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E-cigarettes remain a contentious topic in public health, with debates focussing on their benefits as a smoking cessation aid1–3 versus potential increases in nicotine use among non-smoking young people.4 Accordingly, the public health impact of e-cigarettes will be determined by who is using them and for what purpose.
To date, most studies exploring the prevalence of vaping have been conducted among either youth5–10 or adults,11–13 with little evidence on overall populations of vapers. Specifically, evidence is lacking regarding the relative contribution of youth and adults, smokers and never smokers, and how these groups have contributed to overall increases in vaping at the population level.
Evidence is also required to evaluate the impact of e-cigarette policies on patterns of vaping among these different groups. Canada represents an interesting case study given recent shifts in the regulatory framework for e-cigarettes.14 Prior to May 2018, e-cigarettes containing nicotine could not be sold or marketed without approval; although no products were approved for legal sale, they were widely available.15 In May 2018, the Tobacco and Vaping Products Act (TVPA) permitted the sale of nicotine-containing e-cigarettes, as well as wider advertising and promotion of e-cigarettes, which increased retail accessibility and the presence of international brands.14 Studies have highlighted increases in youth vaping following implementation of the TVPA,5 6 although there are few estimates on changes in vaping at the population level in Canada.
This study uses data from nationally representative surveys to examine how smoking and vaping evolved at the population level in Canada following the implementation of the TVPA.
Data are from the 2019 Canadian Tobacco and Nicotine Survey (CTNS),16 a national monitoring survey in Canada. Briefly, the CTNS is a probability-based sample of the general population of Canada aged 15 years or older (n=8600) and provides the most robust national estimates of e-cigarette prevalence in 2019.16 The CTNS used methods similar to the previous national monitoring survey, the 2017 Canadian Tobacco, Alcohol and Drugs Survey (CTADS; n=16 349).17 A summary of the CTNS and CTADS methods, measures and our analyses are provided in the online supplemental table S1. Briefly, we estimated the prevalence of smoking and vaping in Canada in 2017 and 2019 by age group, including vaping among never, current, and former smokers and smoking among vapers. We also examined reasons for vaping, vaping nicotine and smoking quit attempts/success.
Between 2017 and 2019, the prevalence of current smoking among Canadians aged 15 years or older decreased from 15.1% (95% CI 13.7% to 16.6%) to 11.9% (11.0% to 12.8%), an estimated reduction from 4.56 million (4.12–5.01 million) to 3.67 million (3.38–3.96 million) current smokers. Prevalence of never smoking—defined as smoking fewer than 100 cigarettes in lifetime and not smoking within the past 30 days—increased from 59.2% (57.1% to 61.3%) to 63.7% (62.4% to 64.9%), while former smoking remained comparatively stable from 2017 (25.7%, 24.0% to 27.5%) to 2019 (24.5%, 23.4% to 25.6%). In 2019, current smoking prevalence was highest among adults aged 25 years or older (12.5%, 11.5% to 13.6%) and young adults aged 20–24 years (13.3%, 11.0% to 16.0%), compared with youth aged 15–19 years (5.1%, 3.8% to 6.7%).
The prevalence of past 30-day vaping among Canadians aged 15 years or older increased from 2.8% (an estimated 0.86, 0.681.04, million past 30-day vapers) to 4.7% (1.46,1.30 to 1.63, million) between 2017 and 2019, while daily vaping increased from 1.0% (0.29, 0.20 to 0.38, million daily vapers) to 2.1% (0.65,0.54 to 0.76, million) (table 1). The 2019 CTNS data indicate that the prevalence of vaping was highest among youth and young adults: past 30-day vaping among youth aged 15–19 years (15.1%) and young adults aged 20–24 years (15.2%) was more than five times that of adults aged 25 years or older (2.9%), with similar differences observed for daily vaping among youth (4.7%) and young adults (5.8%) versus adults (1.6%) (table 1).
Young people accounted for most of the increase in the prevalence of vaping between 2017 and 2019 (table 1). Of the estimated 0.60 million additional past 30-day vapers, 15- to 19-year-olds accounted for 49.8% of the increase, compared with 21.6% for 20- to 24-year-olds, and 28.6% for adults aged 25 years or older. Of the estimated 0.36 million additional daily vapers between 2017 and 2019, those aged 25 years or older accounted for 56.2% of the increase. However, these estimates had high variation and must be interpreted with caution. Estimates for increases in daily vaping among youth and young adults were unreportable due to high variation and low sample size.
The 2019 CTNS data also highlight that—while vaping prevalence was substantially higher among current and former smokers—never smokers accounted for a considerable proportion of the vaping population in Canada. The prevalence of past 30-day vaping was 15.4% among current smokers and 4.8% among former smokers, compared with 2.7% among never smokers, with a similar pattern for daily vaping (6.1%, 4.0%, 0.6%, respectively). However, never smokers accounted for more than one-third of all past 30-day vapers (36.7%; 0.54, 0.45 to 0.62, million) and approximately one-fifth of daily vapers (18.7%; 0.12, 0.08 to 0.16, million) (online supplemental table S2). Among youth and young adults, who had the highest vaping prevalence, never smokers accounted for 73.9% of 15- to 19-year-old past 30-day vapers, 63.4% of 15- to 19-year-old daily vapers and 41.1% of 20- to 24-year-old past 30-day vapers (online supplemental table S2).
In addition, never smokers accounted for most (67.2%) of the increase in past 30-day vaping between 2017 and 2019, compared with 0.5% for current smokers. In terms of daily vapers, current smokers accounted for 24.4% of the increase between 2017 and 2019. However, as above, there was high variation for these estimates, and estimates for increases in daily vaping among never smokers and former smokers were unreportable.
The prevalence of never smokers who vape is reflected in the self-reported reasons for vaping. In 2019, 27.9% of past 30-day and 49.0% of daily vapers reported that their main reason for vaping was quitting or avoiding returning to smoking, while an additional 9.3% of past 30-day vapers and 7.3% of daily vapers used e-cigarettes to reduce smoking(online supplemental table S3). In other words, more than half of all past 30-day vapers and almost half of daily vapers in Canada reported using e-cigarettes for reasons other than smoking abstinence or reduction (online supplemental table S3). However, the majority of current smokers (54.4%) and former smokers (64.2%) reported using e-cigarettes to quit smoking, stay quit or reduce their smoking.
Data also indicate the wide availability of nicotine-containing e-cigarettes before they could legally be sold. In 2017, 78.1% (70.0% to 84.5%) of past 30-day vapers reported that the last e-cigarette they vaped contained nicotine. In 2019, 84.1% (79.1% to 88.1%) of Canadian vapers had vaped an e-cigarette containing nicotine in the past 30 days.
Finally, the 2019 CTNS data suggest that the proportion of smokers in Canada that attempted to quit and were successful in their quit attempt changed very little over the previous 2 years. Overall, 44.7% of current and recent former smokers had attempted to quit smoking at least once in the past year, of whom 11.5% were still abstinent at the time of survey. These estimates were largely unchanged from 2017 (43.9% and 12.3%, respectively).
Findings indicate an overall decline in smoking and increase in vaping among the general population in Canada following implementation of the TVPA in 2018, consistent with anecdotal reports, sales data18 and historical estimates.5 19 Smoking was most prevalent among adults aged 25 years or older, while much of the increase in vaping between 2017 and 2019 in Canada was due to increasing use among never smokers, youth and young adults. These findings are similar to patterns of vaping in the USA, in which current vaping13 and the greatest increases in vaping were observed among young adults, more than half of whom were never smokers.20
While e-cigarettes can serve as an effective smoking cessation aid,1–3 many smokers in CTNS reported using e-cigarettes to quit or reduce their smoking, and smoking declined overall between 2017 and 2019, there was limited evidence at the population level in Canada that quit attempts or quit success have changed alongside increased vaping prevalence. In fact, population-level cessation patterns, in regard to the proportion of smokers who attempt to quit and their cessation success, have remained remarkably constant in Canada over the past 20 years, including the years before the emergence of e-cigarettes.19 The current evidence cannot speak to potential substitution/displacement effects among youth given that smoking prevalence has been declining among Canadian youth for several decades and at a similar rate in the ‘pre’ and ‘post’ vaping periods.19
It is important to note that the 2019 CTNS and the 2017 CTADS used different data collection methods (predominantly online vs telephone), were conducted in different months (November to December vs February to December) and had different sample sizes (n=8600 vs n=16 349). These methodological differences may affect direct comparisons across years; however, both surveys were designed to produce nationally representative estimates and provide the best available indictors of smoking and vaping prevalence in Canada. Neither survey included individuals younger than the age of 15 years, which would have resulted in an estimated additional 120 000 past 30-day vapers.10 Specific age groups over 24 years also could not be compared due to low sample size and/or high variation. Neither survey included residents of the three Canadian territories, so these results may not generalise throughout all of Canada.
Findings demonstrate that never smokers, youth and young adults accounted for most of the increase in vaping in Canada between 2017 and 2019, suggesting that e-cigarettes must be better targeted toward adult smokers for the purpose of quitting smoking. In Canada, a range of new regulatory measures are being implemented, including restrictions on flavour, nicotine concentration, marketing and retail access. There is an urgent need to evaluate the impact of these policy measures on vaping and smoking among young people and smokers/former smokers for the purpose of quitting smoking. Finally, future research should examine population-level trends across countries with different regulatory environments, to better understand the use of e-cigarettes across age groups and by smoking status.
What this paper adds
In May 2018, Canada changed their regulatory framework for e-cigarettes and permitted the sale of nicotine-containing e-cigarettes and e-cigarette advertising/promotion.
Studies have highlighted increases in youth vaping following Canada’s new framework, but there is little research at the population level. This study is therefore the first to examine how smoking and vaping evolved between 2017 and 2019, using data from two nationally representative surveys.
Between 2017 and 2019, the prevalence of current smoking among Canadians decreased (15.1%–11.9%) and, in 2019, current smoking was higher among adults than youth.
Between 2017 and 2019, the prevalence of vaping doubled in Canada (past 30-day: 2.8%–4.7%, daily: 1.0%–2.1%). Never smokers, youth, and young adults accounted for most of this increase.
In 2019, over half of all past 30-day vapers and almost half of daily vapers reported using e-cigarettes for reasons other than smoking cessation, abstinence or reduction.
Findings suggest that e-cigarettes should be better targeted toward adult smokers for the purpose of smoking cessation in Canada.
The 2019 Canadian Tobacco and Nicotine Survey and 2017 Canadian Tobacco, Alcohol and Drugs Survey were conducted by Statistics Canada on behalf of Health Canada. This brief report and the views expressed do not necessarily reflect the views or opinions of Statistics Canada or Health Canada.
Contributors DH developed the research questions. KAE led the analysis, with input from JLR and DH. All authors jointly led the write-up and approved the final version of the manuscript.
Funding The 2019 Canadian Tobacco and Nicotine Survey and the 2017 Canadian Tobacco, Alcohol and Drugs Survey were funded by Health Canada.
Competing interests DH has served as a paid expert witness in legal challenges against tobacco and vaping companies.
Provenance and peer review Not commissioned; externally peer reviewed.