Cannabis Use Among Adults in Cigarette Smoking Cessation Treatment in Ontario, Canada: Prevalence and Association With Tobacco Cessation Outcome, 2015-2021.

Objectives. To examine cannabis use prevalence and its association with tobacco cessation among adults enrolled in cigarette smoking cessation treatment before and after Canada legalized recreational cannabis in October 2018. Methods. The sample comprised 83 206 adults enrolled in primary care-based cigarette smoking cessation treatment between 2015 and 2021 in Ontario, Canada. Past-30-day cannabis use was self-reported at enrollment and cigarette smoking abstinence at 6-month follow-up. Results. Past-30-day prevalence of cannabis use increased from 20.2% in 2015 to 37.7% in 2021. The prevalence increased linearly both before and after legalization. Cannabis and tobacco co-use was associated with lower odds of self-reported cigarette smoking abstinence at 6-month follow-up than tobacco use only (24.4% vs 29.3%; odds ratio [OR] = 0.78; 95% confidence interval [CI] = 0.75, 0.81). This association was attenuated after adjustment for covariates (OR = 0.93; 95% CI = 0.89, 0.97) and weakened slightly over time. Conclusions. Cannabis use prevalence almost doubled from 2015 to 2021 among primary care patients in Ontario seeking treatment to quit cigarettes and was associated with poorer quit outcomes. Further research into the impact of cannabis policy on cannabis and tobacco co-use is warranted to mitigate harm. (Am J Public Health. 2024;114(1):98-107. https://doi.org/10.2105/AJPH.2023.307445).

Concurrent E-cigarette Use While Enrolled in a Smoking Cessation Program: Associations Between Frequency of Use, Motives for Use, and Smoking Cessation.

INTRODUCTION: Trial evidence suggests that e-cigarettes may aid in quitting smoking, while observational studies have found conflicting results. However, many observational studies have not adjusted for important differences between e-cigarette users and non-users. AIMS AND METHODS: We aimed to determine the association between e-cigarette use frequency and motivation to use e-cigarettes to quit smoking, and smoking cessation using data from Canada's largest smoking cessation program. Participants who completed a baseline assessment and 6-month follow-up questionnaire were divided post hoc into four groups based on their self-reported e-cigarette use during the 30 days before baseline: (1) non-users; (2) users of e-cigarettes not containing nicotine; (3) occasional users; and (4) frequent users. Occasional and frequent users were further divided into two groups based on whether they reported using e-cigarettes to quit smoking. Abstinence at 6-month follow-up (7-day point prevalence abstinence) was compared among groups. RESULTS: Adjusted quit probabilities were significantly higher (both p < .001) for frequent baseline e-cigarette users (31.6%; 95% CI = 29.3%, 33.8%) than for non-users (25.8%; 25.3% and 26.3%) or occasional users (24.2%; 22.5% and 26.0%). Unadjusted proportions favored non-users over occasional users (p < .001), but this was not significant after adjustment (p = .06). People using e-cigarettes to quit smoking were not likelier than other users to be successful, but were likelier to report frequent e-cigarette use during follow-up. CONCLUSIONS: Frequent baseline e-cigarette use predicted successful smoking cessation, compared to occasional and non-users. Use of e-cigarettes to quit did not predict smoking cessation but was associated with continued use during follow-up, perhaps due in part to planned transitions to e-cigarettes. IMPLICATIONS: Prior observational studies investigating e-cigarette use for smoking cessation have found that occasional users have poorer outcomes than either frequent or non-users. Consistent with these studies, occasional users in our data also had poorer outcomes. However, after adjustment for variables associated with cessation success, we found that cessation probabilities did not differ between occasional and non-users. These findings are consistent with trial data showing the benefit of e-cigarette use among people trying to quit smoking. Results of this study suggest that differences between trials and previous observational studies may be because of unaddressed confounding in the latter.

Cumulative Prenatal Risk Factors and Developmental Coordination Disorder in Young Children.

OBJECTIVES: To examine the effect of cumulative prenatal risk factors (RFs) on the presence of Developmental Coordination Disorder (DCD) in young children. METHODS: Participants (N = 589, 338 boys, Mage = 4.5 ± 0.5 years) were from a larger cohort study, the Coordination and Activity Tracking in Children (CATCH). Motor coordination was assessed using the Movement Assessment Battery for Children- 2nd Edition. Children were classified as at risk for DCD (DCDr) based on European Academy of Childhood Disability guidelines. RFs were obtained through a parent-completed survey. A multiple logistic regression was conducted to examine the effect of the RFs on DCD. RESULTS: Results showed that the odds of a child having DCDr are significantly higher with a greater total number of prenatal RFs, after adjustment for mother's age at child's birth, child's sex, child's age, marital status and total annual household income (OR = 1.48, p < 0.01). CONCLUSIONS: These findings warrant further investigation into the cumulative impact of multiple prenatal RFs and whether specific combinations of RFs might be more strongly linked to DCD than others. These results provide additional insight into possible causes and prevention of DCD.

Effectiveness of Bupropion and Varenicline for Smokers With Baseline Depressive Symptoms.

INTRODUCTION: Smokers with concurrent depression are less likely to achieve abstinence, even with pharmacotherapy. The purpose of this secondary data analysis was to evaluate if the presence of any depressive symptoms at baseline alters the effectiveness of bupropion and varenicline for smoking cessation. AIMS AND METHODS: Eligible participants were enrolled via the internet and randomized 1:1 to receive a 12-week supply of either bupropion (n = 465) or varenicline (n = 499). Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-2). Follow-up surveys were conducted at weeks 4, 8, 12, 26, and 52 to assess self-reported quit. The primary outcome was 7-day point prevalence abstinence at 12 weeks follow-up (end-of-treatment). RESULTS: Participants who endorsed any depressive symptoms (PHQ-2 > 0; n = 280) were less likely to be quit at end-of-treatment compared to participants who did not endorse any symptoms (PHQ-2 = 0; n = 684) (OR = 0.56, 95% CI: 0.38 to 0.8, p = .003). Within the varenicline group, quit outcomes did not differ between those with and without depressive symptoms (21.3% vs. 26.9%, respectively). Within the bupropion group, however, those with symptoms had a significantly reduced quit rate compared to those without symptoms (7.0% vs. 17.3%, respectively). CONCLUSIONS: The presence of even one symptom of depression at the start of a quit attempt may adversely affect quit outcomes. Patients should be assessed for depressive symptoms when planning to quit smoking as it may inform the approach to treatment. However, future studies are needed to confirm these findings. IMPLICATIONS: Findings from the current study illustrate the importance of evaluating baseline sub-clinical depressive symptoms before a quit attempt using first-line pharmacotherapies. This secondary analysis of a large-scale randomized trial suggests that bupropion may be less effective for those with baseline depressive symptoms while varenicline may be equally effective for those with and without depressive symptoms.

Outcomes Among People With Schizophrenia Participating in General-Population Smoking Cessation Treatment: An Observational Study.

OBJECTIVE: People with schizophrenia are much more likely than others to smoke tobacco, raising risks of disease and premature mortality. These individuals are also less likely to quit successfully after treatment, but the few existing clinical and observational studies have been limited by small sample sizes, and have generally considered specialized treatment approaches. In this analysis, we examine outcomes, service use, and potential explanatory variables in a large sample of people with schizophrenia treated in a general-population cessation program. METHOD: Our sample comprised 3,011 people with schizophrenia and 77,790 controls receiving free nicotine replacement therapy through 400 clinics and health centres. We analysed self-reported 7-day abstinence or reduction at 6-month follow-up, as well as the number of visits attended and self-reported difficulties in quitting. We adjusted for demographic, socioeconomic, and health variables, and used multiple imputation to address missing data. RESULTS: Abstinence was achieved by 16.2% (95% confidence interval [CI], 14.5% to 17.8%) of people with schizophrenia and 26.4% (95% CI, 26.0% to 26.7%) of others (absolute difference = 10.2%; 95% CI, 8.5% to 11.9%; P < 0.001). After adjustment, this difference was reduced to 7.3% (95% CI, 5.4% to 9.3%; P < 0.001). Reduction in use was reported by 11.8% (95% CI, 10.3% to 13.3%) and 12.5% (95% CI, 12.2% to 12.8%), respectively; this difference was nonsignificant after adjustment. People with schizophrenia attended more clinic visits (incidence rate ratio [IRR] = 1.15, 95% CI = 1.12% to 1.18%, P < 0.001) and reported more difficulties related to "being around other smokers" (odds ratio [OR] = 1.28; 95% CI, 1.11% to 1.47%; P = 0.001). CONCLUSION: There is abundant demand for tobacco cessation treatment in this population. Outcomes were substantially poorer for people with schizophrenia, and this difference was not explained by covariates. Cessation remained much better than for unaided quit attempts, however, and engagement was high, demonstrating that people with schizophrenia benefit from nonspecialized pharmacological treatment programs.

Effects of COVID-19-Related Disruptions on Service Use in a Large Smoking Cessation Program.

INTRODUCTION: The COVID-19 pandemic caused a rapid shift to virtual care, with largely unknown consequences for accessibility. The purpose of this study is to examine pandemic-related changes in use of care for smoking cessation. AIMS AND METHODS: We conducted a secondary analysis 65 565 enrollments in a large smoking cessation program in Ontario, Canada. We used piecewise mixed-effects regression to examine how weeks nicotine replacement therapy (NRT) received, as well as counseling provided and visits attended, varied with date of enrollment over three time periods: more than 6 months before the pandemic began; the 6 months before the pandemic; and the pandemic period itself. We then examined changes in the associations between use of care and participant characteristics by fitting a model including a set of interactions between time and other variables. Based on an omnibus test of these interactions, we then tested individual terms, using the Holm method to control the family-wise error rate. RESULTS: From the start of the pandemic in March 2020, the total weeks of NRT provided rose significantly and then declined, while the amount of counseling fell. Associations between NRT use and participant characteristics changed significantly after the pandemic onset. Individual models showed that people with lower income, living in areas of higher marginalization, unable to work, and reporting higher levels of depressive symptoms all received NRT for a longer time during the pandemic period. CONCLUSIONS: The pandemic led to small but significant changes in the amount of services used per enrollment. The transition to remote care appears to have reduced the effects of socioeconomic and health barriers. IMPLICATIONS: The amount of care used by participants in tobacco cessation treatment is known to be associated with health and sociodemographic characteristics. Most of these associations did not change markedly following the pandemic-related switch to virtual care in 2020; however, the effects of some economic and health barriers seem to have lessened, perhaps because of a likely reduction in transport and time requirements of treatment.

Treatment use patterns in a large extended-treatment tobacco cessation program: predictors and cost implications.

BACKGROUND: Tobacco dependence follows a chronic and relapsing course, but most treatment programmes are short. Extended care has been shown to improve outcomes. Examining use patterns for longer term programmes can quantify resource requirements and identify opportunities for improving retention. METHODS: We analyse 38 094 primary care treatment episodes from a multisite smoking cessation programme in Ontario, Canada that provides free nicotine replacement therapy (NRT) and counselling. We calculate distributional measures of weeks of NRT used, clinical visits attended and total length of care. We then divide treatment courses into four exclusive categories and fit a multinomial logistic regression model to measure associations with participant characteristics, using multiple imputation to address missing data. RESULTS: Time in treatment (median=50 days), visits (median=3) and weeks NRT used (median=8) were well below the maximum available. Of all programme enrolments, 28.8% (95% CI=28.3% to 29.3%) were single contacts, 31.3% (30.8% to 31.8%) lasted <12 weeks, 19.2% (18.8% to 19.6%) were ≥12 weeks with an 8-week interruption and 20.7% (20.3%-21.1%) were ≥12 weeks without interruptions. Care use was most strongly associated with participant age and whether the nicotine patch was dispensed at the first visit. CONCLUSION: Treatment use results imply that the marginal costs of extending treatment programmes are relatively low. The prevalence of single contacts supports additional engagement efforts at the initial visit, while interruptions in care highlight the ability of longer term care to address relapse. Results show that use of the nicotine patch is associated with retention in care, and that improving engagement of younger patients should be a priority.

The Impact of a Clinical Decision Support System for Addressing Physical Activity and Healthy Eating During Smoking Cessation Treatment: Hybrid Type I Randomized Controlled Trial.

BACKGROUND: People who smoke have other risk factors for chronic diseases, such as low levels of physical activity and poor diet. Clinical decision support systems (CDSSs) might help health care practitioners integrate interventions for diet and physical activity into their smoking cessation programming but could worsen quit rates. OBJECTIVE: The aims of this study are to assess the effects of the addition of a CDSS for physical activity and diet on smoking cessation outcomes and to assess the implementation of the study. METHODS: We conducted a pragmatic hybrid type I effectiveness-implementation trial with 232 team-based primary care practices in Ontario, Canada, from November 2019 to May 2021. We used a 2-arm randomized controlled trial comparing a CDSS addressing physical activity and diet to treatment as usual and used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to measure implementation outcomes. The primary outcome was self-reported 7-day tobacco abstinence at 6 months. RESULTS: We enrolled 5331 participants in the study. Of these, 2732 (51.2%) were randomized to the intervention group and 2599 (48.8%) to the control group. At the 6-month follow-up, 29.7% (634/2137) of respondents in the intervention arm and 27.3% (552/2020) in the control arm reported abstinence from tobacco. After multiple imputation, the absolute group difference was 2.1% (95% CI -0.5 to 4.6; F1,1000.42=2.43; P=.12). Mean exercise minutes changed from 32 (SD 44.7) to 110 (SD 196.1) in the intervention arm and from 32 (SD 45.1) to 113 (SD 195.1) in the control arm (group effect: B=-3.7 minutes; 95% CI -17.8 to 10.4; P=.61). Servings of fruit and vegetables changed from 2.64 servings to 2.42 servings in the intervention group and from 2.52 servings to 2.45 servings in the control group (incidence rate ratio for intervention group=0.98; 95% CI 0.93-1.02; P=.35). CONCLUSIONS: A CDSS for physical activity and diet may be added to a smoking cessation program without affecting the outcomes. Further research is needed to improve the impact of integrated health promotion interventions in primary care smoking cessation programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04223336 https://www.clinicaltrials.gov/ct2/show/NCT04223336. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/19157.

The Effectiveness of Nicotine Replacement Therapy in Light Versus Heavier Smokers.

INTRODUCTION: The prevalence of light smoking has increased in North America; however, research on the effectiveness of current treatments in this subpopulation of smokers is limited. We compared quit outcomes between light (1-10 cigarettes per day [CPD]) versus heavier smokers (>10 CPD) enrolled in a treatment program at their primary care clinic. AIMS AND METHODS: This secondary analysis analyzed 45 087 participants (light smokers [n = 9861]; heavier smokers [n = 35 226]) enrolled in a smoking cessation program between April 2016 and March 2020. The program offered cost-free nicotine replacement therapy (NRT) plus in-person counseling. Type, dose, and duration of NRT treatment were personalized. Data were collected at baseline, and at 6 months following enrollment to assess 7-day point prevalence abstinence (PPA), the primary outcome variable of interest. Logistic regression models were used for analyses. RESULTS: Seven-day PPA at 6 months was significantly higher among light smokers (30.6%) than heavier smokers (26.0%; odds ratio = 1.25, 95% confidence interval = 1.18-1.33, p < .001). Heavier smokers were prescribed more weeks of NRT than light smokers (B = 0.82, 95% confidence interval = 0.64-1.0, p < .001). The association between smoking cessation and daily NRT dose did not differ between groups (p = .98). However, a stronger positive relationship between the number of clinic visits attended and 7-day PPA was found among heavier smokers in comparison to light smokers (p < .001). All findings remained significant after adjusting for baseline variables. CONCLUSIONS: There is a paucity of scientific literature on the effectiveness of NRT for light smokers. Our findings suggest that individualized doses of NRT may be helpful in these subpopulations, and highlight the different treatment needs of light smokers. IMPLICATIONS: Current clinical guidelines do not provide formal recommendations for light smokers who want to quit smoking. Similar to heavy smokers, light smokers are at substantial risk for many adverse health problems. As such, it is important to understand what treatment options are effective in assisting light smokers to quit smoking. Findings from this study support the use of personalized treatment for all smokers who are interested in quitting smoking, including light smokers.

Seasonal Variation in Demand for Smoking Cessation Treatment and Clinical Outcomes.

INTRODUCTION: Smoking behaviour shows seasonal variation, with cigarette consumption and youth smoking onset highest in summer and smoking-related web searches and sales of nicotine replacement products highest in winter. Variation in demand for clinical care and in outcomes has not been explored. AIMS AND METHODS: We measure seasonal variation in enrolments, total clinical visits, visits per enrolment, and treatment outcome (7-day abstinence at 6-month follow-up) from 2015 to 2018 in a large (n = 85 869) clinical cohort from 454 clinics across Ontario, Canada. We model seasonality using harmonic logistic and negative binomial regression. For individual-level outcomes, we adjust for variables, selected a priori, known to be associated with treatment use or outcomes. Data are nearly complete for 3 outcomes, but 6m abstinence is missing for 45% of participants. We use multiple imputation to adjust for missing data. RESULTS: All four outcomes showed significant seasonal variation (all p <.001). Total enrolments and visits were 20%-25% higher in January-April than in June-September. Visits per enrolment varied slightly, with lowest levels from May-July. Abstinence at 6 months was lowest among individuals enrolled from February-May and highest for those enrolled from July-November, with an absolute peak-trough difference of 4.3% (95% CI = 3.2% to 5.5%). CONCLUSIONS: There is meaningful seasonal variation in demand for, and outcomes of, smoking cessation treatment. Climate and weather may be indirectly responsible. Seasonal differences underscore the general importance of contextual factors in smoking cessation, may be useful in program promotion, and may explain some variability in outcomes in evaluation and research. IMPLICATIONS: Demand for tobacco cessation treatment and clinical outcomes vary seasonally. This underscores the importance of context in substance-related problems, and implies that some variability in research and evaluation results may be due to the time of year data were collected. Promotion efforts might usefully consider seasonal effects to smooth out demand and possibly improve outcomes.

A Comparison of Quit Outcomes for Men and Women in a Smoking Cessation Program Offering Personalized Nicotine Replacement Therapy and Counseling in Primary Care Clinics.

INTRODUCTION: Women may have greater difficulty achieving long-term abstinence following a quit attempt compared to men. We sought to determine whether there were differences in treatment characteristics or outcome between female and male primary care patients enrolled in a smoking cessation program providing personalized nicotine replacement therapy (NRT) with counseling support. AIMS AND METHODS: The sample included 27 601 Ontarians (53% female, 47% male) who enrolled in the Smoking Treatment for Ontario Patients program between 2016 and 2018. Dose, type, and duration of NRT supplied were personalized to need. Thirty-day point prevalence tobacco smoking abstinence was self-reported via online or telephone survey at 6 months after enrollment. RESULTS: Both female and male participants received a median of 8 weeks of NRT. Types of NRT received were similar, with 80% of both female and male participants receiving patch and short-acting NRT. The total cumulative dose was somewhat higher for men (1373 mg vs. 1265 mg, p < .001); but when calculated as dose per day, per cigarette smoked at baseline, the dose was slightly higher among women (1.6 mg vs. 1.5 mg, p < .001). Quit rates at 6 months were lower for women versus men (24% vs. 27%; adjusted OR = 0.84 [95% CI = 0.78 to 0.90], p < .001). There were no significant interactions between gender and dose, type, or duration of NRT supplied. CONCLUSIONS: Women were slightly less likely to quit than men, despite receiving similar treatment. There was no evidence that women benefitted more or less from variations in dose, type, or duration of NRT supplied. IMPLICATIONS: Women who received personalized NRT with counseling support in a primary care setting had lower quit success than men. Although the absolute difference in quit outcome was small, the public health impact may be large given the burden of disease associated with continued smoking. NRT supplied was similar for women and men, and there was no evidence upon which to suggest tailoring the dose, duration, or type, based on gender alone. Further research to identify the underlying biological and social factors responsible for reduced quit success will help identify ways to optimize treatment for women.

A randomized controlled trial of the effectiveness of Housing First in a small Canadian City.

BACKGROUND: The paper presents two-year findings from a study investigating the effectiveness of Housing First (HF) with assertive community treatment (ACT) in helping individuals with serious mental illness, who are homeless or precariously housed and living in a small city, to become stably housed. METHODS: The research design was a parallel group non-blinded RCT with participants randomly assigned after the baseline interview to receive HF with ACT (N = 100) or treatment as usual (TAU; N = 101). Participants were interviewed every 3 months over 21/24 months to investigate changes on a range of housing and psychosocial outcomes. The primary outcomes were housing stability (as defined by a joint function of number of days housed and number of moves) and improvement in community functioning. Secondary predicted outcomes were improvements in self-rated physical and mental health status, substance use problems, quality of life, community integration, and recovery. RESULTS: An intent-to-treat analysis was conducted. Compared to TAU participants, HF participants who entered housing did so more quickly (23.30 versus 88.25 days, d = 1.02, 95% CI [0.50-1.53], p < 0.001), spent a greater proportion of time stably housed (Z = 5.30, p < 0.001, OR = 3.12, 95% CI [1.96-4.27]), and rated the quality of their housing more positively (Z = 4.59, p < 0.001, d = 0.43, 95% CI [0.25-0.62]). HF participants were also more likely to be housed continually in the final 6 months (i.e., 79.57% vs. 55.47%), χ2 (2, n = 170) = 11.46, p = .003, Cramer's V = 0.26, 95% CI [0.14-0.42]). HF participants showed greater gains in quality of life, (Z = 3.83, p < 0.001, ASMD = 0.50, 95% CI [0.24-0.75]), psychological integration (Z = 12.89, p < 0.001, pooled ASMD = 0.91, 95% CI [0.77-1.05]), and perceived recovery (Z = 2.26, p = 0.03, ASMD = 0.39, 95% CI [0.05-0.74]) than TAU participants. CONCLUSIONS: The study indicates that HF ends homelessness significantly more rapidly than TAU for a majority of individuals with serious mental illness who have a history of homelessness and live in a small city. In addition, compared to TAU, HF produces psychosocial benefits for its recipients that include an enhanced quality of life, a greater sense of belonging in the community, and greater improvements in perceived recovery from mental illness. TRIAL REGISTRATION: International Standard Randomized Control Trial Number Register Identifier: ISRCTN42520374 , assigned August 18, 2009.

A program evaluation of an in-school daily physical activity initiative for children and youth.

BACKGROUND: The school system is one setting in which children's physical activity levels may be increased through daily physical activity (DPA) policies and initiatives. Adherence to DPA policies is typically poor and results are limited in regard to the associated benefits for participating children. Therefore, the purpose of this study was to evaluate a range of psychosocial outcomes following a community-led, in-school DPA initiative for 9-14 year old children and youth. METHODS: This program evaluation examined the impact of a DPA program consisting of 20 min of teacher-led DPA for 20 consecutive weeks. Student outcomes were measured using a questionnaire administered at three time points: baseline, mid-intervention, and post-intervention. A teacher questionnaire regarding program adherence and student behaviour was completed at post-intervention. Mixed effects models were used to test for intervention effects, with random intercepts for students, classes, and schools, as well as fixed effects for age and sex. Due to the large number of outcomes measured, we first conducted an omnibus test of the intervention effect followed by three exploratory analyses examining each outcome separately, associations between outcomes and program adherence, and results from the teacher survey. RESULTS: Thirty classes (N = 19 experimental) from 7 schools participated in the study, with a total of 362 children (n = 265 experimental). There was no significant overall effect of the intervention (z = 0.89, p = 0.38) and the exploratory analyses demonstrated significant differences only for self-esteem and subjective happiness, with the control group slightly increasing relative to the experimental group. Teacher-reported adherence to the program was poor with only 21% of teachers adhering to the program. There was no association between overall adherence and student reported outcomes; however, positive correlations were present between adherence and teacher-reported student behaviour. CONCLUSIONS: The DPA program evaluated here did not improve the psychosocial well-being of elementary school-aged children more than usual practices. However, adherence to the program was poor and it did not have a negative effect on the students. Future work is needed on how best to support DPA implementation in the context of the school day and how student well-being may be positively impacted through school-based physical activity. TRIAL REGISTRATION: Program Evaluation of an in-school Daily Physical Activity Initiative NCT03618927 , August 6, 2018. Retrospectively registered.

Service Use and Unmet Needs for Substance Use and Mental Disorders in Canada.

OBJECTIVE: To investigate patterns and predictors of help seeking and met/unmet needs for mental health care in a national population health survey. METHOD: Participants were respondents to the 2012 Canadian Community Health Survey on Mental Health (CCHS-MH; n = 25,133). We used regression to identify the diagnostic and sociodemographic predictors of the use of informal supports, primary care, and specialist care, as well as perceived unmet needs. RESULTS: Eleven percent of Canadians reported using professionally led services for mental health or substance use in 2012, while another 9% received informal supports. Two-thirds of people with substance use disorders did not receive any care, and among those who did, informal supports were most common. Seventy-four percent of people with mood/anxiety disorders and 88% of those with co-occurring disorders did access services, most commonly specialist mental health care. Men, older people, members of ethnocultural minorities, those not born in Canada, those with lower education, and those with higher incomes were less likely to receive care. Unmet needs were higher among people with substance use disorders. CONCLUSIONS: Gaps in services continue to exist for some potentially vulnerable population subgroups. Policy and practice solutions are needed to address these unmet needs. In particular, the convergence of research pointing to gaps in the availability and accessibility of high-quality services for substance use in Canada demands attention.

Outcome Trajectories among Homeless Individuals with Mental Disorders in a Multisite Randomised Controlled Trial of Housing First.

PURPOSE: Housing First (HF) has been shown to improve housing stability, on average, for formerly homeless adults with mental illness. However, little is known about patterns of change and characteristics that predict different outcome trajectories over time. This article reports on latent trajectories of housing stability among 2140 participants (84% followed 24 months) of a multisite randomised controlled trial of HF. METHODS: Data were analyzed using generalised growth mixture modeling for the total cohort. Predictor variables were chosen based on the original program logic model and detailed reviews of other qualitative and quantitative findings. Treatment group assignment and level of need at baseline were included in the model. RESULTS: In total, 73% of HF participants and 43% of treatment-as-usual (TAU) participants were in stable housing after 24 months of follow-up. Six trajectories of housing stability were identified for each of the HF and TAU groups. Variables that distinguished different trajectories included gender, age, prior month income, Aboriginal status, total time homeless, previous hospitalizations, overall health, psychiatric symptoms, and comorbidity, while others such as education, diagnosis, and substance use problems did not. CONCLUSION: While the observed patterns and their predictors are of interest for further research and general service planning, no set of variables is yet known that can accurately predict the likelihood of particular individuals benefiting from HF programs at the outset.

Housing Quality in a Randomized Controlled Trial of Housing First for Homeless Individuals with Mental Illness: Correlates and Associations with Outcomes.

Housing quality (HQ) is associated with mental health, and may mediate outcomes in housing interventions. However, studies of housing interventions rarely report HQ. The purpose of this study was to describe HQ in a multi-site randomized controlled trial of Housing First (HF) in five Canadian cities and to examine possible differences by treatment group (HF recipients and treatment-as-usual (TAU) participants who were able to find housing through other programs or on their own). We also examined the association between HQ and the primary trial outcome: housing stability. The performance of a new multi-dimensional standardized observer-rated housing quality scale (the OHQS) in a relatively large cross-site sample was also of interest. HQ was rated by trained research assistants for 204 HF participants and 228 TAU participants using the OHQS. General linear regression models were used to examine unit/building quality scores by group and site adjusting for other group differences, and as a predictor of housing stability outcomes after 24 months of follow-up. The OHQS was found to have good reliability and validity, but because most of the neighborhood subscale items were negatively correlated with the overall scale, only unit and building items were included in the total HQ score (possible scores ranging from 13.5 to 135). Unit/building HQ was significantly better for the HF group overall (91.2 (95 % CI = 89.6-92.9) vs. 88.3 (95 % CI = 86.1-90.5); p = .036), and in one site. HQ in the TAU group was much more variable than the HF group overall (W (mean) = 24.7; p < .001) and in four of five sites. Unit/building HQ scores were positively associated with housing stability: (73.4 (95 % CI 68.3-78.5) for those housed none of the time; 91.1 (95 % CI 89.2-93.0) for those housed some of the time; and 93.1 (95 % CI 91.4-94.9)) for those housed all of the time (F = 43.9 p < .001). This association held after adjusting for site, housing characteristics, participant ethnocultural status, community functioning, and social support. This study demonstrates that HQ can be as good or better, and less variable, in HF programs in Canada that systematically and predominantly source housing stock from the private sector compared to housing procured outside of an HF program. HQ is also an important predictor of housing stability outcomes.

Evaluation of the revised Nipissing District Developmental Screening (NDDS) tool for use in general population samples of infants and children.

BACKGROUND: There is widespread interest in identification of developmental delay in the first six years of life. This requires, however, a reliable and valid measure for screening. In Ontario, the 18-month enhanced well-baby visit includes province-wide administration of a parent-reported survey, the Nipissing District Developmental Screening (NDDS) tool, to facilitate early identification of delay. Yet, at present the psychometric properties of the NDDS are largely unknown. METHOD: 812 children and their families were recruited from the community. Parents (most often mothers) completed the NDDS. A sub-sample (n = 111) of parents completed the NDDS again within a two-week period to assess test-retest reliability. For children 3 or younger, the criterion measure was the Bayley Scales of Infant Development, 3rd edition; for older children, a battery of other measures was used. All criterion measures were administered by trained assessors. Mild and severe delays were identified based on both published cut-points and on the distribution of raw scores. Sensitivity, specificity, positive and negative predictive values were calculated to assess agreement between tests. RESULTS: Test-retest reliability was modest (Spearman's rho = .62, p < 001). Regardless of the age of the child, the definition of delay (mild versus severe), or the cut-point used on the NDDS, sensitivities (from 29 to 68 %) and specificities (from 58 to 88 %) were poor to moderate. CONCLUSION: The modest test-retest results, coupled with the generally poor observed agreement with criterion measures, suggests the NDDS should not be used on its own for identification of developmental delay in community or population-based settings.

The Coordination and Activity Tracking in CHildren (CATCH) study: rationale and design.

BACKGROUND: Past studies have found that children with Developmental Coordination Disorder (DCD) engage in less physical activity than typically developing children. This "activity deficit" may result in children with DCD being less physically fit and more likely to be overweight or obese, potentially increasing later risk for poor cardiovascular health. Unfortunately, the majority of DCD research has been limited to cross-sectional designs, leading to questions about the complex relationship among motor ability, inactivity and health-related fitness. Of the few longitudinal studies on the topic, determining precedence amongst these factors is difficult because study cohorts typically focus on mid to late childhood. By this age, both decreased physical fitness and obesity are often established. The Coordination and Activity Tracking in CHildren (CATCH) study will examine the pathways connecting DCD, physical activity, physical fitness, and body composition from early to middle childhood. METHODS: The CATCH study is a prospective cohort study. We aim to recruit a cohort of 600 children aged 4 to 5 years (300 probable DCD [pDCD] and 300 controls) and test them once a year for 4 years. At Phase 1 of baseline testing, we assess motor skills, cognitive ability (IQ), basic anthropometry, flexibility and lower body muscle strength, while parents complete an interview and questionnaires regarding family demographics, their child's physical activity, and behavioural characteristics. Children who move on to Phase 2 (longitudinal cohort) have their body fat percentage, foot structure, aerobic and anaerobic fitness assessed. An accelerometer to measure physical activity is then given to the child and interested family members. The family also receives an accelerometer logbook and 3-day food dairy. At years 2 to 4, children in the longitudinal cohort will have all baseline assessments repeated (excluding the IQ test), and complete an additional measure of perceived self-efficacy. Parents will complete an ADHD index twice within the follow-up period. To assess the association between DCD, fitness and adiposity, our primary analysis will involve longitudinal growth models with fixed effects. DISCUSSION: The CATCH study will provide a clearer understanding of pathways between DCD and health-related fitness necessary to determine the types of interventions children with DCD require.

Patterns and predictors of attrition in a trial of a housing intervention for homeless people with mental illness.

PURPOSE: Participant retention is an important challenge in longitudinal research on homeless people. High attrition can threaten validity, and may represent lost opportunities to deliver interventions. In this article, we report on attrition in the At Home/Chez Soi study, a multi-site randomized controlled trial of a housing intervention for homeless people with mental illness. METHODS: We first calculate life tables, and then use clustered logistic regression to implement a discrete-time survival model. We use splines and indicator variables to capture non-linear and group-specific variation over time in the hazard function. As potential predictors, we consider study group, site, date of recruitment, age, sex, baseline substance dependence, baseline psychotic disorder, time homeless in life, community functioning, and education. RESULTS: The study recruited 2,148 homeless people with mental illness. Of these, 1,158 were randomized to the housing first intervention (HF), and 990 to treatment as usual (TAU). Excluding 79 people known to have died, attrition was 14%. This proportion was higher in TAU than in HF (21 vs. 8%, p < 0.01). Attrition was significantly lower in one site than elsewhere, and was also lower among those with substance dependence (13 vs. 18%, p < 0.01) and among those enrolled earlier in the study. The hazard varied over time in complex ways. CONCLUSIONS: Results imply that study factors are more important than participant characteristics as determinants of retention, and that the immediate period after randomization is a crucial one. The high overall retention demonstrates the effectiveness of existing techniques for retaining participants.

Relative age effects in fitness testing in a general school sample: how relative are they?

When children or adolescents are grouped by age or year of birth, older individuals tend to outperform younger ones. These phenomena are known as relative age effects (RAEs). RAEs may result directly from differences in maturation, but may also be associated with psychological, pedagogic or other factors. In this article, we attempt to quantify RAEs in a simple fitness task and to identify the mechanisms operating. Data come from a 5-year study of 2278 individuals that included repeated administrations of the 20 m shuttle run. We use mixed-effect modelling to characterise change over time and then examine residuals from these models for evidence of an effect for age relative to peers or for season of birth. Age alone appears to account for RAEs in our sample, with no effects for age relative to peers or month of birth. Age grouping produces large disparities for girls under 12, moderate ones for boys of all ages and negligible ones for girls between 12 and 15. RAEs for this task and population appear to arise from simple age differences. Similar methods may be useful in determining whether other explanations of RAEs are necessary in other contexts. Evaluation processes that take age into account have the potential to mitigate RAEs in general settings.