Study on Smoking Cessation Strategies Among Canadian Adults who Smoke

Health Canada

Executive Summary

July 2023

Prepared for: Health Canada

Supplier name: Quorus Consulting Group Inc.
Contract award date: January 20, 2023
Delivery date: July 2023
Contract amount (incl. HST): $186,404.80
Contract #: CW2269609
POR number: 119-22

For more information, please contact: hc.cpab.por-rop.dgcap.sc@canada.ca

Ce rapport est aussi disponible en français.

Study on Smoking Cessation Strategies Among Canadians who Smoke

Executive Summary

Prepared for Health Canada
Supplier name: Quorus Consulting Group Inc.
July 2023

This public opinion research report presents the results of quantitative and qualitative research conducted by Quorus Consulting Group Inc. on behalf of Health Canada in April 2023. The qualitative portion consisted of 19 online focus groups with individuals aged 25 and older who smoke. Focus groups were conducted with participants from Eastern Canada, Western Canada and Quebec. The sessions were completed between April 5 and April 25, 2023. A total of 113 individuals participated in the focus groups. The quantitative portion of the study consisted of a national online survey of 2,548 respondents aged 25 or older in Canada who smoke. Survey data were collected from April 12 to April 28, 2023.

Cette publication est aussi disponible en français sous le titre : Étude sur les stratégies de renoncement au tabac chez les fumeurs d’âge adulte

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

Department of Health
200 Eglantine Driveway
A.L. 1915C
Ottawa, Ontario
K1A 0K9

Catalogue Number:
H14-450/2023E-PDF

International Standard Book Number (ISBN):
ISBN 978-0-660-67765-1

Related publications (registration number: POR 119-22):
Catalogue Number H14-450/2023F-PDF (Final Report, French)
ISBN 978-0-660-67766-8

^© His Majesty the King in Right of Canada, as represented by the Minister of Health, 2023

Political Neutrality Statement

I hereby certify as Senior Officer of Quorus Consulting Group Inc. that the deliverables fully comply with the Government of Canada political neutrality requirements outlined in the Policy on Communications and Federal Identity and the Directive on the Management of Communications - Appendix C.

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:

June 15, 2023
Rick Nadeau, President
Quorus Consulting Group Inc.

Executive summary

Background and research objectives

Canada's Tobacco Strategy has set an ambitious goal of lowering tobacco use among Canadians to less than 5% by the year 2035. To realize this objective, Health Canada needs to prevent initiation of tobacco use as well as support cessation efforts to quit tobacco long-term.

According to the 2020 Canadian Community Health Survey, 13% of Canadians 15 years and older currently smoke. The majority of those who currently smoke have attempted to quit smoking in the past 12 months (58%) and/or are seriously considering quitting smoking within the next 6 months (63%). Adults (25 years of age and older) have a higher prevalence of current smoking (14%) than youth 15-19 (6%) but fewer report attempting to quit within the past year (60%) compared to youth 15-19 (84%) and young adults 20-24 (70%) who smoke. Additionally, some demographic groups have higher prevalence rates (e.g., 16% of men vs. 11% of women, 21% of those diagnosed with a mood and/or anxiety disorder vs. 12% of those not diagnosed with either, 18% of those with less than secondary education vs. 7% of those with a university degree or more). With the vast majority (91%) of current smoking occurring among Canadians 25 years and older, more needs to be done to explore the barriers around cessation faced by adults who currently smoke, notably among those within the higher prevalence rates.

This work will build upon previous adult smoking research conducted by the Tobacco Control Directorate but with a greater focus on the cessation tools and approaches, such as knowledge, use, alternatives to smoking, opinions, barriers, challenges, etc., to try to quit or reduce smoking.

Research objectives

The research objectives are as follows:

Quantitative Research

Gather details on attitudes, beliefs, knowledge, awareness, and use of cessation methods across Canada (e.g., nicotine replacement therapy, vaping with or without nicotine, 'cold turkey', reducing their smoking, etc.).
Investigate a range of experiences with those methods (e.g., challenges and advantages) and how those may impact future attempts.
Explore drivers of ongoing smoking, differentiating between those with or without a recent quit attempt.
Explore how other substance use may impact cessation (e.g., alcohol, cannabis).

Qualitative Research

The focus groups will be used to delve into individual quit methods, their experiences with them and barriers and facilitators of use, with an emphasis on population segments with high prevalence rates of current smoking.

Data from this research will inform the Tobacco Control Directorate's efforts to support Canadians smoking and nicotine cessation efforts.

Methodology

The qualitative portion consisted of 19 online focus groups with individuals aged 25 and older who smoke. Focus groups were conducted with participants from Eastern Canada, Western Canada and Quebec. The sessions were completed between April 5 and April 25, 2023. A total of 113 individuals participated in the focus groups.

The quantitative portion of the study consisted of a national online survey of 2,548 respondents aged 25 or older in Canada who smoke. Survey data were collected from April 12 to April 28, 2023.

Qualitative research results

Journey to their current smoking experience

Participants were asked to describe their "smoking journey," starting from the moment they first started smoking cigarettes to today. Some of the more common trends and patterns from this exercise included the following:

Smoking cigarettes typically began either at high school or college/university. Most who started smoking cigarettes in high school did so either out of peer pressure, general curiosity, to "be cool" or to "fit in." Those who started in college or university did so because it was part of the social scene or to help them manage their academic stress.
A number of participants started smoking due to high stress jobs or jobs where smoking was also more prevalent, such as the hospitality or construction industry.
In the beginning, nearly all participants had someone, or often more than one person, in their life who also smoked cigarettes.
Fast forwarding to today, adults who smoke explain they do so for four main reasons: out of habit, to help them manage their stress, as an activity when they are out with their friends, and for pleasure.
Many who currently smoke cigarettes regularly explained that their circle of friends, coworkers and family members who also smoke cigarettes has shrunk considerably, to the point where some feel they are now the only ones who smoke cigarettes regularly. Those who smoke more casually or in social circumstances explain that they also have friends who smoke.
The journey for many seems to involve an increase in smoking at some point, which tended to coincide either with a stressful time in their life, a particular line of work or an increase in social activity. Many also explained that they have tried to quit smoking entirely.

A few other notable findings pertaining to how smoking cigarettes fit into participants' lives include the following:

Few seem to feel that they plan what they do or where they go based on whether they can smoke cigarettes.
Many do feel that smoking isolates them from others.
The cost of living was seen by all participants as getting more expensive and many had to make compromises and changes in their general household budget. The impact on cigarette use was mixed. Many explained how inflation in general but also the increase in the cost of cigarettes specifically has prompted them to adopt one or a combination of strategies (such as reduce how much they smoke, switch to a less expensive brand, etc.). Some who smoke more regularly and heavily explained that they will purchase their cigarettes no matter what. Some who smoke on a more casual or occasional basis felt that they did not change their use of cigarettes because they don't smoke enough for it to have a meaningful impact on their household budget.

Confidence in and importance of quitting smoking

Most participants would say that quitting smoking is at least somewhat important to them. Those who feel most strongly about this feel that it is long overdue, they understand the impact it is having on their health and their finances and, similarly, they understand the benefits of quitting. Those who feel less strongly about quitting were mostly individuals who smoke more casually or occasionally.

When asked how confident they would be that they would succeed if they tried to quit, most do feel confident they would succeed if they tried to quit. Those who tended to be the most confident were those who smoke occasionally and believe that the infrequent nature of their tobacco use would make it easy for them to quit, and those who have quit in the past (in some cases many times) and given that experience, they believe they can do it again if they put their minds to it. Those who felt less confident tended to be individuals who have never tried quitting in the past as well as some who have tried to quit, sometimes repeatedly and recognized the difficulty of this.

High and low prevalence discussion

Participants struggled to self-identify as fitting into a particular demographic or socio-economic profile which might make them more or less likely to smoke cigarettes. If anything, participants might propose that certain circumstances might make someone more likely to smoke cigarettes, among which the most common were rooted in the past rather than in the present. These included:

parents, close friends and/or close family members smoked cigarettes,
they grew up in a time when cigarette smoking was more common and popular, it was more widely permitted (e.g., in restaurants, in the workplace, etc.), less was known about the health impacts of smoking cigarettes, cigarette advertising was more prevalent, and smoking cigarettes was seen as "cool",
they had or have a lot of stress in their life, and,
the type of work they do or industry in which they work.

Participants reacted to patterns pertaining to prevalence in the following ways:

Younger participants 25 to 44 were typically not surprised to learn that their age group was more likely to smoke compared to older individuals. Conversely, many of those over the age of 44 were surprised to learn that those 25 to 44 were more likely to smoke cigarettes. Many assumed that vaping was overtaking cigarette smoking, that cigarettes were more likely to be vilified, and that younger folks were more educated about the ill-effects of smoking cigarettes and that this would lead younger folks to be less inclined to smoke cigarettes compared to older individuals.
Some men were not surprised to hear that they were more likely to smoke compared to women, mostly because of the kinds of sectors in which they work (such as construction, building maintenance, etc.). Some also explained that it is a more "macho" thing to do.
Many explained that smoking helped them fit in when they were younger and that throughout their life, faced with varying forms of discrimination, they have needed to find ways to cope with stress, isolation or other forms of anxiety. For these individuals, smoking cigarettes was used as a coping mechanism.
Many individuals in both lower and higher income households were not surprised to learn that individuals earning a lower income were more likely to smoke compared to higher income individuals. Proposed contributing factors included stress caused by financial duress, and the sectors in which low-income Canadians might work.
Most individuals with a mood or anxiety disorder were not surprised to learn that they are more likely to smoke compared to individuals with neither type of disorder. Some explained that, faced with their disorder at a young age, smoking helped them "fit in" with others and it helped them manage their anxiety or just cope.
Reactions among members of the LGBTQIA2S+ were mixed. Some did not understand why they might be more likely to smoke whereas for others, the reasons were quite clear. Those in the latter group explained that cigarettes helped them manage the social and personal challenges they endured growing up.
Many individuals from Indigenous communities were also not surprised to learn that they might be more likely to smoke compared to individuals who do not identify as Indigenous. Some felt that smoking and tobacco are traditional in their community and as such smoking does not take on the same meaning as it might in other segments of society. Some also explained that smoking has been and continues to be quite prevalent among their friends who are Indigenous and among family members, which in turn normalizes and perpetuates the behaviour.

Selecting a cessation method

The research explored awareness and experiences with a variety of smoking cessation strategies and methods.

In terms of aided and unaided awareness, participants across all segments seemed fairly aware of a wide range of strategies. The methods of which participants were the least aware included: a 1-800 quitline helpline or smoker's helpline, an internet-based program or smartphone app, attending in-person group counselling, and using smoking cessation medications.

When specifically asked if there were any methods they had never tried and that they would also never likely consider in the future, the least popular strategies were: smoking cessation medications, a 1-800 quitline or smoker's helpline, vaping (with or without nicotine), in-person group counselling, and an internet-based program or smart phone app.

The discussion then focused on methods and strategies that participants had used in the past, irrespective of whether they helped. Some of the highlights from this line of questioning included:

Nicotine replacement therapy (NRT), especially gum and patches, were often mentioned. Participants tended to see mixed results with these approaches. Use was typically triggered because these methods have been around for a long time and they were just aware of them, friends and family had seen success in their use, they were recommended by a pharmacist or their physician, and they were featured prominently at their pharmacy. Participants stopped using NRTs mostly because they did not feel they worked.
Some had tried prescription medication and few felt it worked for them. The side-effects, especially vivid dreams, led them to abandon this method which, for most, had been recommended by their physician.
Hypnosis was also used by some, although few believe it was helpful. This method tended to be a one-time experiment for participants, which had most likely been recommended by friends or through advertising.
Vaping with nicotine was also a popular strategy, which was still being used by certain participants in these focus groups. This approach had been most often recommended by friends and was seeing some success among certain participants.
Strategies such as managing one's stress, exercise, quitting "cold turkey" and gradually reducing the number of cigarettes smoked were also relatively common. Participants were typically led to consider these approaches on their own with no particular recommendation or consultation from other people.

While most participants generally agreed that the decision to quit has to come from them, many also agreed that some form of support from someone can be helpful. Most seemed to feel that support from someone in their circle of friends or family would be most helpful.

In terms of the types of "stars" that should align in their life to increase the odds of success when it comes to quitting, most agreed on three particular factors: having the right mindset, having less stress in their life, and having the right kind of support to keep them motivated.

Qualitative research disclaimer

Qualitative research seeks to develop insight and direction rather than quantitatively projectable measures. The purpose is not to generate "statistics" but to hear the full range of opinions on a topic, understand the language participants use, gauge degrees of passion and engagement and to leverage the power of the group to inspire ideas. Participants are encouraged to voice their opinions, irrespective of whether or not that view is shared by others.

Due to the sample size, the special recruitment methods used, and the study objectives themselves, it is clearly understood that the work under discussion is exploratory in nature. The findings are not, nor were they intended to be, projectable to a larger population.

Specifically, it is inappropriate to suggest or to infer that few (or many) real world users would behave in one way simply because few (or many) participants behaved in this way during the sessions. This kind of projection is strictly the prerogative of probability quantitative research.

Quantitative research results

Smoking use and history

Nearly three quarters (73%) of respondents smoked cigarettes every day of the last month. Another 17% smoked at least once each week while 10% smoked at least once in the month.

Respondents' average age at the time of their first cigarette was just over 16 years old. Across all participants, the average number of years having smoked cigarettes was 30 years.

On average, respondents who smoke daily began to do so around the age of 18-19. These respondents smoke an average of 13 cigarettes per day. Roughly one quarter (26%) of those who smoke daily have a cigarette within 5 minutes of waking up while almost half (47%) smoke within 6-30 minutes of waking up.

Those who smoke occasionally smoke an average of 5 cigarettes on the days that they smoke. More than half of those who smoke occasionally have their first cigarette at least an hour after waking up (54%). A quarter of these respondents smoke within 6-30 minutes of waking up (25%) and a smaller proportion smoke within 31-60 minutes of waking up (15%).

Just under 6 in 10 respondents (59%) were considered "low" on the nicotine dependence index. More than one third (35%) were considered medium on the index and 6% of respondents would be classified as high on the nicotine dependence index. The vast majority of those who smoke occasionally were categorized as "low" on the nicotine dependence index (90% versus 48% of those who smoke daily) whereas more of those who smoke daily were in the "high" category (8% versus 1% of those who smoke occasionally).

Cessation - general awareness and opinions

Respondents were asked to provide their level of agreement with a series of statements.

64% agreed that they value quality of life over quantity of life.
49% would cut back on cigarettes before cutting back on other expenses.
47% would cut back on cigarettes before cutting back on hanging out with friends.
45% agreed that they value their individual rights over the rights of society.
43% agreed that they value their mental health over their physical health.
27% agreed that they value their social life more than time spent on their own.

Over half of respondents (53%) felt satisfied with their life currently. On the other hand, 14% reported being dissatisfied with their current life.

Smoking cessation aids or methods with the highest awareness included nicotine patches (46%) and nicotine gum (37%).

When asked how much various strategies would increase their chances of quitting smoking, the following were perceived to be the most successful:

Reduce the number of cigarettes smoked (22%);
Find better ways to manage stress (22%);
Exercise (21%);
Smoking cessation medication (20%);
Nicotine replacement products (18%).

Most respondents (81%) were not aware of any subsidized smoking cessation options in their province or community. Of the options listed, awareness of subsidized options was highest for nicotine patches (10%) and nicotine gum (5%).

An even 1 in 5 (20%) respondents reported having insurance that covers all or part of the cost of smoking cessation medication.

Cessation history

More than 7 in 10 respondents (72%) reported that at some point in the past, they had stopped smoking for at least 24 hours because they were trying to quit. Of these respondents, 57% reported having tried to quit in the last 12 months.

Cessation plans

Respondents were presented with a list of smoking cessation strategies and asked whether they were currently using the strategy or if they had used the strategy in the past 12 months.

The strategies used more frequently included the following:

56% were currently reducing the number of cigarettes they smoke and another 32% reported having done so in the past 12 months (with 68% describing the method as useful).
35% were currently trying to quit smoking on their own and another 44% reported having done so in the past 12 months (with 60% describing the method as useful).

Cessation methods that were considered to be the most useful included the following:

using a vape with nicotine (74% among the 21% currently using this method);
making a deal with a friend or family member (73% among the 16% currently using this method);
attending in-person group counselling (71% among the 12% currently using this method);
using a 1-800 quit line or smoker's helpline (70% among the 8% currently using this method).

For those who had attempted to quit in the past 12 months, the main positive benefits experienced included:

saving money (65%);
breathing was easier (43%);
home, car, breath and clothes smelled better (41%);
less coughing and/or wheezing (41%).

Despite the positive benefits experienced, respondents reported that they continued to smoke due to too much stress (28%), too much difficulty quitting due to being around friends who smoke or when drinking alcohol (26%), smoking being too ingrained in their routine (25%), and enjoyment of smoking (25%).

Just under one third of respondents (32%) said they plan to quit sometime in the future (beyond 6 months). Another 23% reported that they plan on quitting within the next 6 months while 16% planned on quitting in the next month. On the other hand, 18% had no plans of quitting while another 11% were unsure.

Respondents were split when thinking about their confidence in their ability to quit smoking at the present time with 32% saying they were confident and 33% saying they were not confident. Half (50%) were confident that they could eventually quit for good while 17% were not confident.

Quitting smoking was deemed important by 60% of respondents while 13% did not feel quitting was important to them.

Respondents who had not made any previous quit attempts and did not have plans to quit mainly attributed this to their enjoyment of smoking (38%) or because smoking was too ingrained into their routine (34%).

The main reason that respondents would be compelled to quit smoking was to improve their health (34%), however 12% said they did not think about quitting.

Perceived value of various sources of information

Respondents were asked how much they would value various sources of information when it comes to quitting smoking. The following were considered the most valuable:

A friend or family member who has successfully stopped smoking cigarettes (47%);
Health care professionals (47%);
Someone who has successfully stopped smoking (47%);
Family members (41%);
Individuals who do scientific research of smoking and/or smoking cessation (37%);
Friends (36%).

Risk perception and gaps in knowledge

Respondents were presented with a list of statements and asked how much they agreed with each one. The following was observed:

26% agreed that exercise can undo most of the effects of smoking.
24% agreed that whether a person gets lung cancer depends more on genes than anything else.
17% agreed that vitamins can undo most of the effects of smoking.
15% agreed that there's no risk of getting cancer if someone only smokes for a few years.

Other substance use

Vaping

More than 2 in 5 respondents (42%) reported that they had ever used a vaping device with nicotine. When asked about the frequency of using a vaping device with nicotine within the past month, 19% had done so daily, 20% had used one at least once a week and 17% had used one about once in the past month.

Of respondents who vaped nicotine in the past 30 days, the most common level of nicotine was 10 milligrams (28%). Fewer used products containing 5 milligrams of nicotine (22%). Just over one-third used higher levels: 15 milligrams of nicotine (15%) or 20 milligrams of nicotine (20%).

Those who vaped nicotine in the past 30 days differed on how soon after waking up they used the device. Some did so within 5 minutes (16%), within 6 to 30 minutes of waking up (29%), within 31-60 minutes of waking up (20%) or more than an hour after waking up (29%).

These respondents also differed on the frequency at which they used their device, with the largest proportion reporting having vaped 5 or less times per day (32%).

Preferred product flavours among those who vape typically included fruit (36%), tobacco flavour (18%), mint (14%) or menthol (12%).

Roughly one quarter (24%) had used a vaping device without nicotine in the past 30 days. Of these respondents, 6% had used this type of product daily, 23% did so once a week and 28% had used one about once in the past month.

Of the respondents who used a vaping device (either with or without nicotine) in the past 30 days, 40% used a disposable device while 67% used a reusable device. Reusable vaping devices consisted of systems that use pre-filled cartridges or pods (43%) or devices that contained cartridges which can be manually refilled with e-liquid (64%).

Alcohol

In the past 30 days, 12% of respondents consumed alcohol daily, 29% did so weekly and another 25% consumed alcohol about once in the month.

Half (50%) of those who consume alcohol said they smoked about the same number of cigarettes on days that they drank alcohol while 40% reported smoking more on days that they consumed alcohol.

Disposal

Cigarette butts

The garbage was the most common method for disposing cigarette butts (22% always, 27% most of the time). Public ashtrays were also commonly used for disposal (17% always, 23% most of the time). Littering on the ground was less commonly reported (4% always, 14% most of the time).

Vaping products

Of those who have tried vaping either with or without nicotine, 40% had used a device until the battery died or until the e-liquid ran out.

The most common method of disposal for vaping devices was in the garbage (31% always discarding this way, 25% disposing this way most of the time). The recycling bin was used for disposal always for 9% of respondents while 15% used this method most of the time.

Of the respondents who had vaped, 51% had stopped using a reusable vaping device in the past. Of these respondents, 50% disposed of the device. The most common method of disposal was in the garbage (33% always used the garbage for disposal, 22% did so most of the time). Another way respondents disposed of these devices was at a specialized facility, which was done so always by 11% of respondents while 6% used this method most of the time.

More than one third (35%) of those who had vaped in the past had either replaced a prefilled cartridge or stopped using one. The most common method of disposal for these cartridges was in the garbage with 29% having always done so, and 24% having done so most of the time. Before disposing of the cartridge, 9% always rinsed it, 13% rinsed most of the time while 43% never rinsed the cartridge before disposal.

Of those who had tried vaping, 37% had finished a bottle of e-liquid or stopped using one. The most common method of disposal was in the garbage with 24% always doing this while 18% did this most of the time. The recycling bin was used for disposal always for 12% of respondents while 17% used this method most of the time.

Of the respondents who had disposed of a bottle of e-liquid either in the garbage or recycling bin in the past, 11% said they always rinse the bottle before disposing of it while 13% did so most of the time.

Batteries in vape devices

Of those who had disposed of a vaping device, 29% had removed the battery from the device.

These batteries were mainly disposed of in the garbage (36%), at a specialized facility (31%), or in the recycling bin (27%).

Supplier name: Quorus Consulting Group Inc.
Contract number: CW2269609
Contract award date: January 20, 2023
Contract amount (including HST): $186,404.80
For more information, please contact Health Canada at: hc.cpab.por-rop.dgcap.sc@canada.ca

These results are presented and discussed in-depth throughout the detailed results section of the report.

Non-probability quantitative research disclaimer

This survey was conducting using a non-probability sample (i.e., a commercially available online panel). Thus, the results of this survey are not statistically projectable to the target population because the sampling method used does not ensure that the sample represents the target population with a known margin of sampling error. Reported percentages are not generalizable to any group other than the sample studied, and therefore no formal statistical inferences can be drawn between the sample results and the broader target population it may be intended to reflect. The sample data have been weighted to reflect the demographic composition as per the Methodology section.

Statistical projection is strictly the prerogative of probability quantitative research.