Adam G. Cole

Use of Conventional and Alternative Tobacco and Nicotine Products Among a Sample of Canadian Youth

PURPOSE The purpose of this study was to examine the use of conventional and alternative tobacco and nicotine products among secondary school students. METHODS Respondents were 44,163 grade 9-12 students who participated in Year 2 (2013-2014) of COMPASS, a cohort study of 89 purposefully sampled secondary schools in Ontario and Alberta, Canada. Past-month use of various tobacco and nicotine products was assessed, as well as correlates of use, using a generalized linear mixed effects model. RESULTS Overall, 21.2% of the sample reported past-month use of any tobacco or nicotine product, with 7.2% reporting past-month use of e-cigarettes. E-cigarette users reported significantly greater prevalence of current use for all products. Students who were male, white, had more spending money, and had a history of tobacco use were more likely to report past-month use of e-cigarettes. CONCLUSIONS Approximately one fifth of youth reported past-month use of a nicotine product, with e-cigarettes being the third most common product. Overall, the findings suggest a rapidly evolving nicotine market.

Electronic cigarette use and smoking initiation among youth: a longitudinal cohort study

BACKGROUND: The influence of e-cigarette use on smoking initiation is a highly controversial issue, with limited longitudinal data available for examining temporal associations. We examined e-cigarette use and its association with cigarette-smoking initiation at 1-year follow-up within a large cohort of Canadian secondary school students. METHODS: We analyzed data from students in grades 9–12 who participated in 2 waves of COMPASS, a cohort study of purposefully sampled secondary schools in Ontario and Alberta, Canada, at baseline (2013/14) and 1-year follow-up (2014/15). We assessed cigarette smoking and e-cigarette use at baseline and follow-up using self-completed surveys. We used generalized linear mixed-effects models to examine correlates of past 30-day e-cigarette use at baseline and smoking initiation between waves within the longitudinal sample. RESULTS: Past 30-day e-cigarette use increased from 2013/14 to 2014/15 (7.2% v. 9.7%, p < 0.001), whereas past 30-day cigarette smoking decreased slightly (11.4% v. 10.8%, p = 0.02). Among the 44 163 students evaluated at baseline, past 30-day e-cigarette use was strongly associated with smoking status and smoking susceptibility. In the longitudinal sample (n = 19 130), past 30-day use of e-cigarettes at baseline was associated with initiation of smoking a whole cigarette (adjusted odds ratio [OR] 2.12, 95% confidence interval [CI] 1.68–2.66) and with initiation of daily smoking (adjusted OR 1.79, 95% CI 1.41–2.28) at follow-up. INTERPRETATION: E-cigarette use was strongly associated with cigarette smoking behaviour, including smoking initiation at follow-up. The causal nature of this association remains unclear, because common factors underlying the use of both e-cigarettes and conventional cigarettes may also account for the temporal order of initiation.

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

BackgroundSchool-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.MethodsThis 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.ResultsBetween 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.DiscussionInterventions 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.

A Cross-sectional Study Examining Factors Associated with Youth Binge Drinking in the COMPASS Study: Year 1 Data

Frequent alcohol use and binge drinking are associated with numerous negative health outcomes. Using data from 17,497 grade 9 to 12 students participating in the COMPASS Study (Year 1), we examined the factors associated with current alcohol use and current binge drinking. Overall, 38.4% of students were considered current alcohol users and 25.5% were current binge drinkers. Tobacco or marijuana use, bullying others, weekly spending money, ethnicity, and grade were associated with increased likelihood of current alcohol use and current binge drinking. It is evident that a substantial number of youth in the Year 1 COMPASS sample report frequently using alcohol and in volumes considered harmful to their health. Considering that numerous risk factors were found to predict alcohol use and binge drinking, future research should evaluate the impact of tailoring interventions to change the modifiable factors associated with high-risk drinking or targeting interventions to at-risk youth.

Increasing Rates of Tobacco Treatment Delivery in Primary Care Practice: Evaluation of the Ottawa Model for Smoking Cessation

PURPOSE We report on the effectiveness of the Ottawa Model for Smoking Cessation (OMSC), a multicomponent knowledge translation intervention, in increasing the rate at which primary care providers delivered smoking cessation interventions using the 3 A’s model—Ask, Advise, and Act, and examine clinic-, provider-and patient-level determinants of 3 A’s delivery. METHODS We examined the effect of the knowledge translation intervention in 32 primary care practices in Ontario, Canada, by assessing a cross-sectional sample of patients before the implementation of the OMSC and a second cross-sectional sample following implementation. We used 3-level modeling (clinic, clinician, patient) to examine the main effects and predictors of 3 A’s delivery. RESULTS Four hundred eighty-one primary care clinicians and more than 3,500 tobacco users contributed data to the evaluation. Rates of delivery of the 3 A’s increased significantly following program implementation (Ask: 55.3% vs 71.3%, P <.001; Advise: 45.5% vs 63.6%, P <.001; Act: 35.4% vs 54.4%, P <.001). The adjusted odds ratios (AOR) for the delivery of 3 A’s between the pre- and post-assessments were AOR = 1.94; (95% CI, 1.61–2.34) for Ask, AOR = 1.92; (95% CI, 1.60–2.29) for Advise, and AOR = 2.03; (95% CI, 1.71–2.42) for Act. The quality of program implementation and the reason for clinic visit were associated with increased rates of 3 A’s delivery. CONCLUSIONS Implementation of the OMSC was associated with increased rates of smoking cessation treatment delivery. High quality implementation of the OMSC program was associated with increased rates of 3 A’s delivery.

The association between senior student tobacco use rate at school and alternative tobacco product use among junior students in Canadian secondary schools

BackgroundThe 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.MethodsThis 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.ResultsOver 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).ConclusionsCharacteristics 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.

Youth sleep durations and school start times: a cross-sectional analysis of the COMPASS study

Objectives: This study explored school start times (SST) in relation to sleep duration and adherence to guidelines among Canadian youth. Methods: Using Year 4 (2015/2016) data from the Cannabis, Obesity, Mental health, Physical activity, Alcohol use, Smoking, and Sedentary behaviour (COMPASS) study, the sample included 35,821 grade 9‐12 students at 78 secondary schools in Ontario and Alberta, Canada. Random intercepts models tested student‐reported sleep duration and whether students met sleep recommendations, as a function of SST, controlling for student‐ (race/ethnicity, grade, sex, travel mode to school) and school‐level (school‐area urbanicity and median household income) correlates. Results: For each hour delay in SST, students reported an average of almost 7 minutes longer sleep and had 1.17 (adjusted odds ratio; 95% confidence interval, 1.04‐1.31) higher odds of meeting the recommendations, with other factors held constant. Conclusions: Potential impacts on student sleep require consideration when deciding on school schedules. Delayed SST warrant further exploration as an intervention to help ameliorate the widespread sleep deprivation found among Canadian youth.

An examination of different smoking patterns among Canadian youth: new insight for tobacco control programming.

Patterns of smoking can vary among youth smokers. The purpose of this study was to examine three different patterns of smoking among youth (daily smoking, smoking sporadically on weekdays and weekends, and smoking during weekdays only), and to examine the sociodemographic characteristics that are associated with each smoking pattern in a representative sample of Canadian youth smokers. Data were collected as part of the 2010/2011 Youth Smoking Survey (YSS) from 31,396 students in grades 9 to 12 from secondary schools in 9 Canadian provinces. Data from the YSS were used to assess smoking behaviors and sociodemographic factors that are associated with smoking patterns among youth. We used logistic regression models to examine factors associated with week day only and some day smoking patterns relative to daily smoking patterns. Results indicate that among current youth smokers, the majority are daily smokers (62.0%), followed by some day (23.5%) and week day only (13.5%) smokers. Students who smoke some days were more likely than daily smokers to share cigarettes with others; however, they were less likely than daily smokers to have a parent, step-parent or guardian who smokes cigarettes and less likely to have close friends who smoke cigarettes. Conversely, students who smoke week days only were less likely than daily smokers to have a sibling who smokes cigarettes. These data suggest that the school environment continues to play an important role in reducing youth smoking rates in Canada, especially among youth who only smoke week days. The high percentage of week day only smokers suggests that current school-level tobacco control initiatives may be insufficient for preventing youth smoking onset.

Exploring the Predictive Validity of the Susceptibility to Smoking Construct for Tobacco Cigarettes, Alternative Tobacco Products, and E-Cigarettes

INTRODUCTION Within tobacco prevention programming, it is useful to identify youth that are at risk for experimenting with various tobacco products and e-cigarettes. The susceptibility to smoking construct is a simple method to identify never-smoking students that are less committed to remaining smoke-free. However, the predictive validity of this construct has not been tested within the Canadian context or for the use of other tobacco products and e-cigarettes. METHODS This study used a large, longitudinal sample of secondary school students that reported never using tobacco cigarettes and noncurrent use of alternative tobacco products or e-cigarettes at baseline in Ontario, Canada. The sensitivity, specificity, and positive and negative predictive values of the susceptibility construct for predicting tobacco cigarette, e-cigarette, cigarillo or little cigar, cigar, hookah, and smokeless tobacco use 1 and 2 years after baseline measurement were calculated. RESULTS At baseline, 29.4% of the sample was susceptible to future tobacco product or e-cigarette use. The sensitivity of the construct ranged from 43.2% (smokeless tobacco) to 59.5% (tobacco cigarettes), the specificity ranged from 70.9% (smokeless tobacco) to 75.9% (tobacco cigarettes), and the positive predictive value ranged from 2.6% (smokeless tobacco) to 32.2% (tobacco cigarettes). Similar values were calculated for each measure of the susceptibility construct. CONCLUSIONS A significant number of youth that did not currently use tobacco products or e-cigarettes at baseline reported using tobacco products and e-cigarettes over a 2-year follow-up period. The predictive validity of the susceptibility construct was high and the construct can be used to predict other tobacco product and e-cigarette use among youth. IMPLICATIONS This study presents the predictive validity of the susceptibility construct for the use of tobacco cigarettes among secondary school students in Ontario, Canada. It also presents a novel use of the susceptibility construct for predicting the use of e-cigarettes, cigarillos or little cigars, cigars, hookah, and smokeless tobacco among secondary school students in Ontario, Canada.

Effectiveness of performance coaching for enhancing rates of smoking cessation treatment delivery by primary care providers: Study protocol for a cluster randomized controlled trial.

UNLABELLED Smoking cessation is one of the most powerful preventive interventions available to primary care providers. Rates of tobacco treatment delivery in primary care settings, however, remain sub-optimal. This paper reports on rationale, design, and protocol for a matched-paired, cluster-randomized controlled trial to compare the incremental effectiveness of performance coaching on physician delivery of smoking cessation assistance when delivered as part of a practice-level intervention for smoking cessation (the Ottawa Model for Smoking Cessation; OMSC). Outcome measures included frequency of provider smoking cessation treatment delivery, patient quit attempts, and 7-day point prevalence abstinence measured at 6 months, and changes in provider attitudes and beliefs related to smoking cessation treatment delivery. Primary care clinics were randomly assigned, using a matched paired design, to one of two treatment conditions: OMSC Group or OMSC+Performance Coaching Group. All practices were supported with implementing the OMSC. Half of the practices also received a 1.5 hour, skills-based, coaching session to address barriers encountered in the delivery of smoking cessation treatments and individualized performance feedback reports. All providers, and a cross sectional sample of patients from their practices, were surveyed before and after the implementation of the intervention. Multi-level modeling was used to compare intervention groups. If shown to be effective, the study will lead to an improved understanding of how to best assist clinicians to enhance the delivery of smoking cessation practice and will provide evidence to guide the design of smoking cessation interventions in primary care. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01603524.