ITC Canada National Report - ITC Project

The International Tobacco Control Policy Evaluation Project

ITC Canada National Report

FINDINGS FROM THE WAVE 1 TO 8 SURVEYS (2002-2011) NOVEMBER 2013

Promoting Evidence-Based Strategies to Fight the Global Tobacco Epidemic

Findings from the ITC Canada Wave 1 to 8 Surveys

ITC Canada National Report

2002-2011

Suggested Report Citation ITC Project (November, 2013), ITC Canada National Report. Findings from the Wave 1 to 8 Surveys (2002-2011). University of Waterloo, Waterloo, Ontario Canada.

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,

Nancy Edwards, Ph.D. Scientific Director, Institute of Population and Public Health Canadian Institutes of Health Research

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ITC Canada National Report (2002-2011)

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 (2002 - 2011) 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


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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 (20022012) 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 2011. 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

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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


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“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

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


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