Original quantitative research – Implementing a smoke-free generation policy for Canada: estimates of the long-term impacts

Abstract

Introduction: The aim of this study was to assess the potential impacts of the introduction of a smoke-free generation (SFG) policy in Canada with a perpetual ban on cigarette sales to anyone born after 2009 instigated on 1 January 2025.

Methods: An existing Canadian model relating to smoking cessation was adapted and augmented to assess the impact of an SFG policy on quality-adjusted life years (QALYs), life expectancy, health care costs, smoking-related taxes, and Canadian tobacco industry gross domestic product (GDP). The cumulative impact of the policy for the entire Canadian population was assessed for time horizons up to 90 years with an annual discount rate of 1.5%.

Results: After 50 years, this SFG policy would lead to 476 814 more QALYs, $2.3 billion less in health care costs, $7.4 billion less in smoking-related taxes and a $3.1 billion reduction in tobacco industry GDP. The combined value of health benefits gained and health care costs averted would exceed the sum of tax revenues foregone and reduced GDP, if the value of a QALY was at least $17 147. Use of higher discount rates and inclusion of unrelated health care costs had little impact on the interpretation of the results.

Conclusion: The implementation of an SFG policy will bring substantive health benefits to the population in Canada. Although health care cost savings are lower than the combination of lost tax revenues and the decline in the GDP from the Canadian tobacco industry, the value of the health benefits realized outweigh the negative offsets.

Keywords: tobacco smoking, health policy, smokefree generation

Introduction

Although the prevalence of smoking has decreased consistently over the last 50 years, the proportion of Canadians who are current daily smokers showed a small increase, from 8.4% to 9.1%, in 2022.^{Footnote 1} Despite the decreasing trend in prevalence, smoking remains a major cause of preventable disease and mortality in Canada.^{Footnote 2}

The current target of federal government policy is to reduce tobacco use to less than 5% by 2035.^{Footnote 3} The strategy focuses on helping Canadians who are current smokers to quit and on protecting those who do not smoke, particularly youth, from developing a tobacco addiction. However, provinces vary with respect to smoking cessation initiatives such as the age when it becomes legal to purchase tobacco (between 18 and 21 years).

Despite the restrictions on the sale of tobacco products, responses to the Canadian Student Tobacco, Alcohol and Drugs Survey show that 3% of students in Grades 7 to 12 in 2018 to 2019 (aged 11–18 years) were currently smoking cigarettes.^{Footnote 4} In addition, 58% of the students responded that it would be “fairly easy” or “very easy” to get a cigarette if they wanted one.^{Footnote 4} By the time they were aged 18 years, 7.5% of males and 4.6% of females reported that they were current daily smokers.^{Footnote 4}

Various jurisdictions across the world have contemplated introducing a smoke-free generation policy (SFG) to limit tobacco consumption.^{Footnote 5Footnote 6} An SFG policy involves prohibiting the sale of tobacco products to people born after a specific date for their lifetime. Concerns with current legislation are that smoking initiation continues among individuals who are prohibited from purchasing tobacco and that those individuals for whom the protective measures apply will reach an age where the restriction of tobacco sales is no longer valid. An SFG policy can address both of these concerns.

To determine the impacts of an SFG policy, an existing Markov model for assessing the impact of smoking cessation in Canada was adapted to determine the impacts on life expectancy, quality-adjusted life years (QALYs), smoking-related health care costs, taxes raised through tobacco sales and the Canadian gross domestic product (GDP).

Methods

Analytical approach

An approach was adopted that was similar to a previous analysis that examined the impact of vaping by teenagers on the uptake of smoking tobacco and the subsequent impacts on QALYs and costs.^{Footnote 7} The revised model adopts the same approach to modelling smoking commencement, cessation and relapse and focuses on health states related to smoking status.^{Footnote 7} The model simulates a Canadian population aged 15 years and older and the transition of individuals between the following states: current smokers, former smokers, never smokers and dead. The model predicts the proportion of the cohort in each of these states every 6 months. The numbers of males and females turning age 15 years in 2025 were based on the most recent census figures adjusted for both mortality and immigration.^{Footnote 8Footnote 9Footnote 10}

All data used in the analysis are presented in Table 1.

Table 1. Comprehensive data for Markov model stratified by gender—transition probabilities, disease prevalence, relative risks, costs and utility values

Age, years	Males	Females
6-month probability of starting smoking
15–17	0.0067	0.00272
18–19	0.00735	0.00695
20–24	0.00785	0.00336
25–29	0.00275	0.00105
30–34	0.000001	0.000001
35–39	0.000001	0.000001
40–44	0.000001	0.00096
45–49	0.000001	0.000001
50–54	0.000001	0.000001
55–59	0.000001	0.000001
60–64	0.000001	0.000001
65–69	0.000001	0.000001
70–74	0.000001	0.000001
75–79	0.000001	0.000001
≥ 80	0.000001	0.000001
6-month probability of quitting smoking
15–17	0.3	0.176
18–19	0.143	0.164
20–24	0.1113	0.0979
25–29	0.1513	0.0788
30–34	0.0682	0.0825
35–39	0.0883	0.0648
40–44	0.093	0.0749
45–49	0.0636	0.0592
50–54	0.0638	0.0345
55–59	0.0447	0.049
60–64	0.0796	0.0562
65–69	0.087	0.0665
70–74	0.012	0.0404
75–79	0.046	0.00009
≥ 80	0.0958	0.038
6-month probability of smoking relapse	0.011	0.011
Lung cancer prevalence
< 45	0.00004	0.00004
45–54	0.00086	0.00106
55–64	0.00394	0.00388
65–74	0.01036	0.00913
75–84	0.01715	0.01273
≥ 85	0.01736	0.00917
Stroke prevalence
20–34	0.00118	0.00143
35–49	0.00572	0.00648
50–64	0.02441	0.02048
65–79	0.07701	0.05942
≥ 80	0.18326	0.16371
CHD prevalence
20–34	0.00256	0.00207
35–49	0.02051	0.01231
50–64	0.10480	0.05616
65–79	0.28235	0.16995
≥ 80	0.46176	0.34595
COPD prevalence
35–39	0.009	0.009
40–44	0.025	0.025
45–49	0.044	0.048
50–54	0.069	0.074
55–59	0.093	0.094
60–64	0.119	0.115
65–69	0.154	0.144
70–74	0.197	0.175
75–79	0.242	0.2
80–84	0.284	0.222
≥ 85	0.315	0.236
Relative risks
Lung cancer – current smokers	8.05	7.32
Lung cancer – former smokers	3.08	2.92
COPD – current smokers	4.11	3.28
COPD – former smokers	2.87	2.02
Stroke – current smokers	1.67	1.83
Stroke – former smokers	1.08	1.17
CHD – current smokers	1.6	1.7
CHD – former smokers	1.1	1.4
Death – former smokers	2.24	2.29
Death – current smokers	1.3	1.35
6-month disease costs, $
Lung cancer	10 052	10 164
COPD	3251	3521
Stroke	8220	8220
CHD	2235	2235
Utility values
Non-smoker
16–24	0.95	0.93
25–34	0.95	0.91
35–44	0.92	0.9
45–54	0.88	0.86
55–64	0.82	0.8
65–74	0.79	0.79
> 75	0.74	0.71
Former smoker
16–24	0.93	0.91
25–34	0.93	0.9
35–44	0.91	0.89
45–54	0.86	0.85
55–64	0.8	0.78
65–74	0.78	0.77
> 75	0.74	0.7
Current smoker
16–24	0.92	0.89
25–34	0.91	0.88
35–44	0.89	0.87
45–54	0.84	0.83
55–64	0.78	0.76
65–74	0.76	0.75
> 75	0.71	0.68
Annual probability of death
15	0.00024	0.00017
16	0.00033	0.00022
17	0.00042	0.00026
18	0.0005	0.00028
19	0.00057	0.00028
20	0.00064	0.00029
21	0.00071	0.0003
22	0.00076	0.00031
23	0.00081	0.00032
24	0.00084	0.00034
25	0.00087	0.00036
26	0.00089	0.00038
27	0.00092	0.0004
28	0.00095	0.00042
29	0.00098	0.00045
30	0.00101	0.00047
31	0.00104	0.0005
32	0.00107	0.00052
33	0.0011	0.00054
34	0.00113	0.00057
35	0.00115	0.00059
36	0.00119	0.00061
37	0.00123	0.00065
38	0.00128	0.00069
39	0.00134	0.00074
40	0.00141	0.0008
41	0.0015	0.00087
42	0.00159	0.00094
43	0.0017	0.00103
44	0.00181	0.00111
45	0.00194	0.00121
46	0.00209	0.00132
47	0.00225	0.00143
48	0.00243	0.00155
49	0.00263	0.00168
50	0.00286	0.00182
51	0.00311	0.00198
52	0.00339	0.00215
53	0.00369	0.00234
54	0.00403	0.00254
55	0.00439	0.00277
56	0.0048	0.00302
57	0.00524	0.0033
58	0.00573	0.0036
59	0.00627	0.00394
60	0.00686	0.00432
61	0.00751	0.00473
62	0.00823	0.00519
63	0.00903	0.00571
64	0.00991	0.00627
65	0.01088	0.00691
66	0.01196	0.00761
67	0.01315	0.0084
68	0.01447	0.00928
69	0.01593	0.01025
70	0.01755	0.01135
71	0.01934	0.01257
72	0.02134	0.01394
73	0.02355	0.01548
74	0.02602	0.0172
75	0.02875	0.01914
76	0.0318	0.02131
77	0.03519	0.02376
78	0.03897	0.02652
79	0.04319	0.02963
80	0.04789	0.03313
81	0.05314	0.03709
82	0.059	0.04157
83	0.06555	0.04664
84	0.07287	0.05238
85	0.08106	0.05889
86	0.09024	0.06627
87	0.10051	0.07466
88	0.11203	0.0842
89	0.12495	0.09506
90	0.13946	0.10743
91	0.15535	0.12121
92	0.1723	0.13613
93	0.19026	0.1522
94	0.20917	0.16939
95	0.2303	0.18813
96	0.2506	0.20746
97	0.27158	0.22783
98	0.29308	0.24911
99	0.31492	0.27115
100	0.33693	0.29378
101	0.3589	0.31677
102	0.38065	0.33993
103	0.40199	0.36302
104	0.42277	0.38583

Comparators

Two scenarios were compared: (1) the status quo, where no SFG policy is implemented and the uptake and retention of smoking behaviour over the course of the model is informed by current age–gender specific start and quit rates; and (2) the existence of an SFG policy whereby a perpetual ban is instigated, on 1 January 2025, on cigarette sales to anyone born after 2009, with the aim of no uptake of smoking by Canadians born after 2009.

Despite current age restrictions on the purchase of tobacco, consumption appears to begin during the early teenage years. To allow for potential access to tobacco for those in their early teens during the initial years of the SFG policy, two scenario analyses were conducted: assuming a 5‑year lag such that those born between 2009 and 2013 could obtain tobacco illegally despite the restrictions of an SFG policy from 1 January 2025; and assuming an SFG policy that reduces the uptake of smoking in the relevant age cohorts by 90% rather than 100%.

Model design

Markov models for both males and females were developed to model the transition of a population cohort between states of being a current smoker, former smoker, never smoker or dead from age 15 years to death (Figure 1). Stratification by gender was necessary due to differential input parameters relating to onset of smoking, smoking cessation, utility values and underlying mortality data. The model facilitates estimating the cumulative impacts on life expectancy, QALYs, health care costs, tax revenue and GDP over time horizons of up to 90 years.

Figure 1 : Descriptive text

Schematic showing the Markov model for transition of a population cohort between states of being a current smoker, former smoker, never smoker or dead from age 15 years to death

Node number	Name of node	Name of node(s) this node is connected to with a one-way arrow
1	Never smoker	“Never smoker,” “Current smoker,” “Dead”
2	Current smoker	“Current smoker,” “Former smoker,” “Dead”
3	Former smoker	“Former smoker,” “Current smoker,” “Dead”
4	Dead	Dead

Transitions

For the no SFG policy scenario, age–gender specific probabilities were required for the transition from never smoker to current smoker (“start”), current smoker to former smoker (“quit”) and former smoker to current smoker (“relapse”). Probabilities of starting and quitting were derived from data from the 2017 Canadian Tobacco, Alcohol and Drugs Survey (CTADS),^{Footnote 11} while the long-term probability of relapse after cessation was based on Krall et al.^{Footnote 12} For the SFG policy scenario, in the base (primary) analysis, after policy initiation all individuals were assumed to remain in the never smoker category until death.

The six-month probabilities of dying for each age–gender cohort by smoking status were derived through a calibration process using Statistics Canada mortality data, current smoking status from CTADS data and the relative risk of mortality by smoking status.^{Footnote 13}

Costs of smoking-related diseases

The base analysis focuses on the health care costs associated with the four smoking-related diseases that comprise 75% of smoking-related mortality in developed countries: chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), stroke and lung cancer.^{Footnote 25} The six-month probabilities of having each of these diseases for each age–gender cohort by smoking status was derived through a calibration process using prevalence data, current smoking status data and the relative risk of disease by smoking status. Age–gender specific prevalence rates were obtained from Canadian population-based data for COPD, CHD and stroke.^{Footnote 14} Due to the lack of prevalence data, lung cancer prevalence was estimated by dividing available incidence data by estimates of average life expectancy.^{Footnote 15} Relative risks of disease by smoking status were obtained from published literature.^{Footnote 16Footnote 17Footnote 18Footnote 19}

Average six-month Canadian costs for each of the diseases were derived from the available literature.^{Footnote 20Footnote 21Footnote 22Footnote 23} Costs were estimated in 2023 Canadian dollars, with adjustments where necessary using the Bank of Canada Inflation Calculator.^{Footnote 26}

Additional health care costs

Delaying mortality and avoiding smoking-related diseases may lead to an increase in health care expenditures for other conditions. Thus, a scenario analysis was conducted to include health care costs that are not related to the smoking-related diseases. Values for six-month additional health care costs were derived for individuals with differential values applied depending on whether the individuals died or survived the cycle.^{Footnote 27Footnote 28} These values were obtained by adjusting available estimates of annual health care costs by age group and gender, and health care costs in the last year of life by the prevalence of smoking-related diseases and their costs and by the age–gender specific mortality rates.

Utility values

Utility values represent individuals’ preferences for different health states on a scale of 0 to 1 where 0 represents death and 1 represents perfect health. Age–gender specific utility values by smoking status were obtained from Vogl et al.^{Footnote 24} Values incorporated the impact of smoking-related diseases on health-related quality of life. Thus, further disutilities associated with the four smoking-related illnesses were excluded as this would lead to double counting of the impact of smoking.

Tobacco industry GDP

Tobacco industry GDP is a measure of the total output created through the production of tobacco-related goods and services. The current magnitude of the GDP for the Canadian tobacco industry was divided by the estimated number of smokers in Canada to obtain an average annual contribution to the GDP per smoker of $711.25.^{Footnote 29}

Tobacco-related taxes

The average tobacco-related tax contributed by a smoker in Canada was estimated at $1685 a year.^{Footnote 30}

Analysis

The model calculated the impact of enacting an SFG policy for each year of the analysis across all affected birth year cohorts. For Year 1 (2025), outcomes were assessed for those born in 2010 (i.e. for the year they turned 15). For Year 2 (2026), outcomes were assessed for both those born in 2010 (i.e. for the year they turned 16) and those born in 2011 (i.e. for the year they turned 15). Calculations for further years followed the same logical approach.

Results

The cumulative impact each year up to 90 years, and specifically for time horizons of 10, 25, 50 and 90 years are shown in Figures 2a, b and c and Tables 2, 3a, 3b, 3c and 3d. Analysis determined the threshold value of a QALY whereby the value of health benefits (QALYs weighted by the threshold value) plus health care costs avoided exceeded the sum of tax revenues foregone and the decline in GDP.

Figure 2a : Descriptive text

Cumulative outcomes up to 90 years—QALYs and life years gained

Years after implementation of a SFG policy	QALYs gained	Life years gained
1	175	0
2	531	0
3	1 109	0
4	1 972	0
5	3 183	0
6	4 787	0
7	6 822	0
8	9 320	0
9	12 308	0
10	15 824	0
11	19 863	0
12	24 407	0
13	29 438	0
14	34 944	0
15	40 914	0
16	47 328	0
17	54 168	0
18	61 414	0
19	69 050	0
20	77 072	0
21	85 486	7
22	94 284	32
23	103 459	82
24	113 005	169
25	122 917	299
26	133 192	484
27	143 829	732
28	154 827	1,053
29	166 185	1,455
30	177 901	1,949
31	189 971	2,544
32	202 392	3,250
33	215 163	4,078
34	228 281	5,037
35	241 747	6,139
36	255 560	7,396
37	269 722	8,819
38	284 234	10,422
39	299 100	12,219
40	314 295	14,223
41	329 796	16,449
42	345 608	18,914
43	361 738	21,634
44	378 192	24,627
45	394 979	27,912
46	412 105	31,509
47	429 580	35,439
48	447 411	39,725
49	465 609	44,389
50	484 158	49,455
51	503 044	54,948
52	522 279	60,892
53	541 879	67,314
54	561 857	74,241
55	582 231	81,701
56	603 019	89,724
57	624 245	98,341
58	645 930	107,586
59	668 102	117,498
60	690 746	128,115
61	713 853	139,481
62	737 450	151,642
63	761 568	164,642
64	786 234	178,526
65	811 476	193,337
66	837 317	209,119
67	863 777	225,909
68	890 872	243,737
69	918 611	262,623
70	946 995	282,579
71	976 021	303,606
72	1 005 676	325,694
73	1 035 937	348,819
74	1 066 774	372,946
75	1 098 144	398,022
76	1 129 995	423,981
77	1 162 265	450,741
78	1 194 881	478,206
79	1 227 763	506,271
80	1 260 824	534,817
81	1 293 978	563,726
82	1 327 135	592,877
83	1 360 213	622,154
84	1 393 133	651,450
85	1 425 828	680,668
86	1 458 238	709,727
87	1 490 318	738,558
88	1 522 029	767,108
89	1 553 345	795,337
90	1 584 249	823,218

Figure 2b : Descriptive text

Cumulative outcomes up to 90 years—financial gains and losses

Years after implementation of a SFG policy	Costs avoided (2023 Canadian $)	Tax revenue lost (2023 Canadian $)	Lost GDP (2023 Canadian $)
1	0	2 442 142	1 030 845
2	0	9 191 353	3 879 733
3	7 266	21 178 878	8 939 749
4	34 977	40 894 384	17 261 798
5	139 669	70 529 536	29 770 998
6	384 406	111 486 170	47 059 073
7	781 615	164 722 673	69 530 565
8	1 340 964	230 884 012	97 457 717
9	2 069 958	310 377 208	131 012 338
10	3 006 357	403 428 778	170 290 041
11	4 163 903	508 205 558	214 517 034
12	5 522 506	622 790 109	262 883 955
13	7 067 301	745 777 775	314 797 889
14	8 787 104	876 126 968	369 819 173
15	10 670 664	1 013 054 172	427 617 080
16	12 704 855	1 155 776 847	487 861 295
17	14 879 450	1 303 587 870	550 253 337
18	17 185 445	1 455 890 877	614 541 476
19	19 614 842	1 612 180 468	680 512 379
20	23 019 437	1 772 025 978	747 984 259
21	28 195 818	1 935 003 229	816 778 069
22	35 068 224	2 100 735 881	886 734 953
23	43 566 154	2 268 904 303	957 719 991
24	53 623 541	2 439 235 001	1 029 617 741
25	66 139 465	2 611 492 135	1 102 328 653
26	81 995 497	2 785 587 145	1 175 815 345
27	101 106 057	2 961 473 396	1 250 058 132
28	123 386 251	3 139 102 029	1 325 036 391
29	148 751 827	3 318 421 867	1 400 728 518
30	178 402 781	3 499 379 475	1 477 111 959
31	213 463 356	3 681 912 264	1 554 160 295
32	253 751 119	3 865 950 834	1 631 844 232
33	299 086 352	4 051 421 816	1 710 132 799
34	349 292 005	4 238 248 783	1 788 993 737
35	406 278 336	4 426 352 989	1 868 393 806
36	471 876 944	4 615 715 578	1 948 325 047
37	545 806 433	4 806 326 496	2 028 783 217
38	627 783 834	4 998 163 639	2 109 758 984
39	717 525 137	5 191 194 537	2 191 238 644
40	816 027 442	5 385 377 795	2 273 204 722
41	924 241 067	5 580 687 595	2 355 646 322
42	1 041 816 048	5 777 094 828	2 438 551 155
43	1 168 399 237	5 974 559 883	2 521 902 503
44	1 303 634 731	6 173 033 938	2 605 679 756
45	1 448 150 817	6 372 460 113	2 689 858 905
46	1 602 426 367	6 572 642 517	2 774 357 264
47	1 765 925 549	6 773 366 543	2 859 084 246
48	1 938 133 956	6 974 444 187	2 943 960 491
49	2 118 554 721	7 175 709 174	3 028 915 816
50	2 309 781 615	7 377 012 961	3 113 887 518
51	2 514 103 412	7 578 185 161	3 198 803 677
52	2 730 660 364	7 779 065 274	3 283 596 544
53	2 958 622 487	7 979 512 390	3 368 206 639
54	3 197 183 279	8 179 401 327	3 452 581 124
55	3 446 676 826	8 378 619 466	3 536 672 460
56	3 707 631 056	8 577 236 141	3 620 509 914
57	3 979 466 021	8 775 353 650	3 704 136 667
58	4 261 546 496	8 973 044 831	3 787 583 464
59	4 553 184 575	9 170 354 794	3 870 869 345
60	4 855 930 286	9 367 302 551	3 954 002 338
61	5 170 980 371	9 563 856 608	4 036 969 147
62	5 497 119 128	9 759 963 081	4 119 747 028
63	5 833 112 241	9 955 556 453	4 202 308 325
64	6 177 709 808	10 150 559 857	4 284 620 592
65	6 531 470 667	10 344 885 476	4 366 646 762
66	6 894 067 366	10 538 300 362	4 448 288 506
67	7 263 235 909	10 730 563 868	4 529 444 244
68	7 636 893 176	10 921 472 850	4 610 028 228
69	8 013 117 692	11 110 853 674	4 689 967 166
70	8 390 297 669	11 298 556 297	4 769 197 725
71	8 766 930 348	11 484 450 012	4 847 664 730
72	9 141 495 532	11 668 420 472	4 925 319 917
73	9 512 634 307	11 850 367 735	5 002 121 099
74	9 879 159 092	12 030 205 052	5 078 031 658
75	10 240 065 050	12 207 858 226	5 153 020 275
76	10 594 540 961	12 383 265 326	5 227 060 809
77	10 941 979 242	12 556 376 785	5 300 132 337
78	11 281 981 268	12 727 155 630	5 372 219 254
79	11 614 352 546	12 895 577 363	5 443 311 216
80	11 939 086 509	13 061 629 343	5 513 402 890
81	12 256 337 389	13 225 309 719	5 582 493 494
82	12 566 385 717	13 386 626 002	5 650 586 198
83	12 869 599 884	13 545 593 391	5 717 687 418
84	13 166 397 434	13 702 233 058	5 783 806 091
85	13 457 209 750	13 856 570 532	5 848 952 991
86	13 742 453 069	14 008 634 293	5 913 140 143
87	14 022 507 597	14 158 454 649	5 976 380 338
88	14 297 705 198	14 306 062 891	6 038 686 784
89	14 568 324 914	14 451 490 704	6 100 072 857
90	14 834 594 662	14 594 769 797	6 160 551 940

Figure 2c : Descriptive text

Cumulative outcomes up to 90 years—number of cases prevented

Years after implementation of a SFG policy	Lung cancer (Cumulative number of cases prevented (undiscounted))	CHD (Cumulative number of cases prevented (undiscounted))	Stroke (Cumulative number of cases prevented (undiscounted))	COPD (Cumulative number of cases prevented (undiscounted))
1	0	0	0	0
2	0	0	0	0
3	0	0	0	0
4	1	0	0	0
5	3	0	1	0
6	5	0	3	0
7	8	0	6	0
8	12	0	11	0
9	18	0	18	0
10	24	1	26	0
11	31	5	37	0
12	39	11	49	0
13	48	20	62	0
14	58	30	77	0
15	69	43	93	0
16	81	58	111	0
17	93	75	129	0
18	106	94	150	0
19	119	115	171	0
20	133	144	196	35
21	148	186	225	141
22	164	242	261	317
23	180	310	301	563
24	197	391	346	878
25	214	485	396	1 325
26	232	592	451	1 972
27	250	711	511	2 817
28	270	844	576	3 862
29	289	989	646	5 108
30	318	1 147	722	6 636
31	361	1 318	802	8 526
32	420	1 502	888	10 778
33	495	1 698	979	13 390
34	586	1 907	1 075	16 361
35	692	2 154	1 182	19 784
36	814	2 462	1 308	23 755
37	951	2 831	1 453	28 273
38	1 105	3 261	1 615	33 335
39	1 275	3 752	1 797	38 941
40	1 484	4 302	1 996	45 158
41	1 756	4 910	2 213	52 054
42	2 091	5 578	2 448	59 626
43	2 489	6 303	2 701	67 871
44	2 950	7 086	2 971	76 784
45	3 477	7 926	3 259	86 443
46	4 072	8 822	3 564	96 923
47	4 734	9 772	3 885	108 211
48	5 460	10 775	4 222	120 297
49	6 249	11 827	4 573	133 169
50	7 148	12 973	4 954	146 901
51	8 204	14 252	5 376	161 561
52	9 410	15 659	5 837	177 134
53	10 764	17 186	6 335	193 600
54	12 260	18 830	6 867	210 943
55	13 896	20 584	7 432	229 262
56	15 673	22 444	8 028	248 658
57	17 593	24 410	8 655	269 113
58	19 658	26 476	9 313	290 608
59	21 867	28 639	9 998	313 117
60	24 291	30 893	10 711	336 754
61	26 993	33 232	11 448	361 617
62	29 964	35 646	12 207	387 658
63	33 195	38 123	12 984	414 827
64	36 673	40 652	13 775	443 068
65	40 400	43 246	14 587	472 446
66	44 365	45 903	15 415	502 998
67	48 544	48 597	16 246	534 626
68	52 915	51 302	17 065	567 234
69	57 460	53 995	17 860	600 726
70	62 149	56 655	18 619	635 043
71	66 957	59 261	19 332	670 120
72	71 868	61 795	19 989	705 855
73	76 868	64 241	20 582	742 150
74	81 943	66 586	21 106	778 910
75	87 080	68 820	21 553	816 044
76	92 267	70 933	21 923	853 469
77	97 492	72 923	22 212	891 110
78	102 747	74 788	22 423	928 901
79	108 023	76 533	22 558	966 787
80	113 313	78 163	22 622	1 004 723
81	118 613	79 689	22 621	1 042 677
82	123 918	81 120	22 563	1 080 625
83	129 226	82 470	22 455	1 118 553
84	134 535	83 752	22 306	1 156 455
85	139 843	84 978	22 124	1 194 328
86	145 151	86 161	21 915	1 232 173
87	150 458	87 310	21 686	1 269 994
88	155 763	88 435	21 443	1 307 797
89	161 069	89 542	21 189	1 345 584
90	166 373	90 637	20 928	1 383 361

Abbreviations: CHD, coronary heart disease; COPD, chronic obstructive pulmonary disease; GDP, gross domestic product; QALY, quality-adjusted life year; SFG, smoke-free generation.

Table 2. Base results of the impact of introduction an SFG policy over time—life years, QALYs, health care costs, tax revenue from smoking, GDP and incident cases of smoking-related diseases

Results	Net impact of a smoke-free generation policy
	After 10 years	After 25 years	After 50 years	After 90 years
Discounted
Life years gained, n (95% CI)	0 (0, 0)	214 (182, 248)	39 475 (33 848, 45 220)	769 042 (668 060, 869 939)
QALYs gained, n (95% CI)	15 700 (1031, 30 175)	122 766 (69 351, 175 793)	476 814 (356 366, 596 756)	1 545 288 (1 313 033, 1 786 258)
Health care costs of smoking-related diseases averted, $ (95% CI)	3 026 244 (1 982 557, 4 440 914)	66 717 071 (47 722 982, 89 691 232)	2 347 379 210 (1 555 158 031, 3 374 988 738)	15 323 097 839 (10 080 762 862, 22 120 111 561)
Decline in tax revenue from smoking, $ (95% CI)	403 529 109 (402 420 408, 404 743 294)	2 614 073 547 (2 585 016 743, 2 645 492 764)	7 399 915 299 (7 202 870 009, 7 610 491 722)	14 692 321 355 (14 110 794 329, 15 311 629 335)
Decline in GDP from Canadian tobacco industry, $ (95% CI)	170 332 391 (169 864 401, 170 844 907)	1 103 418 285 (1 091 153 210, 1 116 680 551)	3 123 554 752 (3 040 380 590, 3 212 440 497)	6 201 729 118 (5 956 262 592, 6 463 143 243)
Undiscounted
Cases of lung cancer prevented, n (95% CI)	24 (21, 27)	215 (194, 234)	7239 (6579, 7860)	170 971 (152 642, 188 052)
Cases of CHD prevented, n (95% CI)	1 (1, 2)	494 (158, 842)	13 403 (2295, 24 824)	98 012 (−45 697, 240 391)
Cases of stroke prevented, n (95% CI)	27 (22, 31)	398 (334, 463)	5057 (4149, 5963)	23 474 (9877, 37 022)
Cases of COPD prevented, n (95% CI)	0 (0, 0)	1335 (1145, 1525)	149 095 (128 616, 170 048)	1 420 646 (1 226 684, 1 612 460)

Analysis adhered to guidelines for economic evaluations in Canada.^{Footnote 31} To account for uncertainty in inputs, outcomes were assessed by probabilistic analysis through a Monte Carlo simulation of 5000 replications to ensure stability of the data. Probability distributions were used to account for uncertainty around the parameters of interest, and the choice of distribution was based on common practice.^{Footnote 31} To allow for society’s preferences with regards to the timing of events, an annual discount rate of 1.5% was applied to all costs and utilities.^{Footnote 31}

Scenario analyses

The following scenario analyses were presented as cumulative impacts at 50 years:

• A 90% reduction in smoking initiation to allow for potential illicit market adoption.
• An SFG policy only impacting initiation of smoking after 5 years based on the assumption that individuals may be able to access cigarettes despite the restrictions.
• Different discount rates (0%, 3% and 5%) to assess the impact of discounting.
• Inclusion of additional costs of health care not related to the specific smoking-related diseases.

Base analysis

Table 2 summarizes the impact of an SFG policy after 10, 25, 50 and 90 years. The annual impacts tend to increase over time, although the annual number of disease cases prevented declines in later years, leading to a reduction in the annual health care costs avoided (Figures 2a, 2b and 2c). This results in a non-linear increase in cumulative impacts (Figures 3a, 3b and 3c).

Figure 3a : Descriptive text

Annual undiscounted outcomes up to 90 Years—QALYs and life years gained

Years after implementation of a SFG policy	QALYs gained	Life years gained
1	177	0
2	367	0
3	604	0
4	916	0
5	1 305	0
6	1 755	0
7	2 259	0
8	2 814	0
9	3 417	0
10	4 079	0
11	4 759	0
12	5 433	0
13	6 106	0
14	6 782	0
15	7 463	0
16	8 140	0
17	8 810	0
18	9 473	0
19	10 131	0
20	10 805	0
21	11 502	10
22	12 208	34
23	12 922	71
24	13 647	123
25	14 381	190
26	15 132	272
27	15 900	371
28	16 686	486
29	17 492	620
30	18 313	772
31	19 149	944
32	20 002	1 137
33	20 873	1 353
34	21 764	1 592
35	22 674	1 856
36	23 609	2 148
37	24 568	2 469
38	25 554	2 823
39	26 568	3 210
40	27 564	3 635
41	28 540	4 100
42	29 550	4 607
43	30 596	5 160
44	31 680	5 762
45	32 805	6 419
46	33 971	7 134
47	35 181	7 913
48	36 438	8 758
49	37 745	9 674
50	39 050	10 665
51	40 355	11 737
52	41 719	12 893
53	43 146	14 138
54	44 641	15 478
55	46 207	16 919
56	47 854	18 467
57	49 593	20 133
58	51 428	21 927
59	53 369	23 859
60	55 325	25 940
61	57 301	28 187
62	59 397	30 609
63	61 617	33 212
64	63 963	36 003
65	66 436	38 984
66	69 035	42 163
67	71 750	45 528
68	74 573	49 066
69	77 489	52 759
70	80 483	56 584
71	83 537	60 516
72	86 626	64 522
73	89 724	68 567
74	92 801	72 608
75	95 823	76 597
76	98 752	80 483
77	101 550	84 212
78	104 179	87 729
79	106 603	90 985
80	108 795	93 937
81	110 733	96 556
82	112 408	98 825
83	113 819	100 742
84	114 977	102 318
85	115 902	103 579
86	116 618	104 557
87	117 157	105 294
88	117 551	105 833
89	117 828	106 213
90	118 018	106 474

Figure 3b : Descriptive text

Annual undiscounted outcomes up to 90 years—financial gains and losses

Years after implementation of a SFG policy	Costs avoided (2023 Canadian $)	Tax revenue lost (2023 Canadian $)	Lost GDP (2023 Canadian $)
1	0	2 478 774	1 046 308
2	0	6 953 205	2 934 995
3	7 598	12 535 096	5 291 150
4	29 412	20 925 319	8 832 720
5	112 782	31 925 475	13 475 961
6	267 606	44 783 756	18 903 529
7	440 840	59 084 262	24 939 870
8	630 103	74 530 258	31 459 731
9	833 525	90 891 723	38 366 017
10	1 086 729	107 990 146	45 583 378
11	1 363 530	123 421 696	52 097 140
12	1 624 371	136 999 372	57 828 370
13	1 874 690	149 251 983	63 000 281
14	2 118 378	160 558 364	67 772 781
15	2 354 887	171 190 782	72 260 797
16	2 581 358	181 113 011	76 449 038
17	2 800 924	190 383 603	80 362 218
18	3 014 720	199 111 911	84 046 497
19	3 223 690	207 388 589	87 540 139
20	4 585 497	215 288 726	90 874 840
21	7 076 411	222 799 328	94 045 117
22	9 535 901	229 964 611	97 069 632
23	11 968 291	236 844 563	99 973 707
24	14 377 064	243 488 212	102 778 036
25	18 159 922	249 935 688	105 499 560
26	23 351 328	256 391 381	108 224 552
27	28 566 469	262 914 800	110 978 131
28	33 804 005	269 502 102	113 758 676
29	39 062 492	276 149 056	116 564 401
30	46 346 819	282 851 258	119 393 446
31	55 624 529	289 593 094	122 239 221
32	64 876 364	296 361 786	125 096 332
33	74 099 495	303 148 459	127 961 033
34	83 290 997	309 945 260	130 830 010
35	95 958 217	316 745 159	133 700 293
36	112 117 176	323 647 087	136 613 644
37	128 251 149	330 667 367	139 576 953
38	144 345 668	337 786 512	142 581 992
39	160 386 577	344 986 800	145 621 283
40	178 684 995	352 252 005	148 687 975
41	199 246 029	359 610 006	151 793 838
42	219 729 664	367 055 090	154 936 459
43	240 113 098	374 567 479	158 107 489
44	260 373 361	382 128 652	161 299 112
45	282 415 216	389 721 227	164 503 990
46	306 009 596	397 067 044	167 604 709
47	329 169 488	404 113 487	170 579 061
48	351 904 141	410 897 799	173 442 765
49	374 216 204	417 449 841	176 208 427
50	402 578 969	423 793 271	178 886 032
51	436 599 119	429 868 994	181 450 636
52	469 684 607	435 683 528	183 904 991
53	501 837 292	441 265 578	186 261 212
54	533 046 812	446 637 353	188 528 675
55	565 837 388	451 815 579	190 714 440
56	600 707 020	457 208 266	192 990 729
57	635 140 380	462 900 090	195 393 287
58	668 965 124	468 832 541	197 897 415
59	702 005 834	474 947 391	200 478 535
60	739 674 310	481 186 655	203 112 171
61	781 282 647	487 428 131	205 746 741
62	820 912 806	493 612 955	208 357 397
63	858 402 625	499 706 266	210 929 425
64	893 591 257	505 671 988	213 447 597
65	931 113 290	511 473 110	215 896 290
66	968 685 133	516 712 164	218 107 731
67	1 001 035 589	521 340 767	220 061 496
68	1 028 405 301	525 432 868	221 788 799
69	1 051 003 125	529 045 368	223 313 660
70	1 069 477 339	532 222 586	224 654 786
71	1 083 944 384	534 999 905	225 827 111
72	1 094 164 067	537 406 776	226 843 068
73	1 100 417 312	539 469 146	227 713 608
74	1 103 038 001	541 211 406	228 449 028
75	1 102 420 346	542 657 912	229 059 608
76	1 099 020 869	543 834 029	229 556 055
77	1 093 359 343	544 767 348	229 950 015
78	1 086 007 438	545 488 212	230 254 297
79	1 077 558 420	546 028 698	230 482 440
80	1 068 589 968	546 421 070	230 648 063
81	1 059 625 151	546 696 176	230 764 187
82	1 051 101 988	546 882 051	230 842 646
83	1 043 352 345	547 002 799	230 893 615
84	1 036 592 017	547 078 064	230 925 384
85	1 030 923 373	547 123 006	230 944 355
86	1 026 349 121	547 148 688	230 955 195
87	1 022 794 242	547 162 723	230 961 120
88	1 020 131 979	547 170 058	230 964 216
89	1 018 209 618	547 173 725	230 965 764
90	1 016 870 455	547 175 478	230 966 504

Figure 3c : Descriptive text

Annual undiscounted outcomes up to 90 years—cases prevented

Years after implementation of a SFG policy	Lung cancer (Cumulative number of cases prevented (undiscounted))	CHD (Cumulative number of cases prevented (undiscounted))	Stroke (Cumulative number of cases prevented (undiscounted))	COPD (Cumulative number of cases prevented (undiscounted))
1	0	0	0	0
2	0	0	0	0
3	0	0	0	0
4	1	0	0	0
5	2	0	1	0
6	2	0	2	0
7	3	0	3	0
8	4	0	5	0
9	5	0	7	0
10	6	1	9	0
11	7	4	10	0
12	8	6	12	0
13	9	8	13	0
14	10	11	15	0
15	11	13	16	0
16	11	15	18	0
17	12	17	19	0
18	13	19	20	0
19	14	21	21	0
20	14	29	25	35
21	15	42	30	106
22	15	55	35	176
23	16	68	40	246
24	17	81	45	315
25	17	94	50	448
26	18	107	55	646
27	19	120	60	845
28	19	132	65	1 045
29	20	145	70	1 246
30	28	158	75	1 528
31	44	171	81	1 890
32	59	184	86	2 252
33	75	196	91	2 612
34	90	209	96	2 971
35	106	246	108	3 424
36	122	308	126	3 971
37	138	369	144	4 517
38	154	430	163	5 062
39	170	491	181	5 606
40	209	550	199	6 217
41	272	609	217	6 896
42	335	667	235	7 572
43	398	725	253	8 245
44	461	783	270	8 913
45	527	840	288	9 660
46	595	896	305	10 480
47	661	950	321	11 288
48	726	1 002	337	12 086
49	789	1 053	352	12 872
50	900	1 146	381	13 732
51	1 055	1 279	422	14 660
52	1 206	1 406	461	15 572
53	1 353	1 528	498	16 467
54	1 497	1 644	532	17 343
55	1 636	1 754	565	18 319
56	1 777	1 861	596	19 396
57	1 920	1 965	627	20 455
58	2 065	2 066	657	21 495
59	2 209	2 163	686	22 510
60	2 424	2 255	713	23 637
61	2 702	2 339	737	24 863
62	2 971	2 413	759	26 041
63	3 230	2 477	777	27 169
64	3 479	2 530	791	28 241
65	3 727	2 594	811	29 378
66	3 965	2 657	828	30 552
67	4 179	2 693	830	31 628
68	4 372	2 705	819	32 608
69	4 544	2 693	795	33 492
70	4 689	2 660	759	34 317
71	4 808	2 606	713	35 077
72	4 911	2 534	657	35 735
73	5 000	2 446	594	36 295
74	5 075	2 345	523	36 759
75	5 137	2 233	448	37 134
76	5 187	2 113	369	37 425
77	5 225	1 990	290	37 641
78	5 255	1 866	211	37 791
79	5 276	1 745	135	37 886
80	5 290	1 630	64	37 936
81	5 300	1 525	-1	37 954
82	5 305	1 431	-58	37 948
83	5 308	1 350	-108	37 929
84	5 309	1 282	-149	37 902
85	5 308	1 226	-182	37 873
86	5 308	1 183	-209	37 845
87	5 307	1 149	-229	37 822
88	5 306	1 125	-243	37 802
89	5 305	1 107	-254	37 788
90	5 305	1 095	-261	37 777

Abbreviations: CHD, coronary heart disease; COPD, chronic obstructive pulmonary disease; GDP, gross domestic product; QALY, quality-adjusted life year; SFG, smoke-free generation.

After 10 years, the policy would not impact life years but would lead to substantive gains in QALYs (15700) and a modest decrease in health care costs for smoking-related diseases ($3.0 million). The benefits increase over time with life years gained increasing to 214 after 25 years, 39475 after 50 years and 769042 after 90 years, QALYs gained increasing to 122766 after 25 years, 476814 after 50 years and 1545288 after 90 years and health care costs averted increasing to $66.7 million after 25 years, $2.3 billion after 50 years and $15.3 billion after 90 years. Similarly, the negative impacts of a policy on tobacco tax revenue and Canadian GDP from the tobacco industry increase over time: tax revenues foregone will be $403.5 million after 10 years, $2.6 billion after 25 years, $7.4 billion after 50 years and $14.7 billion after 90 years; decline in GDP would be $170.3 million after 10 years, $1.1 billion after 25 years, $3.1 billion after 50 years and $6.2 billion after 90 years (Table 2).

At 50 years, the proportion of outcomes that occur in females is 28% for life years, 35% for both QALYs and health care costs avoided, and 39% for both tax revenues foregone and decline in GDP (data not shown). Up until Year 9, the largest number of cumulative disease cases prevented is for lung cancer; from Year 10 until Year 21, the largest number of cumulative cases prevented is for CHD and thereafter the largest number of cumulative cases prevented is for COPD (Figure 3c).

For all years the cumulative health care costs averted are less than the sum of tax revenues foregone and decline in GDP, though after 58 years, the annual health care costs averted exceed the sum of tax revenues foregone and decline in GDP (Figures 2b and 3b). After 50 years, if a QALY was valued at at least $17147, the combined value of the QALYs gained and the health care costs averted would exceed the sum of lost tax revenues and reduction in GDP by $36423 after 10 years, $29738 after 25 years and $3605 after 90 years (data not shown).

Scenario analyses

Scenario analyses for cumulative outcomes up to 50 years show that results are consistent across all scenarios explored (Table 4). Although the magnitude of impacts varies across scenarios, the relative values across each component remains consistent. Within the scenario analyses, the necessary threshold value for a QALY required for the SFG policy to be optimal, which was $17147 in the base case, varies between $14091 and $20909, highlighting the consistency in the results.

Table 4. Results of scenario analyses for cumulative outcomes up to 50 years

Group/scenario	Net impact of a smoke-free generation policy after 50 years
	Life years gained	QALYs gained	Health care costs averted, $	Decline in tax revenue, $	Reduction in GDP, $	Threshold value of a QALY, $
Base case	39 475	476 814	2 347 379 210	7 399 915 299	3 123 554 752	17 147
Males	28 286	310 462	1 514 942 781	4 486 393 321	1 893 737 240	15 671
Females	11 190	166 352	832 436 429	2 913 521 978	1 229 817 511	19 903
0% discount rate	108 341	918 711	5 835 615 560	13 206 427 893	5 574 523 346	14 091
3% discount rate	20 981	295 559	1 278 456 727	4 789 828 352	2 021 819 238	18 721
5% discount rate	9271	165 492	587 057 331	2 846 037 620	1 201 331 904	20 909
5-year lag in impact	20 133	362 395	1 363 694 271	5 930 627 350	2 503 358 280	19 510
90% reduction in smoking uptake	35 528	429 133	2 112 641 289	6 659 923 769	2 811 199 276	17 147
Include non-smoking-related disease health care costs	39 475	476 814	2 002 394 607	7 399 915 299	3 123 554 752	17 871

Discussion

The results show that, based on the study assumptions, imposing an SFG policy will lead to substantive health benefits and reduced health care expenses that are only partially offset by reduced tax revenues from smoking and a decline in GDP.

The general conclusions hold across multiple scenario analyses—including adding non–smoking-related disease health care costs, as scenario analysis found that when including all health care costs allowing for the increased life expectancy from the SFG policy, the SFG policy was still associated with reduced health care costs (a reduction of $2 002 394 607 rather than $2 347 379 210).

Analysis predicts that the government’s target for smoking prevalence of less than 5% would be achieved in 2035, should the SFG policy be introduced. Without the SFG policy, and based on current trends, the model predicts that a prevalence of less than 5% would be reached in 2040. The SFG policy would achieve further prevalence targets much more quickly. Of note, a smoking prevalence of less than 2.5% would be achieved in 2050 if the SFG policy were introduced but, without an SFG policy, this rate would not be reached until 2075.

Programs that reduce tobacco smoking also aim to reduce premature deaths, defined by Statistics Canada as deaths prior to age 75 years.^{Footnote 32} The model predicts that for a cohort of 15-year-olds, premature deaths would be reduced from 20.2% without the SFG policy to 19.3% with the SFG policy, a relative reduction of 4.6%.

Strengths and limitations

A major strength of this study is that it uses data pertinent to the Canadian population. However, a number of caveats and limitations should be considered when reviewing the results.

Analysis included the impact of the imposition of an SFG policy on both the amount of tax revenues raised through tobacco sales and the reduction in GDP from the tobacco industry. A concern to do with the introduction of smoking cessation policies is the impact on tax revenue and government expenditure. The percentage reduction in overall tax revenue from an SFG policy is minimal when considered alongside total taxes and government expenditure: equivalent to only 0.2% of total income tax raised and 0.06% of total government expenditure. It is also worth noting that the current analysis does not consider the additional income tax raised by extensions to life expectancy through the SFG policy.

Further, decline in tax revenues is not a loss from a societal perspective as taxation is merely a transfer of funds from individuals to government. The impact of decreasing taxes will be uncertain as the changes in the level of taxation can be associated with either an increase or decrease in economic growth. Reducing the consumption of tobacco will lead to more disposable income available to consume other resources. Thus, by including both lost taxation and a decline in GDP as a negative offset, the estimated threshold values of a QALY required for an SFG policy to be beneficial are likely overestimated.

The analysis does not consider alternative policy options such as raising the legal age for the purchase of tobacco, access to vaping products, reducing nicotine standards for smoked tobacco products, increasing taxation on tobacco products or further restrictions on smoking in public.^{Footnote 33} Such policies are not necessarily mutually exclusive when considering an SFG policy as many of these target current rather than potential smokers. Of note, an SFG policy is akin to raising the legal age for smoking by one year each year. Thus, it avoids the concern that by raising the legal age for smoking to a fixed age there is the high likelihood that those below the legal age will access tobacco products as the disparity between the legal age and the age at which smoking commences remains minimal.

Another limitation with the analysis is that it relies on data for some input parameters (e.g. smoking-related mortality, relapse) that are not recent. Analysis is based on the most contemporaneous data available, but if input parameters have changed noticeably, results may vary.

In addition, although input parameters for the uptake of smoking and quit rates for smoking are based on the most contemporaneous data, they may change over time. This analysis is based on the assumption that such rates will be stable over the time horizon of the model. If uptake rates were to decline without an SFG policy, then the benefits of the SFG policy would decline proportionally. However, the general conclusion is that the benefits are higher than the negative consequences would hold.

Another limitation with the analysis is that it does not consider all the potential benefits and costs of implementing an SFG policy. As noted, the analysis does not include any additional income tax raised by the increased life expectancy through the SFG policy. The analysis also does not consider the impact of an SFG policy on existing illegal markets for tobacco purchase or the costs of enforcing tobacco-related legislation (estimated at $37.6 million per year in 2012).^{Footnote 34} Enforcement costs may grow in the initial years of implementation of an SFG policy but could subsequently decline as the prevalence of smoking declines across the population.

The arguments against tobacco control policies such as an SFG policy from advocates for the tobacco industry tend to focus on three areas: the denial of freedom of behaviour; the unworkability of such a policy; and the contribution of the tobacco industry to society through both GDP and tax generation.^{Footnote 6} It could be argued that the first argument is the least addressed by the analysis in this study. However, it is important to note that tobacco addiction is often initiated during childhood or at least before the age of 21 years, the minimum age for selling tobacco in many provinces. Further, the analysis does not incorporate any additional health and health care benefits from the decline in passive smoking as a result of an SFG policy. Analysis does demonstrate the substantive benefits of an SFG policy even if there is a lag in its effects or a less than perfect cessation of smoking uptake. Thus, concerns relating to unworkability are irrelevant. Analysis directly addresses the final argument by not focusing solely on the impacts on health and health care consumption.

Conclusion

This study highlights the impacts of imposing an SFG policy across Canada, and demonstrates that the health benefits and reduction in health care costs outweigh any positive contribution of tobacco smoking to the Canadian population.

Acknowledgements

Analysis is based on a revised version of a model developed in partnership with Dr. Catherine Pound of the University of Ottawa, Ottawa, Ontario, Canada.

Funding

None.

Conflicts of interest

None.

Author’s contributions and statement

DC: Conceptualization, methodology, formal analysis, writing – original draft, writing – review & editing.

The content and views expressed in this article are those of the author and do not necessarily reflect those of the Government of Canada.

Previous | Table of Contents | Next