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1.  Examining the impact of changes in school tobacco control policies and programs on current smoking and susceptibility to future smoking among youth in the first two years of the COMPASS study: looking back to move forward 
Tobacco Induced Diseases  2015;13(1):8.
School-based prevention activities continue to be an important tobacco control resource, however there is little guidance for school-based tobacco control programming within Ontario. The objective of this study is to identify real-world changes in school-based tobacco control programs or policies in the COMPASS study and examine of those interventions (natural experiments) had any impact on the school-level prevalence of smoking susceptibility and current smoking over time.
This paper uses longitudinal school-level smoking behaviour data from Year 1 (Y1: 2012–13) and Year 2 (Y2: 2013–14) of the COMPASS study. Changes to school-level tobacco control programs and policies were measured using the COMPASS School Programs and Policies Questionnaire and knowledge broker follow-up interviews. Quasi-experimental tests of proportion and difference-in-difference models were used to evaluate the impact of the interventions identified between Y1 and Y2 on school-level prevalence of smoking susceptibility among never smokers and current smoking.
Between Y1 and Y2, 17 schools reported a change in their tobacco control programming or policies. In four of the intervention schools, the increase in the within-school prevalence of susceptible never smokers between Y1 and Y2 was significantly greater than the natural change observed in the control schools. In five of the intervention schools, the decrease in the within-school prevalence of current smokers between Y1 and Y2 was significantly greater than the natural change observed in the control schools. Only two of the new interventions evaluated (both focused on policies of progressive punishment for students caught smoking on school property), were associated with significant desirable changes in both smoking susceptibility and current smoking between Y1 and Y2.
Interventions specific to effective and enforced tobacco control were the most common and consistently had the desired impact on the school-level prevalence of smoking susceptibility and current smoking. Due to the variation in the types of interventions implemented and their effectiveness, additional evaluation evidence is necessary to determine the most successful activities and contexts among individual students. The results presented here highlight which of these real-world promising interventions should be further evaluated using the longitudinal individual-level data in COMPASS over time.
PMCID: PMC4381407  PMID: 25834482
Tobacco; Smoking; Policy; Program; Intervention evaluation; Youth; Adolescence; Schools
2.  Active Healthy Kids Canada’s Position on Active Video Games for Children and Youth 
Paediatrics & Child Health  2013;18(10):529-532.
The effect of active video games (AVGs) on acute energy expenditure has previously been reported; however, the influence of AVGs on other health-related lifestyle indicators remains unclear. To address this knowledge gap, Active Healthy Kids Canada (AHKC) convened an international group of researchers to conduct a systematic review to understand whether AVGs should be promoted to increase physical activity and improve health indicators in children and youth (zero to 17 years of age). The present article outlines the process and outcomes of the development of the AHKC’s position on active video games for children and youth. In light of the available evidence, AHKC does not recommend AVGs as a strategy to help children be more physically active. However, AVGs may exchange some sedentary time for light- to moderate-intensity physical activity, and there may be specific situations in which AVGs provide benefit (eg, motor skill development in special populations and rehabilitation).
PMCID: PMC3907348  PMID: 24497779
Active video games; Children; Exergaming; Physical activity; Position statement
3.  The relationship between school physical activity policy and objectively measured physical activity of elementary school students: a multilevel model analysis 
Archives of Public Health  2014;72(1):20.
There is evidence of school level variability in the physical activity of children and youth. Less is known about factors that may contribute to this variation. The purpose of this study was to examine if the school health environment (Healthy Physical Environment, Instruction and Programs, Supportive Social Environment, and Community Partnerships) is associated with objectively measured time spent in light to vigorous physical activity among a sample of Toronto children.
The sample comprised 856 grade 5 and 6 students from 18 elementary schools in Toronto, Ontario. Multilevel linear regression analyses were used to examine the impact of school physical activity policy on students’ time spent in light-to-vigorous physical activity.
Significant between-school random variation in objectively measured time spent in light-to-vigorous physical activity was identified [σ2μ0 = 0.067; p < 0.001]; school-level differences accounted for 6.7% of the variability in the time individual students spent in light-to-vigorous physical activity. Of the 22 school-level variables, students attending schools with support for active transportation to/from school and written policies/practices for physical activity, accumulated significantly more minutes of physical activity per school week than students who attended schools that did not.
School physical activity policy and support for active school travel is associated with objectively measured time spent in light to vigorous physical activity. School physical activity policy might be a critical mechanism through which schools can impact the physical activity levels of their students.
PMCID: PMC4082160  PMID: 24999387
4.  The association between senior student tobacco use rate at school and alternative tobacco product use among junior students in Canadian secondary schools 
Tobacco Induced Diseases  2014;12(1):8.
The use of alternative tobacco products (ATPs) has grown in popularity among Canadian youth. This study examined the association between a school-level characteristic (the senior student tobacco use rate) and the current use of manufactured cigarettes, little cigars or cigarillos, cigars, roll-your-own cigarettes, smokeless tobacco (SLT), and a hookah among junior students.
This study used nationally representative Canadian data from 29,495 students in grades 9 to 12 as part of the 2010/2011 Youth Smoking Survey. For each ATP, we described rates of senior and junior tobacco use, calculated the variance attributed to school-level factors, and examined the association between the senior student (grades 11 and 12) tobacco use rate and the current use of each ATP among junior students (grades 9 and 10) while accounting for relevant student-level characteristics. SAS 9.3 was used for all analyses.
Over half of schools sampled had senior students that reported using each ATP. School-level differences accounted for between 14.1% and 29.7% of the variability in ATP current use among junior students. Each one percent increase in the number of senior students at a school that currently use manufactured cigarettes, SLT, or a hookah was significantly independently associated with an increased likelihood that a junior student at that school currently used manufactured cigarettes (OR 1.04, 95% CI 1.01 to 1.06), SLT (OR 1.14, 95% CI 1.06 to 1.24), or a hookah (OR 1.09, 95% CI 1.03 to 1.14).
Characteristics of the school environment a junior student attends appear to play an important role in ATP use, and tobacco control programs and policies should be designed to ensure that they include strategies to curb the use of all tobacco products. Additional evidence is needed for the impact of comprehensive school-based tobacco control approaches.
PMCID: PMC4012246  PMID: 24808817
Tobacco products; Adolescent; Tobacco use
5.  The COMPASS study: a longitudinal hierarchical research platform for evaluating natural experiments related to changes in school-level programs, policies and built environment resources 
BMC Public Health  2014;14:331.
Few researchers have the data required to adequately understand how the school environment impacts youth health behaviour development over time.
COMPASS is a prospective cohort study designed to annually collect hierarchical longitudinal data from a sample of 90 secondary schools and the 50,000+ grade 9 to 12 students attending those schools. COMPASS uses a rigorous quasi-experimental design to evaluate how changes in school programs, policies, and/or built environment (BE) characteristics are related to changes in multiple youth health behaviours and outcomes over time. These data will allow for the quasi-experimental evaluation of natural experiments that will occur within schools over the course of COMPASS, providing a means for generating “practice based evidence” in school-based prevention programming.
COMPASS is the first study with the infrastructure to robustly evaluate the impact that changes in multiple school-level programs, policies, and BE characteristics within or surrounding a school might have on multiple youth health behaviours or outcomes over time. COMPASS will provide valuable new insight for planning, tailoring and targeting of school-based prevention initiatives where they are most likely to have impact.
PMCID: PMC4234205  PMID: 24712314
Obesity; Physical activity; Tobacco; Substance use; Diet; Policy; Longitudinal; Built environment
6.  Reported municipal costs from outdoor smoke-free by-laws-experience from Ontario, Canada 
Tobacco Induced Diseases  2014;12(1):4.
In 2006, enclosed public and workplaces in Ontario were made smoke-free by the Smoke-free Ontario Act (SFOA). Numerous area municipalities across the province have since developed local by-laws that are more restrictive than the SFOA and ban smoking in outdoor environments including parks, beaches, and patios. The current study measured reported costs associated with the implementation and enforcement of smoke-free outdoor municipal by-laws including materials and staffing costs. The study also assessed the number of warnings or tickets issued to smokers. Ontario communities with a by-law in force for at least 2 years were included in the sample (n = 42). The study was completed by 88% of area municipalities (n = 37). Municipal staff and managers completed a survey by telephone between June-September 2012.
No area municipality surveyed reported that they hired additional enforcement staff as a result of their community’s smoke-free by-law. Most municipalities (95%) posted signage to support awareness of their by-law; signs costs ranged from $40-$150/sign with most municipalities reporting signs were made in-house. Most communities reported actively enforcing the by-law; six communities reported they had issued tickets to people not in compliance with outdoor smoking restrictions.
The implementation, promotion, and enforcement of outdoor smoke-free by-laws have required municipal staff time and in most cases have promotional costs, but these have come from existing budgets and using existing staff. Outdoor smoke-free by-laws have not created significant burdens on municipal enforcement staff or on municipal budgets.
PMCID: PMC3944976  PMID: 24581326
Municipal by-law; Outdoor smoking; Policy evaluation; Economic impact
7.  A cross-sectional examination of school characteristics associated with overweight and obesity among grade 1 to 4 students 
BMC Public Health  2013;13:982.
Excessive weight gain among youth is an ongoing public health concern. Despite evidence linking both policies and the built environment to adolescent and adult overweight, the association between health policies or the built environment and overweight are often overlooked in research with children. The purpose of this study was to examine if school-based physical activity policies and the built environment surrounding a school are associated with weight status among children.
Objectively measured height and weight data were available for 2,331 grade 1 to 4 students (aged 6 to 9 years) attending 30 elementary schools in Ontario, Canada. Student-level data were collected using parent reports and the PLAY-On questionnaire administered to students by study nurses. School-level policy data were collected from school administrators using the Physical Activity Module of the Healthy School Planner tool, and built environment data were provided by the Enhanced Points of Interest data resource. Multi-level logistic regression models were used to examine the school- and student-level characteristics associated with the odds of a student being overweight or obese.
There was significant between-school random variation in the odds of a student being overweight [σ2μ0 = 0.274(0.106), p < 0.001], but not for being obese [σ2μ0 = 0.115(0.089)]. If a student attended a school that provided student access to a variety of facilities on and off school grounds during school hours or supported active transportation to and from school, he/she was less likely to overweight than a similar student attending a school without these policies. Characteristics of the built environment were not associated with overweight or obesity among this large cross-sectional sample of children.
This new evidence suggests that it may be wise to target obesity prevention efforts to schools that do not provide student access to recreation facilities during school hours or schools that do not support active transportation for students. Future research should evaluate if school-based overweight and obesity prevention programming might be improved if interventions selectively targeted the school characteristics that are putting students at the greatest risk.
PMCID: PMC4015821  PMID: 24139176
Obesity; Body mass index/BMI; Built environment; Physical activity; Children
8.  Where Is Obesity Prevention on the Map? Distribution and Predictors of Local Health Department Prevention Activities in Relation to County-Level Obesity Prevalence in the US 
The system of local health departments (LHD) in the US has potential to advance a locally-oriented public health response in obesity control and reduce geographic disparities. However, the extent to which obesity prevention programs correspond to local obesity levels is unknown.
This study examines the extent to which LHDs across the US have responded to local levels of obesity by examining the association between jurisdiction level obesity prevalence and the existence of obesity prevention programs.
Data on LHD organizational characteristics from the Profile Study of Local Health Departments and county-level estimates of obesity from the Behavioral Risk Factor Surveillance System were analyzed (n=2,300). Since local public health systems are nested within state infrastructure, multilevel models were used to examine the relationship between county-level obesity prevalence and LHD obesity prevention programming and to assess the impact of state-level clustering.
2,300 local health department jurisdictions defined with respect to county boundaries
Practitioners in local health departments who responded to the 2005 Profile Study of Local Health Departments.
Main Outcome Measures
Likelihood of having obesity prevention activities and association with area-level obesity prevalence
The existence of obesity prevention activities was not associated with prevalence of obesity in the jurisdiction. A substantial portion of the variance in LHD activities was explained by state-level clustering.
This paper identified a gap in the local public health response to the obesity epidemic and underscores the importance of multilevel modeling in examining predictors of LHD performance.
PMCID: PMC3711616  PMID: 22836530
Obesity; Primary Prevention; Community Health Services; Public Health Practice; Multilevel Analysis; Geographic Information Systems
9.  Active Video Games and Health Indicators in Children and Youth: A Systematic Review 
PLoS ONE  2013;8(6):e65351.
Active video games (AVGs) have gained interest as a way to increase physical activity in children and youth. The effect of AVGs on acute energy expenditure (EE) has previously been reported; however, the influence of AVGs on other health-related lifestyle indicators remains unclear.
This systematic review aimed to explain the relationship between AVGs and nine health and behavioural indicators in the pediatric population (aged 0–17 years).
Data sources
Online databases (MEDLINE, EMBASE, psycINFO, SPORTDiscus and Cochrane Central Database) and personal libraries were searched and content experts were consulted for additional material.
Data selection
Included articles were required to have a measure of AVG and at least one relevant health or behaviour indicator: EE (both habitual and acute), adherence and appeal (i.e., participation and enjoyment), opportunity cost (both time and financial considerations, and adverse events), adiposity, cardiometabolic health, energy intake, adaptation (effects of continued play), learning and rehabilitation, and video game evolution (i.e., sustainability of AVG technology).
51 unique studies, represented in 52 articles were included in the review. Data were available from 1992 participants, aged 3–17 years, from 8 countries, and published from 2006–2012. Overall, AVGs are associated with acute increases in EE, but effects on habitual physical activity are not clear. Further, AVGs show promise when used for learning and rehabilitation within special populations. Evidence related to other indicators was limited and inconclusive.
Controlled studies show that AVGs acutely increase light- to moderate-intensity physical activity; however, the findings about if or how AVG lead to increases in habitual physical activity or decreases in sedentary behaviour are less clear. Although AVGs may elicit some health benefits in special populations, there is not sufficient evidence to recommend AVGs as a means of increasing daily physical activity.
PMCID: PMC3683002  PMID: 23799008
10.  A cross-sectional examination of modifiable risk factors for chronic disease among a nationally representative sample of youth: are Canadian students graduating high school with a failing grade for health? 
BMC Public Health  2013;13:569.
Substance use and weight gain among youth increase the risk for future disease. As such, the purpose of this study is to examine how many Canadian youth are currently failing to meet substance use and weight gain related public health guidelines.
Data from the 2010–11 Youth Smoking Survey were used to examine grade 9 to 12 students meeting seven different guidelines by sex and by grade.
Among Canadian youth, 8.8% were current smokers, 18.8% were current marijuana users, 25.5% were current binge drinkers, 22.5% were considered overweight or obese, 31.2% did not meet physical activity guidelines, 89.4% exceeded sedentary behaviour guidelines, and 93.6% reported inadequate fruit and vegetable intake. The mean number of risk factors per student was 2.9 (±1.2); only 0.5% of youth reported having none of the risk factors.
Students rarely met all seven public health guideline examined, and the vast majority of actually reported having two or more modifiable risk factors for disease.
PMCID: PMC3751757  PMID: 23758659
Obesity; Physical activity; Tobacco; Alcohol; Marijuana; Diet; Youth
11.  Reliability and validity of the weight status and dietary intake measures in the COMPASS questionnaire: are the self-reported measures of body mass index (BMI) and Canada’s food guide servings robust? 
The COMPASS study is designed to follow a cohort of ~30,000 grade 9 to 12 students attending ~60 secondary schools for four years to understand how changes in school characteristics (policies, programs, built environment) are associated with changes in youth health behaviours. Since the student-level questionnaire for COMPASS (Cq) is designed to facilitate multiple large-scale school-based data collections using passive consent procedures, the Cq is only comprised of self-reported measures. The present study assesses the 1-week (1wk) test-retest reliability and the concurrent validity of the Cq measures for weight status and dietary intake.
Validation study data were collected from 178 grade 9 students in Ontario (Canada). At time 1 (T1), participants completed the Cq and daily recoding of their dietary intake using the web-based eaTracker tool. After one week, (T2), students completed the Cq again, participants submitted their daily eaTracker logs and staff measured their height and weight. Test-retest reliability of the self-reported (SR) weight status and dietary intake measures at T1 and T2, and the concurrent validity of the objectively measured and SR weight status and dietary intake measures at T2 were examined using intraclass correlation coefficients (ICC).
Test-retest reliability for SR height (ICC 0.96), weight (ICC 0.99), and BMI (ICC 0.95) are considered substantial. The concurrent validity for SR height (ICC 0.88), weight (ICC 0.95), and BMI (ICC 0.84) are also considered substantial. The test-retest reliability for SR dietary intake for fruits and vegetables (ICC 0.68) and milk and alternatives (ICC 0.69) are considered moderate, whereas meat and alternatives (ICC 0.41), and grain products (ICC 0.56) are considered fair. The concurrent validity for SR dietary intake identified that fruits and vegetables (ICC 0.53), milk and alternatives (ICC 0.60), and grain products (ICC 0.41) are considered fair, whereas meat and alternatives (ICC 0.34) was considered slight.
While the test-retest reliability of the measures used in this study were all high, the concurrent validity of the measures was considered acceptable. The results support the use of the self-reported COMPASS weight status and dietary intake measures for use in research where objective measures are not possible.
PMCID: PMC3663698  PMID: 23561578
Reliability; Validity; Body mass index; Diet; Food groups; Youth
12.  Changes in Tobacco Use, Susceptibility to Future Smoking, and Quit Attempts among Canadian Youth over Time: A Comparison of Off-Reserve Aboriginal and Non-Aboriginal Youth 
The purpose of this study was to determine whether there is a growing inequity in tobacco use, susceptibility to future smoking, and quit attempts among Off-Reserve Aboriginal (ORA) youth in Canada relative to Non-Aboriginal youth. Current smoking, susceptibility to future smoking and quit attempts were examined among a nationally representative sample of ORA and Non-Aboriginal Canadian youth. Data are from cross-sectional surveys of 88,661 respondents in Grades 6 to 9 across the 2004, 2006 and 2008 survey waves of the Youth Smoking Survey (YSS). At each wave, ORA youth were more likely to be current smokers (overall OR = 3.91, 95% CI 3.47 to 4.41), to be susceptible to future smoking (overall OR = 1.37, 95% CI 1.27 to 1.48), and less likely to have ever made a quit attempt compared to Non-Aboriginal youth (overall OR = 0.74, 95% CI 0.57 to 0.96). Although susceptibility to future smoking declined for Non-Aboriginal youth, the prevalence of susceptibility remained stable among ORA youth. The percentage of ORA youth reporting making a quit attempt increased, however, current smoking rates among ORA youth did not decline. These findings suggest that the disparity in susceptibility to future tobacco use among ORA and Non-Aboriginal youth has increased over time. Despite increased rates of quit attempts, current smoking rates remain significantly higher among ORA youth. Tobacco control programs for Aboriginal youth should be a public health priority.
PMCID: PMC3635174  PMID: 23429753
aboriginal; adolescent; youth; smoking; quit attempts; smoking susceptibility
13.  Bidi and Hookah Use Among Canadian Youth: Findings From the 2010 Canadian Youth Smoking Survey 
Although cigarette use among Canadian youth has decreased significantly in recent years, alternative forms of tobacco use are becoming increasingly popular. Surveillance of youth tobacco use can help inform prevention programs by monitoring trends in risk behaviors. We examined the prevalence of bidi and hookah use and factors associated with their use among Canadian youth by using data from the 2010–2011 Youth Smoking Survey (YSS).
We analyzed YSS data from 28,416 students (2006–2007) and 31,396 students (2010–2011) in grades 9 through 12 to examine prevalence of bidi and hookah use. We conducted multivariate logistic regression analyses of 2010–2011 YSS data to examine factors associated with bidi and hookah use.
From 2006 through 2010, prevalence of hookah use among Canadian youth increased by 6% (P = .02). Marijuana use emerged as a consistent predictor of bidi and hookah use. Males, youth of black, Latin, or other descent, and youth of Asian descent were more likely to use bidis (odds ratio [OR], 1.5; OR, 15.6; OR, 14.9) or hookah (OR, 1.3; OR, 2.4; OR, 1.5). Current cigarette smokers were more likely than nonsmokers to be current users of bidis (OR, 6.7) and hookahs (OR, 3.0), and occasional and frequent alcohol drinkers were also more likely than nondrinkers to be current hookah users (OR, 2.8; OR, 3.6).
Although bidi use has not changed significantly among Canadian youth, the increase in hookah use warrants attention. Understanding the factors associated with use of bidis and hookahs can inform the development of tobacco use prevention programs to address emerging at-risk youth populations.
PMCID: PMC3664211  PMID: 23660115
14.  Roll-your-own tobacco use among Canadian youth: is it a bigger problem than we think? 
BMC Public Health  2012;12:557.
Despite the apparent decline in the popularity of roll-your-own (RYO) cigarettes over the past few decades, RYO tobacco products are widely available and used by a substantial number of adult smokers. Considering research has yet to examine the prevalence of RYO tobacco use among youth populations, this manuscript examines the prevalence of RYO tobacco use and factors associated with RYO use in a nationally representative sample of youth smokers from Canada.
This study used data collected from 3,630 current smokers in grades 9 to 12 as part of the 2008-09 Canadian Youth Smoking Survey (YSS). Descriptive analyses of the sample demographic characteristics, smoking status, cigarettes per day, weekly spending money, and frequency of marijuana use were examined by RYO tobacco ever use and RYO tobacco current use. Two logistic regression models were used to examine factors associated with RYO tobacco ever use and RYO tobacco current use.
We identified that 51.2% of current smokers were RYO ever users and 24.2% were RYO current users. The prevalence of RYO current users was highest in Atlantic Canada (40.1%) and lowest in Quebec (12.3%). RYO current users were more likely to be male (OR 1.27), to be daily smokers (OR 1.75), to use marijuana once a month or more (OR 2.74), and to smoke 11 or more cigarettes per day (OR 6.52). RYO current users were less likely to be in grade 11 (OR 0.65) or grade 12 (OR 0.40) and less likely to have between $20 to $100 (OR 0.44) or more than $100 (OR 0.45) of disposable income.
Developing a better understanding of RYO tobacco use among youth is important for advancing population-level tobacco control prevention strategies and cessation programs. We identified that RYO tobacco use is not a negligible problem among Canadian youth. Ongoing research is needed to continue monitoring the prevalence of RYO use among youth and the factors associated with its use, but to also monitor if this more affordable tobacco product is being targeted to price sensitive youth smokers.
PMCID: PMC3434020  PMID: 22834563
Roll-your-own tobacco; Disposable income; Youth; Drug use; Smoking
15.  A multilevel examination of gender differences in the association between features of the school environment and physical activity among a sample of grades 9 to 12 students in Ontario, Canada 
BMC Public Health  2012;12:74.
Creating school environments that support student physical activity (PA) is a key recommendation of policy-makers to increase youth PA. Given males are more active than females at all ages, it has been suggested that investigating gender differences in the features of the environment that associate with PA may help to inform gender-focused PA interventions and reduce the gender disparity in PA. The purpose of this cross-sectional study was to explore gender differences in the association between factors of the school environment and students' time spent in PA.
Among a sample of 10781 female and 10973 male students in grades 9 to 12 from 76 secondary schools in Ontario, Canada, student- and school-level survey PA data were collected and supplemented with GIS-derived measures of the built environment within 1-km buffers of the 76 schools.
Findings from the present study revealed significant differences in the time male and female students spent in PA as well as in some of the school- and student-level factors associated with PA. Results of the gender-specific multilevel analyses indicate schools should consider providing an alternate room for PA, especially for providing flexibility activities directed at female students. Schools should also consider offering daily physical education programming to male students in senior grades and providing PA promotion initiatives targeting obese male students.
Although most variation in male and female students' time spent in PA lies between students within schools, there is sufficient between-school variation to be of interest to practitioners and policy-makers. More research investigating gender differentials in environment factors associated with youth PA are warranted.
PMCID: PMC3330023  PMID: 22272717
Physical activity; Adolescents; Gender; Environment; Prevention; School
16.  Randomized controlled trial of mailed Nicotine Replacement Therapy to Canadian smokers: study protocol 
BMC Public Health  2011;11:741.
Considerable public health efforts are ongoing Canada-wide to reduce the prevalence of smoking in the general population. From 1985 to 2005, smoking rates among adults decreased from 35% to 19%, however, since that time, the prevalence has plateaued at around 18-19%. To continue to reduce the number of smokers at the population level, one option has been to translate interventions that have demonstrated clinical efficacy into population level initiatives. Nicotine Replacement Therapy (NRT) has a considerable clinical research base demonstrating its efficacy and safety and thus public health initiatives in Canada and other countries are distributing NRT widely through the mail. However, one important question remains unanswered - do smoking cessation programs that involve mailed distribution of free NRT work? To answer this question, a randomized controlled trial is required.
A single blinded, panel survey design with random assignment to an experimental and a control condition will be used in this study. A two-stage recruitment process will be employed, in the context of a general population survey with two follow-ups (8 weeks and 6 months). Random digit dialing of Canadian home telephone numbers will identify households with adult smokers (aged 18+ years) who are willing to take part in a smoking study that involves three interviews, with saliva collection for 3-HC/cotinine ratio measurement at baseline and saliva cotinine verification at 8-week and 6-month follow-ups (N = 3,000). Eligible subjects interested in free NRT will be determined at baseline (N = 1,000) and subsequently randomized into experimental and control conditions to receive versus not receive nicotine patches. The primary hypothesis is that subjects who receive nicotine patches will display significantly higher quit rates (as assessed by 30 day point prevalence of abstinence from tobacco) at 6-month follow-up as compared to subjects who do not receive nicotine patches at baseline.
The findings from the proposed trial are timely and highly relevant as mailed distribution of NRT require considerable resources and there are limited public health dollars available to combat this substantial health concern. In addition, findings from this randomized controlled trial will inform the development of models to engage smokers to quit, incorporating proactive recruitment and the offer of evidence based treatment.
Trial Registration NCT01429129
PMCID: PMC3198706  PMID: 21955930
17.  Tobacco retailer density surrounding schools and youth smoking behaviour: a multi-level analysis 
Youth smoking prevention should be a public health priority. It is not only vital to prevent youth from smoking but also to prevent non-smoking youth from becoming susceptible to smoking. Past research has examined factors associated with youth's susceptibility to become a future smoker, but research has yet to examine tobacco retailer density and susceptibility to smoking among never smokers. The objectives of this study are to examine how tobacco retailer density surrounding schools and social smoking influences are associated with smoking susceptibility among youth of never smokers, and occasional and daily smoking among youth of current smokers.
Data were collected in 2005-2006 from grade 9 to 12 students attending 76 secondary schools in Ontario, Canada, as part of the SHAPES-On study. A series of multi-level logistic regression analyses were performed to understand how student- and school-level factors are associated with three smoking behaviour outcomes: smoking susceptibility among never smokers, occasional smoking, and daily smoking.
The number of tobacco retailers surrounding a school was found to be associated with the likelihood of a never smoker being susceptible to future smoking (OR 1.03, 95CI% 1.01, 1.05). We also identified that being surrounded by smoking social influences, specifically family and close friends, can substantially increase the likelihood that never smokers are at risk for future smoking or that youth are already occasional or daily smokers.
We identified that the number of tobacco retailers surrounding a school was associated with an increased odds of being susceptible to future smoking among male never smokers. Smoking social models surrounding youth also appears to have an important impact on their smoking behaviour regardless of their smoking status. It is important for youth smoking prevention programs to begin early, interrupt youths' susceptibility to future smoking, and focus on subgroups that are at higher risk of smoking. The government should consider the impact of tobacco retailer density on youth smoking behaviour, and be cautious when granting licenses for establishments to sell tobacco products.
PMCID: PMC3158107  PMID: 21791116
18.  Tobacco, alcohol and illicit drug use among Aboriginal youth living off-reserve: results from the Youth Smoking Survey 
Despite the high prevalence of smoking among Aboriginal youth, there is a paucity of research related to tobacco use and other risk behaviours among Aboriginal youth living off-reserve in Canada. We used data from the national Youth Smoking Survey to characterize non-traditional tobacco use, exposure to second-hand smoke, and alcohol and drug use among Aboriginal youth living off-reserve. We examined whether these youth were at increased health risk compared with non-Aboriginal youth.
We examined cigarette smoking behaviour, use of other tobacco products, use of alcohol and other drugs, and exposure to second-hand smoke among 2620 Aboriginal youth living off-reserve and 26 223 non-Aboriginal youth in grades 9 to 12 who participated in the 2008/09 Youth Smoking Survey.
The prevalence of current smoking among the Aboriginal youth was more than double that among non-Aboriginal youth (24.9% v. 10.4%). Aboriginal youth also had a higher prevalence of regular exposure to second-hand smoke at home (37.3% v. 19.7%) and in cars (51.0% v. 30.3%). Aboriginal youth were more likely than non-Aboriginal youth to be current smokers, to be regularly exposed to second-hand smoke, to have tried marijuana and other illicit drugs, and to engage in binge drinking. They were less likely than non-Aboriginal youth to have tried to quit smoking.
Current national estimates of smoking, and alcohol and illicit drug use among youth underestimate the prevalence of these behaviours among Aboriginal youth living off-reserve. Our findings highlight the need for culturally appropriate prevention and cessation policies and programs for this at-risk population.
PMCID: PMC3091934  PMID: 21555383
19.  School and Student Characteristics Associated With Screen-Time Sedentary Behavior Among Students in Grades 5-8, Ontario, Canada, 2007-2008 
Preventing Chronic Disease  2010;7(6):A128.
We examined school and student characteristics associated with screen-time sedentary behavior.
We analyzed data collected from 2,449 students in grades 5 through 8 who attended 30 elementary schools in Ontario, Canada. We used multilevel logistic regression to examine the student- and school-level factors associated with moderate and high screen-time sedentary behavior.
Moderate screen time did not vary significantly across schools. Student characteristics significantly associated with moderate screen time were sex, number of friends who are active, and parental encouragement of physical activity. High screen time did vary significantly across schools; school-level differences accounted for 12% of the variability in the odds of a student reporting high screen time. Students who attended a school in the more advanced phase of emphasizing participation in physical activity through school programs were less likely to report high screen time compared with students who attended schools in the earlier phase for this school-level indicator. Student characteristics significantly associated with high screen time were sex, parental encouragement of physical activity, parental support of physical activity, and race/ethnicity.
High levels of screen-time sedentary behavior are associated with both student characteristics and the characteristics of the school a student attends. Developing a better understanding of the school characteristics associated with sedentary behavior will be valuable for guiding the development of interventions to reduce sedentary behavior among youth populations.
PMCID: PMC2995602  PMID: 20950535
20.  A multi-level examination of school programs, policies and resources associated with physical activity among elementary school youth in the PLAY-ON study 
Given the decline in physical activity (PA) levels among youth populations it is vital to understand the factors that are associated with PA in order to inform the development of new prevention programs. Many studies have examined individual characteristics associated with PA among youth yet few have studied the relationship between the school environment and PA despite knowing that there is variability in student PA levels across schools.
Using multi-level logistic regression analyses we explored the school- and student-level characteristics associated with PA using data from 2,379 grade 5 to 8 students attending 30 elementary schools in Ontario, Canada as part of the PLAY-Ontario study.
Findings indicate that there was significant between-school random variation for being moderately and highly active; school-level differences accounted for 4.8% of the variability in the odds of being moderately active and 7.3% of the variability in the odds of being highly active. Students were more likely to be moderately active if they attended a school that used PA as a reward and not as discipline, and students were more likely to be highly active if they attended a school with established community partnerships. Important student characteristics included screen time sedentary behaviour, participating in team sports, and having active friends.
Future research should evaluate if the optimal population level impact for school-based PA promotion programming might be achieved most economically if intervention selectively targeted the schools that are putting students at the greatest risk for inactivity.
PMCID: PMC2828972  PMID: 20181010
21.  Use of contraband cigarettes among adolescent daily smokers in Canada 
Current tobacco-control strategies seek to inhibit and reduce smoking among adolescents. However, such strategies are probably undermined by the contraband tobacco market. Using data from Canada’s 2006/2007 Youth Smoking Survey, we found that 13.1% of respondents who were daily smokers reported that contraband cigarettes were their usual brand. They consumed significantly more cigarettes than respondents who smoked other brands. Contraband cigarettes accounted for about 17.5% of all cigarettes smoked by adolescent daily smokers in Canada overall, and for more than 25% in the provinces of Ontario and Quebec.
PMCID: PMC2742140  PMID: 19737829
22.  Building research capacity for evidence-informed tobacco control in Canada: a case description 
Tobacco Induced Diseases  2009;5(1):12.
Tobacco use remains the leading cause of death and disability in Canada. Insufficient research capacity can inhibit evidence-informed decision making for tobacco control. This paper outlines a Canadian project to build research capacity, defined as a community's ability to produce research that adequately informs practice, policy, and future research in a timely, practical manner. A key component is that individuals and teams within the community must mutually engage around common, collectively negotiated goals to address specific practices, policies or programs of research. An organizing framework, a set of activities to build strategic recruitment, productivity tools, and procedures for enhancing social capital are described. Actions are intended to facilitate better alignment between research and the priorities of policy developers and service providers, enhance the external validity of the work performed, and reduce the time required to inform policy and practice.
PMCID: PMC2746799  PMID: 19664224
23.  The roll-your-own cigarette market in Canada: a cross-sectional exploratory study 
Even though the use and prevalence of roll-your-own cigarettes (RYO) has been declining over the past decades, RYO remains important. Given the paucity of research examining RYO use, there is a need to better understand the current and potential future context of RYO use.
Data from the 2002 Canadian Tobacco Use Monitoring Survey (CTUMS) were used to examine RYO tobacco use among 23,341 Canadians aged 15 and older. Logistic regression models were conducted to examine factors which differentiate smokers who smoke RYO tobacco all of the time, most of the time or sometimes from smokers who do not smoke RYO tobacco.
We found that 17% (n = 925,000) of current smokers in Canada reported smoking RYO. When compared to manufactured cigarette (MC) smokers, RYO users were heavier smokers, more addicted to nicotine, and less likely to consider quitting smoking. Lower income smokers were more likely to smoke RYO tobacco compared to smokers with high income. Conversely, smokers who had completed secondary school or university were less likely to smoke RYO tobacco compared to smokers who had not completed secondary school.
This study demonstrates that RYO tobacco use is not a negligible problem within Canada and provides valuable new insight for developing future tobacco control initiatives for this population of smokers.
PMCID: PMC2666659  PMID: 19291309
24.  Age of smoking initiation and risk of breast cancer in a sample of Ontario women 
To examine the association between time of smoking initiation and both the independent and joint effects of active and passive tobacco smoke exposure and the risk of breast cancer in a sample of Ontario women.
Data from two large population-based case-control studies conducted among Ontario women aged 25–75 years were combined for analysis (n = 12,768).
Women who had ever smoked and were exposed to passive smoke had a significant increased risk of breast cancer (OR 1.13, 95%CI 1.01–1.25). A significant increased risk was also observed among women who initiated smoking: at age 26 or older (OR 1.26, 95%CI 1.03–1.55); more than five years from menarche (OR 1.26, 95%CI 1.12–1.42); and, after their first live birth (OR 1.25, 95%CI 1.02–1.52).
The results suggest that women who initiate smoking at an older age are at an increased risk of breast cancer.
PMCID: PMC2656478  PMID: 19222858
25.  Association Between Sedentary Behavior, Physical Activity, and Obesity: Inactivity Among Active Kids 
Preventing Chronic Disease  2008;6(1):A26.
Sedentary behavior and physical activity are not mutually exclusive behaviors. The relative risk of overweight for adolescents who are highly sedentary and highly physically active is unclear. A better understanding of the relationship between sedentary behaviors, physical activity, and body mass index (BMI) would provide insight for developing interventions to prevent or reduce overweight.
Using the physical activity module of the School Health Action, Planning and Evaluation System (SHAPES), we collected data from 25,060 students in grades 9 through 12 from 76 secondary schools in Ontario, Canada. Sex-specific logistic regression analyses were performed to examine how BMI, weight perceptions, social influences, team sports participation, and smoking behavior were associated with being 1) high active-high sedentary, 2) low active-low sedentary, and 3) low active-high sedentary.
Low active-high sedentary boys were more likely to be overweight than high active-low sedentary boys (adjusted odds ratio [AOR], 1.60; 95% confidence interval [CI], 1.01-2.58). When compared with high active-low sedentary girls, girls who were low active-high sedentary (OR, 2.24; 95% CI, 1.23-4.09) or high active-high sedentary (OR, 1.91; 95% CI, 1.01-3.61) were more likely to be overweight.
Sedentary behavior may moderate the relationship between physical activity and overweight. Developing a better understanding of sedentary behavior in relation to physical activity and overweight is critical for preventing and reducing overweight among youth.
PMCID: PMC2644601  PMID: 19080032

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