Smoking Behaviour Journey Map - Final report

Prepared for Health Canada

Supplier Name: Environics Research
Contract Number: HT372-184244/001/CY
Contract Value: $99,435.71 (including HST)
Award Date: 2019-02-04
Delivery Date: 2019-03-29

Registration Number: POR 119-18

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.

Smoking Behaviour Journey Map
Final report

Prepared for Health Canada by Environics Research

March 2019

Permission to reproduce
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

© Her Majesty the Queen in Right of Canada, as represented by the Minister of Public Services and Procurement Canada, 2019.

Cat. No. H14-324/2019E-PDF

ISBN 978-0-660-30843-2

Cette publication est aussi disponible en français sous le titre Parcours du comportement tabagique.

Cat. No. H14-324/2019F-PDF (Rapport en français)
ISBN 978-0-660-30844-9

Table of Contents

• Executive summary
• Introduction
• I. Detailed findings – quantitative phase
  • A. Smoking profile
  • B. Outlook and values
  • C. Overall health
  • D. Other substance use
  • E. Efforts to improve health
  • F. Other activities of daily smokers
• II. Detailed findings – qualitative phase
  • A. Participant profile
  • B. Key themes of daily diary exercise
  • C. Challenges and successes (Day 5)
  • D. Stress, aspirations and health aspirations (Day 6)
  • E. Where smoking fits in daily life (Day 7)
  • F. Smoking in relation to other substances (Day 7)
• Conclusions
• Appendix A: Research methodology
• Appendix B: Survey questionnaire
• Appendix C: Qualitative discussion guide

Executive summary

Background and objectives

Canada's Tobacco Strategy has set the ambitious goal of lowering tobacco use among Canadians to 5% by 2035. To do this, Health Canada needs to both prevent the initiation of tobacco use and support users in their cessation efforts. The department identified a need to gather quantitative and qualitative information about smoking habits and feelings, including, (a) situations smokers typically find themselves in when smoking, and (b) how smokers are feeling at the time they are having a cigarette. This approach combines both the behaviour and the emotion of smoking simultaneously.

This research sought to test the salience of smoking behaviour among Canadians who smoke and the extent to which smoking is an integral part of their identity. Unlike other research that poses questions specifically about smoking, this research used a unique diary approach, exploring respondents' daily activities without specifically raising the topic of smoking until the final day of the journal. This approach was designed to understand, from smokers themselves, how smoking is integrated into their lives, without any bias for or against smoking introduced by the research questions themselves.

Use of the findings of this research. This research will help Health Canada better understand the social aspect of smoking – the extent to which smoking is intertwined with smokers' social interactions, the role it plays (i.e., leading to inclusion or exclusion) and the challenges this creates when smokers have quitting intentions. The research will help Health Canada develop new lines of messaging focused on the experience of smoking (both positive and negative). The findings will assist Health Canada to inform program strategy and communications to better meet the needs of smokers when they are ready to quit, by having a more thorough understanding of their patterns of behaviour.

Methodology

The research comprised two data collection phases:

1. A quantitative online survey conducted March 7 to 15, 2019, with 510 adult Canadians (recruited from an online panel) who are daily smokers and have been smoking for at least five years. The survey explored their behaviour values and attitudes, to provide insights into who smokers are; a variety of topics were included to avoid indicating to respondents that the main focus was smoking. The online survey also served as the source for recruiting participants to the second, qualitative phase of the research.
2. A subsample of 80 online respondents participated in a seven-day qualitative journaling exercise. Participants were randomly selected from those who expressed interest in and consented to the journal exercise. The journal took place from March 14 to 20, 2019 and gathered detailed information about the daily lives, habits, emotions and thoughts of daily smokers, and where and how smoking is discussed (or not) in this context.

A more detailed methodology is presented in Appendix A of the full report.

Statement of limitations: Survey respondents were drawn from among panels of individuals who have agreed to participate in online surveys. The data have been weighted to reflect the demographic composition of daily smokers in Canada according to the 2017 Canadian Tobacco Alcohol and Drugs Study (CTADS). Because the 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.

Qualitative research provides insight into the range of opinions held within a population, rather than the weights of the opinions held, as would be measured in a quantitative study. The results of this type of research should be viewed as indicative rather than projectable to the population.

Contract value

The contract value was $99,435.71 (HST included).

Key findings

Quantitative phase

• The results of the quantitative research demonstrate that there is no single "profile" of smokers. While all respondents to the online survey shared the characteristic of being a daily smoker who has been smoking for more than five years, there is a substantial range in their experiences (outside of smoking), attitudes and values. This is relevant because efforts to engage individuals, and what sorts of messages to use, have been shown to be most effective when framed in (that is, consistent with) the values of the individual.
• Their general outlook suggests many are facing substantial challenges in their lives. While majorities of smokers express self-efficacy with respect to their health and to their lives overall, substantial minorities feel they lack control in these areas. They are also experiencing financial concerns, with more than half saying they are just getting by or falling behind on expenses. They express greater skepticism than trust in other people and are as likely to say they have a weak connection to their community as a strong one.
• Self-reported health indicators are reasonably positive, although not universally. A majority of smokers surveyed report being in at least good health. Half say they sleep well, but only one quarter say they eat enough fruit and vegetables. Three in ten report their life is stressful and four in ten regularly have trouble sleeping; the majority get less than 30 minutes of exercise a day.
• There is considerable energy and thought being devoted to developing healthier habits, even if they are not successful. Over half of daily smokers made improvements to their health in the past year (exercise and diet being top mentions), and close to nine in ten say they should make other changes (notably quitting smoking); lack of willpower is the main barrier. Eight in ten say they want to make changes this year, notably quitting smoking and exercising more.

Qualitative phase

• For many participants, the online diary exercise evolved into something more than a daily assignment. It offered an opportunity for self-reflection, a seemingly rare occasion to take time to focus on their feelings, goals and aspirations, and what they feel is holding them back from achieving these goals.
• Overall, participants tended to describe their day-to-day lives in a task-oriented way, even when not specifically asked to do so. The average day can be categorized into three stages: getting ready for the day, going to work, and decompressing from work. Daily routines are well-established, which has proven practical and efficient. However, even the habitual can be hectic. Overcoming challenges to the routine is viewed as a success but doesn't seem to change the routine.
• No more than a handful of participants referred to smoking (unprompted) in their daily diaries. Generally speaking, smoking appears to be a means to manage or cope with feelings and emotions. When it did come up, it was typically associated with the comfort of routine (and primarily the morning routine), or a moment for relaxation or quiet reflection. It can also have a calming effect when feeling overwhelmed or stressed.
• Some participants discussed smoking as something they would like to change about themselves and brought up quitting as an aspiration for the future. However, there is a sense that quitting smoking is a very large challenge that is difficult to overcome, and there was very little evidence of firm plans to quit.
• Participants gave two main reasons for rarely mentioning smoking in their diaries. For many, it is something so ingrained in daily life, and has been for decades, that they didn't think to share it. Others appeared very aware of the social stigma of smoking and expressed shame and embarrassment.

Political neutrality statement and contact information

I hereby certify as senior officer of Environics that the 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.

Sarah Roberton
Vice President, Public Affairs
Environics Research Group
sarah.roberton@environics.ca
613-699-6884

Supplier name: Environics Research Group
PWGSC contract number: 60074-182050/001/CY
Original contract date: 2019-01-03
For more information, contact Health Canada at hc.cpab.por-rop.dgcap.sc@canada.ca

Introduction

Background

Canada's Tobacco Strategy has set the ambitious goal of lowering tobacco use among Canadians to 5% by 2035 and to do this, Health Canada needs to both prevent the initiation of tobacco use and support users in their cessation efforts. Health Canada already has well established measures for understanding how many and how long people have been smoking, when they first tried smoking and other behavioural variables.

Previous work conducted by the Tobacco Control Directorate (TCD) of Health Canada has been mainly retrospective – it has never widely researched a longer view of smoking behaviour in real time before. Research that takes a longitudinal approach and looks at the typical week or two in the life of a smoker will provide the Directorate with a much more nuanced and in-depth understanding of smokers. It will also be used to help TCD better understand the social aspect of smoking – the extent to which smoking is intertwined with smokers' social interactions, the role it plays (i.e., leading to inclusion or exclusion) and the challenges this creates when smokers have quitting intentions.

These insights will help Health Canada develop new lines of messaging that focus on the experience of smoking (both positive and negative). They will assist Health Canada by informing program strategy and communications to better meet the needs of smokers when they are ready to quit, by having a more thorough understanding of their patterns of behaviour. Ultimately, it will help TCD to develop more effective and relatable cessation strategies.

Objectives

Health Canada identified a need to gather quantitative and qualitative information about smoking habits and feelings, including, (a) situations smokers typically find themselves in when smoking, and (b) how smokers are feeling at the time they are having a cigarette. This approach combines both the behaviour and the emotion of smoking simultaneously.

This research sought to test the salience of smoking behaviour among Canadians who smoke and the extent to which smoking is an integral part of their identity. Unlike other research that poses questions specifically about smoking, this research used a unique diary approach, exploring respondents' daily activities without specifically raising the topic of smoking until the final day of the journal. This approach was designed to understand, from smokers themselves, how smoking is integrated into their lives, without any bias for or against smoking introduced by the research questions themselves.

About this report

This report begins with an executive summary outlining key findings and conclusions, followed by a detailed analysis of the quantitative survey data and the qualitative data. A detailed methodology section is provided in Appendix A. Provided under a separate cover is a detailed set of "banner tables" presenting the results for all questions by population segments as defined by region and demographics for the quantitative portion of the research. These tables are referenced by the survey question in the detailed analysis.

In this report, quantitative results are expressed as percentages unless otherwise noted. Results may not add to 100% due to rounding or multiple responses. Net results cited in the text may not exactly match individual results shown in the tables due to rounding.

I. Detailed findings – quantitative phase

A. Smoking profile

The majority of smokers surveyed have been smoking for more than 20 years, and the average number of cigarettes per day is 13. Most report having smokers among their friends, family members and work/school colleagues.

Number of years of smoking cigarettes

To qualify for the survey, Canadians had to indicate they smoke cigarettes every day and that they have been smokers for a minimum of five years (note this means younger smokers are likely underrepresented). Six in ten daily smokers (61%) say they have been smoking cigarettes for more than 20 years; two in ten (19%) have been smoking from 11 to 20 years, and two in ten have been smoking 5 to 10 years (20%). As can be expected, length of time smoking is closely correlated to age.

Q9 For how many years have you been doing each of the following things? I smoke cigarettes every day.

Smoking for more than 20 years is somewhat higher among men (66% vs. 55% of women) and those who have education under the university level (64%). Because it is linked to age, long-term smoking (more than 20 years) is also linked to life stage: it is more common among those without young children at home (70%) and those who are widowed, separate or divorced (87%).

Smokers were asked how many cigarettes they smoke each day. The mean is 13 cigarettes per day. About half (48%) smoke ten cigarettes or fewer per day, while just over half (52%) smoke 11 or more.

Q30 On average, how many cigarettes a day do you smoke?

The mean number of daily cigarettes is higher in Quebec (14.6) and among older smokers (from a mean of 9.2 for those under age 25 to a mean of 14.6 for those age 45 to 64, and 14.0 age 65+). Smoking a greater number of cigarettes is also related to lower levels of education and household income (14.8 high school or less and 15.8 under $40k a year).

Smokers were asked how many of the people in their life are also smokers. Most report having friends (84%), other (non-spouse) family members (58%) or classmates/co-workers (55%) who smoke. A substantial minority say their parents (48%) or spouse (41%) do not smoke.

Q31 How many of the following people in your life smoke cigarettes?

The proportion who say most or all of their friends is highest among those under 45 years of age (26%) and those with household incomes under $40,000 (23%). Reporting a spouse who smokes is higher among women (46% vs. 29% of men) and those with high school or less education (31%).

B. Outlook and values

Majorities of smokers express self-efficacy with respect to their health and to their lives overall. Four in ten think they are better off than their parents at the same age, and yet more than half say they are just getting by or falling behind on expenses. They are divided about their feeling of connection to the community and are more likely to be skeptical about other people than to think they can be trusted.

Survey respondents were asked to indicate their level of agreement with six values statements that touch on health.

Smokers are most likely to agree to some extent that they are confident they can have a positive effect on their health (85% net agreement), and that they feel in control of how and what they learn about their health (81%).

Views about the other statements are more mixed. Over half (53%) agree to some extent that, compared to other people they know, they have a lot of energy, while 44 percent disagree.

In turn, half or more disagree at least somewhat with three negatively-worded statements about the degree of control they feel they have: that destiny is predetermined and history takes its course (53% vs. 42% agree), that they have trouble changing the course of events affecting them (51% vs. 44% agree), or that there is not much to be done about their health except dealing with sickness when it comes (60% vs. 38% agree). In summary, majorities in all three cases believe they have control, but significant minorities do not feel in control of their lives and their health.

Q14 The following is a series of opinions that we often hear expressed. For each one, indicate whether you strongly agree, somewhat agree, somewhat disagree or strongly disagree by selecting the box that corresponds to your opinion.

Agreement is generally consistent across most subgroups, with a few exceptions. Agreement with the positive statements is higher among those who report being in excellent or good health, and, later in the survey, having self-reported lower levels of stress or more financial security. Agreement that they have a lot of energy is also higher among those who smoke 10 or fewer cigarettes a day. Agreement with the three negatively-worded control-related statements is somewhat higher among those with the lowest household incomes, those in poorer health, and those who report greater stress and less financial security.

Canadian daily smokers were asked to compare their current financial situation to that of their parents at the same age. Two-thirds say they are better off (36%) or about the same (29%), compared to one-third (34%) who feel they are worse off.

Q15 Financially speaking, do you feel that you are better off, worse off, or about the same as your parents were at your age?

Perception of being better off than one's parents is higher among those who are married/common law (41%) or have university degrees (47%) and increases as household income increases (from 23% under $40,000 to 56% with $100,000 or more).

Smokers were also asked to indicate their cost of living situation. Fewer than half (44%) fall on the more secure side of the spectrum, indicating they are financially secure (16%) or are getting ahead, with some savings (28%). Another four in ten (39%) report just getting by, with no savings, while one in ten (14%) are falling behind.

Q16 Thinking about the cost of living and your personal financial situation, would you say you are…?

The proportion falling behind on expenses is linked to lower household income (28% with under $40,000), lower levels of education (19% among those without a university education) and to having children in the household (17%). It is also linked to lower levels of self-reported health (23% in fair to poor health) and living outside large urban centres (19%).

When asked to describe their sense of belonging to the local community, smokers are evenly divided between feeling a strong (49%) or weak (51%) connection. In fact, most respondents report a moderate sense of belonging (81% somewhat strong or somewhat weak), compared to a very strong sense of belonging (6%) or isolation (13%).

Q17 How would you describe your sense of belonging to your local community? Would you say it is…?

Having a stronger sense of belonging to one's community (very or somewhat) is highest among those aged 25 to 44 (60%), university graduates (61%), and those with higher household incomes (57% with incomes of $80,000 or more, compared to 42% with incomes under $40,000). Feeling more belonging is linked to better self-reported health (62%), to being financially secure or getting ahead (57%), and to smoking 10 or fewer cigarettes a day (57%).

When it comes to trusting others, smokers lean more towards the view that you cannot be too careful in dealing with people (59%) than that most can be trusted (41%). Scepticism is the dominant view across most of the country (highest in B.C., 67%, and the Prairies, 65%), except for the Atlantic region, where the proportions are flipped and the majority (59%) think most can be trusted.

Q18 Generally speaking, which of the following best reflects your own view?

Optimism that others can be trusted is the minority view in most segments, except for those in the highest income bracket (53% earning $100,000 or more), those with a university degree (50%) and those who are financially secure (50%). Scepticism is higher among those with lower levels of self-reported health (70% in fair or poor health). There are no notable response differences by gender or age.

C. Overall health

A majority of smokers report being in at least good health. Half say they sleep well, but only one quarter say they eat enough fruit and vegetables. Three in ten report their life is stressful and four in ten regularly have trouble sleeping; the majority get less than 30 minutes of exercise a day.

Daily smokers were asked to assess their level of health. A plurality of just over four in ten (43%) indicates they are in good health; a slightly smaller proportion (36%) say their health is either excellent or very good, and two in ten (21%) report being in fair or poor health.

Q10 In general, would you say your health is…?

Reporting very good or excellent health is linked to higher socioeconomic status (49% with a university degree and 50% with incomes over $80,000) and to smoking 10 or fewer cigarettes a day (45%).

Smokers were asked about the amount of sleep they get most nights and number of servings of fruits/vegetables they consume. Half indicate they sleep for at least eight hours a night, but only one-quarter say they eat at least seven servings of vegetable and fruit servings each day.

Q7 Which, if any, of the following apply to you?

The proportion who report getting at least 8 hours of sleep is higher among those age 65 and over (62%) than among younger smokers. Although minorities in any group report eating enough fruit and vegetable servings, this proportion is higher among those with a university degree (32%), those aged 25 to 44 (33%), those in excellent or very good health (39%) and those smoking 10 or fewer cigarettes a day (32%). There are no significant gender differences in reported amount of sleep and vegetable/fruit servings.

When asked about the level of stress in their lives, three in ten (31%) say their days are extremely or quite a bit stressful. Almost four in ten categorize their stress level as moderate (37% a bit stressful), while three in ten report feeling very little stress (32% not very/not at all stressful).

Q11 Thinking about the amount of stress in your life, would you say that most of your days are…?

Higher levels of stress (extremely/quite a bit) are more likely to be reported by residents of Ontario (39%), by younger smokers (47% under age 45), women (39%, vs. 24% of men), those with children at home (34%), those in fair or poor health (41%), and those who feel they are falling behind on expenses (61%).

Four in ten smokers say they have difficulty going to sleep or staying asleep either all or most of the time; one-third say they have trouble sometimes, and three in ten rarely or never have problems sleeping.

Q12 How often would you say you have trouble going to sleep or staying asleep?

Having trouble sleeping (all/most of the time) is higher among those under age 65 (41%), women (46%), those in the lowest education (52% of those with a high school education or less) and household income (49% among those with an income $40k or below) groups, those who smoke at least 16 cigarettes a day (47%), those reporting only fair or poor health (56%) or a lot of stress in their life (68%), and those falling behind on expenses (61%).

Smokers were asked to indicate how many minutes of physical exercise they get in a typical day. Three in ten (29%) smokers say they get more than 30 minutes; one-quarter (23%) get over 20 but under 30. Two in ten get none. The median (including zero) is 32.6 minutes.

Q13 Thinking about a typical day in the past week, for how many minutes, if any, did you do moderate to vigorous physical activities such as brisk walking, cycling, skating or swimming?

Time spent doing physical activity is fairly similar by region and gender, except residents of the Prairies are the least likely to say they are active more than 30 minutes per day (16%). Getting physical activity does not vary notably by education or income level but is lower among those aged 65 and older (50% get 10 minutes or less a day) and those in fair to poor health (51%).

Most smokers (85%) say they are at least somewhat well informed about the factors that increase the risk of cancer, including just under four in ten (35%) who say they are extremely or very well informed.

Q19 How well-informed would you say you are about the factors that increase the risk of developing cancer?

The proportion who consider themselves well informed (extremely or very) about cancer risks is higher among those aged 25 to 44 (43%), those living in large urban centres (41%), those with a university degree (45%) and those who say their health is excellent or very good (49%).

D. Other substance use

Close to nine in ten daily smokers also sometimes drink alcoholic beverages; half occasionally use cannabis, and close to four in ten occasionally use e-cigarettes. Over six in ten who drink alcohol have done so for over 20 years, while cannabis and vaping tend to be more recent introductions.

Daily smokers were asked if they use other substances: alcohol, cannabis or e-cigarettes/vaping devices. Close to nine in ten sometimes drink alcohol, half sometimes use cannabis products, and just under four in ten sometimes use vaping products or e-cigarettes.

Q7 Which, if any, of the following apply to you?

Reported use of alcoholic beverages is higher among men (92% vs. 82% of women) and those with a university degree (92%).

Reported use of cannabis products is lower in Quebec (40%) and the Atlantic region (45%) than elsewhere (52% to 56%). It does not differ by gender but is highest among those under age 45 (66%) compared to older smokers (45% age 45 to 64, and 19% age 65 and over). There are no notable differences by education or household income. Cannabis use is somewhat higher among those reporting higher levels of stress in their lives (57% extremely or quite a bit stressful), and those who are falling behind on expenses (65%).

Like with cannabis use, reported use of vaping products is higher among younger smokers (55% under age 45) and lowest among seniors (12%). Use is higher among those with a university degree (49%) or with household incomes of $100,000 and over (52%), those with children at home (42%) and those who say they are in excellent or very good health (45%). Like cannabis, its use is also higher among those reporting more stressful lives (47%).

Users of other substances were also asked how frequently they partake of them. One in five (22%) daily smokers use vaping products at least weekly, one in three (31%) use cannabis at least once a week and a majority (56%) drink alcohol at least weekly.

Q32 You mentioned that you sometimes use an e-cigarette or vaping device. Which of the following best describes how often you've used an e-cigarette or vaping device in the past 30 days?

Q33 You mentioned that you drink alcoholic beverages. Which of the following best describes how often you usually drink alcohol?

Q34 You mentioned that you use cannabis products. Which of the following best describes how often you usually use them?

The following paragraphs describe the statistically significant differences in these results by population segment:

• People in the 25-44 age group are more likely to vape at least weekly (39% of all smokers 25-44) as are those with a university degree (30%, vs. 18% with lower levels of education).
• Drinking alcohol at least weekly is more common among men (69% vs. 40% of women), those who are married/common-law (63%), among those with an education beyond high school level (62% compared to 44% of those with high school or less) and those with household incomes of $80,000 or higher (71%).
• Weekly cannabis product use is more common among those under 45 years old (47% vs. 21% of those 45 and over), those who are falling behind on expenses (46%), those who are extremely/quite a bit stressed (45%), and those living in a medium or large urban centres (34% vs 23% of those living in small/rural communities).

Smokers were asked how long they have been using these other substances. Over six in ten say they have been drinking alcoholic beverages for over 20 years, vs. one-third of cannabis smokers. A plurality of close to half (46%) of users of e-cigarette have used them for one to under five years.

Q9 For how many years have you been doing each of the following things?

BASE: THOSE DOING EACH ACTIVITY

Length of time drinking alcohol and using cannabis products is higher among smokers aged 45 or older (86% and 52% started using those substances, respectively, over 20 years ago). Vaping devices are a relatively new introduction to the marketplace, and thus there is little differentiation in length of time vaping by segment of the population.

E. Efforts to improve health

Over half of daily smokers made improvements to their health in the past year (exercise and diet being top mentions), and close to nine in ten say they should make other changes (notably quitting smoking); lack of willpower is the main barrier. Eight in ten say they want to make changes this year, notably quitting smoking and exercising more.

Over half (55%) of daily smokers say they did something in the past year to improve their physical health. The proportion who say they made a health improvement in the past year is highest among those reporting to be in excellent or very good health (65%, vs. 44% in fair or poor health) and those who say they smoke 10 or fewer cigarettes a day (61%). Recent efforts to improve their health do not vary significantly by region, age, gender, marital status, income or education.

When those who indicated they made an improvement to their physical health (55% of total sample) were asked what they did, the most common response is to increase their exercise/physical activity, followed by improving their diet, reducing the amount they smoke, and losing weight. A small number indicate they quit smoking in the last year but, as previous research has shown, most smokers require multiple tries before they finally quit.

Q21 What is the single most important change you have made?

Health changes are similar by region and across most population subgroups. Reporting increased exercise is highest among those in excellent or very good physical health (36%). The proportion who say they reduced the amount they smoke is higher among those smoking ten or fewer cigarettes a day (16%, vs. 6% smoking 16 or more). There are no significant differences in the proportion who say they quit smoking or reduced the amount they smoke by length of time they have been smoking.

Smokers were asked if there is anything (or anything else) they should do to improve their health. A strong majority (86%) say there is, a proportion that is higher among women (90%, vs. 83% of men), and among those who made health improvements in the previous year (93%, vs. 80% who did not).

Those indicating they should take additional steps to improve their health were asked what it is they should do. Close to half say they should quit smoking; by far the most mentioned change they perceive to their health.

Q23 What is the most important thing you think you should do to improve your physical health?

Quitting smoking is the most important health change smokers feel they should make across all population segments but is somewhat higher among those who say their life is not stressful (56%) and those who have not made any health improvements in the past year (58%).

Smokers who feel they should take additional steps to improve their health were asked if anything is preventing them from doing so. Six in ten (60%) say no, while just under four in ten (36%) say yes.

Q24 Is there anything stopping you from making this improvement?

The proportion who say something is preventing them from improving their health is higher among women (42%, vs. 31% of men), those in only fair or poor health (45%), and those under a lot of stress (49%).

Those saying there is something preventing them from making improvements to their physical health were asked to indicate what the barriers are, from a list provided. The most common reason given is lack of will power, followed by addiction. One-quarter say they are too stressed, and two in ten cite a disability or health condition.

Among those who specifically identified quitting smoking as the most important health change that should be made, the same top three barriers are mentioned (lack of will power, addiction and stress), but by a larger proportion of the subsample overall.

Q25 What is that?

BASE: THOSE WHO SAY SOMETHING IS PREVENTING THEM FROM IMPROVING THEIR HEALTH

Lack of will power is the top reason given across the country and most subgroups; women are more likely than men to cite stress (37% vs. 13%) or financial constraints (20% vs. 6%). Further subgroup analysis is not possible due to small subsample sizes.

Smokers were asked if they intend to do anything about their physical health in the next year, or not. Eight in ten say they intend to.

Q26 Do you intend to do anything to improve your physical health in the next year, or not?

Strong majorities across the country and all subgroups intend to improve their health in the coming year, but the proportions are higher among women (86%, vs. 75% of men) and those who made an improvement in the previous year (90%, vs. 70% who did not).

Those who say they intend to make a health improvement in the coming year were asked what they will do, again being provided with a list of options. Half say they will start, or increase, exercise/physical activity or sports. Just under half (46%) want to quit smoking; around one-third each want to lose weight (35%) or reduce the amount they smoke (34%). Three in ten (2%) want to improve their diet, one-quarter (24%) want to reduce their level of stress, and two in ten (19%) want to drink less alcohol.

Q27 What is that?

Stated intention to quit smoking is higher among those with household incomes of $80,000 or more (50%), those with children at home (53%), those in fair or poor health (54%) and those who did not make a health improvement in the past year (53%). Aspiring to reduce the amount smoked is more common among those currently smoking 16 or more cigarettes a day (40%), those who use cannabis several days a week/daily (46%), and women (39% vs. 29% of men). The proportion who say they intend to (further) reduce the amount they smoke is higher among those who said they already took steps to reduce smoking in the past year (43%).

F. Other activities of daily smokers

Daily smokers were asked about other activities they do, to minimize the implication that the focus of the survey was solely on smoking. Close to nine in ten are daily coffee drinkers, and eight in ten prefer to pay their bills online. Seven in ten are regular social media users, and two-thirds travelled outside of Canada or more than 100 km away from home last year. Half like to play video games. The activities with the lowest reported participation are volunteering and keeping a journal or diary.

Q7 Which, if any, of the following apply to you?

The following subgroups are among the most likely to do each activity:

• Daily coffee drinking: Aged 65 or older (91%), college or university degree (90%), household income $100,000+ (93%) and those living in large urban centres (92%).
• Paying bills online: Ontario residents (90%), smokers between the ages of 25 and 44 (90%), married/common law (84%), university degree (91%), household income $100,000+ (93%), extremely/very stressful life (90%), smoke 10 or fewer cigarettes per day (86%).
• Use social media: Ages 18-24 (97%) and 25-44 (89%), women (82%), household income $100,000+ (79%), extremely/very stressful life (84%), falling behind on expenses (80%), use e-cigarettes (92%), stronger connection to community (81%), extremely/very informed about cancer risk factors (78%).
• Travel: B.C. residents (72%), men (74%), married/common law (72%), university degree (86%), household income $100,000+ (93%), children in household (70%), excellent/very good health (76%), financially secure (83%), smoke 10 or fewer cigarettes per day (72%), use e-cigarettes (83%), intend to quit smoking (74%).
• Video games: Ages 18-24 (78%) and 25-44 (72%), children in household (57%), extremely/very stressful life (63%), falling behind on expenses (65%), large urban residents (58%), stronger connection to community (61%), smoke 10 or fewer cigarettes per day (60%), extremely/very informed about cancer risk factors (60%).
• Volunteer: Ages 25-44 (45%), university degree (50%), excellent/very good health (46%), financially secure (44%), urban residents (46%), stronger connection to community (50%), smoke 10 or fewer cigarettes per day (41%), use e-cigarettes (61%), made health improvements in past year (44%), extremely/very informed about cancer risk factors (47%).
• Keeping a journal: B.C. residents (26%), ages 25-44 (27%), university degree (23%), excellent/very good health (22%), extremely/very stressful life (23%), urban residents (22%), stronger connection to community (24%), use e-cigarettes (36%), made health improvements in past year (21%), extremely/very informed about cancer risk factors (26%). There were no significant gender differences in the proportion who report keeping a journal.

Those doing these activities (other than daily coffee drinking) were asked how often they do each. Nine in ten often pay their bills online, and half often write in their journal. Responses are generally similar by subgroups.

Q8 How often do you do the following things?

BASE: THOSE DOING EACH ACTIVITY

Those reporting regular use of social media are most likely to indicate daily use of Facebook, followed by YouTube. One-third use Instagram every day, while one-quarter use Twitter. Two in ten or fewer report daily use of other social media platforms.

Q28 Which social media, if any, do you use on a daily basis?

Daily use of social media is generally fairly similar by region, but there are notable age-related differences for some media (other than Facebook, LinkedIn and Tumblr). Daily use of YouTube (60%) is highest among those aged 25 to 44; Instagram use is higher among those aged 18 to 44 (45%), while Snapchat is used most often by those aged 18 to 24 (47%). Women are more likely than men to use Instagram (37%) and Pinterest (23%) whereas men are more likely to use YouTube (58%), Twitter (31%) and LinkedIn (22%). Those with a university degree are more likely to use YouTube (58%), Twitter (40%) and LinkedIn (32%); and Twitter and LinkedIn are more often used by those with household incomes of $100,000 or more (respectively 38% and 28%) or households with children (respectively 29% and 19%).

The majority (58%) of video game players report playing fewer than seven hours in a typical week; three in ten play from 7 to 14 hours. Responses are generally similar across subgroups.

Q29 In a typical week, how much time do you spend playing video games?

II. Detailed findings – qualitative phase

The qualitative phase was designed to take place over seven consecutive days (Thursday to Wednesday).

• Days 1 through 4 (Thursday through Sunday) were very open-ended. The main activity was completing a diary entry about what they did and how they felt throughout the day. There was no mention of smoking in the question instructions.
• Days 5 (Monday) and 6 (Tuesday) also included a diary element but introduced a few probing questions to indirectly guide the discussion towards the topic of interest (e.g., questions about health aspirations). Once again, there was no mention of smoking in the question instructions.
• On Day 7 (Wednesday), participants were asked to look back at their diary entries for the past week and comment on anything that stood out or surprised them. Finally, the topic of smoking was raised; participants were asked how smoking fits into their life and why they spent little (if any) time in their diaries discussing it.

A. Participant profile

Profile based on survey responses. A total of 80 survey participants participated in all seven days of the qualitative diary phase. The table below summarizes the age, gender, language and regional profile of these participants, which is similar to non-participants.

Compared to those who did not participate in the diary, diary participants skew more highly educated (19% with postgraduate degree, vs. 9% of non-participants) and tend to have higher household incomes (32% earning $100K or more, vs. 20% of non-participants). They are also more likely to be living in a large urban centre (57%, vs. 38% of non-participants).

While the opinions, values and reported behaviours of diary participants are largely similar to those of non-participants in most cases, there are some exceptions. Diary participants are more likely to:

• Have done at least some physical activity on a typical day in the past week (89%, vs. 78% of non-participants)
• Be confident they can have a positive effect on their health (33% strongly agree, vs. 21% of non-participants)
• Strongly disagree that they lack control generally (36% strongly disagree that "whatever I do, my destiny is pre-determined", vs. 25% of non-participants; 33% strongly disagree that "no matter what I do, I have a lot of trouble changing the course of events that affect me", vs. 16% of non-participants).
• Say people can be trusted (56%, vs. 38% of non-participants)
• Say there is something they should do to improve their physical health (93%, vs. 85% of non-participants), and that the most important thing would be quitting smoking (58%, vs. 45% of non-participants). However, they are no more likely to intend to make changes in the next year to improve their physical health.

Personality/personal style. When asked to introduce themselves on the first day of the diary, participants provided varied and personal descriptions. The most common personality traits are "logic" and "analytical". There is differentiation in how participants describe themselves in social settings: some describe themselves as "extroverted" and "social", while others say they are "introverted" and "shy". Some participants use traits typically associated with Canadians (e.g., friendly, caring, nice) to highlight their personality style.

Text description: The image shows a visual representation (word cloud) of the words used when participants were asked to introduce themselves on the first day of the diary. Words have different sizes indicating their relative frequencies. The biggest ones being "logic", "analytical", "extroverted", "social", "introverted" and "shy".

Personal profile. When asked to describe themselves in the style of a profile for a magazine, people give varied responses that often revolve around their family life, personality type and career or hobbies. The most relevant finding of this exercise is that not one participant at any point in describing themselves mentioned smoking or cigarettes.

Text description: The image shows a visual representation (word cloud) of the words used when participants were asked to introduce themselves on the first day of the diary. Words have different sizes indicating their relative frequencies. The biggest ones being "logic", "analytical", "extroverted", "social", "introverted" and "shy".

B. Key themes of daily diary exercise

Participants were presented a variety of images and asked to select the one that best captured how they were feeling each day. The most commonly selected images are those associated with being tired, lazy or drained of energy. The top two "negative" images associated with lack of energy are shown below. The image of the sleeping woman was the top choice overall five out of seven days (every day except Friday and Saturday):

Text description: The image of a girl sleeping.

Text description: The image shows a coffee cup being filled

On Friday and Saturday, the top choice was a woman with outstretched arms, which seems to capture a feeling of energy or excitement as the week comes to a close. This image was also a popular, although not top, choice on weekdays, as was another "positive" image of a man pumping his arm in celebration; on these days, we hypothesize the images were possibly chosen to demonstrate a sense of accomplishment with weekly activities.

Text description: The image show a woman outdoor with outstretched arms and the eyes closed.

Text description: The image shows a man pumping his arm in celebration.

In their daily write-ups, participants typically divide their day into three parts: morning routine, daytime activities, and evening routine.

Morning routine: Day-to-day, time spent from wake-up to work, or getting up to get going, tends to follow a regimented, well-established routine. However, habitual doesn't necessarily equate with easy; many describe a hectic or rushed morning routine, particularly where kids are involved.

Most participants did not mention smoking as part of their morning routine. Among the rough dozen who did, it seems to be part of a calm, reflective part of their day before they face the rest of the day; for this group, coffee and a cigarette are a popular pairing.

"As usual, I woke up and made coffee while I watched some tv. Smoked some cigarettes in the process…"

"I put the coffee on, had a cigarette outside. I am home alone this morning and the house is quiet. My boyfriend is still visiting his daughter. I feel okay this morning. The anxiety and depression I suffer from is always there, but the mornings are the best time of day for me."

"I woke up late, but that's not a problem. I did the usual--coffee, cigarette, let the dog out. It was a calm time, my favorite during the day."

"I got up at 8:30 to make my morning coffee which I enjoyed with the first cigarette of the day. Since I smoke outside, I could feel that winter is coming to an end and that made me feel good. After the coffee I spent some time with our cat. He loves to be brushed and knows he gets it after my coffee and cigarette."

"I woke up around 7AM…after about an hour of being on the laptop and watching news, I had some buttered toast and orange juice because I was hungry then I went into the garage to smoke a cigarette because it's part of my morning routine when I am at home from work."

"I had my usual smoke on the balcony with the last of my coffee before driving [my wife to work]. I enjoy this but at the same time I know I need to quit so this morning it was half enjoyment, half feeling guilty as I looked inside to see my wife on the couch, thinking that she doesn't have any bad vices and that I shouldn't be doing this. I'm always thinking of quitting at these moments."

"Woke up around mid-morning, made a cup of coffee, then watched some talk shows while having a cigarette. Eventually got dressed and left my house to do a couple errands for the rest of the morning."

"I woke up by my alarm at 7:00am, feeling kind of sleepy, since I don't usually wake this early, but I have a doctor's appointment today. I got up, got the coffee going and had a cigarette."

"Je me suis levé à midi. Comme d'habitude j'ai callé un grand vers d'eau et j'ai fumé ma première cigarette de la journée." (I got up at noon. As usual, I downed a big glass of water and smoked my first cigarette of the day.)

"I feel a bit sluggish, mentally and physically, but after coffee and a cigarette and making my lunch for later, I'm fine."

"Je me suis réveillé pas mal fatigué ce matin avec très peu d'entrain pour aller au travail. Je me suis fais deux cafés et j'ai fumé une couple de cigarettes pour me stimuler l'esprit lol." (I woke up pretty tired this morning with very little desire to go to work. I made myself two cups of coffee and smoked a couple of cigarettes to revive my spirit lol.)

Daytime/workday activities: For most, this part of their diary was taken up with description of their workday, although a small number are not working and thus describe other activities that fill their time (TV, social media etc.). In general, going to work is an everyday expectation and typically uneventful. It is something to endure more than enjoy. When describing the work day, the tone tends to be neutral and lacking in emotion. However, there is a shift in attitude when there is some success or involvement in a new or interesting project or task. After work, the most frequently cited activities include grocery shopping, meal planning and exercise.

Once again, most participants did not mention smoking during the main part of their day; the few times it did come up were in reference to breaks before or during work.

"Lunch was good. Went for a walk to get some air. A quick smoke and some Chinese food from the food court."

"Went outside at lunch to have a cigarette and listen to music away from the office."

"My afternoon started out with a quick smoke before the drive to work. I don't smoke in the car so I usually have one just before getting in. My mind is settled and I'm thinking of the drive ahead…I get to work around the usual time, 3:30ish and smoke outside until it's time to get in. I like this time as me time and relax before heading in."

"Get to work and grab my bus keys off the wall rack…I head out to the yard to pre-trip inspect my bus. Start up the bus to get it warmed up a bit. I then walk over to my wife's bus to have a cigarette with her before we have to start our bus runs. I head out of the yard at 7:35 am to pick up kids in JK to grade 12 for 12 different schools."

After hours: Evenings are frequently focused on family, and family meals seem to be a meaningful moment in daily life. The typical evening is spent at home and provides an opportunity to unwind and relax and spend time with family. Social activities after hours are not a daily event, but participants occasionally describe outings, parties or gatherings. It is during these types of activities where we most often see references to alcohol consumption.

As with other parts of their day, most participants did not discuss smoking as part of their evening, either when at home or in social situations. There were also fewer mentions of smoking in the evening compared to the morning. The few participants who did mention smoking during this part of their day typically referred to it as part of relaxation or contemplation.

"My urge to smoke takes me to the balcony where I enjoy a few minutes to myself. Having alone time is important to me even when it's brief moments. I love my family more than anything but time to myself is important. I'm thinking to myself...I made it. The long week is over."

"I get in bed after dinner and pick up the book I have been reading 'The Child Finder'. I read a lot. It helps calm me down and it is a form of escape for me...Tonight I escape into my book for hours, with a few cigarette breaks in between, until bedtime. The house seems empty and lonely tonight."

Other themes. Within their daily diary, a few people spontaneously referenced the challenges inherent in quitting:

"I got up and put the coffee on, like usual. And then I got out my cigarette pack and realized I only had one cigarette left and my boyfriend is gone today (he smokes too and I often rely on him when I run out of cigarettes). The panic started to set in. I have been trying to quit for this past year and the best I have done so far is 2 days without a smoke and that was so difficult/stressful/awful. Anyway, I smoked my last cigarette and came inside and put on a nicotine patch I had on hand from my previous attempts at quitting. Still, I could not stop thinking about smoking. It felt like every single minute all morning my brain was screaming "SMOKE SMOKE SMOKE".

"After lunch I had my first smoke of the day! The only good thing about feeling so sick is my cravings for cigarettes is way down. I have a love/hate relationship with those devil sticks and I've told myself a 1000 times, that this is the last one. I had no energy to fight it and I sucked back half a smoke."

"I made myself a bowl of Harvest Crunch and milk for dinner at about 5:00pm. When my boyfriend is not home I do not bother with cooking…I finish my bowl of cereal and have another smoke. I need to quit soon - I am so reliant on these cancer sticks."

Finally, an interesting finding is the reference to positive healthy behaviours in participants' daily diaries (e.g., exercise), when these types of activities are not typically associated with smokers. For example, the diary entry refers to both yoga and smoking on that day:

"I decide to do some yoga on the deck this morning. First time since fall… I put in my earbuds and turn on my yoga app and let the instructor's voice guide me into the positions. I feel so at peace during this forty-minute session. I can transform to another world and it's worry free and perfect. [Later same day] Clean up after dinner was simple and we both lay on the sectional for a movie on Netflix. We decide on Alpha Dog. We share a couple joints throughout the movie and a couple cigarettes. I hate myself each time I light a smoke because I know how horrible it is for me. There's nothing like the first drag of a smoker when you are craving it. This love/hate relationship needs to stop but tell myself, not today it doesn't. I have a horrible problem of procrastinating. I know I do, but only do I regret afterwards. In the moment when I justify it to myself, I need to put it off until tomorrow."

C. Challenges and successes (Day 5)

On the fifth day of the diary, participants were asked to elaborate on the challenges they are facing, as well as their recent successes, and the thing they would most like to change, learn, do better or let go of.

Participants most commonly frame their desired changes in terms of taking a different outlook on life: stop worrying, be more patient, control my emotions, let go of stress, overcome procrastination, get better at forgiving myself, live in the moment. Often, participants mention how this type of outlook or pattern of behaviour in not good for their health. Some participants cite more concrete desires, such as getting a job, finding a partner, playing an instrument, finding a better place to live, losing weight or getting more physical activity.

A small number of participants specifically cited smoking as the thing they would most like to change about themselves or their life. There is a sense that this is a very large challenge and one that will not be easily overcome.

• "The one thing I would definitely like to change (and I've talked to [name] about this) is to quit smoking. I find smoking a way to release stress so I need to find another way to do this. My daughter suggests the new vape products and cut down from there and eventually only vape with non-tobacco products."
• "I would love to change where and how I live. I would live in the country and get away from the city and simplify my life even further. My biggest challenge will however be to quit smoking. Working on that right now."
• "I would really like to stop smoking and have had zero success even getting started. My lungs feel heavy and I am tired almost all the time. I cannot afford to smoke even though I roll my own. I have been feeling angry with myself and that is not helping. I think about it every day. I have even got the things I need to help me with cravings if I should decide to quit. But I do not even seem to be able to get past that first cigarette in the morning. I have been very frustrated by this for long a long time."
• "I want to let go of many habits - My caffeine addiction, moderate my alcohol intake (which I've been able too actually), and mainly get rid of the false notion of having cigarettes or smoking a joint every time I'm stressed and believing that it's the main thing that leaves me calm."
• "J'aimerais sans doute arrêter de fumer mais j'ai pas de courage." (I'd definitely like to quit smoking, but I'm not strong enough.)

D. Stress, aspirations and health aspirations (Day 6)

Stress. As part of the day six exercises, participants were asked to elaborate on how stress affects them and their lives.

When asked what stress means to them, it is described as an overarching, overwhelming force that is synonymous with worry and anxiety. Stress is everywhere; it is part of life and inevitable. It is primarily associated with work, family and finances but also generally linked to the pace of life today. Several participants also associated stress with illness, depression and other chronic conditions.

Participants seem well-aware of the signals that indicate they are stressed, which include:

• Finding their thoughts running in a continuous loop, unable to "turn off" their brain
• Tension (e.g., neck)
• Anxiety
• Shorter, faster breathing rate
• Increased blood pressure/heart rate
• Sleeping poorly
• Nausea
• Being overheated or sweating

Participants describe stress is a significant challenge and therefore something that most try to avoid, control or manage. There is a general awareness that stress can be harmful to health and well-being and lead to more serious issues. Some participants mention exercise and working out as a means to deal with stress; a few mention cannabis use as an effective method to reduce stress. A handful referenced smoking, typically in the context as a remedy for stress.

When asked to complete the sentence: "When I'm stressed, I (blank), because (blank)", a few respondents said they smoke when stressed because:

• It helps calm me down
• I need to stop and clear my head for a bit
• It relaxes me
• It helps
• Being able to focus on those two things (coffee and a smoke) takes my mind off the stressful situation and hopefully avoids the pain that could follow all over my body
• It relieves me

Aspirations. Participants were asked about their aspirations (i.e., hope or ambition of achieving something) within the next three, six and 12 months. A variety of goals are mentioned, including:

• Stronger family relationships (also marriage and having kids)
• Financial goals (e.g., reducing debt, buying a house, financial security)
• Job satisfaction (e.g., changing jobs, getting a promotion)
• Travel/vacation
• Learning a new skill (e.g., learning an instrument, taking a course)
• Health-related goals (e.g., weight reduction, healthy eating, more exercise)

Only two participants say they aspire to quit smoking, both referring to the three-month timeframe; none mentioned quitting either six or 12 months from now.

• (In next 3 months) "I am seriously going to work on stopping smoking cigarettes, I want to stop."

Health aspirations. Next, participants were asked more specifically about their health aspirations within the next three, six and 12 months. The main health aspirations tend to be: reducing weight, healthier eating, exercising more and addressing specific health challenges. Fewer than a dozen say they aspire to quit smoking in the next three, six or 12 months.

• (Repeated at 3, 6, 12 months) "I really should stop smoking!"
• (6 months) "J'espère arrêter de fumer car c'est un des mes plus grand désirs." (I hope to quit smoking because it's one of the things I want most.)
• (12 months) "Hopefully quit smoking completely. I have gone from a long-term smoker to a casual smoker now but would be nice to stop completely."
• (12 months) "By the end of the year I will quit smoking, I'm gonna try to casually cut down while trying this vapor idea. If that fails, I will go to the extreme and call one of the hotlines and find a better solution. This is my main personal goal."
• (12 months) "I want to be a non-smoker in a year...that is a HUGE challenge for me. I know I am not ready now and probably will not be in months, but I really would like to stop. It is so hard...it has been a part of my life for 39 years."
• (12 months) "Cesser de fumer la cigarette même si je ne suis pas un gros consommateur. Je diminue d'année en année et je penses que cette année sera la bonne !" (Stop smoking cigarettes, even though I'm not a big smoker. I'm doing it less every year, and I think this year will be the one!)
• (12 months) "I don't tend to think that far forward in terms of health. I've been a smoker for 30 years, so I'm aware that at some point, there will probably be a major heart or lung problem. And I've accepted that, at this point. If I can manage to keep going for another year in relatively decent health, that's good enough for me."

E. Where smoking fits in daily life (Day 7)

On the last day of the diary, participants were asked to review their journaling for the week and share their thoughts upon looking back on the week. The most common theme was how much they had enjoyed the exercise. Many said it was beneficial to participate in this diary and share their thoughts and feelings. They found it raised their self-awareness and opened their eyes to their routines, patterns and behaviours, and was "therapeutic" because it helped them consider where and how they could make changes.

Participants were then asked about smoking, and specifically, how it fits into their life and why it rarely came up as a topic in their daily diary. Respondents readily acknowledge their addiction and consequences of smoking to their health. There are a few key themes that arise when describing how smoking fits into their life:

• A crutch used to help cope

"Smoking is a crutch. I have anxiety when I am away from my partner and smoking will sometimes help to ground me. I never feel like smoking when we are together because my anxiety simply isn't there."

"Smoking is my comfort spot. Whenever I'm feeling overwhelmed or any kind of feeling I turn to smoking to calm my nerves. To make me relax and feel okay. It helps me unwind. I use it as a crutch though and I need to find a different way of coping because all these smokes are doing is killing me. I have that love/hate relationship with them."

"In a way smoking keeps me going from one thing or task to another. I begin some task with a smoke and look forward to completing the task so I can have another smoke after I complete the task. I do not know how I would survive without the smokes. That is something that keeps me going, especially when I am alone. I enjoy smoking alone more than with people."

"Smoking allows me to get away from the hub of busy life and move to a secluded area. It allows me to decompress."

"Smoking was originally something that I enjoyed very much and began at a time in my life when I was much more social. I smoked very little in comparison to now. As time has progressed, it has become more of a habit and a crutch at times."

• A social activity

"It is an addiction, of course, if we're going to be frank about it. But obviously it also has some tangible benefits such as stress relief, and gives me a chance to slow down, unwind and reflect on my situation, for better or worse. Also, it is somewhat of a social outlet, in that I am often joined by co-workers who also smoke."

"It is a buffer for me to take that mental break outdoors for several times each day where I usually enjoy the company of a co-worker."

"C'est un moment de détente que je partage avec mon conjoint, ma fille et les amis. Comme nous fumons à l'extérieur ça devient un temps pour jaser et échanger." (It's a relaxing moment I share with my partner, my daughter, and friends. Since we smoke outside, it becomes a time to chat and discuss.)

• A small pleasure or reward

"I smoke at work during breaks and at home few times in the evening to a total of about 11-12 cigarettes per day, never indoors, never with or in the front of my son. It is small pleasure that I allow myself to have disregarding for now any potential health risks."

"Smoking for me is like my best friend. If something goes good you celebrate by having a cigarette, if something goes bad you commiserate by having a cigarette."

• A few participants spoke passionately about smoking as a "love-hate relationship", including this diary entry:

"I have a love-hate relationship with smoking. I enjoy smoking most of the time. I like the smell, how it feels when you take a drag. I like that when I'm bored or feeling like I need to get away from something for a minute, I have something to go to. I love that first smoke in the morning with my coffee or after a meal. I like the social aspect of it when I'm at work on a break and you talk to the regular smokers. I really do like and love these things. But I also hate it. I hate that this will likely kill me. It's a blunt way to think but it's reality and I'm not naive. It will likely cause complications before eventually killing me that will be very unpleasant, without sugar coating it. I hate how out of breath I am as a result of smoking for so long. I hate that I spend close to 400 dollars a month on it. That's money that we could really use and it's only until my wife brings up finances that I begin to seriously think of quitting again. I hate how it makes my fingers smell. I hate the stigma that goes with being a smoker. I hate my clothes smelling because of it. I hate getting the odd burn hole in my favourite jacket because the heater blew off and caught my jacket. I hate how it makes my wife feel when we are enjoying a nice movie together and halfway through I have to get up to go outside and smoke. I hate having to go out in the cold or rainy weather to smoke. It's funny how I see the love and hate paragraph's and see which one is bigger, making me see in black and white which one is more convincing. I need to quit again."

• On the other end of the spectrum, a few raised the idea that they haven't previously considered smoking a big part of their life:

"It fits into a small corner of my life...I never really thought of it as part of my life but I guess in fact it is."

"It's something to do to keep my nerves in check and stops me from losing patience in a variety of situations. I don't think of it as a real part of my life but maybe it is."

When asked why smoking was mostly excluded from their diary, participants gave two main reasons. Some said it didn't occur to them to discuss smoking because it is an automatic habit to which they don't give much thought. For others, however, smoking was purposely avoided due to shame or embarrassment.

Smoking is commonly cited as a "bad habit", and most make it clear they know the consequences, and that they should quit. Several indicated a desire to quit and many mention having attempted to quit in past (some multiple times). However, relatively few indicate a firm commitment to quit in the near or longer-term.

The following quotes are from participants who said they didn't think to mention smoking because it is such an ingrained habit:

• "That's an interesting question as when I read that question, I didn't even realize I hadn't incorporated smoking into my daily journals. I guess I never thought about it as it is a daily part of my life."
• "Smoking is so automatic to me, almost like eating or drinking that I don't really think about it when I do it. This, I realize is not a good thing."
• "It is such an integral part of my life...such a routine and regularity that it just was never something that I thought about."
• "It is so embedded in my routine that I have not even thought about mentioning it, I never mentioned going to washroom either as those things to me are sort of same kind."
• "C'est comme aller au toilette.....Nous ne précisons pas cela....." (It's like going to the bathroom…you don't mention it.)
• "I take smoking for granted; it satisfies a craving only. It does not make me happier or more worrisome. It does not satisfy anything except the craving. Smoking is not an important part of my day, it's just something I do, sort of like breathing."
• "Fumer, est pour moi une habitude machinale. Quelque chose de régulier qui soulage mon stress quand le besoin se fait sentir. Je ne porte pas trop d'attention à ça." (For me, smoking is a mechanical habit. Something that relieves my stress when I feel the need. I don't pay much attention to it.)
• "J'aime relaxer avec une cigarette, seul dans mon garage. La cigarette occupe une petite place dans ma vie… Fumer, je n'y pense même pas....ce n'est pas très important dans ma routine. Ça ne prend pas beaucoup de temps dans ma journée." (I like to relax with a cigarette alone in my garage. Cigarettes occupy a small portion of my life... I don't even really think about smoking...it's not a very important part of my routine. It doesn't take up much time in my day.)

The following quotes are from participants who mention the stigma related to smoking:

• "It is a socially and morally unacceptable thing to do. It is a waste of money. I feel the necessity to hide it. If I didn't do it I would be a better person."
• "I think I decided to only include smoking sometimes through my journal because I'm ashamed of it. My mind hid it from my writing without consciously even knowing it. I'm embarrassed of my smoking and how much it is a part of my life. After reviewing my journal entries I have learned a lot about myself and I have setup goals for my future self. I do not want to be a smoker anymore. I don't want to be in the category."
• "I did not bring it up in the diary because it is not something that I am proud of. In fact, it is a habit that I actually hide from my children. I really do not want them to emulate me in this respect."
• "To be entirely honest, I did not mention smoking in my diary as it is something I am actually ashamed of. I know all of the risk factors concerning smoking but I still persist with this dirty habit."

F. Smoking in relation to other substances (Day 7)

The final exercise of the week asked participants to share their views on other substances including alcohol, cannabis and vaping.

Unlike smoking, alcohol consumption was openly shared in the daily diary, although in some cases implicitly rather than explicitly stated (e.g., feeling rough after a late night out with friends). From that perspective, alcohol does not seem to suffer the same stigma as smoking, but it is also a more casual or occasional event compared to the more habitual nature of smoking. Alcohol is also perceived as an occasional indulgence, most often outside the home, with friends or family, in a social context. It tends to be viewed more positively than other substances, so long as it is enjoyed in moderation and controlled.

The following quotes are from participants describing what they think about alcohol and when they use it (if applicable):

• "I drink alcohol when I am socializing. I love a nice glass of red wine."
• "Alcohol is something to enjoy sometimes with friends and family."
• "It's nice to enjoy a drink with friends occasionally or to enjoy a beer on the deck after a long day. I drink occasionally, usually on special occasions, an event or out with friends. I tend to drink more in the summer enjoying the outdoors and campfires."
• "It is something to use to feel rewarded, to enjoy or during special occasions as long as you are able to say no at any time."

Comments on cannabis were not as frequent as alcohol in their daily diary, but when we see references to cannabis use, the tone comes across almost as cavalier. For many, cannabis still carries stigma (despite its legalization in Canada) and elicits a number of negative views (e.g., a crutch to cope with daily life). Others speak to the therapeutic value, not just for chronic conditions and ailments (e.g., fibromyalgia), but also as a vehicle for relaxation, stress reduction and in a few cases, recreational enjoyment.

The following quotes are from participants explaining what they think about cannabis and when they use it (if applicable):

• "It is not an innocuous drug just because it appears to be less dangerous than some of the alternatives. However, I am convinced that there is medical application for it, but just like any other drug there is side effects and possible addiction issues."
• "Scary. It's really just another drug."
• "I need to sleep, when my back pain is bad or when I really need to relax to relieve my tension headaches"
• "To calm my nerves and my anxiety. I use it to help me sleep. But I also use it for a pick me up or when I want to be creative."

Vaping is generally perceived as an alternative to cigarettes, particularly if someone is trying to quit smoking. There are clearly mixed opinions about vaping. While some believe it as less harmful (less "toxic" or "deadly") than cigarettes, others suggest it is just as dangerous. Some see vaping as a fad or trend that is more socially acceptable than cigarette smoking. There are a variety of less favourable opinions (e.g, too costly, "weird", difficult to use) but also an indication from some that vaping does not adequately replace cigarettes, in terms of satisfaction or pleasure. Most participants say they do not vape; the few that do vape say they do so when it is offered to them in a social setting or when they are looking for something different/a change.

The following quotes are from participants explaining what they think about vaping and when they do it (if applicable):

• "Vaping is a waste of time, energy, and money. The chemicals in vaping and the effects of them are not truly understood."
• "I have tried it, but it did not provide the same satisfaction as a cigarette. It is also weird in that there is no definitive "end" to the cigarette when vaping."
• "(I vape when) I want to try getting my fix a different way."

Conclusions

The findings of this unique research project suggest that current assumptions about the significance of smoking in smokers' daily lives may need to be adjusted. The target of smoking cessation policies and initiatives is "smokers", which inherently indicates a belief that smoking is central to the identity of these individuals. However, this in-depth evaluation of a seven-day period, exploring daily habits and feelings, current challenges and future aspirations, found that smoking is not a salient theme that smokers think about and discuss, despite their openness describing other personal details (e.g., depressions, anxiety, drug use, intimacy).

This qualitative research can only begin to hypothesize about the reasons for this. One possible reason is the ingrained habitual nature of the habit (which was compared to going to the bathroom). Another reason appears to be the stigma and shame related to smoking; smokers are very aware that smoking is less socially acceptable than other substances.

The findings support the accepted wisdom that smoking is used as a coping mechanism, particularly with respect to stress. More counterintuitively, some smokers also report healthy behaviours in the form of exercise, challenging typical assumptions about or perceptions of smokers.

In sum, the results demonstrate that smokers are not a single cohesive segment of the population. Comprised within this audience are people with diverse outlooks, values and experiences. This offers new opportunities for cessation messaging, in terms of frames that may better engage smokers.

Appendix A: Research methodology

Quantitative phase

Environics conducted an online survey with 510 adult residents of Canada from March 7 to 15, 2019, who are daily smokers and have been smoking for at least five years. Survey respondents were selected from registered members of an online panel. Since the samples used in online panel surveys are based on self-selection and are not a random probability sample, no formal estimates of sampling error can be calculated. Although opt-in panels are not random probability samples, online surveys can be used for general population surveys provided they are well designed and employ a large, well-maintained panel. Respondents were informed about privacy and anonymity.

Online survey respondents who qualified (were 18+ and were daily smokers) completed the quantitative survey in its entirety. In addition to being a quantitative survey, it also acted as a way to screen and recruit daily smokers into the larger qualitative diary phase. The survey gathered information about a wide range of lifestyle topics and did not focus on smoking particularly for respondents to not be primed to respond in a specific way if they were to take part in the qualitative portion.

The screener/survey gathered information about behaviours and demographic information as well as measuring their suitability for taking part in the qualitative exercise (see the qualitative methodology section below for more details) Once people were finished the quantitative survey, they were asked whether they were available for, and interested in, taking part in the diary exercise. Those who agreed were then selectively sent invitations to complete the diary exercise.

Sample design and weighting

The following sample design was used to gather 510 daily smokers:

* 2017 Canadian Tobacco, Alcohol and Drugs Survey (CTADS) includes proportions for Canadians aged 15-19 but the survey included only smokers age 18 and over.

Weighting was used at the analysis stage to correct any deviation and ensure the final sample is representative of the daily smoker population. The adjustments made with weighting were very minor.

Questionnaire design

The questionnaire was designed by Environics and Health Canada representatives, to serve as both a quantitative survey instrument and as an effective method of recruiting qualified, high-quality participants into the qualitative journaling exercise. The final study questionnaire is included in Appendix B.

Pre-test

Environics' data analysts programmed the questionnaires, then performed thorough testing to ensure accuracy in set-up and data collection. This validation ensured that the data entry process conformed to the surveys' basic logic. The data collection system handles sampling invitations, quotas and questionnaire completion (skip patterns, branching, and valid ranges).

Prior to finalizing the survey for field, a pre-test (soft launch) was conducted in English and French. The pre-test assessed the questionnaires in terms of question wording and sequencing, respondent sensitivity to specific questions and to the survey overall, and to determine the survey length; standard Government of Canada pre-testing questions were also asked. It also tested the measurement of suitability for taking part in the qualitative diary exercise. As no changes were required following the pre-test, the n=48 responses (35 English, 13 French) have been included in the final data set.

Fieldwork

The survey was conducted by Environics using a secure, fully featured web-based survey environment. The interviews took place from March 7 (soft launch pre-test) to 15, 2019. The average interview length was 15 minutes.

All respondents were offered the opportunity to complete the surveys in their official language of choice. All research work was conducted in accordance with the Standards for the Conduct of Government of Canada Public Opinion Research – Online Surveys and recognized industry standards, as well as applicable federal legislation (Personal Information Protection and Electronic Documents Act, or PIPEDA).

Completion results

The completion results are presented in the following table.

Respondent profile

The following table presents the weighted distribution of survey participants by key demographic and other variables.

Qualitative phase methodology

The target population audience for the seven-day qualitative journaling exercise was daily smokers in Canada. Participants were randomly drawn from those who completed the quantitative online survey phase, and expressed interest in, and consented to, participate in the journal exercise. This research is qualitative in nature. The results provide an indication of participants' views about the issues explored but cannot be generalized to the full population of members of the targeted audience segments (daily smokers in Canada).

Recruitment. Respondents to the online survey were screened for their ability to communicate and be forthcoming in the diary exercise. This involved two additional industry standard questions in the online survey, asking them to provide an open-ended response describing the luckiest thing that has ever happened to them in as much detail as possible (Q35) and a battery of questions about their propensity to share detailed opinions (Q36). Each respondent was identified as an 'invite' or a 'hold' based on their responses to these questions (i.e., depending on the length/richness of their response to the open-end and the number of statements to which they provided an agreement score of 7 or higher out of 10). Invite respondents were automatically invited to participate in the qualitative phase; hold respondents were invited only if they were needed to provide a demographically representative group in the diary exercise.

Of the 520 respondents to the quantitative survey, 389 said they would be willing to participate in the qualitative phase. With the aim of generating as demographically representative a group of participants as possible, invitations were sent to hold respondents based on demographic variables. In total, 257 people were sent invitations to participate in the journal exercise and 123 accessed the online diary and set up a profile. A total of 80 participants completed the entire journaling exercise over seven days and received an incentive of $200 in their local panel currency.

Participants in the online journal exercise were informed of the purpose of the exercise, the time commitment and incentive, and provided with guidance on how to protect their privacy. All participants were recruited in a manner adhering to the Government of Canada's standards on qualitative recruitment.

Journal exercise. The journal exercise took place on seven continuous days from March 14 to 20, 2019 and gathered detailed information about the daily lives, habits, emotions and thoughts of daily smokers, and where and how smoking is discussed (or not) in this context. The journal exercise used the Recollective online platform (programmed and hosted in Canada). This interactive platform allows participants to create a profile and access it online at any time they wished (available 24 hours a day). On each of the seven days, they were provided with questions and diary activities to complete that included visual stimuli to help to maintain interest.

Participants were required to complete the exercises posted each day. The exercises were structured in an open-ended way so that the ultimate focus of the research (smoking) was not revealed until the final day to be able to gather unbiased lifestyle and behavioural information about respondents. When it became clear that very few participants were mentioning smoking in any of their diary responses, an additional question was added to the final day to gather valuable insight into why the topic had not come up organically during a week of talking about themselves, their lives and their goals.

Participants completed the journal exercise individually; there was no interaction between participants. The results were monitored daily by Environics and Health Canada. Minimal probing was employed to maintain participant engagement and ensure enough detail was obtained from each question/activity, but did not lead the respondents in any way or introduce new topics.

Analysis. The final data set was cleaned to include only participants who completed all seven days and were indeed daily smokers. Seven participants in the qualitative phase indicated that they were not daily smokers in response to the Day 7 question: "You mentioned in the survey that you smoke every day. Please tell me about how smoking fits into your life." These participants were subsequently removed from both the quantitative and qualitative data sets.

Appendix B: Survey questionnaire

Environics Research
March 6, 2019

Health Canada
2019 Smoking Behaviour Journey Map – Online Survey
Questionnaire
Online survey with 500 regular smokers 18+

LANDING PAGE

Please select your preferred language for completing the survey.

• 01 – English
• 02 – French

Background information

ALL RESPONDENTS

Thank you for agreeing to take part in this short 10-minute survey being conducted by Environics, a Canadian public opinion research firm, on behalf of Health Canada.

The purpose of the survey is to understand Canadians' experiences, opinions and behaviours about a range of lifestyle topics. This feedback will be used by Health Canada to better understand how Canadians feel about these topics. Please be assured that the survey is anonymous and confidential.

How does the online survey work?

• You are being asked to provide feedback about your views, your experiences and your lifestyle behaviours.
• Your participation is completely voluntary. Your decision whether or not to participate will not affect any dealings you may have with the Government of Canada.

What about your personal information?

• Any personal information you provide to Health Canada is governed in accordance with the Privacy Act and is being collected under the authority of section 4 of the Department of Health Act in accordance with the Treasury Board Directive on Privacy Practices. We only collect the information we need to conduct the research project.
• Purpose of collection: We require your personal information such as demographics (e.g. age, gender) to better understand the results of the research. However, your responses are always combined with the responses of others for analysis and reporting; you will never be identified.
• For more information: This personal information collection is described in the standard personal information bank Public Communications – PSU 914, in Info Source, available online at infosource.gc.ca.
• Your rights under the Privacy Act: In addition to protecting your personal information, the Privacy Act gives you the right to request access to and correction of your personal information. For more information about these rights, or about our privacy practices, please contact Health Canada at hc.privacy-vie.privee.sc@hc-sc.gc.ca. You also have the right to file a complaint with the Privacy Commissioner of Canada if you think your personal information has been handled improperly.
• Your personal information will be collected, used, retained and disclosed by Environics in accordance with the applicable provincial privacy legislation or the Personal Information Protection and Electronic Documents Act (PIPEDA). Please click here to review Environics' privacy policy.
• Your survey answers will remain anonymous and will not be attributed to you in any way.

What happens after the survey?

• The final report written by Environics will be available to the public from Library and Archives Canada (http://www.bac-lac.gc.ca/).

If you have any questions about the survey, please contact Environics at robert.hughes@environics.ca.

[CONTINUE TO SCREENING]

Screening

In order to classify your responses, we have some questions about you and your health and lifestyle in general.

1. Have you or any member of your household worked at any point in the past five years or have retired from any of the following:

2. Have you completed a survey for the Government of Canada in the last 30 days?

• 01 – Yes
• 02 – No

SCREEN OUT IF Q1 ANY=YES or Q2=Yes: "Unfortunately, you do not fit the profile to complete the survey. Thank you for your time and interest in this study."

3. In what year were you born?

RANGE: 1930 ONWARD - SCREEN OUT IF 2002-2019 (17 OR YOUNGER): Thank you for your interest in this survey but we are looking to speak to individuals who are 18 years of age or older.

Year (drop down list)

• 9999 – Prefer not to say

4. IF PREFER NOT TO SAY AT Q3: Would you be willing to indicate in which of the following age categories you belong?

• 1 – Under 18 years of age
• 2 – 18 to 24 years of age
• 3 – 25 to 34 years of age
• 4 – 35 to 44 years of age
• 5 – 45 to 54 years of age
• 6 – 55 to 64 years of age
• 7 – 65 years of age or older
• 9 – Prefer not to answer

IF YOUNGER THAN 18, TERMINATE – Text: "Unfortunately, you do not fit the profile to complete the survey. Thank you for your time and interest in this study."

5. In which province or territory do you live?

Drop down list

• 01 - Alberta
• 02 - British Columbia
• 03 - Manitoba
• 04 - New Brunswick
• 05 - Newfoundland and Labrador
• 06 – Northwest Territories
• 07 - Nova Scotia
• 08 – Nunavut
• 09 - Ontario
• 10 - Prince Edward Island
• 11 - Quebec
• 12 - Saskatchewan
• 13 – Yukon

6. How do you identify your gender? (This may be different from the information noted on your birth certificate or other official documents)

• 01 – Woman
• 02 – Man
• 03 – Other

7. Which, if any, of the following apply to you?

RANDOMIZE LIST

IF Q7D=1 CONTINUE. OTHERWISE, THANK AND TERMINATE

8. How often do you do the following things?

RANDOMIZE LIST - ASK ONLY THOSE WHERE Q7F/Q7G/Q7H/Q7M=YES (1)

9. For how many years have you been doing each of the following things?

RANDOMIZE LIST – ASK ONLY THOSE WHERE Q7A-Q7D=YES (1)

IF SMOKING LESS THAN 5 YEARS (Q9D=01 or Q9D=02), TERMINATE – Text: "Unfortunately, you do not fit the profile to complete the survey. Thank you for your time and interest in this study."

10. In general, would you say your health is…?

• 01 – Excellent
• 02 – Very good
• 03 – Good
• 04 – Fair
• 05 – Poor

11. Thinking about the amount of stress in your life, would you say that most of your days are…?

• 01 – Extremely stressful
• 02 – Quite a bit stressful
• 03 – A bit stressful
• 04 – Not very stressful
• 05 – Not at all stressful

12. How often would you say you have trouble going to sleep or staying asleep?

• 01 – All of the time
• 02 – Most of the time
• 03 – Sometimes
• 04 – Rarely
• 05 – Never

13. Thinking about a typical day in the past week, for how many minutes, if any, did you do moderate to vigorous physical activities such as brisk walking, cycling, skating or swimming?

____ ____ ______ minutes per day (RANGE 0-180)

Outlook/values

14. The following is a series of opinions that we often hear expressed. For each one, indicate whether you strongly agree, somewhat agree, somewhat disagree or strongly disagree by selecting the box that corresponds to your opinion.

SHOW ONE AT A TIME (CAROUSEL) – RANDOMIZE ORDER

15. Financially speaking, do you feel that you are better off, worse off, or about the same as your parents were at your age?

• 01 – Better off
• 02 – Worse off
• 03 – About the same

16. Thinking about the cost of living and your personal financial situation, would you say you are…

• 01 – Falling behind on your monthly expenses
• 02 – Just getting by, with no savings
• 03 – Getting ahead, with some savings
• 04 – Financially secure
• 98 – Prefer not to say

17. How would you describe your sense of belonging to your local community? Would you say it is…?

• 01 – Very strong
• 02 – Somewhat strong
• 03 – Somewhat weak
• 04 – Very weak

18. Generally speaking, which of the following best reflects your own view?

RANDOMIZE

• 01 – Most people can be trusted
• 02 – You cannot be too careful in dealing with people

19. How well-informed would you say you are about the factors that increase the risk of developing cancer?

• 01 – Extremely well-informed
• 02 – Very well-informed
• 02 – Somewhat well-informed
• 03 – Not very well-informed
• 04 – Not at all well-informed

Lifestyle profiling

20. Now, some questions about changes made to improve health. In the past 12 months, did you do anything to improve your physical health?

• 01 – Yes
• 02 – No
• 09 – Prefer not to say

21. [ASK IF Q20=1] What is the single most important change you have made?

SELECT ONE RESPONSE ONLY

• 01 - Increased exercise, sports / physical activity
• 02 - Lost weight
• 03 - Changed diet / improved eating habits
• 04 - Quit smoking
• 05 - Reduced the amount you smoked
• 06 - Quit/reduced amount of vaping
• 07 - Drank less alcohol
• 08 - Reduced stress level
• 09 - Received medical treatment
• 10 - Took vitamins
• 11 - Other
• 99 – Prefer not to say

22. Do you think there is [Q20=1 "anything else" / Q20=02,09 "anything"] you should do to improve your physical health?

• 01 – Yes
• 02 – No
• 09 – Prefer not to say

23. [ASK IF Q22=01] What is the most important thing you think you should do to improve your physical health?

SELECT ONE RESPONSE ONLY

• 01 - Start / Increase exercise, sports / physical activity
• 02 - Lose weight
• 03 - Change diet / improve eating habits
• 04 - Quit smoking
• 05 - Reduce the amount you smoke
• 06 - Quit/reduce the amount you vape
• 07 - Drink less alcohol
• 08 - Reduce stress level
• 09 - Receive medical treatment
• 10 - Take vitamins
• 11 - Other
• 99 – Prefer not to say

24. [ASK IF Q22=01] Is there anything stopping you from making this improvement?

• 01 – Yes
• 02 – No
• 09 – Prefer not to say

25. [ASK IF Q24=01] What is that?

SELECT ALL THAT APPLY

• 01 - Lack of will power / self-discipline
• 02 - Family responsibilities
• 03 - Work schedule
• 04 - Addiction
• 05 - Disability / health condition
• 06 - Too stressed
• 07 - Too costly / financial constraints
• 08 - Not available in area
• 09 - Transportation problems
• 10 - Weather problems
• 11 - Fear of not succeeding
• 11 - Other
• 99 – Prefer not to say

26. Do you intend to do anything to improve your physical health in the next year, or not?

• 01 – Yes
• 02 – No
• 09 – Prefer not to say

27. [ASK IF Q26=01] What is that?

SELECT ALL THAT APPLY

• 01 - Start / Increase exercise, sports / physical activity
• 02 - Lose weight
• 03 - Change diet / improve eating habits
• 04 - Quit smoking
• 05 - Reduce the amount you smoke
• 06 - Quit/reduce the amount you vape
• 07 - Drink less alcohol
• 08 - Reduce stress level
• 09 - Receive medical treatment
• 10 - Take vitamins
• 11 - Other
• 99 – Prefer not to say

Social Media Section [if Q7I=1]

Which social media, if any, do you use on a daily basis?

Select all that apply

• 01 – Instagram
• 02 – Twitter
• 03 – YouTube
• 04 – Snapchat
• 05 – Tumblr
• 06 – Pinterest
• 07 – Facebook
• 08 – LinkedIn
• 88 – Other Specify

Video Games Section [if Q7E=1]

29. In a typical week, how much time do you spend playing video games?

• 01 - Less than 7 hours
• 02 – 7 to 14 hours
• 03 – 15 to 20 hours
• 04 – More than 20 hours a week

Randomize each section below (Smoking to Cannabis)

Smoking Section [if Q7D=1]

30. On average, how many cigarettes a day do you smoke?

____ [RANGE 1 – 50]

31. How many of the following people in your life smoke cigarettes?

[GRID FORMAT; RANDOMIZE ROW ITEMS]

[ROWS]

• Friends
• Classmates/Co-workers
• Spouse/partner
• Family members (not including spouse/partner)
• Parents

[COLUMNS]

• 01 – None
• 02 – Some
• 03 – Most or all
• 04 – Not applicable
• 99 – Not sure

Vaping Section [if Q7C=1]

32. You mentioned that you sometimes use an e-cigarette or vaping device. Which of the following best describes how often you've used an e-cigarette or vaping device in the past 30 days?

• 01 – Every day
• 02 – At least once a week, but not daily
• 03 – Less than weekly
• 04 – I have used them, but not in the past 30 days

Alcohol Section [if Q7A=1]

33. You mentioned that you drink alcoholic beverages. Which of the following best describes how often you usually drink alcohol?

• 01 – Every day
• 02 – Several days a week
• 03 – Once a week or so
• 04 – A few times a month
• 05 – Less than once a month

Cannabis Section [if Q7B=1]

34. You mentioned that you use cannabis products. Which of the following best describes how often you usually use them?

• 01 – Every day
• 02 – Several days a week
• 03 – Once a week or so
• 04 – A few times a month
• 05 – Less than once a month

Qualitative screening

35. In the text box below, please describe what you consider to be the luckiest thing that ever happened to you. Please be as specific and detailed as possible, and explain not just what happened, but how you felt.

77 – Text box:

36. On a scale of 1 to 10, how well do the following statements express your feelings. A score of 10 means the statement describes your feelings extremely well, a score of 1 means that the statement does not describe your feelings at all, or you can use any number in between.

ALL RESPONDENTS MUST ENTER AT LEAST 50 CHARACTERS AT Q35 AND HAVE 4 OR MORE STATEMENTS SELECTED AS "7", "8", "9", OR "10" AT Q36. IF NOT RESPONDENT_STATUS=HOLD.

Respondent Characteristics

D1. Do you identify as any of the following?

SELECT ALL THAT APPLY

• 01 - An Indigenous person (First Nations, Inuit or Métis)
• 02 - A member of an ethno-cultural or a visible minority group
• 03 - A member of the LGBTQ2 community
• 04 - None of the above
• 99 - Prefer not to answer

D2. What is the highest level of formal education that you have completed?

SELECT ONE ONLY

• 01 - Some high school or less
• 02 - High School diploma or equivalent
• 03 - Registered Apprenticeship or other trades certificate or diploma
• 04 - College, CEGEP or other non-university certificate or diploma
• 05 - University certificate or diploma below bachelor's level
• 06 - Bachelor's degree
• 07 - Post graduate degree above bachelor's level
• 99 – Prefer not to say

D3. Which of the following categories best describes your current employment status?

SELECT ONE ONLY

• 01 - Working full-time, that is, 35 or more hours per week
• 02 - Working part-time, that is, less than 35 hours per week
• 03 - Self-employed
• 04 - Unemployed, but looking for work
• 05 - A student attending school full-time/part-time
• 06 - Retired
• 07 - Not in the workforce (full-time homemaker, unemployed and not looking for work)
• 97 - Other [DO NOT SPECIFY]
• 99 - Prefer not to say

D3A. [ASK IF D3=01,02,03] Which of the following best describes the sector that you work in?

SELECT ONE ONLY

• 01 - Agriculture
• 02 - Forestry, fishing, mining, quarrying, oil and gas
• 03 - Utilities
• 04 - Construction
• 05 - Manufacturing
• 06 - Wholesale and retail trade
• 07 - Transportation and warehousing
• 08 - Finance, insurance, real estate, rental and leasing
• 09 - Professional, scientific and technical services
• 10 - Business, building and other support services
• 11 - Educational services
• 12 - Health care and social assistance
• 13 - Information, culture and recreation
• 14 - Accommodation and food services
• 15 - Other services (except public administration)
• 16 - Public administration
• 77 - Other (specify)
• 99 - Prefer not to say

D4. Which of the following categories best describes your total household income? That is, the total income of all persons in your household combined, before taxes?

SELECT ONE ONLY

• 01 – Under $20,000
• 02 - $20,000 to just under $40,000
• 03 - $40,000 to just under $60,000
• 04 - $60,000 to just under $80,000
• 05 - $80,000 to just under $100,000
• 06 - $100,000 to just under $150,000
• 07 - $150,000 and above
• 99 – Not sure/Prefer not to say

D5. Are you…

• 01 - Single (never married)
• 02 - Married or common-law
• 03 - Widowed
• 04 - Separated
• 05 - Divorced
• 99 – Prefer not to say

D6. How many people, including yourself, live in your household?

__ - Number of people

• 99 – Prefer not to say

D7. (IF D6=2 OR MORE) How many people living in your household fall into each age category?

__ Under 6 years old

__ 7 to 10 years old

__ 11 to 14 years old

__ 15 to 18 years old

__ Over 18 years old

• 99 – Prefer not to say

D8. How big is the community in which you live? Would you say it is:

• A rural or small community (with a population below 30,000)
• A medium-sized community or city (with a population over 30,000 but under 500,000)
• A large urban centre (with a population over 500,000)

[SHOW IF RESPONDENT_STATUS=HOLD or <> HOLD – ALL QUALIFIED RESPONDENTS]

Congratulations, you may qualify to take part in a fun and interactive online study about your views, your experiences and your lifestyle behaviours! If you are selected, and should you accept and fully participate in this study, you will receive $200 in your local panel currency.

The online journal will start on Thursday March 14 and end on Wednesday March 20. You will need to spend about 25 minutes each day answering questions about your daily activities, thoughts and feelings. To access the online journal, you will need to either log into a specific website or download a mobile application.

Participation is completely voluntary and your decision to participate or not will not affect any dealings you may have with the Government of Canada. All information that you provide will remain anonymous and will be used for research purposes only in accordance with laws designed to protect your privacy*

INV1) Are you willing to engage with our research team online to share your views and experiences?

• Yes
• No [THANK AND COMPLETE SURVEY]

INV2) Will you be available between Thursday March 14 and Wednesday March 20 to complete this study?

• Yes
• No [THANK AND COMPLETE SURVEY]

*The personal information you provide to the Government of Canada is governed in accordance with the Privacy Act and will not be linked with your name on any document including the consent form. In addition to protecting your personal information, the Privacy Act gives you the right to request access to and correct your personal information. You also have the right to file a complaint with the Privacy Commissioner of Canada if you think your personal information has been handled improperly. The final report written by Environics will be available to the public from Library and Archives Canada (http://www.bac-lac.gc.ca/).

Please confirm for us your email address you check and use regularly so we can send you confirmation details.

If you are selected, we'll be sending information within the next week with login details and other instructions for completing your online journals. Be on the lookout for an email from our team at Recollective with the subject line: Health Canada Online Journal Project Invitation.

• FIRST NAME: _______________________
• LAST NAME: _______________________
• EMAIL ADDRESS: _________________________________

Appendix C: Qualitative discussion guide

Overall structure per day:

• Days 1 - 2: No mention of smoking at all – more broad and open conversation about lifestyle and health. Looking to see how much, if at all, smoking is mentioned in descriptions of their daily life.
• Days 3 - 5: Indirectly guiding the conversation toward topics of interest (e.g. triggers of smoking, etc.). This would mostly be done at this phase through probing and using prompts that are still fairly broad. We would expect smoking to come up for some participants in this phase, but not feel as though the study is about smoking.
• Days 6 - 7: More focused prompts and guidance toward discussing smoking in particular, especially on the final day where we would probe for more specific questions about how smoking fits into their life.

• Day 1 (Thursday): open
• Day 2 (Friday): open
• Day 3 (Saturday): structured
• Day 4 (Sunday): open
• Day 5 (Monday): structured
• Day 6 (Tuesday): structured
• Day 7 (Wednesday): wrap up/look back day

Day 1 (Thursday)

HELLO and WELCOME!

Thanks for joining me today! My name is _________ and I will be your moderator for this diary exercise. Over the next seven days, I want to get to know you and what a week in your life looks like.

I'm going to ask you about different parts of your day. I would like you to share your activities, where and who you are with, but especially your thoughts and feelings, both positive and negative. For each part of the day, there will be sub-questions. Please try to be as clear and as detailed as you can when you respond to each question and sub-question, because your answers are really important to me and will help me understand how you think and what is important to you.

Let's get started!

Ice-breaker

1. Introductions

To get us started, I want to know a little more about you.

1. First, please pick three words that describe your personality or personal style.
2. Next, imagine that you were being profiled for a magazine. Please give me a summary of what that profile would look like
3. What is your favourite way to spend your time? Be sure to tell me why.

Warm up questions - easy to answer

2. How are things going today?

I'd like to know how things are going today....

Please review the images presented below and select the image that you would say BEST represents how you feel today.

Text description: The images shows 12 small images representing different feelings.

INSTRUCTIONS: Please select the image that you think BEST captures how you are actually feeling today, drop it in the bucket below and provide a brief explanation of why you chose this image.

Diary example

A day in the life – EXAMPLE

Now, I’d like to ask you about your day to help me learn about what you did and how you felt throughout the course of the day. It’s important to me that you are very specific and detailed as you describe what, where and who you were with, but particularly what you were thinking and how you were feeling.

To show you what I'm looking for please take a look at the example below and get a sense of how to describe all of the parts of your day. This example is simplified - please be much more detailed in yours so that I really get the full picture!

Morning: As usual, my day started with a lot of brouhaha between getting prepared for work and helping the kids to get ready for the bus. I was running late and did not have time for my morning cup of coffee, which made me a little annoyed. When I finally left for work, I got stuck in traffic, but it gave me time to think about my day, and what to buy at the grocery store for the weekend birthday party for my son. I felt nervous because of an important meeting I had today with my boss, but I also used the time in the car to prepare how I was going to handle the meeting.

Lunchtime: When I arrived at work, I found some time to chat with my colleagues and laugh, which helped me to feel a little calmer before the meeting. The meeting ended up going great, which made me very relieved and happy. I decided to treat myself by getting lunch from the new pad Thai place that just opened across from work which made me feel good about myself. The rest of the day went by quickly as I had a lot of work to do before the end of the day and I was feeling tired by the time I left work.

• Afternoon
• Dinnertime
• Evening
• Bedtime

Diary – unguided long form response

3. Diary/A day in the life

Now, think back to your day. Please share with me what you did and how you felt today (if you are filling this out early in the day, please tell me about yesterday instead). Be sure to include as much detail as you can, especially about your thoughts and emotions, so I can really picture the whole thing. What did your life look and feel like today?

That's all for today – thank you so much for sharing! I look forward to hearing about your day tomorrow. Talk to you then!

Day 2 (Friday)

Warm up questions - easy to answer

1. How are things going today?

Welcome back! Again, we want to know how things are going today....

Please review the images presented below and select the image that you would say BEST represents how you feel today.

Text description: The images shows 12 small images representing different feelings.

INSTRUCTIONS: Please select the image that you think BEST captures how you are actually feeling today, drop it in the bucket below and provide a brief explanation of why you chose this image.

Diary – unguided long form response

2. Diary/A day in the life

Once again, think back to your day. Please share with me what you did and how you felt today (if you are filling this out early in the day, include yesterday as well). Be sure to include as much detail as you can so I can really picture the whole thing.

It's important to me that you are very specific and detailed as you describe what, where and who you were with (just explain your relationship to them, e.g. brother, friend, and not their name), but particularly what you were thinking and how you were feeling. What did your life look and feel like today?

Thanks again for your input today! Tomorrow, please come back to tell us about your day. We'll also have some new topics to discuss. Talk to you then!

Day 3 (Saturday)

Warm up questions - easy to answer

1. How are things going today?

Welcome to Day 3! Again today, I'd like to know how things are going for you today.

Please review the images presented below and select the image that you would say BEST represents how you feel today.

Text description: The images shows 12 small images representing different feelings.

INSTRUCTIONS: Please select the image that you think BEST captures how you are actually feeling today, drop it in the bucket below and provide a brief explanation of why you chose this image.

Diary – unguided long form response

2. Diary/A day in the life

Think back to your day. Today this exercise will be a little different. Please share with me what you did today, in each of the categories below (if you are filling this out before these things have happened today, tell me about yesterday instead). Be sure to include as much detail as you can so I can really picture the whole thing.

It's important to me that you are very specific and detailed as you describe what, where and who you were with, but particularly what you were thinking and how you were feeling. What did your life look and feel like today?

1. Where you went/spent your time this morning or afternoon
   • I was at…
   • I was doing …
   • I was with… (just explain your relationship to them, e.g. brother, friend, and not their name)
   • I felt (positive & negative)…
   • I was thinking that…
   • Anything else?
2. How you spent your time in the evening
   • I was at…
   • I was doing…
   • I was with… (just explain your relationship to them, e.g. brother, friend, and not their name)
   • I felt (positive & negative)…
   • I was thinking that…
   • Anything else?

Thanks again for your answers. See you tomorrow.

Day 4 (Sunday)

Warm up questions - easy to answer

1. How are things going today?

Welcome to day 4 of the diary exercise! Tell me how things are going today....

Please review the images presented below and select the image that you would say BEST represents how you feel today.

Text description: The images shows 12 small images representing different feelings.

INSTRUCTIONS: Please select the image that you think BEST captures how you are actually feeling today, drop it in the bucket below and provide a brief explanation of why you chose this image.

Diary – unguided long form response

2. Diary/A day in the life

Now, think back to your day. Please share with me what you did and how you felt today (if you are filling this out early in the day, include yesterday as well). Be sure to include as much detail as you can so I can really picture the whole thing.

It's important to me that you are very specific and detailed as you describe what, where and who you were with (just explain your relationship to them, e.g. brother, friend, and not their name), but particularly what you were thinking and how you were feeling. What did your life look and feel like today?

Guided probing question

3. Lifestyle

Each of us has a lifestyle that is made up of a variety of things such as how we spend our day, how we look at the world and how we see ourselves fitting into it.

Now I want you to think about how you spend your day and how you see the world and your place in it, and tell me how you would describe your lifestyle today. What are the core characteristics that you think BEST capture your lifestyle?

When you think about how you define your lifestyle today, has there been some shift in your priorities and goals over the past few years?

Thanks very much for all your answers! See you tomorrow.

Day 5 (Monday)

Warm up questions / easy to answer

1. How are things going today?

Welcome to Day 5! Again, I'd like to know how things are going today.

Please review the images presented below and select the image that you would say BEST represents how you feel today.

Text description: The images shows 12 small images representing different feelings.

INSTRUCTIONS: Please select the image that you think BEST captures how you are actually feeling today, drop it in the bucket below and provide a brief explanation of why you chose this image.

Diary – guided but unstructured long form response

2. Diary/A day in the life

Think back to your day. Please share with me what you did and how you felt today (if you are filling this out before these things have happened today, tell me about yesterday instead). Be sure to include as much detail as you can so I can really picture the whole thing.

It's important to me that you are very specific and detailed as you describe what, where and who you were with (just explain your relationship to them, e.g. brother, friend, and not their name), but particularly what you were thinking and how you were feeling. What did your life look and feel like today?

Would you characterize this as a "typical" day for you? How so? What was different?

Guided probing question

3. Challenges

I'd like to hear about the challenges you are facing in your life and the changes you are hoping to make.

1. What challenges or difficulties (if any) did you encounter today and how did you cope with them?
2. Thinking of the future, what is one thing about yourself or your life that you would most like to change, learn, do better or let go of – and why?

4. Successes

Before we wrap up today, I'd also like to hear about some recent successes in your life and how you feel they came about.

1. What successes or positive development have happened in your life lately? How did you feel about them?
2. What is one thing about yourself or your life that you would feel most proud of or that you would not want to change about yourself – and why?

Thanks again for your input today! Tomorrow, please come back to tell us more about other parts of your day. Talk to you then!

Day 6 (Tuesday)

Warm up questions - easy to answer

1. How are things going today?

Welcome to Day 6! Please review the images presented below and select the image that you would say BEST represents how you feel today.

Text description: The images shows 12 small images representing different feelings.

INSTRUCTIONS: Please select the image that you think BEST captures how you are actually feeling today, drop it in the bucket below and provide a brief explanation of why you chose this image.

Diary – unguided long form response

2. Diary/A day in the life

Now, think back to your day. Please share with me what you did today, in each of the categories below (if you are filling this out before these things have happened today, tell me about yesterday instead). Be sure to include as much detail as you can so I can really picture the whole thing.

It's important to me that you are very specific and detailed as you describe what, where and who you were with, but particularly what you were thinking and how you were feeling. A reminder when referring to others people to simply explain your relationship to them (e.g., brother, friend) but not use any names. What did your life look and feel like today?

1. Fill in the rest of the sentence with as much detail as possible…
   • Today, work (if applicable) was…
   • Today, school (if applicable) was…
   • Last night I slept…
   • From a health perspective, today I've been eating…
   • My overall energy level is…
2. Think of a break that you took during the day, for example, a mid-morning or mid-afternoon break
   • I was at…
   • I was doing …
   • I was with… (just explain your relationship to them, e.g. brother, friend, and not their name)
   • I felt (positive and/or negative)…
   • In my mind…
3. Think of a social interaction that you had today
   • I interacted with…(just explain your relationship to them, e.g. brother, friend, and not their name)
   • I was at…
   • Feelings about the interaction (positive and/or negative)…
   • In my mind…

Guided probing questions

3. Stress

Let's talk about what you do/how you typically react in different scenarios in your day-to-day life, and why.

Please complete the sentences below:

When you hear the word "stress", what does it mean to you?

I know I am stressed when…

When I'm stressed, I __________________, because _______________________

4. Aspirations

Let's talk about what some of your aspirations are. By aspiration, we mean a hope or ambition of achieving something.

• In general, in the next 3 months, my aspiration is to…
• In the next 6 months, my aspiration is to…
• In the next year, my aspiration is to…

5. Health aspirations

Today I'm also curious about your health.

• When thinking about my health, in the next 3 months, my aspiration is to…
• When thinking about my health, in the next 6 months, my aspiration is to…
• When thinking about my health, in the next year, my aspiration is to…

Thanks again for your input! Tomorrow is our last day together! Talk to you then!

Day 7 (Wednesday)

Warm up questions / easy to answer

1. How are things going today?

Welcome to day 7! Today is our last day together and one last time, I'd like to know how things are going for you today.

Please review the images presented below and select the image that you would say BEST represents how you feel today.

Text description: The images shows 12 small images representing different feelings.

INSTRUCTIONS: Please select the image that you think BEST captures how you are actually feeling today, drop it in the bucket below and provide a brief explanation of why you chose this image.

Diary – unguided long form response

2. Diary/A day in the life

Please briefly look back at your diary entries over the past week. Looking back at the last seven days we have been together, is there:

Anything about those last seven days that stands out to you?

Anything that surprised you?

Anything else you would like to share?

Guided probing question

3. Smoking

You mentioned in the survey that you smoke every day. Please tell me about how smoking fits into your life.

In the online survey, you indicated you are a smoker. In your daily diary, you shared a lot of detailed information about your day, what you did and what you were thinking and feeling, but smoking rarely came up. Please share your thoughts on why smoking was not part of what you wrote about each day.

Unguided response

4. Health-related behaviours

I'd like to hear your views on things like cigarette smoking, vaping (e-cigarettes), cannabis (marijuana) use and alcohol use. For each of these topics, I'd like to know what you think of them, and when you yourself do them, if applicable:

1. To me, smoking is…
2. To me, vaping is…
3. To me, cannabis is…
4. To me, alcohol is…
5. I smoke cigarettes when…
6. I vape (if applicable) when…
7. I use cannabis (if applicable) when…
8. I drink alcohol (if applicable) when…

Follow up…. End and thank.

Thank you very much for your time! Is there anything else you want to add based on what we've discussed over the past 7 days?

Thanks again for everything… hope your next week is great.