APHEO - 5A Smoking Cessation

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5A Smoking Cessation

Description

Proportion of current , daily or occasional smokers who plan on quitting in the next six months
Proportion of current, daily or occasional smokers who have tried to quit for at least 24 hours in the last 12 months

Specific Indicators

Quit intention
Quit attempts

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): There is increased adoption of behaviours and skills associated with reducing the risk of chronic diseases of public health importance.
Board of Health Outcome (Chronic Disease Prevention): Priority populations adopt tobacco-free living.

Assessment and/or Surveillance Requirement Related to this Indicator:

The board of health shall conduct epidemiological analysis of surveillance data... in the areas of comprehensive tobacco control (Chronic Disease Prevention).

http://www.ontario.ca/publichealthstandards

Corresponding Health Indicator(s) from Statistics Canada and CIHI

Statistics Canada

Changes over time in smoking behavior

http://www.statcan.gc.ca/start-debut-eng.html

Click on Publications.
Type in ‘Health Indicators' into search box.
Scroll down and click on the html version of ‘Health Indicators'.
Click on "Data Tables and Maps" and then "Changes over time in smoking behavior"

Corresponding Indicator(s) from Other Sources

Centers for Disease Control (CDC)

Proportion of smokers who intend to quit (Indicator 3.8.3)
Proportion of adult smokers who have made a quit attempt (Indicator 3.11.1)
Proportion of recent successful quit attempts (Indicator 3.13.2)

http://www.cdc.gov/tobacco/tobacco_control_programs/surveillance_evaluation/key_outcome/index.htm

Click on "Chapter 4. Goal Area 3: Promoting Quitting Among Adults and Young People."

National Advisory Group on Monitoring and Evaluation (NAGME)

Rate of quit attempts for one day or longer (Indicator 3.3a)
Intentions to quit smoking, 6 month and 30 days (Indicator 3.3c)
Stages of change (Indicator 3.3d)

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

Data Sources

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

Survey Questions

The Smoking - Stages of change (SCH) module was optional content selected by Ontario in 2007. In 2003, this module was optional and selected by three health units. In 2005, this module was optional but not selected by Ontario.

Data Source	Module	Question	Response Categories	Year	Variable
CCHS	Smoking - Stages of change (SCH) module	Are you seriously considering quitting smoking within the next 6 months?	Yes, No, Don't Know, Refusal	2007	SCH_1
CCHS	Smoking - Stages of change (SCH) module	In the past 12 months, did you stop smoking for at least 24 hours because you were trying to quit?	Yes, No, Don't Know, Refusal	2007	SCH_3

Alternative Data Source(s)

The Rapid Risk Factor Surveillance System (RRFSS) contains a module called Thinking About Quitting Smoking. Question t3 from this module was core from 2001 - 2004 and optional in 2005 (note that it was found in the Tobacco Use by Respondent module in earlier years). The Tobacco Cessation module is an optional module that began in 2004.

Data Source	Module	Question	Response Categories	Year	Variable
RRFSS	Thinking About Quitting Smoking	How do you feel about quitting smoking: are you currently NOT thinking of quitting, considering quitting in the next 6 months, or committed to quit smoking in the next 30 days?	Currently not thinking of quitting, considering quitting in the next 6 months, committed to quit smoking in the next 30 days, volunteers that they are going to quit, but not sure when, don't know, refused	2004-present	t3
RRFSS	Tobacco Cessation	During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit?	Yes, No, Don't Know, Refused	2004-present	tc_1

Analysis Check List

CCHS

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: nterpret 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.

Method of Calculation

Quit Intention:

Weighted number of people aged 12 + who are seriously thinking of quitting smoking in the next six months
Weighted population of current, daily or occasional smokers aged 12+ X 100

Quit Attempts:

Weighted number of people aged 12 + who have tried to quit for at least 24 hours in the last 12 month
Weighted population of current, daily or occasional smokers aged 12+ X 100

Basic Categories

male, female and total
age groups for age-specific rates: 20-44, 45-64, 65+, 20+ (adult), 12+
Geographic areas for: CCHS - all 36 Public Health Units in Ontario; RRFSS - all participating Ontario Public Health Unit areas.

Indicator Comments

These two specific indicators (Quit Intention and Quit Attempts), in addition to an indicator on Stages of Change and one for Quit Duration, are the standard for reporting on smoking cessation.¹
The smoking cessation indicators presented here do not include an indicator on Stages of Change because the numbers were not reportable for 2 of the 5 stages at the public health unit level. It is not recommended to report only 3 of the 5 stages as an indicator based on theory.
A specific indicator measuring the length of time since quitting smoking was investigated using one year of data from the CCHS which was available in March 2009 for each health unit in Ontario (CCHS 2007). Data were categorized into the following categories: < 1 year, 1 year to < 2 years, 2 years to < 3 years and 3+ years. Although data were reportable by health unit for the last category (3+ years since stopped smoking), this indicator was dropped due to low sample sizes for many of the other categories for several health units using this one year of data.
A basic category for 12-19 year olds (adolescents) was considered but due to low sample sizes at the public health unit level in Ontario (CCHS 2007), this category was not included.
In 2006, 33% of current smokers in Ontario reported that they intended to quit smoking in 30 days while 63% reported that they intended to quit smoking in 6 months time. 43% of current smokers reported making one or more serious attempts to quit smoking in the 12 months prior to the survey. Among former smokers, 8% reported quitting 1-6 months prior to the survey, 3% reported quitting 7-12 months prior to the survey, 17% reported quitting 1-5 years prior to the survey, and 72% reported quitting more than 5 years prior to the survey.²
Use discretion when reporting on quit intentions. The 30 day quit intention is preferred because it is a more immediate action demonstrating a commitment to quitting and would be more meaningful for program planning. Whereas the 6 month quit intention indicator is not as meaningful because respondents may change their intentions within the course of 6 months. Upon examination of the 2007 CCHS Share file in March 2009, data for 30-day quit intention (i.e., Are you seriously considering quitting within the next 30 days?) were not reportable for some health units due to the small sample sizes from the one-year data. As a result, the 6 month measure was chosen as a replacement. We recommend users report 30-day quit intention if the data is releasable in the CCHS bi-annual data files.
Research conducted at the University of Toronto Dalla Lana School of Public Health and the Ontario Tobacco Research Unit found that estimates of positive intentions to quit varied quite a bit between surveys and suggested that this may be due to different question wording for measuring intentions to quit³ Specifically, they found higher estimates of positive quit intentions using the measures in the CCHS (identified above as the primary source) and relatively lower estimates using the following one-question measure:

        Are you planning to quit smoking....
        within the next month
        within the next 6 months
        sometime in the future beyond 6 months
        or are you not planning to quit?"

Data for the one question version considered came from the Ontario Tobacco Survey⁴ and International Tobacco Control Study.⁵ The original source of the CCHS measures is Prochaska, Diclemente & Norcross⁶ and the original source of the one question wording is Etter & Perneger.⁷ Note also that the RRFSS single question on quit intentions [alternative data source listed above], is also a single question form, but which uses 3 of the 4 answer options of the version immediately above.
There is evidence that smoking tobacco is related to more than two dozen diseases and conditions. The negative health impacts, as a result of smoking tobacco, affect people of all ages: unborn babies, infants, children, adolescents, adults, and seniors. Smoking tobacco is the leading cause of preventable death.⁸
Individuals who quit smoking will immediately begin to reduce their chances of developing heart disease, cancer, breathing problems, infections, or being in an accident.⁹
Specific benefits to quitting smoking include: reducing the risk of having a smoking-related heart attack by half (within 1 year); reducing the risk of dying from lung cancer by half (within 10 years); and the risk of dying from a heart attack will be equal to a person who never smoked (within 15 years).⁹
A recent systematic review examined the results of several adolescent smoking cessation studies and found that the median 6-month, 12-month and lifetime cessation attempt prevalence was 58%, 68% and 71%, respectively. The median prevalence of relapse among smokers who had attempted to quit was 34% (1 week), 56% (1 month), 89% (6 months), and 92% (1 year). Adolescent smokers under the age of 16 years and non-daily smokers experienced a similar or higher prevalence of cessation attempts compared with older (age >16 years) or daily smokers. The authors of this review recommended that cessation surveillance, research and program development should be more inclusive of younger and non-daily smoker subgroups.¹⁰

Cross References to Other Indicators

Chronic Disease Mortality (Section 4A: Chronic Diseases)
Chronic Health Problems Prevalence (Section 4A: Chronic Diseases)
Cancer Incidence (Section 4B: Cancer Incidence and Early Detection of Cancer)
Cancer Mortality (Section 4B: Cancer Incidence and Early Detection of Cancer)
Smoking Status (Section 5A: Smoking)
Smoke-free Homes (Section 5A: Smoking)
Non-Smoker Second-Hand Smoke Exposure (Section 5A: Smoking)

Cited References

Bancej C, O’Loughlin J, Platt RW, Paradis G, Gervais A. Smoking cessation attempts among adolescent smokers: A systematic review of prevalence studies. Tob Control; 2007;16:e8.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 at: http://www.ctcri.ca/~ctcri/en/index.php?option=content&task=view&id=30&Itemid=49 (Accessed October 16, 2008).
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.
Bondy SJ, Victor JC, O'Connor S, Diemert LM, Brown KS, Cohen JE, Ferrence R, Garcia J, McDonald PW, Schwartz R, Selby P. The effect of measurement on estimates of quit intentions among smokers. Society for Research on Nicotine and Tobacco, 14th Annual Meeting, February 27-March 1, 2008, Portland, Oregon.
Bondy, S., Brown, K., Cohen, J., Ferrence, R., Garcia, J., Mcdonald, P., Selby, P., Stephens, T., Diemert, L. & Victor, J. (2006) Development and design of the Ontario Tobacco Survey. Statistics Canada International Symposium Series - Proceedings. Symposium 2006: Methodological Issues in Measuring Population Health. Ottawa, Ontario, Canada, Statistics Canada.
ITC 4 Country. Available online at: http://www.itcproject.org/research/surveys/itc4coun (Accessed June 9, 2009).
Prochaska, J., Diclemente, C. & Norcross, J. (1992) In search of how people change. Applications to addictive behaviors. American Psychologist, 47, 1102-1114.
Etter, J. F. & Perneger, T. V. (1999) A comparison of two measures of stage of change for smoking cessation. Addiction, 94, 1881-9.
Health Canada. Smoking and your body. Available online at: http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/body-corps/index-eng.php (Accessed June 12, 2009).
Health Canada. Rewards of quitting. Available online at: http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/quit-cesser/ready-pret/reward-gratifiant-eng.php (Accessed June 12, 2009).
Bancej C, O'Loughlin J, Platt RW, Paradis G, Gervais A. Smoking cessation attempts among adolescent smokers: A systematic review of prevalence studies. Tob Control; 2007;16:e8.

Other References

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/ (Accessed May 4, 2009).

Changes Made

Date	Formal Review or Ad Hoc?	Changes made by	Changes
June 2009	This is a new indicator.	Cancer, Smoking and Sun Safety subgroup of Core Indicators.	This is a new indicator.
June 29, 2009	Ad hoc	Harleen Sahota on behalf of CIWG	Removed an out-of-date point in the Analysis Check List on how the Health Indicators department at Statistics Canada handles 'Not Stated' respondents when using CCHS data.

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