Characterizing polysubstance use: What do we know about use of cigarettes, vaping products, cannabis, and alcohol among Canadians?

Introduction: Polysubstance use--the use of multiple substances on the same or different occasions--is a risk factor for substance use disorder. However, national surveillance of substance use in Canada has often focused on use of a single substance. To better understand and address polysubstance use, this study characterized the use of vaping products, cigarettes, inhaled cannabis, and alcohol among Canadians aged 15 years and older. Methods: Nationally representative data from the 2020 Canadian Tobacco and Nicotine Survey were analyzed. Polysubstance use was assessed as use of at least two of the following in the past 30 days: smoking cigarettes, using vaping products (containing nicotine or flavours), using cannabis (in smoked and/or vaped form) and drinking alcohol (daily or weekly frequency). Results: In 2020, past-30-day use of the examined substances was 4.7% for vaping products (1.5 million), 10.3% for cigarettes (3.2 million), 11.0% for inhaled cannabis (3.4 million), and 37.6% for weekly or daily use of alcohol (11.7 million). Polysubstance use was reported by 12.2% of Canadians (3.8 million) and was more prevalent among young Canadians, men and those who vaped. The most common combination of substances among polysubstance users included inhaled cannabis and weekly or daily use of alcohol (29.0%, or 1.1 million). Conclusion: The use of vaping products, cigarettes, inhaled cannabis, and alcohol-individually and in combination-is substantial among Canadians. Frequent consumption of alcohol was most prevalent overall and, in contrast to the other examined substances, was common among Canadians of all ages. Findings may inform a polysubstance use approach for prevention policies and programs.

Prevalence trends and factors associated with vaping in Ontario (2015 to 2018) and Quebec (2017 to 2019), Canada.

Background: Robust surveillance of vaping product use (with or without nicotine) in Canada has been limited by the use of multiple tools with varying designs and content. The objective of the current study was to examine trends over time in vaping prevalence and to examine associated factors using data from the Canadian Community Health Survey (CCHS). Data and methods: Trends in the prevalence of past-30-day vaping over time were examined using data available from optional modules of the CCHS for Ontario from 2015 to 2018 and for Quebec from 2017 to 2019. Multiple logistic regression models were used to examine correlates of vaping in Quebec (2019) and Ontario (2018). Results: Vaping increased in Quebec from 3.4% (233,000) in 2017 to 4.2% (296,000) in 2018 and 4.7% (333,000) in 2019. In Ontario, vaping remained stable in the years 2015 (3.1% or 357,000), 2016 (2.7% or 311,000) and 2017 (2.7% or 309,000), then increased in 2018 (3.4% or 404,000). Increases in vaping in both provinces were driven by youth. Vaping was significantly associated with young age and cigarette smoking in both provinces, as well as with cannabis use in the past 12 months among Quebec respondents. Interpretation: In both provinces, increases in youth vaping were observed in recent years, and this is consistent with national trends. Study findings further our understanding of vaping behaviour and highlight the utility of the CCHS as an additional tool for surveillance of vaping product use among Canadians.

A comparison of self-reported exposure to fast food and sugary drinks marketing among parents of children across five countries.

Exposure to unhealthy food and beverage marketing is an important environmental determinant of dietary intake. The current study examined self-reported exposure to marketing of unhealthy foods and beverages across various media channels and settings among parents of children younger than 18 years in five high and upper-middle income countries. Data from 4827 parents living with their children were analyzed from the International Food Policy Study (2017), a web-based survey of adults aged 18-64 years from Canada, the United States (US), the United Kingdom (UK), Australia, and Mexico. Respondents reported their exposure to marketing of fast food and of sugary drinks across media channels/settings overall and how often they see fast food and sugary drink marketing while viewing media with their children. Regression models examined differences across countries and correlates of marketing exposure. Parents in Mexico and the US reported greater exposure to marketing for fast food and sugary drinks compared to parents in Australia, Canada, and the UK. Patterns of exposure among parents were generally consistent across countries, with TV, digital media, and radio being the most commonly reported media channels for both fast food and sugary drinks. Exposure to marketing of fast food and sugary drinks was associated with a variety of sociodemographic factors, most strongly with ethnicity and education, and sociodemographic trends differed somewhat between countries. The findings demonstrate differences in self-reported parental exposure to marketing of fast food and sugary drinks between countries, and may help to evaluate the impact of marketing restrictions implemented over time.

Exposure to Food and Beverage Advertising on Television among Canadian Adolescents, 2011 to 2016.

Adolescents represent a key audience for food advertisers, however there is little evidence of adolescent exposure to food marketing in Canada. This study examined trends in Canadian adolescents' exposure to food advertising on television. To do so, data on 19 food categories were licensed from Nielsen Media Research for May 2011, 2013, and 2016 for the broadcasting market of Toronto, Canada. The average number of advertisements viewed by adolescents aged 12-17 years on 31 television stations during the month of May each year was estimated using television ratings data. Findings revealed that between May 2011 and May 2016, the total number of food advertisements aired on all television stations increased by 4%, while adolescents' average exposure to food advertising decreased by 31%, going from 221 ads in May 2011 to 154 in May 2016. In May 2016, the advertising of fast food and sugary drinks dominated, relative to other categories, accounting for 42% and 11% of all exposures, respectively. The findings demonstrate a declining trend in exposure to television food advertising among Canadian adolescents, which may be due to shifts in media consumption. These data may serve as a benchmark for monitoring and evaluating future food marketing policies in Canada.

Awareness and interest in IQOS heated tobacco products among youth in Canada, England and the USA.

INTRODUCTION: Heated tobacco products (HTPs), such as IQOS, have been introduced in a growing number of international markets. However, little is known about perceptions of HTP products among youth. METHODS: Data are from wave 1 of the International Tobacco Control Youth Tobacco and E-cigarette Survey (2017), a web-based cohort survey of people aged 16-19 years from Canada, England and the USA. Respondents (n=12 064) were shown an image of IQOS and asked about their awareness, interest in trying and susceptibility to trying the product. Youth awareness, interest in trying and susceptibility to trying IQOS were analysed using descriptive statistics, and logistic regression models were used to examine correlates of these outcomes. RESULTS: Overall, 7.0% of youth reported awareness of IQOS (England=5.6%, Canada=6.4% and USA=9.1%) and 38.6% expressed interest in trying the product (England=41.8%, Canada=33.0% and USA=40.9%). Within each country, all key outcomes varied by smoking status: greater proportions of youth who were currently smoking or had a history of smoking reported being aware of, interested in trying and susceptible to trying IQOS. Interest and susceptibility to trying IQOS were associated with male sex, current tobacco use and current e-cigarette use. Across all countries, susceptibility to trying IQOS (25.1%) was higher than for tobacco cigarettes (19.3%), but lower than for e-cigarettes (29.1%). CONCLUSIONS: Awareness of HTPs, such as IQOS, is emerging among youth in Canada, England and the USA. Interest in trying these products is very high among smokers, but also present among non-smokers.

Monitoring progress toward United Nations commitments: characteristics of Canadian legislation to promote tobacco control, physical activity and healthy eating. A descriptive study.

BACKGROUND: Legal interventions are important mechanisms for chronic disease prevention. Since Canadian laws to promote physical activity and healthy eating are growing, we compared the characteristics of legal interventions targeting physical activity and healthy eating with tobacco control laws, which have been extensively described. METHODS: We reviewed 718 federal, provincial and territorial laws promoting tobacco control, physical activity and healthy eating captured in the Prevention Policies Directory between spring 2010 and September 2017. We characterized the legislation with regard to its purpose, tools to accomplish the purpose, responsible authorities, target location, level of coerciveness and provisions for enforcement. RESULTS: Two-thirds (67.9%) of tobacco control legislation had a primary chronic disease prevention purpose (explicit in 5.3% of documents and implicit in 62.6%), and 29.5% had a secondary chronic disease prevention purpose. One-quarter (27.0%) of physical activity legislation had a primary chronic disease prevention purpose (explicit in 8.8% of documents and implicit in 18.1%), and 53.0% had a secondary chronic disease prevention purpose. In contrast, 69.3% of healthy eating legislation had no chronic disease prevention purpose. Tobacco control legislation was most coercive (restrict or eliminate choice), and physical activity and healthy eating legislation was least coercive (provide information or enable choice). Most tobacco control legislation (85.8%) included provisions for enforcement, whereas 47.4% and 24.8% of physical activity and healthy eating laws, respectively, included such provisions. Patterns in responsible authorities, target populations, settings and tools to accomplish its purpose (e.g., taxation, subsidies, advertising limits, prohibitions) also differed between legislation targeting tobacco control versus physical activity and healthy eating. INTERPRETATION: Legislative approaches to promote physical activity and healthy eating lag behind those for tobacco control. The results serve as a baseline for building consensus on the use of legislation to support approaches to chronic disease prevention to reduce the burden of chronic disease in Canadians.

Trends in sugary drinks in Canada, 2004 to 2015: a comparison of market sales and dietary intake data.

OBJECTIVE: The current study aimed to examine the correspondence between sales data and dietary recall data for sugary drinks in Canada. DESIGN: Repeat cross-sectional analysis of sales data for sugary drinks sold in Canada from 2004 to 2015 from two sources: GlobalData (GD) and Euromonitor (EM). Sugary drinks included ten beverage categories containing free sugars. Analyses examined sales volumes over time, with adjustment for population growth. National intake estimates were drawn from the 2004 and 2015 Canadian Community Health Survey (CCHS) Nutrition. SETTING: Canada. PARTICIPANTS: Not applicable. RESULTS: In 2015, daily per capita sugary drinks consumption was estimated as 356 ml (GD) and 443 ml (EM) from sales data sources, and as 277 ml from dietary recall data. Both sales data sources and dietary recall data indicated that per capita sugary drinks consumption decreased from 2004 to 2015, although the magnitude of this change differed: -23 % (GD), -17 % (EM) and -32 % (CCHS Nutrition). Market sales data showed similar trends among categories of sugary drinks, with decreases in sales of traditional beverage categories (e.g. carbonated soft drinks) and increases in novel categories (e.g. sugar-sweetened coffee). CONCLUSIONS: All data sources indicate a declining trend in sugary drinks consumption between 2004 and 2015, but with considerable differences in magnitude. Consumption estimates from sales data were substantially higher than estimates from dietary recall data, likely due to under-reporting of beverage intake through dietary recall and the inability of sales data to account for beverages sold but not consumed. Despite the observed decline, sugary drinks sales volumes remain high in Canada.

Identification of flavouring chemicals and potential toxicants in e-cigarette products in Ontario, Canada.

OBJECTIVES: The current study examined constituents of e-cigarette products on the Canadian market, with a focus on the province of Ontario. METHODS: E-cigarettes were systematically purchased at 80 retail outlets across 4 cities in Ontario, Canada, in January-February 2015. Product constituents were identified using gas chromatography and mass spectrometry. Additionally, tobacco-specific nitrosamines (TSNAs) were quantified in tested products using liquid chromatography with tandem mass spectrometry. RESULTS: A total of 166 e-cigarette products were purchased, including disposable products (33%), refillable products (14%), and e-liquids (53%). Overall, e-cigarette products had an average of 6.2 (SD = 3.6) flavouring chemicals. E-cigarettes with sweet flavours (e.g., desserts, alcoholic drinks) had a significantly greater number of flavouring chemicals when compared with tobacco- and menthol-flavoured products (p < 0.05). Approximately one fifth (21%) of products contained flavouring chemicals with potential risk of inhalation toxicity (benzyl alcohol, benzaldehyde, vanillin). An additional 8 toxicants (e.g., acrolein, diacetyl) were detected in a total of 14 e-cigarette products. Measurable levels of TSNAs were detected in 70% of tested products. CONCLUSION: E-cigarettes purchased in Ontario, Canada, contained several constituents that may present excess risk, including some flavouring chemicals and carcinogenic nitrosamines. Further research is needed to determine whether the levels of these constituents have implications for the magnitude of risk to users. The findings reveal several policy gaps that may be addressed by developing regulatory product standards and labelling practices for e-cigarettes.

Children and adolescents' exposure to food and beverage marketing in social media apps.

BACKGROUND: Unhealthy food marketing is a powerful determinant of unhealthy diets and obesity among children. Although it is known that food marketers target young people on social media, no study has yet quantified children's exposure on these platforms. OBJECTIVES: To compare the frequency and healthfulness of food marketing seen by children and adolescents on social media apps as well as estimate their weekly exposure. METHODS: 101 children and adolescents (ages 7-16 years) completed a survey on their media use and were recorded using their two favourite social media apps for 5 minutes each on the mobile device they usually use. Recordings of app use were reviewed to identify food marketing exposures. RESULTS: Overall, 72% of participants were exposed to food marketing. Of the 215 food marketing exposures identified, most promoted unhealthy products such as fast food (44%) and sugar-sweetened beverages (9%). Adolescents viewed more instances of food marketing, on average, per 10-minute period compared with children (Mean [SD] = 2.6 [2.7] versus 1.4 [2.1], U = 1606, z = 2.94, P = 0.003). It was also estimated that children and adolescents see food marketing 30 and 189 times on average per week on social media apps, respectively. CONCLUSIONS: Statutory regulations restricting unhealthy food marketing to adolescents and children on social media should be considered.

Biomarkers of Exposure Among "Dual Users" of Tobacco Cigarettes and Electronic Cigarettes in Canada.

INTRODUCTION: "Dual use" refers to the concurrent use of tobacco cigarettes (smoking) and electronic cigarettes (e-cigarettes; vaping). Although dual use is common among e-cigarette users, there is little evidence regarding biomarkers of exposure among dual users and how these change under different conditions of product use. METHODS: A nonblinded within-subjects crossover experiment was conducted with adult daily dual users (n = 48) in Ontario, Canada. Participants completed three consecutive 7-day periods in which the use of tobacco cigarettes and e-cigarettes was experimentally manipulated, resulting in four study conditions: Dual use, Tobacco cigarette use, E-cigarette use, and No product use. Repeated measures models were used to examine changes in product use and biomarkers of exposure. RESULTS: Compared to dual use, cotinine remained stable when participants exclusively smoked (p = .524), but significantly decreased when they exclusively vaped (p = .027), despite significant increases in e-cigarette consumption (p = .001). Levels of biomarkers of exposure to toxicants, including carbon monoxide (CO), 1-hydroxypyrene (1-HOP), and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), were significantly lower when participants exclusively vaped than when they engaged in dual use (CO = -41%, p < .001; 1-HOP = -31%, p = .025; NNAL = -30%, p = .017). Similar findings were observed among participants abstaining from both products as compared to dual use (CO: -26%, p < .001; 1-HOP = -14% [ns]; NNAL = -35%, p = .016). In contrast, levels of biomarkers of exposure increased when participants exclusively smoked as compared to dual use (CO = +21%, p = .029; 1-HOP = +23%, p = .048; NNAL = +8% [ns]). CONCLUSIONS: Although dual use may reduce exposure to tobacco smoke constituents to some extent, abstaining from smoking is the most effective way to reduce such exposure. IMPLICATIONS: Public health authorities should clearly communicate the relative risk of e-cigarettes and tobacco cigarettes to the general public, focusing on two salient points: (1) e-cigarettes are not harmless, but they are less harmful than tobacco cigarettes; and (2) using e-cigarettes while smoking may not necessarily reduce health risks; therefore, consumers should stop smoking completely to maximize potential health benefits.

Carcinogen Exposure among Canadian Tobacco Users: Changes in NNK Exposure from 2007-2009 through 2012-2013.

Background: Tobacco-specific nitrosamines (TSNAs) are a class of carcinogens found in tobacco products, whose levels can vary considerably depending on tobacco blends and manufacturing processes. The current study examined whether recent increases in levels of the TSNA NNK [4-(methylnitrosamino-1-(3-pyridyl)-1-butanone] in Canadian cigarettes translated into differences in exposure among Canadian tobacco users.Methods: Nationally representative data from the Canadian Health Measures Survey (CHMS) were used to measure levels of total urinary NNAL [4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol], a metabolite of the TSNA NNK, among tobacco users. Data from CHMS Cycle 3 (2012-13) were used to examine NNAL, and linear regression was used to examine predictors. Data from CHMS Cycle 1 (2007-09) and Cycle 3 (2012-13) were used to examine changes in NNAL over time.Results: From 2007-2009 through 2012-2013, levels of creatinine-corrected NNAL increased by 64% (P < 0.0001). Levels of NNAL in 2012-2013 were higher among older respondents (P = 0.04), among females (P = 0.03), among respondents identifying as "white" and "Aboriginal" (P < 0.0001), and among those with greater daily cigarette consumption (P < 0.001), as well as greater levels of urinary free cotinine (P < 0.0001) and urinary creatinine (P < 0.0001).Conclusions: The findings indicate that exposure to the TSNA NNK among Canadian tobacco users has increased considerably from 2007-2009 through 2012-2013, in parallel to changes in TSNA levels in Canadian cigarettes. In the absence of epidemiologic data, it is unclear whether this change translates into increased risk.Impact: The study findings have potential implications for tobacco manufacturers, who bear a responsibility to reduce levels of tobacco carcinogens to the full extent possible. Cancer Epidemiol Biomarkers Prev; 27(3); 262-7. ©2018 AACR.

Trends Over Time in Tobacco-Specific Nitrosamines (TSNAs) in Whole Tobacco and Smoke Emissions From Cigarettes Sold in Canada.

Introduction: Tobacco-specific nitrosamines (TSNAs) are potent carcinogens. Levels of TSNAs can be modified through manufacturing practices. In the 2000s, TSNA levels in cigarettes sold in Canada were reduced by changes in tobacco curing processes. The current study examined TSNA levels over the following decade to examine trends over time. Methods: Data submitted to Health Canada under the Tobacco Reporting Regulations were used to examine whole tobacco constituents for 1809 brands and mainstream smoke emissions for 191 brands manufactured by Canada's three leading cigarette companies from 2005 through 2011/12 using one-way analysis of variances (ANOVAs) and linear regression models. Results: Levels of N-nitrosoanatabine (NAT) (p < .001) and 4-(methylnitrosamino-1-(3-pyridyl)-1-butanone (NNK) (p < .001) in whole tobacco showed significant differences over time, decreasing between 2005 and 2007, and generally increasing from 2007 through 2012. Levels of all TSNAs in mainstream smoke emissions reflected a similar pattern: N-nitrosoanabasine (NAB) (p < .001), NAT (p < .001), NNK (p < .001), and N'-nitrosonornicotine (NNN) (p = .021). Linear regression analyses showed that TSNA levels varied by manufacturer over time in whole tobacco for NAT, NNK, and NNN (p < .001 for all), and in smoke emissions for NAB, NAT, NNK, and NNN (p < .001 for all). Conclusions: The findings indicate that levels of TSNAs in whole tobacco and smoke emissions of cigarettes sold in Canada increased from 2007 through 2011/12, following initial reductions over the previous 2 years. Differences in TSNA levels between companies raise questions about manufacturing practices that may be responsible for these changes. Although increased levels of carcinogenic TSNAs may be alarming, it remains unclear whether these differences translate into differences in health risk. Implications: The wide variation of TSNAs within the Canadian market across time and across cigarette companies demonstrates the feasibility of reducing the levels of these potent carcinogens. Although it is unclear whether changes made to levels of TSNAs will result in less tobacco-related disease, the tobacco industry bears a responsibility to minimize the harm from smoking to the fullest extent possible.

How do consumers perceive differences in risk across nicotine products? A review of relative risk perceptions across smokeless tobacco, e-cigarettes, nicotine replacement therapy and combustible cigarettes.

OBJECTIVE: To systematically review the literature regarding relative risk perceptions (RRPs) across non-combustible nicotine products. DATA SOURCES: MEDLINE and PsycINFO databases were searched for articles published up to October 2014. STUDY SELECTION: Of the 5266 records identified, articles not published in English that did not quantitatively assess RRPs across categories of non-combustible nicotine products were excluded, yielding 55 records. DATA EXTRACTION: One reviewer extracted measures and findings of RRPs for product comparisons of smokeless tobacco (SLT), e-cigarettes (ECs) and nicotine replacement therapy (NRT) to one another, and to combustible cigarettes (CCs). DATA SYNTHESIS: A total of 157 samples from 54 studies were included in the analyses. The accuracy of RRPs differed based on the products being compared: although the accuracy of RRPs was variable across studies, substantial proportions of respondents reported inaccurate beliefs about the relative harmfulness of SLT versus CCs, as well as of ECs versus NRT. In addition, in most studies, respondents did not know the relative harmfulness of SLT versus NRT. In contrast, respondents in many studies correctly perceived NRT and ECs as less harmful than CCs. Cigarette smokers and users of non-combustible nicotine products tended to correctly perceive the relative harmfulness of products more often than non-users. Measures used to assess RRPs varied across studies, with different approaches characterised by certain strengths and limitations. CONCLUSIONS: The highly variable and context-specific nature of non-combustible nicotine product RRPs have direct implications for researchers and present several challenges for policymakers working with modified risk products, including issues of measurement, health risk communication and behaviour change.

Consumer preferences for electronic cigarettes: results from a discrete choice experiment.

INTRODUCTION: E-cigarettes present a formidable challenge to regulators given their variety and the rapidly evolving nicotine market. The current study sought to examine the influence of e-cigarette product characteristics on consumer perceptions and trial intentions among Canadians. METHODS: An online discrete choice experiment was conducted with 915 Canadians aged 16 years and older in November 2013. An online commercial panel was used to sample 3 distinct subpopulations: (1) non-smoking youth and young adults (n=279); (2) smoking youth and young adults (n=264) and (3) smoking adults (n=372). Participants completed a series of stated-preference tasks, in which they viewed choice sets with e-cigarette product images that featured different combinations of attributes: flavour, nicotine content, health warnings and price. For each choice set, participants were asked to select one of the products or indicate 'none of the above' with respect to the following outcomes: interest in trying, less harm and usefulness in quitting smoking. The attributes' impact on consumer choice for each outcome was analysed using multinomial logit regression. RESULTS: Health warning was the most important attribute influencing participants' intentions to try e-cigarettes (42%) and perceived efficacy as a quit aid (39%). Both flavour (36%) and health warnings (35%) significantly predicted perceptions of product harm. CONCLUSIONS: The findings indicate that consumers make trade-offs with respect to e-cigarette product characteristics, and that these trade-offs vary across different subpopulations. Given that health warnings and flavour were weighted most important by consumers in this study, these may represent good targets for e-cigarette regulatory frameworks.

Cigarette brands with flavour capsules in the filter: trends in use and brand perceptions among smokers in the USA, Mexico and Australia, 2012-2014.

OBJECTIVE: To describe trends, correlates of use and consumer perceptions related to the product design innovation of flavour capsules in cigarette filters. METHODS: Quarterly surveys from 2012 to 2014 were analysed from an online consumer panel of adult smokers aged 18-64, living in the USA (n=6865 observations; 4154 individuals); Mexico (n=5723 observations; 3366 individuals); and Australia (n=5864 observations; 2710 individuals). Preferred brand varieties were classified by price (ie, premium; discount) and flavour (ie, regular; flavoured without capsule; flavoured with capsule). Participants reported their preferred brand variety's appeal (ie, satisfaction; stylishness), taste (ie, smoothness, intensity), and harm relative to other brands and varieties. GEE models were used to determine time trends and correlates of flavour capsule use, as well as associations between preferred brand characteristics (ie, price stratum, flavour) and perceptions of relative appeal, taste and harm. RESULTS: Preference for flavour capsules increased significantly in Mexico (6% to 14%) and Australia (1% to 3%), but not in the USA (4% to 5%). 18-24 year olds were most likely to prefer capsules in the USA (10%) and Australia (4%), but not Mexico. When compared to smokers who preferred regular brands, smokers who preferred brands with capsules viewed their variety of cigarettes as having more positive appeal (all countries), better taste (all countries), and lesser risk (Mexico, USA) than other brand varieties. CONCLUSIONS: Results indicate that use of cigarettes with flavour capsules is growing, is associated with misperceptions of relative harm, and differentiates brands in ways that justify regulatory action.

Retail availability and marketing of electronic cigarettes in Canada.

OBJECTIVES: Canada is among an increasing number of countries with restrictions on the sale of electronic cigarettes (e-cigarettes). In Canada, e-cigarettes containing nicotine have not been approved for sale; however, e-cigarettes that do not contain nicotine and do not make health claims can be sold. To date, there is little empirical evidence assessing the retail availability and marketing of e-cigarettes in countries such as Canada. METHODS: Audits were conducted at 59 brick-and-mortar retail outlets (grocery stores, convenience stores, tobacconist shops and vape shops) in four cities (Vancouver, Toronto, Montreal and Halifax) in August-October 2014. In addition, a total of 21 e-cigarette manufacturer/retailer websites were audited, and inquiries were made as to whether the companies sold nicotine-containing products. RESULTS: Overall, 76% of the retail outlets sold e-cigarette products. Of convenience stores, grocery stores and tobacconist shops with e-cigarettes for sale, the vast majority (94%) sold nicotine-free products only; in contrast, all the vape shops sold at least one nicotine-containing e-cigarette product. Front counter displays were the most common form of in-store promotions and were present in virtually all convenience stores, tobacconist shops and vape shops. Nicotine-containing e-cigarettes were available for purchase at approximately half (52%) of the online e-cigarette retailers surveyed. CONCLUSION: E-cigarettes with and without nicotine are widely available and marketed at a variety of retail outlets in Canada. "Illegal" sales of nicotinecontaining e-cigarettes were predominantly found at vape shops and online outlets, suggesting limited compliance with existing regulations.

Who is using e-cigarettes in Canada? Nationally representative data on the prevalence of e-cigarette use among Canadians.

The current study examined prevalence and correlates of electronic cigarette (e-cigarette) use in the Canadian population, using data from the nationally representative 2013 Canadian Tobacco, Alcohol and Drugs Survey (n=14,565). Sociodemographic correlates of e-cigarette use (ever, and in the past 30 days) were examined using logistic regression models. Overall, 8.5% of Canadians aged 15 and older reported having ever tried an e-cigarette; 1.8% had used one in the past 30 days. E-cigarette use was particularly high among smokers and young people. Overall, prevalence did not differ between males and females, for ever (P=0.24) or past 30-day use (P=0.30). Smoking status was the strongest correlate of e-cigarette use (ever and in the past 30 days, P<0.0001): 37.3% of current smokers had ever tried an e-cigarette (9.6% used in the past 30 days), compared to 3.0% of never-smokers (0.3% past 30-days), and 5.1% of former smokers (0.9% past 30-day). E-cigarette use also varied by age (P<0.0001): prevalence was highest among youth aged 15-19 (19.8% ever; 2.6% past 30-day) and young adults aged 20-24 (20.1% ever; 3.9% past 30-day), and decreased with age. Among youth, the majority of e-cigarette users were never-smokers, while the majority of adult users were smokers. In Canada, e-cigarette use is particularly high among smokers and young people. Dual use with cigarettes was common, with most e-cigarette users also smoking conventional cigarettes. Continued monitoring of e-cigarette use and its relationship with smoking should be a priority, given the rapidly-evolving e-cigarette market and implementation of new policy measures.

E-cigarette use in Canada: prevalence and patterns of use in a regulated market.

OBJECTIVE: Canada is among the few countries in which e-cigarettes containing nicotine are prohibited. To date, there is little evidence on the prevalence and patterns of use of e-cigarettes in markets with product bans. The current study examines e-cigarette use among a sample of non-smokers and smokers in Canada. DESIGN: Online cross-sectional survey. SETTING: Conducted in October 2013 using a commercial panel of Canadians from Global Market Insite, Inc (GMI). PARTICIPANTS: In total, 1095 Canadians were included in the analysis: 311 non-smokers aged 16-24 years (younger non-smokers), 323 smokers aged 16-24 years (younger smokers) and 461 smokers 25 years and older (older smokers). PRIMARY AND SECONDARY OUTCOME MEASURES: E-cigarette ever and current use, types of products used, and reasons for use. RESULTS: Approximately 79% of younger non-smokers, 82% of younger smokers and 81% of older smokers were aware of e-cigarettes. Ever trial of e-cigarettes was reported by 10% of younger non-smokers, 42% of younger smokers and 27% of older smokers. Moreover, current use of an e-cigarette, which was defined as use in the last 30 days, was reported by 0.3% of younger non-smokers, 18% of younger smokers and 10% of older smokers. Among those who had ever tried an e-cigarette, approximately 10% of younger non-smokers, 46% of younger smokers and 43% of older smokers reported trying an e-cigarette that contained nicotine. The most popular e-cigarette flavours were fruit followed by menthol, and the most common reason for using e-cigarettes was to help them quit smoking. CONCLUSIONS: In the context of previous research, it appears that the prevalence of e-cigarette trial has increased in Canada. Although a considerable proportion of non-smokers have tried e-cigarettes, current use is almost entirely concentrated among smokers. Further research should be conducted to monitor e-cigarette use by Canadians.