Graham Mecredy

Street Connectivity is Negatively Associated with Physical Activity in Canadian Youth

Street connectivity, defined as how well streets connect to one and other and the density of intersections, is positively associated with active transportation in adults. Our objective was to study the relation between street connectivity and physical activity in youth. Study participants consisted of 8,535 students in grades 6–10 from 180 schools across Canada who completed the 2006 Health Behaviour in School-aged Children (HBSC) survey. Street connectivity was measured in a 5 km circular buffer around these schools using established geographic information system measures. Physical activity performed outside of school hours was assessed by questionnaire, and multi-level regression analyses were used to estimate associations with street connectivity after controlling for several covariates. Compared to students living in the highest street connectivity quartile, those in the second (relative risk = 1.22, 95% confidence interval = 1.10–1.35), third (1.25, 1.13–1.37), and fourth (1.21, 1.09–1.34) quartiles were more likely to be physically active outside of school. In conclusion, youth in neighbourhoods with the most highly connected streets reported less physical activity outside of school than youth from neighbourhoods with less connected streets. Relationships between street connectivity and physical activity reported in this national study are in the opposite direction to those previously observed for active transportation in adult populations.

Transitions in Smoking Status Over Time in a Population-Based Panel Study of Smokers

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.

Predictors of Substance Use Among Young Adults Transitioning Away from High School: A Narrative Review

Background: Young adulthood has been shown to be a time of increased substance use. Yet, not enough is known about which factors contribute to initiation and progression of substance use among young adults specifically during the transition year away from high school. Objectives: A narrative review was undertaken to increase understanding of the predictors of changes in use of tobacco, alcohol, cannabis, other illicit drugs, and mental health problems among young adults during the transition period after high school. Methods: A review of academic literature examining predictors of the use of tobacco, alcohol and cannabis, and co-morbidities (e.g., co-occurring substance use and/or mental health issues) among young adults transitioning from high school to post-secondary education or the workforce. Results: Twenty six studies were included in the review. The majority of the studies (19) examined substance use during the transition from high school to post-secondary settings. Seven studies examined substance use in post-secondary settings. The studies consistently found that substance use increases among young adults as they transition away from high school. During the transition away from high school, common predictors of substance use include substance use in high school, and peer influence. Common predictors of substance use in post-secondary education include previous substance use, peer influence, psychological factors and mental health issues. Conclusions/Importance: Further research on social contextual influences on substance use, mental health issues, gender differences and availability of substances during the transition period is needed to inform the development of new preventive interventions for this age group.

Tobacco Retail Outlets and Vulnerable Populations in Ontario, Canada

Interest has been increasing in regulating the location and number of tobacco vendors as part of a comprehensive tobacco control program. The objective of this paper is to examine the distribution of tobacco outlets in a large jurisdiction, to assess: (1) whether tobacco outlets are more likely to be located in vulnerable areas; and (2) what proportion of tobacco outlets are located close to schools. Retail locations across the Province of Ontario from Ministry of Health Promotion data were linked to 2006 Census data at the neighbourhood level. There was one tobacco retail outlet for every 1,000 people over age 15 in Ontario. Density of outlets varied by public health unit, and was associated with the number of smokers. Tobacco outlets were more likely to be located in areas that had high neighbourhood deprivation, in both rural and urban areas. Outlets were less likely to be located in areas with high immigrant populations in urban areas, with the reverse being true for rural areas. Overall, 65% of tobacco retailers were located within 500 m of a school. The sale of tobacco products is ubiquitous, however, neighbourhoods with lower socio-economic status are more likely to have easier availability of tobacco products and most retailers are located within walking distance of a school. The results suggest the importance of policies to regulate the location of tobacco retail outlets.

Association between use of contraband tobacco and smoking cessation outcomes: a population-based cohort study

Background: High tobacco prices, typically achieved through taxation, are an evidence-based strategy to reduce tobacco use. However, the presence of inexpensive contraband tobacco could undermine this effective intervention by providing an accessible alternative to quitting. We assessed whether the use of contraband tobacco negatively affects smoking cessation outcomes. Methods: We evaluated data from 2786 people who smoked, aged 18 years or older, who participated in the population-based longitudinal Ontario Tobacco Survey. We analyzed associations between use of contraband tobacco and smoking cessation outcomes (attempting to quit, 30-d cessation and long-term cessation at 1 yr follow-up). Results: Compared with people who smoked premium or discount cigarettes, people who reported usually smoking contraband cigarettes at baseline were heavier smokers, perceived greater addiction, identified more barriers to quitting and were more likely to have used pharmacotherapy for smoking cessation. People who smoked contraband cigarettes were less likely to report a period of 30-day cessation during the subsequent 6 months (adjusted relative risk [RR] 0.23, 95% confidence interval [CI] 0.09–0.61) and 1 year (adjusted RR 0.30, 95% CI 0.14–0.61), but they did not differ significantly from other people who smoked regarding attempts to quit (at 6 mo, adjusted RR 0.74, 95% CI 0.43–1.20) or long-term cessation (adjusted RR 0.24, 95% CI 0.04–1.34). Interpretation: Smoking contraband cigarettes was negatively associated with short-term smoking cessation. Access to contraband tobacco may therefore undermine public health efforts to reduce the use of tobacco at the population level.

The Prevalence of Tobacco Use Co-morbidities in Canada

ObjectivesTobacco use co-morbidities, including co-occurring tobacco use, substance use and mental health problems, are a serious public health issue that has implications for treatment and policy. However, not enough is known about the prevalence of various types of tobacco use co-morbidities among the Canadian population. The purpose of this study was to increase understanding of the extent of this issue through an examination of prevalence and correlates of tobacco use co-morbidities in Canada.MethodsWe undertook a series of comprehensive secondary analyses of population survey data from the Canadian Community Health Survey (CCHS) and the Canadian Alcohol and Drug Monitoring Survey (CADUMS). Data were analyzed for 123,846 individuals from the CCHS and 13,581 individuals from the CADUMS. Substance use and mental health variables were compared by smoking status, with chi-square tests. Multivariate logistic regression models were fit to quantify the association between smoking, substance use and mental health issues, adjusting for age, sex, and family income.ResultsPrevalence of problematic alcohol and illicit drug use was significantly higher among current smokers than non-smokers. Co-morbid mental health problems were also elevated among current smokers, and co-morbidities varied by age and gender. While smokers of all ages and genders were more likely to report problematic substance use and poor mental health, the effect of smoking status was significantly larger among youth.ConclusionSmoking in Canada is associated with problematic use of alcohol and illicit drugs, as well as co-morbid mental health problems. Youth tobacco use co-morbidities are at a concerning level, especially among young female smokers. More research on this issue in the Canadian context is needed, as well as the development of integrated interventions tailored to treat smokers with co-morbidities, particularly youth.RésuméObjectifsLes comorbidités du tabagisme, dont la concomitance du tabagisme, de la consommation de substances et des troubles de santé mentale, posent un grave problème de santé publique qui a des conséquences sur le traitement et sur les politiques. On n’en sait pas suffisamment long, toutefois, sur la prévalence des diverses comorbidités du tabagisme dans la population canadienne. Le but de notre étude était de mieux comprendre l’envergure de cet enjeu en examinant la prévalence et les corrélats des comorbidités du tabagisme au Canada.MéthodeNous avons mené une série d’analyses secondaires globales des données de deux enquêtes en population: l’Enquête sur la santé dans les collectivités canadiennes (ESCC) et l’Enquête de surveillance canadienne de la consommation d’alcool et de drogues (ESCCAD). Nous avons analysé les données de 123 846 répondants de l’ESCC et de 13 581 répondants de l’ESCCAD. Les variables de consommation de substances et de santé mentale ont été comparées selon l’usage du tabac à l’aide d’analyses du khi-carré. Des modèles multivariés de régression logistique ont servi à chiffrer l’association entre le tabagisme, la consommation de substances et les troubles de santé mentale en tenant compte de l’âge, du sexe et du revenu familial.RésultatsLa prévalence de la consommation abusive d’alcool et de drogues illicites était sensiblement plus élevée chez les fumeurs actuels que chez les non-fumeurs. Les troubles de santé mentale concomitants étaient également élevés chez les fumeurs actuels, et les comorbidités variaient selon l’âge et le sexe. Peu importe leur âge et leur sexe, les fumeurs étaient plus susceptibles de faire état d’une consommation abusive de substances et d’une mauvaise santé mentale, mais l’effet de l’usage du tabac était significativement plus grand chez les jeunes.ConclusionLe tabagisme au Canada est associé à la consommation abusive d’alcool et de drogues illicites, ainsi qu’à des troubles de santé mentale concomitants. Le niveau des comorbidités du tabagisme des jeunes est inquiétant, surtout chez les jeunes fumeuses. Il faudrait pousser la recherche sur cette question dans le contexte canadien et élaborer des interventions intégrées, adaptées au traitement des fumeurs présentant des comorbidités, tout particulièrement les jeunes.

Tobacco retail availability and risk of relapse among smokers who make a quit attempt: a population-based cohort study

Introduction The availability of tobacco is thought to influence smoking behaviour, but there are few longitudinal studies examining if the location and number of tobacco outlets has a prospective impact on smoking cessation. Methods The Ontario Tobacco Survey, a population-representative sample of Ontario adult smokers who were followed every 6 months for up to 3 years, was linked with tobacco outlet location data from the Ontario Ministry of Health. Proximity (distance), threshold (at least one outlet within 500 m) and density (number of outlets within 500 m) with respect to a smokers’ home were calculated among urban and suburban current smokers (n=2414). Quit attempts and risk of relapse were assessed using logistic regression and survival analysis, adjusted for neighbourhood effects and individual characteristics. Results Increased density of tobacco outlets was associated with decreased odds of making a quit attempt (OR: 0.54; 95% CI 0.35 to 0.85) in high-income neighbourhoods, but not in lower income ones. There was an increased risk of relapse among those who had at least one store within 500 m (HR: 1.41 (95% CI 1.06 to 1.88). Otherwise, there was no association of proximity with quit attempts or relapse. Conclusions The existence of a tobacco retail outlet within walking distance from home was associated with difficulty in succeeding in a quit attempt, while the increased density of stores was associated with decreased attempts in higher income neighbourhoods. The availability of tobacco may influence tobacco use through multiple mechanisms.

Outcomes of patients with chronic obstructive pulmonary disease diagnosed with or without pulmonary function testing

BACKGROUND: A small number of people with chronic obstructive pulmonary disease (COPD) receive pulmonary function testing around the time of diagnosis. Because omitting testing increases misdiagnosis, we sought to determine whether health outcomes differed between patients whose COPD was diagnosed with or without pulmonary function testing. METHODS: We conducted a longitudinal population study of patients with physician-diagnosed COPD from 2005 to 2012 using health administrative data from Ontario, Canada. We assessed whether having pulmonary function testing around the time of diagnosis was associated with the composite outcome of admission to hospital for COPD or all-cause death, using adjusted survival analysis. RESULTS: Chronic obstructive pulmonary disease was diagnosed in 68 898 patients during the study period; 41.2% of patients received peridiagnostic pulmonary function testing. In adjusted analysis, patients who underwent testing were less likely to die or be admitted to hospital for COPD (adjusted hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.89–0.94) and were more likely to be prescribed an inhaled long-acting bronchodilator than patients who did not undergo testing. Subgroup analysis suggested that the association of testing and outcomes was confined to patients with COPD diagnosed in the ambulatory care setting (adjusted HR 0.80, 95% CI 0.76–0.84). INTERPRETATION: Confirmation of a COPD diagnosis using pulmonary function testing is associated with a decreased risk of death and admission to hospital for COPD. In ambulatory patients, this effect may be from increased use of appropriate COPD medications. The findings of this study validate current guideline recommendations that encourage pulmonary function testing for diagnosis in all patients with suspected COPD.

Development of quality indicators for chronic obstructive pulmonary disease (COPD): A modified RAND appropriateness method

Abstract RATIONALE: Quality indicators are evidence-based structures, processes and outcomes of care associated with such a strong benefit that failure to address them reduces likelihood of good health outcomes. OBJECTIVES: Our objective was to use synthesized evidence and diverse expert opinion to create a comprehensive set of evidence-based COPD quality indicators spanning the health care continuum from prevention to outcome. METHODS: COPD quality indicators were developed using a modified RAND Appropriateness Method consisting of a systematic review of the medical literature followed by a Delphi method survey. The review took place in three parts: searching first for existing high quality COPD quality indicators, then for meta-analyses and systematic reviews and, lastly, for individual studies. The Delphi method had an expert panel rate and discussed the indicators in an in-person meeting followed by rounds of electronic surveys until consensus was reached. RESULTS: The systematic review produced 26 highly rated quality indicators, and 10,002 titles for further assessment. Of these, 32 full-text articles provided supporting evidence for 39 additional COPD quality indicators, for 65 in total. After rounds of review by the expert panel, a final list of 33 quality indicators was endorsed by all. CONCLUSIONS: We generated a comprehensive set of 33 evidence-based COPD quality indicators. These can be used to measure current quality of COPD health and healthcare, develop and implement strategies to improve it and otherwise provide a foundation for quality improvement. Before using in other jurisdictions, these made-in-Canada indicators should be validated to ensure they address their unique circumstances.

Typologies of smokers and non-smokers: encouraging changes over time

Previous research has classified smokers and non-smokers on the basis of their attitudes and behaviours towards smoking and smoking restrictions.1–3 Work by Poland et al ,1 using data from 1996, concluded that Ontario smokers clustered into three groups: (1) ‘adamant’ smokers who believe smoking restrictions have gone too far and are unlikely to accommodate non-smokers; (2) ‘easy going’ smokers who support smoking restrictions and will not smoke around non-smokers; and, (3) ‘reluctant’ smokers who support smoking restrictions and are concerned that others know they smoke. Similarly, non-smokers clustered into: (1) ‘adamant’ non-smokers who do not tolerate smoking in their attitudes and their actions; (2) ‘unempowered’ non-smokers who oppose smoking but tend not to act on it; and, (3) …