Abstract
Objectives
Among Canadian adults who currently or formerly smoked cigarettes, we examined: consultations with healthcare providers (HPs) in the last two years; among those, the proportion who received any smoking cessation advice and the type of support recommended; and whether receiving cessation advice varied by social determinants of health (SDH) and health conditions.
Methods
Data are from the 2022 Canada International Tobacco Control Survey (online; August–December 2022). Eligible respondents included 1163 adults who smoked daily for at least two years or quit smoking in the last two years, but previously smoked daily. SDH and health variables included: sociodemographics, financial insecurity, depression/anxiety, lung disease, and alcohol use.
Results
Almost half consulted an HP (48.7 %); among those, 51.0% received cessation advice: 46.8 % were advised to use nicotine replacement therapy, 32.0 % varenicline, 14.0 % bupropion, 13.3 % a quitline, 14.5 % a smoking cessation program, and 2.6 % an e-cigarette. Adults with heart disease were more likely to receive advice to quit [odds ratio (OR) 2.74, 95 % confidence interval (CI):1.26,5.98)]. Among adults who were smoking, those who had no interest in quitting (OR 0.25, 95 % CI: 0.09,0.68) or reported that they wanted to quit a little/somewhat (OR 0.42, 95 % CI: 0.22,0.80) were less likely to receive advice compared to those who wanted to quit smoking a lot. There were no significant differences by SDH, mental health, lung disease, or alcohol use.
Conclusion
The low rate of smoking cessation advice from HPs underscores the need for systematic engagement across clinical settings to encourage quitting smoking and offer evidence-based methods to support cessation.
Keywords: Healthcare providers, Cigarette smoking, Cessation, Advice, Adults
Highlights
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Nearly half of Canadian adults who smoked or recently quit consulted a healthcare provider between 2020 and 22.
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Half of the adults who consulted a healthcare provider received smoking cessation advice.
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Most people received smoking cessation advice from a doctor.
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More than a quarter of adults did not receive advice about types of available cessation support.
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Tobacco dependence treatment should be integrated into all clinical settings.
1. Introduction
In Canada, cigarette smoking has caused more than one million deaths over the last 25 years, with 48,000 annual deaths from smoking-related causes (Government of Canada, 2023). Encouragement and assistance with smoking cessation is a critical component of preventive medicine (Reid et al., 2016), offering significant health benefits and reducing the risk of smoking-related diseases and premature death. Healthcare providers (HPs) play an important role in helping people to quit smoking (Canadian Pharmacists Association (CPA), 2001; Devonish et al., 2022). Studies have shown that multi-component interventions and strategies using the “5As” (Ask, Advise, Assess, Assist, and Arrange) improve smoking cessation outcomes in primary care settings (Papadakis et al., 2014, Papadakis et al., 2015; World Health Organization (WHO), 2014). Canadian evidence-based guidelines highlight the significant role of HPs in encouraging and supporting people to quit smoking, which includes systematic screening for smoking, assessment, and offering treatment such as approved cessation aids (nicotine replacement therapy (NRT) or other prescription medications, including varenicline or bupropion) and referral to a smoking cessation/behavioural counselling program (CAMH, 2021). Studies also show that even brief advice from an HP can be impactful (Papadakis et al., 2014, Papadakis et al., 2020; Reid et al., 2016) for increasing rates of quit attempts and the use of quit aids (e.g., NRT) (Zhang et al., 2016).
According to previous studies, many Canadian HPs do not provide assistance or advice in line with clinical practice guidelines (Papadakis et al., 2014, Papadakis et al., 2015). A 2002 study of adults who smoked in Ontario found that 41.7 % and 7.6 % received smoking cessation advice in the last year from their physician or pharmacist, respectively (Brewster et al., 2007). Among respondents who were recontacted in 2007, 54.9 % reported that in the last year they had been advised to quit smoking by their physician, 44.0 % by their dentist, and 14.7 % by a pharmacist (OTRU, 2008). Another study in Ontario in 2012 found that prior to an intervention designed to increase rates at which Ontario primary care providers delivered smoking cessation interventions, 55 % of patients were asked by their physician if they smoked, 45 % were advised to quit, and 35 % of patients received assistance with quitting from their physician (Papadakis et al., 2016). Similarly, a study from the 2016 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Survey found that among a nationally representative sample of Canadian adults who smoked daily and had visited an HP in the previous two years, 47.1 % received cessation advice from an HP (Gravely et al., 2019).
Although a few Canadian studies have documented low rates of cessation advice from HPs, it is unclear whether the likelihood of such advice differs across social determinants of health (SDH) or by health conditions that are directly related to smoking. Notably, smoking rates are unevenly distributed in Canada, with certain groups facing higher risks due to SDH (Callard and Chaiton, 2016). There is also well-established literature demonstrating that certain subpopulations more commonly smoke cigarettes compared to the general population, including people who engage in risky alcohol use and those with poorer mental health (Callard and Chaiton, 2016), and would likely benefit from cessation advice from an HP.
Using a nationally representative sample of Canadian adults who currently or formerly smoked daily in the last two years (2020−2022), we assessed (1) prevalence of consulting with an HP in the last two years; (2) among those, the proportion who received cessation advice and the type of support recommended; and (3) whether SDH characteristics (age, sex, income, education, race, financial stress), mental/physical health problems, and frequency of alcohol use were associated with receiving smoking cessation advice. Notably, this study was conducted during the COVID-19 pandemic, which would have been an opportune time for HPs to intervene and encourage smoking cessation, considering that smoking was considered a risk factor for greater disease burden from COVID-19 (Patanavanich and Glantz, 2021).
2. Methods
2.1. Study design and data collection
This study used data from the Wave 4 Canada ITC 4CV Survey (August–December 2022) and initially included 1163 Canadian adults (≥18 years) who reported smoking cigarettes daily for at least two years (n = 1125) or quit smoking in the last two years, but previously smoked daily (n = 38). Respondents were recruited from Leger Opinion's online probability-based panel across 10 provinces. All respondents provided informed consent. The survey protocols and all materials received ethics approval. Details about the Wave 4 ITC 4CV Survey are presented in the technical report: https://itcproject.org/methods/technical-reports/october-1-2024-itc-4cv-wave-4-2022-technical-report/.
2.2. Measures
The 2022 Canada ITC 4CV Survey questionnaire is available from the ITC Project's website (https://itcproject.org/surveys/canada/4cv4-ca/).
2.3. Independent variables
SDH variables included age group, sex at birth, annual household income, highest level of education and racial background (derived from the Canadian Census). Respondents were also asked “In the last 30 days, because of a shortage of money, were you unable to pay any important bills on time, such as electricity, telephone or rent bills?” (financial insecurity). Physical and mental health measures were assessed using the survey question: “Select all that apply: Are you currently being treated for, or have you been diagnosed with, any of the following: depression, anxiety (combined into ‘mental health condition’), heart disease, and chronic bronchitis, emphysema (combined into ‘lung disease’)”. Frequency of alcohol use was also assessed. Adults who smoked were also asked about how much they wanted to quit smoking (see Table 1 for response categories).
Table 1.
Provider type(s) who offered smoking cessation advice and patient-level characteristics associated with receiving advice in the last two years (2020–2022).
| Characteristics (total sample size who consulted with an HP, unweighted) |
Received smoking cessation advice (yes) (n = 321) |
|
|---|---|---|
| % yes (weighted) | 95 % CI | |
| Overall (N = 598) | 51.0 | 45.7, 56.3 |
| Provider type who offered cessation advice* | ||
| Doctor | 42.3 | 37.1, 47.5 |
| Dentist | 12.1 | 8.5, 15.8 |
| Other type of healthcare provider | 14.6 | 10.8, 18.5 |
| % yes (weighted) | OR (95 % CI) | |
| Smoking status | ||
| Formerly smoked daily (n = 33) | 57.9 | 1.76 (0.31, 1.76) |
| Currently smoking daily (n = 565) | 50.2 | 1.00 |
| Age group in years | ||
| 18–24 (n = 35) | 53.3 | 1.00 (0.24, 4.13) |
| 25–39 (n = 85) | 48.1 | 0.81 (0.33, 1.97) |
| 40–54 (n = 221) | 49.7 | 0.86 (0.47, 1.59) |
| ≥55 (n = 257) | 53.4 | 1.00 |
| Sex (at birth) | ||
| Female (n = 322) | 48.5 | 0.84 (0.55, 1.27) |
| Male (n = 276) | 53.0 | 1.00 |
| Annual household income ($ CAD) | ||
| Not reported (n = 37) | 57.2 | 1.83 (0.57, 5.90) |
| Low (<$30,000) (n = 159) | 57.2 | 1.43 (0.71, 2.89) |
| Moderate ($30,000–$59,999) (n = 162) | 46.2 | 0.92 (0.45, 1.85) |
| High (≥$60,000) (n = 240) | 48.4 | 1.00 |
| Education | ||
| Low (≤ high school) (n = 163) | 52.4 | 1.26 (0.63, 2.49) |
| Moderate (technical/trades/college/some university) (n = 267) | 51.0 | 1.19 (0.64, 2.20) |
| High (≥university degree) (n = 168) | 46.7 | 1.00 |
| Racial background | ||
| Black, Chinese, South Asian, Other race (n = 78) | 62.4 | 1.69 (0.85, 3.35) |
| White (n = 519) | 49.6 | 1.00 |
| Financial insecurity | ||
| No (n = 479) | 49.7 | 0.78 (0.45, 1.36) |
| Yes (n = 118) | 55.8 | 1.00 |
| Health Conditions† | ||
| Heart disease | ||
| Yes (n = 47) | 72.4 | 2.74 (1.26, 5.98) |
| No (n = 546) | 48.9 | 1.00 |
| Lung disease: chronic bronchitis and/or emphysema | ||
| Yes (n = 50) | 77.1 | 3.41 (0.99, 11.75) |
| No (n = 548) | 49.7 | 1.00 |
| Mental health condition: depression and/or anxiety | ||
| Yes (n = 196) | 55.0 | 1.26 (0.79, 2.01) |
| No (n = 402) | 49.2 | 1.00 |
| Frequency of alcohol use† | ||
| 4 or more times a week (n = 117) | 57.0 | 1.66 (0.65, 4.26) |
| 2–3 times a week (n = 95) | 44.6 | 1.01 (0.40, 2.51) |
| Once a month or less or 2–3 times per month (n = 256) | 54.4 | 1.49 (0.70, 3.17) |
| Never (n = 129) | 44.5 | 1.00 |
| How much do you want to quit smoking (N = 565)± | ||
| Not at all (n = 56) | 31.9 | 0.25 (0.09, 0.68) |
| Don't know (n = 18) | 42.7 | 0.40 (0.09, 1.79) |
| A little/somewhat (n = 266) | 44.1 | 0.42 (0.22, 0.80) |
| A lot (n = 225) | 65.3 | 1.00 |
Data were collected online in 2022. Among the 1163 Canadian adults who smoked cigarettes daily for at least two years (n = 1125) or quit smoking in the last two years, but previously smoked daily (n = 38), 598 respondents (weighted: 48.7 %) reported consulting with a healthcare provider (HP) in the last two years. Among those who consulted with an HP, 321 respondents (weighted: 51.0 %) reported receiving smoking cessation advice. Sample sizes that do not add up to 598 have missing data (respondent declined to answer).
All percentages are weighted. All comparisons controlled for smoking status and were adjusted using a Bonferroni correction. †Comparisons for health conditions also controlled for age group. ±Analysis only included adults who currently smoke (N = 565). OR: odds ratio. CI: Confidence interval. CAD: Canadian dollars. *Responses are not mutually exclusive: more than one type of provider could be selected. Other HP: pharmacist, nurse, dietitian. Outcomes were categorized as ‘yes’ vs. ‘no/don't know’.
2.4. Outcome variables
Respondents were first asked, “In the last 24 months, have you consulted any doctors, dentists, or other health professionals (e.g., pharmacists, nurses, dieticians)?” If the respondent answered ‘yes’, they were asked, “Which health professional(s) have you consulted? (a) doctor, (b) dentist, or (c) other health professional (e.g., pharmacist, nurse, dietitians)”, after which they were filtered on the type of HP they consulted with and asked, “On any occasion when you consulted a health professional in the last 24 months, did you receive any advice about quitting smoking”. Responses were coded as either ‘yes’ or ‘no’ for having consulted with/or received advice from any of the three HP categories.
Finally, among those who received cessation advice, we estimated the types of cessation support that were recommended by HPs. Support tyes assessed included (1) NRT, (2) varenicline, (3) bupropion, (4) vaping products (e-cigarettes), (5) telephone/online quitline service, or (6) clinic, individual or group counselling, stop-smoking course, or behaviour therapy. Respondents could select more than one type of support.
2.5. Statistical analyses
Weighted descriptive statistics were used to estimate: (1) prevalence of consulting an HP in the last two years; (2) among those, the proportion who received any cessation advice (overall and by provider type), and the type of cessation support recommended; (3) whether receiving cessation advice varied by social determinants of health (SDH) and health conditions; and (4) among adults who smoked daily, we examined whether interest in quitting smoking was associated with receiving advice. All comparisons controlled for smoking status and were adjusted using a Bonferroni correction. Analyses for health conditions also controlled for age group. Cross-sectional sampling weights were computed to ensure the sample represented the Canadian population of adults who smoke by sex, age group, education level, language, and geographical region. The Canadian Tobacco and Nicotine Survey was used as the benchmark to construct the weights (see technical report for further details). All analyses were conducted in SAS Version 9.4. Statistical significance and confidence intervals (CI) were computed at the 95 % confidence level with two-tailed tests.
3. Results
Supplemental Figure 1 shows the study flow diagram (from initial eligibility to receiving cessation advice). In 2022, among Canadian adults who currently or formerly smoked daily in the last two years (N = 1163), 48.7 % (n = 598) consulted/visited an HP in the last two years.
Table 1 presents the proportion of adults who consulted with an HP and received cessation advice, overall and by SDH and health conditions. Among adults who consulted an HP, 51.0 % received cessation advice. Among adults who received cessation advice (n = 321): (a) 83.0 % received advice from a doctor, 23.8 % from a dentist, and 28.7 % from another HP; and (b) 46.8 % were advised to use NRT, 32.0 % varenicline, 14.0 % bupropion, 14.5 % a telephone or quitline, 14.5 % a smoking cessation program, and 2.6 % an e-cigarette (see Table 2).
Table 2.
Healthcare provider type who offered smoking cessation advice and the type of cessation support that was recommended to Canadian adults who currently or formerly smoked daily (2020–2022).
| Type of provider who offered advice | n | % (95 % CI) |
|---|---|---|
| Advice received from a doctor | 266 | 83.0 (76.9, 87.7) |
| Advice received from a dentist | 70 | 23.8 (17.9, 31.0) |
| Advice received from another type of HP | 91 | 28.7 (22.4, 36.0) |
| Support type recommended | ||
| Nicotine Replacement Therapy | 139 | 46.8 (39.6, 54.2) |
| Varenicline | 99 | 32.0 (25.4, 39.4) |
| Bupropion | 43 | 14.0 (9.5, 20.0) |
| Telephone or quitline service | 48 | 13.3 (9.2, 18.8) |
| Smoking cessation clinic, individual or group counselling, stop-smoking course or behaviour therapy | 48 | 14.5 (10.3, 20.0) |
| E-cigarette | 13 | 2.6 (1.0, 6.7) |
| Any support listed above | 238 | 71.5 (64.7, 77.4) |
Data were collected online in 2022. 321 respondents (weighted: 51.0 %) reported consulting with an HP in the last two years and received advice about quitting smoking. n: unweighted sample size. Percentages are weighted. Advice received from an HP and the type of cessation support recommended are not mutually exclusive (i.e., respondents could select all that apply). Outcomes were categorized as ‘yes’ vs ‘no/don't know’.
Adults who were currently being treated for/diagnosed with heart disease (vs. no heart disease) were more likely to receive advice (odds ratio (OR) = 2.74, 95 % CI:1.26,5.98). Adults diagnosed with lung disease had higher rates of receiving cessation advice, but this did not reach statistical significance. There were no statistically significant differences across SDH, mental health, or by frequency of alcohol use. Among adults who were smoking daily, those who did not want to quit smoking (OR = 0.25, 95 % CI: 0.09,0.68) and those who said that they wanted to quit a little/somewhat (OR = 0.42, 95 % CI: 0.22,0.80) were less likely to receive advice compared to those who wanted to quit smoking a lot (see Table 1).
4. Discussion
About half of Canadian adults who smoked daily in 2022 or quit smoking daily in the last two years reported consulting/visiting an HP between 2020 and 2022, and among those who did, half reported receiving smoking cessation advice. We did not find any differences in receiving advice across any of the SDH characteristics. With regard to health problems, those diagnosed with, and/or currently receiving treatment for heart disease were more likely to have received advice to quit smoking. Adults with lung disease had a much higher rate of receiving cessation advice, but this did not reach statistical significance, likely owing to the small sample size. Mental health status and frequency of alcohol use were not significantly associated with receiving advice. We also found that adults with lower interest in quitting smoking were less likely to have received advice to quit, which may represent a lost opportunity to encourage patients to quit smoking and offer them information about the benefits of quitting, even if they are not interested in doing so (Tucker et al., 2018).
Our findings also demonstrate a missed opportunity for HPs to recommend a cessation aid to their patients. Only 47 % of those who received advice were recommended NRT and 32 % were recommended varenicline, both of which can increase the chances of success (Reid et al., 2016). Only 13 % were recommended to use a quitline service, which is effective, free, and convenient. We also found that only 3 % of HPs recommended an e-cigarette as a form of cessation support. As e-cigarettes have a lower-risk toxicant profile than regular cigarettes, and have been found to be more effective than NRT (Lindson et al., 2025), HPs could consider this as an alternative form of support for those who do not want to use medically approved cessation aids. Increased cessation using an e-cigarette has been found among adults with little interest in quitting smoking (Kasza et al., 2023).
While this cross-sectional study has many strengths (e.g., a large population-based sample of Canadian adults who smoke or formerly smoked), the results should be interpreted with some caution. First, asking about receipt of advice over a two-year period may have resulted in recall bias. Next, we only assessed advice received among adults who consulted with an HP. We recognize that this survey was conducted during the COVID-19 pandemic, where many people likely did not consult with HPs during periods of lockdown or unless they were sick. However, among those who did consult with an HP, we still found that only half of adults reported receiving any advice to quit smoking, which aligns with our previous estimate of 47 % in 2016 (Gravely et al., 2019). Moreover, as COVID-19 was primarily a respiratory illness and cigarette smoking was found to be associated with more severe outcomes from COVID-19 (Patanavanich and Glantz, 2021), this should have been an impetus for HPs to provide cessation advice for their patients who smoke thereby emphasizing the importance of quitting. Finally, we also recognize that some adults are more likely to seek regular care from various HPs (e.g., older adults, those with mental or physical health problems), therefore other ways of reaching smoking populations who do not regularly visit an HP is important to consider.
5. Conclusion
In 2022, 3.8 million Canadians (12 % of the population) aged ≥15 years smoked cigarettes, with mortality from smoking having exceeded deaths from alcohol, opioids, suicides, murders, and traffic collisions combined (Government of Canada, 2023). Thus, a substantial amount of work is needed to achieve Canada's Tobacco Strategy target, which aims for less than 5 % tobacco use prevalence by 2035 (Government of Canada, 2024). Further, despite the fact that we did not find any differences in getting advice on quitting smoking by SDH, a “vulnerable population approach” may help drive down smoking rates among people who are disadvantaged by economic, social or other individual or contextual factors, and smoke at much higher rates than the general population (Callard, 2016).
CRediT authorship contribution statement
Shannon Gravely: Writing – original draft, Visualization, Methodology, Investigation, Formal analysis, Conceptualization. Pete Driezen: Writing – review & editing, Investigation. Janet Chung-Hall: Writing – review & editing. Anne C.K. Quah: Writing – review & editing, Project administration, Methodology. Christopher B. Lok: Writing – review & editing, Methodology. Thomas K. Agar: Writing – review & editing, Project administration, Methodology. Geoffrey T. Fong: Writing – review & editing, Methodology, Investigation, Funding acquisition.
Ethics
The survey protocols and all materials, including the survey questionnaires, were cleared for ethics by the Research Ethics Board, University of Waterloo, Canada (REB#20803/30570). Ethics clearance from the Medical University of South Carolina was waived due to minimal risk. The study met the guidelines for protection of human subjects concerning safety and privacy.
Funding
The ITC Four Country Smoking and Vaping Survey was supported by grants from the US National Cancer Institute (P01 CA200512) and the Canadian Institutes of Health Research (FDN-148477). Additional support to GTF was provided by a Senior Investigator Grant from the Ontario Institute for Cancer Research (AI-004). The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.
Declaration of competing interest
GTF has served as an expert witness or consultant for governments defending their country’s policies or regulations in litigation. All other authors declare no conflict of interest. All authors declare no potential conflicts of interest with respect to the research, authorship, or publication of this article.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.pmedr.2025.103168.
Appendix A. Supplementary data
Supplemental Figure 1. Study flow diagram
Data availability
In each country participating in the international Tobacco Control Policy Evaluation (ITC) Project, the data are jointly owned by the lead researcher(s) in that country and the ITC Project at the University of Waterloo. Data from the ITC Project are available to approved researchers 2 years after the date of issuance of cleaned data sets by the ITC Data Management Centre. Researchers interested in using ITC data are required to apply for approval by submitting an International Tobacco Control Data Repository (ITCDR) request application and subsequently to sign an ITCDR Data Usage Agreement. The criteria for data usage approval and the contents of the Data Usage Agreement are described online (http://www.itcproject.org).
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental Figure 1. Study flow diagram
Data Availability Statement
In each country participating in the international Tobacco Control Policy Evaluation (ITC) Project, the data are jointly owned by the lead researcher(s) in that country and the ITC Project at the University of Waterloo. Data from the ITC Project are available to approved researchers 2 years after the date of issuance of cleaned data sets by the ITC Data Management Centre. Researchers interested in using ITC data are required to apply for approval by submitting an International Tobacco Control Data Repository (ITCDR) request application and subsequently to sign an ITCDR Data Usage Agreement. The criteria for data usage approval and the contents of the Data Usage Agreement are described online (http://www.itcproject.org).