Smoking Lived Experience Study

Final Report

Prepared for Health Canada

Supplier name: Earnscliffe Strategy Group

Contract number: HT372-204272/001/CY

Contract value: $227,293.62 (including HST)

Award date: January 19, 2021

Delivery date: April 19, 2021

Registration number: POR 103-20

For more information on this report, please contact Health Canada at:

hc.cpab.por-rop.dgcap.sc@canada.ca

Ce rapport est aussi disponible en français.

Smoking Lived Experience Study

Final Report

Prepared for Health Canada

Supplier name: Earnscliffe Strategy Group

April 2021

This public opinion research report presents the results of ethnographic diaries and in-depth interviews conducted by Earnscliffe Strategy Group on behalf of the Department of Health Canada. The research was conducted from February to March of 2021.

Cette publication est aussi disponible en français sous le titre : Étude sur l'expérience vécue en matière de tabagisme

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

Catalogue Number: H14-368/2021E-PDF

International Standard Book Number (ISBN): 978-0-660-39313-1

Related publications (registration number: POR 103-20)

Étude sur l'expérience vécue en matière de tabagisme Rapport final (Final Report, French)

ISBN 978-0-660-39314-8

^©Her Majesty the Queen in Right of Canada, as represented by the Minister of Health, 2021

TABLE OF CONTENTS

• EXECUTIVE SUMMARY
• INTRODUCTION
• DETAILED FINDINGS
• CONCLUSIONS
• APPENDIX A: METHODOLOGY REPORT
• APPENDIX B: PHASE 1 DIARY EXERCISE ACTIVITY GUIDE
• APPENDIX C: PHASE 2 IN-DEPTH INTERVIEW GUIDE
• APPENDIX D: RECRUITMENT SCREENER

EXECUTIVE SUMMARY

Earnscliffe Strategy Group (Earnscliffe) is pleased to present this report to Health Canada summarizing the results of the ethnographic and qualitative research exploring the lived experience of someone who smokes.

Health Canada sought to conduct this research as it continues to work towards the ambitious goal set out by Canada's Tobacco Strategy of lowering tobacco use among Canadians to 5% by the year 2035. Past research indicates that half of current smokers have made an attempt to quit in the past 12 months however this number decreases with age. There is significantly less research that has been conducted on real-time smoking behaviours. Therefore, in order to prevent the initiation of tobacco use, as well as support users in their cessation efforts to quit tobacco long-term, Health Canada contracted Earnscliffe to utilize a 'lived experience' approach. The specific objectives of the research were to gather information about smoking behaviours and feelings in real-time, with the overall goal of learning more about situations smokers typically find themselves in when smoking. Findings from the research will be used to help Health Canada develop new lines of messaging that focus on the experience of smoking. In addition, findings will also be used to provide program strategy and communications with a more fulsome understanding of smokers' patterns of behaviour to better meet their needs when they are ready to quit. The contract value for this project was $227,293.62 including HST.

To meet these objectives, Earnscliffe conducted a comprehensive two-phased research project. Phase 1 involved an ethnographic approach in order to understand participants' daily activities/lives. Participants were asked to journal about their daily lives on a daily basis for three weeks. While they were not provided with specific guidance to journal about their tobacco use, participants were aware of the focus of the study on smoking. Over the course of the engagement, participants were also asked to complete an initial introductory 'Getting to know you' activity and a 'Final thoughts' activity in addition to individual facilitator probing and discussion topics. This phase was comprised of a three-week diary exercise involving 110 participants across Canada. The diary exercise was conducted between February 19^th and March 12^th, 2021. Of the 110 participants, 21 participated in French and 89 participated in English. Participants were those who smoke daily with good representation across key demographics.

Following the initial diary exercise, we conducted a second wave of qualitative research, involving in-depth interviews with a select group of fifty (50) participants from the initial diary exercise. Participants were selected based on the thought and effort devoted to their diary reflections. Special attention was paid to ensure good representation of key demographics. The interviews were conducted by telephone between March 10^th and March 23^rd, 2021. Ten interviews were conducted in French, while the rest were conducted in English. The interviews were on average 30 minutes in length.

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

The key takeaways can be summarized as follows:

• Overall participation in the engagement was exemplary. Diary reflections were consistently detailed, thoughtful, personal, and sincere. Many participants were pleasantly surprised about how much they enjoyed maintaining a daily journal. In fact, maintaining a daily journal was a practice that several participants envisioned maintaining going forward.
  • When probed in the interviews whether maintaining a journal as part of a quit attempt would be a helpful exercise, several participants felt that it would, especially as a means to understand their tobacco use.
• Of the thousands of sentiments (thoughts, moods, feelings, etc.) expressed across all of the diary reflections, about half were expressions of a neutral (neither positive nor negative) feeling. Among the other half, positive feelings were expressed more than twice as often as negative feelings. And, while very few of the specific sentiments included variations of the words smoke or cigarette, when the terms came up, it was more often the case that the sentiment being expressed was positive in nature, rather than negative.
• Given this, it is perhaps not surprising to see that at a high level, participants tended to recount how they were feeling, as well as what they were doing and with whom over the course of their days.
• Having said that, almost all mentioned smoking at least once in their diary reflections; many mentioned it in at least half. A few participants did not mention smoking in any of their diary reflections.
• Participants expressed varying degrees of guilt and shame about their tobacco use in different ways over the course of the engagement. For most, smoking was not something they were particularly proud of or broadcast. In fact, but for a few participants who have no desire to quit, quitting smoking was raised in at least one diary reflection for the majority of participants.
• These mixed emotions and feelings related to their smoking behaviour perhaps explain why it did not figure prominently in ways one might have expected. For example, it did not figure prominently in reflections about what health (generally) and feeling good or great meant to them; what they would tell their five-year old self; or, where they go from here (after the diary exercise). It did, however, figure prominently in reflections about what three things they could give up that would give them more time, energy and peace.
• Observations of the diary reflections suggested that there were four primary roles of smoking as part of the lived experience of those who smoke daily: routine, coping mechanism (stress relief), reward and pleasure.
• The key themes that emerged related to smoking (some of which fall under the roles of smoking) included: the COVID-19 pandemic; a desire to quit or reduce smoking; stigma; and, use of other substances (alcohol or cannabis).
• Perhaps not surprising, the pandemic seemed to have had a profound impact on participants' lives. While there have been some positive impacts, most seemed to have been impacted adversely.
  • Upon further probing in the interviews, many participants indicated that dealing with the pandemic had resulted in increased tobacco use which was mainly attributed to increased stress/anxiety, boredom and/or increased opportunity to smoke.
• A desire to quit or reduce smoking was a theme that was raised in at least one diary reflection for the majority of participants. It was reflected in a variety of different ways: desire/intentions to quit; past quit attempts (both successful and unsuccessful); efforts to reduce the number of cigarettes they smoke; resisting the urge to smoke cigarettes; and, conversely, a cohort who has no intention to ever quit smoking.
• While not one of the more common themes observed in the reflections, stigma did come up in a number of ways. Participants mentioned hiding their tobacco use from certain family members (i.e., parents, spouses/partners, and especially children) and choosing when and where they smoke in public spaces which speaks to the guilt and shame they feel about their tobacco use.
  • Probing in the interviews revealed that those who did hide their tobacco use seemed to do so for a few reasons: so as not to set a bad example, especially for children; so that their personal brand/image was not defined by their tobacco use; and, to avoid receiving stigmatizing comments that were either judgemental or guilt-inducing.
• With respect to the correlation between smoking and the use of other substances, there definitely appeared to be a much stronger correlation between smoking and alcohol consumption than there was between smoking and cannabis consumption.
  • In the interviews, those who drink alcohol tended to describe smoking and drinking as behaviours that go together and a noticeable increase in cigarette smoking while drinking. The opposite was true for those who consume cannabis in that they felt they smoked less (and fewer cigarettes) when consuming cannabis.

Research Firm:

Earnscliffe Strategy Group Inc. (Earnscliffe)

Contract Number: HT372-203701/001/CY

Contract award date: November 17, 2020

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

Signed: Date: April 19, 2021

Stephanie Constable

Principal, Earnscliffe

INTRODUCTION

Earnscliffe Strategy Group (Earnscliffe) is pleased to present this report to Health Canada summarizing the results of the ethnographic and qualitative research exploring the lived experience of someone who smokes.

Health Canada sought to conduct this research as it continues to work towards the ambitious goal set out by Canada's Tobacco Strategy of lowering tobacco use among Canadians to 5% by the year 2035. Past research indicates that half of current smokers have made an attempt to quit in the past 12 months, however this number decreases with age. There is significantly less research that has been conducted on real-time smoking behaviours. Therefore, in order to prevent the initiation of tobacco use, as well as support users in their cessation efforts to quit tobacco long-term, Health Canada contracted Earnscliffe to utilize a 'lived experience' approach.

The specific objectives of the research were to gather information about smoking behaviours and feelings in real-time, with the overall goal of learning more about situations smokers typically find themselves in when smoking. Further, the research sought to understand how smokers are feeling at the time they are having a cigarette in order to combine both the behaviour and emotion of smoking simultaneously. More specifically, the objectives of the research included:

• Exploring daily patterns of smoking, in terms of:
  • Frequency,
  • Time of day,
  • People they are with, and
  • Other activities being conducted at the same time;
• Gauging the feelings experienced when smoking each particular cigarette;
• Investigating the motivation for having a cigarette in that moment; and,
• Examine any stigma experienced by those who smoke.

Findings from the research will be used to help Health Canada develop new lines of messaging that focus on the experience of smoking. In addition, findings will also be used to provide program strategy and communications with a more fulsome understanding of smokers' patterns of behaviour to better meet their needs when they are ready to quit.

To meet these objectives, Earnscliffe conducted a comprehensive two-phased research project.

Phase 1 involved an ethnographic approach in order to understand participants' daily activities/lives. Participants were asked to journal about their daily lives on a daily basis for three weeks. While they were not provided with specific guidance to journal about their tobacco use, participants were aware of the focus of the study on smoking. Over the course of the engagement, participants were also asked to complete an initial introductory 'Getting to know you' activity and a 'Final thoughts' activity in addition to individual facilitator probing and discussion topics. This phase was comprised of a three-week diary exercise involving 110 participants across Canada. The diary exercise was conducted between February 19^th and March 12^th, 2021. Of the 110 participants, 21 participated in French and 89 participated in English. Participants were those who smoke daily with good representation across key demographics.

Following the initial diary exercise, we conducted a second phase (Phase 2) of qualitative research, involving in-depth interviews with a select group of fifty (50) participants from the initial diary exercise. Participants were selected based on the thought and effort devoted to their diary reflections. Special attention was paid to ensure good representation of key demographics. The interviews were conducted by telephone between March 10^th and March 23^rd, 2021. Ten interviews were conducted in French, while the rest were conducted in English. The interviews were on average 30 minutes in length.

The following outlines the profile of participants that were recruited and participated in both phases:

Appended to this report are the methodology report, diary activity guide, in-depth interview guide, and recruitment screener.

DETAILED FINDINGS

This report presents the combined results of both phases of research. The main thrust of the results is informed by the initial ethnographic (diary) exercise with nuance informed by the follow-up in-depth interviews. The results are presented in four sections: background about the diary exercise; high-level results of the diary reflections; how smoking appeared (or did not appear) in the diary reflections; the role of smoking as part of the lived experience; and, key themes observed that related to smoking cigarettes.

Except where specifically identified, the findings also represent the combined results regardless of audience or language (English and French). Quotations used throughout the report were selected on the basis of bringing the analysis to life and providing unique verbatim commentary from participants across the various locations.

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

Please refer to Appendix A: Methodology Report for a glossary of terms used throughout this report.

Background about the Diary Exercise

The diary exercise was conducted over the course of three weeks. The engagement required participants to respond to an initial 'Getting to know you' activity on the first day, complete a minimum of one diary entry per day beginning the second day, and a 'Final thoughts' activity the third to last day of the engagement. In addition, participants were required to respond to four discussion topics that were added over the course of the engagement to build on the learnings as well as respond to individual moderator probing.

For the ethnographic diary exercise, participants were provided with little direction in terms of what they should journal about other than their daily lives (i.e., what they did that day, who they were with, how they were feeling, how they handled/addressed different situations and feelings over the course of the day, etc.). They were, however, encouraged to journal whenever, and as many times as they liked, over the course of each day. Worth noting, the platform is digital and intuitive with device adaptive design which meant participants had full access from any device at any time.

As the engagement was self-guided, other than the title of the project, Smoking Lived Experience, and a mention in the introduction of the objective of the study, "to understand the lived experience of someone who smokes," participants were not prompted to discuss smoking as part of their daily reflections nor did any of the initial or final activities mention smoking. The only specific reference to smoking over the course of the engagement was in individual moderator probing and three of the four additional discussion topics.

Finally, participants were asked not to mention anyone by name (either themselves or people they referred to in their diary reflections). They were also asked not to share personal photos but to rely on images available publicly online.

High-Level Results of the Diary Exercise

Overall participation in the engagement was exemplary. All tolled, there were 2,366 reflections and approximately 710,141 words recorded across all of the diary entries for all participants. The average entry was 300 words which was 20% more than the minimum we set of 250 words.

Diary reflections were consistently detailed, thoughtful, personal, and sincere, and many participants were pleasantly surprised about how much they enjoyed and appreciated the ritual of maintaining a daily journal. As one participant noted, "I've learned that writing and reflection on your day is important. It is something that I haven't been in the routine of doing recently, and I feel if most people were to take some time, everyday, to reflect, it would be greatly beneficial in many aspects of their life. It is like a form of meditation and therapy. I found it calming and totally satisfying to do at the end of each day."

In fact, some mentioned their intention to continue doing so on a daily basis. As part of the 'Final Thoughts' activity, when asked to reflect on their journaling experience and to re-introduce themselves, participants discussed how cathartic, relaxing, and positive keeping a daily diary had been. Participants felt that journaling allowed them to reflect on past choices, decisions, and work through feelings and emotions better. Some participants even compared journaling to meditation or therapy. They also reflected on: how routine smoking was in their lives; how much stress affects their tobacco use; and, how boring/routine life had become as a result of dealing with the COVID-19 pandemic. All of these will be explored in more detail in this report.

"Yes, I learned that I probably don't need to smoke to relieve my stress. I just need to relax and take a break and enjoy my family."

"Looking back at the diary entries over the last few weeks, I can really see that I am a creature of habit. I have a morning routine and I rarely stray from it. All of my routine activities throughout the day typically involve a cigarette. Coffee and cigarette. Play outside with the dog, cigarette. Run an errand, cigarette before jumping back into the car."

Despite the encouragement that they could enter as often as they liked over the course of each day, almost all participants entered only once per day to record their reflections. Of the few who entered more than once per day, it was either in error (posted the same journal twice in one day) or an entry in the morning about their plans for the day and then an entry at the end of the day recounting what actually happened.

Given the sheer volume of information collected over the course of the engagement, many thousands of sentiments were expressed across all of the diary reflections. About half were in expression of a neutral (neither positive nor negative) feeling. Among the other half, where a feeling was expressed one way or the other, positive feelings were expressed more than twice as often as negative ones. Very few of the specific sentiments (positive or negative) included any variation of the words smoke or cigarette, but again when the term came up, it was more often the case that the sentiment being expressed was positive in nature, rather than negative.

Given this, it is perhaps not surprising to see that at a high level, participants tended to recount how they were feeling and what they did most days. The following two exhibits illustrate the different topics discussed as well as the relative frequency of mention.

For ease of use in interpreting the following table (Exhibit A2), words that appeared at least 200 times throughout the diary reflections are depicted. Words such as prepositions, conjunctions and interjections have been suppressed to better flesh out the results.

The topic of smoking was raised spontaneously throughout the diary reflections. Almost all mentioned smoking in at least one diary reflection; many mentioned it in at least half of their diary reflections. As depicted in Exhibit A2, mentions of smoking cigarettes appeared in words such as: "smoke", "smoking", "cigarette(s)", and "smoked". Other captures not in Exhibit A2 given the infrequency of mentions were "pack(s)", "puff", "drag", and "[cigarette] butt".

How Smoking Appeared (or Did Not Appear) in the Diary Exercise

Perhaps because the title of this engagement, 'Smoking: Lived Experience', was visible to participants as was the objective, "to understand the lived experience of someone who smokes", almost all participants mentioned smoking in at least one of their daily diary reflections over the course of the three-week engagement. Many mentioned smoking in their first diary reflection and most mentioned it by their third reflection. And, while the subject did not necessarily figure prominently in all of participants' daily reflections, a few (8) participants never mentioned smoking in any of their diary reflections.

When asked why they did not mention smoking at all or often in their daily reflections, many explained that they do not think much about it or identify smoking as a characteristic about themselves. Incidentally, only a few participants mentioned the fact they smoke when asked to introduce themselves. As one participant explained, "I was just thinking, if someone asked me to describe myself, it would take me a long time to get to 'smoker'. And, I might never get there."

As we will see later in this report, it is perhaps worth noting here that most participants expressed varying degrees of guilt and shame about their tobacco use in different ways over the course of the engagement. While, when prompted, many said they do not hide the fact they smoke from others, smoke for pleasure (in addition to other reasons), and have no intentions to quit, the fact they smoke rarely seemed to be something they broadcast or particularly liked about themselves.

"It's similar to smoking [how I feel about my job]. I know it's bad for me, yet I spend more time thinking about it, feeling guilty about it, but doing nothing to change it."

"I often feel disappointed in myself that I've fallen into this 'smoking/addiction' trap and can't seem to climb out."

"I occasionally do get pleasure in smoking a cigarette but lately that pleasure is followed by disgust and maybe even a little shame and disappointment in myself."

In fact, smoking was not often raised in response to different questions where one might have expected it to come up.

• When asked, 'What health means to you?', the word smoking, in the context of it being bad for one's health, was only mentioned by a few participants. Most participants tended to think of health more holistically. They described it as very important and a state of being; as in mental, emotional and physical well-being. Some also spoke of regular exercise, a balanced diet, limiting toxic influences (i.e., resisting temptation, removing toxic people from their lives, relying less on vices), and the absence of ailments.

  "Health means everything. Without it, you're not left with much."

  "Mental, physical, financial, emotional and spiritual, combined. Feeling good in my skin and exuding that in a way that makes others do so, with a focus on sustainability and personal integrity.

  "Une alimentation saine, mais aussi couplée à de l'exercice physique. Des contacts avec les gens qu'on aime, car le mental est aussi très important." / [TRANSLATION] "A healthy diet, but also coupled with physical exercise. Contacts with people we love because the mental is also very important."

  "From the ages of 15 to 31, health meant nothing to me. I ate like crap, did lots of drugs and smoked so many cigarettes. Now I'm a health freak. My body looks amazing and I hate drugs. Just smoking. But in life you need to enjoy what makes you happy and choose your battles."

  When prompted how this view of health fits with their tobacco use, the irony was not lost on most participants. The majority recognized that smoking was not good for their health; however, many rationalized their tobacco use, did not feel they were ready to quit/reduce, or suggested they need to smoke for other reasons. These reasons included: for their health as they have defined it above (i.e., for their mental, emotional, and/or physical well-being) and choosing their vices/battles. Indeed, those who smoke often talked about other's having 'their own crutches' and unhealthy behaviours such as drinking, overeating, sugar, etc. Several also explained that they did other healthy things like exercise and eating well to offset their tobacco use while others spoke of having established an acceptable number of cigarettes, they could smoke per day to be 'healthy'.

  "Pour être actif, pour moi, il faut être bien mentalement et psychologiquement car ça va nous permettre d'être productif. Dans mon cas, la cigarette joue un grand rôle car elle me permet de respecter cet équilibre mental et psychologique. C'est un moyen de détente et de relaxation qui me permet d'être dans cet état." / [TRANSLATION] "To be active, for me, one has to be good mentally and psychologically because that allows us to be productive. In my case, cigarettes play a big role because they allow me to respect my mental and psychological equilibrium. It's a way to relax and unwind that allows me to be in that equilibrium."

  " I guess in my case, I would really like to quit but it's really hard. So as much as I can, I try to be fit so maybe even if I'm smoking I don't get really sick. Now that this answer made me realize this, I'm thinking, maybe the reason why I try to get fit at the same is that I want to enjoy smoking for as long as I can without getting sick."

  "I wish I wasn't asthmatic. And, because I love smoking it doesn't help because I don't want to quit anytime soon. There's nothing I can really do to stop this problem."

  A few older participants mentioned relying on the advice of their family doctors who were monitoring their tobacco use, with the expectation that they would advise them when they felt it was becoming problematic (to their health). Worth noting, as part of this discussion - which was focused specifically on the correlation between health and tobacco use - only 31 of 110 participants mentioned quitting smoking.

  Worth noting, while there were no gender differences in how many diary entries mentioned health with smoking or cigarettes, women mentioned health more in general than men. Those 18-35 and 36-50 years old were also more likely to mention health in the same diary as smoking or cigarettes than those 51-60 or 61+. Those with higher annual household incomes ($100k+) mentioned health and smoking or cigarettes less frequently (than those with incomes under $100k annually) as did those living in rural Canada (as opposed to those living in urban or suburban Canada).

• Similarly, when asked as part of a separate discussion, "What does feeling good mean to you? What would it take for you to feel great?", there were only three mentions of smoking. Two participants mentioned smoking as a reason they feel bad, whereas one participant mentioned smoking as the reason she feels good, "Le bien être et le tabagisme, vous allez trouvé cela bizarre si je vous dit, la cigarette comblait un vide. C'est comme une amie qui est là pour toi. J'aime son goût, elle me réconforte quand je suis stresser ou anxieuxe. Elle m'accompagne quand j'ai une joie à partager. J'ai vite compris qu'elle avait pris le contrôle de ma vie." [TRANSLATION] "Feeling good and smoking, you may find this strange when I say this, cigarettes fill a void for me. They're like a friend that is there for you. I love the taste. It comforts me when I'm stressed or anxious. It accompanies me when I have a joy to share. I quickly realized that it had taken control of my life."

• When asked, "If you could change one thing about yourself, what would it be?", several participants mentioned 'quit smoking.' However, it was the third most often mentioned response; it was much lower than, better myself/self-care/improve self-confidence and improve my health/exercise more/lose weight.

  If you could change one thing about yourself, what would it be?	n
  Better myself/Self-care/Improve self-confidence	39
  Improve my health/Exercise more/Lose weight	21
  Quit smoking	16
  Stop procrastinating	8
  Learn/Go back to school	6
  Manage money better/Make/Save more money	4
  More time to relax/Rest/Sleep	3
  Other	4
  Nothing/Wouldn't change anything about myself	9
  TOTAL	110

• As part of the 'Final thoughts' activity (Day 20 of the engagement), participants were asked, 'Where do you go from here?', thirteen (13) participants expressed a desire to stop smoking, while 11 said be more conscious of smoking. Both of these responses followed: keep journaling (36), no change (26), and be more conscious of my feelings and actions (22).
• As part of the same activity, twenty-six (26) participants said that they would tell their five-year old selves not to start smoking; and, only a handful of participants mentioned that that they would like to quit smoking as one of the things that they learned about themselves over the course of this engagement.

Interestingly, the one question where the plurality of participants mentioned smoking, where one might have expected, was in response to the question, 'What three things could you give up that would give you more time, energy and peace?'. Giving up smoking was by far the most popular response, followed by giving up junk/fatty/fast food, my job/chores, smartphones and social media.

The Role of Smoking As Part of the Lived Experience

Observations of the diary reflections suggested that there were four primary roles of smoking as part of the lived experience: routine, coping mechanism (stress relief), reward and pleasure. Unexpectedly, one participant characterized one of their reflections, and explained the role of smoking at different points throughout their day:

"I woke up this morning feeling good. I did not sleep a lot but I feel like the half sleep yesterday day and last night equaled a whole night's sleep. I got up and made coffee and sat at my laptop. I was drinking coffee and smoking which is routine. Work phoned and said they were very short and asked if I could come in for the remainder of the day shift to help them out. I agreed and got ready and I went to work. I was there for an hour and went for break. I went for a smoke which is routine. After a couple hours I went for lunch. I sat outside and smoked and ate lunch. This was routine. I went back to finish my day. They asked me to stay for a second shift and I agreed. I took an extra break in the afternoon and went out for a smoke. This was stress smoking. I went back to work and started my next shift. It was very busy and everything went wrong. I took first lunch and sat outside and smoked and did not really eat. This was stress smoking. I should have said no and gone home. On my next break I again sat outside and smoked. This would have been routine but it felt more frustrating/stress smoking. When my next break came the girls asked if I wanted to skip my break and leave early. I felt like I did not need to smoke so I agreed. After work I went home and unwound by sitting and smoking for a bit and then went to sleep."

Routine

The role of routine was prevalent throughout the majority of diary reflections (that mentioned smoking). In fact, it was mentioned quite regularly as a passing comment; it being a matter of course. When probed, many acknowledged that smoking had become so intrinsically part of their daily lives that the vast majority were not even cognizant of their tobacco use at different points throughout their days. One participant explained that they consider smoking, "as mundane as going to the bathroom". The most well-established routines tended to be around: drinking a morning coffee, work breaks, driving (often to work), while on a walk with the dog, after a meal (particularly dinner), with alcohol, and before bed. Worth noting, men were more likely than women to mention coffee and smoking or cigarettes in the same diary reflection.

"I had my usual cup of coffee and my morning cigarette to get my day going."

"Hello, well Tuesday ended up being a busy day. I got up around 8 AM, had a coffee and cigarette, watched the morning news."

"Had my last cigarette for the day before I head for an early night."

Notably, these established routines fit very well with the lifestyle preferences we gleaned when participants responded to the 'This or That?' task as part of the 'Getting to know you' activity on the first day of the engagement. It is worth acknowledging that these preferences only reflect the participants of this study; we do not have a comparison that illustrates how others (e.g., those who do not smoke regularly) would have completed the same task.

Figure 1 - Text description

The image shows a chart that represents the number of participants who selected a response. While there were 110 participants, totals could be greater or lesser than 110, as participants had the option of selecting both or neither options. The results are the following:

Card game	59	41
Time	60	46
Television	65	41
Cake	65	41
Alcohol	67	38
Streaming	68	40
Burger	69	42
Movies	70	44
Dog	70	34
Ocean	72	36
Dinner	73	43
PC	73	31
Sense of humour	77	35
Shower	82	30
Coffee	84	28
Music	93	12
Summer	93	11

In addition to the preference for coffee (over tea), dogs (over cats), alcohol (over cannabis), and dinner (over breakfast), some of the other lifestyle preferences that seemed to fit with the observations of the routine of smoking included:

• Preference for summer (over winter). Instances where this was observed in the reflections included: the ease of smoking outside in the summer months and not having to bundle up to go outside to smoke a cigarette; more frequent outdoor gatherings and socializing (post-pandemic). As one participant said, "I took several smoke breaks to break up the day and get outside to enjoy the weather, which always feels great coming out of a cold spell where the majority of time is spent indoors."
• Preference for oceans (over mountains). Where this was observed in the diary reflections was around the desire and yearning to vacation in the South again (post-pandemic). A few participants mentioned smoking more routinely in this setting, given the prevalence of smoking on and essence of (to be free and let go) all-inclusive ocean resorts. "Smoked more than I wanted to, but I was enjoying the sun and it made me think of being on the beach." Worth noting, as we will see later in this report, a few participants mentioned smoking less while on vacation.
• Preference for streaming (over cable), watching movies (over documentaries) and television (over books). While difficult to assess whether the frequency of these routines was higher given the pandemic (vs. pre-pandemic), participants certainly seemed to be watching a lot of media. Observed behaviour included spending time streaming content, watching a movie or sports (on cable) and depending on the company they were in, smoking cigarettes.

  "I called my friend to see if she would want to get together and watch Drag Race. We made plans to meet up. When we get to my friend's house, the first thing we do is smoke then we go inside to pour drinks and settle in for the show. We've watched the show together a few times now and kind of have a routine."

  When asked about the role of media as an influence on their tobacco use, most participants did not think that the media played a very important role. In fact, most participants did not think that smoking figures all that prominently in the media anymore (i.e., no ads and the prevalence of smoking in television or film is minimal). Having said that, several participants did volunteer that when they do see smoking in media, it does often elicit a craving for a cigarette.

• Preference for a card game (over a board game). While this was only observed among a few participants, playing poker seemed to routinely involve smoking (and sometimes more) cigarettes.

  "I was playing poker so when I'm in a tournament I usually smoke once an hour which is more than usual."

  "Had a great day playing poker in a million dollar tournament but never won anything but was in the top 25 percent. Overall everything went well. The only frustration I had was it was so cold and I won't smoke in house so I froze going outside. I guess that is good in a way as I didn't smoke that much."

Coping Mechanism (Stress Relief)

Not surprising, the role of smoking as a coping mechanism (stress relief) was very prevalent throughout the diary reflections. Whether it be work, schoolwork, interpersonal relationships, dealing with the pandemic, finances, or whatever, stress relief was often noted as an important trigger to indulge in cigarettes. And, when prompted, almost all participants indicated that they smoke more when they feel stressed or anxious, in addition to other uncomfortable feelings.

"What is the role of stress? I am much more likely to smoke when I am stressed, it feels like an adult version of sucking my thumb to be honest."

"I've been quite sensitive since I was young. As a teenager I cried a lot. Smoking has always allowed me to stop crying. I've quit a couple of times and cried almost non-stop until I had a cigarette. After my son's birth, I went about 2 weeks without a cigarette. I cried the whole time. Had a cigarette and felt back to normal...back in control of my emotions."

"I really got angry, to the point I had to remove myself from being around the kids or wife and just stewed in my rage and frustration and self-pity. It was a little thing that triggered a sense of everything going wrong, of failure, of everything being stacked against me. So I took a walk, had a smoke, and took a little 'me time' to get my emotions back under control."

In terms of interesting demographic differences, mentions of stress (and associated words such as anxiety, panic, depression) were mentioned in the same diary as smoking or cigarettes more for: those living alone/single, and those who identify as non-Caucasian or Indigenous. These terms appeared slightly less often in the same diary for those with higher annual household incomes (above $100k).

Of note, there was a divergence of effects observed related to cigarettes smoked in these instances. For many, there seemed to be a physiological benefit that was both pleasurable and stimulating. Participants indicated being better able to move on and focus as a result. For others, these were not always the most pleasurable cigarettes smoked; often smoked as a 'knee jerk' reaction to an uncomfortable situation. Indeed, we observed that, for some, the initial instances of pleasure or relaxation were quickly followed by feelings of guilt or shame. This seemed to be particularly acute when participants smoked multiple cigarettes in a row to help deal with a particularly stressful situation.

"My heart just sank and I immediately grabbed a cigarette. I ended up having three cigarettes in a row without even thinking what I was doing until after."

"My head space is really bad today now and when I usually would have had two or three cigarettes I've had five."

Worth noting, this range of benefits - physiological, spiritual and mental - was probed in more depth in the interviews. Consistent with the observations in the diary exercise, virtually all said their smoking tends to increase when they are feeling stressed. When asked if they could explain why that is, the tendency was to describe it as being largely a routine response, a comforting reaction. Some became pensive when asked this question, offering that it was a good, thought-provoking question they had not really considered. Probing into this stress-response behaviour elicited two very common sets of responses:

• Many either voluntarily raised that smoking enables them to step away from a stressful situation and that action alone is probably responsible for alleviating some stress, regardless of whether the cigarette offers any additional relief. Among those who did not voluntarily describe enabling a temporary removal from the stressor, when prompted, most did say they felt this was the case.

  "Yeah, I don't think it's the cigarette, exactly, that eases stress. It's the time away from what I'm doing."

  "But in the moment, I feel like better and like less stressed out like this is helping but I don't know if it's a mental thing, just taking that little moment away and breathing and just having that little time to yourself that's actually making you feel better?"

• There were also many participants who felt that the nicotine delivered by the cigarette has an independent, calming effect on them. Some felt the calming was from momentarily addressing the irritating demands of their addiction - satisfying the urge. Others felt that the chemicals in the cigarette were somehow calming.

  "I'm definitely more likely to smoke if I'm stressed. Because it definitely is a weird thing, right? Because it's like sometimes the stress is exaggerated by the physical urge for nicotine, which would not have existed had I not started smoking. So it's like a weird catch 22 in that way, which is kind of like the delivery of nicotine to begin with."

Many found it very difficult to provide firm answers on whether their stress levels would be worse or better handled if they were not a person who smokes. Many leaned toward assuming their stress would be the same, but they would rely on other ways to relieve it. Only a few felt that smoking itself may be contributing to increased stress.

Most said they have tried alternatives to smoking for dealing with stress at some point in their lives with varying degrees of claimed success. However, initial responses to this question tended to be about nicotine replacement options rather than other methods of coping with stress itself. When specifically asked about stress-reducing alternatives (i.e., yoga, meditation, exercise, breathing exercises), responses were mixed. Some participants, typically those who had not tried these alternatives, were curious as to whether they could be beneficial. While they could see the benefit of these alternatives (to their mental and physical well-being), they were skeptical as to their ability to curb their urge for a cigarette (other than keeping them busy/pre-occupied), which seemed to be a potential inhibitor. Others who had tried some of these alternatives, or had incorporated them into their lives already, implied that the relief provided by these alternatives was not the same relief provided by smoking a cigarette. One participant remarked that when they had tried yoga once in the past, they had to excuse themselves to smoke a cigarette to be able to focus on the practice because they were preoccupied with the thought of not being able to have a cigarette.

"Definitely exercise. I haven't really done too much meditation. But I noticed when I have days when I really want to exercise, and I just don't have the need for a cigarette."

"I've been doing the exercise, but the problem that I found is that, it's in certain moments, that the stress comes and I become irritable. [In those times] It's difficult to go and exercise in the middle of work."

Worth noting, as mentioned above, there seemed to be specific points in time throughout the reflections when participants commonly seemed to smoke less than expected/'normal'. This was observed when participants appeared to be busy or preoccupied with work, cleaning, yard work, playing with the kids, playing sports or doing physical activity (i.e., walking, hiking, skiing/snowboarding, etc.), while on vacation, and when sick or prior to upcoming surgery. As one participant explained, "My consumption [of cigarettes] has definitely increased over the years as my activity level and level of exciting opportunities (i.e. outside stuff: climbing, skiing, whitewater rafting, etc.) has decreased."

The few who were ill (i.e., virus, flu) over the course of the engagement stopped smoking cigarettes completely on each of the days they were ill. They acknowledged in their journals not having any desire to smoke a cigarette. Interestingly, one the first things they did as soon as they started to feel better was smoke a cigarette.

"Je n'ai presque rien mangé, je remange le potage le soir, on commande du mcdo pour les enfants car pas d'énergie pour faire à manger. Une fois les enfants couché, nous nous couchons nous aussi, très fatigué. Aujourd'hui je n'ai pas du tout fumé, au moins une bonne nouvelle." / [TRANSLATION] "I have hardly eaten anything, I ate leftovers, and we ordered McDonald's for the kids because we have no energy to cook. Once the kids are in bed, we go to bed too, very tired. Today, I didn't smoke at all, at least that's good news."

Reward

Perhaps not as prevalent as the role of routine or the role of coping mechanism in tobacco use, we did observe participants who smoked as a reward for having accomplished something. Some of the examples provided included smoking a cigarette in recognition of a work success; completion of a big task (i.e., cleaning the house); after exercise/workout; for good behaviour (i.e., seeing someone who often stigmatizes them for smoking); and, having resisted smoking cigarettes over the course of a day, among other things.

"What stood out for me is the fact that I often use the cigarette as a reward for everything I do whether it is negative or positive. My surprise was realizing it and seeing it on paper so to speak I guess (in my journaling). What I have learned about myself is that I need to find a new reward system other than smoking."

"It felt amazing to get outdoors and exercise while breathing in fresh crisp Canadian winter air. I got lots of sun too. To start the adventure I would have a smoke while walking on the lake. When I do hikes, usually when I get to the top of the goal location, I reward myself with another smoke."

Pleasure

Finally, the role of pleasure in tobacco use was also quite prevalent although it was not pleasurable for all. Our understanding of the role of pleasure also encapsulates smoking socially and in conjunction with consumption of other substances (i.e., coffee, alcohol, or cannabis). As observed in the diary reflections, smoking for pleasure was often tied to coffee drinking, socializing (especially with friends), after a meal, after exercise, with alcohol, or after sex.

Participants described the pleasure of smoking as a calming, relaxing, satisfying, centering, exhilarating sensation. Several spoke of the pure enjoyment of the ritual of smoking: slipping a cigarette out of the pack, lighting it, the draw (especially the first one), the taste, the feeling it creates at the back of the throat, and the deep breaths in and out. Some spoke of the pleasure of a pause, or "me time"; while, others described it as a stimulant that brought clarity and focus. As one participant explained, "The role of pleasure for me is to get 5 minutes alone sometimes. I enjoy watching the smoke leave my body. Everyone has a favourite part of the smoke; whether it's the inhale, the finger hold, etc. Mine is the exhale."

With respect to smoking and consumption of other substances, most participants do enjoy smoking with their morning coffee (which was also characterized as routine). In fact, the majority of participants mentioned the words smoking or cigarette with coffee in at least one diary reflection. As one participant explained, "Coffee and nicotine are a gloriously indulgent pleasure. So every morning is coffee and nicotine."

As we will see later in this report, smoking was also something pleasurable that some participants did while consuming other substances. Observations of the reflections certainly pointed to a strong correlation between smoking cigarettes (and more cigarettes) while drinking alcohol. The pleasure of a cigarette with a glass of wine or cold beer was often reflected in the diaries. Conversely, cannabis consumption was not always something that participants enjoyed with cigarettes.

Socializing with friends, especially friends who smoke, was another way in which smoking for pleasure was reflected in the diaries. Like alcohol, participants indicated that they tend to smoke more in these circumstances. Mentions of socializing in the same diary reflection as smoking or cigarettes was higher for men than women as well as those 61 years of age or older.

"The role of pleasure when it comes to smoking is enormous. I love it! I love the pause I get when I have a cigarette. It's my time."

"The role of smoking when it comes to pleasure, it that I often associate smoking with the social aspect of my life. In both the construction and music industry (my career and hobby) smoking is very commonplace during breaks, as a way to get outside and have a quick chat. While smoking surely isn't necessary, the common habit seems to bring people together in a strange way."

"For me the role of smoking in terms of pleasure is one of relaxation and is linked to the people I'm with and what I'm doing. For example, having drinks and playing a round of cards with my guy friends, camping or having a fire or cookout. I think enjoying a cigarette at those times is really about the pleasure of it."

Those who no longer derive pleasure from smoking tended to discuss the dependence on smoking and a sense that it plays a bigger role for them in other areas such as routine or as a coping mechanism. As one participant explained, "Pour moi, j'avais du plaisir a fumer quand j'étais plus jeune, à l'adolescence, mais maintenant fumer n'est plus un plaisir. Je n'ai pas besoin de fumer pour avoir du plaisir comme avant. Fumer est plus un besoin, une nécessité, une dépendance. Je n'associe pas le plaisir avec fumer." / [TRANSLATION] "For me, I did enjoy smoking when I was younger, as an adolescent, but smoking is no longer pleasurable. I don't need to smoke to have fun like I did before. Smoking is more a need, a necessity, a dependence. I don't associate smoking with pleasure."

Key Themes Observed that Related to Smoking Cigarettes

In addition to the role of smoking in the lived experience of someone who smokes cigarettes, there were a number of themes that were observed that related to tobacco use: the COVID-19 pandemic; the desire to quit or reduce smoking; stigma, and the use of other substances.

COVID-19 Pandemic

Perhaps not surprising, the pandemic seemed to have had a profound impact on participants' lives, especially residents of Ontario who mentioned the pandemic in their reflections more in general and in the same diary as smoking or cigarettes than any other region. For some, the impact has been positive. They spoke of having more time for self-reflection and self-care, with close family, and, the opportunity to re-evaluate/re-prioritize different aspects of their lives. The majority, however, seemed to have been impacted adversely; one extremely common sentiment offered was that this impact has resulted in increased stress levels. A few spoke of having lost their jobs, financial instability, grieving the loss of a loved one (which was especially difficult given social distancing restrictions). The majority spoke of general fatigue; being cooped up; boredom; the impacts of not being able to see family or friends, which was particularly difficult for those who live alone; and, missing the opportunity to do the things they enjoy doing (i.e., travel/vacations, going to the gym, sports, socializing, etc.).

The impacts of the pandemic on tobacco use varied and, depending on the participant and their personal living situation, resulted in both increased and diminished tobacco use. The main factors observed in the reflections seemed to be opportunity and mood (mental health, boredom, etc.).

Prompted more specifically in the interviews, many participants said that dealing with the pandemic has affected their tobacco use and any impact was consistently described as an increase in smoking. This was mainly attributed to the increased stress and anxiety they had been feeling coupled with the changes in their opportunity to smoke. For many, the circumstances of the pandemic have meant they are less often forced to be in places where smoking is prohibited. Being at home more, spending more time outside, spending less time in workplaces, businesses (e.g., stores, restaurants or bars) or less time on public transit have resulted in increased opportunity to light a cigarette.

"Yeah, especially like being home because I tend to smoke more when I'm at home and we're not doing anything right now other than going to work and coming home so I feel like I'm smoking a lot more."

"I would say, 'Yes, definitely'. I have noticed that I've been smoking more out of sheer boredom."

Worth noting, several mentioned having reduced their tobacco use from the initial stages of the pandemic to now. When probed, they explained this was partly due to reduced stress as we learned more and as the COVID-19 numbers decreased, and for a few, as they became more aware of their increased use.

For others, asked whether they felt this change in increased tobacco use would be temporary or sustained post-pandemic, while a few said they felt it would be temporary, it was more often the case that people said they "hoped" it would. It certainly seemed to be the aim for almost all and there was also a sense that as they returned to work, the opportunities to smoke would be more limited.

Desire to Quit or Reduce Smoking

The desire to quit or reduce smoking was a theme that was raised in at least one diary reflection for the majority of participants. It was reflected in a variety of different ways: desire/intentions to quit; past quit attempts (both short-term and long-term); efforts to reduce the number of cigarettes they smoke; and, resisting the urge to smoke cigarettes. As mentioned earlier, but for a few participants who have no desire to quit, the majority were preoccupied with what they know about the (negative) health consequences of smoking, their own feelings of guilt and shame, especially at being 'captive' to the addiction, as well as the cost and inconvenience of tobacco use. As one participant indicated, "I never quit quitting!!!"

To quit, several have fixed target quit dates in mind and have begun the process of quitting (i.e., reduced the number of cigarettes they smoke, are relying on nicotine replacement therapies such as gum and patches, begun using vape devices, etc.). However, the power of the addiction and the commensurate difficulty quitting was very well understood (and obvious) as participants rationalized why now is not the time to quit and that they will when they are ready (the time is right). There was definitely a sense that the conditions need to be right for a quit attempt, especially as participants do not wish to fail and worry about the perception (stigma) of an unsuccessful quit attempt (which adds another level of pressure). Worth noting, the pandemic seemed to provide additional justification to postpone a quit attempt (i.e. not ideal timing or conditions).

"I woke up feeling anxious, almost scared. It's like when you're on a diet and you're starving but you know what your daily ration is so you start to worry about food and being hungry. That's how I feel today, like I'm on a smoking diet. It's all so overwhelming. One minute I'm cool; the next I'm jonesing like a crackhead. I don't know what to do, so I smoked a cigarette, the whole thing."

"But that's what addiction feels like at this point. It's been more than 20 years I've been addicted to nicotine. I try to substitute and keep the smoking to a minimum, but it's not at all easy due to habituation and withdrawal. At this point, I just don't deal well with withdrawal. I find the more I exercise, the less I consume. COVID messes with all that though because the usual avenues aren't really available. So COVID plays nicely into the 'I'm gonna quit tomorrow' mantra of addiction."

A few participants referred to using a vaping device in their reflections although the reasons for doing so varied and were not strictly related to a quit attempt. Those who mentioned vaping reflected on doing so to help reduce/replace smoking cigarettes or to satisfy their urges at times when it is difficult to smoke a cigarette. A number seemed to question whether they were replacing cigarette smoking or had introduced a new routine.

"A few weeks ago I bought a vape device in the hopes of helping me cut back."

"Because I wasn't feeling the greatest, I did avoid going outside for too many smokes as I relied on my vape when necessary as I can enjoy it indoors."

"Limited my coffee and cigarette count [today]. Have been vaping more than smoking cigarettes. The discretion they offer can be really insidious."

"I bought a vape pen a few days ago thinking that I would try to have a few puffs of that when I feel like I really need a cigarette. However, I've had occasion to have a few puffs and then I still seem to want a cigarette very shortly after. It is not quite doing the trick."

As mentioned earlier, observations of the diary reflections also identified a small cohort of participants who have no desire to quit smoking. More often than not, this included those for whom the role of pleasure in smoking was preeminent. As one participant noted, "I'm comfortable with my current standing of living a healthy lifestyle including this vice of smoking. I would tell anyone who even remotely tries to hint about getting me to quit that I strongly believe in having quality of life, not quantity of life!"

Finally, when probed in the interviews whether maintaining a journal as part of a quit attempt would be a helpful exercise, several participants felt that it would, especially as a means to understand their tobacco use. Upon further probing, while a few felt that having to think of smoking might elicit a craving, others felt that the benefit of tracking their tobacco use as a means to hold themselves accountable would be beneficial.

Stigma

While not one of the more common themes observed in the reflections, stigma did come up in a number of ways. Participants mentioned hiding their tobacco use from certain family members (i.e., parents, spouses/partners, and especially children) and choosing when and where they smoke in public spaces. Even those not overly concerned about it, seemed to prefer not having strangers, clients/customers and/or new acquaintances witness to their tobacco use. Sometimes, such as when there were children in the vicinity, participants said they do not smoke to avoid exposing them to second-hand smoke or setting a bad example. We also observed that participants hid their tobacco use to avoid receiving stigmatizing comments that were either judgmental or guilt-inducing.

"While my teenage sons know I smoke - they've never actually seen it. They are only aware it takes place. I guess part of it is embarrassment and part of it is trying to set a good example but for whatever reason I've never wanted to smoke in front of them. I'm under no misunderstanding that smoking is bad for my health, I don't want my sons to do it and it seems like doing it in front of them is somehow making it seem more acceptable than them just knowing that I do it. While it's rarely discussed they've only really known for the last year or so - and considering the oldest is now 16 years old, that's a pretty impressive feat. It was only possible because I don't smoke that much and could go long periods of time without one - days when required on weekends or family vacations as examples."

"I try to keep my smoking to only a few a day if they are around. They have never seen me smoke. I've told them exactly why: because it's dumb, unhealthy, and if they see me doing it, it normalizes the behaviour."

"Later that day, I saw my sister, she asked me to go out and have a cigarette with her. I refuse to go out and smoke while visiting my Mom [in the hospital]. My Mom keeps pleading with us to quit smoking because of what she is going through."

That said, almost all reported that there were certainly times when they smoked openly in front of others. These tended to be either with trusted people who already know they smoke (and often, also smoke) or situations (such as in a designated smoking area) where they felt they were entirely within their right to smoke.

Of particular relevance to this topic, when asked, 'What does acceptance mean to you?', participants spoke of mutual respect, lack of judgment, equality, and being understood. This was very much in line with what participants most wanted those who do not smoke to know about those who do: be understanding, respectful, less judgmental, and remember that everyone has their own vice/coping mechanism. Some were a little more defensive in their position and would urge those who do not smoke to mind their own business and tell them that smoking is a personal choice that they make because they enjoy smoking. Finally, they also wished to remind them that smoking is very easy to start and much harder to stop.

When probed in the interviews, almost all have had people in their lives encourage them to quit or discourage them from smoking. Participants universally described tobacco use as something they would discourage anyone from starting and a very difficult addiction for them to stop once and for all. As mentioned, most have tried quitting at some time and many described intentionally reducing the number of cigarettes they smoke. There was often a sense of disappointment in oneself for not succeeding at quitting.

As observed in the diary reflections, participants understand that smoking is bad for their health and their behaviour is not due to a lack of knowledge of the risks, even if some underestimate the risks. Interviewees often explained that encouragement to quit could sometimes be judgmental or critical, rather than constructive and encouraging. For example, many described being frustrated with comments from people who do not smoke that assume the person who smokes must be unintelligent or not trying hard enough. Several participants also mentioned that people they knew who had managed to quit could be either constructive, empathetic and motivating or among the more judgmental.

Stigma was also observed in response to the question about how you respond to someone who asks you whether you have plans to quit. Indeed, in the interviews, participants revealed a lot of emotion in response to this question. While a lot of the emotion could be heated and reactionary, many said they would - and do - temper their comments. Some indicated a strong temptation to express something that effectively implied, "mind your own business" but may be more aggressively stated. Some said they took a "live and let live" approach hoping others recognized that we all have our faults and "you do you and I'll do me." Others said they would not engage at all because there was nothing to be gained by it.

Regardless of what, if anything, participants said they would want to say to these people, two things were often also mentioned that shed light on the way participants feel about their smoking. First, participants implied that they feel these people are often right - smoking is bad, and they should quit; and second, that quitting is something many would do but it is so much harder to do than the commenting people realize.

"Telling me 'it's bad for you, 'it's expensive' or 'you're just not trying hard enough', just makes me want to have a smoke. It's like explaining the colour blue to a blind person. Support and understanding would go a lot further than platitudes and criticism."

"When people ask me if I plan on quitting smoking I say 'yes'. I feel like I have to respond that way because if you say no or not yet, you get the 'you'll feel better', 'you'll save so much money', 'it's so bad for you' advice. I always want to respond with 'What? It's bad for me? How come they never told us?' Non-smokers seem to think smokers are stupid and think they are superior to us because they never started. Maybe they had easier lives or no anxiety and never felt the need to start something. When people inquire about my smoking habits it makes me feel ashamed that I started in the first place and like a failure for not being able to quit so far."

"I don't tell people not to drink or get high. I know plenty of people that do both every day but I am the pariah because I smoke cigarettes. I would just rather people not ask me at all."

Use of Other Substances

As mentioned earlier, one of the more important roles of smoking in the lived experience is pleasure which was highly correlated with consumption of other substances. As observed in the diary reflections, there definitely appeared to be a much stronger correlation between smoking and alcohol consumption than there was between smoking and cannabis consumption.

In terms of interesting demographic differences, men were more likely to mention alcohol consumption in more diary reflections in general and slightly more likely to mention it in the same diary reflection with smoking or cigarettes. Mentions of alcohol or cannabis consumption and smoking or cigarettes in the same diary reflection was also higher for those 18-35 years of age and those living in suburban or rural parts of Canada.

When probed in the interviews, those who drink alcohol often said they have a tendency to smoke more cigarettes when they are doing so, although it was not universal. There was certainly a sense that the combination of cigarette smoking and alcohol consumption were heavily influenced by the social circles with whom they found themselves at any given time. Worth noting, a few who had quit smoking in the past mentioned having been triggered to start smoking again while socializing (at a party or with friends, with alcohol).

"We drove over to their parents' house and proceeded to make dinner. Dinner consisted of potatoes and BBQ ribs. I had a glass or two of wine and the conversations flowed between conspiracy theories and the abusive powers of the RCMP. This calls for many cigarette breaks as these type of conversations get quite heated and everybody smokes in the household so there is lots of time for smoke breaks."

However, when it comes to cannabis, few participants described cannabis use as increasing the number of cigarettes they smoke. In fact, some said the opposite was true - that smoking cannabis made them less inclined to have a cigarette. A few mentioned mixing tobacco with cannabis which might relate to the amount of tobacco they use but was also described as enhancing the effect in some way.

To understand the relative stigma associated with smoking as compared to alcohol drinking or cannabis consumption, we probed the notion of hiding alcohol or cannabis consumption in the interviews. The question was met with quite different reactions than hiding cigarette smoking. With respect to alcohol, most did not feel the need to hide the fact they drank alcohol. Although a few described hiding it when they were underage or in rare circumstances when they had perhaps over-indulged or have had a drinking problem, the tendency was for participants to feel there was no reason to hide alcohol consumption. It was described as something acceptable and done by most others they are around when they are doing it.

Hiding cannabis use was something that some described doing, perhaps more so during the years it was not legal. A few did say they try not to smoke cannabis near neighbours and would not want clients or perhaps employers to know they smoke cannabis, because of the sense of it being seen as an irresponsible thing to do. Smoking cannabis in front of others seemed to be described as something that was done only among those with whom one was already comfortable smoking cannabis. Discussions suggested the nature of the stigma around cannabis consumption was different (than smoking cigarettes) - judgmental still, but perhaps less hostile, irritating or insulting.

CONCLUSIONS

The purpose of this research was to help Health Canada understand the lived experience of someone who smokes daily to understand the patterns, motivations and feelings related to cigarette smoking. The ethnographic qualitative research demonstrated that despite the fact that tobacco use was not always mentioned or top of mind, it certainly seemed to play a variety of important, if not, complex, roles in the lived experience of someone who smokes.

In terms of feelings, of the thousands of sentiments expressed across all of the diary reflections, about half were neutral, while of the other half, positive feelings were expressed more than twice as often as negative feelings. And, while very few of the specific sentiments included variations of the words smoke or cigarette, when the terms came up (in at least one diary reflection for almost all participants), it was more often the case that participants were expressing positive, rather than negative, feelings.

Yet while participants can express generally positive feelings about their tobacco use, they do not hide the fact they smoke from others, smoke for pleasure (among other reasons), and have no intentions to quit; the fact they smoke rarely seemed to be something they broadcast or particularly liked about themselves.

This complex set of views and feelings may explain why smoking, or quitting smoking, did not figure prominently over the course of the engagement in ways some might have expected. For example, on the topic of health, despite the fact the vast majority of participants were well aware of the health risks associated with smoking, very few raised smoking or, more importantly, quitting smoking when they reflected on what health means to them. In fact, when prompted, some went so far as to explain that their tobacco use was in fact among the reasons they made healthy lifestyle choices (i.e., exercise, meditation/yoga) a priority; to offset the risk associated with their tobacco use.

That being said, the desire to quit or reduce smoking was a theme that was raised in at least one diary reflection for the majority of participants although there was a cohort who has no intention of ever quitting. Accomplishment of such, however, was certainly something the vast majority described as a daunting task and one in which all of the stars need to be aligned before making a quit attempt to limit the potential for failure.

As observed in the diary reflections, a failed quit attempt was an important motivational barrier that seemed to play into the "I'll quit when I'm ready" mentality and the stigma that almost all have experienced at one time or another. While not one of the more common themes observed in the reflections, participants did mention hiding their tobacco use so as not to set a bad example for children; so that their personal brand/image was not defined by their tobacco use; and, to avoid receiving stigmatizing comments that were either judgemental or guilt-inducing.

Which brings us to the perceived roles of smoking: routine; as a coping mechanism (stress relief); as a reward; and, for pleasure. While each of these roles were exhibited by the vast majority of participants, the importance of each varied by participant. The role of routine was observed regularly and in ways that suggest the vast majority were not even cognizant of their tobacco use at different points throughout the day. The role of smoking as a coping mechanism was also quite prevalent and perhaps moreso given the timing of the study and increased stress/anxiety as a result of dealing with the global COVID-19 pandemic. The role of smoking a cigarette as a reward was offered by some participants for having accomplished something including, as mentioned above, doing physical exercise. And, lastly, the role of smoking for pleasure which was tied to social interactions, use of other substances (i.e., alcohol and cannabis), the privilege of alone time, and, also the pleasure associated with the ritual of smoking a cigarette (i.e., lighting it, the draw, the taste, the feeling it creates, etc.).

APPENDIX A: METHODOLOGY REPORT

Methodology

This qualitative project involved two research phases: an initial 3-week diary exercise followed by in-depth interviews.

The diary exercise was conducted separately in English and French and was comprised of participants recruited by Quality response who met the requirements laid out in the screener (Appendix D).

In total, 110 participants across Canada completed the initial 3-week diary exercise; 50 participants were selected from among that group to participate in a 30-minute in-depth interview.

The diary exercise was conducted over a period of 21 days, from February 19 ^th to March 12^th, 2021. Of the 110 participants, 21 participated in French and 89 participated in English. Participants were those who smoke daily with good representation across key demographics (as outlined below). Participants were offered a $525 incentive as a thank-you for their time. Only those who completed all the required activities were eligible to receive the incentive.

The diary exercises were hosted online using Recollective, an industry-leading research tool for developing robust insights communities and conducting online research studies of any duration and size. Recollective was developed by the Ramius Corporation (Ramius), an enterprise social software and services company.

This platform allows the moderator to program modules, made up of different activities, for participants to complete. The platform afforded participants the flexibility to complete a daily journal whenever they wanted over the course of each day. The flexibility to access the diary from any device and at a time convenient to them was an important feature to gain a real sense of the daily lives, and more specifically, the feelings, interactions, and routines of people who smoke. The activities for this study included fill in the blanks, open-ended text responses, image uploads, in addition to the recurring daily diary exercise. Participants were prompted to log in daily to complete their journal activity, as well as respond to moderator questions and additional discussion topics added over the course of the 3 week engagement. Participants were not able to view or engage with any other participants, however periodically many were asked to respond to follow-up questions posed by the moderator.

Following the initial diary exercise, we conducted fifty (50) in-depth interviews with a select group of participants from the initial diary exercise. Participants were selected based on the thought and effort devoted to their diary reflections. Special attention was paid to ensure good representation of key demographics (as outlined below). The interviews were conducted by telephone from March 10th to March 23rd, 2021. Ten interviews were conducted in French, while the rest were conducted in English. The interviews were on average of a 30 minute duration. Participants were offered a $75 honorarium as a thank you for their time.

Below is a table to show the demographic representation among interviewees.

Recruitment

Participants were recruited using a screening questionnaire (Appendix D). Participants were recruited at the outset with the understanding that they may be required to complete both phases (the initial diary exercise and the follow up in-depth interview).

The fifty (50) participants selected to take part in the second interview phase were selected based on the thought and care they demonstrated in their diary reflections, with special careful attention paid to ensure representation based on key demographics such as age, gender, location, community type, and ethnicity (as outlined above). Quality Response followed up with selected participants to schedule a mutually convenient interview date and time.

The target audience for the research were adults 18+ who smoke regularly (defined as daily or almost daily use), and have been smoking for at least 5 years. The screener contained a series of standard screening questions to ensure participants qualified based on their ages and smoking behaviours. Additionally, we screened participants to ensure we aimed for a good mix of gender, region, household income, ethnicity, etc.

Quality Response and their selected suppliers reached out to members of their respective databases first via email and followed up with telephone calls to pre-qualify participants for speed and economies. All participants were contacted pre-group to confirm attendance.

For residents of Ontario, Quality Response relied on their proprietary database of Canadians. For residents of other cities, Quality Response used selected suppliers who each have their own respective proprietary database of Canadians living in their local area. For residents of Atlantic Canada, Manitoba, Saskatchewan, and Northern Canada Quality response relied on the assistance of Metroline. For residents of Quebec, Quality Response relied on the assistance of MBA Recherche. For residents of Albert, Quality Response relied on the assistance of Qualitative Coordination. For residents of British Columbia, Quality Response relied on the assistance of Walmsley Research.

Quality Response's database includes approximately 35,000 Canadians with profiling on a range of attributes including standard personal demographics, household composition, medical background, technology usage, financial services, health and wellness, business profiles, and other relevant criteria. Potential group participants are recruited to their database via mixed-mode: following a proprietary telephone survey, online, referral, social media and print advertising. Initial contact is often made via email or online pre-screening for speed and economies, followed up by personal telephone recruitment and pre-group attendance confirmation.

Metroline's database varies. Their Halifax database includes 5,300 Canadians. New participants are added to their database via referrals and online advertising. Metroline profiles their database based on a variety of characteristics including but not limited to: location; marital status; occupation; income; smoking behaviours; drinking behaviours etc.

MBA Recherche has a vast database of 35,000 Canadians across Quebec. They use Google ads, their website, telephone RDD lists, and referrals to recruit new participants. In addition to a variety of demographics, MBA Recherche's profiling includes automobile types, substance use, and mobile phone attributes.

Qualitative Coordination's database is approximately 5,500 Canadians. Qualitative Coordination uses referrals and online advertisements to find new participants. Their database is not profiled, and new registrants are only asked for their full name, email address, date of birth, and where they reside.

Walmsley Research's database is comprised of approximately 5,500 Canadians. They rely on referrals and online advertisements to recruit to their database. In addition to a variety of demographics, their database is profiled for: age of children, occupation, spouse's occupation, health issues, etc.

Moderation

For the initial diary exercise, two moderators were charged with monitoring the online communities over the course of the week, ensuring participants completed the modules and probing for further information when required. Each moderator took notes and summarized their findings and debriefed periodically throughout the diary exercise to ensure that new, interesting findings were recognized and probed over the course of the engagement.

For the follow-up in-depth interviews, four facilitators were involved in conducting the interviews although the bulk of interviews were conducted by the project lead. After the initial interviews, our project lead led a debrief session with the other interviewers to ensure understanding of the objectives, familiarity with the guide, interview flow, and key themes to probe/pay attention to.

A note about interpreting qualitative research results

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

Reporting

Except where specifically identified, the findings represent the combined results regardless of location or language (English and French). Quotations exhibited throughout the report are selected on the sole basis of bringing the report to life, and providing unique verbatim commentary from the participants across the various locations.

Glossary of terms

The following is a glossary of terms used throughout the report. These phrases are used when groups of participants share a specific point of view. Unless otherwise stated, it should not be taken to mean that the rest of participants disagreed with the point; rather others either did not comment or did not have a strong opinion on the question.

APPENDIX B: PHASE 1 DIARY EXERCISE ACTIVITY GUIDE

Diary Home Page

[DISPLAY NAMES & PHOTOS OF MODERATORS]

Hello! Thank you so much for agreeing to share your experiences, thoughts and feelings with us over the next few weeks.

As your study facilitators, we're looking forward to uncovering new insights with you. We work at an independent public affairs and market research company called Earnscliffe. We are conducting this diary exercise on behalf of the Government of Canada and Health Canada more specifically. The objectives of this study are to understand the lived experience of someone who smokes.

As this is a diary exercise, you are encouraged to enter whenever and as often as you like throughout each day. Each day there will be a few short programmed questions to answer in addition to your diary entries. Again, your diary entry can be completed at multiple times throughout the day.

You are encouraged to be as open, honest and detailed in your diary entries as possible. The more colour you can add to help us understand, especially how you're feeling and how you react to different situations in your day, the better.

Please note, this platform is highly intuitive and adapts to your device whether you are logging in using a computer, tablet or smartphone - so don't be afraid to journal throughout each day, to share what you're doing, where and who you are with, but especially your thoughts and feelings, both positive and negative.

This page will display your next available activity as well as any relevant updates. Please check in regularly because we expect to be adding discussions on new topics at different points over the course of the three weeks. And, please don't hesitate to contact us if you have any questions or concerns.

Your first activity is ready!

Getting to Know You

LIVE: Friday, February 19, 2021 (@ 12 pm EST)

[TASK 1]: Let's get started

Welcome to this first ice-breaker activity!

We would like to take a few minutes to get to know you a little better. We also want to make sure you are comfortable using the platform and the various tools we will be using throughout the discussion. Today will be focused primarily on learning a little bit more about you, whereas the rest of your daily exercises will be much more open for you to simply reflect on your day, in as much detail as possible.

If you're ready to get started, go ahead and click on the "continue" button.

[TASK 2]: Where do you live?

In which part of the country do you live? Please click on the map below and then drag and drop the yellow circle marker onto the part of the country in which you live. Once you've done that, click the red pin labelled "I live here". Please place the pin as close as you can to where you live in Canada.

[TASK 3]: Introduce yourself [IMAGE UPLOAD]

Please take a moment to tell us a bit about yourself and bring your interests to life.

To do so, please tell us what makes you unique and upload a photo that represents your interests. This photo should not be of you but rather it should be from a different source (i.e., Google images, etc.) but should depict something you're passionate about.

[TASK 4]: This or That? [IMAGE SORT]

Now let's have a little fun! We have curated a list of This or That questions.

Please sort through the cards by selecting this or that (the one you prefer of the two). Simply drag and drop the one you prefer of each pair into the THUMBS UP box. Have fun!

• Coffee or Tea
• Cat or Dog
• Breakfast or Dinner
• Music or Podcasts
• Cake or Pie
• Bath or Shower
• Burger or Taco
• Money or Time
• Intelligence or Sense of humour
• Winter or Summer
• TV or Book
• Ocean or Mountains
• Mac or PC
• Card game or Board game
• Alcohol or Cannabis
• Movies or Documentaries
• Cable or Streaming

[TASK 5] Getting to Know You

Seeing as this study is a diary exercise in which you will be sharing your experiences, thoughts and feelings each day, we wanted to start with some reflections to help get you in the right frame of mind.

What does your ideal day look like? Be specific - who are you with (if anyone) (i.e., a spouse/partner, a loved one, a friend, - no proper names please)? What are you doing? How do you feel?

What do you love most about yourself? Why?

If you could change one thing about yourself, what would it be and, if anything, what's stopping you from taking action?

How are you feeling about taking part in this study? What are your hopes, fears (if any) and expectations? Why?

[TASK 6] Quality of Life

Now let's explore how you define different aspects of quality of life.

• What does health mean to you?
• What does happiness mean to you?
• What does acceptance mean to you?
• What does financial stability mean to you?

[TASK 7]: Well done!

Thank you for completing this first ice-breaker activity! We enjoyed getting to know you and we look forward to hearing about your day tomorrow.

Daily Diary Entry

LIVE: Saturday, February 20, 2021 - Friday, March 12, 2021 (@ 11:59 pm EST)

[TASK 1] Mood

Welcome back! Please find a picture online that BEST captures your mood (how you feel) today. Please make sure to pick a picture online, not one of your own personal photos.

Why did you select this picture?

[TASK 2] Diary Reflection

Now we would love for you to take us through your day. Be sure to include as much detail as you can, especially your thoughts and emotions, so we can really picture the whole thing. What did your life look and feel like today? What were you doing? Who were you with (please describe your relationship rather than using proper names)? How did you feel? How did you handle different situations and address different feelings throughout your day? If you weren't feeling quite yourself at any point in the day, what (if anything) did you do to make yourself feel better or change your frame of mind?

Feel free to write in your diary first thing in the morning for the previous day, at the end of the day, or at multiple points throughout the day!

[TASK 3]: Well done!

Please click submit to complete your diary entry. Thank you for your input and for sharing J We look forward to hearing about your day tomorrow. Talk to you then!

Final Thoughts

LIVE: Wednesday, March 10, 2021 to Friday, March 12, 2021 (@ 11:59 pm PST)

[TASK 1] Re-introduce yourself [IMAGE UPLOAD]

Welcome back! Today's activities will be centred around your experience having participated in this study.

As you reflect on your diary entries over the past three weeks, please take a moment to tell us… What you have learned about yourself? What stood out for you? Were there any surprises?

Please find a picture online that BEST captures what you have learned about yourself. Please make sure to pick a picture online, not one of your own personal photos.

Why did you select this picture?

[TASK 2]: Journaling

In the spirit of this engagement, we wanted to wind down with some final reflections.

What would you tell your five-year old self?

What three things could you give up that would give you more time, energy, and peace?

Assuming your life is a story and you are the author, what does your happy ending look like?

What one word best describes your best life moving forward?

[TASK 3]: Lasting changes?

Where do you go from here? In other words, how will this engagement impact your day-to-day going forward, if at all? PS - It's ok if the answer is "it won't"; again, there is no judgment, just curiosity…

[TASK 4]: Understanding people who smoke

What would you most want people who do not smoke to know/understand about people who do smoke?

[TASK 5]: Well done!

Thank you for completing these final thoughts and for sharing over the past few weeks. We have really enjoyed getting to know you through your diary entries.

We're not quite done yet… the last day for daily diary entries is Friday, March 12, 2021. We look forward to reading your last reflectionsJ

Additional Discussions (added throughout the engagement)

LIVE: Tuesday, February 23, 2021

[TITLE]: Feeling Good

What does feeling 'good' mean to you? Would you say you currently feel 'good'? What would it take to feel 'great'?

LIVE: Wednesday, February 24, 2021

[TITLE]: Health Priorities

Reflecting on your diary entries, there appears to be a strong interest in being active and healthy. How does being active and healthy fit with smoking cigarettes?

LIVE: Friday, March 5, 2021

[TITLE]: The Role of Smoking

For you, when it comes to smoking…

• What is the role of pleasure?
• What is the role of stress?
• What is the role of routine?
• What is the role of media (TV, film, etc.)?

As you input your responses, please be sure to add the specific qualifying words so that we know which you are referring to (i.e., The role of pleasure is xxx, the role of stress is xxx, etc.).

LIVE: Monday, March 8, 2021

[TITLE]: That Question

When someone asks you whether you have plans to quit smoking, what do you tell them? Do you feel you have to say "yes" when they ask you that question? Why? And, when you do say "yes", as a percentage, how strong is your conviction?

APPENDIX C: PHASE 2 IN-DEPTH INTERVIEW GUIDE

Name:

Date/Time:

Phone number:

Interview conducted by:

Highlights for each interviewee extracted from the diary reflections:

Thank you for agreeing to take part in this next phase of the Smoking Lived Experience project on behalf of Health Canada. We want to thank you so much for sharing your experiences with us as part of the initial diary phase. We very much appreciated the thought and care you put into your reflections and wanted to meet with you to discuss some of the things we learned so that we can better understand your experience.

Before we begin the interview, I just want to remind you that:

• There are no right or wrong answers, so please speak openly and frankly.
• It is also important to note that we are researchers and curious by nature. We are not trying to convince you of anything or provide a perspective. And, most importantly, there is no judgment on our parts. We are just trying our best to understand smoking through your experiences. And, if at any point you don't feel comfortable answering a specific question, please let me know.
• As with the diary reflections, results are confidential. Your name is anonymous and your views, as well as those of others participating in the research, are compiled into a report that will provide feedback to Health Canada.
• We will be recording the interview for reporting purposes as it is difficult to take notes and lead the conversation at the same time.
• With your approval, we would also like to share a transcript of the interview; again, any personal identifiable information would be removed beforehand.
• Do you approve of us sharing a transcript of the interview with Health Canada?
• The interview will last approximately 20-30 minutes.

Impact of the COVID-19 Pandemic on Smoking Behaviour

As you know, we are currently dealing with an unprecedented (and historic) moment with the COVID-19 pandemic. Wondering if we could start by talking a little bit about how it has impacted your life, and more specifically, your smoking behaviour.

• Overall, how would you say the pandemic has affected your life? Why? How so?
• And, how would you say the pandemic has affected your smoking behaviour, if at all?
  • Have you noticed any differences in your smoking behaviour (i.e. smoking more/less, in different situations, at different times, etc.)?
  • [IF YES] What differences have you noticed? Why do you think that is?
• Do you think that the changes in your smoking behaviour during the pandemic will be behaviours you continue going forward? Why or why not? Which ones?

Mental Health/Stress

• One of the common threads that we detected in the diary reflections was around mental health and stress.
• In general, how would you describe your mental health these days - would you say it is excellent, good, fair or poor? Why?
• [IF NOT MENTIONED EARLIER] What would you say are the biggest stressors/challenges you are facing?
• How big of an influence is stress on your smoking behaviour? What have you noticed? Why?
  • For example, have you noticed whether you smoke more or less when you're stressed? Why do you think that is?
    • [IF SMOKE MORE WHEN STRESSED] If you smoke more when you're stressed, what effect does your smoking have on the stress you're experiencing? Why do you think that is?
    • Do you think it is the smoking of the cigarette that helps alleviate the stress or the fact you have given yourself permission to take a break from the stress to step away and smoke the cigarette?
    • Have you tried alternatives to smoking a cigarette when you're feeling stressed (i.e., meditate, exercise, breathing exercises?) What was your experience?
• How do you think smoking impacts your overall stress level? For example, if you were someone who didn't smoke, how, if at all, do you think your level of stress would be different? Why?

Smoking Around Others/Stigma

• Do you hide your smoking from anyone? Who? Why?
• Is smoking something you do openly in front of others? In other words, do you smoke in front of members of your family, friends, co-workers, strangers, etc.? Why or why not?
• Has anyone ever asked you if you have plans to quit? Who? How does it make you feel?
  • When people ask if you plan to quit, do you feel that you have to say "yes" because that is the right answer?
• Do non-smokers (i.e., family, co-workers, friends, strangers, etc.) express judgment or make statements that make you feel uncomfortable about your smoking?
  • What have they said/done to make you feel that way?
  • How does this make you feel? How do you react in those situations?
  • Have you noticed whether this has had an impact/effect on your smoking behaviour (i.e., do you smoke any less or more as a result)? Why?
• Is there anything you wish you could say to people who do not smoke that perhaps stigmatize you for smoking? What would that be? Why?

Use of Other Substances

• Do you use/consume other substances like alcohol, or cannabis?
• When or why do you typically use/consume these other substances?
• Generally, do you use/consume these other substances when you smoke cigarettes OR are there times you do one over the other? When and why?
• Have you noticed that using/consuming these substances makes you want a cigarette more or less? Why?
• Earlier we talked about the fact you "hide" your smoking from others. What about your use/consumption of other substances that you use/consume (i.e., alcohol or cannabis) - do you "hide" your use/consumption of those substances from others? Why or why not?
  • [IF NOT] Why do you think that is? Why are you more comfortable [insert: drinking alcohol or consuming cannabis] in front of others than smoking cigarettes?

Conclusion (5 minutes)

This wraps up all of the formal questions I had for you today.

• Before we conclude, do you have any final thoughts and/or advice you would like to pass along?

We really appreciate you taking the time to speak with us today. Your input will be very helpful to Health Canada as they try to better understand the lived experience of someone who smokes.

APPENDIX D: RECRUITMENT SCREENER

SUMMARY

• Recruit 125 total in the hopes 100 participate in the diary exercise (every day for 21 days) AND 50 participate in a 30-minute one-on-one interview (by phone or videoconference, depending on their preference)
• Must have access to a computer, tablet or mobile device they can use to participate in the diary exercise, as well as a stable internet connection
• Must have a personal email address
• Participants will receive an incentive of $525 for completing all of the daily activities and diary entry for three weeks (21 days) AND $75 for completing the 30-minute interview
• All smoke cigarettes daily (S5)
• Have been smoking for at least 5 years (S6)
• Mix of interest in smoking cessation (S7)
• Please ensure a good mix across demographics: gender, age, income, education, ethnicity, etc.
• Across region, please aim for a mix of participants from urban, suburban and rural communities (S11) across the following regions (S10):

Hello, my name is _______________ and I'm calling on behalf of Earnscliffe, a national public opinion research firm. We are organizing a research study that will explore issues of importance to Canadians, on behalf of the Government of Canada. We are looking for people who would be willing to participate in a two-part qualitative research exercise. Participants will receive an honorarium for their participation. May I continue?

• Yes CONTINUE
• No THANK AND TERMINATE

Participation is voluntary. We are interested in hearing your opinions; no attempt will be made to sell you anything or change your point of view.

The first phase of research will be conducted online, in the form of a diary exercise, with a professional moderator who will issue questions and tasks to complete. Over the course of this engagement, you will be asked to log onto a website and complete daily tasks and a minimum of one diary entry per day over the course of 21 days. Each day's activities will take you approximately 15 to 25 minutes to complete. The online engagement will take place starting February 12, 2021 at noon Eastern (EST) and end on March 5, 2021 at 11:55 pm EST.

Those invited to take part will receive an honorarium ($525) in appreciation for their participation, although you must complete all of the activities including a minimum of one diary entry each day over the course of 21 days. To participate in this study, you must provide us with an email address that you have access to daily.

The second phase of research will be conducted either by phone or videoconference (depending on your preference), in the form of a follow-up one-one-one interview. Fifty (50) participants from the first phase will be selected to take part. If selected, the interviews will take place for 30 minutes between March 8 and 26, 2021. Those selected to take part in the interview will receive an honorarium of $75 in appreciation for their participation.

But before we invite you to attend, we need to ask you a few questions to ensure that we get a good mix and variety of people. May I ask you a few questions?

• Yes CONTINUE
• No THANK AND TERMINATE

This research will require viewing and interacting on a website. To this end, I have a few questions about your use of the internet.

S1. On a scale of 1 to 10, where, 1, is not at all comfortable and, 10, is extremely comfortable, please tell me how comfortable you are with each of the following:

IF "1-6" TO ANY OF THE ABOVE, THANK AND TERMINATE.

S2. Do you have daily access to a computer, tablet or smartphone with high speed internet where you can complete the questions, diary entries or each of the activities?

• Yes CONTINUE
• No THANK AND TERMINATE

S3. Do you have a personal email address that is currently active and available to you?

• Yes CONTINUE
• No THANK AND TERMINATE

S4. Do you or any member of your household work for or at…

IF "YES" TO ANY OF THE ABOVE, THANK AND TERMINATE.

S5. During the past 30 days, how often did you smoke cigarettes? Was it…

S6. How many years have you been smoking cigarettes?

S7. Are you planning to quit smoking cigarettes…?

PLEASE ENSURE A GOOD MIX.

The next set of questions are to help us ensure we get a good mix and variety of people. May I ask you a few more questions?

S8. Which gender do you identify with? [DO NOT READ, PLEASE RECORD] [ENSURE GOOD MIX]

S9. Could you please tell me what age category you fall in to? Are you…? [ENSURE GOOD MIX]

S10. In which province or territory do you reside?

S11. How would you describe the area in which you live?

PLEASE ENSURE A GOOD MIX OF URBAN, SUBURBAN AND RURAL WITHIN EACH PROVINCE/TERRITORY.

S12. What is your ethnic background? [DO NOT READ] [ENSURE GOOD MIX]

S13. What is your current employment status? [ENSURE GOOD MIX]

S14. Which of the following categories best describes your total household income; that is, the total income of all persons in your household combined, before taxes? [READ LIST] [ENSURE GOOD MIX]

S15. What is the last level of education that you have completed? [ENSURE GOOD MIX]

Invitation:

We would like to invite you to participate in this study which will be facilitated by an experienced, professional moderator. Just to confirm, the first phase will involve an online study beginning on February 12, 2021 at noon Eastern (EST) and ending on March 5, 2021 at 11:55 PM (EST).

You will be asked to answer questions daily and to complete a minimum of one diary entry per day over the course of the 21 days. Each day will take you approximately 15-25 minutes to complete, and you'll be expected to engage each day for 21 days. You must complete ALL of the activities between February 12 and March 5, 2021.

A day or two before the study begins, you will receive an email with detailed instructions on how and when to access the study. This email will include the necessary login information.

Once you have completed all of the activities and answered all of the questions, we will send you an honorarium in the amount of $525.00, as a thank you for your time and participation. Please note that if you do not complete all of the activities (a daily entry for 21 days), you will not receive the incentive.

The second phase will involve follow-up interviews with fifty participants. If selected, you will take part in a one-on-one interview (by phone or videoconference depending on your preference) for up to 30 minutes. The interviews will take place between March 8, 2021 and March 26, 2021. If selected, you will receive an honorarium of $75.00 as a thank you for your time and participation.

Would you be willing to participate in both phases of this study?

Yes 1 RECRUIT

No 2 THANK AND TERMINATE

DK/NR 9 THANK AND TERMINATE

Can I please confirm your email address? This is the email address that you can use and would like to use to receive login information and communications about this study:

[RECORD AND VERIFY EMAIL ADDRESS].

PRIVACY QUESTIONS

Now I have a few questions that relate to privacy, your personal information and the research process. We will need your consent on a few issues that enable us to conduct our research. As I run through these questions, please feel free to ask me any questions you would like clarified.

P1) First, we will be providing the facilitators with a list of respondents' names and profiles (screener responses) so that they can sign you into the platform. This information will not be shared with the Government of Canada department organizing this research. Do we have your permission to do this? I assure you it will be kept strictly confidential.

Yes 1 GO TO P2

No 2 GO TO P1A

We need to provide the session moderator with the names and background of the people participating in the engagement because only the individuals invited are allowed in the session and the moderator must have this information for verification purposes. Please be assured that this information will be kept strictly confidential. GO TO P1A

P1) Now that I've explained this, do I have your permission to provide your name and profile to the moderator?

Yes 1 THANK & CONTINUE

No 2 THANK & TERMINATE

P2) A transcript of the diary exercise will be produced for analytical purposes. It is necessary for the research process for us to transcribe the session as the researchers need this material to complete their analysis.

Do you agree to have your comments transcribed for research/analytical purposes?

Yes 1 THANK & CONTINUE

No 2 THANK & TERMINATE

P3) These transcripts will also be shared with the Government of Canada for analytical purposes. Any identifiable information (i.e. your last name, etc.) will be deleted from the transcripts.

Do you agree to have the transcripts shared with the Government of Canada?

Yes 1 THANK & CONTINUE

No 2 THANK & TERMINATE

P4) Employees from the Government of Canada may be online to review the online diary.

Do you agree to have your comments reviewed by Government of Canada employees?

Yes 1 THANK & CONTINUE

No 2 GO TO P3A

P4a) It is standard qualitative procedure to invite clients, in this case, Government of Canada employees, to review the online diary. They will be online simply to understand your views firsthand although they may take their own notes and confer with the moderator on occasion to discuss whether there are any additional questions to ask.

Do you agree to have your comments reviewed by Government of Canada employees?

Yes 1 THANK & CONTINUE

No 2 THANK & TERMINATE

AS REQUIRED, ADDITIONAL INFO FOR THE INTERVIEWER:

Please be assured that this information is kept confidential and is strictly accessed and used by professional market research firms to review participation and prevent "professional respondents" from attending sessions.

As we are only inviting a small number of people to participate, your participation is very important to us. If for some reason you are unable to participate, please call us so that we may get someone to replace you. You can reach us at [1-800 NUMBER] at our office. Please ask for [NAME]. Someone will call you the day before to remind you about the discussion.

So that we can call you to remind you about the diary exercise or contact you should there be any changes, can you please confirm your name and contact information for me? [READ INFO WE HAVE AND CHANGE AS NECESSARY.]

First name

Last Name

email

Daytime phone number

Evening phone number

If the respondent refuses to give his/her first or last name or phone number please assure them that this information will be kept strictly confidential in accordance with the privacy law and that it is used strictly to contact them to confirm their attendance and to inform them of any changes to the discussion group. If they still refuse THANK & TERMINATE.