This month Health Canada released the results of the most recent Canadian Student, Alcohol and Tobacco Survey, with data collected in selected schools across Canada (except New Brunswick) during the 2021-2022 school year.
This is the most recent version of the school-based smoking and drug survey which has been conducted periodically since 1994. In recent years the survey covers students in grades 7 to 12. To focus on the health status of these young Canadians as they complete their public school years, many of the results discussed below are limited to those for the senior grades 10 to 12. An excel chart with the tables shown below can be downloaded here.
Health Canada provides a useful summary of topline results – and the media has reported on the concerns raised about the continuing high rate of vaping that was produced by the survey.
This post identifies 6 important take-away messages from these results.
1. Health Canada has not undone the damage of its 2018 policy change.
In May 2018, the federal government implemented a major policy change and allowed vaping products to be sold with few regulatory restrictions. The impact of those policies was immediate: past month e-cigarette use among senior high school students doubled between 2016-2017 and 2018-2019 (from 14.6% to 29.4%).
Beginning in 2020, the federal government began to restrict the market freedoms which it had initially extended to vaping companies. Most promotions were banned in the fall of 2020, nicotine concentration was capped at 20 mg/ml the following summer. Starting in 2019, provincial governments began to increase their own restrictions on the marketing of e-cigarettes (a summary of measures can be viewed here).
The student survey taken after these changes were in place shows a flattening of the curve, but there is no evidence that the harms caused by the 2018 policy change are being reversed. Past-month vaping by students in grade 10 to 12 has been reduced from 29.4% to 23.6%, and the frequency of daily vaping in this age group has remained at more than 1 in 10 students (11.8% in 2020-21, compared with 11.6 in 2018-19 and 2.2% in 2016-17).
The continuing high rate of vaping is particularly worrisome in the context of Health Canada’s failure to implement other marketing restrictions. In June 2021, the government announced plans to restrict flavours in vaping products, but has seemingly walked away from that intention. In April 2021 it announced plans to curtail youth-friendly product designs, but abandoned these the following year.
2. Many Canadian students think there are few risks to smoking or vaping
During last year’s survey, more than 1 in 20 Canadian students (6.3%) perceive no risk of harm from smoking cigarettes on a regular basis — twice as many as held that view in 2014-15. Roughly the same percentage hold this view about e-cigarettes (6.6%). In this case, the number who think regular vaping causes no risk has fallen in half, from 11.9% in 2014.
A large proportion (almost half) of students perceive little or no risk to using cigarettes or e-cigarettes once in a while.
3. E-cigarettes seem to addict more quickly than cigarettes
A much higher proportion of young people who ever try vaping become daily users before they leave school.
Among the senior high school students surveyed, the path from experimental to regular use appears faster or deeper for vaping products than for cigarettes. Over the past 8 cycles, an average of 1 in 10 senior high school students who ever tried cigarettes was using them daily at the time of the survey (from a low of 5% in 2018-19 to a high of 14% in 2008-09). This “conversion factor” can be calculated by dividing the number of daily users by the number of ever users and expressing the result as a percentage.
The rate of conversion to regular use of vaping products was much higher in the 3 cycles in which data that allows for this calculation to be made, growing from 5% in 2016-2017 to 29% in 2021-22.
4. Health Canada has now missed one of its three tobacco control targets, but has not said how it will address this failing.
The federal government sets policy targets for its programs, and – as shown on Treasury Board’s InfoBase – three such targets are set for Canada’s Tobacco Strategy:
- smoking prevalence no greater than 5% by 2035 (as measured by CCHS)
- past-month tobacco use by children in grades 7 to 12 no greater than 5% by March 2023 (as measured by CSTADS)
- past month e-cigarette use by children in grades 7 to 12 no greater than 5% by March 2023 (as measured by CSTADS).
Because Health Canada delayed CSTADS by one year, there will be no measure of tobacco or e-cigarette use among students in March 2023. The data released for 2022 however show that the target for e-cigarettes has been exceeded by 1 in 20 children (16% instead of 10%).
Health Canada has not established a target for overall nicotine use by young people and surprisingly does not release an estimate of the number of students who use nicotine through either tobacco or vaping products.
5. The steady decline in cigarette smoking pre-dates the availability of e-cigarettes.
Senior high school students (grades 10 to 12) were included in the survey for the first time in 2006-2007. Since then, the proportion of senior high school students who have never smoked a single cigarette has increased from one-half (52%) to more than three-quarters (78% in 2021-2022). During the same period, the number of students who were smoking each day or on an occasional basis fell by more than two-thirds (from 11.4% to 3.1%).
The label “current smoker” is applied only to those who have smoked more than 100 cigarettes (4 to 5 packs) in their lifetime. If those who have smoked in the past month but have not yet reached that amount are included, the percentage of senior students who are currently using tobacco increases to 6%. (3.1% who had moved past the experimental phase and were smoking on a daily or occasional basis and 2.9% who had smoked fewer than 100 cigarettes in their lifetime but had smoked in the past month). (CSTADS definitions are available here).
6. Provincial flavour restrictions are not preventing youth from using flavoured e-cigarettes.
Three Canadian provinces had flavour bans in place at the time of this survey: Prince Edward Island, Nova Scotia and New Brunswick. (New Brunswick did not participate in the survey). Three other provinces had restrictions which prohibited flavoured vaping liquids from being sold other than in specialty shops where young people are not allowed to enter.
The reported choices of students shows that these restrictions were not sufficient to prevent young people from having access to flavoured products. Among those who reported having a usual flavour, three quarters (75%) said they used a fruit flavour: this was only marginally lower in the provinces where such flavours were not permitted for sale. The second most frequently identified flavour category was mint-menthol (14% nationally).
Nova Scotia, where only tobacco-flavoured liquids are permitted for sale, was the only province with a reportable number of students who said they usually used tobacco flavourings – fewer than 1 in 20 (4%).
Implications for public health: The growing population of never-smoking vapers
The students who spent an hour of classroom time answering the CSTADS survey last year are the first generation of Canadians who entered high school after e-cigarettes were legalized in Canada. From this new cohort alone, there are 360,000 school children who are vaping, and 174,000 who already do so every day. By the time the next school surveys are taken, many of these children will no longer be included – although they will be captured by surveys like the Canadian Tobacco and Nicotine Survey (CTNS), which will describe them as the “young adults” that they have grown into — allowing policy makers and tobacco-nicotine companies to suggest that such nicotine use reflects a choice made after the duty of the state and manufacturer to protect young people from these products has ended.
The effect of the aging-out of youth vapers is already apparent in the CTNS surveys. The results to winter 2021 are shown below, with the winter 2022 results likely to be released this summer.
We should acknowledge that each successive cohort of children recruited into vaping adds to the number of Canadians injured by the policy decision to allow tobacco companies to promote and supply vaping products as consumer goods. These young people (and as the adults they will soon be) are the collateral damage in a poorly designed harm reduction approach. The damage will grow until the policy is changed.
Bans on flavourings and youth-friendly designs are urgently required, as are meaningful barriers to youth access. Equally important is the need for Canada to re-think its approach to managing nicotine supply. The CSTADs results are another indication that Canada’s tobacco harm reduction approach is not working.
Background on CSTADS
The Youth Smoking Survey was conducted by Statistics Canada in 1994 and 2002. From 2004 to 2019, the University of Waterloo conducted the survey on a biennial basis, during which time it was renamed to the Canadian Student, Tobacco, Alcohol and Drug Survey. In 2020, administration of the survey was awarded to CCI Research, resulting in a one-year delay in the cycle. It was most recently conducted during the 2021-2022 school year and is scheduled for the 2023-2024 year.
The survey, which is designed to take under an hour to complete, is conducted in classrooms under the supervision of teachers. It is conducted in selected schools in the provinces which have agreed to participate. Students in grades 7 to 12 (secondary I to V in Quebec) are asked to participate, and parental consent is requested for those under 16 years of age.