A study protocol for a predictive model to assess population-based avoidable hospitalization risk: Avoidable Hospitalization Population Risk Prediction Tool (AvHPoRT).

INTRODUCTION: Avoidable hospitalizations are considered preventable given effective and timely primary care management and are an important indicator of health system performance. The ability to predict avoidable hospitalizations at the population level represents a significant advantage for health system decision-makers that could facilitate proactive intervention for ambulatory care-sensitive conditions (ACSCs). The aim of this study is to develop and validate the Avoidable Hospitalization Population Risk Tool (AvHPoRT) that will predict the 5-year risk of first avoidable hospitalization for seven ACSCs using self-reported, routinely collected population health survey data. METHODS AND ANALYSIS: The derivation cohort will consist of respondents to the first 3 cycles (2000/01, 2003/04, 2005/06) of the Canadian Community Health Survey (CCHS) who are 18-74 years of age at survey administration and a hold-out data set will be used for external validation. Outcome information on avoidable hospitalizations for 5 years following the CCHS interview will be assessed through data linkage to the Discharge Abstract Database (1999/2000-2017/2018) for an estimated sample size of 394,600. Candidate predictor variables will include demographic characteristics, socioeconomic status, self-perceived health measures, health behaviors, chronic conditions, and area-based measures. Sex-specific algorithms will be developed using Weibull accelerated failure time survival models. The model will be validated both using split set cross-validation and external temporal validation split using cycles 2000-2006 compared to 2007-2012. We will assess measures of overall predictive performance (Nagelkerke R2), calibration (calibration plots), and discrimination (Harrell's concordance statistic). Development of the model will be informed by the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) statement. ETHICS AND DISSEMINATION: This study was approved by the University of Toronto Research Ethics Board. The predictive algorithm and findings from this work will be disseminated at scientific meetings and in peer-reviewed publications.

A national cohort study of community belonging and its influence on premature mortality.

BACKGROUND: Community belonging, an important constituent of subjective well-being, is an important target for improving population health. Ageing involves transitioning across different social conditions thus, community belonging on health may vary across the life course. Using a nationally representative cohort, this study estimates the life stage-specific impact of community belonging on premature mortality. METHODS: Six cycles of the Canadian Community Health Survey (2000-2012) were combined and linked to the Canadian Vital Statistics Database (2000-2017). Respondents were followed for up to 5 years. Multivariable-adjusted modified Poisson regression models were used to estimate the relative risk of premature mortality for three life stages: early adulthood (18-35 years), middle adulthood (36-55 years) and late adulthood (56-70 years). RESULTS: The final analytical sample included 477 100 respondents. Most reported a 'somewhat strong' sense of belonging (45.9%). Compared with their 'somewhat strong' counterparts, young adults reporting a 'somewhat weak' sense of belonging exhibited an increased relative risk (RR) of 1.76 (95% CI 1.27 to 2.43) for premature mortality, whereas middle-aged adults reporting the same exhibited a decreased RR of 0.82 (95% CI 0.69, 0.98). Among older adults, groups reporting a 'very strong' (RR 1.10, 95% CI 1.01, 1.21) or a 'very weak' sense (RR 1.14, 95% CI 1.01, 1.28) of belonging exhibited higher RRs for premature mortality. CONCLUSION: The results demonstrate how community belonging relates to premature mortality differs across age groups underscoring the importance of considering life stage-specific perspectives when researching and developing approaches to strengthen belonging.

"Whatever journey you want to take, I'll support you through": a mixed methods evaluation of a peer worker program in the hospital emergency department.

BACKGROUND: People who are unhoused, use substances (drugs and/or alcohol), and who have mental health conditions experience barriers to care access and are frequently confronted with discrimination and stigma in health care settings. The role of Peer Workers in addressing these gaps in a hospital-based context is not well characterized. The aim of this evaluation was to 1) outline the role of Peer Workers in the care of a marginalized populations in the emergency department; 2) characterize the impact of Peer Workers on patient care, and 3) to describe how being employed as a Peer Worker impacts the Peer. METHODS: Through a concurrent mixed methods evaluation, we explore the role of Peer Workers in the care of marginalized populations in the emergency department at two urban hospitals in Toronto, Ontario Canada. We describe the demographic characteristics of patients (n = 555) and the type of supports provided to patients collected through a survey between February and June 2022. Semi-structured, in-depth interviews were completed with Peer Workers (n = 7). Interviews were thematically analyzed using a deductive approach, complemented by an inductive approach to allow new themes to emerge from the data. RESULTS: Support provided to patients primarily consisted of friendly conversations (91.4%), discharge planning (59.6%), tactics to help the patient navigate their emotions/mental wellbeing (57.8%) and sharing their lived experience (50.1%). In over one third (38.9%) of all patient interactions, Peer Workers shared new information about the patient with the health care team (e.g., obtaining patient identification). Five major themes emerged from our interviews with Peer Workers which include: (1) Establishing empathy and building trust between the patient and their care team through self-disclosure; (2) Facilitating a person-centered approach to patient care through trauma-informed listening and accessible language; (3) Support for patient preferences on harm reduction; (4) Peer worker role facilitating self-acceptance and self-defined recovery; and (5) Importance of supports and resources to help Peer Workers navigate the emotional intensity of the emergency department. CONCLUSIONS: The findings add to the literature on Peer Worker programs and how such interventions are designed to best meet the needs of marginalized populations.

Towards a community-driven definition of community wellbeing: A qualitative study of residents.

BACKGROUND: Understanding what promotes or hinders a community's capacity to serve the priorities of its residents is essential for the alignment of citizen needs and governance. Participatory approaches that engage community residents on the topic of community wellbeing are useful methods for defining outcomes that reflect a community's goals and priorities. Using qualitative focus group methods, the aim of this study was to outline bottom-up definitions of community wellbeing from a diverse pool of community residents in Ontario, Canada. METHODS: Semi-structured, two-hour group interviews were conducted with adult (≥18 years) participants (N = 15) residing in four communities across Canada's largest province of Ontario. Participants were purposively selected from a pool of screening questionnaires to ensure diverse group compositions based on race, gender, age, and educational attainment. Interviews were thematically analysed using descriptive and interpretive methods to characterize resident conceptions of community wellbeing. RESULTS: Focus group participants were between 18 and 75 years of age and most had lived in their local community for 5 or more years. Four major themes emerged: (1) a sense of community belonging is cultivated through shared spaces, routines, support, and identities; (2) a community constitutes the amenities and social contexts that enable residents to thrive; (3) effective regional decision-making must be community-informed; and (4) the wellbeing of a community relies on equal opportunities for engagement and participation. CONCLUSIONS: Residents described their communities and their associated wellbeing as a combination of accessible amenities and opportunities to engage without marginalization. This study underscores the value of participatory approaches in community wellbeing research, where the viewpoint and life experience of residents is used to inform local decision-making and service delivery. Future research will capture more diverse perspectives towards community belonging, particularly from community newcomers, for the development of regionally appropriate indicators of community wellbeing.

Modelling population-level and targeted interventions of weight loss on chronic disease prevention in the Canadian population.

Obesity is a known risk factor for major chronic diseases. Prevention of chronic disease is a top global priority. The study aimed to model scenarios of population-level and targeted weight loss interventions on 10-year projected risk of chronic disease in Canada using a population-level risk prediction algorithm. The validated Chronic Disease Population Risk Tool (CDPoRT) forecasts 10-year risk of chronic disease in the adult population. We applied CDPoRT to the 2013/14 Canadian Community Health Survey to generate prospective chronic disease estimates for adults 20 years and older in Canada (n = 83,220). CDPoRT was used to model the following scenarios: British Columbia's (BC) and Quebec's (QC) provincial population-level weight reduction targets, a population-level intervention that could achieve weight loss, targeted weight loss interventions for overweight and obese groups, and the combination of a population-level and targeted weight loss intervention. We estimated chronic disease risk reductions and number of cases prevented in each scenario compared with the baseline. At baseline, we predicted an 18.4% risk and 4,151,929 new cases of chronic disease in Canada over the 10-year period. Provincial weight loss targets applied to the Canadian population estimated chronic disease reductions of 0.6% (BC) and 0.1% (QC). The population-level intervention estimated a greater reduction in risk (0.2%), compared to the targeted interventions (0.1%). The combined approach estimated a 0.3% reduction in chronic disease risk. Our modelling predicted that population-level approaches that achieve weight loss in combination with targeted weight loss interventions can substantially decrease the chronic disease burden in Canada.

Experiences and Reported Outcomes of Patients and Caregivers Enrolled in an Integrated Care Program for Thoracic Surgery: A Qualitative Evaluation.

Background: Health care delivery is often poorly coordinated and fragmented. Integrated care (IC) programs represent one solution to improving continuity of care. The aim of this study was to understand experiences and reported outcomes of patients and caregivers in an IC Program that coordinates hospital and home care for thoracic surgery. Methods: A process evaluation was undertaken using qualitative methods. We conducted semi-structured interviews with 10 patients and 8 caregivers who received IC for thoracic surgery and were discharged between June 2019 and April 2020. A phenomenological approach was used to understand and characterize patient and caregiver experiences. Thematic analysis began with a deductive approach complemented by an inductive approach. Results: Four major themes evolved from patient and caregiver interviews, including 1) coordination and timeliness of patient care facilitated by an IC lead; 2) the provision of person-centred care and relational continuity fostered feelings of partnership with patients and caregivers; 3) clear communication and one shared digital record increased informational continuity; and 4) impacts of IC on patient and caregiver outcomes. Conclusions: Patients and caregivers generally reported this IC Program met their health care needs, which may help inform how future IC programs are designed.

A retrospective population-based analysis of wait times for cataract surgery in Ontario, Canada.

BACKGROUND: Current methods used to estimate surgical wait times in Ontario may be subject to inconsistencies and inaccuracies. In this population-level study, we aimed to estimate cataract surgery wait times in Ontario using a novel, objective and data-driven method. METHODS: We identified adults who underwent cataract surgery between 2005 and 2019 in Ontario, using administrative records. Wait time 1 represented the number of days from referral to initial visit with the surgeon, and wait time 2 represented the number of days from the decision for surgery until the first eye surgery date. In the primary analysis, a ranking method prioritized referrals from optometrists, followed by ophthalmologists and family physicians. RESULTS: The cohort consisted of 1 138 532 people with mostly female patients (57.4%) and those aged 65 years and older (79.0%). In the primary analysis, the median was 67 days for wait time 1 (interquartile range [IQR] 29-147). There was a median of 77 days for wait time 2 (IQR 37-155). Overall, the following proportions of patients waited less than 3, 6 and 12 months: 54.1%, 78.5% and 91.7%, respectively. For wait time 2, the proportions of patients who waited less than 3, 6 and 12 months were 49.5%, 77.1% and 93.3%, respectively. In total, 19.3% of patients did not meet the provincial target for wait time 1, 20.5% did not meet the target for wait time 2 and 35.0% did not meet the target for wait times 1 or 2. INTERPRETATION: Administrative health services data can be used to estimate cataract surgery wait times. With this method, 35.0% of patients in 2005-2019 did not receive initial consultation or surgery within the provincial wait time target.

Can the Healthcare System Improve Food Security? A Need for Collaborative Community Partnerships.

The COVID-19 pandemic has heightened the food insecurity crisis in Canada, and existing supports have been largely insufficient to meet the food needs of communities. In response to increasing reports of food insecurity among Toronto residents during the pandemic, the Food RX program was developed as a collaborative initiative between FoodShare Toronto - a local, community-based food justice organization - and the University Health Network, a large university-affiliated hospital network in downtown Toronto, ON. This commentary describes the Food RX program, highlights the lessons learned during its early implementation and offers a set of recommendations for building community partnerships moving forward.

Human factors applications in the design of decision support systems for population health: a scoping review.

INTRODUCTION: Public health professionals engage in complex cognitive tasks, often using evidence-based decision support tools to bolster their decision-making. Human factors methods take a user-centred approach to improve the design of systems, processes, and interfaces to better support planning and decision-making. While human factors methods have been applied to the design of clinical health tools, these methods are limited in the design of tools for population health. The objective of this scoping review is to develop a comprehensive understanding of how human factors techniques have been applied in the design of population health decision support tools. METHODS AND ANALYSIS: The scoping review will follow the methodology and framework proposed by Arksey and O'Malley. We include English-language documents between January 1990 and August 2021 describing the development, validation or application of human factors principles to decision support tools in population health. The search will include Ovid MEDLINE: Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid MEDLINE 1946-present; EMBASE, Scopus, PsycINFO, Compendex, IEEE Xplore and Inspec. The results will be integrated into Covidence. First, the abstract of all identified articles will be screened independently by two reviewers with disagreements being resolved by a third reviewer. Next, the full text for articles identified as include or inconclusive will be reviewed by two independent reviewers, leading to a final decision regarding inclusion. Reference lists of included articles will be manually screened to identify additional studies. Data will be extracted by one reviewer, verified by a second, and presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. ETHICS AND DISSEMINATION: Ethics approval is not required for this work as human participants are not involved. The completed review will be published in a peer-reviewed, interdisciplinary journal.

Is life satisfaction associated with future mental health service use? An observational population-based cohort study.

OBJECTIVE: To investigate the prospective association between life satisfaction and future mental health service use in: (1) hospital/emergency department, and (2) outpatient settings. DESIGN AND SETTING: Population-based cohort study of adults from Ontario, Canada. Baseline data were captured through pooled cycles of the Canadian Community Health Survey (CCHS 2005-2014) and linked to health administrative data for up to 5 years of follow-up. PARTICIPANTS: 131 809 Ontarians aged 18 years and older. MAIN OUTCOME MEASURE: The number of mental health-related visits in (1) hospitals/emergency department and (2) outpatient settings within 5 years of follow-up. RESULTS: Poisson regression models were used to estimate rate ratios in each setting, adjusting for sociodemographic measures, history of mental health-related visits, and health behaviours. In the hospital/emergency setting, compared to those most satisfied with life, those with the poorest satisfaction exhibited a rate ratio of 3.71 (95% CI 2.14 to 6.45) for future visits. In the outpatient setting, this same comparison group exhibited a rate ratio of 1.83 (95% CI 1.42 to 2.37). When the joint effects of household income were considered, compared with the highest income and most satisfied individuals, the least satisfied and lowest income individuals exhibited the highest rate ratio in the hospital/emergency setting at 11.25 (95% CI 5.32 to 23.80) whereas in the outpatient setting, the least satisfied and highest income individuals exhibited the highest rate ratio at 3.33 (95% CI 1.65 to 6.70). CONCLUSION: The findings suggest that life satisfaction is a risk factor for future mental health visits. This study contributes to an evidence base connecting positive well-being with health system outcomes.

Predictors of perceived success in quitting smoking by vaping: A machine learning approach.

Prior research has suggested that a set of unique characteristics may be associated with adult cigarette smokers who are able to quit smoking using e-cigarettes (vaping). In this cross-sectional study, we aimed to identify and rank the importance of these characteristics using machine learning. During July and August 2019, an online survey was administered to a convenience sample of 889 adult smokers (age ≥ 20) in Ontario, Canada who tried vaping to quit smoking in the past 12 months. Fifty-one person-level characteristics, including a Vaping Experiences Score, were assessed in a gradient boosting machine model to classify the status of perceived success in vaping-assisted smoking cessation. This model was trained using cross-validation and tested using the receiver operating characteristic (ROC) curve. The top five most important predictors were identified using a score between 0% and 100% that represented the relative importance of each variable in model training. About 20% of participants (N = 174, 19.6%) reported success in vaping-assisted smoking cessation. The model achieved relatively high performance with an area under the ROC curve of 0.865 and classification accuracy of 0.831 (95% CI [confidence interval] 0.780 to 0.874). The top five most important predictors of perceived success in vaping-assisted smoking cessation were more positive experiences measured by the Vaping Experiences Score (100%), less previously failed quit attempts by vaping (39.0%), younger age (21.9%), having vaped 100 times (16.8%), and vaping shortly after waking up (15.8%). Our findings provide strong statistical evidence that shows better vaping experiences are associated with greater perceived success in smoking cessation by vaping. Furthermore, our study confirmed the strength of machine learning techniques in vaping-related outcomes research based on observational data.

Governing partnerships with technology companies as part of the COVID-19 response in Canada: A qualitative case study.

Cross-sector partnerships are vital for maintaining resilient health systems; however, few studies have sought to empirically assess the barriers and enablers of effective and responsible partnerships during public health emergencies. Through a qualitative, multiple case study, we analyzed 210 documents and conducted 26 interviews with stakeholders in three real-world partnerships between Canadian health organizations and private technology startups during the COVID-19 pandemic. The three partnerships involved: 1) deploying a virtual care platform to care for COVID-19 patients at one hospital, 2) deploying a secure messaging platform for physicians at another hospital, and 3) using data science to support a public health organization. Our results demonstrate that a public health emergency created time and resource pressures throughout a partnership. Given these constraints, early and sustained alignment on the core problem was critical for success. Moreover, governance processes designed for normal operations, such as procurement, were triaged and streamlined. Social learning, or the process of learning from observing others, offset some time and resource pressures. Social learning took many forms ranging from informal conversations between individuals at peer organisations (e.g., hospital chief information officers) to standing meetings at the local university's city-wide COVID-19 response table. We also found that startups' flexibility and understanding of the local context enabled them to play a highly valuable role in emergency response. However, pandemic fueled "hypergrowth" created risks for startups, such as introducing opportunities for deviation away from their core value proposition. Finally, we found each partnership navigated intense workloads, burnout, and personnel turnover through the pandemic. Strong partnerships required healthy, motivated teams. Visibility into and engagement in partnership governance, belief in partnership impact, and strong emotional intelligence in managers promoted team well-being. Taken together, these findings can help to bridge the theory-to-practice gap and guide effective cross-sector partnerships during public health emergencies.

Real-world vaping experiences and smoking cessation among cigarette smoking adults.

INTRODUCTION: E-cigarettes may have the potential to be an effective cessation aid for some cigarette smokers. However, the extent to which smokers' experiences using e-cigarettes (vaping) to quit smoking impact their cessation outcomes is unclear. In this cross-sectional survey study, we develop a multidimensional measure of vaping experiences in adults who quit smoking by vaping and test its association with perceived success in smoking cessation. METHODS: In 2019, recruitment invitations were emailed to adult past-year smokers who had accessed cessation services across Ontario, Canada. Respondents who tried vaping to quit smoking in the past year completed a detailed online survey. Factor analysis was performed on ratings of 45 vaping experiences items to identify dimensions of vaping experiences. Factor scores were entered into logistic regressions to test if vaping experiences dimensions had differential impact on perceived success in smoking cessation. RESULTS: Of the 889 participants, 56.0% were female, 81.1% were Caucasian, and the mean age was 37.7 ± 11.9 years. Twenty percent (19.6%) reported having successfully quit smoking by vaping in the past year. Among the six vaping experiences factors, better experiences in five factors-Relationships, Flexibility of Vaping, Side Effects, Vaping Devices, and Sensory Functions-were each independently and positively associated with improved odds of successful quitting. Notably, Relationships [OR = 2.01, 95% CI: 1.61-2.64] and Side Effects [OR = 1.95; 95% CI 1.54-2.29] were the strongest correlates of perceived success in smoking cessation. CONCLUSIONS: These findings indicate an opportunity to increase cessation rates by improving the experiences of smokers who vape to quit smoking.

Perceived addiction to vaping among youth and young adult regular vapers.

BACKGROUND: The prevalence of e-cigarette use among youth and young adults has increased markedly in recent years; however, little is known about young people's perceptions of e-cigarette addiction. This study examines factors associated with self-reported addiction to e-cigarette use among this population. METHODS: In 2018, 1048 Canadians aged 16-25 years were recruited through online social media platforms to complete a survey. Quota sampling was used to oversample regular e-cigarette users (vaping at least weekly); these 578 regular users were included in this analysis. Self-perceived addiction was assessed by asking participants if they felt they were 'very', 'somewhat' or 'not at all' addicted to e-cigarettes. A proportional odds model was employed to identify factors associated with the ordinal outcome. RESULTS: Almost half of regular users perceived themselves to be 'not at all addicted', 41% felt they were 'somewhat addicted' and 13% felt they were very addicted to e-cigarettes. Women, former cigarette smokers, daily vapers and those vaping for more than a year were more likely to report higher levels of perceived addiction. Similarly, high sensation-seeking youth, those reading blogs and websites about vaping, those frequently dripping and those using higher nicotine strengths had a greater likelihood of higher perceived addiction than their respective counterparts. CONCLUSION: More than half of youth and young adult regular e-cigarette users felt they had some level of addiction. The findings identify possible opportunities for targeted programming for education and treatment, as well as potential opportunities for policy change such as maximum allowable nicotine strengths.

A study protocol for a predictive algorithm to assess population-based premature mortality risk: Premature Mortality Population Risk Tool (PreMPoRT).

BACKGROUND: Premature mortality is an important population health indicator used to assess health system functioning and to identify areas in need of health system intervention. Predicting the future incidence of premature mortality in the population can facilitate initiatives that promote equitable health policies and effective delivery of public health services. This study protocol proposes the development and validation of the Premature Mortality Risk Prediction Tool (PreMPoRT) that will predict the incidence of premature mortality using large population-based community health surveys and multivariable modeling approaches. METHODS: PreMPoRT will be developed and validated using various training, validation, and test data sets generated from the six cycles of the Canadian Community Health Survey (CCHS) linked to the Canadian Vital Statistics Database from 2000 to 2017. Population-level risk factor information on demographic characteristics, health behaviors, area level measures, and other health-related factors will be used to develop PreMPoRT and to predict the incidence of premature mortality, defined as death prior to age 75, over a 5-year period. Sex-specific Weibull accelerated failure time models will be developed using a Canadian provincial derivation cohort consisting of approximately 500,000 individuals, with approximately equal proportion of males and females, and about 12,000 events of premature mortality. External validation will be performed using separate linked files (CCHS cycles 2007-2008, 2009-2010, and 2011-2012) from the development cohort (CCHS cycles 2000-2001, 2003-2004, and 2005-2006) to check the robustness of the prediction model. Measures of overall predictive performance (e.g., Nagelkerke's R2), calibration (e.g., calibration plots), and discrimination (e.g., Harrell's concordance statistic) will be assessed, including calibration within defined subgroups of importance to knowledge users and policymakers. DISCUSSION: Using routinely collected risk factor information, we anticipate that PreMPoRT will produce population-based estimates of premature mortality and will be used to inform population strategies for prevention.

Relationship between sense of community belonging and self-rated health across life stages.

BACKGROUND: Health interventions aimed at facilitating connectedness among seniors have recently gained traction, seeing as social connectedness is increasingly being recognized as an important determinant of health. However, research examining the association between connectedness and health across all age groups is limited, and few studies have focused on community belonging as a tangible aspect of social connectedness. Using a population-based Canadian cohort, this study aims to investigate (1) the associations between community belonging with self-rated general health and self-rated mental health, and (2) how these associations differ across life stages. METHODS: Data from six cycles of a national population health survey (Canadian Community Health Survey) from 2003 to 2014 were combined. Multinomial logistic regressions were run for both outcomes on the overall study sample, as well as within three age strata: (1) 18-39, (2) 40-59, and (3) ≥ 60 years old. RESULTS: Weaker community belonging exhibited an association with both poorer general and mental health, though a stronger association was observed with mental health. These associations were observed across all three age strata. In the fully adjusted model, among those reporting a very weak sense of community belonging, the odds of reporting the poorest versus best level of health were 3.21 (95% CI: 3.11, 3.31) times higher for general health, and 4.95 (95% CI: 4.75, 5.16) times higher for mental health, compared to those reporting a very strong sense of community belonging. The largest effects among those reporting very weak community belonging were observed among those aged between 40 and 59 years old. CONCLUSION: This study contributed to the evidence base supporting life stage differences in the relationship between community belonging and self-perceived health. This is a starting point to identifying how age-graded differences in unmet social needs relate to population health interventions.

Predictors of E-Cigarette Initiation: Findings From the Youth and Young Adult Panel Study.

OBJECTIVES: Although previous studies have identified reasons why youth try e-cigarettes, longitudinal research is needed to identify predictors of e-cigarette initiation. This study assesses predictors of e-cigarette initiation among youth and young adults in the 2018-2019 Youth and Young Adult Panel Study. METHODS: This study examined the proportion of Canadian participants aged 16 to 25 (n = 137) reporting never use of e-cigarettes at baseline in 2018. Individuals were categorized as not initiated and initiated at 12-month follow-up. We examined demographic characteristics, substance use, health status, social influences and perception by initiation category. Adjusted odds ratios (AORs) were calculated using logistic regression models and multivariable logistic regression model. RESULTS: Among the 137 never e-cigarette users at baseline, 59% remained never users while 41% initiated use of e-cigarettes during the 12-month follow-up. The results of multivariable logistic regression analysis showed that regularly seeing anyone use e-cigarettes (AOR: 4.11; 95% CI: 1.04, 16.31) and seeing anyone use e-cigarettes very often or always at baseline (AOR: 4.54; 95% CI: 1.21, 17.01) is associated with initiating e-cigarette use among youth and young adults. CONCLUSION: The results revealed social influences to be the most important predictors of initiation among youth and young adults. Interventions to prevent youth and young adults from initiating e-cigarette use should expand from only focusing on peer use to reducing use in public space such as parks and recreational facilities.

Real-World Effectiveness of Pharmaceutical Smoking Cessation Aids: Time-Varying Effects.

BACKGROUND: There are a limited number of studies that have examined the real-world effectiveness of smoking cessation aids and relapse longitudinally in population-representative samples. This study examines the association between use of nicotine gum, patch, bupropion, and varenicline and time to relapse as well as any changes in the association with increased length of abstinence. METHODS: Data of 1821 current adult smokers (18+) making their first serious quit attempt were compiled from 4504 individuals enrolled in the Ontario Tobacco Survey, a representative telephone survey of Ontario adults, which followed smokers every 6 months for up to 3 years. Use of cessation aids at the time of initial report of a quit attempt was analyzed. A flexible parametric survival model was developed to model length of abstinence, controlling for potential confounders. RESULTS: The best fit model found knots at 3, 13, 43, and 212 days abstinent, suggesting different rates of relapse in the periods marked by those days. Use of the patch and varenicline was associated with lower rates of relapse, but no positive effect was found for bupropion or nicotine gum. The effectiveness of the patch reversed in effect after the first month of abstinence. CONCLUSIONS: This study is one of few reports of long-term quitting in a population-representative sample and demonstrates that the effectiveness of some pharmacological cessation aids (the patch and varenicline can be seen in a population sample). Previous failures in real-world studies of the effectiveness of smoking cessation aids may reflect differences in the products individuals use and differences in the timing of self-reported cessation. IMPLICATIONS: While a large number of randomized controlled trials have shown the efficacy of many pharmaceutical smoking cessation aids, evidence of their effectiveness in observational studies in the real world is ambiguous. This study uses a longitudinal cohort of a representative sample of smokers to show that the effectiveness of pharmaceutical cessation aids can be demonstrated in real-world use situations, but effectiveness varies by product type and has time-varying effects.

Marketing IQOS in a dark market.

INTRODUCTION: Phillip Morris International (PMI) is pushing hard to promote IQOS heat-not-burn cigarettes in Ontario, Canada. Canada regulates IQOS as a tobacco product so that the robust tobacco marketing ban creates challenges to its promotion. METHODS: We collected data on IQOS promotion in 49 retail outlets, and through interviews with clerks and observations outside an IQOS store. RESULTS: The dominant marketing channel is the visible availability of IQOS in a large number of tobacco retail outlets-1029 across Ontario. Several stores display the price of 'heated tobacco' on one of three price signs which are permitted despite Ontario's total display ban. IQOS boutique stores are the locus of aggressive promotion including exchanging a pack of cigarettes or lighter for an IQOS device, launch parties, 'meet and greet' lunches and after-hour events. Outside the store, promotion includes a prominent IQOS sign, a sandwich board sign reading 'Building a Smoke-Free Future' and sales representatives regularly smoking IQOS. Membership services: Upon acquiring an IQOS device one can register to access the IQOS website store5 and receive customer support services, a map of retail locations and a product catalogue. Members receive regular email invitations to complete surveys with opportunities to win prizes. CONCLUSIONS: These promotion activities have undoubtedly made substantial numbers of Ontarians aware of IQOS. Yet, the government has not provided guidance as to absolute and relative potential harms. Our observations of tactics to promote a new tobacco product in a dark market may inform government regulatory policy and non-governmental organisation efforts wherever heat-not-burn products are introduced.