Qualitative and quantitative research on perceptions of nicotine - Final report

Prepared for Health Canada

Supplier name: Earnscliffe Strategy Group
Contract number: HT372-183684/001/CY
Contract value: $238,145.61
Award date: November 13, 2018
Delivery date: March 28, 2019

Registration number: POR 067-18
For more information on this report, please contact Health Canada at:
hc.cpab.por-rop.dgcap.sc@canada.ca

Ce rapport est aussi disponible en français.

Qualitative and quantitative research on perceptions of nicotine
Final report

Prepared for Health Canada
Supplier name: Earnscliffe Strategy Group
March 2019

This public opinion research report presents the results of focus groups conducted by Earnscliffe Strategy Group on behalf of Health Canada. The research was conducted from December 2018 to March 2019.

Cette publication est aussi disponible en français sous le titre : Recherche qualitative et quantitative sur les perceptions de la nicotine

This publication may be reproduced for non-commercial purposes only. Prior written permission must be obtained from Health Canada. For more information on this report, please contact Health Canada at: hc.cpab.por-rop.dgcap.sc@canada.ca or at:

Health Canada, CPAB
200 Eglantine Driveway, Tunney's Pasture
Jeanne Mance Building, AL 1915C
Ottawa, Ontario K1A 0K9

Catalogue Number: H14-317/2019E-PDF

International Standard Book Number (ISBN): 978-0-660-30412-0

Related publications (registration number: POR 067-18):
H14-317/2019F-PDF (Final Report, French)
978-0-660-30413-7

© Her Majesty the Queen in Right of Canada, as represented by the Minister of Health, 2019

Table of contents

• Executive summary
• Introduction
• Detailed findings
  • Section 1: Perceptions of nicotine
    1. Understanding behaviours and motivations
    2. Health effects associated with smoking and nicotine
    3. Impressions of nicotine
    4. Very low nicotine content (VLNC) cigarette concept testing
    5. Harm associated with forms of Nicotine
    6. Information sharing
    7. Current, past and potential behaviours
  • Section 2: Perceptions of vaping
• Conclusions
• Appendix A: Discussion guides
• Appendix B: Handout
• Appendix C: Screeners
• Appendix D: Survey methodology report
• Appendix E: Focus group methodology report
• Appendix F: Survey instrument

Executive summary

Earnscliffe Strategy Group (Earnscliffe) is pleased to present this report to Health Canada summarizing the results of the qualitative and quantitative research conducted to understand public perceptions of nicotine.

Given tobacco use is the leading preventable cause of death and disease in Canada, the Government of Canada has announced a target of less than 5% tobacco use by 2035. Research was needed to understand Canadians' views on the health effects of nicotine and how it contributes to the health hazards of smoking. The specific objectives of the research were to gather information from Canadians about their knowledge of the health hazards and risks associated with smoking and nicotine, as well as test reactions to the hypothetical concept of a very low nicotine content cigarette. Feedback from this research will help Health Canada understand how to maximize different policies to achieve their 2035 target. The total cost to conduct this research was $238,145.61 including HST.

To meet these objectives, Earnscliffe conducted a three-phased research program.

The research began with an initial qualitative phase, which included a series of fifteen focus groups with three segments of the Canadian population: youth (16-19) non-smokers; young adult (20-24) non-smokers; and, adult (40-55) smokers. Three sessions were conducted in each of the following five cities: Toronto (December 3, 2018); Halifax (December 4, 2018); Montreal (December 5, 2018); Winnipeg (December 5, 2018); and Vancouver (December 6, 2018).

Following the initial focus groups, we conducted a quantitative phase which involved an online survey of 4,190 Canadians aged 13 and older. The online survey was conducted using our data collection partner, Leger's, proprietary online panel. A total of 2,000 cases were collected as a sample to reflect the general population. Oversamples were also collected, achieving the following overall sample sizes in each of the audiences listed below:

• Youth (aged 13-14), n=501;
• Youth (aged 15-19), n=523;
• Young adults (aged 20-24), n=548; and
• Smokers, n=1,662.

The survey was conducted from February 11 to March 7, 2019 in English and in French. The data was weighted to reflect the demographic composition of the Canadian population aged 13 and older, including the incidence of daily and occasional smoking. Because the online sample is based on those who initially self-selected for participation in the panel, no estimates of sampling error can be calculated, and the results cannot be described as statistically projectable to the target population. The treatment here of the non-probability sample is aligned with the Standards for the Conduct of Government of Canada Public Opinion Research for online surveys.

Finally, a follow-up night of qualitative research was conducted, which included two focus groups with two segments of the Canadian population: youth (16-18) and young adults (19-24) who occasionally vape or may be susceptible to trying it. The groups were conducted in Toronto (March 19, 2019).

It is important to note that qualitative research is a form of scientific, social, policy and public opinion research. Focus group research is not designed to help a group reach a consensus or to make decisions, but rather to elicit the full range of ideas, attitudes, experiences and opinions of a selected sample of participants on a defined topic. Because of the small numbers involved the participants cannot be expected to be thoroughly representative in a statistical sense of the larger population from which they are drawn and findings cannot reliably be generalized beyond their number.

The key findings from the research are presented below. Bolded results indicate that the result of the demographic group mentioned is significantly higher (at the 95% confidence interval) than the result found in other subgroups discussed in same analysis.

Behaviours and motivations

As the results of the survey were weighted to reflect the incidence of smoking as identified by the Canadian Tobacco, Alcohol and Drugs Survey (CTADS) 2017, the incidence of smokers in the survey results is 15% (11% daily, 4% occasional). Youth 13-14 report a smoking incidence of 4% (2% daily, 2% occasional), 7% (4% daily, 3% occasional) of those aged 15-19 say they are smokers and 15% (9% daily, 6% occasional) of youth aged 20-24 offer responses indicating they are smokers.

Compared to the proportion who smoke cigarettes, fewer members of the general population vape with products containing nicotine (11%), but incidences among the youth oversamples indicate this is an activity that is being done more by younger respondents than older respondents. Among those aged 13-14, 7% vape (6% occasionally, and, 1% daily), as do 13% of youth aged 15-19 (11% and 2%) and 18% of those aged 20-24 (13% and 5%).

Combining the results on the use of cigarettes and vaping products with nicotine, the survey shows that 19% of Canadians are consuming nicotine using one or the other of these two sources. Roughly one in ten (9%) smoke but do not vape with nicotine, another 6% are dual users who both smoke and vape nicotine, and 4% of Canadians aged 13 and older vape with nicotine but do not smoke.

The results vary widely by age, with youth aged 13-14 least likely to be consuming nicotine at all, least likely to exclusively smoke (1%), half as likely as the national average to be dual users (3%), but are just as likely as the national population overall to be exclusively vaping with nicotine (4%). Youth aged 15-19 and young adults (20-24) are the age groups in Canada most likely to be exclusively vaping with nicotine (9% daily or occasionally). Dual use is highest (14%) among those aged 25-34 and beyond that age, the incidence of vaping (dual or exclusive) declines as age increases.

Personal experience with cigarettes is fairly common among non-smokers, with 61% saying they have tried it at least once. The younger segments have much lower incidences of claimed experience, but it rises rapidly through the three younger age groups oversampled. Among 13-14 year-old non-smokers, 18% say they have tried smoking. This proportion rises to 23% among non-smokers aged 15-19 and 38% among those aged 20-24.

Conversely, personal experience using vaping products with nicotine is uncommon, with 10% of non-vapers of nicotine saying they have ever tried it. Again, incidences rise with age among the younger oversampled segments. Among 13-14 year-old non-vapers with nicotine, only 6% say they have tried it. This proportion rises to 13% among non-smokers aged 15-19 and 24% among those aged 20-24.

People who have never tried cigarettes are quite certain they will not do so in the future, with fully 85% saying definitely not. The proportion of non-smokers who have never tried cigarettes who are susceptible to trying (offering an answer of definitely, probably or probably not) is 13%. Among youth aged 13-14 who have never tried a cigarette, close to one in three (32%) indicate being susceptible to trying it, but unlike experience, the proportion who are susceptible declines with age among the age groups oversampled. Among youth aged 15-19, just one quarter (25%) of those who have never tried smoking indicate being susceptible and this proportion drops to 14% among young adults aged 20-24.

Those who have never tried vaping with nicotine indicate being slightly more susceptible to trying it than is found with smoking. Among the general population, 17% of respondents who have never tried vaping indicate being susceptible to vaping with nicotine in the future. As with smoking, this proportion is highest among youth aged 13-14 years (37%) and is lower among youth aged 15-19 (26%), but only insignificantly lower among those aged 20-24 (23%). Those aged 20-24 who have never vaped are clearly more likely to try vaping with nicotine than 20-24 year-old never-smokers are likely to try cigarettes.

People who have never smoked hold numerous very strong opinions about why they do not smoke. Whether looking at the results among the general population or any of the oversampled age groups, the three most widely and strongly agreed rationales are: to avoid the diseases associated with smoking; seeing no good reason to smoke; and disliking the smell.

The majority of those who vape with nicotine buy vaping devices and/or liquids themselves, primarily at a vape shop (59%), but also online to a notable degree (21%). Young adults ages 20-24 are the most likely of the oversampled age groups to also purchase vaping devices online (24%).

The most common place for respondents who vape using nicotine and are of legal age to purchase a vaping device is a vape shop (62%). Notably fewer teens aged 13-14 (41%) and 15-19 who are not of legal age in their province (24%) get their devices at these stores (note that 46% of teens 15-19 who are of legal age purchase vaping devices at vape shops). Another key difference is that these groups are more likely to get a device in some way from their peers. For teens aged 13-14, significantly more acquire a vaping device by buying it (45%) or borrowing it (22%) from friends. Similarly, among those ages 15-19 who are not of legal age, 27% buy a device from a friend and 35% borrow it. In comparison, just 7% of the general population sample who are of age (n=631) claims they buy vaping devices from friends and 14% say they borrow them from friends.

In the initial round of focus groups, recall of vaping or e-cigarette related promotion was very low and tended to revolve around promotional materials (posters) in convenience stores. Some youth and young adults mentioned seeing videos on social media of people using vaping products to do tricks, such as blowing "O"s. They did not immediately connect these videos to any sort of deliberate promotion or advertising.

Impressions of nicotine

Overall, most survey respondents consider themselves knowledgeable of the health impacts of smoking (91%) and almost as many (84%) consider themselves knowledgeable of the health impacts of nicotine. Youth and young adults are less likely to consider themselves knowledgeable about smoking and nicotine than the general population, but still largely feel knowledgeable. Youth aged 13-14 are the least likely to feel knowledgeable about either smoking (77%) or nicotine (69%). Youth aged 15-19 are slightly more knowledgeable about smoking (86%) and nicotine (71%), as are young adults aged 20-24 (83% and 72%, respectively).

There is little difference found between smokers and non-smokers, although smokers are more likely to report that they are very knowledgeable of the impacts of nicotine (50% compared to 44% of non-smokers) along with the impacts of smoking (60% compared to 56%).

Focus group participants of all ages, regardless of whether or not they smoked, were well aware of many long and short-term effects of smoking and linked negative health effects to the chemicals they believe are added to cigarettes, as well as tar and carcinogens.

In terms of the level of concern about the health effects of nicotine on its own, or of how harmful nicotine is to those who use it, the survey demonstrated there is both widespread concern and a widespread sense that nicotine is harmful to those who use it. Across the targeted oversampled groups, vast majorities of all segments are at least somewhat concerned: 85% (very or somewhat concerned) of youth ages 13-14 and 15-19, 82% of young adults ages 20-24, 77% of smokers and 89% of non-smokers. However, it is worth noting that smokers are the least likely of all the oversample groups to be very concerned (28%). They are also less inclined to describe nicotine as very harmful (32%) than non-smokers (63%).

Focus group participants spontaneously linked nicotine to addiction, but lacked detailed knowledge of what the substance is, where it comes from and where it is found. Participants were hard-pressed to name any health effects associated with nicotine apart from addiction, though when presented with a list of ailments, they easily believed these ailments could be caused by nicotine.

Confirming the findings of the focus groups, a majority of survey respondents (72%) feel addiction is a health impact of both smoking and nicotine. In addition, survey results demonstrate that there is a tendency for respondents to feel that many other health effects are related to both smoking and to nicotine, including cancer (75%), health effects on unborn children (75%), and heart disease (74%), among others. Of seventeen possible health effects tested, none tended to be seen as attributed to just nicotine on its own, with the highest of such incidence being the 19% who feel that addiction is related only to nicotine on its own.

Demonstrating a lack of certainty about the nature of nicotine, just under a majority of survey respondents agree that nicotine is a naturally occurring substance (46%) and is a substance added to cigarettes during the manufacturing process (47%). The majority also think it can be synthetically manufactured (60%) and is found naturally in tobacco plants (55%). On all of these questions, roughly one in four respondents decline to offer an opinion one way or the other.

When focus group participants were asked to classify products with nicotine on a spectrum, from most to least harmful, cigarettes were clearly perceived to be the most harmful source due to the combustible properties and inclusion of chemicals, tar and carcinogens. Those who mentioned chewing tobacco as a source of nicotine typically felt it was just as harmful or slightly less harmful than regular cigarettes. Vaping was often classified next and seen as less harmful than regular cigarettes because it involves vapour as opposed to combustion. Nicotine gum, patches, etc., were deemed the least harmful, largely because they were clearly viewed as cessation tools.

The results from the survey confirmed these qualitative findings, although using a more restricted list of nicotine sources. Cigarettes are clearly identified as decidedly harmful (91% harmful/very harmful), with vaping with nicotine (68% harmful/very harmful) and a nicotine inhaler a distant second in terms of the perceived harm (58% harmful/very harmful). Other nicotine sources were considered less harmful still, but none were found to be harmless by large proportions of respondents (nicotine spray, 52%; very low nicotine content cigarettes, 52%; nicotine lozenge, 43%; nicotine gum, 39%; and, nicotine patch, 36% saying harmful/very harmful).

On the topic of vaping, majorities of survey respondents across all targeted audiences indicate discomfort with the notion of young people using vaping products, particularly those containing nicotine. The attitude is almost as broad and strong as the expressed discomfort over young people taking up smoking cigarettes. While 86% of the general population disagree with the statement "I don't see any problem with young people taking up smoking cigarettes," almost as many (81%) disagree with the statement "I don't see any problem with young people using vaping products with nicotine." Indeed, the level of disagreement is also relatively high (65%) when it comes to young people using vaping products without nicotine. A majority of participant in the general population (71%) and in the targeted age audience oversamples (13-14 = 60%, 15-19 = 59%, 20-24 = 59%) do not view vaping as socially acceptable.

Survey respondents are somewhat divided over whether cigarettes would be less harmful if nicotine was removed from them. Among the general population, more people disagree (45%) with this notion than agree with it (32%), but among smokers there is a greater tendency to agree (47%) than disagree (31%) with this assertion. Among the youth oversamples, opinion tends to be more evenly divided. Among youth 13-14, 38% agree and an equal proportion disagree. Among youth 15-19, 38% agree, and 37% disagree.

Although opinion is similarly divided, respondents find it slightly easier to agree with the notion that removing nicotine from vaping products would make these products less harmful – over a third (39%) agree, while 31% disagree.

Very low nicotine content (VLNC) cigarette concept testing

A very low nicotine cigarette is a tobacco cigarette that is still smoked but has the vast majority (95% or more) of the nicotine removed from it. Right now, each cigarette typically contains 12-13 mg of nicotine. A very low nicotine content (VLNC) cigarette could have less than 1 mg of nicotine in it. All other aspects of smoking a cigarette would be the same, with the exception of the nicotine level. Note that the very low nicotine content cigarette is not the same as "light" or "mild" products that used to be available in Canada.

The concept of VLNC cigarettes elicited mixed reactions from focus group participants. A few who indicated having some knowledge of VLNC cigarettes were clearly conflating the term with "light" or "mild" cigarettes.

Among focus group participants, the perceived benefits of VLNC cigarettes included: being less addictive; a cessation tool; less harmful (because there is less nicotine); a sense that for those who may consider trying a cigarette for the first time, it may be better to try one that does not have nicotine than one that does; and may diminish alcohol consumption.

The perceived drawbacks of VLNC cigarettes included: potential to smoke more VLNC cigarettes to get the desired nicotine "fix"; continued exposure to the harmful chemicals found in cigarettes; potential to entice non-smokers to try smoking; continued ritual/habit of smoking; and questions about what fillers would be added to compensate for the decrease in nicotine.

Survey respondents confirmed the concept is not immediately well-received, with half (51%) offering unfavourable opinions of the concept and only 18% feeling positively toward it. Among the targeted populations oversampled in the survey, smokers clearly stand apart as the only segment where more respondents feel favourably than unfavourably towards the idea – almost half (48%) have a favourable opinion, while 15% have an unfavourable view.

Youth and young adults in the focus groups reported that they would not be likely to consider trying a VLNC cigarette if such a product was introduced, while adult smokers were more interested.

The younger, non-smoking groups were not interested primarily because the reasons for which they do not smoke now (i.e., inclusion of harmful chemicals, combustion, lingering unpleasant odour, hygiene related effects) would not change drastically.

Adult smokers, on the other hand, would be willing to try VLNC cigarettes, either out of curiosity or in an attempt to wean themselves off regular cigarettes. However, most felt that experience and cost could influence their continued use of VLNC cigarettes.

Quantitatively, among the general population, 24% are susceptible to trying VLNC cigarettes as they indicate they would either definitely (5%), probably (9%), or probably not (10%) try VLNC cigarettes if they were available in Canada. The susceptibility rates are similar among the three youth groups oversampled, but the results contrast sharply based upon smoking status. Among smokers, the vast majority (82%) offer this level of likelihood to try VLNC cigarettes. Among non-smokers, there is a much smaller proportion (14%) who feel they would probably not, probably or definitely try a VLNC.

Among smokers, more than half expect that if VLNC cigarettes were made available they would either entirely (27%) or partially (31%) replace current cigarettes smoked.

Echoing results described above about the removal of nicotine, respondents are divided over whether VLNC cigarettes would be just as harmful as regular cigarettes (41%) or at least a little less harmful (44%). Again, smokers are slightly more decidedly of the view that VLNC cigarettes would be less harmful than regular cigarettes (58%, compared to 42% of non-smokers).

Across a variety of quantitative measures, respondents demonstrate having mixed and soft opinions on the VLNC cigarette concept. There's more agreement (50%) than disagreement (22%) that VLNC cigarettes would help smokers who are trying to quit, but there is simultaneously more agreement than disagreement that the introduction of VLNC cigarettes might convince some who would otherwise not smoke to try smoking them. Further, opinion is nearly evenly divided over whether VLNC cigarettes have more benefits (27%) or drawbacks (25%) for smokers – although on this point, smokers are more convinced of a net benefit (42%) than a net-drawback (16%).

Information sharing (Between parents and teens)

The survey shed some light on the kinds of substance-related discussions that have been occurring between parents and their teenage children. Most parents of teens and teens themselves indicate having had conversations about drug use (82% and 72%, respectively), alcohol (both 81%), smoking (78% and 76%) and cannabis (77% and 74%). However, the proportions claiming to have had conversations about vaping are significantly lower – 55% of parents and youth say they have discussed it. The proportions claiming to have had conversations about nicotine are lower still (44% of parents and 43% of youth).

Research Firm:

Earnscliffe Strategy Group Inc. (Earnscliffe)
Contract Number: HT372-183684/001/CY
Contract award date: November 13, 2018

I hereby certify as a Representative of Earnscliffe Strategy Group that the final deliverables fully comply with the Government of Canada political neutrality requirements outlined in the Communications Policy of the Government of Canada and Procedures for Planning and Contracting Public Opinion Research. Specifically, the deliverables do not include information on electoral voting intentions, political party preferences, standings with the electorate or ratings of the performance of a political party or its leaders.

Signed:
Date: March 28, 2019
Doug Anderson
Principal, Earnscliffe

Introduction

Earnscliffe Strategy Group (Earnscliffe) is pleased to present this report to Health Canada summarizing the results of the qualitative and quantitative research conducted to understand public perceptions of nicotine.

Given tobacco use is the leading preventable cause of death and disease in Canada, the Government of Canada has announced a target of less than 5% tobacco use by 2035.

The specific objectives of the research were to:

• Gather information on the general populations', with a focus on smokers', youth and young adult non-smokers', knowledge of the health hazards of smoking;
• Gather information on smokers' and youth and young adult non-smokers' knowledge of the health effects and health hazards of nicotine;
• Gather information about the continuum of risk of various products containing nicotine; and,
• Test reactions to a hypothetical concept of a very low nicotine content cigarette, including:
  • Overall reactions;
  • Perceived health effects and health hazards; and,
  • Potential to induce non-smokers to consider smoking.

Feedback from the research will help Health Canada understand how to maximize different policies to achieve its target of reducing tobacco use to 5% by the year 2035.

To meet these objectives, Earnscliffe conducted a three-phased research program.

The first phase involved qualitative research which included a series of fifteen focus groups with three segments of the Canadian population: youth (16-19) non-smokers; young adult (20-24) non-smokers; and, adult (40-55) smokers. For each group, a maximum of ten (10) individuals were recruited as participants. In total, 128 people participated in this phase of focus group discussions. Three sessions were conducted in each of the following five cities: Toronto (December 3, 2018); Halifax (December 4, 2018); Montreal (December 5, 2018); Winnipeg (December 5, 2018); and Vancouver (December 6, 2018). The groups in Montreal were conducted in French whereas all other locations were conducted in English. Please refer to the Recruitment Screener in the Appendix of this report for all relevant screening and qualifications criteria.

In each city, the groups with young adult non-smokers began at 4:30 pm, the groups with youth non-smokers began at 6:00 pm and the groups with adult smokers began at 7:30 pm. The sessions were approximately 1.5 hours in length. Focus group participants were given an honorarium of $90 as a token of appreciation for their time. Appendix C provides greater detail on how the groups were recruited, while Appendix A provides the discussion guides used for the focus groups and Appendix B provides the handouts used in the focus groups.

The initial phase of qualitative research was followed by a quantitative phase involving an online survey of 4,190 Canadians aged 13 and older. The online survey was conducted using our data collection partner, Leger's, proprietary online panel. The data collection began with a total of 2,000 interviews conducted collected as a core sample of the general population aged 15 years and older. Oversamples were also collected, with the intent of achieving the following numbers of additional cases in the audiences listed below:

• 500 additional cases among youth aged 13-14;
• A total of 500 cases among youth aged 15-19;
• A total of 500 cases among youth aged 20-24; and
• 1,000 additional cases among smokers aged 15 years and older.

Although the intent had been for the additional oversample of smokers to include both daily and occasional smokers, due to an error in screening, the additional oversample of smokers is only among daily smokers. For the tables, wherever the term smokers is used, it includes both daily and occasional smokers. The total group of smokers has been weighted by the 2017 Canadian Tobacco, Alcohol and Drugs Survey (2017) to ensure the results reflect appropriate relative proportions of daily and occasional smokers.

Since the base survey of 2,000 as well as each of the age-specific oversamples included both smokers and non-smokers, the total number of smokers studied is the sum of daily and occasional smokers found in each of the unique samples.

The tables below indicate the total number of cases both overall and by region, for the final total sample of 4,190 cases, as well as for the base sample of 2,000 Canadians aged 15 years and older and each of the oversamples.

The surveys were conducted from February 11 to March 7, 2019 in English and in French. The data was weighted to reflect the demographic composition of the Canadian population aged 13 and older, including the incidence of daily and occasional smoking. Because the online sample is based on those who initially self-selected for participation in the panel, no estimates of sampling error can be calculated, and the results cannot be described as statistically projectable to the target population. The treatment here of the non-probability sample is aligned with the Standards for the Conduct of Government of Canada Public Opinion Research for online surveys. For more details on the methodology of the survey, please see Appendix D.

Bolded results presented in this report indicate that the difference between the demographic groups analysed are significantly higher than results found in other columns in same demographic analysis. Within the tables included in the body of the report, letters beside percentages indicate results that are significantly higher than those found in the specific comparison columns indicated by the letter. Unless otherwise noted, differences highlighted are statistically significant at the 95% confidence level. The statistical test used to determine the significance of the results was the Z-test. Due to rounding, results may not add to 100%.

For the tabular results selected for highlighting in the body of the report, the "Total" column always includes all respondents answering a particular question, but in the interest of brevity, not all subset categories are necessarily compared with each other. For example, in many cases specific age breaks under 25 years of age are displayed, but not the responses of older age categories, although the "Total" column includes respondents from all age categories.

Finally, we conducted follow-up qualitative research, which included two focus groups with two segments of the Canadian population: youth (16-18) and young adults (19-24) who occasionally vape or may be susceptible to trying it. The groups were conducted in Toronto (March 19, 2019). The groups with youth aged 16-18 began at 6:00 pm, and the groups with young adults aged 19-24 began at 7:30 pm. The sessions were approximately 1.5 hours in length and participants received an honorarium of $90 as a token of appreciation for their time. Please refer to the Phase 3 Recruitment Screener in the Appendix C of this report for all relevant screening and qualifications criteria.

The objectives of this final phase of qualitative research were to delve more deeply into some of the previous findings surrounding basic knowledge and impressions of vaping. More specifically, this phase tested initial reactions to proposed health warning messages that may be used on vaping product advertisements.

It is important to note that qualitative research is a form of scientific, social, policy and public opinion research. Focus group research is not designed to help a group reach a consensus or to make decisions, but rather to elicit the full range of ideas, attitudes, experiences and opinions of a selected sample of participants on a defined topic. Because of the small numbers involved the participants cannot be expected to be thoroughly representative in a statistical sense of the larger population from which they are drawn and findings cannot reliably be generalized beyond their number.

Detailed findings

The following report is divided into two main sections: the first presents the perceptions of nicotine informed by the initial qualitative research and the follow-up quantitative survey; the second presents the perceptions of vaping informed by the additional qualitative phase of research. The findings on perceptions of nicotine are explored across five key sections: behaviours and motivations; knowledge and perceptions of nicotine; impressions of nicotine; VLNC cigarette concept testing; and, information sharing. The findings on perceptions of vaping follow and are reported in one section.

Except where specifically identified, the qualitative findings represent the combined results across the various audiences and for both English and French. The quantitative findings focus primarily on the differences across the five target segments: the four oversamples and the general population as a whole. Appended data tables provide results of findings across a much broader range of characteristics, behaviours and attitudes.

For purposes of reporting, when examining the quantitative results among smokers, the sample includes smokers (who smoke daily and occasionally) as found in the general population sample and all oversamples and is weighted to correct for the overrepresentation of daily smokers and underrepresentation of occasional smokers. Thus, the data on smokers is reflective of the population of smokers as defined by both daily and occasional smokers. The table below illustrates the CTADS results as compared to our weighted sample.

Section 1: Perceptions of nicotine

A. Understanding behaviours and motivations

This chapter focuses on behaviours and motivations specifically relating to smoking and vaping products with and without nicotine. Throughout this chapter of the report and in subsequent chapters, results among certain key subsets are examined (e.g., smokers/non-smokers; vapers/non-vapers, etc.). The identification of these subsets was made through a series of questions on current, past and potential behaviours related to cigarettes, using vaping products that do and do not contain nicotine. For a full examination of the results of that line of questioning, please see chapter G: Current, Past and Potential Behaviours.

Smokers' behaviours

To better understand smokers' behaviours, they were asked about the number of cigarettes they have smoked in their lives and how many cigarettes they smoke.

Just under two-thirds (63%) of those who have at least tried smoking say that they have smoked at least 100 tobacco cigarettes in their life. This proportion is much higher among daily (99%) and occasional (89%) smokers. One-quarter (26%) of teens who have at least tried smoking say they have smoked 100 cigarettes in their life. A similar proportion (25%) of teens aged 15-19 say the same. More young adults aged 20-24 (40%) report having smoked at least 100 cigarettes to date.

Whether or not a respondent has smoked more than 100 cigarettes varies by the following demographic variables:

• Men (67%) are more likely than women (61%) to have smoked over 100 cigarettes.
• Atlantic Canadians (71%) and Quebecers (68%) are more likely than respondents from other regions to have smoked 100 cigarettes.
• Those with a household income of $80,000 or more are less likely to have smoked 100 cigarettes (58%) compared to those with a lower income (68% of those with a household income of $40,000-$80,000 and 70% of those with a household income less than $40,000).
• Respondents with a post-graduate degree are among the least likely to have smoked 100 cigarettes (51%).

Over half of smokers (56%) smoke more than 11 cigarettes a day. Over a third (35%) say they smoke between 5 and 10 cigarettes daily. Few teens (aged 13-14) are smokers and among those who are, the vast majority smoke 10 or fewer cigarettes in a day. The same tendency holds true, if less universal, among teens (aged 15-19) and young adults (aged 20-24).

When asked how many cigarettes they smoke on the days that they do smoke, 60% of occasional smokers replied between 1 and 4 cigarettes. Just over one-quarter (28%) report smoking between 5 and 10 cigarettes, and 5% smoke 11 or more. Almost three-quarters (72%) of teens 13-14 who smoke occasionally smoke between 1 and 4 cigarettes a day. Over three-quarters (78%) of 15-19 year-olds and 70% 20-24 year-olds smoke between 1 and 4 cigarettes on the days they do choose to smoke.

Understanding non-smokers

Non-smokers were asked a series of attitudinal statements to understand their motivations for not smoking.

Among non-smokers (n=2495), the chief reason they do not smoke is to avoid the associated diseases. The vast majority (80%) strongly agree that this is an important reason for them. Responses are fairly uniform across the age groups analyzed – 76% of teens aged 13-14 and 15-19 strongly agree, as do 81% of young adults aged 20-24.

Similarly, non-smokers feel strongly that there is little reason to smoke (74%) and answers vary little by age group – 72% of teens aged 13-14 and young adults 20-24 and 73% of teens aged 15-19 strongly agree they do not see any good reason to smoke.

The smell and monetary cost associated with smoking also appear to be strong deterrents. Over two-thirds (68%) strongly agree that they do not smoke because they do not like the smell. Similar proportions of the youth oversample also strongly agree: 73% of teens aged 13-14, 67% of teens aged 15-19 and 69% of young adults aged 20-24. Almost two-thirds (64%) of the general population sample strongly agree the expense, for them, is a good reason not to smoke. Fewer, though still a majority of teens aged 13-14 (65%), 15-19 (68%) and young adults aged 20-24 (68%) strongly agree that they do not smoke to avoid addiction.

Avoiding addiction is important to non-smokers – two-thirds (64%) strongly agree it is a reason why they do not smoke. Again, the younger oversample groups are in line with the general population. Roughly two-thirds of 13-14 year-olds (65%), 15-19 year-olds (68%) and 20-24 year-olds (68%) strongly agree. Those who vape with nicotine were less likely to strongly agree (46%) compared to those who vape without nicotine (65%).

Over half of the general population sample claims they do not enjoy smoking – 57% strongly agree it is a reason to not smoke. The 13-14 year-olds (58%), 15-19 year-olds (58%) and 20-24 year-olds (55%) tend to feel the same way.

Social acceptability is less of a deterrent than potential health impacts, though still over half (61%) strongly agree or agree it is a reason not to smoke. A greater proportion of teens aged 13-14 (46%) strongly agree it is a good reason not to smoke compared to 15-19 year-olds (34%) and 20-24 year-olds (24%).

Among the general population, 42% agree the reason that they do not smoke is because they quit. As might be expected, fewer teens aged 13-14, 15-19 and young adults aged 20-24 (all 16%) agree this is a reason for them.

There are some demographic differences when it comes to non-smokers' decision not to smoke. They include the following:

• Women are more concerned about smell than men – three quarters (73%) strongly agree it is a reason they do not smoke, compared to 62% of men.
• Fewer Indigenous respondents strongly agree that social acceptability is a strong deterrent to smoking (25%) than non-Indigenous respondents (39%).
• One-in-five (19%) of respondents with a household income of less than $40,000 disagree that social acceptability is a deterrent, compared to 10% of those with an income of $80,000 or more.
• Cost is less of a deterrent to those with an income less than $40,000 (80% agree) than it is for those with an income between $40,000 and $80,000 (88% agree).
• Half (51%) of Indigenous respondents strongly agree they do not see any good reason to smoke, compared to 75% of non-Indigenous respondents.

Understanding vapers

As with smokers, vapers were asked a series of questions to better understand their daily use of e-cigarettes or vaping devices; the nicotine content; and, where they procure their vaping devices or liquids.

The frequency with which daily vapers (n=185) use a vaping device with nicotine is split. One-third (33%) say they use their device between 5 and 10 times a day. Roughly one in five (21%) report using it less (1-4 times a day), while 17% say they use it 11-20 times and 22% exceed 20 uses per day. The cell sizes for all of the youth oversamples were very small. Results should be regarded with caution and considered only qualitative in nature.

Over half (54%) of respondents who use a vaping device with nicotine occasionally (n=612) do so 1-4 times per day, on the days they choose to vape. Just under one-quarter (22%) use their vaping device 5 to 10 times a day, and 9% use it 11 times or more. Once again, the number of teens and young adults who vape occasionally is small, and caution should be taken when interpreting the results. Three-quarters of teens (76%) aged 13-14 use their device 1-4 times per day. Just under two-thirds (64%) of teens 15-19 use their device 1-4 times, as do 59% of young adults 20-24.

Regionally, use is highest among occasional vapers in Manitoba and Saskatchewan, where one-in-five (19%) report using their device more than 20 times a day. There are also differences in frequency of use based on education: three-quarters (77%) of those with a post-graduate degree use their device 1-4 times on the days they do vape, significantly more than the 43% of respondents with a high school education and 38% without a high school education who say the same.

Respondents who use vaping products with nicotine were asked to indicate what nicotine strength they typically consume when vaping. This line of enquiry permitted respondents to enter a numerical response and to separately identify whether that measure was in mg/ml, ml, or %. Results demonstrated that regardless of the metric, the distribution of numerical responses is quite similar. As a result, for ease of analysis, the results across the three metrics have been combined together and displayed below as "mg/ml/%".

Among those who vape using a product that contains nicotine, the concentration of nicotine in the product varies. Twelve percent (12%) claim the concentration is 1 mg/ml/%, 25% say 2-3 mg/ml/%, 18% say 4-5 mg/ml/% and 36% say over 5 mg/ml/%. Across the various age groups, teens (aged 15-19) are more likely than other targeted age groups to be using concentrations of nicotine higher than 10 mg/ml/%, with one quarter (26%) indicating this level of strength. As well, daily vapers are more likely to indicate using higher concentrations of nicotine than occasional vapers, with 55% of daily vapers using concentrations over 5 mg/ml/% compared to 30% among occasional vapers.

Looking at the frequency of vaping by the typical nicotine strength a vaper describes using, there is a clear tendency for those using higher levels of nicotine content to be vaping more times during a typical day or in the case of occasional users, a typical day in which they vape. Only 1% of those using vaping products containing the lowest nicotine concentration say they vape more than 20 times a day, whereas this proportion is 22 times higher (22%) among those who vape products with a nicotine concentration of 6 mg/ml/% or more.

The most common place for respondents who vape using nicotine and are of legal age (n=631) to purchase a vaping device is a vape shop (62%), followed distantly by online (21%). Notably fewer teens aged 13-14 (41%) and 15-19 who are not of legal age in their province (24%) get their devices at these stores (note that 46% of teens 15-19 who are of legal age purchase vaping devices at vape shops). Another key difference is that these groups are more likely to get a device in some way from their peers. For teens aged 13-14, significantly more acquire a vaping device by buying it (45%) or borrowing it (22%) from a friend. Similarly, among those ages 15-19 who are not of legal age, 27% buy a device from a friend and 35% borrow it. In comparison, just 7% of the general population sample who are of age (n=631) claims they buy vaping devices from friends and 14% say they borrow them from friends. Young adults ages 20-24, much like the general population, are most likely to buy a vaping device at a vape shop (56%), online (24%) or at a convenience store (24%).

The cell sizes of teens aged 13-14 and 15-18 who say that a friend, family member or other person bought the vape for them or gave it to them are very small and, therefore, results should be regarded with caution and considered only qualitative in nature. The majority of both age groups say the friend, person or family member they bought their device from is older than them. Similarly, most say the family member they borrowed a device from is older than them. However, when it comes to borrowing from friends, almost half (45%) of those 13-14 say the friend was there age, as does over two-thirds (69%) of teens ages 15-18.

Few teens ages 13-14 and 15-18 have sources who are younger than them. Most common are sources of the same age (30% of teens 13-14 and 36% of teens 15-18). More teens 13-14 have an enabler who is more than a couple of years older (28%) than those ages 15-18 (10%).

Key takeaways: Understanding behaviours and motivations

• Among non-smokers, the chief reason they do not smoke is to avoid the associated diseases (80% strongly agree). Similarly, non-smokers feel strongly that there is little reason to smoke (74%). Smell (68%) and monetary cost (64%) also appear to be strong deterrents.
• The concentration of nicotine used by vapers in their vaping products was varied. Twelve percent (12%) claim the concentration is 1 mg/ml/%, 25% say 2-3 mg/ml/%, 18% say 4-5 mg/ml/% and 36% say over 5 mg/ml/%.
• One-third of daily vapers (33%) say they use their device between 5 and 10 times a day. Roughly one in five (21%) report using it less (1-4 times a day), while 5% say they use it 11-20 times and 34% exceed 20 uses per day.
• Over half (54%) of respondents who use a vaping device with nicotine occasionally do so 1-4 times per day, on the days they choose to vape. Just under one-quarter (22%) use their vaping device 5 to 10 times a day, and 9% use it 11 times or more. Fewer use it 11 or more times a day (9%).
• The most common place for respondents who vape using nicotine and are of legal age to purchase a vaping device is a vape shop (62%), followed distantly by online (21%). Notably fewer teens aged 13-14 (41%) and 15-19 who are not of legal age in their province (24%) get their devices at these stores (note that 46% of teens 15-19 who are of legal age purchase vaping devices at vape shops).
• Another key difference is that these groups are more likely to get a device in some way from their peers. For teens aged 13-14, significantly more acquire a vaping device by buying it (45%) or borrowing it from friends (22%). Similarly, among those ages 15-19 who are not of legal age, 27% buy a device from a friend and 35% borrow it.
• Few teens ages 13-14 and 15-18 have sources who are younger than them. Most common are sources of the same age (30% of teens 13-14 and 36% of teens 15-18). More teens 13-14 have an enabler who is more than a couple of years older (28%) than those ages 15-18 (10%).

B. Health effects associated with smoking and nicotine

Respondents were asked a series of questions related to their knowledge of the health impacts associated with smoking and nicotine.

Overall, most respondents consider themselves knowledgeable of the health impacts of smoking (91% very or somewhat knowledgeable). Slightly less consider themselves knowledgeable of the health impacts of nicotine (84%).

Among the general population, over half (56%) consider themselves very knowledgeable of the health impacts of smoking, and another third (35%) consider themselves moderately knowledgeable. In terms of the health impacts of nicotine, 45% consider themselves very knowledgeable about nicotine, and 39% consider themselves moderately knowledgeable. Self-reported knowledge of the health impacts of smoking is high across demographic groups.

There is a little more variation when it comes to knowledge of nicotine:

• Women are more likely to consider themselves very knowledgeable (47%) than men (42%).
• Well over half of Quebecers (61%) say they are very knowledgeable, a significantly greater proportion than in other regions.
• Fewer Indigenous (38%) than non-Indigenous (45%) respondents consider themselves very knowledgeable.

Taking a closer look at the oversamples, youth and young adults are less likely to consider themselves knowledgeable about smoking and nicotine than the general population. Youth 13-14 report lower levels of knowledge (very/moderately knowledgeable) about the health impacts of smoking (77%) and nicotine (69%). In comparison, a larger proportion of youth 15-19 consider themselves knowledgeable about smoking (very/moderately knowledgeable 86%) although the proportion feeling as knowledgeable about nicotine is similar (71%). Young adults 20-24 report similar knowledge levels to the 15-19 year-old group. Just a little over eight in ten (83%) say they are knowledgeable (very/moderately knowledgeable) about smoking and 72% about nicotine.

There are small differences between the proportion of smokers and non-smokers who consider themselves very knowledgeable about the health impacts of smoking and nicotine. Overall, smokers are more likely to report that they are very knowledgeable about smoking (60%) and nicotine (50%), compared to non-smokers. That said, knowledge among non-smokers is still widespread. Over half (55%) consider themselves very knowledgeable about the health impacts of smoking, and another third (36%) say they are moderately knowledgeable. When it comes to the health impacts of nicotine, 44% consider themselves very knowledgeable and 40% say they are moderately knowledgeable.

How knowledgeable would you say you are about each of the following?

Qualitative insights: Health effects associated with smoking cigarettes

The qualitative findings of the first phase of research will be woven throughout Section 1 of the report.

To recap, the first phase of focus groups were conducted with three key audiences: youth (16-19) non-smokers; young adult (20-24) non-smokers; and, adult (40-55) smokers.

Except where specifically identified, the qualitative findings in this report represent the combined results for all audiences, as the findings were very consistent.

Participants of all ages were well aware of a number of long- and short-term health effects associated with smoking cigarettes. Most had the sense that the severity of the health effect amplified with increased use (number of years) and frequency (number of cigarettes smoked daily) and that the long-term health effects were in some instances not reversible, but that some of the short-term health effects were. Smokers were able to more readily volunteer health effects associated with smoking cigarettes.

The health effects associated with smoking cigarettes included (in no particular order):

Setting aside "addiction", participants tended to link the other health effects listed above to the presence of unknown chemicals in cigarettes. These chemicals were often referred to as: "tar," "rat poisoning," "rocket fuel," "benzene," "carcinogens," and other "unknown chemicals". Most had the impression these were "added" to cigarettes. While many were aware of the presence of tobacco in cigarettes, this was described as a natural ingredient derived from the tobacco plant.

In terms of "addiction", the overwhelming majority of participants (across all audiences) linked it to the presence of nicotine in cigarettes, although there was some confusion as to whether there were other addictive substances found in or added to cigarettes. For example, some questioned whether any of the chemicals/substances listed above had addictive properties, as well.

When asked about the health effects associated with nicotine, participants were hard pressed to volunteer with any certainty anything beyond addiction. In fact, many questioned how nicotine could be harmful if it was prescribed by health care professionals as a smoking cessation tool (i.e. nicotine gum, patches, lozenges, etc.). When asked to volunteer potential health effects, participants reasoned that nicotine could: cause withdrawal (which could cause mood swings, irritation, agitation, etc.); have a calming effect; and contribute to high blood pressure.

When presented with a variety of possible ailments related to nicotine, participants could believe that most were true. For example, most could relate nicotine to increased heart rate, increased blood pressure, nausea/vomiting, poisoning, and fetal lung and brain development. Many also believed that nicotine could relate to cancer although there was some debate as to whether cancer was more directly related to the other harmful ingredients in cigarettes or to the presence of nicotine.

Interestingly, what we observed as part of this particular conversation was that participants typically came out of that discussion believing that nicotine was a more harmful substance than they originally thought. This, we will see later, proved to be especially important in the context of their evaluations of very low nicotine content cigarettes (VLNC cigarettes).

Half (53%) of the general population are very concerned about the health effects/hazards of nicotine on its own and another 34% are somewhat concerned.

Analysis by the age groups shows little fluctuation, with the plurality or more indicating being very concerned. Among youth 13-14, almost half (49%) are very concerned a proportion nearly identical to that among 15-19 year-olds (47%). That number is slightly lower (44%) among young adults 20-24. In contrast, those 55 and older are more likely to be very concerned (63%). Differences between other demographic groups tend to be in the strength of concern. For example, 56% of women are very concerned, compared to 50% of men.

Non-smokers are slightly more concerned than the general public, and vastly more concerned about the health effects of nicotine than smokers. Over half (58%) are very concerned, and another third (32%) are somewhat concerned, for a combined 90%. This proportion is smaller among smokers. Less than a third (28%) of smokers are very concerned, and half (50%) are somewhat concerned. In total, 78% of smokers are concerned of the health effects and hazards of nicotine on its own.

Nicotine is widely viewed as harmful to the health of those using products containing it. Over half (58%) of the general population find nicotine very harmful. Another quarter (24%) believe nicotine is harmful, for a combined 82%.

As with concern of the effects/hazards of nicotine, firm belief that nicotine is harmful is lower among youth 15-19 (53% believe it is very harmful) and young adults 20-24 (45% say it is very harmful). Youth 13-14 most closely mirror the opinion of the general population with 58% responding very harmful and 25% responding harmful.

Smokers are less likely than non-smokers to believe nicotine is harmful. Among smokers, a total of 64% say nicotine is either very harmful (32%) or harmful (32%). Non-smokers are nearly twice as likely to believe nicotine is very harmful (62%) and an additional 23% say it is harmful, bringing to 85% the total of non-smokers who feel that nicotine is harmful.

Interestingly, within the universe of smokers, daily smokers are more inclined to view nicotine as harmful than occasional smokers. A combined 68% of daily smokers find nicotine harmful, compared to 53% of occasional smokers.

Like smokers, those who vape with products containing nicotine daily or occasionally are much less likely than the general population and those who do not vape to find nicotine harmful to the health of those using it. One quarter (26%) of vapers say it is very harmful, compared to 58% of the general population and 61% of those who do not vape using nicotine.

Notable demographic differences include:

• More women (63%) than men (52%) believe nicotine is very harmful.
• Quebecers are more concerned about the health effects of nicotine on those who use products with it (69%) than in any other region.
• More respondents who are not Indigenous believe nicotine is very harmful (58%) than Indigenous respondents (39%).

When provided with a list of possible health effects there was a lot of overlap as to whether the cause of the effects were attributed to smoking tobacco cigarettes, or nicotine on its own. The majority of respondents believe the series of health impacts analyzed in this study can be attributed to both smoking tobacco cigarettes and nicotine, with the exception of impotence (48% say it is related to both) and Sudden Infant Death Syndrome (SIDS) (37%). Over 70% relate smoking tobacco cigarettes and nicotine to cancer (75%), effects on unborn children (75%), heart problems (74%), heart diseases (74%) and addiction (72%). Roughly two-thirds believe nicotine and smoking cigarettes can cause lung problems (69%), worsen one's physical condition (69%), cause gum disease/tooth loss (68%), lung diseases (68%), bad breath (66%) and can affect one's appearance (66%).

Though the tendency among the general public is to tie both smoking cigarettes and nicotine to most of the health impacts, roughly one-quarter believe lung problems (25%), bad breath (25%), lung diseases (25%) and effects on appearance (23%) are related solely to smoking tobacco cigarettes. Slightly fewer attribute gum disease (18%), cancer (17%), heart disease (14%), poor physical condition (13%) and heart problems (12%) to smoking on its own. Very few respondents believe that any of the health impacts are caused by nicotine on its own, with the exception of addiction: one in five (19%) believe nicotine is the sole cause. In addition to addiction, the only instances in which more respondents believe the effects are linked to nicotine over smoking include; poisoning (10% think it's related to nicotine while 6% think it's related to smoking), attention cognition effects (9%/5%), and headaches (8%/5%). The health effects that were less clear (and where respondents recorded a "don't know"/"prefer not to answer" response), include SIDS (38%), impotence (30%), attention or cognition effects (24%), headaches (21%), poisoning (18%), and effects on unborn children (11%).

Teens' (13-14 and 15-19) beliefs about the relationships between nicotine, smoking tobacco cigarettes and health effects are similar to the general population's views on the topic. In contrast, young adults aged 20-24 are more likely than the other oversample groups and the general population to attribute a number of health effects to smoking tobacco cigarettes, including:

• Bad breath (33%);
• Lung problems (32%) and diseases (31%);
• Gum disease (28%); and
• Cancer (21%).

Smokers, compared to non-smokers, are in general more likely to attribute health impacts to either smoking cigarettes or nicotine, but less likely to relate them to both together. Some examples include:

• Bad breath: 30% of smokers relate bad breath to only smoking cigarettes, 4% say nicotine and 56% say both. Over two-thirds of non-smokers (68%) attribute bad breath to both, while 24% say cigarettes and 2% say nicotine.
• Effects on unborn children: 13% of smokers relate effects on unborn children to only smoking cigarettes, 7% say nicotine and 63% say both. Over three-quarters of non-smokers (77%) attribute effects on unborn children to both, while 8% say cigarettes and 3% say nicotine.
• Heart disease: 19% of smokers relate heart disease to only smoking cigarettes, 5% say nicotine and 63% say both. Over three-quarters of non-smokers (76%) attribute heart disease to both, while 13% say cigarettes and 2% say nicotine.

Turning to demographic differences, men are more likely than women to attribute each of the health impacts included in this study solely to smoking cigarettes, though for each health impact the majority still believe nicotine is a cause in some way. For example, almost a third of men (29%) believe lung disease is related solely to smoking cigarettes, compared to 20% of women. Similarly, 17% of men relate heart disease solely to smoking cigarettes, compared to 12% of women. Other notable demographic trends include:

• Albertans are more likely than respondents from other regions to attribute gum disease (24%), effects on appearance (31%), bad breath (29%) and lung problems (31%) solely to smoking tobacco cigarettes.
• Respondents with a post-graduate degree are more likely to attribute the following solely to smoking tobacco cigarettes: lung problems (36%), lung diseases (33%), heart problems (17%), gum disease (26%), cancer (26%), and bad breath (34%).

Key takeaways: Health effects associated with smoking and nicotine

• Most consider themselves at least somewhat knowledgeable about the health impacts of smoking (91%) and nicotine (84%), including large majorities of every subgroup surveyed.
• Similarly, high proportions across all subgroups are at least somewhat concerned with the health hazards of nicotine on its own, including 87% of the total sample. Although smokers are much more likely than non-smokers to say they are only "somewhat" rather than "very" concerned, the proportion who are at least somewhat concerned is fully 78%.
• In focus groups, participants of all ages tended to be well aware of a number of short- and long-term health effects associated with smoking, but beyond "addiction" participants found it more difficult to name health effects associated with nicotine, specifically.
• When prompted in the survey with a list of 16 possible health effects, respondents are inclined to attribute nearly all of them to both nicotine and smoking tobacco cigarettes.
• Those who describe themselves as at least somewhat knowledgeable about nicotine are more likely than those claiming less knowledge to attribute any of the 16 health effects to both nicotine and smoking cigarettes.

C. Impressions of nicotine

In order to develop a deeper understanding of the impressions and views held regarding nicotine, respondents were asked to indicate their level of agreement with each of twenty-one statements. The presentation of the list was divided into three blocks of questions to respondents to make the respondent experience easier. The order of the blocks was the same for all respondents, but within each block the order of statements tested was randomized.

Results demonstrate that impressions of nicotine vary widely.

Origin of nicotine

The first block consisted of four statements (Q28A-D) concerning the origin of nicotine and shows contrasting and in some ways, conflicting opinions. Over half agree that nicotine can be synthetically manufactured (60%), while nearly half (46%) agree it is a naturally occurring substance. There is a significant degree of overlap on these two questions, with one-third (33%) of respondents indicating they agree that nicotine is both naturally occurring and can be synthetically manufactured. Similarly, over half of respondents (55%) agree that nicotine can be found naturally in tobacco, while just under half (47%) agree nicotine is added as part of the manufacturing process, again the degree of overlap between these two is one-third (32%) of respondents.

Young adults 20-24 are more likely to agree with the statement discussing nicotine as a synthetically manufactured substance (66%) and added as part of the manufacturing process (53%). Young adults are less likely to agree that it is a naturally occurring substance (41%) or found naturally in tobacco (45%). The responses from youth aged 13-14 and 15-19 more closely resemble those of the general population. The opinions of smokers and non-smokers are nearly identical with regards to the first block of statements. Of note, roughly one quarter of respondents are not sure or do not offer an answer when asked if nicotine is naturally occurring (26%) or synthetically manufactured (27%), reinforcing that knowledge of nicotine's origins and composition may be limited.

There are differences in opinion on this topic by education level:

• Well over one third (39%) of those with a post-graduate degree strongly agree that nicotine is naturally occurring, and over half (69%) either somewhat or strongly agree. Under half of those without a high school education (34%), high school diploma (39%) or college/university degree (47%) agree.
• Similarly, almost half (48%) of those with a post-graduate degree strongly agree that nicotine is a naturally occurring substance in tobacco plants. In contrast, one-in-five respondents without a high school education strongly agree, while 25% of those with a high school diploma and 27% of those with a college or university degree strongly agree.
• Those without a complete high school education are more likely to disagree that nicotine can be synthetically manufactured (10%).

Qualitative insights: Awareness of nicotine

Despite broad awareness of the term (nicotine), detailed knowledge of what nicotine is, where it comes from, and where it is found was limited. Typically, a few participants in each group mentioned having an understanding that it was naturally found in the tobacco plant, which seemed to make sense to most; although, very few, if any, were aware that nicotine could be found naturally in other plants. Most participants were under the impression that nicotine was something that could be extracted or man-made, especially in the context of their awareness of its inclusion in other products (i.e., vaping liquids, nicotine gum and patches, etc.). Indeed, some participants thought nicotine might be created by cigarette companies as a means of creating a dependency and, therefore, increasing sales.

Nature of concern over nicotine use

Opinion is also divided over the second block of ten statements (Q28E-N) relating to the nature of concern over nicotine use, including concern for nicotine in different forms. Half (51%) agree with the statement that most people who are vaping don't know if the product contains nicotine. However, those who vape – particularly those who do so daily – feel somewhat differently from non-vapers on this point. One in three (35%) of daily vapers agree while 42% disagree. Furthermore, fewer vapers agree (37%) than disagree (46%) with the statement, 'I really don't think about the level of nicotine in vaping products.' Taken together, these views suggest that vapers may be more aware of and thinking about the level of nicotine they are vaping, but it is still the case that less than a majority of vapers hold these views.

In contrast, more daily smokers (47%) agree than disagree (30%) that they don't really think about the level of nicotine in cigarettes. The results suggest vapers might be more conscious of the nicotine in the product they use than smokers, or at least they claim to be, possibly due to the fact that vaping products are available in a variety of nicotine concentrations.

Two in five respondents (40%) agree that if nicotine was removed from vaping products, they would be less harmful. Fewer respondents (32%) agree that if nicotine was removed from cigarettes, cigarettes would be less harmful. The results suggest that cigarettes are associated with a whole host of negative health impacts that not all think apply to vaping.

Qualitative insights: Perceptions of different sources of nicotine

To understand participants' perceptions of the different sources of nicotine, participants were asked to plot them on a spectrum. Most participants, across all groups, were able to differentiate between the different sources of nicotine. Smoking regular cigarettes was typically believed to be the most harmful source of nicotine because of the combustible properties and inclusion of chemicals, tar, carcinogens and other harmful substances. Those who mentioned chewing tobacco and self-rolled tobacco leaves as sources of nicotine typically felt they were just as harmful as or slightly less harmful than regular cigarettes. Vaping was often classified next and seen as less harmful than regular cigarettes. The main differentiator of vaping was the vaping process – that it involved vapour as opposed to combustion – and the perceived lack of harmful chemicals that are found in regular cigarettes. Nicotine Replacement Therapies (NRTs), such as gums, patches, etc. were typically categorized together and felt to be the least harmful sources of nicotine. Again, the fact these were commonly understood to be smoking cessation tools differentiated these from the other aforementioned sources.

Worth noting, there was a difference between non-smokers and smokers with respect to vaping. Non-smokers, especially the youth (16-19) tended to view the harm associated with vaping as dependent on the level of nicotine being used. Many believed that vaping was a much better alternative to smoking cigarettes. For some smokers, however, vaping was viewed as harmful albeit less harmful to smoking cigarettes. A number of participants across all audiences, although smokers seemed to be most familiar with it, spoke of having heard of 'popcorn lung' and 'pneumonia' linked to vaping.

The general population sample is broadly opposed to young people vaping with nicotine and smoking. The vast majority disagree with the statements, 'I don't see any problem with young people taking up smoking' (86%) and 'I don't see any problem with young people using vaping products with nicotine' (81%). Youth and young adults are slightly less concerned about these situations, but even so approximately three-quarters also disagree.

Opposition to young people vaping without nicotine is softer (65% disagree) and again, youth 13-14 (59%), 15-19 (55%) and young adults (47%) are less likely to disagree. Of note, more (47%) disagree than agree (27%) with the statement, 'I don't see any problem with young people using nicotine replacement therapies', indicating that where youth are concerned, the general population feel even cessation tools are concerning.

The statement that read "I don't see a problem with young people using nicotine replacement therapies," received stronger disagreement from respondents who were knowledgeable of nicotine (48%) than those who were not knowledgeable (40% disagree). Almost half of respondents (47%) who are concerned about the health effects of nicotine on its own, compared to a third (36%) of those who are not concerned. Further, when looking at perceived harmfulness of each cessation tool (gum, spray, lozenge, patch, and inhaler), those who perceived them as harmful disagreed more than those who did not view them as harmful.

Of note, some groups are less concerned about teens using vaping products, whether or not they contain nicotine. For example:

• There is slightly less disagreement with regards to youth using vaping products with nicotine among urban residents (80%) than rural residents (89%), and without nicotine (64% vs. 72%).
• Indigenous respondents are also less opposed – 59% disagree with the statement, 'I don't see any problem with young people using vaping products with nicotine', compared to 82% of non-Indigenous respondents. Under half (46%) of Indigenous respondents disagree with the statement, 'I don't see any problem with young people using vaping products without nicotine ", compared to 65% of non-Indigenous respondents.
• Women are more strongly opposed to young people vaping than men. Almost half (49%) strongly disagree with the statement, "I don't see any problem with young people using vaping products without nicotine" compared to 39% of men, and 73% strongly disagree with the statement, "I don't see any problem with young people using vaping products with nicotine" compared to 60% of men.

Social acceptability of smoking and vaping

The third block consisted of seven statements (Q28O-U) dealing with the social acceptability of both smoking and vaping. It offers more insight into the relative impressions of each behaviour and shows some particularly interesting differences among daily smoker and vaper opinions as compared to non-vapers and smokers.

Consistently, smoking is seen as much less socially acceptable than vaping. While 82% of non-smokers agree people close to them would be upset if they smoked, 68% of non-vapers said the same about vaping. Further, two-thirds of daily smokers (65%) agree that people close to them are upset by their smoking, while a little over one third of vapers (37%) agree that people close to them are upset by their vaping.

Neither smoking nor vaping are seen as socially acceptable, though smoking is by far the less acceptable of the two. Two-thirds of respondents (68%) disagree with the idea that smoking is socially acceptable while less than half (47%) disagree that vaping is socially acceptable. Of note, half of respondents (53%) agree that vaping is embarrassing/not cool.

The social acceptability of vaping varies by demographic group:

• Women (26%) are slightly more likely to agree than men (22%) that vaping is socially acceptable.
• Regionally, vaping is seen as more socially acceptable in Ontario (26%) and the Prairies (29%), particularly when compared to Quebec (21%).
• Vaping is more socially acceptable among urban (25%) compared to rural (18%) respondents.
• It is also more acceptable among Indigenous (42%) than non-Indigenous (23%) respondents.

Qualitative insights: Youth perspectives on vaping

In some cities (Montreal, Winnipeg, and Vancouver) we explored views and perspectives on vaping with youth and young adult non-smokers.

Views on vaping among most youth and some young adults tended to be generally favourable. Certainly, the majority felt vaping was less harmful than smoking cigarettes. They substantiated that vaping generally smelled good; was vaped rather than smoked (i.e., no combustion); and, other than nicotine (which was only perceived as being addictive) did not contain the other harmful chemicals found in cigarettes. Most described smoking cigarettes as very undesirable– 'gross' and 'dirty'.

Interestingly, there was a noticeable difference in terms of the perceived 'cool' factor associated with vaping between the youth and young adult groups. Those in the youth groups explained that vaping was common in their schools and that they thought the majority of youth engaged in vaping. Conversely, those in the young adult groups did not seem to view vaping as a 'cool' behaviour although most had either tried vaping or knew people who vaped.

Vaping was characterized by some youth as a hobby. Unlike cigarettes, they spoke of the ability to do tricks with the smoke and the ability to customize their vapes. They also explained that vaping could be done virtually anywhere, including in school bathrooms or at parties, which means one does not need to be isolated to participate (such as those who have to go outside or to designated areas to smoke cigarettes).

As compared to cigarettes, vaping products were felt to be much easier to procure; where ID is required for a cigarette purchase, the perception was that few ID for the purchase of vaping products. They also argued that they have never noticed any graphic health warning messages on vaping product packaging like they do on cigarette packages.

When asked whether there were any challenges around quitting vaping, many youth participants questioned why they would want to. They reasoned that the only perceived health effect was linked to nicotine (and therefore addiction). They also stated that given the infancy of vaping, there was limited information on the effects and dangers of vaping. While some, particularly young adults, had heard of 'popcorn lung', it did not seem to be much of a deterrent as yet.

Key takeaways: Impressions of nicotine

• Respondents are not sure of where nicotine originates from, whether it can be synthetically manufactured or occur naturally.
• Concern relating to nicotine use received contradicting reactions. Half of the general population agree that those who are vaping do not know if their products contain nicotine, whereas half of daily vapers disagree that they do not think about the level of nicotine in their vaping products.
• Smokers on the other hand were more in agreement that they do not think about the level of nicotine in their cigarettes.
• Two in five respondents (40%) agree that if nicotine was removed from vaping products, they would be less harmful. Fewer respondents (32%) agree that if nicotine was removed from cigarettes, cigarettes would be less harmful.
• The vast majority of respondents are opposed to young people vaping and smoking with nicotine. Youth and young adults are slightly less concerned about these situations, but even so approximately three-quarters also disagree.
• Consistently, smoking is seen as much less socially acceptable than vaping. While 82% of non-smokers agree people close to them would be upset if they smoked, only 68% of non-vapers said the same about vaping.
• Neither smoking nor vaping are seen as socially acceptable, though smoking is by far the less acceptable of the two.

D. Very low nicotine content (VLNC) cigarette concept testing

The research included questions aimed at gathering reactions to, interest in, and impacts of, a conceptual very low nicotine content (VLNC) product. In order to introduce the concept, the following text was read to focus group participants and displayed for survey respondents:

A very low nicotine content cigarette is a tobacco cigarette that is still smoked but has the vast majority (95% or more) of the nicotine removed from it. Right now, each cigarette typically contains 12-13 mg of nicotine. A very low nicotine content (VLNC) cigarette could have less than 1 mg of nicotine in it. All other aspects of smoking a cigarette would be the same, with the exception of the nicotine level.

[for the survey only]: Note that the very low nicotine content cigarette is not the same as "light" or "mild" products that used to be available in Canada.

Based upon this description, the general population sample has an overall unfavourable opinion of VLNC cigarettes. Half of respondents (51%) have an unfavourable opinion compared to one in five (18%) who have a favourable opinion of VLNC cigarettes, and a large portion who are unsure about them (30%, neutral or don't know). These results were drastically different when comparing non-smokers to smokers. One in two smokers (48%) has a favourable opinion of VLNC cigarettes compared to one in ten (13%) non-smokers. Youth and young adults also have differing opinions of VLNC cigarettes. Youth 13-14 have the least favourable opinion (48% unfavourable) of VLNC cigarettes. In contrast, youth 15-19 (38%) and young adults 20-24 (31%) are less likely to hold an unfavourable view of VLNC cigarettes than the general population.

Other demographic differences include:

• Respondents with a high school diploma (46% unfavourable) or less (39% unfavourable) are less likely to view VLNC cigarettes unfavourably than those who have a college/university education (53%) or a post-grad degree (58%).
• Respondents with an income of $80,000 or more have a more unfavourable opinion (54%) than those whose household income is less than $40,000 (44%).
• Non-Indigenous respondents have a less favourable view (52%) than Indigenous respondents (28%).

Among the general public, 5% say they would 'definitely yes' try a VLNC cigarette, another 9% would 'probably yes' try one. Results among youth and young adults are very similar to each other and closely resemble those of the general public. However, it is results among the smoking and non-smoking populations that are undoubtedly of greater interest than the overall results. Most smokers indicated some likelihood of potentially trying a VLNC cigarette if they were to become available in Canada, with two-thirds (69%) saying that it would be either probable or definite that they would try them. Among the country's non-smokers, interest is decidedly lower, but not non-existent, with 5% of non-smokers saying they would either definitely (1%) or probably (4%) try VLNC cigarettes if they were available in Canada.

The following table displays the proportions of respondents categorized as susceptible to different substances. These figures were calculated using only respondents who had never tried a particular substance, and indicated they would definitely, probably, or probably not do so in the future. Thus, respondents who perhaps tried the substance in the past were not included. Nevertheless, one in four respondents (24%) are susceptible to begin smoking VLNC cigarettes, including 14% of those who are not currently smokers.

Qualitative insights: Impressions of VLNC cigarettes

When asked, unaided, about their awareness of VLNC cigarettes, a few participants who indicated having some knowledge, were clearly conflating the term with "light" or "mild" cigarettes.

Once participants were read a brief description, initial reactions to VLNC cigarettes were mixed although they were quite similar across the groups. Interestingly, top of mind reactions did not always include that VLNC cigarettes were meant to be smoking cessation tools. While many reasoned that a lower nicotine content would result in a less addictive cigarette, some wondered whether the motivation to lower the nicotine levels was to reduce the amount of nicotine and make a less harmful cigarette. This speaks to the finding mentioned earlier that participants came away from the initial discussion about the health effects associated with smoking and nicotine, thinking that nicotine was more harmful than they originally thought. Because of this, many wondered whether the motivation to create VLNC cigarettes was to create a cigarette that was less harmful because nicotine had been removed.

When asked to reflect on the perceived benefits and drawbacks, participants cited the following:

• Perceived benefits
  • Less addictive (because less nicotine)
  • Less harmful (because less nicotine)
  • Cessation tool
  • Better for those who may consider smoking cigarettes for the first time
  • May diminish alcohol consumption (for those who tend to drink when they smoke)
• Perceived drawbacks
  • Potential to smoke more VLNCs to get the desired nicotine fix
  • Continued exposure to the harmful chemicals found in cigarettes
  • Potential to entice non-smokers to try smoking
  • Continued ritual/habit of smoking
  • Potential fillers (harmful chemicals) added to VLNCs to compensate for the reduced nicotine
  • Same harmful effects from second hand smoke

Of those smokers who indicate some potential to try VLNC cigarettes (responding probably not, probably yes, or definitely yes) (n=1390), over half (58%) would partially or completely use them to replace their current cigarettes smoked. Roughly a fifth of smokers (19%) would try VLNC cigarettes but likely go back to their current cigarettes. This number was higher among daily smokers (22%), and lower among occasional smokers (12%).

With regards to youth and young adult smokers, results varied, but majorities across all age groups felt that VLNC cigarettes would at least partially replace their current regular cigarettes. Youth 13-14 were more enthusiastic about VLNC cigarettes with two-thirds (64%) saying they would entirely or partially use them to replace their current cigarettes. Youth 15-19 were slightly less inclined to use VLNC cigarettes as a replacement for their regular cigarettes, with 54% reporting they would partially or entirely make the switch. Young adults were similarly inclined, with only 55% stating the same.

Other notable demographic differences among smokers include:

• Women are more likely than men to say the VLNC cigarettes would entirely replace the cigarettes they currently smoke (34% compared to 20%).
• Quebecers are also more open to switching out all their regular cigarettes – 34% say they would do so.
• Rural residents (36%) are more likely than urban residents (26%) to stop smoking their regular cigarettes entirely and replace them with VLNC cigarettes.

Qualitative insights: Intended use of VLNC cigarettes

In terms of participants' intended use of VLNC cigarettes, youth and young adult non-smokers did not feel that the introduction of VLNC cigarettes would entice them to try smoking (a VLNC cigarette). The fact that most of the reasons they do not smoke now (i.e., inclusion of harmful chemicals, combustion, lingering unpleasant odour, hygiene-related effects) would persist in VLNC cigarettes was an important demotivator. In fact, these younger cohorts would be (and have been) much more likely to try vaping which they described as less harmful and more popular.

Smokers (40-55), on the other hand, seemed to be open to trying VLNC cigarettes. Some said they would try them out of curiosity; while others said they would try them to wean off regular cigarettes. Most felt that the experience and cost would be two important factors determining their continued use of VLNC cigarettes. Many felt that if they were trying to quit smoking, they could potentially overlook a situation where the experience was not the same (i.e., taste, pull, etc.) or the cost was more expensive.

With respect to the experience, many wondered whether VLNC cigarettes would deliver the same 'hit' as a regular cigarette. Many questioned whether smoking VLNC cigarettes might be worse than smoking regular cigarettes as they felt they would need to smoke more VLNC cigarettes to achieve the desired effect.

In terms of the cost, reactions were mixed. Some smokers felt that if they were trying to quit smoking, they would be prepared to pay more for VLNC cigarettes than regular cigarettes. Others, typically those not as motivated to quit, were not prepared to pay more. In fact, some claimed they would continue to pay more for regular cigarettes even if VLNC cigarettes were less expensive than regular cigarettes. Interestingly, some wondered whether VLNC cigarettes would be subsidized like other smoking cessation tools, which seemed to be an appealing proposition.

Ultimately, most smokers felt that if they were not actively attempting to quit smoking, and tried a VLNC out of curiosity, if the experience was not the same or the cost was more expensive, they would not likely continue smoking VLNC cigarettes.

When asked how they would react if VLNC cigarettes were the only cigarettes on the market, participants across all audiences, seemed to think "other" smokers might turn to a black market. Some smokers said they would go to the United States or reserves for cigarettes instead. A small number of smokers thought this might encourage them to quit smoking.

When participants were asked if they would recommend the VLNC cigarettes to friends or family who currently smoke, slightly more (43%) would likely recommend them than would not (37%). However, smokers are decidedly more likely than non-smokers to say they would recommend VLNC cigarettes. Over two-thirds (67%) of smokers would likely recommend VLNC cigarettes, compared to just 39% of non-smokers. Interestingly, non-smokers were three times as likely (16%) to select 'not applicable, I don't have friends or family who smoke' compared to smokers (5%). Youth and young adults were only slightly more likely than the general population to think they would recommend VLNC cigarettes to current smokers that they know.

The impact of VLNC cigarettes on the number of cigarettes currently smoked by smokers varies between smokers and non-smokers. Non-smokers, when asked if smokers shifting to VLNC cigarettes might change the total number of cigarettes smokers had in a day, are not all that hopeful – just 15% believe there would be a net decrease. Roughly a third believe there will be a net increase (28%) or the number will not change (32%). Smokers, on the other hand, are more optimistic. When asked how the number of cigarettes they personally smoke in a day would change if they started using VLNC cigarettes, a third (30%) say it would decrease, another third (33%) believe it would stay the same and 21% say it would increase.

Youth non-smokers 13-14 and 15-19 have similar expectations compared to the general population when it comes to the change in the number of cigarettes smoked. Slightly more (26%) non-smoking young adults think the number of cigarettes smoked would decrease, compared to the youth and general non-smoking population.

For the most part, youth 15-19 and young adults 20-24 who smoke have a similar view as the broader population of smokers about the effect VLNC cigarettes would have on their habits. However, that trend does not hold for youth 13-14, who are more likely to report the number of cigarettes they smoke would increase (44%).

The general population is fairly evenly divided over whether VLNC cigarettes are just as harmful as regular cigarettes (41%), or a little or a lot less harmful (45%). Few (6%) see VLNC cigarettes as more harmful than regular cigarettes. Over half (58%) of smokers view them as less harmful while only 42% of non-smokers do so. Almost half of youth 13-14 (47%), youth 15-19 (49%) and young adults 20-24 (50%) view VLNC cigarettes as less harmful than regular cigarettes.

Views towards the level of addiction associated with VLNC cigarettes compared to regular cigarettes were similar to those regarding both products' harmfulness. Two in five (39%) view them as a little or a lot less addictive, while 5% view them as more addictive. The majority of smokers (54%) view them as less addictive than regular cigarettes, compared to 36% of non-smokers. Interestingly, while the percentage of those who expect VLNC cigarettes are less addictive was similar between those knowledgeable and those not knowledgeable of nicotine, the percentage of respondents who expect they are equally as addictive changes significantly. Almost half (48%) of those who say they are knowledgeable say that VLNC cigarettes would be equally as addictive, compared to 39% among those not knowledgeable.

Overall, youth's sense of the addictiveness of VLNC cigarettes decreases slightly with age. Young adults 20-24 are more inclined to believe they would be less addictive (49%) than youth aged 13-14 (38%). There are a few differences between other demographic groups:

• A greater proportion of men (42%) than women (36%) agree VLNC cigarettes are less addictive than regular cigarettes.
• More Indigenous respondents feel VLNC cigarettes are more addictive than regular cigarettes (14%) than non-Indigenous respondents (5%). The latter are more likely to say they are just as addictive (47%) compared to the former (35%).

In order to more deeply understand how the public feels about the concept of VLNC cigarettes, respondents were asked to indicate their level of agreement or disagreement with each of nine statements. Opinions about the VLNC statements were mixed. The statement that the largest proportion of the general population sample strongly agrees with is, 'If very low nicotine content (VLNC) cigarettes were to become available in Canada as the only type of cigarette available, it would increase the number of regular cigarettes sold on the black market'. Over half (57%) agree with this statement. The statement that receives the most negative responses was, 'smoking a very low nicotine content (VLNC) cigarette would be acceptable in my social circles' (over half, 59%, disagree).

Fewer agree (21%) than disagree (42%) that if regular cigarettes were still available, non-smokers would start using VLNC cigarettes. Of note, fewer youth 13-14 (27%) and 15-19 (28%) disagree with this idea, along with 30% of young adults.

Please indicate how strongly you agree or disagree with each of the following statements about very low nicotine content (VLNC) cigarettes.

Overall, more respondents also disagree (41%) than agree (25%) with the statement, "If regular cigarettes with nicotine were unavailable, non-smokers who would otherwise not try smoking would decide to start smoking very low nicotine content (VLNC) cigarettes." Of note, more youth 13-14 (33%), youth 15-19 (30%) and young adults 20-24 (34%) agree. Roughly a third (30%) of smokers agree with this statement, while a quarter (23%) of non-smokers agree.

One in two respondents (49%) agree that VLNC cigarettes would help smokers quit. Agreement is broader among smokers (66%) than among non-smokers (47%). Youth and young adults all show a slightly higher level of agreement than the general public. A little over half (52%) of youth 13-14 agree that VLNC cigarettes would help smokers quit, 56% of youth 15-19 agree, and 58% of young adults 20-24 agree.

Almost half (48%) of respondents are under the impression that if nicotine was removed from cigarettes something else would be added to replace it. Only one in ten (12%) respondents disagree with the statement. Over half (52%) of youth 13-14 agreed with the statement while 47% of youth 15-19 and 46% of young adults 20-24 agree. Results among the smokers and non-smokers were near identical with regards to this statement.

The majority (57%) of respondents agree with the statement 'If very low nicotine content (VLNC) cigarettes were to become available in Canada as the only type of cigarette available, it would increase the number of regular cigarettes sold on the black market'. A quarter strongly agree (23%), and another third (34%) somewhat agree. Youth 13-14 and young adults 20-24 were less certain of this statement than the general population. While agreement is 48% among youth 13-14, and 51% among young adults 20-24, slightly more neither agree nor disagree (21% and 22%, respectively). Opinion among youth 15-19 is more closely aligned with that of the general public: 57% agree with the statement.

Over half of smokers (53%), and non-smokers (57%) agree with this statement. Of note, daily smokers are more likely to agree (55%) than occasional smokers (48%).

A majority of respondents (59%) disagree with the statement, 'Smoking a very low nicotine content (VLNC) cigarette would be acceptable in my social circles' and only 13% agree. Youth and young adults are slightly more likely to agree that smoking a VLNC cigarette would be acceptable in their social circles. Youth 13-14 most closely resemble the overall findings, with 55% disagreeing, and 17% agreeing. Youth 15-19 exhibit slightly less disagreement at 51% and a fifth (22%) agreeing. Finally, only 2 in 5 (42%) young adults 20-24 disagree, and almost a quarter (23%) agree smoking a VLNC cigarette would be acceptable in their social circles. Regionally, Quebecers are more likely to disagree with this statement (64%) than respondents in other provinces. Those with a post-graduate degree (68%), a household income of $80,000 or more (64%), rural residents (64%) and non-Indigenous respondents (60%) are also more likely to report that smoking a VLNC cigarette would not be socially acceptable in their circles.

Roughly two-thirds (64%) of non-smokers disagree with the statement, while only a third (34%) of smokers disagree.

These topline results are nearly identical to those found when asking the same question of regular cigarettes. On that question, 68% disagree that smoking cigarettes is socially acceptable. However, among smokers, the level of disagreement with the social acceptability of cigarettes is much higher (48%) than the disagreement with the social acceptability of VLNC cigarettes (34%).

The statement, 'Smoking a very low nicotine content (VLNC) cigarette would be just as enjoyable for smokers as smoking a regular cigarette' receives polarized reactions. A fifth (20%) of the general population agree, a similar portion (22%) neither agree nor disagree, and slightly more (29%) of respondents disagree, while the remaining 29% offer no opinion either way.

Interestingly, smokers (36%) are twice as likely as non-smokers (17%) to agree that VLNC cigarettes would be just as enjoyable for smokers as smoking a regular cigarette.

Opinions are also divided regarding the statement, 'If regular cigarettes were still available, people would only choose very low nicotine content (VLNC) cigarettes instead of regular cigarettes if they were less expensive than regular cigarettes.' Roughly a quarter (23%) disagree, another quarter (23%) neither agree nor disagree, and just over a third agree (38%). Smokers (49%), particularly those who smoke daily (51%), are more likely to agree than non-smokers (37%).

Two in five respondents (39%) disagree with the statement, 'I don't see any reason why someone would choose very low nicotine content (VLNC) cigarettes instead of regular cigarettes.' There are no differences in responses among youth and young adults. With regards to smoking habits, 38% of non-smokers disagree with the statement, lower than the proportion of smokers who disagree (46%).

While the plurality of respondents (34%) feel that VLNC cigarettes have benefits and drawbacks that are equal, a quarter believe there are either net benefits (27%), or net drawbacks (25%). Responses among youth and young adults are also divided. The plurality of each group agrees the benefits and drawbacks are equal, while roughly three in ten believe there are benefits and roughly two in ten feel there are drawbacks.,

Smokers are more likely than non-smokers to view VLNC cigarettes as having a net benefit (42% compared to 24%). Other demographic differences include:

• Men are more likely to believe there are net drawbacks (29%) compared to women (22%).
• Quebecers perceive more net drawbacks (31%) than those in other regions.

Key takeaways: Very low nicotine content cigarettes concept testing

• The general population sample has an overall unfavourable opinion of VLNC cigarettes. Though 43% would recommend the VLNC cigarettes to friends or family who currently smoke. Also, one in two general population respondents (49%) agree that VLNC cigarettes would help smokers quit.
• Smoker's favourability of VLNC cigarettes was much higher than non-smokers. One in two smokers (48%) has a favourable opinion of VLNC cigarettes compared to one in ten (13%) non-smokers.
• Most smokers indicated some likelihood of potentially trying a VLNC cigarette if they were to become available in Canada, with two-thirds (69%) saying that it would be either probable or definite that they would try them.
• Of those smokers who indicate some potential to try VLNC cigarettes over half (58%) would partially or completely use them to replace their current cigarettes smoked.
• When asked if the number of cigarettes smoked would decrease with the introduction of VLNC cigarettes 15% of non-smokers said it would decrease, while 30% of smokers believed it would decrease.
• The general population is fairly evenly divided over whether VLNC cigarettes are just as harmful as regular cigarettes (41%), or a little or a lot less harmful (45%).
• The statement that the largest proportion of the general population sample strongly agrees with is, 'If very low nicotine content (VLNC) cigarettes were to become available in Canada as the only type of cigarette available, it would increase the number of regular cigarettes sold on the black market'. Over half (57%) agree with this statement.
• The statement that receives the most negative responses was, 'smoking a very low nicotine content (VLNC) cigarette would be acceptable in my social circles' (over half, 59%, disagree).
• Interestingly, smokers (35%) are twice as likely as non-smokers (17%) to agree that VLNC cigarettes would be just as enjoyable for smokers as smoking a regular cigarette.

E. Harm associated with forms of nicotine

By a wide margin, cigarettes are viewed as the most harmful product containing nicotine. Almost three-quarters (71%) of respondents say they are very harmful, and another 19% say they are harmful. No respondent believes cigarettes are not harmful at all. Vaping a product containing nicotine is perceived to be the second most harmful form of nicotine, with 32% reporting them as very harmful. Moving down the hierarchy, nicotine inhaler was next (58% harmful), followed by nicotine spray (52%), VLNC cigarettes (51%), nicotine lozenges (43%), nicotine gum (39%), and perceived as least harmful was the nicotine patch (36%).

The hierarchy remains the same among those who find nicotine harmful, however among those who do not find nicotine harmful, VLNC cigarettes were viewed as more harmful (40%) than other products containing nicotine including the spray (17%) and gum (13%).

In terms of the youth oversamples, the harmfulness hierarchy remains fairly consistent with the exception of young adults 20-24, who rank VLNC cigarettes as the third most harmful form rather than the fifth like the general population. The biggest difference between the younger groups is that the youth 13-14 view all forms of nicotine as more harmful than youth 15-19 and young adults 20-24. In most instances, youth 13-14 believe the forms of nicotine are more harmful than the general public, while the other younger groups rate them as equally or less harmful than the general population. For example, 62% of youth 13-14 think the nicotine inhaler is harmful, compared to 58% of the general population, 55% of youth 15-19 and 46% of young adults 20-24.

While the hierarchy of harmfulness for the products tested is similar for smokers and non-smokers, there are a few differences worth noting. For example, smokers believe VLNC cigarettes are less harmful than nicotine spray. That being said, smokers rated all tested forms of nicotine an average of 17% less harmful, compared to the ratings given by non-smokers.

People can get nicotine in a variety of forms. How harmful do you feel nicotine is, or would be, to the health of those using each of the following products with nicotine in it? Please use a 5-point scale where '1' means not at all harmful, and '5' means very harmful.

Qualitative insights: Information needs related to VLNC cigarettes

Participants were asked whether they had ever looked up information about nicotine and VLNC cigarettes, including where they would go for information. Very few participants indicated that they had looked up information about nicotine in the past.

Those interested in learning more about nicotine or VLNC cigarettes suggested that they would most likely consult multiple sources to develop an informed perspective. Sources they would consult included the internet, their family doctor or a pharmacist. Trusted internet sources mentioned most often included: the Government of Canada; WebMD; the Mayo Clinic; the Canadian Cancer Society; and Wikipedia.

With respect to information provided by the Government of Canada, and about VLNC cigarettes, specifically, a few participants wondered whether the information would be factual and unbiased. These participants thought the Government might communicate what they wanted people to understand about VLNC cigarettes. That being said, information supported with research and science could help dispel those concerns. Indeed, most felt that academic journals and scientific studies would be credible and trusted.

Worth noting, a handful of participants suggested that they might consult the websites of cigarette manufacturers (mostly out of curiosity), although, there was some debate about whether the information would be deemed credible.

Key takeaways: Harm associated with forms of nicotine

• The qualitative and quantitative results demonstrate that cigarettes are viewed as the most harmful form of nicotine. In fact, no survey respondent believes cigarettes are not harmful at all.
• Vaping a product containing nicotine is perceived as the second most harmful form of nicotine.
• These are followed by nicotine inhaler, nicotine spray, VLNC cigarettes, nicotine lozenges, nicotine gum and the nicotine patch.
• Youth 13-14 tend to view nicotine as more harmful than all other age groups.
• And, smokers rate all products with nicotine as less harmful than non-smokers.

F. Information sharing

In order to gather some information on whether parents and teens discuss nicotine with one another, the survey included a list of different substance-related topics that may arise and asked parents to identify which, if any, they have discussed with their teen and similarly, asked teens which, if any, they have discussed with their parents.

Around eight in ten parents claim to have discussed alcohol and drug use broadly with their children. Roughly three-quarters have discussed smoking (78%) and cannabis (77%). Just over half (55%) say they have discussed vaping. Less than half have discussed nicotine (44%) or opioids (38%) with their children. Worth noting, more mothers than fathers have had conversations with their child about opioids (54% vs. 26%), smoking (84% vs. 74%) and vaping (71% vs. 44%).

Roughly eight in ten (81%) teens also report that their parents have discussed alcohol with them. Around three-quarters recall discussing smoking (76%), cannabis (74%) and drug use (72%). Over half (55%) say they have discussed vaping with their parents. Less than half have discussed nicotine (43%) or opioids (40%).

Qualitative insights: Awareness and impressions of vaping promotions

Participants were asked about their awareness and impressions of vaping promotions. Recall of current promotions for vaping products or e-cigarettes was very low across all audiences.

Those in the younger cohorts mentioned having seen videos on their social media feeds or online of people using vaping products (i.e., doing tricks such as blowing "O"s, etc.), which they did not feel were promoting a specific product or communicating a message per se. In deeper discussions probing the topic, many youth and young adults clearly knew about people having set up "vape accounts" on social media apps such as Instagram with the specific aim of making videos and promoting images of vaping that could attract sponsorship from manufacturers.

Those in the older cohort mentioned having seen posters in convenience stores and gas stations that featured a vaping device. Some were linked to messaging about trying to quit smoking.

Key takeaways: Information sharing

• The majority of parents claim to have had conversations with their children about drug use, alcohol, cannabis, and smoking.
• Fewer are having conversations about vaping; and, even fewer still about nicotine and opioids.

G. Current, past and potential behaviours

This chapter reviews the results on current past and potential behaviours related to cigarettes, using vaping products (that do and do not contain nicotine), cannabis and alcohol. Responses from this line of enquiry were used to define subsets examined throughout this report (e.g., smokers/non-smokers; vapers/non-vapers, etc).

Current behaviours

To begin, respondents were asked whether they currently undertake a list of behaviours.

As the results of the survey were weighted to reflect the incidence of smoking as identified by the Canadian Tobacco, Alcohol and Drugs Survey (CTADS) 2017¹, the incidence of daily smokers in the general population sample is 11% and 4% for occasional smokers. Youth 13-14 and 15-19 are less likely to smoke daily and occasionally. Just 2% of youth 13-14 and 4% of youth 15-19 smoke on a daily basis. The incidence of occasional smokers for both groups is similar – 2% among the 13-14 year-olds and 3% for 15-19 year-olds. Young adults 20-24 are less likely than the general population to smoke daily (9%) but slightly more likely to smoke occasionally (6%).

For each of the following, please indicate whether, at the present time, this is something you do every day, occasionally or not at all.

Other demographic differences include:

• Less educated respondents are more likely to be daily smokers. One quarter of respondents (25%) without a high school diploma smoke daily, along with 15% of those with only a high school diploma.
• Respondents with an income of less than $40,000 (17%) are more likely than those with reported higher incomes to smoke daily.
• More Indigenous than non-Indigenous respondents are daily smokers (29% compared to 10%).

Fewer members of the general population vape with products containing nicotine on a daily basis (3%) than smoke, but more vape occasionally (8%). Very few of those aged 13-14 and 15-19 say they vape every day (1% and 2%, respectively). Slightly more young adults aged 20-24 report vaping daily (5%). Youth 13-14 are the least likely to occasionally vape with products containing nicotine (6%) compared to those 15-19 (11%) and 20-24 years old (13%).

Other notable demographic differences include:

• Male respondents are slightly more likely to vape with products containing nicotine daily or occasionally (a combined 11%) compared to female respondents (8%).
• Vaping occasionally with products containing nicotine is more common in urban areas (8%) than rural (5%).
• Significantly more Indigenous respondents vape with products containing nicotine daily (11%) or occasionally (22%) than non-Indigenous respondents.

Combining the results on smoking and vaping products with nicotine, the survey shows that roughly one in ten (9%) smoke but do not vape with nicotine, another 6% are dual users who both smoke and vape with nicotine and 4% of Canadians aged 13 and older vape with nicotine but do not smoke. In total, 19% of Canadians are using one or the other of these products with nicotine. The results vary widely by age, with youth aged 13-14 least likely to be using products with nicotine, least likely to exclusively smoke (1%), half as likely as the national average to be dual users (3%), but are just as likely as the national population overall to be getting nicotine by vaping but not by smoking (4%). Youth (15-19) and young adults (20-24) are the age groups in Canada most likely to be vaping exclusively with nicotine (9%). Dual use is highest (14%) among those aged 25-34 and as age increases beyond 35 years, the incidence of both dual and exclusively vaping with nicotine decreases significantly.

Fewer members of the general population vape with non-nicotine products on a daily basis (1%) compared to those who vape with nicotine, while a roughly equal proportion vapes without nicotine occasionally (9%). Just 2% of teens 13-14 and 1% of teens 15-19 vape without nicotine daily. More do so occasionally (12% of those 13-14 and 15% of those 15-19). Vaping daily (4%) and occasionally (15%) using products that do not contain nicotine is more common among those aged 20-24.

Combining the questions on vaping with products that contain nicotine and vaping with products that do not, finds that 14% of the general population indicate being daily or occasional vapers and this segment includes 4% who only vape with products containing nicotine, 6% who vape with both products containing nicotine and products that do not contain nicotine and another 4% that only vape with products that do not contain nicotine. Among the three oversampled age groups, the tendency to vape at all and to vape with products containing nicotine increases with age, while the tendency to vape only products that do not contain nicotine remains identical across the three age groups.

Smoking a cannabis cigarette or joint is less common among the general population than vaping, and less common than smoking a regular cigarette. Few (4%) say they smoke cannabis daily, but four times as many (16%) claim to do so occasionally. Daily (2%) and occasional (8%) use is lower among teens aged 13-14. Smoking cannabis behaviour for those 15-19 is similar to the general population – 3% do so daily, 17% occasionally. Young adults aged 20-24 are more likely than the other younger groups and the sample as a whole to report smoking a cannabis cigarette or joint daily (7%) or occasionally (31%).

Few use cannabis in another form (including vaping it) daily (3%), while 13% use it occasionally. Following the pattern of cannabis cigarette or joint use, teens 13-14 are less likely to consume cannabis in another form daily (1%) or occasionally (9%), while daily (2%) and occasional (13%) use among teens 15-19 reflects the general public's results. Young adults 20-24 are more likely than the other younger groups and the general population to report using cannabis in other formats, such as vaping, daily (6%) or occasionally (24%).

Drinking alcohol is by far the most common used substance reported by respondents. While 9% of the general population sample report drinking every day, 70% drink occasionally. One in five (21%) say they do not drink at all. Significantly fewer teens aged 13-14 drink daily (2%) or occasionally (19%). Over three-quarters (76%) say they do not drink alcohol at all. This proportion falls to 48% among teens 15-19 and 20% among youth aged 20-24. Though 1% of teens 15-19 say they drink daily, 48% report doing so on occasion. Drinking daily (5%) and occasionally (74%) is more common among those aged 20 to 24.

The following two tables summarize the daily users and the users (daily and occasional combined) for each of the behaviours.

Past behaviours

For each of the same list of behaviours, respondents who do not currently undertake a behaviour were asked whether it is something they have ever tried.

Among the various behaviours, respondents are most likely to have tried alcohol and cigarettes. Two-thirds (66%) of those who do not currently use alcohol have tried it, and 61% who are not current smokers have tried smoking a cigarette. Fewer teens 13-14 have tried alcohol (43%), compared to those 15-19 (55%) and 20-24 (54%). Similarly, fewer of the youngest teen cohort have tried smoking a cigarette (18%) compared to the older groups (23% of 15-19 year-olds and 38% of 20-24 year-olds).

When it comes to having tried vaping with or without nicotine once, there is little difference among the general population. One in ten have tried vaping with a product containing nicotine, while 13% have tried a vaping product without nicotine. A smaller proportion of 13-14 year-olds say they have tried vaping with a product containing nicotine (6%) compared to one without (9%). Teens 15-19 follow the same pattern, though more have tried vaping with (13%) and without (17%) nicotine. Young adults aged 20-24 are more likely than the general population and the younger youth samples to have tried vaping with (24%) and without (30%) nicotine.

Respondents from the following demographic groups are more likely to have tried vaping with nicotine:

• Respondents in Manitoba and Saskatchewan (14%);
• Indigenous respondents (30%); and
• Respondents ages 25-34 (18%).

Other groups more likely to have tried vaping without nicotine include:

• Respondents with a household income of less than $40,000 (16%), particularly compared to those with an income of $80,000 or more (11%);
• Respondents in Manitoba and Saskatchewan (20%);
• Indigenous respondents (25%); and
• Respondents ages 25-34 (27%).

One-in-ten have tried cannabis in a form that is not a cigarette or joint. Fewer 13-14 year-olds (3%) have tried it compared to the general population and the 15-19 year old (6%) and 20-24 year old (15%) samples.

And for each of the following, please indicate whether this is something you have ever tried – even if it was just once.