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SUMMARYTo determine whether drinking water contaminated with antimicrobial-resistant E. coli is associated with the carriage of resistant E. coli, selected households sending water samples to Ontario and Alberta laboratories in 2005-2006 were asked to participate in a cross-sectional study. Household members aged 12 years were asked to complete a questionnaire and to submit a rectal swab. In 878 individuals, 41% carried a resistant strain of E. coli and 28% carried a multidrug-resistant strain. The risk of carriage of resistant E. coli was 1·26 times higher for users of water contaminated with resistant E. coli. Other risk factors included international travel [prevalence ratio (PR) 1·33], having a child in nappies (PR 1·33), being male (PR 1·33), and frequent handling of raw red meats (PR 1·10). Protecting private water sources (e.g. by improving systems to test and treat them) may help slow the emergence of antimicrobial resistance in E. coli. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We sought to assess the knowledge of, use of and barriers to the use of personal protective equipment for airway management among emergency medical technicians (EMTs) during and since the 2003 Canadian outbreak of Severe Acute Respiratory Syndrome (SARS). METHODS: Using a cross-sectional survey, EMTs in Toronto, Ont., were surveyed 1 year after the SARS outbreak during mandatory training on the use of personal protective equipment in airway management during the outbreak and just before taking the survey. Practices that were addressed reflected government directives on the use of this equipment. Main outcome measures included the frequency of personal protective equipment use and, as applicable, why particular items were not always used. RESULTS: The response rate was 67.3% (n = 230). During the SARS outbreak, an N95-type particulate respirator was reported to be always used by 91.5% of respondents. Conversely, 72.9% of the respondents reported that they never used the open face hood. Equipment availability and vision impairment were often cited as impediments to personal protective equipment use. In nonoutbreak conditions, only the antimicrobial airway filter was most often reported to be always used (52.0%), while other items were used at an intermediate frequency. The most common reason for not always donning equipment was that paramedics deemed it unnecessary for the situation. CONCLUSION: Personal protective equipment is not consistently employed as per medical directives. Reasons given for nonuse included nonavailability, judgment of nonnecessity or technical difficulties. There are important public health implications of noncompliance. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We sought to assess whether the specialty of the surgeon or the hospital involved in the initial management of women with ovarian cancer determined the likelihood of unnecessary repeated abdominal surgery and long-term patient survival. METHODS: We conducted a population-based study involving women in Ontario, Canada, who had epithelial ovarian cancer treated initially with abdominal surgery between January 1996 and December 1998. We documented incident surgical cases using hospital contact data and the Ontario Cancer Registry. We obtained data on patient characteristics, clinical findings, surgical techniques and perioperative care from electronic administrative data records and patient charts. We performed regression analyses to assess the influence of surgeon and hospital specialization and of case volumes on the likelihood of repeat surgery and survival. We controlled for stage of disease and other factors associated with these outcomes. We also examined the relation between the adequacy of surgery and adjuvant chemotherapy with survival. RESULTS: A total of 1341 women met our inclusion criteria. Our analysis showed that repeat surgery was associated with the surgeon's discipline, younger patient age, well-differentiated tumours and early stage of disease. However, survival was not associated with the surgeon's discipline; rather, it was associated with advanced patient age, increasing comorbidities, advanced stage of disease, poorly differentiated tumours, urgent surgery and adjuvant chemotherapy. We observed a trend between inadequate surgery and a decreased likelihood of survival. CONCLUSION: Further study is needed to understand patterns of repeat surgery for ovarian cancer. Improved quality of operative reporting is required to classify surgical adequacy. [ABSTRACT FROM AUTHOR]

Background: Women are less likely than men to receive some stroke care interventions. It is not known whether gender differences in patient preferences explain some of the observed variations in stroke care delivery.Methods: Outpatients with and without a history of cerebrovascular disease were recruited from stroke, vascular, and general internal medicine ambulatory clinics between September 2002 and October 2003. Self-administered surveys described hypothetical scenarios, and participants were asked if they would accept therapy with thrombolysis for acute ischemic stroke or carotid endarterectomy for secondary stroke prevention. The surveys also included questions on sociodemographic factors and decision-making preferences.Results: A total of 586 patients (45% women) completed the survey. Women were less likely than men to accept thrombolysis (79% vs. 86%, P=0.014), even after adjustment for other factors (adjusted odds ratio [OR] 0.58, 95% confidence interval [CI] 0.37-0.92). Women and men were equally likely to accept carotid endarterectomy (82% vs. 84%, P=0.502), even after adjustment for other factors (adjusted OR 0.94, 95% CI 0.58- 1.53). Women were less confident in their decisions, were more risk averse, and would have preferred more information to assist them in their decision-making.Conclusions: No gender differences were found in patient preferences for carotid surgery. However, we observed gender differences in patient preferences for thrombolysis and in general attitudes toward stroke care decision-making. Health care providers should be aware that, compared with men, women may be more concerned about risks and may require more information before they make a decision. [ABSTRACT FROM AUTHOR]

Background: The demand for COVID-19 vaccines has diminished as the pandemic lingers. Understanding vaccine hesitancy among essential workers is important in reducing the impact of future pandemics by providing effective immunization programs delivered expeditiously., Method: Two surveys exploring COVID-19 vaccine acceptance in 2021 and 2022 were conducted in cohorts of health care providers (HCP) and education workers participating in prospective studies of COVID-19 illnesses and vaccine uptake. Demographic factors and opinions about vaccines (monovalent and bivalent) and public health measures were collected in these self-reported surveys. Modified multivariable Poisson regression was used to determine factors associated with hesitancy., Results: In 2021, 3 % of 2061 HCP and 6 % of 3417 education workers reported hesitancy (p < 0.001). In December 2022, 21 % of 868 HCP and 24 % of 1457 education workers reported being hesitant to receive a bivalent vaccine (p = 0.09). Hesitance to be vaccinated with the monovalent vaccines was associated with earlier date of survey completion, later receipt of first COVID-19 vaccine dose, no influenza vaccination, and less worry about becoming ill with COVID-19. Factors associated with hesitance to be vaccinated with a bivalent vaccine that were common to both cohorts were receipt of two or fewer previous COVID-19 doses and lower certainty that the vaccines were safe and effective., Conclusion: Education workers were somewhat more likely than HCP to report being hesitant to receive COVID-19 vaccines but reasons for hesitancy were similar. Hesitancy was associated with non-receipt of previous vaccines (i.e., previous behaviour), less concern about being infected with SARS-CoV-2, and concerns about the safety and effectiveness of vaccines for both cohorts. Maintaining inter-pandemic trust in vaccines, ensuring rapid data generation during pandemics regarding vaccine safety and effectiveness, and effective and transparent communication about these data are all needed to support pandemic vaccination programs., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Brenda L Coleman reports financial support was provided by Canadian Institutes of Health Research. Allison McGeer reports financial support was provided by Canadian Institutes of Health Research. Allison McGeer reports financial support was provided by Physicians' Services Inc. Foundation. Dawn Bowdish reports financial support was provided by Weston Family Foundation. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: COVID-19 added to healthcare provider (HCP) distress, but patterns of change remain unclear. This study sought to determine if and how emotional distress varied among HCP between March 28, 2021 and December 1, 2023., Methods: This longitudinal study was embedded within the 42-month prospective COVID-19 Cohort Study that recruited HCP from four Canadian provinces. Information was collected at enrollment, from annual exposure surveys, and vaccination and illness surveys. The 10-item Kessler Psychological Distress Scale (K10) was completed approximately every six months after March 28, 2021. Linear mixed effects models, specifically random intercept models, were generated to determine the impact of time on emotional distress while accounting for demographic and work-related factors., Results: Between 2021 and 2023, the mean K10 score fell by 3.1 points, indicating decreased distress, but scores increased during periods of high levels of mitigation strategies against transmission of SARS-CoV-2, during winter months, and if taking antidepression, anti-anxiety or anti-insomnia medications. K10 scores were significantly lower for HCP who were male, older, had more children in their household, experienced prior COVID-19 illness(es), and for non-physician but regulated HCP versus nurses. A sensitivity analysis that included only those who had submitted at least five K10 surveys consisted of the factors in the full model excluding previous COVID-19 illness, occupation, and season, after adjustment. Models were also created for K10 anxiety and depression subscales., Conclusions: K10 scores decreased as the COVID-19 pandemic continued but increased during periods of high mitigation and the winter months. Personal and work-place factors also impacted HCP distress scores. Further research into best practices in distress identification and remediation is warranted to ensure future public health disasters are met with healthcare systems that are able to buffer HCP against short- and long-term mental health issues., (© 2024. The Author(s).)

Background: Epidemiologic research suggests that youth cannabis use is associated with psychotic disorders. However, current evidence is based heavily on 20th-century data when cannabis was substantially less potent than today., Methods: We linked population-based survey data from 2009 to 2012 with records of health services covered under universal healthcare in Ontario, Canada, up to 2018. The cohort included respondents aged 12-24 years at baseline with no prior psychotic disorder ( N = 11 363). The primary outcome was days to first hospitalization, ED visit, or outpatient visit related to a psychotic disorder according to validated diagnostic codes. Due to non-proportional hazards, we estimated age-specific hazard ratios during adolescence (12-19 years) and young adulthood (20-33 years). Sensitivity analyses explored alternative model conditions including restricting the outcome to hospitalizations and ED visits to increase specificity., Results: Compared to no cannabis use, cannabis use was significantly associated with psychotic disorders during adolescence (aHR = 11.2; 95% CI 4.6-27.3), but not during young adulthood (aHR = 1.3; 95% CI 0.6-2.6). When we restricted the outcome to hospitalizations and ED visits only, the strength of association increased markedly during adolescence (aHR = 26.7; 95% CI 7.7-92.8) but did not change meaningfully during young adulthood (aHR = 1.8; 95% CI 0.6-5.4)., Conclusions: This study provides new evidence of a strong but age-dependent association between cannabis use and risk of psychotic disorder, consistent with the neurodevelopmental theory that adolescence is a vulnerable time to use cannabis. The strength of association during adolescence was notably greater than in previous studies, possibly reflecting the recent rise in cannabis potency.

Epidemiologic research suggests a modest association between youth cannabis use and mood and anxiety disorders (MADs). However, current evidence is based mostly on cohort studies using data from the 20th century when cannabis was significantly less potent than today. We linked population-based survey data from 2009 to 2012 with administrative records of health services covered under universal healthcare up to 2017. The cohort included youth aged 12 to 24 years at baseline living in Ontario, Canada with no prior MAD health service use (n = 8,252). We conducted a multivariable Cox model to estimate the association between cannabis use frequency (never,

Introduction: There is considerable controversy about the development of dependence among e-cigarette users. This study describes the average amount of time using e-cigarettes before dependence milestones emerge and the differences in developing dependence between e-cigarette users who smoke cigarettes compared to those who do not., Methods: Adolescents and young adults aged 16-25 living in Canada were recruited into an online survey in 2021. Current (past-month) e-cigarette users completed 15 items assessing dependence from the Penn-State Electronic Cigarette Dependence Index and the E-cigarette Dependence Scale for a total of 12 behavioural (e.g., difficulty refraining from vaping) and 3 frequency (e.g., using e-cigarette daily, weekly, or monthly) indicators of dependence milestones. Number of years after e-cigarette onset at which the cumulative probability of attaining each milestone was 25 % was computed., Results: Among 1205 participants, most (80.6 %) were female, 73.7 % were Caucasian, and 49.7 % resided in Ontario. Ten of the 12 e-cigarette use milestones were attained by 25 % of respondents 2 years after starting vaping except for daily cigarette use (2.5 years after onset) and waking at night to vape (5.6 years after onset). Within the entire study population, frequency milestones (weekly, monthly, daily e-cigarette use) were attained faster by ever-smokers (hazard ratio compared to attainment by never-smokers: 1.12, 1.21, and 1.28 respectively), whereas for at least monthly users, behavioural milestones were attained faster by never-smokers., Discussion: Many current e-cigarette users developed symptoms of e-cigarette dependence between two and five years since onset. Never smokers may be at higher risk of becoming e-cigarette dependent since they attained e-cigarette dependence milestones faster than smokers., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Eissenberg is a paid consultant in litigation against the tobacco industry and also the electronic cigarette industry and is named on one patent for a device that measures the puffing behavior of electronic cigarette users, on another patent application for a smartphone app that determines electronic cigarette device and liquid characteristics, and a third patent application for a smoking cessation intervention. The other authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2023. Published by Elsevier Ltd.)

Introduction: Although the relationship between smoking and depression has been well-established, little is known about the association between use of e-cigarette and depression, particularly among youth and young adults. This study proposes that e-cigarette dependence, rather than simply use, serves as a potential stressor and may interact with pre-existing vulnerabilities to contribute to depression in youth, consistent with the diathesis-stress theory. This study examines the longitudinal association of vaping dependence and vaping frequency on depression symptoms among youth and young adults who have never smoked cigarettes., Methods: People who used e-cigarettes in the past month who reported never smoking a cigarette (N=1,226) aged between 16 and 25 years were followed longitudinally every 3 months for up to 1 year beginning in 2020. The Penn State E-Cigarette Dependence Index at time t was used to predict depression symptoms assessed using the Center for Epidemiologic Studies Depression Scale at time t+1., Results: A total of 32.1% reported vaping in the past month with the Penn State E-Cigarette Dependence Index score (M=8.5) and a Center for Epidemiologic Studies Depression Scale score (M=15.8). Higher vaping dependence scores were significantly associated with increased depression symptoms scores at follow-up among youth and adults (β=0.08; 95% CI=0.01, 0.15), controlling for baseline depression symptom scores and covariates. Although vaping dependence was highly associated with vaping frequency level, no significant association between the frequency of vaping and depression was found (β= -0.33; 95% CI= 1.21, 0.54)., Conclusions: These results are consistent with the diathesis-stress model of the relationship between substance use and depression. Vaping dependence but not vaping frequency was associated with increased depressive symptoms among people who never smoked cigarettes., (Copyright © 2023 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: To inform preparedness and population health action, we need to understand the effects of COVID-19 on health inequities. In this study, we assess the impact of COVID-19 on opioid toxicity deaths among people who experience incarceration compared to others in the general population in Ontario, Canada., Methods: We conducted a retrospective cohort study for the period of January 1, 2015 to December 31, 2020. We accessed and linked coronial data on all opioid toxicity deaths in Ontario with correctional data for people aged 18 years and older who were incarcerated in a provincial correctional facility. We used data from the Statistics Canada Census to calculate whole population rates. We used an interrupted time series design and segmented regression to assess for change in the level or rate of increase in deaths due to opioid toxicity coinciding with the COVID-19 pandemic. We compared the impact of COVID-19 on the opioid toxicity death rates for people exposed and not exposed to incarceration., Results: Rates of opioid toxicity death increased with a linear positive slope in both persons exposed to incarceration and those not exposed over the study period. The start of COVID-19 measures coincided with a marked upward shift in the trend lines with modification of the effect of COVID-19 by both sex and exposure to incarceration. For persons exposed to incarceration, the risk ratio (RR) was 1.50 (95%CI 1.35-1.69) for males and 1.21 (95%CI 1.06-1.42) for females, and for persons not exposed to incarceration, the RR was 1.25 (95%CI 1.13-1.38) for males and not significant for females., Conclusions: COVID-19 substantially exacerbated the risk of opioid toxicity death, impacting males and females who experienced incarceration more than those who had not, with an immediate stepwise increase in risk but no change in the rate of increase of risk over time. Public health work, including pandemic preparedness, should consider the specific needs and circumstances of people who experience incarceration., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Butler et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Iron deficiency and overload may negatively impact women's health. There has been limited assessment of iron status and its associated factors among Canadian women., Objectives: This study investigated associations of various sociodemographic, lifestyle, medication, and dietary factors with body iron stores among pre- and postmenopausal women in Canada., Methods: Analyses were conducted using cross-sectional, nationally representative survey and biomarker data from women aged 20-79 y (n = 6362) in the Canadian Health Measures Survey (2009-2017). Body iron stores were assessed by measuring serum concentrations of ferritin (SF). Information on potential correlates was collected during an in-home interview. Multivariable linear regression analyses were performed to evaluate associations with SF concentration, and logistic regression was used to estimate associations with iron deficiency (SF <15 μg/L) or elevated iron stores (SF >150 μg/L)., Results: Geometric mean SF concentrations were significantly higher in postmenopausal than in premenopausal women (73.2 versus 33.8 μg/L; P < 0.001). The prevalence of iron deficiency among pre- and postmenopausal women was 16.0% and 4.0%, respectively, whereas that of elevated iron stores was 2.7% and 21.0%, respectively. After simultaneous adjustment for multiple factors, including high-sensitivity CRP (inflammation marker), we found that age, East/Southeast Asian (versus White) race/ethnicity, alcohol, and red meat consumption were positively associated with SF concentration among pre- and postmenopausal women. In addition, aspirin use and dairy consumption were inversely associated with SF concentration among postmenopausal women only. Similar patterns were observed for associations with elevated iron stores among postmenopausal women, whereas higher grain consumption was associated with an increased prevalence of iron deficiency among premenopausal women., Conclusions: Sociodemographic, lifestyle, medication, and dietary factors are correlated with iron status determined by SF concentration among Canadian women. The findings may have implications for intervention strategies aimed at optimizing body iron stores in pre- and postmenopausal women., (Copyright © 2022 American Society for Nutrition. Published by Elsevier Inc. All rights reserved.)

Introduction: E-cigarettes have been steadily increasing in popularity, both as cessation methods for smoking and for recreational and social reasons. This increase in vaping may pose cardiovascular and respiratory risks. We aimed to assess respiratory symptoms in youth users of e-cigarettes and cigarettes., Methods: A retrospective survey design was utilized to assess Canadian youth aged 16-25 years. Participants were recruited from the Ontario Tobacco Research Unit Youth and Young Adult Research Registration Panel November 2020 to March 2021. A total of 3082 subjects completed the baseline survey. Of these, 2660 individuals who did not have asthma were included in the analysis. The exposure of interest was pack-equivalent years, a novel measure of vaping exposure equivalent conceptually to cigarette pack years incorporating number of puffs per day, number of days vaped per month, and number of years vaped. Respiratory symptoms were measured using the five-item Canadian Lung Health Test. Poisson regression analyses were performed while adjusting for demographic confounders, stratified by smoking status. A non-stratified model tested the interaction of status and vaping dose and the effect of vaping device used was assessed among ever vapers. Analyses controlled for demographic characteristics, use of cannabis and alcohol, and survey date., Results: Each additional puff year increased the rate ratio (RR) of respiratory symptoms by a factor of 11.36 (95% CI: 4.61-28.00; p<0.001) for never smokers, but among current daily smokers higher pack-equivalent years were not associated with more respiratory symptoms (RR=0.83; 95% CI: 0.23-3.11). Among current vapers, those using pod-style devices were more likely to have more respiratory symptoms (RR=1.25; 95% CI: 1.08-1.45) after adjusting for dose., Conclusions: Vaping is associated with an increased risk of reporting respiratory symptoms among never smoking youth and non-daily ever cigarette smokers. Use of e-cigarettes among non-smokers should be discouraged., Competing Interests: The authors have each completed and submitted an ICMJE form for disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. M. Chaiton, M. Pienkowski, I. Musani, S.J. Bondy, J.E. Cohen, J. Dubray, P. Kaufman, M. Stanbrook and R. Schwartz report that since the initial planning of the work this manuscript was supported by CIHR. T. Eissenberg reports that since the initial planning of the work, the Virginia Commonwealth University was supported by USFDA/NIH(NIDA), and that in the past 36 months he received consulting fees for an expert opinion he wrote to be used in litigation against the tobacco and electronic cigarette industry, a payment for expert testimony in litigation against the tobacco and electronic cigarette industry; and that T. Eissenberg is named on one patent for a device that measures the puffing behavior of electronic cigarette users, on another patent application for a smartphone app that determines electronic cigarette device and liquid characteristics, and a third patent application for a smoking cessation intervention (no payments involved)., (© 2023 Chaiton M. et al.)

Objective: Identify and review the body of tobacco research literature that self-identified as using machine learning (ML) in the analysis., Data Sources: MEDLINE, EMABSE, PubMed, CINAHL Plus, APA PsycINFO and IEEE Xplore databases were searched up to September 2020. Studies were restricted to peer-reviewed, English-language journal articles, dissertations and conference papers comprising an empirical analysis where ML was identified to be the method used to examine human experience of tobacco. Studies of genomics and diagnostic imaging were excluded., Study Selection: Two reviewers independently screened the titles and abstracts. The reference list of articles was also searched. In an iterative process, eligible studies were classified into domains based on their objectives and types of data used in the analysis., Data Extraction: Using data charting forms, two reviewers independently extracted data from all studies. A narrative synthesis method was used to describe findings from each domain such as study design, objective, ML classes/algorithms, knowledge users and the presence of a data sharing statement. Trends of publication were visually depicted., Data Synthesis: 74 studies were grouped into four domains: ML-powered technology to assist smoking cessation (n=22); content analysis of tobacco on social media (n=32); smoker status classification from narrative clinical texts (n=6) and tobacco-related outcome prediction using administrative, survey or clinical trial data (n=14). Implications of these studies and future directions for ML researchers in tobacco control were discussed., Conclusions: ML represents a powerful tool that could advance the research and policy decision-making of tobacco control. Further opportunities should be explored., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Household composition may be an important factor associated with anxiety during the COVID-19 pandemic as people spend more time at home due to physical distancing and lockdown restrictions. Adults living with children-especially women-may be particularly vulnerable to anxiety as they balance additional childcare responsibilities and homeschooling with work. The objective of this study was to examine the association between household composition and anxiety symptoms during the COVID-19 pandemic and explore gender as an effect modifier., Methods: Data were derived from seven waves of a national online survey of Canadian adults aged 18+ years from May 2020 to March 2021, which used quota sampling by age, gender, and region proportional to the English-speaking Canadian population (n = 7,021). Multivariable logistic and modified least-squares regression models were used., Results: Compared to those living alone, significantly greater odds of anxiety symptoms were observed among single parents/guardians (aOR = 2.00; 95%CI: 1.41-2.84), those living with adult(s) and child(ren) (aOR = 1.39; 95%CI: 1.10-1.76), and those living with adult(s) only (aOR = 1.22; 95%CI: 1.00-1.49). Gender was a significant effect modifier on the additive scale (p = 0.0487) such that the association between living with child(ren) and anxiety symptoms was stronger among men than women., Conclusion: Additional tailored supports are needed to address anxiety among adults living with children-especially men-during the COVID-19 pandemic and future infectious disease events., Competing Interests: The authors have declared that no competing interests exist.

Background: The prison setting and health status of people who experience imprisonment increase the risks of COVID-19 infection and sequelae, and other health impacts of the COVID-19 pandemic., Objectives: To conduct a mixed methods systematic review on the impacts of the COVID-19 pandemic on the health of people who experience imprisonment., Data Sources: We searched Medline, PsycINFO, Embase, the Cochrane Library, Social Sciences Abstracts, CINAHL, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Sociology Database, Coronavirus Research Database, ERIC, Proquest Dissertations and Theses, Web of Science, and Scopus in October 2021. We reviewed reference lists for included studies., Study Eligibility Criteria: Original research conducted in or after December 2019 on health impacts of the COVID-19 pandemic on adults in prisons or within three months of release., Study Appraisal and Synthesis Methods: We used the Joanna Briggs Institute's Critical Appraisal Checklist for Qualitative Research for qualitative studies and the Joanna Briggs Institute's Critical Appraisal Checklist for Studies Reporting Prevalence Data for quantitative studies. We qualitized quantitative data and extracted qualitative data, coded data, and collated similar data into categories., Results: We identified 62 studies. People in prisons had disproportionately high rates of COVID-19 infection and COVID-19 mortality. During the pandemic, all-cause mortality worsened, access to health care and other services worsened, and there were major impacts on mental wellbeing and on relationships with family and staff. There was limited evidence regarding key primary and secondary prevention strategies., Limitations: Our search was limited to databases. As the COVID-19 pandemic is ongoing, more evidence will emerge., Conclusions: Prisons and people who experience imprisonment should be prioritized for COVID-19 response and recovery efforts, and an explicit focus on prisons is needed for ongoing public health work including emergency preparedness., Prospero Registration Number: 239324., Competing Interests: The authors have declared that no competing interests exist.

Loneliness and associated mental health problems are of particular concern during the COVID-19 pandemic due to physical distancing and lockdown restrictions. Loneliness is most common among young adults and women during the pandemic, but it is unclear if the association between loneliness and mental health problems, notably anxiety, is strongest in these groups. The objective of this study was to examine whether the association between loneliness and anxiety differed by age and/or gender during the pandemic. We analyzed data from a multi-wave national online survey of Canadians aged 18+ years from May 2020 to March 2021 (n = 7,021). Multivariable modified least-squares regression was used to examine whether the association between loneliness and moderate to severe anxiety symptoms (GAD-7 10+) differed by age and/or gender on the additive scale, controlling for socio-demographic factors, depression, hopefulness, and survey wave. Age significantly moderated the association between loneliness and anxiety symptoms while gender did not. Loneliness was associated with anxiety symptoms for all age groups, but the association was not as strong among those aged 70+ years compared to other age groups. Evidence-based loneliness interventions that target younger adults are needed to mitigate the mental health effects of infectious disease events such as COVID-19., (Copyright © 2022. Published by Elsevier B.V.)

Objective: Previous studies conducted on hepatitis C virus (HCV) transmission have focused primarily on its transmission among people who inject drugs. However, there is evidence that transmission may also occur through the sharing of contaminated non-injection implements used to consume drugs nasally, orally, or by inhalation. Studies to date have not conclusively established a relationship between these routes of cocaine use and HCV. We quantified the association between cocaine use and HCV, specifically among individuals who have never injected an illicit substance., Method: Data from the 2011-2018 National Health and Nutrition Examination Survey were analyzed. Multivariable logistic regression was used to test for an association between cocaine use and HCV among 10,106 individuals (5,201 females). Covariates included age, race, sex, education, income, and immigrant status., Results: In the unadjusted model, individuals who reported cocaine use had 4.79 (95% CI [2.70, 8.47]) times the odds of ever having HCV compared with those who did not use cocaine. In the adjusted model, individuals who reported cocaine use had 4.48 (95% CI [2.36, 8.50]) times the odds of ever having HCV compared with those who did not use cocaine., Conclusions: This study highlights that individuals who report non-injection cocaine use have an inflated risk of HCV compared with individuals who report no cocaine use. Harm reduction interventions to reduce the transmission of HCV should therefore be targeted to all people who use drugs, including those who use cocaine orally, intra-nasally, and by inhalation.

Introduction: Changes to federal legislation allowed nicotine-based e-cigarettes legal entry into the Canadian market in 2018. This included pod-type e-cigarettes (pods), such as JUUL, that were later found to be associated with steeply increasing prevalence and greater frequency of e-cigarette use among US and Canadian youth. Multiple studies of risk factors of JUUL use and use initiation have been conducted among various population groups in the US, but little evidence exists pointing to similar risk factors of pod use among Canadian youth and young adults. Understanding these risk factors can inform use prevention and intervention strategies in Canadian and other jurisdictions., Methods: A total of 668 Canadian youth and young adults recruited by the 2018-19 Youth and Young Adult Panel Study were provided a baseline survey 3 months before and a follow-up survey 9 months after the relaxation of federal nicotine e-cigarette regulations. We used multivariable logistic regression to understand and rank importance of baseline predictors of future pod use among respondents., Results: Past-month cannabis use (OR [odds ratio] = 2.66, 95% CI: 1.66-4.21, p < 0.001), established cigarette use (OR = 3.42, 1.53-7.65, p < 0.01), past cigarette experimentation (OR = 2.40, 1.34-4.31, p < 0.01), having many friends who vaped (OR = 2.15, 1.37-3.34, p < 0.001), age below 18 compared to age over 22 (OR = 5.26, 2.63-10.00, p < 0.001) and male sex (OR = 1.69, 1.16-2.50, p < 0.01) were significant and the most influential predictors of future pod use., Conclusion: Similar factors drove pod use among Canadian and US youth and young adults. Appropriate preventive strategies can benefit from considering polysubstance use among high school-aged youth., Competing Interests: None to be declared.

Background: Individuals with eating disorders have a high mortality risk. Few population-based studies have estimated this risk in eating disorders other than anorexia nervosa., Aims: To investigate all-cause mortality in a population-based cohort of individuals who received hospital-based care for an eating disorder (anorexia nervosa, bulimia nervosa or eating disorder not otherwise specified) in Ontario, Canada., Method: We conducted a retrospective cohort study of 19 041 individuals with an eating disorder from 1 January 1990 to 31 December 2013 using administrative healthcare data. The outcome of interest was death. Excess mortality was assessed using standardised mortality ratios (SMRs) and potential years of life lost (PYLL). Cox proportional hazards regression models were used to examine sociodemographic and medical comorbidities associated with greater mortality risk., Results: The cohort had 17 108 females (89.9%) and 1933 males (10.1%). The all-cause mortality for the entire cohort was five times higher than expected compared with the Ontario population (SMR = 5.06; 95% CI 4.82-5.30). SMRs were higher for males (SMR = 7.24; 95% CI 6.58-7.96) relative to females (SMR = 4.59; 95% CI 4.34-4.85) overall, and in all age groups in the cohort. For both genders, the cohort PYLL was more than six times higher than the expected PYLL in the Ontario population., Conclusions: Patients with eating disorders diagnosed in hospital settings experience five to seven times higher mortality rates compared with the overall population. There is an urgent need to understand the mortality risk factors to improve health outcomes among individuals with eating disorders.

Recognition of ADHD in the adult population is relatively recent. Epidemiological research examining the mental health impact of ADHD in adulthood is thus limited. The objective of this study was to examine whether adult ADHD symptoms are associated with psychological distress, hazardous drinking, and problem gambling, after controlling for traumatic brain injury and sociodemographic characteristics. We analyzed data from a population-based survey administered in 2015 and 2016 to adults aged 18 years and over in Ontario, Canada (N = 3,817). Logistic regression was used to construct unadjusted and multivariable models for each of the three focal relationships. In the unadjusted models, ADHD symptoms were significantly related to psychological distress (OR = 9.3; 95% CI:6.1, 14.0) and hazardous drinking (OR = 2.1; 95% CI: 1.3, 3.4), but not to problem gambling (OR = 1.5; 0.5, 4.3). After adjustment, ADHD symptoms were significantly related to psychological distress (OR = 7.1; 95% CI: 4.6, 11.1), but not hazardous drinking (OR = 1.4; 95% CI: 0.8, 2.5) or problem gambling (OR = 0.6; 95% CI: 0.2, 2.5). This study further highlights the importance of clinicians assessing for concomitant ADHD and psychological distress in adults., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Iron has been suggested to contribute to breast cancer development through oxidative stress generation. Our study investigated associations between iron intake and breast cancer risk, overall and by menopausal and estrogen receptor/progesterone receptor (ER/PR) status, and modification by oxidative stress-related genetic polymorphisms (MnSOD, GSTM1 and GSTT1). A population-based case-control study (3,030 cases and 3,402 controls) was conducted in Ontario, Canada. Iron intake (total, dietary, supplemental, heme, nonheme) was assessed using a validated food frequency questionnaire. Odds ratios (OR) and 95% confidence intervals (CI) were estimated from multivariable logistic regression models. Interactions between iron intake and genotypes were assessed among 1,696 cases and 1,761 controls providing DNA. Overall, no associations were observed between iron intake and breast cancer risk. Among premenopausal women, total, dietary and dietary nonheme iron were positively associated with ER-/PR- breast cancer risk (all p trend  < 0.05). Among postmenopausal women, supplemental iron was associated with reduced breast cancer risk (OR >18 vs. 0 mg/day = 0.68, 95% CI: 0.51-0.91), and dietary heme iron was associated with an increased risk, particularly the ER-/PR- subtype (OR highest vs. lowest quintile = 1.69, 95% CI: 1.16-2.47; p trend = 0.02). Furthermore, GSTT1 and combined GSTM1/GSTT1 polymorphisms modified some of the associations. For example, higher dietary iron was most strongly associated with increased breast cancer risk among women with GSTT1 deletion or GSTM1/GSTT1 double deletions (p interaction  < 0.05). Findings suggest that iron intake may have different effects on breast cancer risk according to menopausal and hormone receptor status, as well as genotypes affecting antioxidant capacity., (© 2020 UICC.)

Background: Since 2005, the Smoking Treatment for Ontario Patients (STOP) program has provided smoking cessation treatment of varying form and intensity to smokers through 11 distinct treatment models, either in-person at partnering healthcare organizations or remotely via web or telephone. We aimed to characterize the patient populations reached by different treatment models., Methods: We linked self-report data to health administrative databases to describe sociodemographics, physical and mental health comorbidity, healthcare utilization and costs. Our sample consisted of 107,302 patients who enrolled between 18Oct2005 and 31Mar2016, across 11 models operational during different time periods., Results: Patient populations varied on sociodemographics, comorbidity burden, and healthcare usage. Enrollees in the Web-based model were youngest (median age: 39; IQR: 29-49), and enrollees in primary care-based Family Health Teams were oldest (median: 51; IQR: 40-60). Chronic Obstructive Pulmonary Disease and hypertension were the most common physical health comorbidities, twice as prevalent in Family Health Teams (32.3% and 30.8%) than in the direct-to-smoker (Web and Telephone) and Pharmacy models (13.5%-16.7% and 14.7%-17.7%). Depression, the most prevalent mental health diagnosis, was twice as prevalent in the Addiction Agency (52.1%) versus the Telephone model (25.3%). Median healthcare costs in the two years up to enrollment ranged from $1,787 in the Telephone model to $9,393 in the Addiction Agency model., Discussion: While practitioner-mediated models in specialized and primary care settings reached smokers with more complex healthcare needs, alternative settings appear better suited to reach younger smokers before such comorbidities develop. Although Web and Telephone models were expected to have fewer barriers to access, they reached a lower proportion of patients in rural areas and of lower socioeconomic status. Findings suggest that in addition to population-based strategies, embedding smoking cessation treatment into existing healthcare settings that reach patient populations with varying disparities may enhance equitable access to treatment., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: DB reports grants from the Canadian Cancer Society Research Institute during the conduct of the study; she also reports grants from a Pfizer GRAND award, outside the submitted work. LZ reports grants from the Canadian Cancer Society Research Institute during the conduct of the study; she also reports grants from Pfizer GRAND Awards, outside the submitted work. PLS reports receiving grants from the Centre for Addiction and Mental Health, Ontario Ministry of Health and Long-Term Care, Health Canada, Canadian Institutes of Health Research, Canadian Cancer Society Research Institute, Canadian Partnership Against Cancer, Medical Psychiatry Alliance, Ontario Neurotrauma Foundation, the Patient-Centered Outcomes Research Institute, Bhasin Consulting Fund Inc and Pfizer Inc./Canada. PLS also reports serving on advisory boards and receiving consulting fees and honoraria from Pfizer Canada Inc., Johnson & Johnson Group of Companies, Evidera Inc., Miller Medical Communications, NVision Insight Group, Myelin & Associates, University of Ottawa Heart Institute, Royal College of Physicians and Surgeons of Canada, Royal Victoria Regional Health Centre, the University of Toronto Department of Family and Community Medicine, Northern Ontario School of Medicine, Canadian Partnership Against Cancer, Battle River Treaty 6 Healthcare, Lung Association of Nova Scotia, Exchange Summit, Toronto Public Health, Ontario Association of Public Health Dentistry and ECHO. PLS also reports that MedPlan Communications assisted in organizing Pfizer Canada Inc. Advisory Board events for which he was a consultant and that Pfizer Inc., Novartis, and Johnson & Johnson are vendors of record for providing free/discounted smoking cessation pharmacotherapy for research studies on which he is principal or co-investigator. No other author has competing interests to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

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., (© The Author(s) 2018. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: A history of childhood abuse may affect people's health and criminal justice system involvement. Understanding the prevalence of childhood abuse among individuals in prison is important to inform effective and appropriate correctional services., Objectives: To review and summarize data on the prevalence of childhood abuse among people experiencing imprisonment in Canada., Search Methods: We searched for studies in bibliographic indexes, reference lists, and gray literature, and we consulted experts., Selection Criteria: We included studies published since 1987 that reported data on prevalence of a history of abuse before the age of 18 years among people in Canadian prisons, including any abuse, physical abuse, sexual abuse, emotional abuse, and neglect., Data Collection and Analysis: Two authors independently reviewed titles and abstracts for eligibility and reviewed full texts for eligibility. Analyses included summary estimates and meta-regression with random effects., Main Results: The search identified 1429 records. We included 34 unique studies in our review and 29 nonoverlapping studies in our meta-analysis. The summary prevalence for any type of childhood abuse was 65.7% (95% confidence interval [CI] = 52.6, 77.7; range = 56.2% to 75.0%) among women; only one study reported the prevalence among men (35.5%). The summary prevalence of sexual abuse was 50.4% (95% CI = 33.5, 67.2; range = 9.9% to 77.3%) among women and 21.9% (95% CI = 15.7, 28.8; range = 8.3% to 55.6%) among men. The prevalence of neglect was 51.5% (95% CI = 43.1, 59.7; range = 45.5% to 65.1%) among women and 42.0% (95% CI = 12.7, 74.6; range = 6.8% to 99.0%) among men. The prevalence of physical abuse was 47.7% (95% CI = 41.3, 54.0; range = 16.3% to 83.0%), and the prevalence of emotional abuse was 51.5% (95% CI = 34.8, 67.9; range = 8.7% to 96.0%); we did not find differences according to gender. Prevalence estimates for all types of abuse showed high and unexplained variability across studies., Conclusions: Half of people in prisons in Canada experienced abuse in childhood. Public Health Implications. Prisons should incorporate trauma-informed approaches. Research is required to understand the association between a history of childhood abuse and criminal justice system involvement and to prevent childhood abuse and mitigate its adverse effects. Systematic Review Registration. PROSPERO CRD42017056192.

Introduction: Socio-economic disparities in smoking rates persist, in Ontario, despite public health care and universal tobacco control policies. Mechanisms for continuing disparities are not fully understood. Unequal access or utilization of assistance for cessation may contribute. The objective of this research was to use longitudinal data on smokers to examine the associations between socioeconomic status (SES) and access to care measures and assisted and unassisted quit attempts., Methods: Data were taken from 3578 smokers with at least one follow-up interview participating in the Ontario Tobacco Survey (OTS). Multinomial regression models with imputed missing values were run for each measure of SES and access to care to assess the association with quitting behavior and use of assistance, unadjusted and while adjusting for smoking history and demographic covariates., Results: Adjusted analyses found smokers living in areas with the lowest ethnic concentration were more likely to make an assisted quit attempt compared to unassisted quitting (RR = 1.64; 95% CI = 1.08-2.50) or making no quit attempt (RR = 1.65; 95% CI = 1.15-2.37). Smokers who reported visiting a doctor in the previous 6 months were more likely to quit with assistance versus unassisted compared to those not visiting a doctor, whether they were advised (RR = 1.89, 95% CI = 1.43-2.48) or not advised to quit (OR = 1.32, 95% CI = 1.01-1.74). Similar results were seen when comparing assisted quit attempts with no quit attempts., Conclusions: Adjusted analyses showed that quitting with assistance was unrelated to measures of SES except ethnic concentration. Physician intervention with patients who smoke is important for increasing assisted quit attempts., Implications: For most measures of SES there were no significant associations with either assisted or unassisted quitting adjusting for demographic and smoking history. Smokers who live in areas with the lowest ethnic concentration were most likely to use assistance as were smokers who visited their doctor and were advised to quit smoking. Interventions to increase the delivery of effective quitting methods in smokers living in areas with high ethnic concentrations and to increase physician compliance with asking and advising patients to quit may increase assisted quit attempts., (© The Author 2017. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Chiropractic manipulation is a popular treatment for neck pain and headache, but may increase the risk of cervical artery dissection and stroke. Patients with carotid artery dissection can present with neck pain and/or headache before experiencing a stroke. These are common symptoms seen by both chiropractors and primary care physicians (PCPs). We aimed to assess the risk of carotid artery stroke after chiropractic care by comparing association between chiropractic and PCP visits and subsequent stroke., Methods: A population-based, case-crossover study was undertaken in Ontario, Canada. All incident cases of carotid artery stroke admitted to hospitals over a 9-year period were identified. Cases served as their own controls. Exposures to chiropractic and PCP services were determined from health billing records., Results: We compared 15,523 cases to 62,092 control periods using exposure windows of 1, 3, 7, and 14 days prior to the stroke. Positive associations were found for both chiropractic and PCP visits and subsequent stroke in patients less than 45 years of age. These associations tended to increase when analyses were limited to visits for neck pain and headache-related diagnoses. There was no significant difference between chiropractic and PCP risk estimates. We found no association between chiropractic visits and stroke in those 45 years of age or older., Conclusions: We found no excess risk of carotid artery stroke after chiropractic care. Associations between chiropractic and PCP visits and stroke were similar and likely due to patients with early dissection-related symptoms seeking care prior to developing their strokes., (Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Clinical trials show the efficacy of dentists' counseling in smoking cessation. However, little is known about the effectiveness of such advice in the general population of smokers., Objective: To examine the association between dentists' advice, use of cessation medications and quitting behaviours in the general population of adult smokers in Ontario, Canada., Methods: Data were from the Ontario Tobacco Survey panel study, which followed people who were smokers in July 2005 semi-annually for up to 3 years until June 2011. Baseline smokers, who were seen by a dentist during the study, were included in the analysis (n = 2714 with 7549 observations). Logistic regression analysis with generalized estimating equations was used to examine associations among dentists' advice, use of cessation medications and quitting outcomes (quit attempts and short-term quitting ≥ 30 days)., Results: Those who received dentists' advice were more addicted to tobacco, compared with those who did not receive dentists' advice (self-perceived addiction to tobacco: 96% vs. 89%, p < 0.001). Dentists' advice alone was not associated with making an attempt to quit smoking or short-term quitting. However, receiving dentists' advice in conjunction with cessation medications was associated with a higher likelihood of quit attempts (adjusted odds ratio [OR] 9.85, 95% confidence interval [CI] 7.77-12.47) and short-term quitting (adjusted OR 3.19, 95% CI 2.20-4.62), compared with not receiving dentists' advice and not using cessation medications., Conclusion: Dentists play an important role in smoking cessation, because they can encourage patients to stop smoking and promote success by advising patients to use cessation medications.

Background: The National Lung Screening Trial (NLST) results indicate that computed tomography (CT) lung cancer screening for current and former smokers with three annual screens can be cost-effective in a trial setting. However, the cost-effectiveness in a population-based setting with >3 screening rounds is uncertain. Therefore, the objective of this study was to estimate the cost-effectiveness of lung cancer screening in a population-based setting in Ontario, Canada, and evaluate the effects of screening eligibility criteria., Methods and Findings: This study used microsimulation modeling informed by various data sources, including the Ontario Health Insurance Plan (OHIP), Ontario Cancer Registry, smoking behavior surveys, and the NLST. Persons, born between 1940 and 1969, were examined from a third-party health care payer perspective across a lifetime horizon. Starting in 2015, 576 CT screening scenarios were examined, varying by age to start and end screening, smoking eligibility criteria, and screening interval. Among the examined outcome measures were lung cancer deaths averted, life-years gained, percentage ever screened, costs (in 2015 Canadian dollars), and overdiagnosis. The results of the base-case analysis indicated that annual screening was more cost-effective than biennial screening. Scenarios with eligibility criteria that required as few as 20 pack-years were dominated by scenarios that required higher numbers of accumulated pack-years. In general, scenarios that applied stringent smoking eligibility criteria (i.e., requiring higher levels of accumulated smoking exposure) were more cost-effective than scenarios with less stringent smoking eligibility criteria, with modest differences in life-years gained. Annual screening between ages 55-75 for persons who smoked ≥40 pack-years and who currently smoke or quit ≤10 y ago yielded an incremental cost-effectiveness ratio of $41,136 Canadian dollars ($33,825 in May 1, 2015, United States dollars) per life-year gained (compared to annual screening between ages 60-75 for persons who smoked ≥40 pack-years and who currently smoke or quit ≤10 y ago), which was considered optimal at a cost-effectiveness threshold of $50,000 Canadian dollars ($41,114 May 1, 2015, US dollars). If 50% lower or higher attributable costs were assumed, the incremental cost-effectiveness ratio of this scenario was estimated to be $38,240 ($31,444 May 1, 2015, US dollars) or $48,525 ($39,901 May 1, 2015, US dollars), respectively. If 50% lower or higher costs for CT examinations were assumed, the incremental cost-effectiveness ratio of this scenario was estimated to be $28,630 ($23,542 May 1, 2015, US dollars) or $73,507 ($60,443 May 1, 2015, US dollars), respectively. This scenario would screen 9.56% (499,261 individuals) of the total population (ever- and never-smokers) at least once, which would require 4,788,523 CT examinations, and reduce lung cancer mortality in the total population by 9.05% (preventing 13,108 lung cancer deaths), while 12.53% of screen-detected cancers would be overdiagnosed (4,282 overdiagnosed cases). Sensitivity analyses indicated that the overall results were most sensitive to variations in CT examination costs. Quality of life was not incorporated in the analyses, and assumptions for follow-up procedures were based on data from the NLST, which may not be generalizable to a population-based setting., Conclusions: Lung cancer screening with stringent smoking eligibility criteria can be cost-effective in a population-based setting., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: HJdK, CMvdA, and KtH are members of the the Cancer Intervention and Surveillance Modeling Network (CISNET) Lung working group (grant 1U01CA199284-01 from the National Cancer Institute). HJdK is the principal investigator of the Dutch-Belgian Lung Cancer Screening Trial (Nederlands-Leuvens Longkanker Screenings onderzoek; the NELSON trial). CMvdA and KtH are researchers affiliated with the NELSON trial. HJdK, CMvdA, and KtH received a grant from the University of Zurich to assess the cost-effectiveness of computed tomographic lung cancer screening in Switzerland. HJdK took part in a one-day advisory meeting on biomarkers organized by M.D. Anderson/Health Sciences during the 16th World Conference on Lung Cancer. MCT is a Senior Scientist for Cancer Care Ontario and serves as Scientific Lead on their High Risk Cancer Screening Pilot Study and Program Development in a part-time position. MCT's involvement with Cancer Care Ontario funded his research in this study. HJdK and LFP were both involved in the Cancer Care Ontario Health Technology Assessment Study for CT Lung Cancer Screening in Canada, and LFP received funding for this specific to conduct research presented in this study.

Background: Diagnosis of influenza in older adults may be complicated by atypical presentations or when patients present with complications of an underlying illness. We aimed to identify clinical characteristics and epidemiological factors associated with influenza among community-dwelling adults aged ≥60 years presenting to emergency departments., Methods: We identified patients with influenza-compatible chief complaints presenting to emergency departments of six acute care hospitals in Ontario, Canada during the 2011/12 and 2012/13 influenza seasons. Clinical characteristics, medical history and demographics were collected by patient interview, chart review and by contacting vaccine providers. Nasopharyngeal swabs were tested for influenza using polymerase chain reaction. We modeled predictors of influenza using multivariable logistic regression models that compared individuals with and without influenza., Results: Of 1318 participants, 151 (11 %) had influenza (98 A/H3N2, 12 A/H1N1, 4 A [not sub-typed], 37 B). In the multivariable model, clinical symptoms associated with influenza were cough (OR 6.4, 95 % CI 3.2, 13.0), feverishness and/or triage temperature ≥37.2 °C (OR 3.0, 95 % CI 2.0, 4.7), 2-5 days from symptom onset to the emergency department visit (OR 2.2, 95 % CI 1.5, 3.2), and wheezing (OR 2.1, 95 % CI 1.3, 3.3). The effect of cough on influenza increased with older age. Epidemiological factors associated with increased odds for influenza included weeks when ≥10 % influenza tests from provincial laboratories were positive (OR 5.1, 95 % CI 1.2, 21.7) and exposure to a person with influenza-like illness (OR 1.9, 95 % CI 1.3, 2.8). Among participants with influenza, only 47 (31 %) met the U.S. Centers for Disease Control and Prevention criteria for influenza-like illness (temperature ≥37.8 °C and cough and/or sore throat)., Conclusions: As in younger adults, cough and feverishness are the two symptoms most predictive of influenza in the elderly. Current influenza-like illness definitions did not adequately capture influenza in older adults.

Introduction: The mediating role of cessation medications in the association between health professional advice and quitting behaviors is unclear., Methods: Data were from the Ontario Tobacco Survey longitudinal study, collected between July 2005 and June 2011 in Ontario, Canada. The analytic sample included 3437 baseline smokers who were seen by health professionals during follow-up. Logistic regression with generalized estimating equations and mediation analysis techniques were used to examine the impact of advice and medications on quitting outcomes (making a quit attempt, short-term quitting 1-6months and long-term quitting>6months)., Results: Those who received advice to quit smoking were more likely to use cessation medications than those who did not receive advice (21% vs. 13%, P<0.001). Receiving advice was associated with making a quit attempt (adjusted odds ratio (OR) 1.25, 95% confidence interval (CI) 1.10-1.41) and long-term quitting (adjusted OR 1.49, 95% CI 1.10-2.02), but not with short-term quitting. Use of cessation medications was associated with making a quit attempt (adjusted OR 11.83, 95% CI 9.93-14.08), short-term quitting (adjusted OR 3.69, 95% CI 2.90-4.68), and long-term quitting (adjusted OR 2.73, 95% CI 1.95-3.82). Using prescription medications was associated with a higher likelihood of quitting short-term (adjusted OR 2.43, 95% CI 2.59-3.74) and long-term (adjusted OR 2.27, 95% CI 1.23-4.17) than using NRT. Use of cessation medications was a significant mediator in the pathway from receiving advice to quitting., Conclusion: Health professionals should advise smokers to quit and encourage them to use cessation medications, especially prescription medications when trying to quit., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: The number of quit attempts it takes a smoker to quit successfully is a commonly reported figure among smoking cessation programmes, but previous estimates have been based on lifetime recall in cross-sectional samples of successful quitters only. The purpose of this study is to improve the estimate of number of quit attempts prior to quitting successfully., Design: We used data from 1277 participants who had made an attempt to quit smoking in the Ontario Tobacco Survey, a longitudinal survey of smokers followed every 6 months for up to 3 years beginning in 2005. We calculated the number of quit attempts prior to quitting successfully under four different sets of assumptions. Our expected best set of assumptions incorporated a life table approach accounting for the declining success rates for subsequent observed quit attempts in the cohort., Results: The estimated average number of quit attempts expected before quitting successfully ranged from 6.1 under the assumptions consistent with prior research, 19.6 using a constant rate approach, 29.6 using the method with the expected lowest bias, to 142 using an approach including previous recall history., Conclusions: Previous estimates of number of quit attempts required to quit may be underestimating the average number of attempts as these estimates excluded smokers who have greater difficulty quitting and relied on lifetime recall of number of attempts. Understanding that for many smokers it may take 30 or more quit attempts before being successful may assist with clinical expectations., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objectives: Smoke-free policies not only reduce harm to non-smokers, they may also reduce harm to smokers by decreasing the number of cigarettes smoked and increasing the likelihood of a successful quit attempt. However, little is known about the impact of exposure to smoking on patios on smoking behaviour., Design and Participants: Smokers from the Ontario Tobacco Survey, a longitudinal population representative cohort of smokers (2005-2011). There were 3460 current smokers who had completed one to six follow-ups and were asked at each follow-up whether or not they had been exposed to smoking on patios in the month., Main Outcome Measures: Generalised estimating equations and survival analysis were used to examine the association between exposure to patio smoking and smoking behaviour changes (making a quit attempt and time to relapse after a quit attempt), controlling for potential confounders., Results: Smokers who were exposed to smoking on patios (adjusted incident rate ratio (aIRR) = 0.89; 95% CI 0.81 to 0.97) or had been to a patio (aIRR = 0.86; 95% CI 0.74 to 0.99) were less likely to have made a quit attempt than smokers who had not visited a patio. Smokers who were exposed to smoking on patios were more likely to relapse (adjusted HR=2.40; 95% CI 1.07 to 5.40)) after making a quit attempt than those who visited a patio but were not exposed to smoking., Conclusions: Exposure to smoking on patios of a bar or restaurant is associated with a lower likelihood of success in a quit attempt. Instituting smoke-free patio regulations may help smokers avoid relapse after quitting., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

This article examines prevalence and gender differences of alcohol use and risk drinking in a representative sample of Ontario adults. Data were drawn from the Centre for Addiction and Mental Health (CAMH) Monitor survey of Ontario adults aged 18 and older collected between January 2005 and December 2010. The prevalence of self-reported lifetime, current, and high-risk drinking were all higher among the Canadian and the European-origin groups compared with other ethnic groups. Within-group gender differences were evident for all ethnic groups. The narrowest gender gap was observed within the North European group and the widest in the South Asian group. The non-European ethnic groups had higher rates of abstinence and lower alcohol consumption rates; nevertheless, a considerable proportion of people from these groups may be at risk of alcohol-related harm due to risky and harmful alcohol consumption patterns. Future research should continue to investigate alcohol use in these groups and identify subgroups at risk and factors that increase or decrease their vulnerability to risky and problem drinking.

In the present study, we examined the association between duration of nicotine replacement therapy (NRT) use and smoking cessation using data from the Ontario Tobacco Survey longitudinal study (3 waves of data collected between July 2005 and December 2009). We used logistic regression with generalized estimating equations to examine the association between NRT use (any use and <4 weeks, 4.0-7.9 weeks, 8.0-11.9 weeks, and ≥ 12 weeks of use compared with nonuse) and quitting smoking (≥ 1 month). Using NRT was not associated with quitting when use duration was not taken into account (adjusted odds ratio (OR) = 1.08, 95% confidence interval (CI): 0.86, 1.35). Compared with abstaining from NRT when attempting to quit smoking, using NRT for less than 4 weeks was associated with a lower likelihood of quitting (adjusted OR = 0.51, 95% CI: 0.38, 0.67); however, using NRT for 4 weeks or longer was associated with a higher likelihood of cessation (for 4.0-7.9 weeks of NRT use, adjusted OR = 2.26, 95% CI: 1.58, 3.22; for 8.0-11.9 weeks of NRT use, adjusted OR = 3.84, 95% CI: 2.24, 6.58; and for ≥ 12 weeks of NRT use, adjusted OR = 2.80, 95% CI: 1.70, 4.61). Thus, use of NRT for less than 4 weeks was associated with reduced likelihood of cessation, whereas NRT use for longer periods of time was associated with a higher likelihood of cessation., (© The Author 2015. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health.)

Objective: To compare how the infectious disease outbreaks H1N1 and severe acute respiratory syndrome (SARS) affected community-based GPs and FPs., Design: A mailed survey sent after the H1N1 outbreak compared with the results of similar survey completed after the SARS outbreak., Setting: Greater Toronto area in Ontario., Participants: A total of 183 randomly selected GPs and FPs who provided office-based care., Main Outcome Measures: The perceptions of GPs and FPs on how serious infectious disease outbreaks affected their clinical work and personal lives; their preparedness for a serious infectious disease outbreak; and the types of information they want to receive and the sources they wanted to receive information from during a serious infectious disease outbreak. The responses from this survey were compared with the responses of GPs and FPs in the greater Toronto area who completed a similar survey in 2003 after the SARS outbreak., Results: After the H1N1 outbreak, GPs and FPs still had substantial concerns about the effects of serious infectious disease outbreaks on the health of their family members. Physicians made changes to various office practices in order to manage and deal with patients with serious infectious diseases. They expressed concerns about the effects of an infectious disease on the provision of health care services. Also, physicians wanted to quickly receive accurate information from the provincial government and their medical associations., Conclusion: Serious community-based infectious diseases are a personal concern for GPs and FPs, and have considerable effects on their clinical practice. Further work examining the timely flow of relevant information through different health care sectors and government agencies still needs to be undertaken., (Copyright© the College of Family Physicians of Canada.)

Objectives: To describe the prevalence of drug use in males in a provincial detention centre during the year before incarceration and to examine the association between socio-demographic and behavioural factors and drug use., Methods: In 2009, 500 adult males completed a survey after admission to a provincial detention centre in Ontario. Past-year prevalence rates were calculated for the use of opioids, cocaine, crack and methamphetamine, and by route of administration. Bivariate logistic regression was used to examine associations between drug use and socio-demographic and behavioural factors., Results: More than 56% of participants reported use of opioids, cocaine, crack or methamphetamine in the previous year. Risk factors for blood-borne and sexually transmitted infections were commonly reported for the previous year: 12.2% had injected drugs, 78.0% had had unprotected sex, and 48.0% had had more than one sexual partner. In unadjusted analyses, participants who were older than 24 years were more likely to have used any drugs and to have injected drugs in the previous year., Conclusions: This study provides the first Canadian data in the past decade on drug use by recently incarcerated adults. We found that drug use and behaviours that increase the risk of transmission of sexually transmitted and blood-borne infections remain very common in this population. Incarceration provides an opportunity to provide services and links to programs for people who use drugs, which could decrease drug-related harms to individuals and society.