Health Care Providers' Views and Experiences with Smoking Cessation and Alternative Nicotine Products - Final Report

Prepared for: Health Canada
Supplier Name: Phoenix SPI
Contract Number: HT372-192432-001_CY
Contract Value: $174,669.58 (including HST)
Award Date: 2019-06-07
Delivery Date: 2019-10-12
Registration Number: POR 019-19

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.

Health Care Providers’ Views and Experiences with Smoking Cessation and Alternative Nicotine Products
Final Report

Prepared for Health Canada
Supplier name: Phoenix Strategic Perspectives Inc.
November 2019

This public opinion research report presents the results of an online survey conducted with 1,125 Canadian health care providers (HCPs) between August 2 and 30, 2019.

This publication may be reproduced for non-commercial purposes only. Prior written permission must be obtained from Health Canada. For more information on this report, please contact Health Canada at:

HC.cpab.por-rop.dgcap.SC@canada.ca or at:

Communications and Public Affairs Branch
Health Canada
200 Eglantine Driveway, Jeanne Mance Building
AL 1915C, Tunney’s Pasture
Ottawa, Ontario  K1A 0K9

Catalogue number:
H14-338/2020E-PDF

International Standard Book Number (ISBN):
978-0-660-32599-6

Related publications (registration number: POR 019-19):
Catalogue number H14-338/2020F-PDF (Final report, French)
ISBN 978-0-660-32600-9

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

Cette publication est aussi disponible en français sous le titre : Points de vue et expériences des prestataires de soins de santé sur l’arrêt du tabac et les produits alternatifs à la nicotine

Table of Contents

• Executive Summary
• Introduction
  1. Background and Objectives
  2. Methodology
  3. Notes to Reader
• Profile of Survey Respondents
• Detailed Findings
  1. Experience with patients who use tobacco products
  2. Experience with patients who use vaping products
  3. Comfort talking to patients about tobacco and vaping products
  4. Knowledge and attitudes toward tobacco, nicotine, and vaping products
  5. Smoking cessation and vaping products resources
• Conclusions and Observations
• Appendix
  1. Technical Specifications
  2. Survey Questionnaire

Figures

• Figure 1: Primary profession
• Figure 2: Primary work setting
• Figure 3: Location of primary place of work
• Figure 4: Community size where primary place of work is located
• Figure 5: Length of time working in primary work setting
• Figure 6: Length of time practicing in profession
• Figure 7: Stage of career
• Figure 8: Patient populations typically served
• Figure 9: Smoking status
• Figure 10: Values
• Figure 11: Frequency of seeing patients who use tobacco products
• Figure 12: HCPs who see patients multiple times a day who use tobacco products
• Figure 13: Importance of talking about cessation with patients who smoke
• Figure 14: Proportion of HCPs who consider talking about smoking cessation to be very important
• Figure 15: Percentage of HCPs’ patients who smoke cigarettes
• Figure 16: Percentage of HCPs’ patients who smoke cigarettes [Differences by HCP]
• Figure 17: Length of time HCP has been seeing/treating patients who smoke
• Figure 18: Length of time HCP has been seeing/treating patients who smoke [Differences by HCP]
• Figure 19: Patient records
• Figure 20: Patient record files [Differences by HCP]
• Figure 21: Proportion that say a flag prompts a discussion about smoking status
• Figure 22: Proportion that say a flag prompts a discussion about smoking status [Differences by HCP]
• Figure 23: Documentation of patients’ smoking status at every visit
• Figure 24: HCPs who document their patients’ smoking status at every visit [Differences by HCP]
• Figure 25: Frequency of discussing smoking cessation with patients
• Figure 26: Frequency of HCP raising smoking cessation with patients [Differences by HCP]
• Figure 27: Patient populations with whom HCPs discuss smoking cessation
• Figure 28: Patient populations with whom HCPs discuss smoking cessation [Differences by HCP]
• Figure 29: Other patient populations with whom HCPs discuss smoking cessation
• Figure 30: Discussion of smoking cessation with pregnant women [Differences by HCP]
• Figure 31: Frequency of patients wanting to discuss smoking cessation compared to one year ago
• Figure 32: HCPs who indicate that patients want to discuss smoking cessation more often, compared to a year ago
• Figure 33: Advice HCPs give patients about quitting smoking
• Figure 34: HCPs who recommend a drug therapy for smoking cessation
• Figure 35: HCPs who provide a prescription to a drug therapy for smoking cessation
• Figure 36: Proportion of HCPs that schedule appointments to proactively discuss smoking cessation
• Figure 37: Proportion of HCPs that schedule appointments to proactively discuss smoking cessation
• Figure 38: Frequency of follow-up with patients quitting smoking
• Figure 39: HCPs who follow-up with patients every visit, or almost every visit, once they start the process of quitting smoking
• Figure 40: Reasons given by patients to explain a relapse
• Figure 41: Top 5 reasons given by patients to their HCP to explain a relapse [Differences by HCP]
• Figure 42: Patients’ definition of “successfully” quitting smoking
• Figure 43: Patients definition of “successfully” quitting smoking [Differences by HCP]
• Figure 44: HCPs’ definition of “successfully” quitting smoking
• Figure 45: Reasons HCPs do not consider switching from cigarettes to alternative nicotine products as “successfully” quitting smoking
• Figure 46: HCPs’ definition of “successfully” quitting [Differences by HCP]
• Figure 47: HCPs who say “The person is still addicted to/dependent on nicotine”
• Figure 48: Challenges encountered talking to patients about quitting smoking
• Figure 49: Top 3 challenges HCPs encounter when talking to patients about quitting smoking
• Figure 50: Estimated percentage of patients using vaping products
• Figure 51: Proportion of health care providers who don’t know the number of patients who vape
• Figure 52: Frequency of patients asking HCPs about vaping products
• Figure 53: Frequency of patients asking HCPs about vaping products [Differences by HCP]
• Figure 54: Frequency of patients asking questions about vaping products compared to one year ago
• Figure 55: Frequency of patients asking HCPs about vaping products compared to a year ago [Differences by HCP]
• Figure 56: Advice HCPs give to patients about vaping products
• Figure 57: Top 3 reasons health care providers give to patients about vaping products
• Figure 58: Level of comfort talking to patients about cannabis, alcohol, tobacco, opioids and vaping
• Figure 59: Proportion of health care providers who are comfortable talking to patients about cannabis, alcohol, tobacco, opioids and vaping [Differences by HCP]
• Figure 60: HCPs’ self-assessed knowledge of smoking cessation and vaping products
• Figure 61: Knowledge of smoking cessation [Differences by HCP]
• Figure 62: Knowledge of vaping products [Differences by HCP]
• Figure 63: HCPs familiarity with tobacco, nicotine and vaping products
• Figure 64: HCPs’ familiarity with tobacco, nicotine and vaping products [Differences by HCP]
• Figure 65: HCPs’ familiarity with, and knowledge of, vaping products
• Figure 66: Perceived harmfulness of tobacco, nicotine and vaping products
• Figure 67: Perceived harmfulness of tobacco, nicotine and vaping products [Differences by HCP]
• Figure 68: Knowledge of vaping products and perceived harm of vaping WITH nicotine
• Figure 69: Knowledge of vaping products and perceived harm of vaping WITHOUT nicotine
• Figure 70: Familiarity with vaping products and perceived harm of vaping products WITH nicotine
• Figure 71: Relationship between familiarity of vaping products and perceived harm of vaping WITHOUT nicotine
• Figure 72: Perceived impact of switching to vaping on a cigarette smoker’s health
• Figure 73: Perceived impact of switching to vaping products with nicotine on a cigarette smoker’s health [Differences by HCP]
• Figure 74: HCPs' knowledge of vaping products and views on switching to vaping with nicotine
• Figure 75: HCPs' knowledge of vaping products and views on switching to vaping without nicotine
• Figure 76: Perceived impact of switching to vaping products without nicotine on a cigarette smoker’s health [Differences by HCP]
• Figure 77: Reasons switching to vaping will improve a smoker’s health
• Figure 78: Reasons switching to vaping will worsen a smoker’s health
• Figure 79: Reasons switching to vaping will have no impact on a smoker’s health
• Figure 80: HCPs’ attitudes toward tobacco, nicotine and vaping products
• Figure 81: Proportion of HCPs who agree with the following statements about tobacco, nicotine and vaping products
• Figure 82: Proportion of HCPs who disagree with the following statements about tobacco, nicotine and vaping products
• Figure 83: HCPs’ views on tobacco as a government priority
• Figure 84: Health care professions who say tobacco should continue to be a high government priority
• Figure 85: Sources of information about smoking cessation and vaping products
• Figure 86: Top five sources for information about smoking cessation and vaping products
• Figure 87: Sources of information about smoking cessation [Differences by HCP]
• Figure 88: Sources of information about vaping products [Differences by HCP]
• Figure 89: Health Canada resources consulted in the past few years
• Figure 90: Top 3 Health Canada resources consulted in the past few years [Differences by HCP]
• Figure 91: Length of time since HCP last consulted Health Canada’s website
• Figure 92: Length of time since HCP last consulted Health Canada’s website [Differences by HCP]
• Figure 93: Frequency of sending patients home with smoking cessation information
• Figure 94: HCPs who always, or often, send patients home with smoking cessation information [Differences by HCP]
• Figure 95: Type of smoking cessation information provided to patients
• Figure 96: Top 3 types of smoking cessation information HCPs provide to patients [Differences by HCP]
• Figure 97: Effective methods for communicating about smoking cessation with patients
• Figure 98: Top methods recommended by HCPs for communicating about smoking cessation  [Differences by HCP]
• Figure 99: Suggestions for how Health Canada can help HCPs encourage patients to quit smoking
• Figure 100: Top suggestion for how Health Canada can help HCPs encourage patients to quit smoking [Differences by HCP]
• Figure 101: Suggestions for how Health Canada can help HCPs encourage patients to switch to vaping products
• Figure 102: Top suggestions for how Health Canada can help HCPs encourage patients to switch to vaping products [Differences by HCP]

Executive Summary

Tobacco use is the leading cause of preventable death in Canada. It is a contributing factor to serious chronic diseases, such as cancer, respiratory ailments, and heart disease. In order to reduce the burden of disease and disability, the Government of Canada announced a target of less than 5% tobacco use by 2035.  The Strategy will feature broad, population-based approaches needed to achieve the ambitious target, and targeted approaches focussed on specific populations with high levels of tobacco use.

Health care providers (HCPs) are considered by Canadians as a credible source of information when seeking advice about health in general, as well as about quitting smoking. As such, they have a role to play in realizing this objective. The purpose of this research, therefore, was to quantify the knowledge, attitudes, behaviours, and perceptions among health care providers on smoking cessation and alternative nicotine products. The primary objective was to gather information on the perspectives and experiences of HCPs with respect to alternative nicotine products.

An online survey was administered to 1,125 HCPs between August 2 and August 30, 2019. To be eligible to complete the survey, HCPs needed to see patients who use tobacco products. The survey averaged 20 minutes to complete. The sample was drawn from SmartPoint Research's online panel of HCPs. Panellists were invited to participate in the survey through an email invitation which contained a password-protected URL to access the survey. Survey data was weighted by region and profession using the Canadian Institute for Health Information's (CIHI) Health Workforce data. Surveys that use samples drawn from online panels cannot be described as statistically projectable to the target population. No estimates of sampling error can be calculated because the sample is based on those who initially self-selected for participation in the panel.

Key findings include:

• Virtually all HCPs consider it important to discuss smoking cessation with patients who smoke.
  • There is virtual unanimity that it is at least somewhat important for health care providers to discuss smoking cessation with their patients who smoke cigarettes. Moreover, 78% of the health care providers surveyed believe that discussing smoking cessation with patients is very important.
• Nearly three-quarters of health care professionals believe that flagging a patient's record for smoking status would prompt a discussion about smoking.
  • 52% of the HCPs surveyed say that their patients who smoke have a flag in their record file about their smoking status. Asked if such a flag does or would prompt a discussion about their patients' smoking status, 73% said yes.
  • 49% of HCPs who flag the smoking status of patients in their files document a patient's smoking status at every visit. Fewer (20%) schedule appointments with patients specifically to discuss their smoking status.
  • The likelihood of proactively scheduling appointments with patients varies greatly by type of practitioner: 49% of family/general practitioners proactively meet with patients to discuss smoking status compared to just 12% of specialists who reported doing so.
• Patients rarely raise the topic of smoking cessation with their health care provider. Health care providers are under the impression that patients are not receptive to advice about quitting smoking.
  • Frequent discussions with patients about smoking cessation are much more likely to be initiated by HCPs than their patients. Just 6% of HCPs say that their patients raise the topic of smoking cessation at every visit or almost every visit. 
  • Occasional discussions about smoking cessation are almost equally likely to be initiated by HCPs (37%) or their patients (39%).
  • The most frequently mentioned challenge in talking to patients about quitting smoking is the impression that patients are not receptive to receiving advice or help to quit.
• Many HCPs follow-up with patients once they start the process of quitting smoking.
  • Once patients have started the process of quitting smoking, 20% of HCPs follow-up at every visit, 30% at almost every visit, 4% annually, and 9% once only and then not again.
  • 21% said they never follow-up with patients once they start the process of quitting smoking.
• Stress is the main factor identified by patients to explain a smoking relapse.
  • Stress was the most frequently mentioned reason for a smoking relapse.Three-quarters of HCPs said that, when a patient relapses, they point to a stressful life event or stress in general as the reason for the relapse.
  • Other reasons mentioned by patients include having a spouse/partner or family member who still smokes (57%), depression or mental health (47%), and thinking they could smoke occasionally (38%).
• Just over three-quarters of HCPs do not consider using another product containing nicotine as successfully quitting smoking.
  • Fewer than one-quarter (23%) of HCPs would consider a patient to have successfully quit smoking if this patient completely switched from smoking cigarettes to using another product containing nicotine.
  • The main reason given by HCPs to explain why switching from smoking cigarettes to using another product containing nicotine would not be considered a successful quit attempt was that these patients are still dependent upon/addicted to nicotine.
• Health care providers are receiving more questions about vaping products now than a year ago. The main advice about vaping products health care providers give patients is that the long-term health effects of vaping products are unknown.
  • 54% of HCPs do not know what percentage of their patients use vaping products.
  • While 61% of HCPs said their patients rarely or never ask about vaping products, respondents were three times more likely to say that this is happening more often now than less often, compared to one year ago (31% versus 10%).
  • Two pieces of advice vis-à-vis vaping products were identified by a majority of HCPs: 67% advise patients that the long-term health effects of vaping are unknown, and 55% advise them of the potential risks and harms of vaping.
• Most HCPs reported a high degree of comfort talking to patients about smoking cessation and tobacco use.
  • 96% of HCPs are somewhat or very comfortable talking to patients about smoking cessation and 94% are somewhat or very comfortable talking to patients about tobacco use. Far fewer expressed comfort talking about vaping products: 20% are very comfortable and 35% are somewhat comfortable doing this.
• Vaping products with nicotine were perceived to be more harmful in comparison to vaping products without nicotine. Views on the health impact of quitting smoking and switching to vaping tend to be mixed.
  • 76% of HCPs believe that vaping products with nicotine are at least moderately harmful; just 53% believe this about vaping products without nicotine. 
  • 42% think that completely switching to vaping with nicotine from cigarettes will improve the health of a smoker a little (34%) or a lot (8%), while 60% think that switching to vaping without nicotine will improve the health of a smoker a little (36%) or a lot (24%).
• HCPs believe that tobacco should continue to be a high priority for the Government of Canada, and nearly half believe the health risk posed by tobacco has increased in recent years..
  • 9 in 10 HCPs think that tobacco should continue to be a high government priority.
  • Nearly half (47%) agree that the health risk to Canadians posed by tobacco has increased in the past five years.
• Health Canada is the main resource consulted by health care providers when searching for information about smoking cessation and vaping.
  • 75% of HCPs consult Health Canada for information about smoking cessation and 47% do so for information about vaping products.
  • Asked specifically which Health Canada resources, if any, they have consulted over the past few years, HCPs were most likely to access the general departmental website (43%), followed by Health Canada's Quit Smoking Services and Information (31%), and Quit4Life (28%).

The contract value was $174,669.58 (including HST).

Political Neutrality Certification

I hereby certify, as a Senior Officer of Phoenix Strategic Perspectives, 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 contain any reference to electoral voting intentions, political party preferences, standings with the electorate, or ratings of the performance of a political party or its leader.

Signed:

Alethea Woods, President
Phoenix Strategic Perspectives Inc.

Introduction

Phoenix Strategic Perspectives (Phoenix SPI) was commissioned by Health Canada to conduct an online survey of health care providers.

1. Background and Objectives

Tobacco use is the leading cause of preventable death in Canada. It is a contributing factor to serious chronic diseases, such as cancer, respiratory ailments, and heart disease. Approximately fifty percent of long-term smokers die prematurely from smoking-related diseases, amounting to over 45,000 deaths attributable to smoking in Canada each year.

In order to reduce the burden of disease and disability, the Government of Canada announced a target of less than 5% tobacco use by 2035.¹ The Strategy will feature broad, population-based approaches needed to achieve the ambitious target, and targeted approaches focussed on specific populations with high levels of tobacco use. To realize this objective, Health Canada needs to prevent initiation of tobacco use as well as support smoking cessation.

Health care providers (HCPs) are considered by Canadians as a credible source of information when seeking advice about health in general, as well as about quitting smoking. However, Health Canada has limited data on Canadian health care provider awareness, perceptions, beliefs, attitudes, knowledge and behaviours regarding smoking cessation and alternative nicotine products with their patients. For this reason, Health Canada commissioned an online survey to quantify the knowledge, attitudes, behaviours, and perceptions among health care providers on smoking cessation and alternative nicotine products.

The primary objective of this research was to gather information on the perspectives and experiences of HCPs with respect to alternative nicotine products. The research was needed to understand how HCPs communicate with patients about smoking cessation and alternative products and what tools and resources HCPs are aware of/utilize. Specifically, the research was designed to:

• determine HCPs’ knowledge, attitudes and beliefs on tobacco and nicotine products;
• assess HCPs’ experience with patients asking about;
  • Alternatives to tobacco smoking
  • Efficacy of non-tobacco nicotine products
• understand HCPs comfort with discussing smoking cessation strategies with patients;
• uncover what documents, tools or other resources HCPs currently use to find:
  • General information on tobacco cessation and other nicotine products
  • Tips to encourage/convince their patients to begin a smoking cessation process
  • Information on alternative nicotine products
• uncover which messages/strategies HCPs use to discuss alternative nicotine products with their patients; and
• determine if HCPs have unmet needs for discussing smoking cessation and tobacco alternatives.

This research will help Health Canada understand gaps in information that health care providers need to have meaningful discussions with their patients about smoking cessation and alternative nicotine products.

2. Methodology

An online survey was administered to 1,125 HCPs between August 2 and August 30, 2019. The survey averaged 20 minutes to complete. The sample was drawn from SmartPoint Research’s online panel of HCPs. Panellists were invited to participate in the survey through an email invitation which contained a password-protected URL to access the survey. Survey data was weighted by region and profession using Canadian Institute for Health Information (CIHI) Health Workforce data. Surveys that use samples drawn from online panels cannot be described as statistically projectable to the target population. No estimates of sampling error can be calculated because the sample is based on those who initially self-selected for participation in the panel.

3. Notes to Reader

• In the report, the acronym “HCP” is used to refer to health care providers.
• All results are expressed as percentages, unless otherwise noted. Throughout the report, percentages may not always add to 100 due to rounding and/or multiple responses being offered by respondents.
• At times, the number of respondents changes in the report because questions were asked of sub-samples of the survey population. Accordingly, readers should be aware of this and exercise caution when interpreting results based on smaller numbers of respondents.
• Where base sizes are reported in tables and graphs, they reflect the actual number of respondents who were asked the question.
• Demographic and other subgroup differences are identified in the report. When reporting subgroup variations, only differences that are significant at the 95% confidence level and that pertain to a subgroup sample size of more than n=30 are discussed in the report. If one or more categories in a subgroup are not mentioned in a discussion of subgroup differences (for example, if two out of four age groups are compared), it can be assumed that significant differences were found only among the categories reported.
• The survey questionnaire can be found in the Appendix along with more information about the technical specifications of research.

Profile of Survey Respondents

This section provides information about respondents and their work environments.

Primary professions of the surveyed HCPs

A total of 1,125 HCPs were surveyed for this study: 44% were family/general practitioners, 22% were pharmacists, 23% were nurses, and 11% were specialty physicians. Please note that, in the context of this study, the nursing profession includes registered nurses and nurse practitioners, and specialty medicine includes cardiologists, respirologists and obstetricians/gynecologists. When weights are applied to the data to bring the survey sample in proportion to the population of HCPs in Canada, 7% of the sample represents family/general practitioners, 8% pharmacists, 78% nurses, and 7% specialty physicians.

Figure 1: Primary profession

Two in five HCPs work in a hospital setting

The largest proportion of HCPs surveyed (41%) identified their primary work setting as a hospital. This was followed at a distance by a family medicine clinic (16%), a community health centre (11%), a pharmacy (7%), and a specialized health centre (6%). Smaller numbers (4% or less) work in a range of settings which include a multi-disciplinary clinic, solo practice, public health clinic, long-term care residence, home care, and walk-in-clinic/urgent care.

More than half of HCPs work in central Canada

Over half of respondents work in central Canada (36% in Ontario and 23% in Quebec). Nineteen percent work in the Prairies, 13% in British Columbia, and 8% in the Atlantic region.

Nearly two-thirds of HCPs surveyed work in large urban centres

Nearly two-thirds of HCPs (63%) described the area in which their primary place of work is located as a large urban population centre. Approximately one in five (21%) described it as a medium population centre, 9% as a small population centre, and 6% as a rural location.

Six in ten HCPs have been working in their primary work setting for more than ten years

The majority of HCPs (59%) have been working in their primary work setting for over ten years, including 38% who have been working in this setting for more than 15 years.

More than half of HCPs have been practicing their profession for more than 15 years

More than half (57%) of the HCPs surveyed said they have practicing their profession for more than 15 years.

Just over half of HCPs surveyed consider themselves to be in the middle of their career

Slightly more than half of the HCPs surveyed (56%) self-describe as being in mid-career in terms of practicing their profession. Approximately one-third (32%) describe themselves as close to retirement and one in ten (10%) describe themselves as just starting their career.

More than three in four  HCPs serve patients with chronic illnesses and seniors

The majority of HCPs identified patients with chronic illnesses (86%) and seniors (78%) as the populations they typically serve. In addition, 68% of HCPs identified lower income communities, and 52% identified acute care patients as their typical patients. Fewer than half, but a substantial minority, identified new Canadians (43%), Indigenous patients (40%), and patients who speak neither French nor English (37%) as their typical patient population.²

Most HCPs are non-smokers

Nearly all HCPs (94%) identified themselves as non-smokers at the present time (37% of whom identified themselves as having smoked cigarettes in the past).

Most HCPs value accountability and open-mindedness, followed by happiness

At the end of the survey, HCPs were asked to rate their level of agreement or disagreement with these statements:

• [Accountability] It’s important to own your actions, mistakes, and current life situation.
• [Happiness] It’s more important to be happy than to be wealthy.
• [Traditionalist] I strive to follow the traditions handed down to me from my family or religion.
• [Pursuit of joy] Life is short, so I do things that bring me joy.
• [Honesty] It’s important to be honest even if you risk hurting someone by telling the truth.
• [Practical] I prefer to do work that isn’t overly interesting but pays well
• [Empathetic] I like to put myself in another person's shoes and to imagine how I would have felt in his/her place
• [Open-mindedness] If you want to learn and grow in life, it is essential to meet and converse with different kinds of people, who come from all kinds of backgrounds
• [Materialistic] I often buy things just because they are beautiful, whether or not they are practical

Health care providers were most likely to agree that It’s important to own your actions, mistakes, and current life situation, that If you want to learn and grow in life, it is essential to meet and converse with different kinds of people, who come from all kinds of backgrounds, and that It’s more important to be happy than to be wealthy. Conversely, they were least likely to agree with the statement, I often buy things just because they are beautiful, whether or not they are practical, and I prefer to do work that isn’t overly interesting but pays well.

Nurses were more likely to agree with the following statements:

• 92%: If you want to learn and grow in life, it is essential to meet and converse with different kinds.
• 86%: It’s more important to be happy than to be wealthy.
• 81% Life is short, so I do things that bring me joy.
• 80%: I like to put myself in another person’s shoes and to imagine how I would have felt.

Pharmacists (24%) and family and general practitioners (19%) were more likely to agree with the following statement: I prefer to do work that isn’t overly interesting but pays well.

Health care providers who agree with the statement I prefer to do work that isn’t overly interesting but pays well were most likely to consider someone who switched from smoking cigarettes to using another product containing nicotine to have successfully quit smoking.

Detailed Findings

1. Experience with patients who use tobacco products

This section reports on health care providers’ experience with patients who use tobacco products.

Nearly two-thirds see patients who use tobacco products multiple times a day

Nearly two-thirds (65%) of HCPs said that, on average, they see patients who use tobacco products³ multiple times a day. Just over one-quarter (26%) see patients who use tobacco products at least a few times a week, including 8% who see such patients once a day. The rest (8%) see patients who use tobacco products about once a week or less.⁴

The likelihood of seeing patients who use tobacco products multiple times a day was higher among:

• HCPs who practice in Ontario (70%) and B.C. (68%) compared to Atlantic Canada (51%).
• Those who practice in rural communities (87%) rather than large urban centres (62%).
• Those who have been practicing for less than 6 years (82%).

Family and general practitioners (85%) as well as specialists (82%) were more likely than nurses (63%) and pharmacists (62%) to report seeing patients who use tobacco products multiple a day.

Virtually all HCPs consider it important to discuss smoking cessation with patients who smoke

There is virtual unanimity among HCPs that it is at least somewhat important for them, as health care providers, to discuss smoking cessation with their patients who smoke cigarettes. Moreover, over three-quarters (78%) described this as very important.

The likelihood of saying that talking about smoking cessation with patients is very important was higher among:

• HCPs who practice in Quebec (88%) and Atlantic Canada (84%).
• Those who have been practicing for less than 6 years (85%).
• Those with patients in lower income communities (81%) and with chronic illness (81%).

Family/general practitioners (95%), as well as specialty physicians (95%), were more likely than nurses (75%) and pharmacists (83%) to attribute high importance to discussing smoking cessation with patients who smoke.

A majority of HCPs estimate that fewer than half of their patients smoke cigarettes

The majority of HCPs (55%) estimate that fewer than half of their patients smoke cigarettes. Nearly identical proportions (just over one-quarter each) estimate the proportion to be under 25% and between 25-49%. By contrast, approximately three in ten (29%) estimate that half or more of their patients smoke cigarettes, including one in ten estimating the proportion at 75% or more. Seventeen percent of HCPs say they do not know the proportion of their patients who smoke cigarettes.

Family and general practitioners were significantly more likely than other HCPs to estimate that less than one-quarter of their patients smoke cigarettes. Nurses are more likely to estimate that 50% (or more) of their patients smoke cigarettes.

Figure 16: Percentage of HCPs’ patients who smoke cigarettes [Differences by HCP]

Almost half of HCPs have been treating patients who smoke for more than 15 years

Almost half of HCPs who have been practicing for at least one year (47%) said they have been seeing and/or treating patients who smoke cigarettes for more than 15 years. Similar proportions have been seeing and/or treating patients who smoke for six to 10 years (19%) and 11 to 15 years (20%). The rest have been doing so for one to five years (12%) or less than a year (2%).

Generally, the longer HCPs have been practicing, the longer they have been treating and/or seeing patients who smoke. Eighty-one percent of those who have been seeing/treating patients who smoke for more than 15 years have been practicing for more than 15 years (most of the remainder have been seeing smokers for 11-15 years). At the other end of the spectrum, 92% of those who have been seeing/treating patients who smoke for one to five years have been practicing for under six years (the remainder—8%—have been seeing smokers for less than one year).

Pharmacists, as well as nurses, are more likely than other HCPs to have said they have been seeing and/or treating patients who smoke cigarettes for 11 to 15 years.

Figure 18: Length of time HCP has been seeing/treating patients who smoke [Differences by HCP]

Half of HCPs flag smoking status in a patient’s record file

Approximately half (52%) of the HCPs surveyed said that their patients who smoke have a flag in their patient record file about their smoking status (43% said no and 5% did not know).

The following HCPs were more likely to say their patients who smoke have a flag in their file about their smoking status:

• Those working in family medicine clinics (79%).
• Those practicing in Quebec (71%).
• Those who have been practicing for less than 6 years (70%).
• Those who said that under 25% of their patients smoke cigarettes (62%).

Family and general practitioners are significantly more likely than other HCPs to flag a patient’s record file to indicate their smoking status. Almost three-quarters (73%) do so compared to 51% of nurses, 50% of specialists, and 46% of pharmacists.

Nearly three-quarters of HCPs surveyed say that flagging a patient record for smoking status does or would prompt a discussion about smoking

When respondents were asked if having a flag in the patient record file of smokers does, or would, prompt a discussion about the patient’s smoking status, nearly three-quarters (73%) said yes (17% said no and 9% did not know).

Having a flag in a patient’s file is more likely to trigger a discussion about smoking status with HCPs who say they are knowledgeable about smoking cessation (76%) and HCPs who have been working in their primary work setting for less than 11 years (less than six years, 81% and six to ten years, 77%). In addition, HCPs who report that under 25% of their patients smoke were more likely to have a flag in their patient record compared to HCPs those who say that 25% or more of their patients smoke.

Approximately eight in ten family and general practitioners (79%) and pharmacists (78%) indicate that flagging a patient’s record file to reflect their smoking status does/would trigger a discussion about their smoking status, compared to 73% of nurses and 71% of specialists. These differences, however, are not statistically significant.

Almost half document patients’ smoking status at every visit

HCPs who said having a flag in their patient record files would prompt a discussion about smoking (n=853) were divided when asked if a patient’s smoking status is documented at every visit: 49% said yes and 47% said no. A few (4%) said they did not know.

Just over two-thirds (68%) of specialty physicians said they document their patients’ smoking status at every visit. This is a statistically significant difference when compared to other health care providers.

Patients rarely raise the topic of smoking cessation with their health care provider

Frequent discussions with patients about smoking cessation are much more likely to be initiated by HCPs than their patients. Over half the HCPs surveyed (56%) indicated that discussions about smoking cessation with patients at every visit or almost every visit originate with them (compared to only 6% who said their patients raise the topic with this frequency). Conversely, only 7% of HCPs said they ‘rarely’ or ‘never’ raise this topic with their patients, while 55% said their patients ‘rarely’ or ‘never’ raise the topic. Occasional discussions about smoking cessation are almost equally likely to be initiated by HCPs (37%) or their patients (39%).

The likelihood of raising the topic of smoking cessation with a patient at almost every visit or every visit was higher among HCPs in the Prairies (67%). In addition, those who see patients that use tobacco products daily were more like to raise smoking cessation at almost every visit or every visit (62%). Health care providers who sometimes raise the topic of smoking cessation were more likely to see patients a few times a week (51%) than daily (33%).

When compared to other health care providers, specialists were more likely to say they discuss smoking cessation at every visit or almost every visit with patients who smoke (87% of which do so).

The likelihood of saying they sometimes raise the topic of smoking cessation with patients was highest among pharmacists (63%), followed by family/general practitioners (37%) and nurses (37%), and was lowest among specialists (10%).

HCPs discuss smoking cessation with a variety of patient populations

Approximately half or more of HCPs talk about smoking cessation with youth, young adults, adults, seniors, and patients with a chronic health condition.

The patient population that HCPs are most likely to discuss smoking cessation with is adults, while the population HCPs are least likely to talk about smoking cessation with is youth. HCPs are almost equally likely to talk about smoking cessation with female and male patients in each of these patient populations.

The likelihood of talking to all of these patient populations was higher among family/general practitioners.

Roughly two-thirds of HCPs (67%) said they discuss smoking cessation with other patient populations. Over half (56%) talk about smoking cessation with pregnant women—note: respondents were explicitly asked about pregnant women and then had the opportunity to volunteer other patient populations with whom they discuss smoking cessation.

Nine in ten family/general practitioners discuss smoking cessation with pregnant women. This is significantly higher than other health care providers: 65% of pharmacists, 58% of specialists, and 52% of nurses.

Most HCPs report no change in the frequency of patients wanting to discuss smoking cessation

Nearly three-quarters of HCPs (74%) think there has been no change over the past year in the frequency with which their patients want to discuss smoking cessation. Thirteen percent think this is happening more often than a year ago, one in 10 think it is happening less often, and 4% do not know.

Just over one in five (22%) pharmacists said that their patients have been wanting to discuss smoking cessation with them more often now than one year ago. This difference is significant when compared to family/general practitioners and nurses.

Informing patients of the health benefits of quitting smoking is the leading smoking cessation advice given by health care providers

The piece of advice most HCPs offer their patients is that quitting smoking is good for their health (82%). Other types of advice or support offered by a majority of HCPs include providing general advice, such as finding a support system and setting a quit date (66%), recommending nicotine replacement therapy products (60%), and advising patients to talk to their family physician⁵ (55%). In addition, 49% provide a pamphlet or self-help resource on smoking cessation, 44% recommend a drug therapy for smoking cessation, and 42% provide nicotine replacement therapy products.

Those who offer a referral to a smoking cessation program mentioned the following when prompted to do so: Alberta Quits, QuitNow BC, the Centre for Addiction and Mental Health’s (CAMH) Smoking Treatment for Ontario Patients (STOP) Program, Ligne J'ARRÊTE / Défi J'arrête, j'y gagne!, community health unit programs, hospital in-house programs, and smokers’ helplines.

HCPs working in Atlantic Canada (96%) were the most likely to say they tell patients that quitting smoking is beneficial to their health and HCPs in Quebec were more likely to recommend a drug therapy for smoking cessation (61%). Compared to HCPs in Ontario (33%), those working in the Prairies and B.C. (48%) were more likely to provide Nicotine Replacement Therapy (NRT) products.

In addition to these regional differences, the following differences are noteworthy:

• HCPs working in large urban centres (57%) were more likely than those working in medium-sized (41%) or rural (27%) communities to advise patients to talk to their family physician.
• HCPs who have been practicing for less than six years were more likely to say they recommend a drug therapy for smoking cessation (74%) and provide NRT products to patients (64%).

Compared to other health care providers, family/general practitioners were significantly more likely say they recommend a drug therapy to patients for smoking cessation.

Family/general practitioners were also significantly more likely to say they provide patients with a prescription to a drug therapy for smoking cessation.

Most HCPs do not schedule meetings to discuss smoking cessation

Eight in 10 (80%) HCPs said they do not schedule appointments with patients specifically to discuss smoking cessation.

Those who said their patients who smoke have a flag in their patient record file about their smoking status were more likely to schedule appointments to discuss smoking cessation (25% versus 15% of those who do not have flags in their system about their patients’ smoking status).

Family/general practitioners were more likely than other HCPs to say they schedule appointments to proactively discuss smoking cessation with patients.

Half follow up at least almost every visit once patients start the process of quitting smoking

Half of HCPs (50%) follow up with patients who have started the process of quitting smoking at every visit (20%) or almost every visit (30%). Smaller numbers say they do so only once (9%) or annually (4%), while 21% never follow up with these patients. The types of responses included in the “other” category are weekly or monthly follow-ups, follow-ups on an as-needed or occasional basis, or follow-ups of a specific nature, such as to assist with patients’ use of nicotine replacement therapies or to refill patients’ nicotine replacement therapy.

Specialists were more likely than other HCPs to say they follow-up with patients who have started the process of quitting smoking at every visit, while family/general practitioners were more likely to say they do so at almost every visit.

Stress is the main factor identified by patients to explain a smoking relapse

HCPs who have patients who have tried to quit smoking (n=1,097) were asked what reasons patients give when they experience a relapse. Three-quarters identified a stressful life event (76%) or stress in general (75%) as the reason given by their patients for the relapse. Following stress, 57% said patients will point to a spouse/partner or family member who smokes as the reason for their relapse, and 47% identified depression or mental health. Thirty-eight percent said patients have attributed their relapse to thinking they could smoke occasionally, while approximately one-quarter said patients have explained their relapse by saying they are not able to stop thinking about how much they enjoy smoking (25%) or they have new friends/acquaintances who smoke (23%). Nearly one in five (19%) said patients explain their relapse by saying they felt deprived or sorry for themselves.

Of the possible reasons given by patients to their HCPs to explain a relapse, all reasons were mentioned by a higher proportion of family and general practitioners than by all other types of HCPs. Specialty physicians and family/general practitioners were more likely than other HCPs to say their patients have pointed to a stressful life event or to stress in general to explain a relapse. Additionally, family/general practitioners were more likely than pharmacists and nurses to say patients have attributed their relapse to a spouse, partner, or family member who still smokes. Depression or mental health was more likely to be mentioned by specialists and family/general practitioners than pharmacists. Family/general practitioners were more likely than pharmacists to say that patients point to the perception that they could smoke occasionally.

Figure 41: Top 5 reasons given by patients to their HCP to explain a relapse [Differences by HCP]

Patients consider a successful quit attempt as going a certain period of time without having a cigarette

HCPs who have patients who have tried to quit smoking (n=1,097) were also asked how their patients who are former smokers define successfully quitting. Approximately half (52%) said that this is defined by their patients as going a certain period of time without having a cigarette, while nearly half said it is defined as being able to describe oneself as a former smoker (47%) or no longer craving a cigarette (44%). Three in 10 (31%) said their patients define success as no longer needing nicotine replacement therapies, while one-quarter (25%) said it is defined as going a certain amount of time without a craving. Eleven percent said their patients consider a quit attempt successful when they only need nicotine replacement therapies.

Family/general practitioners were more likely than nurses to say that their patients define successfully quitting smoking as going a certain period of time without having a cigarette, while pharmacists were more likely than nurses to say patients define this as no longer needing nicotine replacement therapies.

Figure 43: Patients definition of “successfully” quitting smoking [Differences by HCP]

Most HCPs do not consider using another product containing nicotine as successfully quitting smoking

Health care providers who have patients who have tried to quit smoking (n=1,097) were asked the following question:

If one of your patients completely switched from smoking cigarettes to using another product containing nicotine, would you consider this patient to have successfully quit smoking?

In response, just over three-quarters (77%) said no and 23% said yes.

The likelihood of considering a patient who has switched from smoking cigarettes to using another product containing nicotine to have successfully quit smoking was higher among HCPs who have been practicing for ten years or less (38% of those who have been practicing for less than six years and 37% of those who have been practicing for six to ten years).

Nurses were significantly less likely than other HCPs to say that a patient has successfully quit smoking if they completely switch from smoking cigarettes to using another product containing nicotine: 19% of nurses believe this is true, compared to 36% of pharmacists, 37% of family/general practitioners and 44% of specialists.

Health care providers who have patients who have tried to quit smoking and who do not consider a patient to have successfully quit smoking when they switch from cigarettes to another product containing nicotine (n=723) were asked why. In response, nearly half (45%) said it was because such a patient is still addicted to or dependent on nicotine.

Explanations provided by smaller numbers included the impression that using nicotine replacement therapy is part of the process, not the goal (10%), that such products still contain nicotine (9%), that nicotine is harmful regardless of its source (8%), that such products are still harmful (3%), and that there is a chance of relapse (1%). Nearly one in five (18%) said they did not know why they would not consider this a successful quit attempt.

Looking at differences by HCP, specialists were less likely than all other health care providers to say the reason they do not consider switching from cigarettes to alternative nicotine products as “successfully” quitting smoking is because the person is still addicted to, or dependent on, nicotine.

HCPs believe patients are not receptive to advice about quitting smoking

All HCPs were asked what challenges, if any, they encounter when talking to patients about quitting smoking. The most frequently given challenge, identified by two-thirds of respondents (66%), was the impression that patients are not receptive to receiving advice or help to quit. This was followed by challenges posed by limited time for smoking cessation interventions during appointments (52%) and limited time to follow-up with patients who are attempting to quit (46%). Additionally, a notable proportion of HCPs say that a significant challenge they face when discussing smoking cessation with patients is a poorly integrated health care system (21%).

Most of the other challenges mentioned involved a lack of some sort. These include a lack of useful resources/tools to share with patients (27%), as well as lack of awareness of such resources/tools (24%), a lack of training in smoking issues and cessation activities (25%), a lack of referral experts (22%), a lack of incentive to provide smoking cessation advice (19%), a lack of experience providing smoking cessation advice (17%), a lack of skills and knowledge needed to advise patients, and a lack of comfort providing smoking cessation advice (16% each).

A few respondents (5%) said they encounter no challenges in this regard.

HCPs practicing in the Prairies (76%) were more likely than those from Atlantic Canada (57%) and B.C. (60%) to say that patients are not receptive to receiving advice or help to quit smoking. Limited time for interventions was less likely to be mentioned as a challenge for HCPs working in rural communities (21%).

Turning to differences by type of HCP and the top challenges, health professionals were similarly likely to mention patients’ lack of receptivity to advice/help as a challenge. Compared to nurses (50%), the challenge of limited time for smoking cessation interventions during appointments was particularly prevalent among specialists (66%) and family/general practitioners (59%). Similarly, the challenge of limited time to follow-up with patients who are quitting smoking was less likely to be mentioned by nurses (43%) compared to pharmacists (61%) and specialists (56%).  

Figure 49: Top 3 challenges HCPs encounter when talking to patients about quitting smoking

2. Experience with patients who use vaping products

This section reports on health care providers’ experience with patients who use vaping products.

The majority of HCPs do not know what percentage of their patients use vaping products

The majority of the HCPs surveyed (54%) said they do not know approximately what percentage of their patients use vaping products. Recall that only 17% of HCPs could not estimate the percentage of their patients who smoke cigarettes. Nearly four in 10 (38%) estimated the proportion to be less than one-quarter of their patients, while small numbers estimated it to be higher (6% estimated the use of vaping products to be somewhere between 25-49% and 2% estimated the use to be somewhere between 50-74%).

Pharmacists (68%) were the most likely, and specialists (35%) were the least likely, to indicate they do not know how many of their patients use vaping products.

Over one-third of HCPs say their patients rarely ask them about vaping products

According to HCPs, the frequency with which patients ask about vaping products varies, but it is more likely to be infrequent than frequent. Approximately one in ten HCPs (11%) said their patients ask about vaping products often or always, while roughly six in ten (61%) said their patients rarely or never ask about it.

Specialists (29%) were more likely than other HCPs to say their patients always or often asked about vaping products. In contrast, 75% of pharmacists say they are never or rarely asked about vaping products. This is significant when compared to all other health care providers.

Health care providers were three times more likely to say their patients have been asking questions about vaping products more often now (31%) than a year ago (10%). Almost four in ten (38%) think there has been no change in this regard, while just over one in five (21%) said they do not know.

Recall that a similar comparative question was asked regarding the frequency of discussions about smoking cessation. Compared to a year ago, HCPs were more than twice as likely to say that questions from patients about vaping products have occurred more often compared to one year ago than discussions about smoking cessation (31% versus 13%).

More than half of the family/general practitioners (55%) and specialists (54%) surveyed believe that patients are asking about vaping products more often now than they did a year ago. A statistically significant proportion of nurses (22%) and pharmacists (21%) reported not knowing whether patients are asking about vaping products more or less frequently now compared to a year ago.

Figure 55: Frequency of patients asking HCPs about vaping products compared to a year ago [Differences by HCP]

Most HCPs advise patients that the long-term effects of vaping are unknown

Health care providers offer a variety of different advice to patients about vaping products. Two pieces of advice were identified by a majority of respondents: just over two-thirds (67%) advise patients that the long-term health effects of vaping are unknown, and over half (55%) advise them of the potential risks and harms of vaping.

Four in ten (41%) pharmacists, specialists and nurses⁶ said they advise their patients to talk to their family physician and over one-third (35%) of HCPs advise their patients not to use vaping products. Approximately one-quarter (26%) said they advise patients that vaping is a last resort way to quit smoking.

In all, 17% of respondents said they do not give advice to patients about vaping products. This is much higher than the proportion of HCPs who said they do not give advice to patients about quitting smoking (1%).

The full range of advice offered can be found in Figure 56.

Family/general practitioners were more likely than nurses and pharmacists to say they advise patients that the long-term health effects of vaping are unknown and of the potential risks and harms of vaping. Nurses, on the other hand, were most likely to advise patients to talk to their family physician.

Figure 57: Top 3 reasons health care providers give to patients about vaping products

3. Comfort talking to patients about tobacco and vaping products

This section reports on health care providers’ level of comfort in talking about tobacco and vaping, as well as their perceived level of knowledge about them.

Fewer HCPs are comfortable discussing vaping products with patients compared to alcohol, tobacco, and drug use, as well as smoking cessation

Health care providers expressed the highest degrees of comfort talking to patients about smoking cessation, tobacco use, and alcohol consumption. Nearly all (93-96%) expressed comfort talking about these substances, with majorities expressing a high degree of comfort (58-60% said they were ‘very comfortable’ with these discussions). Smaller, but substantial majorities, also expressed comfort talking about opioid use (80%) and cannabis use (74%), though in the case of the latter, comfort was more likely to be moderate than strong.

The degree of comfort was lowest in relation to talking to patients about vaping products. Over half expressed comfort talking about this, but comfort was more likely to be described as moderate (35%) than strong (20%). In addition, nearly one-third (31%) said they were not very comfortable talking to patients about this, and 13% said they were not at all comfortable doing so.

Figure 59: Proportion of health care providers who are comfortable talking to patients about cannabis, alcohol, tobacco, opioids and vaping [Differences by HCP]

The likelihood of being comfortable talking about these substances was generally higher among family/general practitioners. All HCPs noted a high degree of confidence when talking about smoking cessation, tobacco use, and alcohol consumption. Comfort talking about opioid and cannabis use, as well as vaping products, varied among the HCPs. Family/general practitioners and pharmacists were more likely than nurses and specialists to be comfortable talking about opioid use. When it comes to cannabis use, however, pharmacists were least likely to be comfortable discussing it with patients. Comfort talking about vaping products was higher among specialty physicians and family/general practitioners.

Years in their current work setting had some impact on HCPs’ comfort in talking to patients about opioid and cannabis use. Those who have been in their current work setting for less than six years were more likely to be comfortable discussing these topics with patients.

HCPs feel more knowledgeable about smoking cessation than vaping products

Health care providers were much more likely to consider themselves knowledgeable about smoking cessation than about vaping products. Almost nine in ten (87%) HCPs described themselves as at least somewhat knowledgeable about smoking cessation. However, only 37% described themselves as at least somewhat knowledgeable about vaping products. In contrast, more than six in ten (64%) HCPs described themselves as either not very knowledgeable (46%) or not at all knowledgeable (18%) about vaping products.

The following HCPs were more likely to feel knowledgeable about smoking cessation: those who have been practicing for less than six years (95%), and; those who see daily patients that use tobacco products (91%).

Pharmacists were significantly more likely than other HCPs to indicate being very knowledgeable about smoking cessation. More than half (57%) feel very knowledgeable regarding smoking cessation compared to 49% of family/general practitioners, 34% of specialists, and 23% of nurses. In contrast, nurses (62%) and specialists (61%) were more likely to describe themselves as somewhat knowledgeable when it comes to smoking cessation.

The likelihood of being somewhat or very knowledgeable about vaping products was higher among specialists (52%) and family physicians/general practitioners (44%) than pharmacists (36%) or nurses (34%).

4. Knowledge and attitudes toward tobacco, nicotine, and vaping products

This section reports on health care providers’ knowledge and attitudes towards tobacco, nicotine, and vaping products.

Familiarity with different tobacco, nicotine and vaping products varies

Familiarity tended to be higher for nicotine patches and gums, and lower for vaping and heated tobacco products. Specifically, 76% of HCPs said they know at least a fair amount about nicotine patches and 67% said this about nicotine gums, while 17% and 3% said this about vaping and heated tobacco products, respectively.

Health care providers were most likely to say they know little to nothing about vaping products (74%), and smokeless tobacco products (68%), with an additional 9% saying they have never heard of vaping products and a further 5% saying the same about smokeless tobacco products. Health care providers were least likely to have heard about heated tobacco products (65% say they have never heard of it).

Figure 63: HCPs familiarity with tobacco, nicotine and vaping products

Familiarity with nicotine patches was higher among HCPs in B.C. (84%) than in Atlantic Canada (69%) or Ontario (73%). No other regional differences were noteworthy. Familiarity with nicotine patches was higher among HCPs in rural areas (95%) and among those who see daily patients that use tobacco products (83%).

While the majority of HCPs know at least a fair amount about nicotine patches and gums, this was particularly the case among pharmacists. Virtually all pharmacists surveyed (98% and 99%, respectively) stated that they know at least a fair amount about these two nicotine replacement therapies. Pharmacists were also the most likely to be familiar with the following products: nicotine lozenges (94%), inhalers (87%), and sprays (74%).-

Familiarity with smokeless tobacco and vaping products was higher among family physicians/general practitioners compared with other HCPs, and familiarity with heated tobacco products was higher among specialists and physicians/general practitioners compared to nurses and pharmacists. Additionally, one in five specialists say they are at least somewhat familiar with vaping products, though this difference is not statistically significant when compared to pharmacists and nurses.

Figure 64: HCPs’ familiarity with tobacco, nicotine and vaping products [Differences by HCP]

Familiarity with vaping products generally mirrors HCPs’ perceived knowledge of vaping products. Health care providers who describe themselves as not familiar with vaping products (i.e., never heard of such products or know them by name only) also say they are not very or not at all knowledgeable about these products. In contrast, HCPs who say they know vaping products well also describe themselves as very knowledgeable about these products.

Figure 65: HCPs’ familiarity with, and knowledge of, vaping products

Nearly all HCPs consider cigarettes to be very or extremely harmful

Most of the HCPs surveyed rate many tobacco, nicotine and vaping products as at least moderately harmful to the health of the person using them. Specifically, 98% of HCPs indicate that cigarettes are at least moderately harmful (73% said they are extremely harmful), 94% cigars/little cigars, 81% smokeless tobacco products, 76% vaping products with nicotine, 70% water-pipes with tobacco, and 53% vaping products without nicotine. Of these six products, those perceived by most HCPs to be ‘very’ or ‘extremely’ harmful included cigarettes (96%) and cigars/little cigars (83%), followed at a distance by smokeless tobacco products (56%), and vaping products with nicotine (53%).

Prescription drugs for smoking cessation (72%) and nicotine replacement therapies (69%) stood out among these products in terms of their likelihood of being considered of little or no harm at all. Health care providers were most likely to be unsure about the health effects of heated tobacco products (57%), with nearly all the rest (41%) perceiving them as at least moderately harmful. A number of HCPs also said they did not know about the health effects of vaping products without nicotine (24%) and water-pipes with tobacco (20%).

Figure 66: Perceived harmfulness of tobacco, nicotine and vaping products

Figure 67 depicts differences in perceptions by HCP. Health care providers are similarly likely to view cigarettes as very or extremely harmful. Although a large proportion of all HCPs perceive cigars/little cigars to be very or extremely harmful, this is most notable (and significant) among pharmacists (87%) and nurses (84%). Two-thirds of pharmacists (66%) indicated that they believe smokeless tobacco products are very or extremely harmful. This is significantly higher than nurses and specialists. Pharmacists were also more likely to view water-pipes with tobacco as very or extremely harmful (59%) compared to specialists (51%), family/general practitioners (49%), and nurses (47%).

Overall, vaping products with nicotine were perceived to be more harmful than vaping products without nicotine. Nurses were particularly concerned regarding the harmfulness of vaping products with nicotine: 58% said they believe these products are very or extremely harmful. Though less than half, a significant number of pharmacists (43%) also believe vaping products with nicotine are very or extremely harmful. Nurses were also more likely than other HCPs to consider vaping products without nicotine to be very or extremely harmful. Pharmacists were the most likely to view heated tobacco products as very or extremely harmful.

Figure 67: Perceived harmfulness of tobacco, nicotine and vaping products [Differences by HCP]

HCPs who indicate the following products are “extremely harmful’ or “very harmful”

When looking at knowledge of vaping products and perceptions of harm, differences are evident. Specifically, HCPs who think that vaping with nicotine is not at all harmful were more likely to describe themselves as very knowledgeable about vaping products. Those who view vaping with nicotine as extremely harmful, however, were similarly likely to characterize themselves as very knowledgeable and not at all knowledgeable about vaping products (i.e., the difference is not statistically significant).

Figure 68: Knowledge of vaping products and perceived harm of vaping WITH nicotine

Perceived harm of vaping without nicotine also varies based on HCPs’ knowledge of vaping products. Health care providers who think that vaping without nicotine is not at all harmful were more likely to describe themselves as very knowledgeable rather than somewhat knowledgeable about vaping products. Those who view vaping without nicotine as extremely harmful were more likely to characterize themselves as very knowledgeable rather than not very knowledgeable about vaping products.

Figure 69: Knowledge of vaping products and perceived harm of vaping WITHOUT nicotine

The likelihood of viewing vaping products with nicotine as very harmful was higher among HCPs who know these products well.

Figure 70: Familiarity with vaping products and perceived harm of vaping products WITH nicotine

The perceived harm of vaping withoutnicotine varies, regardless of HCPs’ familiarity with such products. 

Figure 71: Relationship between familiarity of vaping products and perceived harm of vaping WITHOUT nicotine

The majority of respondents indicate that switching to vaping products without nicotine will improve a cigarette smoker’s health

Views on the health impact of quitting smoking and switching to vaping, either with or without nicotine, tend to be mixed, especially in the case of vaping with nicotine.

While a majority (60%) think that quitting smoking completely and switching to vaping without nicotine will improve the health of a smoker, HCPs are more likely to characterize the improvement as small than large. Among the remainder, 14% think the effects of this switch will adversely affect the individual’s health at least a little, 7% think there will be no effect on health, and 20% said they do not know.

When it comes to quitting smoking and switching to vaping with nicotine, the largest proportion think the switch will improve the health of a smoker, but HCPs are five times more likely to characterize the improvement as small (34%) than large (7%). Among the remainder, nearly one-quarter (23%) think the effects of completely switching will adversely affect the individual’s health at least a little, 17% think there will be no effect on health, and 18% said they do not know.

The perceived health benefits/risks of vaping products with nicotine on a cigarette smoker’s health vary across health care professions. The majority of specialists (62%), and just over half of family/general practitioners (56%) indicated that switching to vaping products with nicotine will improve a cigarette smoker’s health. In contrast, one-quarter of nurses surveyed believe that switching from cigarettes to vaping products with nicotine would worsen a patient’s health.

The large majority of health care providers believe that switching to vaping products without nicotine would improve a cigarette smoker’s health at least a little. The largest proportion, again, is found among specialists (74%) and family/general practitioners (67%).

Health care providers who think that cigarette smokers’ health will get worse if they quit completely and switch to vaping with nicotine were more likely to describe themselves as somewhat or very knowledgeable about vaping products. In contrast, those who think vaping with nicotine will improve one’s health a little were more apt to say they are somewhat or not very knowledgeable about vaping products.

Figure 74: HCPs' knowledge of vaping products and views on switching to vaping with nicotine

The likelihood of saying that cigarette smokers’ health will improve a lot if they switch to vaping without nicotine was higher among HCPs who say they are very knowledgeable about vaping products.

Figure 75: HCPs' knowledge of vaping products and views on switching to vaping without nicotine

Varied reasons offered to explain why switching will improve, worsen or have no impact on a smoker’s health

Health care providers were asked to explain why they feel that switching to vaping products will improve, worsen or have no impact on a smoker’s health. Health care providers say that switching to vaping products with nicotine will improve a cigarette smokers health due to the consumption of fewer harmful chemicals (14%), that, in general, vaping products are less harmful than smoking (14%), and that vaping products with nicotine contain fewer carcinogens.

When asked why vaping products without nicotine will improve a cigarette smoker’s health, HCPs offered the following reasons: these products contain less nicotine (29%), they contain fewer harmful chemicals (12%), and in general, vaping products are less harmful than smoking (11%).

The full range of reasons offered are depicted in Figure 77.

Figure 77: Reasons switching to vaping will improve a smoker's health

Health care providers who believe switching to vaping products with nicotine will make a smoker’s health a little or a lot worse offered the following explanations: that the effects of vaping are unknown (22%), vaping products still involve inhalation/respiratory problems (19%), and in general, nicotine is harmful (10%). When asked the same question regarding vaping products that do not contain nicotine, 17% of HCPs say that the effects of vaping are unknown, 15% that vaping, even without nicotine, still involves inhalation and can cause respiratory problems, and 12% say that vaping is still harmful.

Figure 78: Reasons switching to vaping will worsen a smoker’s health

More than four in ten (44%) HCPs who believe that switching to vaping products with nicotine will have no impact on a smoker’s health say they think this because vaping products still contain nicotine, which they view as harmful. This is followed, at a distance, by 19% who say that the switch will have no impact because in general, nicotine is harmful, and 12% each who say that vaping products are addictive and still involve inhalation which can cause respiratory problems. When it comes to vaping products without nicotine, the top reason offered is that the effects of vaping products are still unknown.

Figure 79: Reasons switching to vaping will have no impact on a smoker’s health

HCPs’ attitudes toward tobacco, nicotine, vaping and smoking cessation varies

Health care providers were asked to rate their level of agreement with statements about tobacco, nicotine, vaping and smoking cessation.

A majority of HCPs expressed some level of agreement or disagreement with all but one of these statements. Health care providers were most likely to disagree that giving smoking cessation advice is not part of their job (81%), with nearly two-thirds expressing strong disagreement. Just over three-quarters (76%) disagreed that it is inappropriate to ask patients whether they smoke unless it’s directly related to the reason for the interaction (over half expressing strong disagreement), and almost as many (73%) disagreed with the statement I have no interest in receiving additional training on smoking cessation. Smaller majorities disagreed with the statements I don’t have much sympathy for people who smoke cigarettes (61%), and people who are dependent upon cigarettes could stop smoking if they really wanted to (56%).

Respondents were most likely to agree that nicotine addiction is a disease. Over three-quarters (79%) agreed with this statement, and agreement was more likely to be strong than moderate. A smaller majority (60%) agreed that vaping with nicotine is as bad as smoking cigarettes, though agreement was more likely to be moderate than strong. Nearly half the HCPs (47%) agreed that the health risk to Canadians posed by tobacco has increased in the past five years, with most of the rest (40%) neither agreeing nor disagreeing with this statement.

Figure 80: HCPs’ attitudes toward tobacco, nicotine and vaping products

When looking at HCPs’ reaction to the statement, vaping with nicotine is as bad as smoking cigarettes, and their views of the health impact of switching to vaping, the following is noteworthy:

• Two-thirds of those who strongly disagree that vaping is as bad as smoking cigarettes say the switch to vaping with nicotine would improve a smokers’ health a lot (33%) or a little (33%).
• Nearly three-quarters of those who somewhat disagree that vaping is as bad as smoking also agree that a smokers’ health would improve a lot (15%) or a little (59%) if they switched to using vaping products with nicotine.
• More than seven in ten HCPs who strongly disagree with the statement that vaping is as bad as smoking cigarettes think that switching to vaping products without nicotine would improve the health of someone who quits smoking cigarettes a lot (60%) or a little (13%).
• Most HCPs who somewhat disagree that vaping is as bad as smoking say that the switch to vaping without nicotine would improve the health of someone who quits smoking cigarettes a lot (34%) or at little (49%).

A large majority of all HCPs (approximately 8 in 10 each) believe that nicotine addiction is a disease. There are no notable differences by type of health care provider. This is also the case for views on dependency and a patient’s role (or lack thereof) in addiction. Health care providers are similarly likely to agree (approximately 3 in 10 each) that people who are dependent could stop smoking cigarettes if they really wanted to. Additionally, nearly half of HCPs agree that they still would not recommend vaping products even if product standards were in place (25% say they strongly agree with this statement). Only 7% of HCPs strongly agree that they would be comfortable recommending vaping products if they knew there were product standards in place; however, 36% say they somewhat agree with the statement. 

The perceived harmfulness of vaping with nicotine varied significantly across the health care providers. While 64% of nurses and half of pharmacists agreed that vaping with nicotine is as bad as smoking cigarettes, only 39% of family/general practitioners believe this to be the case. Opinions about the relative health risk tobacco poses to Canadians also varied by type of health care provider. While half of nurses believe the health risk has increased in the past five years, fewer family/general practitioners and specialists agree with this statement (34% each). Nurses and pharmacists (50% each) were more likely than family/general practitioners (31%) and specialists (41%) to agree that they still would not recommend vaping products even if product standards were in place. 

Figure 81: Proportion of HCPs who agree with the following statements about tobacco, nicotine and vaping products

The level of disagreement with the following statement, “Giving smoking cessation advice is not part of my job”, was higher among pharmacists (93%), family/general practitioners (90%) and specialists (87%) than it was among nurses. Specialists and family/general practitioners were more likely than other HCPs to disagree with the opinion that it is inappropriate to ask if patients smoke, unless it’s related to the purpose of their visit (89% and 87% respectively). Conversely, pharmacists and nurses were more likely to disagree with the statement, “I have no interest in receiving additional training on smoking cessation”, and pharmacists (71%) were more likely than nurses to disagree with the statement, “I don’t have much sympathy for people who smoke cigarettes”.

Figure 82: Proportion of HCPs who disagree with the following statements about tobacco, nicotine and vaping products

Nine in ten respondents feel that tobacco should remain a high government priority

The vast majority of HCPs (90%) think that tobacco should continue to be a high government priority. This impression came in response to the following question:

Some people say smoking rates in Canada are decreasing and public focus should now be on other health issues, such as obesity or wait times. Other people say there are still 4.6 million smokers in Canada so tobacco should continue to be a high priority. From your own point of view, should tobacco continue to be a high government priority?

Specialists and family/general practitioners, in particular, believe that tobacco should continue to be a high government priority – 95% of each of these HCPs feel this way, which is significant when compared to pharmacists and nurses.

5. Smoking cessation and vaping products resources

This section reports on health care providers’ perceptions regarding sources of information and resources related to smoking cessation and vaping products.

The types of sources for information about smoking cessation and vaping products varies

Health care providers use a variety of sources for information about smoking cessation and vaping devices. The top sources for information about both smoking cessation and vaping products are Health Canada, a general internet search, and the Public Health Agency of Canada. Asking a colleague or co-worker and social media were noteworthy sources of information particularly for vaping products. For most sources, though, greater proportions of HCPs use them for information about smoking cessation than for information for vaping products. The exceptions are general internet searches, social media, and professional insurers.

Figure 86 presents the top five sources for information about smoking cessation and vaping products. Health care providers are more likely to consult medical journals or CME programs for information about smoking cessation, but they are more likely to consult a colleague or social media when informing themselves about vaping products.

Figure 86: Top five sources for information about smoking cessation and vaping products

There were noteworthy differences in the sources consulted for smoking cessation information by type of HCP. Although Health Canada is the leading source of information used by HCPs when searching for information about smoking cessation, the proportion across the different health care professions varies. Nurses (78%) and pharmacists (74%) were more likely to say they consult Health Canada when searching for such information (compared to 61% of family/general practitioners and 49% of specialists).

Figure 87: Sources of information about smoking cessation [Differences by HCP]

Other noteworthy differences include:

• Nurses were more likely to conduct a general internet search, and use the Public Health Agency of Canada as a resource.
• Pharmacists were more likely than others to take a CME program, consult their professional association, or participate in a webinar.
• Nurses were less likely than other HCPs to obtain this information from conferences.
• Webinars and regulatory bodies were more likely to be preferred by pharmacists and nurses compared to specialists.

For information on vaping, nurses are more likely to refer to Health Canada or the Public Health Agency of Canada, as well as webinars, social media and the CDC. The likelihood of pointing to medical journals, CME programs, conferences, and professional associations was higher among specialty physicians.

Figure 88: Sources of information about vaping products [Differences by HCP]

Health Canada’s general website is the main resource consulted by respondents in the past few years

Asked specifically which Health Canada resources, if any, they have consulted over the past few years, HCPs were most likely to say they access the general departmental website (43%), followed by Quit Smoking Services and Information (31%), and Quit4Life (29%). Smaller, and almost identical proportions, said they have consulted Canada’s tobacco Strategy (16%) and On the Road to Quitting (15%), while relatively few said they have consulted the Consultation on the Future of Tobacco control in Canada and Break it Off (5% each).

Over one-quarter (28%) said they have not consulted any of these Health Canada resources in the past few years. The likelihood of not consulting any of these resources was higher among specialists (54%) and family/general practitioners (42%) compared to nurses (24%) and pharmacists (31%).

Of all the Health Canada resources in question, the leading resource used by HCPs in the past few years was Health Canada’s general website. This was particularly the case among nurses (46%) and pharmacists (44%). Compared to specialists, pharmacists (32%) and nurses (32%) were more likely to have consulted Health Canada’s Quit Smoking Services and Information. Quit4Life was more likely to be consulted by nurses (32%) and pharmacists (26%), followed by family/general practitioners (18%) and specialists (9%).  

Length of time since Health Canada website has been consulted

Health care providers who said they consulted Health Canada’s general website in the past few years (n=419) were asked how long it has been since they had last done so. In response, nearly two-thirds (63%) said they have done so within the last year, with nearly half doing so within the last six months, and one-quarter within the past three months. Just over one in five said it has been more than one year since they last consulted Health Canada’s general website, and 15% could not recall the last time they consulted the site.

There were no notable differences by type of HCP when it came to how long ago they last visited Health Canada’s general website.

Figure 92: Length of time since HCP last consulted Health Canada’s website [Differences by HCP]

Most send patients home with smoking cessation information at least sometimes

While most HCPs (89%) send patients home with smoking cessation information, the frequency with which they do so varies. Approximately one in five (19%) said they often or always do so, 41% said they sometimes do this, and nearly three in 10 (29%) said they rarely do this.

Booklets and pamphlets are the main type of smoking cessation information provided to patients

Information about smoking cessation typically given to patients by HCPs who said they do so (n=1,027) consists mainly of booklets or pamphlets (61%), links to online/web-based resources (56%), and fact sheets (41%). Small numbers volunteered that they provide referrals in general, phone numbers, and verbal advice.⁷

Pharmacists (66%) and nurses (63%) were more likely than family/general practitioners (45%) to send patients home with booklets and pamphlets. The likelihood of sending patients home with fact sheets was also higher among pharmacists (53%) and nurses (41%) compared to specialists (29%). Pharmacists (46%), on the other hand, were the least likely to say they send patients home with links to online or web-based resources.

A large proportion of HCPs don’t know which method of communication about smoking cessation is particularly effective with patients

Health care providers identified a variety of messages or approaches they consider effective when communicating with patients about smoking cessation, though none stands out in terms of the frequency with which it was identified.⁸ The most frequently identified approach was to be realistic/emphasize the difficulty of quitting (16%). This was followed by a cluster of approaches identified by between 8-12% of HCPs: providing non-judgemental facts, communicating the health benefits of quitting smoking, communicating specific smoking-related health problems, providing motivation and encouragement, assessing readiness to quit, empathizing/trying to be understanding, and asking open-ended questions/listening to patients.

Pharmacists were more likely than family/general practitioners and specialists to say communicating the health benefits of quitting for a patient and motivating or encouraging patients are effective approaches.

Figure 98: Top methods recommended by HCPs for communicating about smoking cessation  [Differences by HCP]

[Response categories reflect analysis of open-ended feedback provided by respondents]

Few suggestions for how Health Canada can help HCPs encourage patients to quit smoking

A split sample of HCPs (n=562) was asked in an open-ended manner how Health Canada can best help HCPs encourage patients to quit smoking. In response, a variety of suggestions were offered, but the only one mentioned by more than one in 10 HCPs was to provide free resources for quitting smoking.⁹ In total, 19% of HCPs offered this for Health Canada’s consideration. The single largest proportion—35%—offered no suggestions at all.

Provide free resources for quitting smoking, such as smoking cessation aids and nicotine replacements,was more likely to be mentioned by pharmacists (22%) and specialists (22%) than by family/general practitioners (13%).

Few suggestions for how Health Canada can help HCPs encourage patients to switch to vaping products

A split sample of HCPs (n=563) was asked in an open-ended manner how Health Canada can best help HCPs encourage patients to switch to vaping products. In response, more than four in 10 (44%) HCPs offered no suggestions at all. Just over one in ten (13%) say that Health Canada should provide HCPs with more information on vaping products, and one in ten say that Health Canada should not encourage patients to switch to vaping. The full range of suggestions are depicted in Figure 92.¹⁰

The only significant difference by type of HCP related to whether or not Health Canada should encourage people to switch to vaping products. Specifically, specialists (19%) were more likely than family/general practitioners (7%) and pharmacists (7%) to suggest that Health Canada should not encourage switching from cigarettes to vaping.

Figure 102: Top suggestions for how Health Canada can help HCPs encourage patients to switch to vaping products [Differences by HCP]

Conclusions and Observations

This research yielded some noteworthy observations and conclusions concerning the knowledge, attitudes, behaviours, and perceptions of health care providers on smoking cessation and alternative nicotine products.

• Flagging a patient’s record file may encourage health care providers to have discussions about smoking cessation with their patients.
  • A large majority of health care providers noted that they believe flagging a patient’s record file to reflect their smoking status does or would prompt a discussion about smoking status/cessation during future visits. Despite this, only around half of HCPs reported that they do flag their patient files.
• Health care providers may need to focus on proactively scheduling appointments with patients to discuss smoking cessation.
  • HCPs indicated that patients rarely raise the topic of smoking cessation (or vaping products); rather, the discussion is almost always prompted by the health care practitioner. Despite the fact that these discussions largely originate with HCPs, HCPs also reported that they do not have enough time in a regular appointment to discuss smoking status/smoking cessation.
• More tools/resources may need to be made available to health care providers to help encourage patients to quit smoking.
  • HCPs reported their perception that they have a lack of (and lack of awareness of) useful resources and tools to share with patients to help them quit smoking. Notably, some HCPs also indicated that they feel they have a lack of training in smoking cessation issues and cessation activities, a lack of experience providing smoking cessation advice, and a lack of skills and knowledge needed to advise patients.
• Additional training/education may be required to inform HCPs on vaping products.
  • While three in 10 HCPs feel that patients are asking about vaping products more often compared to a year ago, few HCPs reported a high level of comfort in talking to patients about vaping products. In contrast, nearly all HCPs indicated a high level of comfort in talking to patients about tobacco use and smoking cessation.

Appendix

1. Technical Specifications

• An online survey was administered to 1,125 HCPs.
• The sample quotas compared to the actual number of completed surveys were as follows:

• The survey averaged 20 minutes to complete, and the fieldwork was conducted between August 2 and August 30, 2019.
• The survey questionnaire was programmed using computer-assisted web interviewing (CAWI) technology. The programming was tested for skip logic by the initial programmer, as well as by a second senior programmer. Following this, the script was tested through random data generation.
• Following survey best practices, the questionnaire was pre-tested in advance of the fieldwork to ensure that it measured what it was intended to measure. There were 10 completions in each official language. No issues or concerns arose during the pre-test and the pre-test responses were included in the final survey results. In addition to the pre-test, the survey programming was tested using a random number generator and the output verified prior to the launch of the fieldwork. Following the fieldwork, the data were cleaned and checked using SPSS syntax. The review assessed response ranges and the length of time taken to complete the survey to identify any respondent who took an unreasonably short time answering, who “straightlined” responses. Any cases flagged for data quality were replaced prior to the weighting and tabulation of the data.
• The sample was drawn from SmartPoint Research’s panel of online Canadians. Surveys that use samples drawn from online panels cannot be described as statistically projectable to the target population.
• Panellists were rewarded for taking part in the survey per the panel’s incentive program, which is structured to reflect the length of survey and the nature of the sample.
• Survey data were weighted by region and profession using data the Canadian Institute for Health Information’s (CIHI) Health Workforce data to reflect the composition of the target population.
• Because the sample is based on those who initially self-selected for participation in the panel, no estimates of sampling error can be calculated.
• All survey respondents were informed that their participation was voluntary, and that information collected was protected under the authority of privacy legislation.
• Sponsorship of the study was revealed (i.e., the Government of Canada).
• The response rate was 12%, calculated using the formula outlined in the Standards for the Conduct of Government of Canada Public Opinion Research (Online Surveys).

All steps of the project complied with market research industry standards and the Standards for the Conduct of Government of Canada Public Opinion Research.

2. Survey Questionnaire

Landing Page

Please select the language in which you wish to complete the survey.

• English
• French

[NEXT]

Survey Introduction Page
Welcome and thank you for agreeing to take part in this survey. We anticipate that the survey will take up to 15 minutes to complete.

Background information
This research is being conducted by Phoenix Strategic Perspectives (Phoenix SPI), a Canadian public opinion research firm, on behalf of Health Canada.

The purpose of this online survey is to collect opinions and feedback from health care providers with respect to smoking cessation and alternative nicotine products.

How does the online survey work?

• Your participation in the survey is completely voluntary and confidential.
• Your decision on whether or not to participate will not affect any dealings you may have with the Government of Canada, now or in future.

What about your personal information?

• Please be assured that all opinions will remain anonymous and will not be attributed to you personally in any way.
• The personal information you will 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. For more information, click here.
• Your personal information will be collected by Phoenix SPI in accordance with the applicable provincial privacy legislation or the Personal Information Protection and Electronic Documents Act (PIPEDA).

What happens after the online survey?

The final report written by Phoenix SPI will be available to the public through Library and Archives Canada (www.bac-lac.gc.ca).  

If you have any questions about the survey, you may contact Phoenix SPI at research@phoenixspi.ca.

Your help is greatly appreciated, and we look forward to receiving your feedback.

[CONTINUE]

PROGRAMMING NOTES:

SECTION TITLES SHOULD NOT APPEAR ON SCREEN FOR RESPONDENTS.
DO NOT PRESENT QUESTION NUMBERS.
INCLUDE A PROGRESS BAR.
ALL QUESTIONS ARE MANDATORY.

Industry Screening

1. In the previous 30 days, in which, if any, of the following have you participated?

Select all that apply

• A Government of Canada survey - TERMINATE
• A survey about smoking cigarettes - TERMINATE
• A survey on vaping/electronic cigarettes - TERMINATE
• A survey on smoking cessation - TERMINATE
• A survey on nicotine products - TERMINATE
• None of the above                                                                 

2. Do you, or any member of your immediate family, work for…? 

Select all that apply

• A marketing research firm          
• A magazine or newspaper          
• A radio or television station        
• A public relations company         
• The government, whether federal, provincial, territorial or municipal
• An advertising agency or graphic design firm
• Tobacco or e-cigarette company - TERMINATE
• Company that produces smoking cessation aids - TERMINATE
• Legal or law firm - TERMINATE

INDUSTRY TERMINATION MESSAGE:
Thank you very much for your interest in completing this survey. Unfortunately you are not eligible for this survey.

Respondent Screening/Quotas/Characteristics

3. In which province or territory do you work?

• 01 Newfoundland and Labrador
• 02 Nova Scotia
• 03 Prince Edward Island
• 04 New Brunswick
• 05 Quebec
• 06 Ontario
• 07 Manitoba
• 08 Saskatchewan
• 09 Alberta
• 10  British Columbia
• 11  Yukon
• 12  Nunavut
• 13  Northwest Territories
• 14  Outside of Canada - TERMINATE*
• 99  Prefer not to answer - TERMINATE

*IF OUTSIDE OF CANADA:
Thank you very much for your willingness to complete this survey. We’re sorry. You must practice in Canada to be eligible.

4. Which of the following best describes your primary profession?

• 01 Family physician/general practitioner
• 02 Pharmacist
• 03 Registered Nurse
• 04 Nurse Practitioner
• 05 Cardiologist
• 06 Respirologist
• 07 Obstetrician/Gynecologist
• 08 Retired - TERMINATE*                                    
• 88   Other. Please specify: [TEXT]

QUOTA TERMINATION:
Thank you very much for your willingness to complete this survey. We’re sorry, but at this time we’ve already received a sufficient number of completed surveys from people with a similar profile to yours.

*RETIRED:
Thank you very much for your willingness to complete this survey. We’re sorry. You must be currently practicing to be eligible.

5.  [IF Q4=88] For how long have you been practicing? [IF Q4=01-07, ADD] as a [INSERT Q4 RESPONSE]?

• 01 Less than 1 year - [SKIP Q8 and Q11]
• 02 1 to 5 years
• 03 6 to 10 years
• 04 11 to 15 years
• 05 More than 15 years

6. On average, how often do you see patients who use tobacco products? This includes patients who smoke, chew, or sniff tobacco. For the purposes of this survey, the term “patients” means your patients or clients.

• 01 Multiple times a day
• 02 Once a day
• 03 A few times a week
• 04 About once a week
• 05 Less often than once a week
• 06 Never - TERMINATE*

*THOSE WHO DO NOT SEE PATIENTS WHO USE TOBACCO PRODUCTS:
Thank you very much for your willingness to complete this survey. We’re only looking for professionals who see patients who use tobacco products.

Section 1. Work Environment

These next few questions are about your work environment.

7. What is your primary work setting?

• 01 Solo practice     
• 02 Family medicine clinic
• 03 Hospital setting
• 04 Walk-in-clinic / Urgent Care
• 05 Multi-disciplinary clinic
• 06 Specialized health centre
• 07 Community health centre
• 08 Long-term care residence
• 09 Public Health clinic/setting
• 10   Pharmacy
• 88   Other. Please specify:

[SKIP Q8 IF Q5=01]

8. You indicated that a [INSERT Q7 RESPONSE] is your primary work setting. For how many years have you been working in this setting?

• 01 Less than 1 year               
• 02 1 to 5 years
• 03 6 to 10 years
• 04 11 to 15 years
• 05 More than 15 years

Section 2. Experience with Patients who use Tobacco Products

9. As a health care provider, how important is talking about smoking cessation with your patients who smoke cigarettes?

• 01 Not at all important
• 02 Not very important
• 03 Somewhat important
• 04 Very important

These next questions are about your experience with patients who smoke cigarettes.

10. Approximately what percentage of your patients smoke cigarettes?

• 01 [TEXT BOX] Percentage
• 99 Don’t know

[SKIP Q11 IF Q5=01]

11. How long have you been seeing and/or treating patients who smoke cigarettes?

• 01 Less than 1 year
• 02 1 to 5 years
• 03 6 to 10 years
• 04 11 to 15 years
• 05 More than 15

12. Do your patients who smoke have a flag in their patient record file about their smoking status?

• 01 Yes
• 02 No
• 03 Don’t know

13. [Does/Would] having a flag in their patient record file prompt or trigger a discussion about their smoking status?

• 01 Yes
• 02 No
• 03 Don’t know

[IF Q13=01]

14. Is a patient’s smoking status documented at every visit?

• 01 Yes
• 02 No
• 03 Don’t know

15. When interacting with a patient who smokes cigarettes, how often do the following occur?

[GRID]
[ROWS]

• a. You raise the topic of smoking cessation with a patient
• b. A patient raises the topic of smoking cessation with you

[COLUMNS]

• 01 Every visit
• 02 Almost every visit
• 03 Sometimes
• 04 Rarely
• 05 Never

16. With whom are you talking about smoking cessation?

Select all that apply

[GRID]
[ROWS]

• a) Youth (Up to 19 years)
• b) Young adults (20-24 years)
• c) Adults (25-64 years)
• d) Seniors (65+ years)
• e) Patients with a chronic health condition (unrelated to smoking cigarettes)
• f) Patients with a chronic health condition (related to smoking cigarettes)

[COLUMNS]
Male Patients
Female Patients

17. Do you talk about smoking cessation with pregnant women or any other patient populations?

• 01 Pregnant women
• 88   Other populations. Please specify: [TEXT BOX]

18. Approximately what percentage of your patients use vaping products¹¹?

• 01 [TEXT BOX] Percentage
• 99 Don’t know

19. How often, if at all, do patients ask about vaping products*?

• 01 Never
• 02 Rarely
• 03 Sometimes
• 04 Often
• 05 Always

20. Compared to one year ago, do you find the following has been happening more often, less often, or with about the same frequency?

[GRID]
[ROWS]

• a. Patients want to discuss smoking cessation
• b. Patients ask questions about vaping products*

[COLUMNS]

• 01 More often
• 02 Less often
• 03 About the same
• 04 Don’t know

21. What advice, if any, do you currently give patients about vaping products*?

Select all that apply
[ROTATE LIST]

• 01 Tell them that vaping products can be used for smoking cessation
• 02 Recommend vaping to patients who want to quit smoking cigarettes
• 03 Recommend vaping to patients who are not ready to quit smoking cigarettes
• 04 Tell patients vaping products can be used to control nicotine cravings
• 05 Tell patients to be careful to get the right strength of nicotine in their e-liquid
• 06 I advise patients not to use vaping products
• 07 [DO NOT DISPLAY IF Q4 = 01] Advise them to talk to their family physician
• 08 Provide a pamphlet or other self-help resource on vaping/vaping products
• 09 Advise patients of the potential risks and harms of vaping
• 10 Advise that the long-term health effects of vaping are unknown
• 11 Advise that vaping should only be viewed as a last resort way to quit
• 88 Other: Please specify: [TEXT BOX]
• 12 None, I don’t give advice to patients on vaping products

22. What advice, or support, if any, do you currently give patients about quitting smoking?

Select all that apply

[ROTATE LIST]

• 01 Tell them that quitting smoking is beneficial to their health
• 02 Provide a pamphlet or other self-help resource on smoking cessation
• 03 [DO NOT DISPLAY IF Q4 = 01] Advise them to talk to their family physician
• 04 Offer a referral to a smoking cessation program
  • Please provide the name of this program: [TEXT]
• 05 Provide the pan-Canadian, toll-free quitline (1-866-366-3667)
• 06 Tell them to visit gosmokefree.gc.ca/quit
• 07 Provide a prescription to a drug therapy for smoking cessation
• 08 Recommend a drug therapy for smoking cessation
• 09 Recommend nicotine replacement therapy products
• 11   Recommend trying vaping
• 12   Provide nicotine replacement therapy products
• 13   Offer follow-up support at a smoking cessation clinic
• 14   Provide general advice, such as finding a support system, setting quit date, etc.
• 88   Other: Please specify: [TEXT BOX]
• 15   None, I don’t give advice to patients about quitting smoking

23. Do you schedule appointments with patients specifically to discuss smoking cessation?

• 01 Yes
• 02 No

24. How often do you follow-up with patients once they start the process of quitting smoking?

• 01 Every visit
• 02 Almost every visit
• 03 Annually
• 04 Once, then not again
• 05 Never
• 88 Other: Please specify: [TEXT BOX]
• 98 I don’t have any patients who have tried to quit smoking

[SKIP TO Q29 IF Q24=98]

25. When patients who have quit smoking have a relapse, what reasons do they give to explain the relapse?

Select all that apply

[ROTATE LIST]

• 01 Stress (unspecified)
• 02 Stressful life event
• 03 New friends/acquaintances who smoke
• 04 Feeling deprived/feeling sorry for oneself
• 05 Thought they could smoke occasionally
• 06 Couldn’t stop thinking about how much they enjoyed smoking
• 07 Depression/mental health
• 08 Spouse/partner/other family members still smoke
• 88 Other: Please specify: [TEXT BOX]
• 98 I haven’t had a patient relapse
• 99 My patients don’t give me a reason

26. How do your patients who are former smokers define “successful” quitting?

Select all that apply

[ROTATE LIST]

• 01 No longer craving cigarettes
• 02 No longer needing nicotine replacement therapies
• 03 Only needing nicotine replacement therapies
• 04 Going a certain period of time without having a cigarette
• 05 Going a certain period of time without having a craving
• 06 Being able to describe oneself as a former smoker
• 88 Other: Please specify: [TEXT BOX]
• 98 I haven’t had a patient quit smoking
• 99 Don’t know

27. If one of your patients completely switched from smoking cigarettes to using another product containing nicotine, would you consider this patient to have successfully quit smoking?

• 01 Yes
• 02 No

[ASK IF Q27=02]

28. Why would you not consider switching from smoking cigarettes to using another product containing nicotine successfully quitting smoking?

[TEXT BOX]

• 99   Don’t know

29. What challenges, if any, do you encounter in talking to patients about quitting smoking?

Select all that apply

[ROTATE LIST]

• 01 Lack of useful resources/tools to share with patients
• 02 Lack of awareness of useful resources/tools to share with patients
• 03 Lack of skills and knowledge needed to advise patients
• 04 Lack of training in smoking issues and cessation activities
• 05 Limited time for smoking cessation interventions during appointment
• 06 Limited time to follow-up with patients who are quitting smoking
• 07 Lack of referral experts
• 08 Poorly integrated health care system
• 09 There’s no incentive in my work setting to provide smoking cessation interventions
• 10 Patients are not receptive to receiving advice or help to quit
• 11 Lack of experience providing smoking cessation advice
• 12 Lack of comfort providing smoking cessation advice
• 88 Other. Please specify: [TEXT]
• 13 None, I don’t have any challenges

Section 3. Comfort Talking to Patients about Tobacco and Vaping Products

30. How comfortable are you talking to patients about the following?

[GRID]
[ROWS; RANDOMIZE ITEMS]

• a. Tobacco use
• b. Alcohol consumption
• c. Cannabis use
• d. Opioid use
• e. Smoking cessation
• f. Vaping products

[COLUMNS]

• 01 Not at all comfortable
• 02 Not very comfortable
• 03 Somewhat comfortable
• 04 Very comfortable
• 05 Does not apply

31. How knowledgeable do you feel about?

[GRID]
[ROWS]

• a. Smoking cessation
• b. Vaping products

[COLUMNS]

• 01 Not at all knowledgeable
• 02 Not very knowledgeable
• 03 Somewhat knowledgeable
• 04 Very knowledgeable

Section 4. Knowledge and Attitudes toward Tobacco, Nicotine and Vaping Products

These next questions are about your familiarity with various tobacco, nicotine and vaping products.

32. How familiar are you with the following tobacco, nicotine and vaping products?

[GRID]
[ROWS; RANDOMIZE ITEMS]

• a. Nicotine patches
• b. Nicotine gums
• c. Nicotine lozenges
• d. Nicotine inhalers
• e. Nicotine sprays
• f. Heated tobacco products¹² (iQOS™, PLOOM Tech™ Glo™)
• g. Vaping products (vape, vape pen, tank, pod, mod, & mini mod) (e.g., JUUL, Vype, Aspire, Eleaf, Joyetech, SMOK etc.)
• h. Smokeless tobacco products (e.g., chewing tobacco, snuff, snus, dip, chew)

[COLUMNS]

• 01 Never heard of it             
• 02 Heard of it but know nothing about it
• 03 Know a little
• 04 Know a fair amount
• 05 Know it well

33. In your opinion, how harmful, if at all, do you think each of the following are to the health of the person using them?

[GRID]
[ROWS; RANDOMIZE ITEMS]

• a. Smokeless tobacco products (e.g., chewing tobacco, pinch, dip, snuff)
• b. Heated tobacco products** (iQOSTM or GloTM)
• c. Nicotine replacement therapies (e.g., gums, lozenges, inhalers, sprays, patches)
• d. Vaping products WITH nicotine (vape, vape pen, pod, tank, mod & mini mod)
• e. Vaping products WITHOUT nicotine (vape, vape pen, pod, tank, mod & mini mod)
• f. Cigars/Little cigars
• g. Water-pipes with tobacco (also known as hookah, sheesha, narg-eelay, hubble-bubble, or gouza)
• h. Cigarettes
• i. Prescription drugs for smoking cessation (e.g., Champix, Zyban)

[COLUMNS]

• 01 Extremely harmful
• 02 Very harmful
• 03 Moderately harmful
• 04 A little harmful
• 05 Not at all harmful
• 99   Don’t know

34. How do you think it would affect the health of a smoker if they quit smoking cigarettes completely and switched to using the following products?

[GRID]
[ROWS; ROTATE]

• a) vaping products WITH nicotine
• b) vaping products WITHOUT nicotine

[COLUMNS]

• 01 Improve their health a lot
• 02 Improve their health a little
• 03 No effect on their health
• 04 Make their health a little worse
• 05 Make their health a lot worse
• 99   Don't know

35. Why do you think the health of a smoker will [INSERT] if they quit smoking cigarettes completely and switched to using  [SPLIT SAMPLE: vaping products WITH nicotine / vaping products WITHOUT nicotine]?

[TEXT BOX]

• 99   Don’t know

[INSERT]

• IF Q34 = 01: improve at lot
• IF Q34 = 02: improve a little
• IF Q34 = 03: not change
• IF Q34 = 04: be a little worse
• IF Q34 = 05: be a lot worse

36. Please indicate how strongly you agree or disagree with each of the following statements.

[GRID; RANDOMIZE]
[ROWS]

• a. Vaping with nicotine is as bad as smoking cigarettes.
• b. People who are dependant upon cigarettes could stop smoking if they really wanted to.
• c. Nicotine addiction is a disease.
• d. I don’t have much sympathy for people who smoke cigarettes.
• e. Giving smoking cessation advice is not part of my job.
• f. I don’t think it’s appropriate to ask a patient whether s/he smokes unless it’s directly related to the reason for the health care provider-patient interaction.
• g. The health risk to Canadians that is posed by tobacco has increased in the past five years.
• h. I have no interest in receiving additional training on smoking cessation.
• i. SPLIT SAMPLE: [I would be comfortable recommending vaping products if I knew there were product standards in place/I still would not recommend vaping products even if product standards were in place].

[COLUMNS]

• 01 Strongly disagree
• 02 Somewhat disagree
• 03 Neither disagree nor agree
• 04 Somewhat agree
• 05 Strongly agree

Section 5. Smoking Cessation and Vaping Products Resources

37. Where do you get information about smoking cessation and vaping products?

Select all that apply

[GRID]
[ROWS; ROTATE LIST]

• a. General internet search
• b. Colleague or co-worker
• c. Professional association
• d. Regulatory body
• e. Continuing Medical Education (CME) programs
• f. Professional insurer
• g. Conferences
• h. Webinars
• i. Social media
• j. Medical journals
• k. Health Canada
• l. Public Health Agency of Canada
• m. Centers for Disease Control and Prevention (CDC)
• n. Other: Please specify: [TEXT BOX]

[COLUMNS]

• Smoking cessation
• Vaping products

38. Which Health Canada resources, if any, have you consulted in the past few years?

Select all that apply

[ROTATE LIST]

• 01 Canada’s Tobacco Strategy (formerly the Federal Tobacco Control Strategy)
• 02 Consultation on the Future of Tobacco Control in Canada
• 03 Health Canada’s general website
• 04 Health Canada’s Quit Smoking Services and Information
• 05 Break It Off
• 06 Quit4Life
• 07 On the Road to Quitting
• 88   Other: Please specify: [TEXT BOX]
• 07   I have not consulted any of the above resources in the past few years (skip to Q40)

[ASK IF Q38 = 03]

39. When did you last consult Health Canada’s general website?

• 01 Within the last month
• 02 2 to 3 months ago
• 03 4 to 6 months ago
• 04 7 to 12 months ago
• 05 1 to 2 years ago
• 06 More than 2 years ago
• 07 Can’t recall

40. How often do you send patients home with information about smoking cessation?

• 01 Never - SKIP TO Q42
• 02 Rarely
• 03 Sometimes
• 04 Often
• 05 Always

41. What information about smoking cessation do you typically send home with patients?

Select all that apply

[ROTATE LIST]

• 01 Booklets or pamphlets
• 02 Fact sheets
• 03 Links to online/web-based resources
• 88   Other: Please specify: [TEXT BOX]

42. When communicating with patients about smoking cessation, what messages or approaches have you found particularly effective?

[TEXT BOX]

• 99   I don’t know

Final Thoughts

We have just a few final questions for you.

43. Some people say smoking rates in Canada are decreasing and public focus should now be on other health issues, such as obesity or wait times. Other people say there are still 4.6 million smokers in Canada so tobacco should continue to be a high priority. From your own point of view, should tobacco continue to be a high government priority?

• 01 Yes
• 02 No

44. Based on your experience, how can Health Canada best help health care providers encourage patients who smoke to [SPLIT SAMPLE: quit smoking / switch to vaping products]?

[TEXT BOX]

• 99   I don’t know

Respondent Profile

The following are questions to help us to group the results. Your responses will be anonymous and kept strictly confidential.

45. Please indicate how strongly you agree or disagree with each of the following statements.

• a. It’s important to own your actions, mistakes, and current life situation.
• b. It’s more important to be happy than to be wealthy.
• c. I strive to follow the traditions handed down to me from my family or religion.
• d. Life is short so I do things that bring me joy.
• e. It’s important to be honest even if you risk hurting someone by telling the truth.
• f. I prefer to do work that isn’t overly interesting but pays well
• g. I like to put myself in another person's shoes and to imagine how I would have felt in his/her place
• h. If you want to learn and grow in life, it is essential to meet and converse with different kinds of people, who come from all kinds of backgrounds
• i. I often buy things just because they are beautiful, whether or not they are practical

[COLUMNS]

• 01 Strongly disagree
• 02 Somewhat disagree
• 03 Neither disagree nor agree
• 04 Somewhat agree
• 05 Strongly agree

46. As a health care provider, are you…?

• 01 Just starting your career
• 02 Mid-career
• 03 Close to retirement
• 99  Prefer not to say

47. Which of the following best describes the area where your primary place of work is located?

• 01 Large urban population centre (more than 100,000 individuals)
• 02 Medium population centre (between 30,000 and 100,000 individuals)
• 03 Small population centre (between 1,000 and 29,999 individuals)
• 04 Rural location
• 99  Prefer not to say

48. Which of the following patient populations do you typically serve?

Select all that apply

[ROTATE LIST]

• 01 Patients who speak neither French nor English
• 02 New Canadians
• 03 Acute care patients
• 04 Patients with chronic illnesses
• 05 Lower income communities
• 06 Seniors (65+ years)
• 07 Indigenous patients
• 88   Other: Please specify: [TEXT BOX]

49. At the present time, do you smoke cigarettes every day, occasionally or not at all?

• 01 Every day - SKIP TO COMPLETION PAGE                                       
• 02 Occasionally - SKIP TO COMPLETION PAGE
• 03 Not at all - CONTINUE         

50. Have you ever smoked cigarettes?

• 01 Yes                                                                        
• 02 No         

Completion Page

Footnotes

1. https://www.canada.ca/en/health-canada/services/publications/healthy-living/canada-tobacco-strategy.html
2. Families/mothers and youth/teenagers/students were volunteered by respondents.
3. This includes patients who smoke, chew, or sniff tobacco.
4. Health care providers who do not see patients who use tobacco products were excluded from the survey.
5. This option was not presented to family physicians.
6. This option was not presented to family physicians.
7. These responses were not presented as options to respondents. They were volunteered.
8. Respondents were asked in an open-ended manner what messages or approaches they have found particularly effective. The response categories presented here reflect the analysis and grouping of such feedback into themes.
9. The response categories presented here reflect the analysis and grouping of respondents' verbatim feedback into themes.
10. The response categories presented here reflect the analysis and grouping of respondents' verbatim feedback into themes.
11. Include hyperlink to description of “vaping products”. Hyperlink: Vaping is the act of inhaling and exhaling an aerosol produced by a vaping product. These vaping products have many names, including mods, vapes, sub-ohms, vape pens, e-hookahs, tank systems, electronic cigarettes/e-cigarettes, or electronic nicotine delivery systems (ENDS). Vaping products may also be known by various brand names, such as JUUL, Vype, Aspire, Eleaf, Joyetech, or SMOK.
12. Hyperlink: Heated tobacco products (HTPs) are tobacco products that produce aerosols containing nicotine and other chemicals. HTPs are not e-cigarettes or vaping devices. HTPs heat tobacco to generate nicotine. E-cigarettes/vaping devices heat e-liquid, which may or may not contain nicotine.