Qualitative and quantitative research on perceptions of nicotine - Executive summary

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 résumé analytique est aussi disponible en français.

Qualitative and quantitative research on perceptions of nicotine
Executive summary

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

This executive summary 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

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:

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