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Canadian Journal of Public Health = Revue Canadienne de Santé Publique logoLink to Canadian Journal of Public Health = Revue Canadienne de Santé Publique
. 2024 Nov 18;116(2):309–315. doi: 10.17269/s41997-024-00960-z

Where public health meets public opinion: Understanding political support for fluoridation in Calgary, 2021

Jack Lucas 1, R Michael McGregor 2,✉, Simon Kiss 3, Andrea M L Perrella 3
PMCID: PMC12076985  PMID: 39557770

Abstract

Objectives

To understand variables associated with support for community water fluoridation among ordinary citizens during periods of heightened issue salience, with a particular focus on how support varies on the basis of demographic characteristics, attitudes toward public health science, and political variables such as ideology, populism, and issue salience.

Methods

Statistical analysis of individual-level data from a large-scale survey of eligible voters in the City of Calgary, Alberta in 2021, collected at the time of a community water fluoridation plebiscite.

Results

Survey data (N = 1130) reveal substantively important and statistically significant relationships with fluoridation support in each of our three analysis categories (demographics, public health expertise, and politics). Support for fluoridation tends to be higher among men, university-educated, higher-income; among those with trust in experts and knowledge of fluoride governance; and among those who consider the issue important and have low levels of populist attitudes. Two exceptions to findings in past studies are age and ideology: younger respondents were more likely than older respondents to support fluoridation in Calgary, as were those on the ideological left, as compared to the right.

Conclusion

Incorporating studies of the correlates of public attitudes related to public health policies is important for understanding public health policy failure and success, especially in instances involving public consultation mechanisms, such as plebiscites.

Supplementary Information

The online version contains supplementary material available at 10.17269/s41997-024-00960-z.

Keywords: Fluoridation, Public opinion, Calgary, Plebiscite

Introduction

Community water fluoridation continues to be controversial within municipalities across Canada. It also serves as a case study of wider challenges related to public health interventions, scientific literacy, and public opinion, which have taken on increasing importance in the wake of the COVID-19 pandemic. The following analyses survey data of individual-level public attitudes toward water fluoridation in the City of Calgary in 2021.

Calgary’s municipal water supply had been fluoridated but the city council surprisingly ceased the practice in 2011 (CBC, 2011). Fluoridation later became a significant issue in local politics, spurred in part by a study of local children that showed increasing rates of cavities after fluoridation had stopped (McLaren et al., 2022). City councillors supportive of fluoridation and citizen activists soon mobilized to force a plebiscite for 2021. The vote resulted in 61.6% of voters supporting fluoridation, reversing council’s previous decision (Elections Calgary, 2021).

Using survey data collected at the time of the 2021 plebiscite, this study considers the impacts that demographic factors, attitudes toward public health expertise, and a series of political variables have on attitudes toward water fluoridation. We find statistically significant results for variables of all three types, but not all of the observed relationships are consistent with findings from other communities in Canada. This analysis demonstrates the value in applying methods from political science to the study of public health matters, and that the drivers of support for fluoridation vary by location.

Public opinion and public health

Despite the established safety and efficacy of community water fluoridation, this practice has consistently generated conflict, often spilling over into political disputes. Such a scenario provides an avenue for applying insights from political science to the study of public health (Fafard, 2015). There are many reasons for political conflict over public health measures. For one, the cost–benefit calculation of any given measure might be different for different respondents. Older people might be more susceptible to the spread of disease than younger people and may thus be more supportive of public health interventions. In the case of fluoridation in Canada, recent surveys have examined the relationship between various demographic measures and views about fluoridation and found that support for fluoridation increases with age, education, and income (Perrella & Kiss, 2015; Perrella et al., 2023; Quiñonez & Locker, 2009). However, those same also suggest support is lower among women.

In addition to differential cost–benefit calculations based on life experiences, there may be information problems that lead to different conclusions. Some may be misinformed or uninformed about public health intervention facts or expert consensus. Indeed, political sophistication and knowledge (or their absence) are foundational determinants of theories of opinion formation (Carpini & Keeter, 1996; Converse, 1964, 2000; Fournier, 2002). Zaller’s (1992) theory of the mass public opinion suggests voters take their cues from elites (e.g., party leaders, senior officials) with whom they identify in order to form an opinion. In this vein, early cross-party consensus in Canada about the necessity for strict public health measures during the COVID-19 pandemic led to mass public support for those measures (Merkley et al., 2020). Similarly, Sheluchin et al. (2020) found that Canadians followed the advice of Canada’s public health leadership as they reversed their early recommendations against wearing masks. In this vein, Perrella et al. (2023) found that high levels of scientific literacy and trust in scientific experts were related to support for fluoridation. Merkley (2020) found the latter as well.

However, alongside the so-called knowledge deficit model, Fafard emphasizes the importance of considering ideas alongside evidence in public health policymaking, recognizing that policies are shaped not only by factual knowledge but also by broader notions of right and wrong (Fafard, 2012; Simis et al., 2016). For instance, studies from disciplines such as sociology, history, and political science have demonstrated that conflicts over medical interventions and technology often centre more on conflicting worldviews and fundamental beliefs than on objective facts (Kahan, 2011; Kiss et al., 2020). Krashinsky and Naylor (2024) find that more widespread adherence to fundamental values of laissez-faire attitudes in the United States than in Canada go some way to explain greater opposition there to public health interventions. However, this politicization works both ways. Scoville et al. (2022) found that although mask wearing became normalized and largely depoliticized in American society, the backlash against mask refusal became more prevalent and the primary way in which masks became linked to politics. There is also emerging research that suggests that the recent rise of populist tendencies complicates public health innovations because they inculcate an anti-intellectual tendency which primes people to reject advice from experts (Merkley, 2020).

Although the bulk of the literature on attitudes toward COVID-19 interventions suggests that left-wing individuals are more likely to support those interventions than are those on the right, Perrella et al. (2023) found that support for fluoridation was correlated with right-wing ideology. Reflecting this, Carstairs and Elder (2008) argued that opposition to fluoridation could be mobilized even during the heyday of scientific innovation based on notions of unnaturalness and pollution. Beyond ideology, we also examine the perceived importance of fluoridation as an issue as a marker of support. One element of these value conflicts is not just valence, but salience as well. That is to say, voters do not just hold conflicting values about what is desirable, they also have differing levels of concern for competing values. Even in situations where there is a widespread agreement that something is desirable, where a dissenting minority feels more strongly, it can overpower majority support. Consistent with this, Kiss et al. (2018) highlight the importance of local dynamics that can occur during campaigns. They found that one explanation for the anti-fluoridation result of the 2010 plebiscite in Waterloo, Ontario, was simply because of greater motivation by local anti-fluoridationists compared to supporters.

The existing studies of support and opposition to fluoridation in Canada do leave important gaps which this contribution can address. Notably, while Quiñonez and Locker (2009) find majority support for community water fluoridation, their study did not include any political psychological variables. By contrast, Perrella and Kiss (2015) examined the case of a referendum in the City of Waterloo, and while they introduce political psychological variables, the study’s small sample and its post-plebiscite timeframe pose some limitations. Perrella et al.’s extensive survey (2023) of North Americans was more comprehensive and covered a broad range of variables, including socio-demographics, scientific knowledge, and political-psychological commitments, but is nonetheless limited by the absence of any local campaign context, thus impacting external validity. As a consequence, the results below address a significant void in international and Canadian literature, being one of the few examples of a survey of individual voters before and during a municipal fluoridation plebiscite. Following the advice of Fafard et al. (2022) that political science and public health must learn from each other, this study contributes to the understanding of contemporary support and opposition to community water fluoridation.

Methods

Data

Analysis is based upon data from a three-wave panel survey of eligible voters in Calgary in 2021. The first wave of the survey was fielded from July 6 to August 4, 2021. The second was fielded from October 5 to October 17, and the third was open from October 19 to November 1. Questionnaires were administered online by Forum Research Inc. Respondents were recruited using random digit dialling (and a combination of robo- and voice-call), and were then contacted via email, and provided with a link for each wave of the survey. To ensure sufficient sample size, Forum recruited 1201 new respondents in the second wave of the survey (who were then invited to complete the third wave). Appendix 1 (Supplementary Material) contains question wording for all variables used in our analysis.

A comparison of respondents who completed the final wave of our survey (where our outcome variable is measured) to official Statistics Canada census data (2021) reveals that our sample is representative of eligible Calgary voters in important dimensions, including gender and income—our sample is 53% female, as compared to the actual population share of 51%, and the median household income in our sample is listed as between $75,000 and $99,999, and the actual median household income is $98,000.1 This sample is slightly less representative in other dimensions; respondents are slightly older and better educated than the voting age population as a whole. The median age of respondents is 58, while the actual value among voting age Calgarians is between 45 and 49. Fifty-four percent of our sample has a university degree, as compared to 36% of the actual voting age population. We do not view this observation as a problem, however. It is well established that voters are overrepresented in political surveys of this nature (Burden, 2000). It is also the case that voters are not representative of their communities as a whole, and that municipal voters tend to be older and more well educated than their non-voting contemporaries (McGregor & Spicer, 2016). Accordingly, though our sample does not perfectly reflect Calgarians as a whole, we argue that the sample provides a good representation of the voting population.

Outcome variable

Our outcome variable is each survey respondent’s self-reported vote in the Calgary water fluoridation plebiscite (N = 1130). We used survey question wording identical to the fluoride plebiscite itself. Individuals who did not report voting in the fluoride plebiscite (N = 259) and those who refused to report their vote choice (N = 11) were excluded from the analysis.

Covariates

Our objective was to better understand the role of demographic, public health expertise, and political factors in citizens’ attitudes to community water fluoridation. To measure demographic factors, we focus on those which are standard in previous examinations of fluoride support, including age (in years), gender (a dummy), education (coded as dummies, with “less than college” as baseline), and income (in three tertiles, with “low income” as baseline). We include two measures relevant to public health expertise, including a two-item measure of one’s own fluoride-related knowledge, and a five-item measure of trust in experts (including doctors, scientists, economists, professors, and “experts”). The three political variables considered in our analysis are measures of left–right ideology, an index that taps into populism, and the level of importance respondents place upon the issue of water fluoridation. Although mistrust of “experts” is often an important conceptual part of populism, it need not be. Populism is also about the belief in a coherent, pure, and uncorrupted “people”, who are denied access to decision-making. Our questions adhere closely to this conceptualization. Our data also reveal that the correlation between these variables is moderate at best (− 0.37). Merkley (2020) finds that his measures of trust in experts and populism are highly correlated but models them as distinct covariates nonetheless.

Estimation strategy

We consider the correlates of fluoride plebiscite vote choice in a single statistical model containing all variables. To avoid listwise deletion of observations with missing values on one of our covariates, we impute missing values using bootstrap aggregated decision trees (“bagging”), a machine learning imputation procedure with excellent performance for imputation tasks. While our results are substantively similar with and without listwise deletion, we gain valuable precision in our coefficient estimates by avoiding listwise deletion. To maximize interpretability, we employ an ordinary least squares approach, but to ensure that our findings are robust to alternative modelling assumptions, we show in Appendix 2 (Supplementary Material) that our results are substantively identical when using logistic regression.

Results

The panel surveys were fielded in the summer (N = 2334), just prior to the October 18th municipal election (N = 2159), and just afterwards (N = 1400). Our outcome variable—self-reported vote in the Calgary water fluoridation plebiscite—was measured in the third wave and had an N of 1130.

Our model results are shown in Table 1. This includes all variables simultaneously. All variables have been rescaled to range between 0 and 1; coefficients can be interpreted as the expected difference in the probability of support for community water fluoridation when comparing individuals who are at the minimum and maximum values of each variable and who are otherwise similar on the other variables in the model. Sample size and model fit statistics (adjusted R2) are available at the bottom of the table.

Table 1.

The correlates of fluoride support—ordinary least squares regression

Coef Std. err
Demographics
Age  − 0.14**  − 0.07
Woman  − 0.08**  − 0.03
Education: college  − 0.01  − 0.05
Education: university 0.05  − 0.05
Income: middle 0.04  − 0.03
Income: high 0.10**  − 0.03
Public health science
Fluoride governance knowledge 0.23***  − 0.04
Trust in experts 0.35***  − 0.08
Politics
Left–right ideology  − 0.20***  − 0.06
Populism  − 0.11*  − 0.06
Issue importance: fluoride 0.42***  − 0.04
Intercept 0.14  − 0.11
Num. obs 1130
R2 0.197
R2 adj 0.190
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*p < 0.1, **p < 0.05, ***p < 0.01

The results in Table 1 illustrate that each of our three families of variables—demographics, public health expertise, and politics—are important correlates of fluoridation attitudes. Support for community water fluoridation is higher among younger (as compared to older) respondents, men (as compared to women), and individuals with high incomes (as compared to low). The results for gender and income are consistent with expectations, but this is not the case with age. In contrast to studies from elsewhere in Canada, in Calgary, it is younger voters who are comparatively supportive of fluoridation.

Turning to public health expertise, we find that both factual knowledge and trust in experts are powerfully related to citizens’ attitudes on community water fluoridation. In this instance, our results match expectations. Individuals who correctly answered our two factual questions about fluoride policy and governance were some 23 percentage points more likely to support fluoridation in the plebiscite, as compared to respondents who answered no questions correctly. Even more powerfully, high-trust individuals—those who expressed high trust in a variety of scientific experts—were some 35 percentage points more likely than low-trust individuals to support water fluoridation. These are substantively important differences, demonstrating that objective and subjective aspects of scientific expertise and policy knowledge are important for understanding public attitudes toward community water fluoridation.

The political variables similarly reveal relationships that are substantively important and statistically significant. In contrast to some past findings and our hypothesis, individuals who place themselves on the ideological left in Calgary are substantially more likely to support fluoridation than those on the ideological right—a difference of 20 percentage points when comparing far-left to far-right respondents (p < 0.01). Whereas Perrella et al.’s study (2023) of North America as a whole found that those on the right are more supportive of fluoridation, the opposite appears to be true in Calgary. We return to this finding in the conclusion.

The difference between populists and non-populists is somewhat smaller (11 points), but in the direction suggested by existing literature. Finally, as expected, those who consider community water fluoridation an important issue were dramatically more likely to support water fluoridation (some 42 percentage points) than those who considered it a low-importance issue. This is the largest coefficient in the model and indicates that there were very large differences in support for fluoridation among those who considered the issue important and those who did not. As a whole, the variables in the model are not only substantively large in their individual coefficients, they are also collectively important as predictors of fluoride support or opposition—our model has an adjusted r-square value of nearly 0.2.

These coefficients for the political variables are large enough to produce very large substantive differences in support for community water fluoridation; respondents who are left-leaning, low-populism, and consider fluoridation an important issue have an extremely high probability of voting in favour of fluoridation in the plebiscite (91%), while those who are right-leaning, high-populism, and do not consider fluoridation important have a very low probability of supporting fluoridation (17%).2

Discussion and conclusion

Understanding public opinion on public health issues is important for understanding why policy change succeeds or fails in Canadian communities, particularly when issues are highly salient or involve formal public consultation mechanisms such as plebiscites. This study has examined the correlates of support for community water fluoridation using a large public opinion survey at a moment when the issue was on the public agenda. We add to past studies by considering demographic, public health, and political variables alongside one another in a single model, allowing for a more robust analysis of the individual-level drivers of attitudes toward fluoridation.

In general, our findings reinforce past studies. In keeping with past studies, we find that men, university-educated, and higher-income respondents are more likely to support fluoridation. We also find that public health knowledge and trust in science are positively related to support for fluoridation—this, too, aligns with past studies. Finally, issue importance and populism are related to fluoride support in the expected directions: higher salience is associated with higher support, and populism is associated with lower support.

In two cases, however, our findings do not align with past studies. First, we find that younger Calgarians were more supportive of community water fluoridation, whereas past studies have found the opposite. This may suggest that the relationship between age and support for fluoridation varies across communities, or it may result from our more detailed model; by including more variables in our model, we may be able to better isolate the relationship between age and support for fluoridation.

We also find that the relationship between ideology and support for fluoridation is the opposite of the relationship observed in past studies: in Calgary, those on the ideological right are less likely to support fluoridation. While this finding is in keeping with more general research on support for public health interventions—such as attitudes toward COVID-19 policies (Merkley, 2020)—we speculate it also suggests that the relationship between ideology and fluoridation is likely to vary by geographic, temporal, and issue-salience contexts. In Calgary, for instance, those on the right may have been activated in opposition to community water fluoridation by a wider pandemic-related context and the increased salience of the issue due to the plebiscite, whereas the relationship might look different in a period of “quiet politics” on fluoridation. Alternatively, the relationship between ideology and fluoride support may be related to the positions of prominent local leaders on the issue, allowing pro-fluoride and anti-fluoride attitudes to be organized into different ideological coalitions in different communities (Martin, 2015). Other questions stemming from the fact that 2021 was just one year into the pandemic are also worthy of future consideration. Is it the case that public health concerns (over subjects such as fluoride) were more salient in the COVID context? Were Calgarians paying more or less attention to this issue given that they were so frequently exposed to public health news during this period? Would cues from politicians be more or less important in a context where COVID had not already been so heavily politicized? Public health debates do not happen in a vacuum, and we see these questions as an important priority for future research.

Contributions to knowledge

What does this study add to existing knowledge?

  • Our study uses data from a prominent Canadian case (Calgary, AB) to provide a systematic test of past findings on the correlates of public support for community water fluoridation.

  • We contribute to knowledge by (a) replicating findings in past studies, (b) testing the robustness of past findings by considering the relative importance of several correlates within a single statistical model, and (c) extending past studies to a new Canadian context.

  • Our analysis strengthens confidence in some relationships while indicating that others, such as political ideology, may vary by context.

What are the key implications for public health interventions, practice, or policy?

  • Individual-level characteristics—including political values—matter for public health outcomes, especially when the public is consulted on public health policy changes in plebiscites or other formal and informal consultative mechanisms.

  • Proponents of public health policy change must consider how public health policy issues are mobilized into pre-existing political coalitions in specific community contexts and appreciate that scientific communication and knowledge is an important part, but by no means the only meaningful correlate, of citizens’ public health policy attitudes.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 24 KB) (23.9KB, docx)

Author contributions

Lucas: data analysis, writing. McGregor: theorizing, writing. Kiss: research, writing. Perrella: research, writing. All authors read and approved the final manuscript.

Funding

This study was funded by the Social Sciences and Humanities Research Council of Canada, Partnership Engage Grant # 892–2020-2003.

Data availability

Data available upon publication.

Code availability

R coding available upon publication.

Declarations

Ethics approval

Conjoint Faculties Research Ethics Board, University of Calgary, ID: REB21-0619.

Consent to participate

Written informed consent was obtained from all participants.

Consent for publication

Not applicable.

Conflict of interest

The authors declare no competing interests.

Footnotes

1

Estimates are based upon data from Statistics Canada – Calgary (City) community profile, focusing on individuals 18 years and older. Note that some statistics are provided as medians, as data are binned by Statistics Canada, which prevents the calculation of means.

2

These probabilities are drawn from logistic regression models, with all other variables set at their median values. Pr(support) for left-ideology, low-populism, high-importance respondents = 0.91 (95% CI = 0.85, 0.95). Pr(support) for right-ideology, high-populism, low-importance respondents = 0.17 (95% CI = 0.1, 0.27). These probability estimates are statistically significantly different from each other (p < 0.01) and each is statistically significantly different from Pr = 0.5 (p < 0.01).

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary file1 (DOCX 24 KB) (23.9KB, docx)

Data Availability Statement

Data available upon publication.

R coding available upon publication.

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