Evaluating early implementation of the innovative Canadian policy of cigarette stick warnings among adults in Canada who smoke: An assessment using repeat cross-sectional surveys and daily diaries

Abstract

INTRODUCTION In 2024, Canada became the first country to implement warning messages on cigarette sticks. Warnings were required on king-size cigarettes in April 2024 at the manufacturer level and July 2024 at the retail level. The purpose of this study was to evaluate responses to cigarette stick warnings among adults who smoke in Canada using a standard survey and a daily diary study. METHODS We used two separate online survey (i.e. questionnaire) methods with Canadian adults who smoke daily and use king-size cigarettes, with data collected in February, May, and August 2024. The first method was a standard cohort survey (observations=1724; participants=999), with one survey each data collection period. Participants were followed up in subsequent waves. Participants reported noticing health information on cigarette sticks ‘any’ vs ‘none’, and ≥ ‘almost all’ vs ‘fewer cigarettes’ in last month. The second method was a daily diary study (observations=10572; participants=527), with brief surveys every evening for two weeks during each data collection period. Participants reported noticing health information on cigarette sticks (‘any’ vs ‘none’ in last 24 hours). Samples for the two studies were distinct. In both studies, we also assessed feelings about the look of cigarette sticks (1=very bad to 5=very good), forgoing cigarettes normally smoked (no vs yes), and quit motivation (continuous). Generalized estimating equations regressed outcomes on survey period, adjusting for sociodemographic and smoking-related covariates. RESULTS Noticing stick warnings increased in both surveys [standard ‘any’: May=58%, August=73%, OR=2.29 (95% CI: 1.81–2.91); standard ≥ ‘almost all’: May=27%, August=44%, OR=2.56 (95% CI: 1.99–3.30); daily diary: February=6%, May=10%, OR=1.77 (95% CI: 1.29–2.44), August=16%, OR=2.92 (95% CI: 1.73–4.93), all p<0.001]. Over time, negative feelings toward sticks [February=4.10, August=3.91, mean diff= -0.19 (95% CI: -0.32 – -0.05), p=0.006], forgoing cigarettes [February=56%, August=63%, OR=1.44 (95% CI: 1.12–1.86), p=0.004] and quit motivation [February=4.74, August=5.03, mean diff=0.30 (95% CI: 0.06–0.53), p=0.014] increased in the standard surveys, but not the daily diary study. CONCLUSIONS Canadian adults who smoke king-size cigarettes increasingly noticed cigarette stick warnings over the early implementation period. The standard survey also found increases in cessation-related responses to stick warnings. Future research should assess long-term impacts of this policy and validate standard and daily diary survey methods for evaluating labeling policies.