Description |  Specific Indicators | Corresponding Outcome(s) from the Ontario Public Health Standards |  Corresponding Health Indicator(s) from Statistics Canada and CIHI | Corresponding Health Indicators From Other Sources | Data Sources |  Survey Questions |  Alternative Data Sources |  Analysis Check List | Method of Calculation | Basic Categories | Indicator Comments  |  Cross-References to Other Indicators  | Cited References | Other References | Change Made


Description

• Proportion of non-smokers aged 12 years and over who were regularly exposed to tobacco smoke in their home, vehicle or in public places.

Specific Indicators

• Non-smoker exposure to second-hand smoke in the home
• Non-smoker exposure to second-hand smoke in a vehicle
• Non-smoker exposure to second-hand smoke in public places

Corresponding Outcome(s) from the Ontario Public Health Standards (OPHS)  

The Ontario Public Health Standards (OPHS) establish requirements for the fundamental public health programs and services carried out by boards of health, which include assessment and surveillance, health promotion and policy development, disease and injury prevention, and health protection. The OPHS consist of one Foundational Standard and 13 Program Standards that articulate broad societal goals that result from the activities undertaken by boards of health and many others, including community partners, non-governmental organizations, and governmental bodies. These results have been expressed in terms of two levels of outcomes: societal outcomes and board of health outcomes. Societal outcomes entail changes in health status, organizations, systems, norms, policies, environments, and practices and result from the work of many sectors of society, including boards of health, for the improvement of the overall health of the population. Board of health outcomes are the results of endeavours by boards of health and often focus on changes in awareness, knowledge, attitudes, skills, practices, environments, and policies. Boards of health are accountable for these outcomes. The standards also outline the requirements that boards of health must implement to achieve the stated results.  

Outcome Related to this Indicator

• Societal Outcome (Chronic Disease Prevention): An increased proportion of the population lives, works, plays, and learns in healthy environments that contribute to chronic disease prevention
• Societal Outcome (Chronic Disease Prevention): There is increased adoption of behaviours and skills associated with reducing the risk of chronic disease of public health importance.
• Board of Health Outcomes (Chronic Disease Prevention): Priority populations adopt tobacco-free living.
• Societal Outcome (Child Health): An increased proportion of community partners provide safe and supportive environments for children and their families.
• Societal Outcome (Child Health): An increased proportion of families provide safe and supportive environments for their children.

Assessment and Surveillance Requirement Related to this Indicator (Chronic Disease Prevention):

• The board of health shall conduct epidemiological analysis of surveillance data in the areas of comprehensive tobacco control.

http://www.ontario.ca/publichealthstandards

 Corresponding Health Indicator(s) from Statistics Canada and CIHI

The Internet publication Health Indicators, produced jointly by Statistics Canada and the Canadian Institute for Health Information, provides over 80 indicators measuring the health of the Canadian population and the effectiveness of the health care system. Designed to provide comparable information at the health region and provincial/territorial levels, these data are produced from a wide range of the most recently available sources.

• Exposure to second-hand smoke at home (non-smoking population aged 12 and over who reported that at least one person smoked inside their home every day or almost every day).
• Exposure to second-hand smoke in vehicles and public places (non-smoking population aged 12 and over who reported being exposed to second-hand smoke in private vehicles and/or public places everyday or almost every day during the past month).

http://www.statcan.ca/bsolc/english/bsolc?catno=82-221-X

Click on "view" beside "Free", "Latest issue".
Click on "Data tables and maps" on the left side menu.
Click on the indicator "Exposure to second-hand smoke at home" or "Exposure to second-hand smoke in vehicles and public places" under Non-medical determinants of health, Environmental factors.

Corresponding Health Indicator(s) from Other Sources

Centers for Disease Control (CDC) 

·         Proportion of the population reporting exposure to secondhand smoke at home or in vehicles (Indicator 2.7.3)

http://www.cdc.gov/tobacco/tobacco_control_programs/surveillance_evaluation/key_outcome/00_pdfs/Chapter3.pdf

National Advisory Group on Monitoring and Evaluation (NAGME)

• Proportion of population reporting exposure to secondhand smoke at home
• Proportion of population who report their home is smoke-free
• Proportion of population reporting exposure to secondhand smoke in public places
• Proportion of population reporting exposure to secondhand smoke in vehicles
• Proportion of the non-smoking population reporting regular exposure to secondhand smoke
• Proportion of population who report their personal vehicle is smoke-free

http://ctcri.ca/en/index.php?option=com_docman&task=doc_download&gid=4

Centers for Disease Control (CDC)

• Proportion of the population reporting exposure to secondhand smoke at home or in vehicles (Indicator 2.7.3)

http://www.cdc.gov/tobacco/tobacco_control_programs/surveillance_evaluation/key_outcome/00_pdfs/Chapter3.pdf

Data Sources

Numerator & Denominator: Canadian Community Health Survey (CCHS)
Original source: Statistics Canada
Distributed by:
1. Ontario Ministry of Health and Long-Term Care
2. Statistics Canada
Suggested citation (see Data Citation Notes):
1. Canadian Community Health Survey [year], Statistics Canada, Share File, Ontario Ministry of Health and Long-Term Care.
2. Canadian Community Health Survey [year], Statistics Canada, Public Use Microdata File, Statistics Canada.

Survey Questions

The Canadian Community Health Survey contains an Exposure to Second-Hand Smoke (ETS) module (core content in 2003, 2005 and 2007-08). The Smoking module was core content in 2003, 2005 and 2007-08.

The Rapid Risk Factor Surveillance System (RRFSS) contains a Tobacco –Home module (core module 2001-2008) and a Tobacco- Exposure to Environmental Tobacco Smoke (ETS) module (optional content 2004-2008). The question in the Tobacco-Home module is not asked if the respondent is a non-smoker and he/she is the only adult living in the household (t1=5 or t2=5 and nadults=1). The Tobacco- Exposure to Environmental Tobacco Smoke (ETS) module is only asked of former (t1=1 and t2=5) and non-smokers (t1=5). RRFSS includes only adults ages 18+. 

Analysis Check List

CCHS

•  For the indicators “non-smoker exposure to second-hand smoke in the home” (question ETS_Q10), “non-smoker exposure to second-hand smoke in a vehicle” (question ETS_Q20) and “non-smoker exposure to second-hand smoke in public places” (question ETS_Q20B), exclude smokers (SMKDSTY=1,2,3). Non-smoker is defined as SMKDSTY=4,5,6.
• The number of “don’t know” (coded as 97), “refusal” (coded as 98) and “not stated” (coded as 99) respondents are likely small and can be excluded. Users should check numbers before excluding these non-respondents.
•  It is recommended that public health units use the Share File provided by the Ministry of Health and Long-Term Care rather than public use file (PUMF) provided by Statistics Canada. The Share File has a slightly smaller sample size because respondents must agree to share their information with the province to be included; however, the share file has more variables and fewer grouped categories within variables. The Share File is a cleaner dataset for Ontario analysis because all variables that were not common content, theme content or optional content for Ontario have been removed.
•  There may be slight differences between results from the share file and data published on the Statistics Canada website for the Health Indicators because rates calculated for Health Indicators use the master CCHS data file.
•  Not applicable respondents should be excluded; however, it is important to understand who these respondents are from the questionnaire skip patterns to be able to describe the relevant population. 
• Users need to consider whether or not to exclude the ‘Refusal, ’Don’t Know’ and ‘Not Stated’ response categories in the denominator. Rates published in most reports, including Statistics Canada’s publication Health Reports generally exclude these response categories.  In removing not stated responses from the denominator, the assumption is that the missing values are random, and this is not always the case.  This is particularly important when the proportion in these response categories is high. 
•  Estimates must be appropriately weighted (generally the share weight for the CCHS) and rounded. 
• Users of the CCHS Ontario Share File must adhere to Statistics Canada's release guidelines for the CCHS data when publishing or releasing data derived from the file in any form. Refer to the appropriate user guide for guidelines for tabulation, analysis and release of data from the CCHS. In general, when calculating the CV from the share file using the bootstrap weights, users should not use or release weighted estimates when the unweighted cell count is below 10. For ratios or proportions, this rule should be applied to the numerator of the ratio.  Statistics Canada uses this approach for the tabular data on their website. When using only the Approximate Sampling Variability (CV) lookup tables for the share file, data may not be released when the unweighted cell count is below 30. This rule should be applied to the numerator for ratios or proportions.  This provides a margin of safety in terms of data quality, given the CV being utilized is only approximate.
•  Before releasing and/or publishing data, users should determine the CV of the rounded weighted estimate and follow the guidelines below:
• Acceptable (CV of 0.0 - 16.5) Estimates can be considered for general unrestricted release. Requires no special notation.
• Marginal (CV of 16.6 - 33.3) Estimates can be considered for general unrestricted release but should be accompanied by a warning cautioning subsequent users of the high sampling variability associated with the estimates. Such estimates should be identified by the letter E (or in some other similar fashion).
• Unacceptable (CV greater than 33.3) Statistics Canada recommends not to release estimates of unacceptable quality. However, if the user chooses to do so then estimates should be flagged with the letter F (or in some other fashion) and the following warning should accompany the estimates: "The user is advised that...(specify the data)...do not meet Statistics Canada’s quality standards for this statistical program. Conclusions based on these data will be unreliable and most likely invalid". These data and any consequent findings should not be published. If the user chooses to publish these data or findings, then this disclaimer must be published with the data.
•  Caution should be taken when comparing the results from Cycle 1.1 (2000/01) to subsequent years of the survey, due to a change in the mode of data collection. The sample in Cycle 1.1 had a higher proportion of respondents interviewed in person, which affected the comparability of some key health indicators. Please refer to http://www.statcan.gc.ca/imdb-bmdi/document/3226_D16_T9_V1-eng.pdf for a full text copy of the Statistics Canada article entitled "Mode effects in the Canadian Community Health Survey: a Comparison of CAPI and CATI".

RRFSS

• Users should refer to the most recent RRFSS Manual of Operations for a complete list of RRFSS analysis guidelines.
• Denominator Data - cell size less than 30 not to be released (based on unweighted data).
• Numerator Data - cell size less than 5 not to be released (based on unweighted data).
• Coefficients of variation (CV) should be calculated for every estimate. The following categories determine the release of the data:
• CV between 0 and 16.5:  estimate can be released without qualification.
• CV between 16.6 and 33.3:  estimate can be released with qualification:  interpret with caution.  High variability.
• CV greater than 33.3:  estimate should not be released, regardless of the cell size.
• 95% confidence intervals should accompany all released estimates.  In general the simple computation of the C.I. for a proportion assuming SEp = sqrt(pq/n) and CI95% = p +/- 1.96*SEp is sufficient. However, if estimates are close to 0 or 100% and the simple computation confidence intervals include values less than zero or greater than 100 then the Fleiss 2^nd edition computation for skewed estimates should be employed.
• Weighting:
• General household weight will be applied for questions related to the individual. 
• Household weight is to be applied for questions about households when we wish to determine the population/number of people affected. 
• Household weight is not to be applied for child proxy questions (bicycle helmet use, car seat safety), dog and cat immunization modules, or other questions that relate to the household rather than the respondent. 
• Household weights are not required to be recalculated for sub-population based questions; for example mammography in women ages 35+ years and 50-74 years.
• If the weights supplied with the data set (health unit wave specific, health unit cumulative total, all health units combined wave specific, all health units combined cumulative total) are not appropriate for the required analysis, then a time-specific weight must be calculated.  For example, a new weight is required for all seasonal modules.
• If the cell size of ‘Don’t Know’ responses is 5% or greater, ‘Don't Know’ responses should be included in the denominator of the analyses and reported separately.
• If the cell size of ‘Refusal’ responses is 5% or greater, ‘Refusal’ responses should be included in the denominator of the analyses and reported separately.
• When an indicator is being compared between groups (e.g. health units, time periods, gender), if any one group has ‘Don’t Know’ and/or ‘Refusal’ responses that are 5% or greater, ‘Don't Know’ and/or ‘Refusal’ responses should be included in the denominator of the analyses and reported separately for all groups.
• A provincial sample is not available with the RRFSS.

Refer to the RRFSS Data Dictionaries at http://www.rrfss.ca/ for more information about module questions and indicators.

Method of Calculation

Non-smoker exposure to second-hand smoke in the home:

Weighted number of non-smokers aged 12+ whereby someone smokes inside their home every day or almost every day Total weighted population of non-smokers aged 12+

X 100

Non-smoker exposure to second-hand smoke in the vehicle:

Weighted number of non-smokers aged 12+ who were exposed to second-hand smoke in a car or other private vehicle every day or almost every day Total weighted population of non-smokers aged 12+

X 100

Non-smoker exposure to second-hand smoke in public places:

Weighted number of non-smokers aged 12+ who were exposed to second-hand smoke in public places every day or almost every day Total weighted population of non-smokers aged 12+

X 100

Basic Categories

• Age groups for age-specific rates: 12-19, 20-44, 45-64, 65+.
• Sex: male, female and total.
• Geographic areas for: CCHS - Public Health Units; RRFSS - participating health units that chose the tobacco in the home module or environmental tobacco smoke module.

Indicator Comments

• Exposure to second-hand smoke causes heart disease, cancers of the lung, nasal sinus, bladder, esophagus, mouth, throat, stomach, pancreas, cervix and kidney, chronic bronchitis, cataracts, pneumonia, acute myeloid leukemia, abdominal aortic aneurysm, periodontitis and reproductive effects in adults. In children, it causes sudden infant death syndrome, fetal growth impairment including low birth weight and small-for-gestational age, bronchitis, pneumonia and other lower respiratory tract infections, asthma exacerbation, middle ear disease, and respiratory symptoms.^1,2,3
• Exposure to second-hand smoke has also been linked to other adverse health effects where the relationships may be causal. These include: in adults - stroke, breast cancer, cervical cancer and miscarriages; and in children - adverse impact on cognition and behaviour, decreased lung function, asthma induction, exacerbation of cystic fibrosis.^1,2,3
• Second-hand smoke in cars can reach unhealthy levels under the most realistic ventilation conditions. Smoking just one cigarette in a car can lead to levels of tobacco smoke pollution that match and exceed by several times the levels found in the smokiest bars and restaurants.⁴
• In 2003, 33% of non-smokers reported that they were regularly exposed to second-hand smoke. The risk of exposure was greatest in public places, but regardless of setting, rates of exposure were higher for men than women. Exposure rates varied by age and peaked in young adulthood. However, at home and at work, the younger the non-smokers, the more likely they were to be exposed to second-hand smoke.⁵
• Respondents to surveys may be reluctant to admit that they or someone in the household smoke regularly.
• This indicator is limited to measuring second-hand smoke exposure for non-smokers. Smokers may also be exposed to second-hand smoke in the home, vehicle and public places.
•  Skip patterns and wording related to ETS exposure in the home were different between CCHS Cycle 1.1 (2000/01) and Cycle 2.1 (2003). In Cycle 1.1, only non-smokers who were “exposed to second-hand smoke on most days in the past month” were asked about exposure at home, in cars/vehicles and in public places. In Cycle 2.1, all respondents except smokers who lived alone were asked whether anyone smoked inside the home. Only non-smokers were asked questions about second-hand smoke exposure in vehicles and public places. Because of differences in question wording and skip patterns between the two surveys, it is suggested that only Cycle 2.1, 3.1 and 4.1 data be used.
• To keep comparisons comparable between home, vehicles and public places, non-smokers should be the denominator in all three cases. However, to get an overall population measure of the percentage of people whereby someone smokes inside the home every day or almost every day, include smokers and assume that “not applicable” respondents (i.e. smokers living alone) were in the “Yes” category (See Smoke-Free Homes: Section-5A).
• There is an optional module in RRFSS – Tobacco – Vehicle. Although this module does not directly measure non-smoker exposure to second hand smoke in the vehicle, it measures rules about smoking in the vehicle.
• The Smoke-Free Ontario Act prohibits smoking in all enclosed workplaces and enclosed public places in Ontario as of May 31, 2006. This Act may affect response to the question on exposure to second-hand smoke in public places.⁶
• The Smoke-Free Ontario Act prohibits smoking in all vehicles carrying children under the age of 16 years in Ontario as of Jan 21, 2009. This Act may affect response to the question on exposure to second-hand smoke in vehicles.⁶
• Data gaps exist for compliance with workplace and vehicle smoking restrictions.

Cross-Reference(s) to Other Indicator(s)

• Smoke-Free Homes (Section 5A: Smoking)

Cited References

1. Ontario Tobacco Research Unit. Protection from second-hand tobacco smoke in Ontario: A review of the evidence regarding best practices. Toronto: University of Toronto, 2001. Available online at: http://www.otru.org/pdf/special/special_ets_eng.pdf.
2. The Health Consequences of Smoking: a report of the Surgeon General. Atlanta, Ga: Dept. of Health and Human Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004.
3. National Cancer Institute. Health Effects of Exposure to Environmental Tobacco Smoke: The Report of the California Environmental Protection Agency. Smoking and Tobacco Control Monograph No. 10. Bethesda, MD., U.S. Department of Health and Human Services, National Institutes of Health, 1999. Available online at: http://cancercontrol.cancer.gov/tcrb/monographs/10/.
4. Sendzik TS, et al. An Experimental Investigation of Tobacco Smoke Pollution in Cars. Toronto, ON: Ontario Tobacco Research Unit, Special Report, March 2008. Available online at: http://www.otru.org/pdf/special/special_mar_2008.pdf.
5. Perez CE. Second-hand smoke exposure - who's at risk? Health Reports 2004;16(1):9-15, October 2004.
6. Smoke-Free Ontario Act: Available online at: http://www.health.gov.on.ca/english/public/updates/archives/hu_05/smoke_free_ontario_act.pdf.

Other Reference(s)

1. Health Canada. Canadian Tobacco Use Monitoring Survey (CTUMS). Health Canada, 2008. Available online at: http://www.hc-sc.gc.ca/hl-vs/tobac-tabac/research-recherche/stat/.
2. Ontario Tobacco Research Unit. (2008, August). Indicators of Smoke-Free Ontario Progress. (Special Reports: Monitoring and Evaluation Series, 2006-2007 [Vol. 13, No. 2]). Toronto: Ontario Tobacco Research Unit. Available online at: http://www.otru.org/pdf/13mr/13mr_no2.pdf.
3. Ontario Tobacco Research Unit - Monitoring Reports. Available online at: http://www.otru.org/special_reports.html.
4. Staff G, Rogers T, Schooley M, Porter S, Wiesen E, Jamison N. Key outcome indicators for evaluating comprehensive tobacco control programs. Atlanta, GA: Centers for Disease Control and Prevention; 2005. Available online at: http://www.cdc.gov/tobacco/tobacco_control_programs/surveillance_evaluation/key_outcome/
5. Copley TT, Lovato C, O'Connor S. Indicators for monitoring tobacco control: A resource guide for decision-makers, evaluators and researchers. On behalf of the National Advisory Group on Monitoring and Evaluation. Toronto, ON: Canadian Tobacco Control Research Initiative, 2006. Available online at: http://www.ctcri.ca/~ctcri/en/index.php?option=content&task=view&id=30&Itemid=49.
6. Edwards R, et al. After the smoke has cleared : evaluation of the impact of a new national smoke-free law in New Zealand. Tob. Control 2008; 17e2.
7. Fong, GT et al. Reductions in tobacco smoke pollution and increases in support for smoke-free public places following the implementation of comprehensive smoke-free workplace legislation in the Republic of Ireland: findings from the ITC Ireland/UK Survey. Tob. Control 2006; 15;iii51-iii58.