping was associated with a greater number of days used in the past month (Canada, USA), shorter time to first use (all countries), and a higher likelihood of frequent strong urges (Canada, USA) compared to youth smoking. CONCLUSIONS: From 2017 to 2022, indicators of vaping dependence increased substantially. By 2022, vaping dependence indices were comparable to those of smoking. IMPLICATIONS: Indicators of vaping dependence among youth have increased substantially since 2017 to levels that are comparable to cigarette dependence among youth who smoke. Future research should examine factors underlying the increase in dependence among youth who vape, including changes to the nicotine profile and design of e-cigarette products.

Awareness, use and understanding of nutrition labels among children and youth from six countries: findings from the 2019 - 2020 International Food Policy Study.

BACKGROUND: Nutrition facts tables (NFTs) on pre-packaged foods are widely used but poorly understood by consumers. Several countries have implemented front-of-package labels (FOPLs) that provide simpler, easier to use nutrition information. In October 2020, Mexico revised its FOPL regulations to replace industry-based Guideline Daily Amount (GDA) FOPLs with 'Warning' FOPLs, which display stop signs on foods high in nutrients of concern, such as sugar and sodium. This study examined self-reported awareness, use, and understanding of NFTs and FOPLs among young people in six countries with different FOPLs, with an additional focus on changes before and after implementation of Mexico's FOPL warning policy. METHODS: A 'natural experiment' was conducted using 'pre-post' national surveys in Mexico and five separate comparison countries: countries with no FOPL policy (Canada and the US), countries with voluntary FOPL policies (Traffic Lights in the UK and Health Star Ratings in Australia), and one country (Chile) with mandatory FOPL 'warnings' (like Mexico). Population-based surveys were conducted with 10 to 17-year-olds in 2019 (n = 10,823) and in 2020 (n = 11,713). Logistic regressions examined within- and between-countries changes in self-reported awareness, use, and understanding of NFTs and FOPLs. RESULTS: Across countries, half to three quarters of respondents reported seeing NFTs 'often' or 'all the time', approximately one quarter reported using NFTs when deciding what to eat or buy, and one third reported NFTs were 'easy to understand', with few changes between 2019 and 2020. In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were higher than for NFTs in all countries, and compared with GDA FOPLs in Mexico (p < .001). Mandated Warning FOPLs in Mexico and Chile had substantially higher levels of awareness, use, and understanding than the voluntary Traffic Lights in the UK and Health Star Ratings in Australia (p < .001 for all). CONCLUSIONS: Mandated easy-to-understand FOPLs are associated with substantially greater levels of self-reported awareness, use and understanding at the population-level compared to NFT and GDA-based labeling systems.

Awareness, use and understanding of nutrition labels among adults from five countries: Findings from the 2018-2020 International Food Policy Study.

Few studies have compared the effects of different front-of-package label (FOPL) systems in the 'real world'. This study assessed adults' awareness, use and understanding of nutrition facts labels (NFLs) and nationally implemented FOPLs such as Health Star Ratings (HSR), Traffic lights, and Guideline Daily Amounts (GDAs) in five countries, including before and after implementation of Mexico's warning FOPLs in 2020. Data were from the International Food Policy Study, an annual repeat cross-sectional study conducted in 2018-2020 among adults (N=64,032) in Australia, Canada, Mexico, the UK and the US. Self-reported awareness, use, and understanding of NFLs (in all five countries) and FOPLs (in Australia, Mexico, and UK) were assessed over time, between countries, and between NFLs and FOPLs. Most respondents in all countries reported seeing their country's NFLs (awareness) 'often' or 'all the time' across all three years, with one third to half of respondents using NFLs 'often' or 'all the time' (Australia: 43-45%; Canada: 47-50%; Mexico: 36-39%; UK: 32-34%; US: 47-49%), and approximately one half to two thirds finding NFLs 'easy' or 'very easy to understand' (56-57%; 67-69%; 51-54%; 48-51%; 70-71%). In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were highest among all countries with a FOPL (p<0.001), whereas awareness and use were lowest for Australia's HSR (p<0.001). In countries with FOPLs, self-reported understanding was higher for FOPLs than NFLs, except for the GDA FOPL in Mexico. Only modest changes were observed over time. Warning FOPLs were associated with greater levels of self-reported awareness, use and understanding among adults compared to NFLs and GDA-based FOPLs. FOPLs implemented on a voluntary basis, such as Australia's HSR, may be less likely to be seen and used.

Nonalcoholic and Alcoholic Beverage Intakes by Adults across 5 Upper-Middle- and High-Income Countries.

BACKGROUND: Despite considerable public health interest in sugary drink consumption, there has been little comparison of intake across countries. OBJECTIVES: This study aimed to compare the consumption frequency and amounts of commonly consumed beverages among adults in 5 upper-middle- and high-income countries, and examine differences in consumption between population subgroups. METHODS: Adults aged 18-65 y completed online surveys in December 2017 in Australia (n = 3264), Canada (n = 2745), Mexico (n = 3152), the United Kingdom (n = 3221), and the USA (n = 4015) as part of the International Food Policy Study. The frequency of consuming beverages from 22 categories in the past 7 d was estimated using the Beverage Frequency Questionnaire. Regression models were used to examine differences in the likelihood of any consumption and in the amounts consumed of sugar-sweetened beverages (SSBs), sugary drinks (SSBs and 100% juice), diet, and alcoholic beverages between countries and across sociodemographic subgroups. RESULTS: The prevalence of reported SSB consumption in the past 7 d ranged from 47% (United Kingdom) to 81% (Mexico), and that of sugary drinks ranged from 62% (United Kingdom) to 87% (Mexico). Rates of consumption of diet drinks ranged from 26% (Mexico) to 37% (United Kingdom), whereas alcoholic drink consumption rates ranged from 45% (USA) to 52% (Canada). Respondents in Mexico were more likely to consume SSBs and sugary drinks, and in greater amounts, than those in other countries. Respondents in the United Kingdom were more likely to consume diet drinks than those in Australia, Canada, and Mexico, and greater amounts of diet drinks were consumed in the United Kingdom and the USA. Across countries, younger respondents and males were more likely to consume greater amounts of SSBs and sugary drinks. CONCLUSIONS: Most adult respondents across all countries consumed SSBs and sugary drinks, with greater consumption in Mexico and the USA. Consumption varied greatly across countries, but patterns of association among subpopulations were relatively similar.

Influence of package colour, branding and health warnings on appeal and perceived harm of cannabis products among respondents in Canada and the US.

'Plain packaging' and health warnings can reduce appeal and increase risk perceptions of tobacco products. This study tested the effect of health warnings and restricted brand imagery on perceptions of cannabis products. Participants in Canada and the US (n = 45,378) were randomized to view packages of three cannabis brands in 2019. A 3 (health warning) x 4 (brand imagery) between-group factorial experimental design was used. Health warning conditions were: none, Canadian or US warning. The Canadian warning conditions had three messages counterbalanced across brands: pregnancy, adolescent risk, and impaired driving. The US warning mentioned the same broad risk categories. The four branding conditions ranged from packages displaying no brand imagery and uniform colours-'plain packaging'-to full brand imagery. Regression tested differences between conditions on product appeal, perceived harm, and free recall of warning messages. Overall, full branding and plain packaging were rated the most and least appealing, respectively (p < 0.001). Products were rated as significantly less harmful when they had a white background with no or limited branding versus a coloured background (p ≤ 0.01). Products with health warnings were rated significantly less appealing and more harmful than those with no warning (p < 0.001). Message recall was significantly higher for Canadian versus US health warnings, and for the US warning versus no warning (p < 0.001). Message recall was greater among those who saw plain versus fully branded packages for two of the three warning messages (p < 0.01). Prominent health warnings and restrictions on brand imagery may be warranted in jurisdictions considering non-medical cannabis legalization.

Indicators of dependence and efforts to quit vaping and smoking among youth in Canada, England and the USA.

OBJECTIVE: The current study examined indicators of dependence among youth cigarette smokers and e-cigarette users in Canada, England and the USA, including changes between 2017 and 2019. METHODS: Data are from repeated cross-sectional online surveys conducted in 2017, 2018 and 2019 with national samples of youth aged 16-19 years, in Canada (n=12 018), England (n=11 362) and the USA (n=12 110). Measures included perceived addiction to cigarettes/e-cigarettes, frequency of experiencing strong urges to smoke/use an e-cigarette, plans to quit smoking/using e-cigarettes and past attempts to quit. Logistic regression models were fitted to examine differences between countries and changes over time. RESULTS: The proportion of ever-users who vaped frequently was significantly higher in 2019 compared with 2017 for all outcomes in each country. Between 2017 and 2019, the proportion of past 30-day vapers reporting strong urges to vape on most days or more often increased in each country (Canada: 35.3%, adjusted OR (AOR) 1.69, 95% CI 1.20 to 2.38; England: 32.8%, AOR 1.55, 1.08 to 2.23; USA: 46.1%, AOR 1.88, 1.41 to 2.50), along with perceptions of being 'a little' or 'very addicted' to e-cigarettes (Canada: 48.3%, AOR 1.99, 1.44 to 2.75; England: 40.1%, AOR 1.44, 1.03 to 2.01; USA: 53.1%, AOR 1.99, 1.50 to 2.63). Indicators of dependence among smokers were consistently greater than e-cigarette users, although differences had narrowed by 2019, particularly in Canada and the USA. CONCLUSIONS: Prevalence of dependence symptoms among young e-cigarette users increased between 2017 and 2019, more so in Canada and the USA compared with England. Dependence symptom prevalence was lower for e-cigarettes than smoking; however, the gap has narrowed over time.

Vegetarianism and other eating practices among youth and young adults in major Canadian cities.

OBJECTIVE: To estimate the prevalence and sociodemographic characteristics of youth and young adults in major Canadian cities with self-reported vegetarian dietary practices and examine efforts to alter their diets. DESIGN: Data were collected in autumn 2016 via web-based surveys. Respondents reported vegetarian dietary practices (vegan, vegetarian or pescatarian) and efforts in the preceding year to consume more or less of several nutrients, food groups and/or foods with particular attributes. Logistic regression models examined sociodemographic correlates of each vegetarian dietary practice and differences in other eating practices by diet type. SETTING: Participants were recruited from five major Canadian cities. PARTICIPANTS: Youth and young adults, aged 16-30 years (n 2566). RESULTS: Overall, 13·6 % of respondents reported vegetarian dietary practices: 6·6 % vegetarian, 4·5 % pescatarian and 2·5 % vegan. Sex, race/ethnicity, self-reported frequency of using the Nutrition Facts table and health literacy were significantly correlated with self-reported vegetarian dietary practice (P < 0·01 for all). Efforts to consume more fruits and vegetables (66·8 %) and protein (54·8 %), and less sugar (61·3 %) and processed foods (54·7 %), were prevalent overall. Respondents with vegetarian dietary practices were more likely to report efforts to consume fewer carbohydrates and animal products, and more organic, locally produced, ethically sourced/sustainably sourced/fair trade and non-GM foods (P < 0·01 for all), compared with those without these reported dietary practices. CONCLUSIONS: Nearly 14 % of the sampled youth and young adults in major Canadian cities reported vegetarian dietary practices and may be especially likely to value and engage in behaviours related to health-conscious diets and sustainable food production.

Who is using e-cigarettes in Canada? Nationally representative data on the prevalence of e-cigarette use among Canadians.

The current study examined prevalence and correlates of electronic cigarette (e-cigarette) use in the Canadian population, using data from the nationally representative 2013 Canadian Tobacco, Alcohol and Drugs Survey (n=14,565). Sociodemographic correlates of e-cigarette use (ever, and in the past 30 days) were examined using logistic regression models. Overall, 8.5% of Canadians aged 15 and older reported having ever tried an e-cigarette; 1.8% had used one in the past 30 days. E-cigarette use was particularly high among smokers and young people. Overall, prevalence did not differ between males and females, for ever (P=0.24) or past 30-day use (P=0.30). Smoking status was the strongest correlate of e-cigarette use (ever and in the past 30 days, P<0.0001): 37.3% of current smokers had ever tried an e-cigarette (9.6% used in the past 30 days), compared to 3.0% of never-smokers (0.3% past 30-days), and 5.1% of former smokers (0.9% past 30-day). E-cigarette use also varied by age (P<0.0001): prevalence was highest among youth aged 15-19 (19.8% ever; 2.6% past 30-day) and young adults aged 20-24 (20.1% ever; 3.9% past 30-day), and decreased with age. Among youth, the majority of e-cigarette users were never-smokers, while the majority of adult users were smokers. In Canada, e-cigarette use is particularly high among smokers and young people. Dual use with cigarettes was common, with most e-cigarette users also smoking conventional cigarettes. Continued monitoring of e-cigarette use and its relationship with smoking should be a priority, given the rapidly-evolving e-cigarette market and implementation of new policy measures.

Trends and Patterns of Tobacco and Nicotine Product Use Among Youth in Canada, England, and the United States From 2017 to 2019.

PURPOSE: The tobacco and nicotine market is diversifying. Implications for public health will depend on trends in use, including overall use, and who is using these products. This study examined differences over time (2017-2019), across countries (Canada, England, the United States (US)), and by smoking and vaping, in use of other tobacco/nicotine products and overall use. METHODS: The study includes online repeat cross-sectional surveys of youth aged 16-19 years in Canada (N = 11,714), England (N = 11,170), US (N = 11,838) in 2017, 2018, and 2019. Past 30-day use of tobacco/nicotine products (any, cigarette, e-cigarette, other combusted [cigars/cigarillos/waterpipe], other non-combusted [smokeless tobacco/nicotine replacement therapies) were examined by country, year, and, for other combusted and non-combusted products, past 30-day cigarette smoking and vaping. Use of emerging products (IQOS, nicotine pouches) was explored in 2018-2019. RESULTS: From 2017 to 2019, use of any product increased in Canada (17.1%-23.2%, AOR = 1.07 [95% CI = 1.04-1.09]) and the US (18.0%-24.0%, AOR = 1.06 [1.04-1.09]) but not England (20.8%-21.7%, AOR = 1.01 [.99-1.03]). Use of other combusted products (cigars/cigarillos/waterpipe) showed little change (Canada: 8.1%-7.8%; England: 6.3%-7.3%; US: 8.6%-8.5%; p ≥ .151). Use of other non-combusted products (smokeless/nicotine replacement therapies) increased in all countries (Canada: 1.5%-3.2%, AOR = 1.02 [1.01-1.02]; England: 1.4%-2.6%, AOR = 1.02 [1.01-1.03]; US: 3.3%-4.9%, AOR = 1.02 [1.01-1.02]). Vaping increased in all countries (Canada: 8.4%-17.8%; England: 8.7%-12.6%; United States: 11.1%-18.5%; all p < .001). Smokers and vapers reported greater use of other combusted and non-combusted products than those who neither smoked/vaped (p < .001). Emerging product use was rare (≤1.5%). CONCLUSIONS: Youth past 30-day tobacco and nicotine product use increased from 2017 to 2019 in Canada and the United States, largely due to increases in vaping and other non-combusted products. "Other" tobacco/nicotine products were used predominantly by youth who smoked cigarettes and/or vaped.

E-cigarette Marketing Regulations and Youth Vaping: Cross-Sectional Surveys, 2017-2019.

BACKGROUND: Increased electronic cigarette (e-cigarette) use among young people is often attributed to industry marketing practices; however, the effectiveness of regulations that limit e-cigarette advertising and promotions has yet to be examined. New federal legislation that liberalized the Canadian e-cigarette market in May 2018, along with differences in provincial regulations, provides an opportunity to examine the impact of regulatory restrictions on e-cigarette marketing. METHODS: Repeat cross-sectional surveys of 12 004 16- to 19-year-olds in Canada, completed online in 2017, 2018, and 2019. Logistic regression models were used to examine differences over time in exposure to e-cigarette marketing and e-cigarette use, including between provinces with differing strengths of marketing restrictions. RESULTS: The percentage of youth surveyed who reported noticing e-cigarette promotions often or very often approximately doubled between 2017 and 2019 (13.6% vs 26.0%; adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.97-2.56). Overall exposure to marketing was generally more prevalent in provinces with fewer regulatory restrictions. Respondents who reported noticing marketing often or very often were more likely to report vaping in the past 30 days (AOR = 1.41, 95% CI = 1.23-1.62), past week (AOR = 1.44, 95% CI = 1.22-1.70), and ≥20 days in the past month (AOR = 1.42, 95% CI = 1.11-1.81, P = .005). Provinces with low restrictions on marketing had higher prevalence of vaping in the past 30 days (AOR = 1.50, 95% CI = 1.25-1.80, P < .001), and in the past week (AOR = 1.65, 95% CI = 1.33-2.05, P < .001). CONCLUSIONS: Exposure to marketing and the prevalence of vaping increased among Canadian youth after the liberalization of the e-cigarette market in 2018. Comprehensive provincial restrictions on e-cigarette marketing were associated with lower levels of exposure to marketing and lower prevalence of e-cigarette use.

Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: repeat national cross sectional surveys.

OBJECTIVE: To examine differences in vaping and smoking prevalence among adolescents in Canada, England, and the United States. DESIGN: Repeat cross sectional surveys. SETTING: Online surveys in Canada, England, and the US. PARTICIPANTS: National samples of 16 to 19 year olds in 2017 and 2018, recruited from commercial panels in Canada (n=7891), England (n=7897), and the US (n=8140). MAIN OUTCOME MEASURES: Prevalence of vaping and smoking was assessed for use ever, in the past 30 days, in the past week, and on 15 days or more in the past month. Use of JUUL (a nicotine salt based electronic cigarette with high nicotine concentration) and usual vaping brands were also assessed. Logistic regression models examined differences in vaping and smoking between countries and over time. RESULTS: The prevalence of vaping in the past 30 days, in the past week, and on 15 days or more in the past month increased in Canada and the US between 2017 and 2018 (P<0.001 for all), including among non-smokers and experimental smokers, with no changes in England. Smoking prevalence increased in Canada (P<0.001 for all measures), with modest increases in England, and no changes in the US. The percentage of ever vapers who reported more frequent vaping increased in Canada and the US (P<0.01 for all), but not in England. The use of JUUL increased in all countries, particularly the US and Canada-for example, the proportion of current vapers in the US citing JUUL as their usual brand increased threefold between 2017 and 2018. CONCLUSIONS: Between 2017 and 2018, among 16 to 19 year olds the prevalence of vaping increased in Canada and the US, as did smoking in Canada, with little change in England. The rapidly evolving vaping market and emergence of nicotine salt based products warrant close monitoring.

Stop-Smoking Medication Use, Subsidization Policies, and Cessation in Canada.

INTRODUCTION: In 2000, Quebec began reimbursing stop-smoking medications (SSMs) through their provincial public drug insurance plan. Several other Canadian provinces have since begun offering SSM subsidies. Clinical trials indicate that SSMs can increase quit success; however, little evidence exists on patterns of use in "real-world" settings and impact on population quit rates. This study examines Canadian trends in SSM use and quit success over time, comparing provinces with differing subsidization policies. METHODS: Secondary analyses were conducted in 2014 using nationally representative Canadian Tobacco Use Monitoring Survey data, 2004-2012, for current and former smokers who made a quit attempt in the past 2 years (N=26,094). Regression models tested for differences in SSM use and quit success in provinces with differing SSM coverage (i.e., none, partial, or comprehensive). RESULTS: Smokers were more likely to use nicotine replacement therapy (NRT) in jurisdictions with comprehensive SSM coverage versus jurisdictions with partial (OR=1.39, 95% CI=1.22, 1.59) or no coverage (OR=1.43, 95% CI=1.21, 1.68). Prescription medication use was more likely in provinces with partial (versus no) coverage (OR=1.27, 95% CI=1.01, 1.59). Overall, smokers who attempted to quit were more likely to remain abstinent in jurisdictions with comprehensive versus partial (OR=1.20, 95% CI=1.12, 1.28) or no coverage (OR=1.23, 95% CI=1.00, 1.50). An interaction between coverage and cigarettes per day was observed, suggesting potentially greater impact of comprehensive coverage among heavier smokers. CONCLUSIONS: Comprehensive subsidization policies are associated with modest increases in NRT use and quit success, but do not appear to impact prescription SSM use.

Geographic disparity in premature mortality in Ontario, 1992-1996.

BACKGROUND: Standardized mortality ratios are used to identify geographic areas with higher or lower mortality than expected. This article examines geographic disparity in premature mortality in Ontario, Canada, at three geographic levels of population and considers factors that may underlie variations in premature mortality across geographic areas. All-cause, sex and disease chapter specific premature mortality were analyzed at the regional, district and public health unit level to determine the extent of geographic variation. Standardized mortality ratios for persons aged 0-74 years were calculated to identify geographic areas with significantly higher or lower premature mortality than expected, using Ontario death rates as the basis for the calculation of expected deaths in the local population. Data are also presented from the household component of the 1996/97 National Population Health Survey and from the 1996 Statistics Canada Census. RESULTS: Results showed approximately 20% higher than expected all-cause premature mortality for males and females in the North region. However, disparity in all-cause premature mortality in Ontario was most pronounced at the public health unit level, ranging from 20% lower than expected to 30% higher than expected. Premature mortality disparities were largely influenced by neoplasms, circulatory diseases, injuries and poisoning, respiratory diseases and digestive diseases, which accounted for more than 80% of all premature deaths. Premature mortality disparities were also more pronounced for disease chapter specific mortality. CONCLUSION: Geographic disparities in premature mortality are clearly greater at the small area level. Geographic disparities in premature mortality undoubtedly reflect the underlying distribution of population health determinants such as health related behaviours, social, economic and environmental influences.