Research has shown that tobacco users have an increased risk of collisions compared to nonsmokers. Studies from 1967 through 2013 documented a crude relative risk of collision involvement of about 1.5 among smokers compared to nonsmokers. In January 2009, in response to concerns about the health risks associated with potentially high concentrations of secondhand smoke resulting from smoking in vehicles, the provincial government in Ontario, Canada, introduced legislation restricting smoking in vehicles where children and adolescents are present. We examined the association between reported smoking and involvement in a motor vehicle collision in a large representative sample of adult drivers in Ontario, Canada, from 2002 and 2016, with particular focus on 2002-2008 and 2010-2016, periods before and after the legislation. Data are based on the Centre for Addiction and Mental Health (CAMH) Monitor. Among licensed drivers, prevalence of self-reported collision involvement within the past year for 2002-2008 was 9.39% among those who currently smoked compared to 7.08% of nonsmokers. Following implementation of the legislation, for 2010-2016, the prevalence of collisions for smokers was 7.01% and for nonsmokers was 6.02%. The overall difference for both smokers and nonsmokers between the two time periods was statistically significant; however, the difference between the two groups for the pre-legislation period was significant even after adjusting for potential confounders, while post legislation the difference was not significant. Prior to the legislation, the prevalence of collision was higher among smokers than nonsmokers; following the introduction of the legislation the prevalence was similar for the two groups.

BACKGROUND:There are a limited number of studies that have examined the real-world effectiveness of smoking cessation aids and relapse longitudinally in population-representative samples. This study examines the association between use of nicotine gum, patch, bupropion, and varenicline and time to relapse as well as any changes in the association with increased length of abstinence.METHODS:Data of 1821 current adult smokers (18+) making their first serious quit attempt were compiled from 4504 individuals enrolled in the Ontario Tobacco Survey, a representative telephone survey of Ontario adults, which followed smokers every 6 months for up to 3 years. Use of cessation aids at the time of initial report of a quit attempt was analyzed. A flexible parametric survival model was developed to model length of abstinence, controlling for potential confounders.RESULTS:The best fit model found knots at 3, 13, 43, and 212 days abstinent, suggesting different rates of relapse in the periods marked by those days. Use of the patch and varenicline was associated with lower rates of relapse, but no positive effect was found for bupropion or nicotine gum. The effectiveness of the patch reversed in effect after the first month of abstinence.CONCLUSIONS:This study is one of few reports of long-term quitting in a population-representative sample and demonstrates that the effectiveness of some pharmacological cessation aids (the patch and varenicline can be seen in a population sample). Previous failures in real-world studies of the effectiveness of smoking cessation aids may reflect differences in the products individuals use and differences in the timing of self-reported cessation.IMPLICATIONS:While a large number of randomized controlled trials have shown the efficacy of many pharmaceutical smoking cessation aids, evidence of their effectiveness in observational studies in the real world is ambiguous. This study uses a longitudinal cohort of a representative sample of smokers to show that the effectiveness of pharmaceutical cessation aids can be demonstrated in real-world use situations, but effectiveness varies by product type and has time-varying effects.

This paper investigates the impacts of smoke-free housing policies on compliance, enforcement and smoking behavior. From 2012 to 2014, we studied two affordable housing providers in Canada with comprehensive smoke-free policies: Waterloo Regional Housing that required new leases to be non-smoking and exempted existing leases, and Yukon Housing Corporation that required all leases (existing and new) to be non-smoking. Focus groups and key informant interviews were conducted with 31 housing and public health staff involved in policy development and implementation, and qualitative interviews with 56 tenants. Both types of smoke-free policies helped tenants to reduce and quit smoking. However, exempting existing tenants from the policy created challenges for monitoring compliance and enforcing the policy, and resulted in ongoing tobacco smoke exposure. Moreover, some new tenants were smoking in exempted units, which undermined the policy and maintained smoking behavior. Our findings support the implementation of complete smoke-free housing policies that do not exempt existing leases to avoid many of the problems experienced by staff and tenants. In jurisdictions where exempting existing leases is still required by law, adequate staff resources for monitoring and enforcement, along with consistent and clear communication (particularly regarding balconies, patios and outdoor spaces) will encourage compliance.

Objective: Although most research on drugs and driving has focused on the use of alcohol and cannabis, research that has been conducted on cigarette smoking and collisions has found that smokers have an increased collision involvement. Studies dating from 1967 through 2013 have shown a crude relative risk of about 1.5 among smokers compared to nonsmokers. In Canada, the association between smoking and collisions has not been recently investigated. Studies that have examined the association between smoking and collisions often did not control for all confounding factors, such as alcohol use and driving exposure, which have been associated with increased collision rates. Additionally, a number of these studies were examined in countries and at times when prevalence of smoking was much higher than is currently the case in Canada. The purpose of this research is to examine the association between self-reported current smoking and past-year collision involvement, controlling for confounding factors, in a large representative sample of adult drivers in Ontario, Canada, from 2002 and 2014. Method: Data are based on the Centre for Addiction and Mental Health (CAMH) Monitor, an ongoing, rolling telephone survey of Ontario adults that provides epidemiological surveillance of indicators related to alcohol, tobacco, and other drug use, as well as physical and mental health. The survey uses random-digit-dialing methods via Computer-Assisted Telephone Interview, with response rates over 50%. Results: Prevalence of self-reported collision involvement within the past year for 2002-2014 was 8.6% among those who currently smoke compared to 6.5% of nonsmokers. Logistic regression analysis, controlling for the potential confounding effects of sociodemographics, driving exposure measures, drinking frequency, and hazardous alcohol use, found that the overall odds for collision involvement in the preceding year among current smokers for 2002-2014 was 1.27 (95% confidence interval [CI], 1.06-1.53) times that of nonsmokers. Conclusions: These findings indicate that despite a substantial reduction in overall prevalence of smoking in Canada, smokers still have a significantly increased odds of collision involvement, even when controlling for alcohol and exposure. Additionally, the results are consistent with the increased odds/risks of motor vehicle collisions found in other countries.

Insurance coverage for evidence-based smoking cessation treatments (SCTs) promotes uptake and reduces smoking rates. Published studies in this area are based in the US where employers are the primary source of health insurance. In Ontario, Canada, publicly funded healthcare does not cover SCTs, but it can be supplemented with employer-sponsored benefit plans. This study explores factors affecting the inclusion/exclusion of smoking cessation (SC) benefits. In total, 17 interviews were conducted with eight employers (auto, retail, banking, municipal and university industries), four health insurers, two government representatives and three advisors/consultants. Overall, SCT coverage varied among industries; it was inconsistently restrictive and SCT differed by coverage amount and length of use. Barriers impeding coverage included the lack of the following: Canadian-specific return on investment (ROI), SC cost information, employer demand, government regulations/incentives and employee awareness of and demand. A Canadian evidence-based calculation of ROI for SC coupled with government incentives and public education may be needed to promote uptake of SCT coverage by employers.

Introduction: Common short screening measures of dependence that use number of cigarettes per day may not be appropriate for use in populations of occasional smokers.Aims: In this study, we investigate whether perceived addiction (PA) predicts quit attempts and successful cessation among occasional smokers.Methods: Current occasional smokers (18+) in the Ontario Tobacco Survey (OTS) longitudinal cohort study followed up every six months for up to three years. Respondents rated their self-perceived level of addiction (very vs. somewhat or not very addicted). Generalised Estimating Equation models and proportional hazard models were used to test the predictive ability of PA.Results/Findings: Occasional smokers with very high PA had a higher likelihood of reporting a quit attempt (RR: 2.49; 95% CI: 1.88, 3.30) after adjusting for demographics. Given an incident quit attempt, occasional smokers who reported being very addicted were 2.93 times more likely to relapse (95%: 2.01, 4.28). The effect of PA was independent of other predictors of smoking behaviour.Conclusions: For some, occasional smokers, smoking cessation is a difficult process that may require significant support. Asking occasional smokers about PA is an effective way to predict likely success in quitting smokers that may be easily assessed in population based, as well as in community and clinical, settings.

Electronic cigarettes (e-cigarettes) have been steadily increasing in popularity among smokers, most of whom report using them to quit smoking. This study systematically reviews the current literature on the effectiveness of e-cigarettes as cessation aids.We searched PubMed, MEDLINE, PsycINFO, CINAHL, ERIC, ROVER, Scopus, ISI Web of Science, Cochrane Library, the Ontario Tobacco Research Unit (OTRU) library catalogue, and various gray literature sources. We included all English-language, empirical quantitative and qualitative papers that investigated primary cessation outcomes (smoking abstinence or reduction) or secondary outcomes (abstinence-related withdrawal symptoms and craving reductions) and were published on or before February 1, 2016.Literature searches identified 2855 references. After removing duplicates and screening for eligibility, 62 relevant references were reviewed and appraised. In accordance with the GRADE system, the quality of the evidence in support of e-cigarettes' effectiveness in helping smokers quit was assessed as very low to low, and the evidence on smoking reduction was assessed as very low to moderate. The majority of included studies found that e-cigarettes, especially second-generation types, could alleviate smoking withdrawal symptoms and cravings in laboratory settings.While the majority of studies demonstrate a positive relationship between e-cigarette use and smoking cessation, the evidence remains inconclusive due to the low quality of the research published to date. Well-designed randomized controlled trials and longitudinal, population studies are needed to further elucidate the role of e-cigarettes in smoking cessation.This is the most comprehensive systematic evidence review to examine the relationship between e-cigarette use and smoking cessation among smokers. This review offers balanced and rigorous qualitative and quantitative analyses of published evidence on the effectiveness of e-cigarette use for smoking abstinence and reduction as well as important outcomes such as withdrawal symptoms and craving to smoke. While inconclusive due to low quality, overall the existing literature suggests e-cigarettes may be helpful for some smokers for quitting or reducing smoking. However, more carefully designed and scientifically sound studies are urgently needed to establish unequivocally the long-term cessation effects of e-cigarettes and to better understand of how and when e-cigarettes may be helpful.

Objectives Smoke-free policies not only reduce harm to non-smokers, they may also reduce harm to smokers by decreasing the number of cigarettes smoked and increasing the likelihood of a successful quit attempt. However, little is known about the impact of exposure to smoking on patios on smoking behaviour. Design and participants Smokers from the Ontario Tobacco Survey, a longitudinal population representative cohort of smokers (2005–2011). There were 3460 current smokers who had completed one to six follow-ups and were asked at each follow-up whether or not they had been exposed to smoking on patios in the month. Main outcome measures Generalised estimating equations and survival analysis were used to examine the association between exposure to patio smoking and smoking behaviour changes (making a quit attempt and time to relapse after a quit attempt), controlling for potential confounders. Results Smokers who were exposed to smoking on patios (adjusted incident rate ratio (aIRR) = 0.89; 95% CI 0.81 to 0.97) or had been to a patio (aIRR = 0.86; 95% CI 0.74 to 0.99) were less likely to have made a quit attempt than smokers who had not visited a patio. Smokers who were exposed to smoking on patios were more likely to relapse (adjusted HR=2.40; 95% CI 1.07 to 5.40)) after making a quit attempt than those who visited a patio but were not exposed to smoking. Conclusions Exposure to smoking on patios of a bar or restaurant is associated with a lower likelihood of success in a quit attempt. Instituting smoke-free patio regulations may help smokers avoid relapse after quitting.

Introduction. The mediating role of cessation medications in the association between health professional advice and quitting behaviors is unclear.Methods. Data were from the Ontario Tobacco Survey longitudinal study, collected between July 2005 and June 2011 in Ontario, Canada. The analytic sample included 3437 baseline smokers who were seen by health professionals during follow-up. Logistic regression with generalized estimating equations and mediation analysis techniques were used to examine the impact of advice and medications on quitting outcomes (making a quit attempt, short-term quitting 1-6 months and long-term quitting > 6 months).Results. Those who received advice to quit smoking were more likely to use cessation medications than those who did not receive advice (21% vs. 13%, P < 0.001). Receiving advice was associated with making a quit attempt (adjusted odds ratio (OR) 1.25, 95% confidence interval (CI) 1.10-1.41) and long-term quitting (adjusted OR 1.49, 95% CI 1.10-2.02), but not with short-term quitting. Use of cessation medications was associated with making a quit attempt (adjusted OR 11.83, 95% CI 9.93-14.08), short-term quitting (adjusted OR 3.69, 95% CI 2.90-4.68), and long-term quitting (adjusted OR 2.73, 95% CI 1.95-3.82). Using prescription medications was associated with a higher likelihood of quitting short-term (adjusted OR 2.43, 95% CI 2.59-3.74) and long-term (adjusted OR 2.27, 95% CI 1.23-4.17) than using NRT. Use of cessation medications was a significant mediator in the pathway from receiving advice to quitting.Conclusion. Health professionals should advise smokers to quit and encourage them to use cessation medications, especially prescription medications when trying to quit. (C) 2016 Elsevier Inc. All rights reserved.

INTRODUCTION:There are limited data on the use of electronic cigarettes (e-cigarettes) among youth, particularly with regard to the use of nicotine versus nonnicotine products. This study investigates ever use of nicotine and nonnicotine e-cigarettes and examines the demographic and behavioral correlates of e-cigarette use in Ontario, Canada.METHODS:Data for 2,892 high school students were derived from the 2013 Ontario Student Drug Use and Health Survey. This province-wide school-based survey is based on a 2-stage cluster design. Bivariate and multivariate analyses were used to investigate the factors associated with ever use of e-cigarettes. Ever use of e-cigarettes was derived from the question, "Have you ever smoked at least one puff from an electronic cigarette?" All analyses included appropriate adjustments for the complex study design.RESULTS:Fifteen percent of high school students reported using e-cigarettes in their lifetime. Most students who ever used e-cigarettes reported using e-cigarettes without nicotine (72%), but 28% had used e-cigarettes with nicotine. Male, White/Caucasian, and rural students, as well as those with a history of using tobacco cigarettes, were at greater odds of e-cigarette use. Seven percent of students who had never smoked a tobacco cigarette in their lifetime reported using an e-cigarette. Five percent of those who had ever used an e-cigarette had never smoked a tobacco cigarette.CONCLUSION:More students reported ever using e-cigarettes without nicotine than with nicotine in Ontario, Canada. This underscores the need for greater knowledge of the contents of both nicotine and nonnicotine e-cigarettes to better guide public health policies.

OBJECTIVE:To examine waterpipe use and its association with demographic factors, tobacco cigarette smoking, ever use of electronic cigarettes (e-cigarettes) and alcohol use among high school students.METHODS:Data were derived from the 2013 Ontario Student Drug Use and Health Survey, a school-based survey of 7th to 12th grade students. This province-wide survey was based on a stratified two-stage cluster design. Analyses were based on a subsample of 2,873 high school students and included adjustments for the complex sample design.RESULTS:Overall, 12.5% of high school students (grades 9-12) had used a waterpipe in the previous year. Awareness of waterpipes was high - 68.4% of students reported that they were aware of waterpipes but had not used one in the past year; 19.1% had never heard of waterpipes or hookah. The percentage of high school students reporting waterpipe use in the past year was similar to reports of tobacco cigarette use (12.5% and 11% respectively). Waterpipe use was highly associated with past-year tobacco cigarette and regular alcohol use as well as ever use of e-cigarettes. In multivariate analyses, males and females had similar odds of waterpipe use, and non-White students and those in higher grades had greater odds of use after controlling for other substance use.CONCLUSION:These findings suggest that waterpipe use among high school students should be of some concern and suggest the need for policy measures to address potential risks associated with use.

Despite extensive research on social norms, the sources of norm formation are not well understood. Social exposure to a behavior (defined as the composite of ways through which people see that behavior in their social, physical, and symbolic environments) can serve as a source of normative influence. Using tobacco as a case study, we propose that research should move beyond categories of individuals as sources of norms and focus on a broader range of sources of normative influences. An understanding of social exposure as a source for norms may be important to better understand and intervene in environments to promote public health. We make policy recommendations arising from the explication of social exposure and propose directions for future research.

INTRODUCTION:Few studies have examined the transitions of smokers in the general population through multiple periods of daily, occasional smoking, or abstinence over time. Transitions from daily to occasional smoking are particularly of interest as these may be steps toward cessation.METHODS:The Ontario Tobacco Survey panel study followed 4,355 baseline smokers, semiannually for up to 3 years. Probabilities of all possible changes in smoking status more than 6 months were estimated using 13,000 repeated measures observations generated from sets of 3 consecutive interviews (n = 9,932 daily smokers, 1,245 occasion smokers, and 1,823 abstinent for at least 30 days, at Time 1).RESULTS:For initial daily smokers, an estimated 83% remained daily smokers more than 2 follow-ups. The majority of those who had been abstinent for 30 days at 1 interview, were also former smokers at the following interview. In contrast, occasional smoking status was unstable and future smoking status was dependent upon smoking history and subjective dependence. Among daily smokers who became occasional smokers 6 months later, an estimated 20% became a former smoker, at the next interview, but 50% returned to daily smoking. Daily, turned occasional smokers who rebounded back to daily smoking were more likely to describe themselves as addicted at Time 1. Continuing occasional smokers were somewhat less likely to intend to quit, or have tried, despite considering themselves less addicted.CONCLUSIONS:Reducing to occasional smoking can be a stepping stone toward cessation but entails a greater risk of return to daily smoking, compared with complete abstinence.

Background Tobacco and non-tobacco-based waterpipe smoking has increased exponentially in many countries in recent decades, particularly among youth and young adults. Although tobacco smoking is banned in many indoor public places, waterpipe smoking, ostensibly non-tobacco, continues in Ontario and other jurisdictions where only tobacco smoking is prohibited. This study assessed air quality and exposure in waterpipe cafes using multiple methods and markers. Methods Indoor (n=12) and outdoor (n=5) air quality was assessed in Toronto, Canada waterpipe cafes from 30 August to 11 October 2012. Real-time measurements of air nicotine, fine particulate matter less than 2.5 microns in diameter (PM2.5) and ambient carbon monoxide (CO) were collected in 2 h sessions. Levels of CO in breath were collected in non-smoking field staff before entering and upon leaving venues. Observations of occupant behaviour, environmental changes and venue characteristics were also recorded. Results In indoor venues, mean values were 1419 µg/m3 for PM2.5, 17.7 ppm for ambient CO, and 3.3 µg/m3 for air nicotine. Levels increased with increasing number of active waterpipes. On outdoor patios, mean values were 80.5 µg/m3 for PM2.5, 0.5 ppm for ambient CO, and 0.6 µg/m3 for air nicotine. Air quality levels in indoor waterpipe cafes are hazardous for human health. Outdoor waterpipe cafes showed less harmful particulate levels than indoors, but mean PM2.5 levels (80.5 µg/m3) were still ‘poor’. Conclusions Staff and patrons of waterpipe cafes are exposed to air quality levels considered hazardous to human health. Results support eliminating waterpipe smoking in hospitality venues indoors and out.

Aims It has been hypothesized that the smoking population is represented by an increasingly hardcore group of smokers who are resistant to quitting. Many definitions of hardcore smokers have been used, but their predictive validity is unknown. To evaluate whether hardcore smoker definition components predict quitting behaviours and which combinations of hardcore components are most predictive. Design, setting and participants Longitudinal, random telephone survey of a representative sample of adult smokers in Ontario, Canada (n = 4130, recruited 2005-08 and followed for 1 year). Measurements Multiple logistic regression models were compared to evaluate the predictive ability of 'hardcore' components (high daily cigarette consumption, high nicotine dependence, being a daily smoker, history of long-term smoking, no quit intention and no life-time quit attempt) on three outcomes [continued smoking, not attempting to quit and having unsuccessful quit attempt(s)]. Findings All 'hardcore' components predicted having no quit attempt and continued smoking during follow-up (P < 0.05), except for history of long-term smoking and no life-time quit attempt (for continued smoking). Among respondents who made 1 + quit attempts during follow-up, only high nicotine dependence, high daily cigarette consumption and being a daily smoker were predictive of quitting failure (P < 0.01). The best combination of components depended on the outcome. Conclusions Measures of 'hardcore' include a mixture of motivational, dependence and behavioural variables. As found previously, motivational and behavioural measures, such as intention to quit, predict failure to make quit attempts. However, dependence components best predicted continued smoking and thus would be best for further exploring the hardening hypothesis.

We estimated the impact of a smoke-free workplace bylaw on non-smoking bar workers' health in Ontario, Canada. We measured bar workers' urine cotinine before (n = 99) and after (n = 91) a 2004 smoke-free workplace bylaw. Using pharmacokinetic and epidemiological models, we estimated workers' fine-particle (PM2.5 ) air pollution exposure and mortality risks from workplace secondhand smoke (SHS). workers' pre-law geometric mean cotinine was 10.3 ng/ml; post-law dose declined 70% to 3.10 ng/ml and reported work hours of exposure by 90%. Pre-law, 97% of workers' doses exceeded the 90th percentile for Canadians of working age. Pre-law-estimated 8-h average workplace PM2.5 exposure from SHS was 419 μg/m(3) or 'Very Poor' air quality, while outdoor PM2.5 levels averaged 7 μg/m(3) , 'Very Good' air quality by Canadian Air Quality Standards. We estimated that the bar workers' annual mortality rate from workplace SHS exposure was 102 deaths per 100000 persons. This was 2.4 times the occupational disease fatality rate for all Ontario workers. We estimated that half to two-thirds of the 10620 Ontario bar workers were non-smokers. Accordingly, Ontario's smoke-free law saved an estimated 5-7 non-smoking bar workers' lives annually, valued at CA $50 million to $68 million (US $49 million to $66 million).

AIMS:To examine the use and role of planned quit attempts by smokers and their impact on abstinence.DESIGN:Retrospective, using longitudinal data from the Ontario Tobacco Survey.SETTING:Ontario, Canada.PARTICIPANTS:A total of 551 adult smokers who reported having made a quit attempt during 2007-08.MEASUREMENTS:Reported planning of the most recent quit attempt (i.e. unplanned or planned some time in advance), engaging in preparatory behaviours believed to be related to planning (i.e. use of quit aids such as pharmacotherapy, formal support or health professionals) and abstinence at 1 week and 1 month following the attempt.FINDINGS:Of the smokers, 73.6% planned their quit attempt in advance. Reported planning was more likely among those who thought they were very addicted, compared with those who were less addicted [odds ratio (OR)=2.22, 95% confidence interval (CI): 1.15-4.28]. Smokers who planned a quit attempt were much more likely to use a quit aid (OR=3.50, 95% CI: 1.80-6.79), particularly pharmacotherapy (OR=6.13, 95% CI: 3.05-12.34). The odds of abstaining for 1 week were lower among those who planned (OR=0.45, 95% CI: 0.22-0.89), independent of perceived addiction. No significant difference was observed for abstinence lasting 1 month. Other factors associated with abstinence were smoking fewer cigarettes per day and having personal support.CONCLUSIONS:Although most quit attempts were planned and planners had higher odds of using quit aids, planning did not increase the likelihood of success.

Background: Comprehensive, multi-level approaches are required to address obesity. One important target for intervention is the economic domain. The purpose of this study was to synthesize existing evidence regarding the impact of economic policies targeting obesity and its causal behaviours (diet, physical activity), and to make specific recommendations for the Canadian context.Methods: Arksey and O'Malley's (2005) methodological framework for conducting scoping reviews was adopted for this study and this consisted of two phases: 1) a structured literature search and review, and 2) consultation with experts in the research field through a Delphi survey and an in-person expert panel meeting in April 2010.Results: Two key findings from the scoping review included 1) consistent evidence that weight outcomes are responsive to food and beverage prices. The debate on the use of food taxes and subsidies to address obesity should now shift to how best to address practical issues in designing such policies; and 2) very few studies have examined the impact of economic instruments to promote physical activity and clear policy recommendations cannot be made at this time. Delphi survey findings emphasised the relatively modest impact any specific economic instrument would have on obesity independently. Based on empirical evidence and expert opinion, three recommendations were supported. First, to create and implement an effective health filter to review new and current agricultural polices to reduce the possibility that such policies have a deleterious impact on population rates of obesity. Second, to implement a caloric sweetened beverage tax. Third, to examine how to implement fruit and vegetable subsidies targeted at children and low income households.Conclusions: In terms of economic interventions, shifting from empirical evidence to policy recommendation remains challenging. Overall, the evidence is not sufficiently strong to provide clear policy direction. Additionally, the nature of the experiments needed to provide definitive evidence supporting certain policy directions is likely to be complex and potentially unfeasible. However, these are not reasons to take no action. It is likely that policies need to be implemented in the face of an incomplete evidence base.