Examining the impact of a province-wide physical education policy on secondary students' physical activity as a natural experiment.

BACKGROUND: The purpose of this paper is to examine the impact of a province-wide physical education (PE) policy on secondary school students' moderate to vigorous physical activity (MVPA). METHODS: Policy: In fall 2008, Manitoba expanded a policy requiring a PE credit for students in grades 11 and 12 for the first time in Canada. The PE curriculum requires grades 11 and 12 students to complete a minimum of 55 h (50% of course hours) of MVPA (e.g., ≥30 min/day of MVPA on ≥5 days a week) during a 5-month semester to achieve the course credit. STUDY DESIGNS: A natural experimental study was designed using two sub-studies: 1) quasi-experimental controlled pre-post analysis of self-reported MVPA data obtained from census data in intervention and comparison [Prince Edward Island (PEI)] provinces in 2008 (n = 33,619 in Manitoba and n = 2258 in PEI) and 2012 (n = 41,169 in Manitoba and n = 4942 in PEI); and, 2) annual objectively measured MVPA in cohorts of secondary students in intervention (n = 447) and comparison (Alberta; n = 224) provinces over 4 years (2008 to 2012). ANALYSIS: In Study 1, two logistic regressions were conducted to model the odds that students accumulated: i) ≥30 min/day of MVPA, and ii) met Canada's national recommendation of ≥60 min/day of MVPA, in Manitoba versus PEI after adjusting for grade, sex, and BMI. In Study 2, a mixed effects model was used to assess students' minutes of MVPA per day per semester in Manitoba and Alberta, adjusting for age, sex, BMI, school location and school SES. RESULTS: In Study 1, no significant differences were observed in students achieving ≥30 (OR:1.13, 95% CI:0.92, 1.39) or ≥60 min/day of MVPA (OR:0.92, 95% CI: 0.78, 1.07) from baseline to follow-up between Manitoba and PEI. In Study 2, no significant policy effect on students' MVPA trajectories from baseline to last follow-up were observed between Manitoba and Alberta overall (-1.52, 95% CI:-3.47, 0.42), or by covariates. CONCLUSIONS: The Manitoba policy mandating PE in grades 11 and 12 had no effect on student MVPA overall or by key student or school characteristics. However, the effect of the PE policy may be underestimated due to the use of a nonrandomized research design and lack of data assessing the extent of policy implementation across schools. Nevertheless, findings can provide evidence about policy features that may improve the PE policy in Manitoba and inform future PE policies in other jurisdictions.

Prevalence and correlates of electronic cigarette use among Canadian students: cross-sectional findings from the 2014/15 Canadian Student Tobacco, Alcohol and Drugs Survey.

BACKGROUND: Over the past decade, youth tobacco use has declined, and electronic cigarettes (e-cigarettes) have entered the market. The aims of this study were to describe the prevalence of e-cigarette use among youth in Canada, by province, across sociodemographic variables and smoking-related correlates; and to examine associations among e-cigarette use, sociodemographic variables and smoking-related correlates, with adjustment for other factors. METHODS: The 2014/15 Canadian Student Tobacco, Alcohol and Drugs Survey, a biennial, school-based survey, was administered to students in grades 6-12 in all Canadian provinces. Logistic regression models were fitted to estimate odds of ever and past 30-day e-cigarette use by sociodemographic variables and smoking-related correlates. RESULTS: A total of 336 schools from 128 school boards (47% of eligible schools approached) and 42 094 students (66% of eligible students approached) participated in the survey. In Canada, 17.7% (95% confidence interval [CI] 16.4%-18.9%) of students in grades 6-12 reported ever using e-cigarettes, and 5.7% (95% CI 5.2%-6.3%) reported past 30-day use. Substantial variation was observed across provinces. Female students had decreased odds of past 30-day use relative to male students (odds ratio [OR] 0.71, 95% CI 0.59-0.86), whereas current smokers (OR 10.0, 95% CI 6.66-15.02) and experimental smokers (OR 3.61, 95% CI 2.40-5.42) had increased odds relative to never smokers. Students who perceived that access was easy also had increased odds of using e-cigarettes relative to students who perceived that access was difficult (OR 3.86, 95% CI 2.96-5.03). Students who believed that regular use entailed slight risk (OR 0.68, 95% CI 0.52-0.88) and those who did not know risk levels (OR 0.31, 95% CI 0.21-0.46) had decreased odds compared with those perceiving no risk. INTERPRETATION: Our data confirm that many youth used e-cigarettes in the 30 days preceding the survey, although rates were substantially higher among current and experimental smokers than among students who had never tried smoking.

Youth retail tobacco access in Canada: regional variation, perceptions, and predictors from YSS 2010/2011.

PURPOSE: Retail tobacco access is an important determinant of youth smoking prevalence. This study examines perceptions of ease in obtaining cigarettes and how prevalence of self-reported retail tobacco access among youth smokers varies by province in Canada. Additionally, relevant retail experiences, such as being asked for identification by a store clerk, are described. METHODS: Data from grades 9-12 students who participated in the 2010/2011 Youth Smoking Survey, a nationally generalizable sample of Canadian students (n=31396) were used to examine retail tobacco access and related experiences. Logistic regression models were used to examine differences in retail tobacco access and retail tobacco experiences by sociodemographic and regional characteristics. RESULTS: 79% of students who never smoked thought it would be easy to get cigarettes. About one-quarter of smokers reported usually buying cigarettes from stores, and the percent of student smokers usually buying cigarettes in stores ranged from 16% in British Columbia to 36% in Quebec. Compared to grade 9 students, grade 12 students had higher odds of report being asked for identification (OR=6.3, 95% CI 1.9-21.5). CONCLUSIONS: Retail tobacco access appears to be a significant source of cigarette access among Canadian youth. Retail tobacco access varies significantly by province, which suggests provincial policies should be strengthened.

Hookah use prevalence, predictors, and perceptions among Canadian youth: findings from the 2012/2013 Youth Smoking Survey.

PURPOSE: Few national surveys currently assess hookah smoking among youth. This study describes the prevalence, patterns of use, and perceptions about hookah in a nationally representative survey of Canadian grades 9-12 students. METHODS: The Youth Smoking Survey 2012/2013 was administered to 27,404 Canadian grades 9-12 students attending schools in nine Canadian provinces representing 96 % of Canadian population. Relevant dichotomous outcomes included ever use, use in the last 30 days, and the belief that hookah use is less harmful than cigarette smoking. Covariates included smoking status, sex, grade, province of residence, race/ethnicity, and amount of weekly spending money. Logistic regression models were used to examine: covariates related to the odds of ever and last-30-day hookah use; covariates related to perceptions about the harms of hookah smoking; the extent to which perceptions were associated with odds of hookah use; and whether survey year (2010/2011 or 2012/2013) was associated with hookah use, and marginal effects were calculated. RESULTS: In Canada, 5.4 % of students in grades 9-12 currently use hookah and 14.3 % report ever using hookah. In 2012/2013, students had significantly higher odds of using hookah compared to students in 2010/2011 (OR 1.5, 95 % CI 1.2, 2.1). About half of hookah users (51 %) used flavored hookah. Students who believed that hookah use was less harmful than cigarette smoking had significantly higher odds of current hookah use (OR 2.6, 95 % CI 1.9, 3.5), as did students who reported higher amounts of weekly spending money. Current smokers had an 18 % higher predicted probability of currently using hookah compared to non-smokers. CONCLUSIONS: Hookah use among youth is of growing concern in Canada. Findings can be used to inform policy development related to youth hookah smoking.

Cigarette smoking susceptibility among youth alternate tobacco product users: implications of flavoured tobacco from a national cross-sectional Canadian sample (YSS 2012/2013).

OBJECTIVES: Declines in cigarette smoking have been accompanied by increases in alternative tobacco product (ATP) use, particularly among youth. This study examines smoking susceptibility and ATP use in a national sample of Canadian youth. METHODS: Data from grades 9-12 students who participated in the 2012/2013 Youth Smoking Survey, a nationally generalisable sample of Canadian students (n=27,404) were used to examine cigarette smoking susceptibility among never smokers (n=17,396). Logistic regression models were used to examine differences in smoking susceptibility by use of flavoured and all ATPs and by sociodemographic and lifestyle characteristics. RESULTS: Overall, 30% of Canadian grades 9-12 never smokers were susceptible to cigarette smoking. Compared to never users, those who had ever tried ATPs (OR=1.96, 95% CI 1.59 to 2.42) and those who had ever tried flavoured ATPs (OR=2.20, 95% CI 1.63 to 2.96) had significantly higher odds of being susceptible to cigarette smoking. CONCLUSIONS: ATP use is associated with smoking susceptibility among youth never smokers. Findings from this study, along with existing evidence, can be used by policymakers to improve regulation around youth access to ATPs (particularly flavoured varieties).

Flavored tobacco use among Canadian students in grades 9 through 12: prevalence and patterns from the 2010-2011 youth smoking survey.

INTRODUCTION: This study examined patterns of use of flavored tobacco products in a nationally generalizable sample of Canadian students in grades 9 through 12 after the implementation of a national ban on certain flavored tobacco products. METHODS: Data from the 2010-2011 Youth Smoking Survey, a nationally generalizable sample of Canadian students in grades 9 through 12 (n = 31,396), were used to examine tobacco product use. Logistic regression models were used to examine differences in use of flavored tobacco products (cigarettes, pipes, little cigars or cigarillos, cigars, roll-your-own cigarettes, bidis, smokeless tobacco, water pipes, and blunt wraps) by sociodemographic and regional characteristics. RESULTS: Approximately 52% of young tobacco users used flavored products in the previous 30 days. Flavored tobacco use varied by product type and ranged from 32% of cigarette smokers reporting menthol smoking to 70% of smokeless tobacco users reporting using flavored product in the previous 30 days. The percentage of last-30-day users who used flavored tobacco was significantly higher in Quebec than in Ontario and significantly higher among youths who received weekly spending money than among those who received no money. CONCLUSION: More than half of tobacco users in grades 9 through 12 in Canada use flavored tobacco, despite a national ban on certain flavored tobacco products.

Smoking intensity and intent to continue smoking among menthol and non-menthol adolescent smokers in Canada.

PURPOSE: Research suggests that menthol cigarette use is associated with nicotine dependence. However, findings on the relationship between menthol smoking status and quantity of cigarettes smoked are less clear. The objective of this paper was to examine whether menthol cigarette smoking is associated with higher smoking intensity and intention to continue smoking among adolescents. METHODS: A nationally representative sample of 4,736 Canadian students in grades 9-12 was drawn from the 2010-2011 Canadian Youth Smoking Survey. Associations between smoking intensity and menthol smoking were examined using linear regression. A logistic regression was used to examine whether menthol smoking increased the odds that a student reported intention to continue smoking. RESULTS: Thirty-two percentage of smokers in grades 9-12 smoked menthol cigarettes in the last 30 days. Unadjusted average number of cigarettes reported by menthol smokers was 6.86 compared with 4.59 among non-menthol smokers (p < 0.001). Multivariable results showed that the average number of cigarettes smoked by menthol smokers was greater than non-menthol smokers (ß = 1.92; 95 % CI = 1.16-2.68). Similar results were found using the total number of cigarettes smoked in the past week. Additionally, menthol smokers had greater odds of reporting intent to continue smoking compared with non-menthol smokers (OR = 2.95; 95 % CI = 2.24-3.90). These results were similar when separate analyses were conducted for established smokers and experimental smokers. CONCLUSIONS: The findings of this study along with existing evidence suggest the need for banning mentholated tobacco products in Canada, in part because of its significant effect on adolescent smoking.

Are environmental influences on physical activity distinct for urban, suburban, and rural schools? A multilevel study among secondary school students in Ontario, Canada.

BACKGROUND: This study examined differences in students' time spent in physical activity (PA) across secondary schools in rural, suburban, and urban environments and identified the environment-level factors associated with these between school differences in students' PA. METHODS: Multilevel linear regression analyses were used to examine the environment- and student-level characteristics associated with time spent in PA among grades 9 to 12 students attending 76 secondary schools in Ontario, Canada, as part of the SHAPES-Ontario study. This approach was first conducted with the full data set testing for interactions between environment-level factors and school location. Then, school-location specific regression models were run separately. RESULTS: Statistically significant between-school variation was identified among students attending urban (σ(2) µ0 = 8959.63 [372.46]), suburban (σ(2) µ0 = 8918.75 [186.20]), and rural (σ(2) µ0 = 9403.17 [203.69]) schools, where school-level differences accounted for 4.0%, 2.0%, and 2.1% of the variability in students' time spent in PA, respectively. Students attending an urban or suburban school that provided another room for PA or was located within close proximity to a shopping mall or fast food outlet spent more time in PA. CONCLUSION: Students' time spent in PA varies by school location and some features of the school environment have a different impact on students' time spent in PA by school location. Developing a better understanding of the environment-level characteristics associated with students' time spent in PA by school location may help public health and planning experts to tailor school programs and policies to the needs of students in different locations.

Young adult smoking cessation: predictors of quit attempts and abstinence.

We examined young adult smoking cessation behaviors, coding cessation behavior as no attempt, quit attempt (< 30 days), or abstinence (≥ 30 days) during follow-up from July 2005 through December 2008, observed in 592 young adult smokers from the Ontario Tobacco Survey. One in 4 young adults made an attempt; 14% obtained 30-day abstinence. Cessation resources, prior attempts, and intention predicted quit attempts, whereas high self-efficacy, using resources, having support, and low addiction predicted abstinence, indicating that young adult smokers require effective and appropriate cessation resources.

School and community predictors of smoking: a longitudinal study of Canadian high schools.

OBJECTIVES: We identified the most effective mix of school-based policies, programs, and regional environments associated with low school smoking rates in a cohort of Canadian high schools over time. METHODS: We collected a comprehensive set of student, school, and community data from a national cohort of 51 high schools in 2004 and 2007. Hierarchical linear modeling was used to predict school and community characteristics associated with school smoking prevalence. RESULTS: Between 2004 and 2007, smoking prevalence decreased from 13.3% to 10.7% in cohort schools. Predictors of lower school smoking prevalence included both school characteristics related to prevention programming and community characteristics, including higher cigarette prices, a greater proportion of immigrants, higher education levels, and lower median household income. CONCLUSIONS: Effective approaches to reduce adolescent smoking will require interventions that focus on multiple factors. In particular, prevention programming and high pricing for cigarettes sold near schools may contribute to lower school smoking rates, and these factors are amenable to change. A sustained focus on smoking prevention is needed to maintain low levels of adolescent smoking.

The Happy Meal® Effect: the impact of toy premiums on healthy eating among children in Ontario, Canada.

OBJECTIVES: "Toy premiums", offered with McDonald's Happy Meals®, are a prominent form of food marketing directed at children. Two California jurisdictions recently implemented policies that only permit offering fast-food toy premiums with meals that meet certain nutritional criteria. The primary objective of the current study was to examine elements of this policy in a Canadian context and determine if children select healthier food products if toy premiums are only offered with healthier food options. The study also examined if the impact of restricting toy premiums to healthier foods varied by gender and age. METHODS: A between-groups experimental study was conducted with 337 children aged 6-12 years attending day camps in Ontario, Canada. Children were offered one of four McDonald's Happy Meals® as part of the camp lunch program: two "healthier" meals that met the nutritional criteria and two meals that did not. In the control condition, all four meals were offered with a toy premium. In the intervention condition, the toy was only offered with the two "healthier" meals. RESULTS: Children were significantly more likely to select the healthier meals when toys were only offered with meals that met nutritional criteria (OR=3.19, 95% CI: 1.89-5.40). The effect of pairing toys with healthier meals had a stronger effect on boys than girls (OR=1.90, 95% CI: 1.14-3.17). CONCLUSION: Policies that restrict toy premiums to food that meet nutritional criteria may promote healthier eating at fast-food restaurants.

Youth Excel: towards a pan-Canadian platform linking evidence and action for prevention.

Population-level intervention is required to prevent cancer and other chronic diseases. It also promotes health for those living with established risk factors and illness. In this article, the authors describe a vision and approach for continuously improving population-level programs and policies within and beyond the health sector. The vision and approach are anchored in contemporary thinking about what is required to link evidence and action in the field of population and public health. The authors believe that, as a cancer prevention and control community, organizations and practitioners must be able to use the best available evidence to inform action and continually generate evidence that improves prevention policies and programs on an ongoing basis. These imperatives require leaders in policy, practice, and research fields to work together to jointly plan, conduct, and act on relevant evidence. The Propel Center and colleagues are implementing this approach in Youth Excel-a pan-Canadian initiative that brings together national and provincial organizations from health and education sectors and capitalizes on a history of collaboration. The objective of Youth Excel is to build sustainable capacity for knowledge development and exchange that can guide and redirect prevention efforts in a rapidly evolving social environment. This goal is to contribute to creating health-promoting environments and to accelerate progress in preventing cancer and other diseases among youth and young adults and in the wider population. Although prevention is the aim, health-promoting environments also can support health gains for individuals of all ages and with established illness. In addition, the approach Youth Excel is taking to link evidence and action may be applicable to early intervention and treatment components of cancer control.

The influence of school policies on smoking prevalence among students in grades 5-9, Canada, 2004-2005.

INTRODUCTION: School characteristics may account for some of the variation in smoking prevalence among schools. The purpose of this study was to investigate the relationships between characteristics of school tobacco policies and school smoking prevalence. We also examined the relationship between these characteristics and individual smoking status. METHODS: Tobacco policy data were collected from schools in 10 Canadian provinces during the 2004-2005 school year. Written tobacco policies were collected from each school to examine policy intent, and school administrators were surveyed to assess policy enforcement. Students in grades 5 through 9 completed the Youth Smoking Survey to assess smoking behaviors and attitudes. We used negative binomial regression and multilevel logistic regression to predict the influence of school policies on smoking behavior at the school and student levels. RESULTS: School policies that explicitly stated purpose and goals predicted lower prevalence of smoking at the school and individual levels. Policies that prohibited smoking on school grounds at all times predicted lower smoking prevalence at the school level but not at the individual level. CONCLUSION: For maximum effectiveness, school smoking policies should clearly state a purpose and goals and should emphasize smoking prohibition. These policies can help reduce smoking prevalence among youths and are part of a comprehensive school approach to tobacco control.

Do students' perceptions of school smoking policies influence where students smoke?: Canada's Youth Smoking Survey.

OBJECTIVE: The objective of this study was to explore students' perceptions of school policy characteristics that influence the location of smoking while at school. METHODS: Data were collected from a nationally representative sample of Canadian youth in grades 7-12 as part of the 2006-2007 Youth Smoking Survey. We used multilevel logistic regression to examine how students' perceptions of school policies predicted smoking behavior on and off school grounds in 11,881 students who had ever smoked. Separate analyses were conducted for grades 7-9 and 10-12. RESULTS: In both grades 7-9 and 10-12, perceiving clear rules about smoking decreased the likelihood that a student would smoke on school grounds, while perceiving that a high percentage of peers smoke, that there are school rules about smoking, that students obey the rules, and that students can be fined for smoking increased the likelihood that a student would smoke off school grounds. CONCLUSIONS: Clearly perceived rules about smoking encourage students not to smoke on school grounds; however, perceptions of rules, along with strong enforcement, may displace behavior off of school grounds. Non-smoking policies should be part of a comprehensive approach, that supports cessation.

A multi-level examination of school programs, policies and resources associated with physical activity among elementary school youth in the PLAY-ON study.

BACKGROUND: Given the decline in physical activity (PA) levels among youth populations it is vital to understand the factors that are associated with PA in order to inform the development of new prevention programs. Many studies have examined individual characteristics associated with PA among youth yet few have studied the relationship between the school environment and PA despite knowing that there is variability in student PA levels across schools. METHODS: Using multi-level logistic regression analyses we explored the school- and student-level characteristics associated with PA using data from 2,379 grade 5 to 8 students attending 30 elementary schools in Ontario, Canada as part of the PLAY-Ontario study. RESULTS: Findings indicate that there was significant between-school random variation for being moderately and highly active; school-level differences accounted for 4.8% of the variability in the odds of being moderately active and 7.3% of the variability in the odds of being highly active. Students were more likely to be moderately active if they attended a school that used PA as a reward and not as discipline, and students were more likely to be highly active if they attended a school with established community partnerships. Important student characteristics included screen time sedentary behaviour, participating in team sports, and having active friends. CONCLUSION: Future research should evaluate if the optimal population level impact for school-based PA promotion programming might be achieved most economically if intervention selectively targeted the schools that are putting students at the greatest risk for inactivity.

Use of contraband cigarettes among adolescent daily smokers in Canada.

Current tobacco-control strategies seek to inhibit and reduce smoking among adolescents. However, such strategies are probably undermined by the contraband tobacco market. Using data from Canada's 2006/2007 Youth Smoking Survey, we found that 13.1% of respondents who were daily smokers reported that contraband cigarettes were their usual brand. They consumed significantly more cigarettes than respondents who smoked other brands. Contraband cigarettes accounted for about 17.5% of all cigarettes smoked by adolescent daily smokers in Canada overall, and for more than 25% in the provinces of Ontario and Quebec.

Susceptibility to smoking and its association with physical activity, BMI, and weight concerns among youth.

Research has yet to examine how physical activity, body mass index (BMI) and concerns about weight among youth populations are associated with susceptibility to smoking among never smokers. The Physical Activity Module of the School Health Action, Planning and Evaluation System (SHAPES) was completed by 25,060 students in grades 9 to 12 within 76 secondary schools in Ontario (Canada) to examine how being overweight, weight concerns, and physical activity are associated with susceptibility to smoking in a large sample of youth. Among the 14,795 students who were never smokers, 3,809 (25.8%) were classified as susceptible to future smoking and 10,986 (74.2%) were classified as non-susceptible to future smoking. Smoking susceptibility was negatively associated with being highly active or at risk of overweight and positively associated with perceptions of being slightly overweight or slightly underweight. Students who report 1 or more hours of screen or phone time per day were also more likely to be susceptible. This is the first study to identify that susceptibility to future smoking among never smokers is associated with physical activity, overweight and concerns about weight. This is valuable new insight for tailoring and targeting future school-based tobacco control and/or physical activity programming to youth populations.

Effective practices for school-based tobacco use prevention.

BACKGROUND: Research evidence addressing effectiveness of tobacco use prevention interventions has accumulated since the 1970s. Systematic reviews 1985-2006 were considered, building on previous syntheses and spanning tobacco control and prevention efforts to date. Practitioners' experience was drawn upon to supplement research evidence. METHODS: A systematic, comprehensive approach was used to synthesize published literature evaluating the effectiveness of school-based tobacco use prevention interventions. Systematic reviews conducted on all populations published in English, peer-reviewed journals were included. Reviews were screened for relevance and assessed for methodological quality using pre-tested, standardized tools. The best available evidence was extracted and integrated with experiential evidence from individual interview and focus group results from practitioners involved in tobacco use prevention programming. RESULTS: Considerable consensus among the three evidence sources indicates that school-based tobacco use prevention interventions are effective in reducing smoking prevalence, reducing smoking initiation and intended smoking intentions in the short term. There is adequate evidence from over three decades of research and years of experience to recommend ongoing implementation of school-based tobacco use prevention interventions. CONCLUSION: There is strong evidence that school-based tobacco use prevention programs are largely effective for most tobacco use related outcomes, at least in the short term.

Heterogeneity among adolescent non-daily smokers: implications for research and practice.

Cluster analysis modeling was used to identify distinct smoking taxonomies among 4,473 smokers from 29 secondary schools (2000-2001) in Ontario, Canada. Analyses revealed a two-cluster solution (4,349 [97.2%] situational smokers and 124 [2.8%] ubiquitous smokers). Different psychosocial characteristics influenced the smoking behavior of these unique groups. Our findings are substantially different from the traditional definitions for non-daily and daily smoking used in the literature, which typically impose rules about smoking frequency or volume when defining smoking status. These findings suggest that more robust taxonomies of youth smoking are required in future tobacco control research. The study's limitations are noted.