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


Description

• Proportion of people aged 12-19 (teen smoking rate) and aged 20 and older (adult smoking rate) that are current cigarette smokers.
• Proportion of adults that are daily cigarette smokers.
• Proportion of adults that are non-smokers but did smoke at one time (former smokers).
• Proportion of people aged 12-19 (teens) and aged 20 and older (adults) that have completely abstained from smoking cigarettes in their lifetime. 

• Adult daily smoking rate
• Adult former smoking rate
• Adult current smoking rate
• Adult smoking abstinence rate
• Teen current smoking rate
• Teen smoking abstinence rate

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

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.health.gov.on.ca/english/providers/program/pubhealth/oph_standards/ophs/index.html

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.

• Type of smoker (previously referred to as Smoking status)

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

Click on “Publications”Type in “Health Indicators” into the search boxScroll down and click on the html version of “Health Indicators”
Click on “Data Tables and Maps” and then “ Type of Smoker”

Corresponding Indicator(s) from Other Sources

Comparable Health Indicator (Select "View" under latest issue then "Data tables")

http://www.statcan.ca/bsolc/english/bsolc?catno=82-401-XIE

• Proportion current teenage smokers (previously referred to as Percent teenaged smokers)

•  Proportion of young people who are (Indicator 1.1):
• Never smokers (never smoked a whole cigarette)
• Puffers (puffed on a cigarette, but has not had a whole cigarette)
• Non-current experimenters (used fewer than 100 in lifetime, but not smoked in past 30 days)
• Current experimenters (used fewer than 100 cigarettes in lifetime, smoked in past 30 days)
• Non-current established smokers (used 100 cigarettes in lifetime, but not smoked in past 30 days)
• Current established smokers (used 100 cigarettes in lifetime, smoked in past 30 days)

•  Proportion of the population who are (Indicator 3.2):
• Current smokers (100 cigarettes in lifetime, some in past 30 days)
• Daily smokers (100 cigarettes in lifetime, smokes daily)
• Occasional smokers (100 cigarettes in lifetime, smoked in past 30 days but not every day_
• Former smokers (100 cigarettes in lifetime, has not smoked in past year)
• Never smokers (less than 100 cigarettes in lifetime)

Centers for Disease Control (CDC) (Click on "Chapter 4. Goal Area 3: Promoting Quitting Among Adults and Young People. http://www.cdc.gov/tobacco/tobacco_control_programs/surveillance_evaluation/key_outcome/00_pdfs/Chapter4.pdf 

• Smoking prevalence (Indicator 3.14.1)
  
  

Data Sources (see Resources: 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 Smoking module has been included in the CCHS as core content since 2000/01.

The CCHS has a derived variable, type of smoker, which groups the type of smoker into six categories. Please note that the derived variable definition for each category varies slightly from the NAGME recommended indicator definitions in that the CCHS derived variable categories do not all include the 100 cigarette in lifetime criterion and are not based on past 30 day use. Below is a detailed description of how each of the CCHS type of smoker categories is derived.

Daily smoker =  Smokes daily at present time (SMK_202=1).

Occasional smoker (former daily smoker) = Smokes occasionally at present time (SMK_202=2) AND has previously smoked cigarettes daily (SMK_05D=1).

Occasional smoker (never a daily smoker or has smoked less than 100 cigarettes) = Smokes occasionally at present time (SMK_202=2) AND has never smoked cigarettes daily (SMK_05D=2 or NA).

Former daily smoker (non-smoker now) = Does not smoke at present time (SMK-202=3) AND has previously smoked cigarettes daily (SMK_05D=1).

Former occasional smoker (at least one whole cigarette, non-smoker now) = Does not smoke at present time (SMK-202=3) AND [has never smoked cigarettes daily (SMK_05D=2) AND {has smoked 100 cigarettes in lifetime (SMK_01A=1) OR has smoked a whole cigarette (SMK_01B=1)}]. 

Never smoked (a whole cigarette) = Does not smoke at present time (SMK-202=3) AND has never smoked 100 cigarettes in lifetime (SMK_01A=2) AND has never smoked a whole cigarette (SMK_01B=2).

The Rapid Risk Factor Surveillance System (RRFSS) contains a module called Tobacco - Use by Respondent. This module has been a core module since 2001.

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 using the Approximate Sampling Variability (CV) lookup tables only, data may not be released when the unweighted cell size is below 30. This provides a margin of safety in terms of data quality, given the CV being utilized is only approximate. When calculating the CV using the bootstrap weights, the guidelines are not to use/release when the unweighted cell size is below 10. Statistics Canada uses this approach for the tabular data on their website. 
• 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". 

• 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 2nd 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 www.rrfss.ca for more information about module questions and indicators.

Method of Calculation

Teen Current Smoking Rate:

Weighted number of people aged 12-19 who are current (daily + occasional) cigarette smokers Weighted total population aged 12-19

X 100

Teen Smoking Abstinence Rate:

Weighted number of people aged 12-19 who have never smoked a whole cigarette in their life Weighted total population aged 12-19

X 100

Basic Categories

• Age groups for age-specific rates: 12-19 (teen), 20-44, 45-64, 65+, 20+(adult), 12+(total)
• Sex: male, female, total
• Geographic areas for: CCHS - all 36 Public Health Units in Ontario and 14 Local Health Integration Networks (LHINs); RRFSS - participating health units.

Indicator Comments

• The National Advisory Group on Monitoring and Evaluation (NAGME) of the Canadian Tobacco Control Research Initiative (CTCRI) in their Indicators for Monitoring Tobacco Control: A Resource for Decision Makers, Evaluators and Researchers report ¹ recommended defining smoking status as follows:
• Current smokers (100 cigarettes lifetime, some in past 30 days)
• Daily smokers (100 cigarettes lifetime, smokes daily)
• Occasional smokers (100 cigarettes lifetime, smoked in past 30 days but not every day)
• Former smokers (100 cigarettes in lifetime, has not smoked in past year)
• Never smokers (less than 100 cigarettes in lifetime)
• The smoking status indicators presented here follow the CCHS definition for smoking status not the NAGME definitions. CCHS does not use the 100+ cigarette (lifetime) or the past 30 day criteria to determine smoking status.  Statistics Canada would like to maintain their trend data and is not willing to align their derived smoking status variable (SMKnDSTY) with the NAGME recommendations.
• Teen daily smoker and teen former smoker indicators were not included based on recommendations from external reviewers. Neither indicator are typically used when describing the smoking status among the youth population. Teens are more likely to smoke cigarettes occasionally than daily and the number of teens who have quit smoking would not likely be reportable at the health unit level. 
• Smoker is defined differently in the CCHS and RRFSS. In order to be considered a smoker in RRFSS, the respondent must have smoked at least 100 cigarettes in their lifetime. This is not a requirement in the CCHS.
• The CCHS PUMF and share files contain a derived variable for smoking status (smkedsty).  Complete documentation for the derived variable is provided by Statistics Canada.²
• Use or non-use of the 100 cigarette criterion (in defining former smokers, current smokers or both) has been the subject of debate and, as seen above, is a source of disagreement between various Canadian indicators, and data sources. CIHI/Statistics Canada indicators do not use the 100 cigarette rule, whereas tobacco-specific consensus statements (NAGME) do use it.  CCHS and other sources make use of the criterion optional (by use of skip patterns), whereas the RRFSS standard questions (skip patterns) force the use of the 100 cigarette criterion.  
• A review from OTRU³ described the origin and uses of the 100 cigarette indicator.  Its popularity is most likely attributable to its use in the important US NHIS studies (1966-), and that the US CDC adopted it as a standard in 1994.  However, actual use of the 100 cigarette question and rule (from the mid 1950s to present) has been very inconsistent in Canada, in the United States and by WHO initiatives. It has been used: to separate former from never smokers; as a requirement for current and former smokers alike; or, not used at all. 
• The 100 cigarette question was originally designed as a simple measure to approximate lifetime never smoking in adults, and to reduce data collection burden for adults whose lifetime exposure to tobacco was negligible in multi-purpose health questionnaires.  A quantity of 100 cigarettes has not been shown to represent a meaningful threshold of exposure, biologically or behaviourally – it’s just a screener.  Experts and researchers in the area of youth smoking behaviour, and uptake of smoking are least likely to use the 100 cigarette criterion and far more detailed measures of experimentation and repeated experimentation are used (e.g., “even one puff of one cigarette”) and the 100 cigarette measure may or may not be used as an adjunct for comparison to adult data.³
• Surveys are generally thought to underestimate smoking rates because smokers may be reluctant to admit they smoke or they may be unable to accurately report the regularity of their smoking habit.
• The omission of other forms of tobacco use (e.g., cigar, cigarillo, smokeless tobacco, etc.) in the smoking status definition may also contribute to an underestimation of smoking rates by up to 5% for some populations such as 15-19 year olds.⁴
• There is evidence that smoking tobacco is related to more than two dozen diseases and conditions. It is the leading cause of preventable death and has negative health impacts on people of all ages: unborn babies, infants, children, adolescents, adults, and seniors.⁵ 
• Smoking tobacco is the most important preventable cause of lung cancer, accounting for 85% of all new lung cancer cases in Canada. Smoking tobacco can lead to respiratory and upper digestive tract cancers and has been shown to be a contributing cause of leukemia and cancers of the bladder, stomach, kidney and pancreas. Female smokers have an increased risk for developing cervical cancer. Smoking tobacco is associated with Chronic Obstructive Pulmonary Disease (COPD) and cardiovascular diseases caused by smoking include coronary heart diseases, peripheral vascular disease and cerebrovascular diseases.⁵
• Cigarette smoking during pregnancy has been associated with increased risks of complications in pregnancy and to cause serious adverse fetal outcomes including low birth weight, still births, spontaneous abortions, decreased fetal growth, premature births, placental abruption, and sudden infant death syndrome (SIDS).⁵
• There is evidence that people repeatedly exposed to environmental tobacco smoke are more likely to develop and die from heart problems, lung cancer, and breathing problems. Environmental tobacco smoke can also cause chest infections, ear infections, excessive coughing and throat irritation.⁵
• “In 1988 the U.S. Surgeon General concluded that nicotine in tobacco is addictive. The three major findings were:
• Cigarette smoking and other forms of tobacco use are addictive
• Nicotine is the drug in tobacco that causes addiction
• Nicotine addiction is similar to heroin or cocaine addiction.”⁵
• Approximately 25% of smokers between 20-24 had their first cigarette before entering their teen years and 66% had their first cigarette by 15.⁶
• Research findings indicate that if people have not started smoking during their adolescent years, they probably will not smoke at all.⁷
• Research has shown that smoking prevalence varies by age/grade during adolescence.⁸ If sample size permits, youth smoking indicators should be broken into two separate age groups: 12-14 years and 15-19 years.

• Teen – age 12-19
• Adult – age 20+
• Current smoker – daily smoker + occasional smoker
• Former smoker – smoked daily or occasionally before but currently does not smoke
• Daily smoker – smoking at least one cigarette per day 
• Occasional smoker – does not have at least one cigarette per day

• 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)
• Smoke-free Homes (Section 5A: Smoking)
• Minors’ Access to Tobacco (Section 5A: Smoking)

Cited References

1. Copley TT, Lovato C, O’Connor S. Canadian Tobacco Control Research Initiative. Indicators for Monitoring Tobacco Control: A Resource for Decision-Makers, Evaluators and Researchers. Toronto, ON: Canadian Tobacco Control Research Initiative on behalf of the National Advisory Group on Monitoring and Evaluation, 2006. Available online at: http://www.ctcri.ca/en/index.php?option=com_content&task=view&id=33&Itemid=52 (Accessed 2007).
2. Statistics Canada. Canadian Community Health Survey (CCHS) Cycle 3.1 (2005): Public Use Micro Data File (PUMF), Integrated Derived Variable (DV) and Grouped Variable Specifications. Ottawa, ON: Statistics Canada, 2006. 
3. Bondy SJ, Victor CD, Diemert LD. The criterion of 100 cigarettes in a lifetime in tobacco use surveillance: A love-hate relationship with a self-report question. [Conference: Ontario Tobacco Research Unit, Tobacco Control for the 21st Century]. November 10–12, 2008. Toronto, ON: Ontario Tobacco Research Unit, 2008.
4. Physicians for a Smoke-Free Canada. Cigarillo Smoking in Canada: A review of results from CTUMS, Wave 1 – 2007. Available online at: http://www.smoke-free.ca/pdf_1/cigarillos-2008.pdf (Accessed May 21, 2009).
5. Health Canada. Smoking and your body. Available online at: http://www.hc-sc.gc.ca/hl-vs/tobac-tabac/body-corps/index-eng.php (Accessed October 16, 2008).
6. Health Canada. Smoking in Canada: Young adults. Available online at: http://www.hc-sc.gc.ca/hl-vs/tobac-tabac/research-recherche/stat/_ctums-esutc_fs-if/2003-youn-jeun-eng.php (Accessed October 16, 2008).
7. Maggi S. Changes in smoking behaviours from late childhood to adolescence: 4 years later. Drug Alcohol Depend 2008; 94:251-53. 
8. Ontario Tobacco Research Unit. Indicators of Smoke-Free Ontario progress. [Special Reports: Monitoring and Evaluation Series, 2005-2006 (Vol 12, No. 2)]. Toronto, ON: Ontario Tobacco Research Unit, 2006. Available online at: http://www.otru.org/pdf/12mr/12mr_no2_final.pdf.

Other Reference(s) 

• Single E, Rehm J, Robson L, Van Truong M. The relative risk and etiologic fractions of different cause of death and disease attributable to alcohol, tobacco and illicit drug use in Canada. CMAJ 2000; 162(12):1669-1675.
• Ontario Tobacco Research Unit. Toward Smoke-Free Ontario Strategy Objectives 2005-2006. [Special Reports: Monitoring and Evaluation Series, 2005-2006 (Vol 12, No. 1)]. Toronto, ON: Ontario Tobacco Research Unit, 2006. Available online at: http://www.otru.org/pdf/12mr/12mr_no1_final.pdf.
• Chen J, Millar WJ. Age of smoking initiation: Implications for quitting. Health Reports 1998; 9(4):39-46.
• Holowaty P, Feldman L, Harvey B, Shortt L. Cigarette smoking in multicultural, urban high school students. Journal of Adolescent Health 2000; 27:281-288.
• Gilmore J. Report on Smoking Prevalence in Canada, 1985-2001 (Catalogue 82F0077XIE2001001). Statistics Canada, 2002. Available online at: http://www.statcan.ca/english/research/82F0077XIE/82F0077XIE2001001.pdf. 
• Centre for Addiction and Mental Health. Ontario Student Drug Use and Health Survey. Toronto, ON: Centre for Addiction and Mental Health, 2008. Available online at: http://www.camh.net/Research/osdus.html.
• 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/index-eng.php.
• Population Health Research Group. School Health Action, Planning and Evaluation System (SHAPES). Waterloo, ON: University of Waterloo, 2005. Available online at: http://www.shapes.uwaterloo.ca/ontario/.