CORE INDICATORS AND MEASURES OF YOUTH HEALTH TOBACCO CONTROL MODULE:

CORE INDICATORS AND MEASURES OF YOUTH HEALTH TOBACCO CONTROL MODULE: Indicators and Questions to use with Youth Respondents and/or School Setting Assessments CIM of Youth Tobacco Control i

Suggested citation Kroeker C & Manske S on behalf of Youth Excel. (2012, November) Core Indicators and Measures of Youth Health Tobacco Control Module: Indicators and Questions to use with Youth Respondents and/or School Setting Assessments. Waterloo, Ontario: Propel Centre for Population Health Impact, University of Waterloo. Note: This version of the CIM of Youth Tobacco Control replaces all previously published versions. The indicators and measures presented in this report have been updated based on pilot test results. Youth Excel aims to integrate the prevention of cancers with the prevention of other chronic diseases; integrate science, policy and practice to optimize prevention efforts; and catalyze cross-provincial/territorial partnerships to accelerate progress as part of an initiative called CLASP: Coalitions Linking Action and Science for Prevention. Efforts are currently focused on tobacco control, physical activity and healthy eating. Youth Excel is a team of teams including researchers, policy and program leaders from provinces. From 2009 to 2012, provincial teams were led by the following host organizations: NL (Memorial U), PE (U of PEI), NB (UNB), ON (Public Health Ontario), MB (CancerCare Manitoba), AB (U of Alberta), BC (U of Victoria), plus the pan-canadian Joint Consortium for School Health and the University of Waterloo/Canadian Cancer Society s Propel Centre for Population Health Impact, which served as the secretariat. Development of the Core Indicators and Measures of Youth Health was funded by Development of the core indicators and measures described in this report was made possible through a financial contribution from Health Canada, through the Canadian Partnership Against Cancer. The views expressed herein represent the views of Youth Excel and do not necessarily represent the views of the project funder. For more information visit our website www.propel.uwaterloo.ca/youthexcel or email cim@uwaterloo.ca. CIM of Youth Tobacco Control i

Acknowledgements Development of the Core Indicators and Measures of Youth Tobacco Control was a multi-stage process. Initial development began with a two day workshop, plus pre and post meeting written feedback. The initial refinement stage involved more written feedback and a series of teleconferences. Pilot testing occurred during the Spring of 2012 and refinements were made by a subset of initial contributors. We thank the many individuals and organizations that contributed to the development phase. Major Contributors Rashid Ahmed, Statistician Propel Centre for Population Health Impact University of Waterloo Frankie Best, Project Manager Tobacco Control Program, Chronic Disease/Injury Prevention and Built Environment British Columbia Ministry of Health Services Steve Brown, Director of Biostatistics Propel Centre for Population Health Impact University of Waterloo Philip Davidson, Policy Analyst Cross-Sector Strategic Initiatives Branch British Columbia Ministry of Education Lynn Ann Duffley, Director, Wellness Initiatives Health and Education Research Group University of New Brunswick Murray Kaiserman, Independent Consultant Scott Leatherdale, Scientist & CCO Research Chair Department of Prevention & Cancer Control Cancer Care Ontario Tanya Barnes Matthews, Regional Health Education Consultant, Western Health, Newfoundland Marlien McKay, Manager, Strategic Initiatives, Wellness Branch, New Brunswick Department of Wellness, Culture and Sport Kathy Moran, Epidemiologist Durham Region Health Department, Ontario Donna Murnaghan, Associate Professor School of Nursing, Comprehensive School Health Research Group, University of Prince Edward Island Shawn O Connor, Senior Research Associate Ontario Tobacco Research Unit Melody Roberts, Strategic Advisor Health Promotion, Chronic Disease & Injury Prevention, Public Health Ontario Additional Contributors Kathleen Brennan, Analyst [Health Promotion Chronic Disease Prevention], Sport, Recreation & Healthy Living Division, PEI Department of Health and Wellness Marla Delaney, Manager Prevention and Public Issues Canadian Cancer Society, PEI Division Anne-Marie Holt, Manager Epidemiology & Evaluation Services, Senior Epidemiologist Haliburton, Kawartha, Pine Ridge District Health Unit, Ontario CIM of Youth Tobacco Control Donna Kosmack, Southwest TCAN Manager South West Tobacco Control Area Network Middlesex London Health Unit, Ontario Mark Latendresse, Senior Epidemiologist Bio- Statistician, Controlled Substances and Tobacco Directorate, Health Canada Andrew Loughead, Manager Tobacco Control and Cessation, Manitoba Healthy Living, Youth and Seniors ii

Kevin McDonald, Manager, Tobacco Control Program, Hamilton Public Health Services, City of Hamilton, Ontario Daniela Panait, Senior Biostatistician Controlled Substances and Tobacco Directorate, Health Canada Joanne Pelley, Manager Health Promotion and Wellness Central Health, Newfoundland Lucille Pica, Chargée de projet Direction des statistiques de santé Institut de la statistique du Québec Ruth Sanderson, Chronic Disease Epidemiologist Public Health Ontario Michèle Tremblay, Médecin Conseil Institut national de santé publique du Québec Allison Watts, PhD Candidate School of Population and Public Health University of British Columbia Staff Support Esther Russell, Project Manager Propel Centre for Population Health Impact University of Waterloo Rebecca Digby, MSc Candidate Department of Health Studies and Gerontology University of Waterloo CIM of Youth Tobacco Control iii

Table of Contents SUMMARY... 1 1.0 VISION... 7 2.0 WHY CORE INDICATORS AND MEASURES?... 7 3.0 WHAT ARE THE CORE INDICATORS AND MEASURES OF YOUTH TOBACCO CONTROL?... 7 3.1 GUIDING FRAMEWORK... 9 3.2 DEFINITIONS... 10 4.0 DEVELOPMENT PROCESS... 10 4.1 PILOT TESTING... 11 4.2 ONGOING MAINTENANCE... 11 5.0 CORE INDICATORS AND MEASURES FOR YOUTH RESPONDENTS ( INDIVIDUAL-LEVEL )... 12 5.1 INDICATOR PROFILES... 15 Topic 1: Reduced susceptibility to experimentation with cigarettes... 15 Topic 2: Reduced use of cigarettes... 17 Topic 3: Reduced use of tobacco products (excluding cigarettes)... 19 Topic 4: Increased desire to quit using tobacco... 21 Topic 5: Reduced exposure to secondhand smoke... 23 5.2 DEMOGRAPHIC VARIABLES... 26 6.0 CORE INDICATORS AND MEASURES FOR THE SCHOOL SETTING ( SCHOOL-LEVEL )... 27 6.1 INDICATOR PROFILES... 30 Topic 1: Increased presence and strength of policies prohibiting tobacco use... 30 Topic 2: Increased enforcement of policies prohibiting tobacco use... 33 Topic 3: Health curriculum is supplemented with additional opportunities for learning about tobacco control issues... 35 Topic 4: Schools have partnerships and resources that help students remain or become tobacco free... 36 6.2 SCHOOL CHARACTERISTIC VARIABLES... 38 7.0 COMMON REPORTING GUIDELINES... 39 7.1 CALCULATING INDICATORS AND SUBGROUPS FOR YOUTH RESPONDENTS ( INDIVIDUAL LEVEL )... 39 7.2 CALCULATING INDICATORS AND SUBGROUPS FOR THE SCHOOL SETTING ( SCHOOL-LEVEL )... 45 7.3 SURVEY DESIGN VARIABLES TO REPORT... 50 List of Appendices Appendix A: Questions used by recent Canadian surveys of youth Appendix B: Questions used by recent school setting assessments CIM of Youth Tobacco Control iv

Summary Use of consistent measures to generate and report comparable indicators can more rapidly advance our knowledge of what types of interventions work in different settings with different populations, and help inform change (for example, program and policy decisions). Adopting core indicators and measures (CIM) can minimize duplication and reduce burden on respondents by coordinating our efforts. Our hope in producing the CIM of Youth Health is that that individuals and organizations in Canada who conduct, or make use of, surveillance and evaluation data will voluntarily and consistently adopt the CIM of Youth Health as they have been developed, each time measurement occurs. There are currently three modules of the CIM of Youth Health: Tobacco Control, Physical Activity & Sedentary Behaviour, and Nutrition. Each module is described in a different report. This report describes the CIM of Youth Tobacco Control and replaces all previously published versions. All indicators and measures described in this report have been updated from the original versions based on pilot test results. Building on past efforts, a group of experts developed two separate sets of core indicators and measures that can be implemented together or independently: 1) for use with youth respondents aged 10-19 ( individual-level ) and 2) for use with school health teams/administrators when assessing aspects of school settings related to tobacco control ( school-level ). Both sets of core indicators and measures were designed to be used with any data collection tool, either as a stand-alone set of measures (questions) or integrated with additional questions and/or topics. The individual-level CIM set contains 10 indicators measured by 9 questions about tobacco use behaviour, tobacco use intentions and exposure to secondhand smoke, plus 5 demographic questions. The individual-level CIM are designed to be used with youth respondents aged 10-19, regardless of their living, working and playing environment(s). For example, implementation of the CIM is not intended to be limited to students attending school. The school-level CIM set contains 9 indicators measured by 7 questions about the existence and enforcement of rules prohibiting tobacco use, extra-curricular activities and community partnerships designed to reduce tobacco use among youth, plus 3 school characteristic variables. The school-level CIM is designed to be used with respondents (as individuals or a team) who can accurately report on various aspects of their school setting. We limited the scope of the school-level CIM to processes, programs and structures which educators and their community partners can reasonably be expected to influence. To balance standardization with flexibility, we have structured the CIM of Youth Tobacco Control so that topics can be assessed independently, but hope that all the indicators associated with a particular topic will be reported publicly (where possible) and that all the measures associated with these indicators will be included in the data collection tool exactly as they appear in this report. Common reporting guidelines are included to facilitate comparison across implementations. The core indicators and measures for youth respondents and school setting assessments are summarized in the tables that follow, and explained in detail in the body of this report. CIM of Youth Tobacco Control 1

Core Indicators and Measures for Youth Respondents ( Individual-level ) Topics Select those relevant to your data collection objective(s) 1. Reduced susceptibility to experimentation with cigarettes Indicators For each topic selected, report all indicators where possible 1. Proportion of youth who have never had a puff of a cigarette 2. Proportion of youth who have never had a puff of a cigarette who are susceptible to cigarette smoking Measures For each topic selected, include all questions in your data collection tool 1. Have you ever tried cigarette smoking, even just a few puffs? Yes No 2. At any time during the next year do you think you will smoke a cigarette? Definitely yes Probably yes Probably not Definitely not 3. Do you think in the future you might try smoking cigarettes? Definitely yes Probably yes Probably not Definitely not 4. If one of your best friends was to offer you a cigarette would you smoke it? Definitely yes Probably yes Probably not Definitely not 2. Reduced use of cigarettes 1. Proportion of youth who smoked cigarettes a. every day for the past 30 days b. almost every day for the past 30 days c. on some of the past 30 days 2. Proportion of youth who did not smoke cigarettes at all in the past 30 days 1. During the past 30 days, did you smoke a cigarette, even just a few puffs? Yes, every day (30 days) Yes, almost every day (15-29 days) Yes, some days (1-14 days) No (0 days) 3. Reduced use of tobacco products (excluding cigarettes) 1. Proportion of youth who used tobacco (excluding cigarettes) a. every day for the past 30 days b. almost every days for the past 30 days c. on some of the past 30 days 2. Proportion of youth who did not use tobacco (excluding cigarettes) at all during the past 30 days 1. During the past 30 days, did you use any form of tobacco other than cigarettes? (for example, cigars or little cigars or chew) Yes, every day (30 days) Yes, almost every day (15-29 days) Yes, some days (1-14 days) No (0 days) CIM of Youth Tobacco Control 2

Topics Select those relevant to your data collection objective(s) 4. Increased desire to quit using tobacco 5. Reduced exposure to secondhand smoke Indicators For each topic selected, report all indicators where possible 1. Proportion of youth that want to quit using tobacco a. in the next 30 days b. in the next 6 months 2. Proportion of youth that do not want to quit using tobacco 1. Proportion of youth that report being exposed to secondhand smoke a. Daily b. almost every day c. some days d. never 2. Proportion of youth reporting exposure to secondhand smoke a. in their home in the past 30 days b. on school grounds in the past 30 days c. while at work in the past 30 days d. in a vehicle in the past 30 days Measures For each topic selected, include all questions in your data collection tool 1. Do you want to quit using tobacco (both cigarettes and other tobacco)? I have never used tobacco I have already quit for at least 30 days Yes, within 30 days Yes, within 6 months Yes, but I am not sure when No, I do not want to quit 1. During the past 30 days, how often did you breathe in secondhand smoke, meaning the smoke from someone else s cigarette? If you smoke, do not include your own cigarette smoke in your answer. Every day (30 days) Almost every day (15-29 days) Some days (1-14 days) Never (0 days) 2. During the past 30 days, did you breathe in secondhand smoke, meaning the smoke from someone else s cigarette (If you smoke, do not include your own cigarette smoke in your answer) a. in your home? Yes No I do not have a home (exclude if sample will not contain homeless youth) b. on school grounds? Yes No I do not go to school (exclude if entire sample attends school) c. while at work? Yes No I do not work d. in a vehicle? Yes No I have not been in a vehicle in the past 30 days Demographic Variables Variables For each indicator, report by Measures Include all if possible 1. Age 1. How old are you today? (Response options can be customized for sample) 10 years or younger 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years or older CIM of Youth Tobacco Control 3

Variables For each indicator, report by 2. Grade Exclude if the entire sample does not attend school Measures Include all if possible 1. What grade are you in? List each relevant grade as a separate response option. If sample may contain youth that do not attend school, include I do not go to school as a response option. 3. Gender 1. Are you OR 2. Are you a Male? Boy? Female? Girl? 4. Disposable income of youth respondent 1. About how much money do you usually get each week to spend on yourself or to save? (remember to include all money from allowances and jobs like babysitting, delivering papers ) Zero $1 to $5 $6 to $10 $11 to $20 $21 to $40 $41 to $100 More than $100 I do not know how much money I get each week 5. Recent immigration 1. Did you move to Canada for the first time in the last 5 years? Yes No I do not know Core Indicators and Measures for School Setting Assessments ( School-level ) Topics Select those relevant to your data collection objective(s) 1. Increased presence and strength of policies prohibiting tobacco use Indicators For each topic selected, report all where possible 1. Proportion of schools that report having policies prohibiting all forms of tobacco use, in all locations 2. Proportion of schools that report having policies prohibiting all forms of tobacco use in the following locations a. On school grounds during school hours b. On school grounds outside of school hours c. Off school grounds but within a specified distance of the boundary d. In school buses or other vehicles used to transport students e. In private vehicles parked on school grounds f. At school events off school grounds continued on next page Measures For each topic selected, include all questions in your data collection tool 1. Policies include management practices, decisionmaking processes, procedures and rules at any level. Does your school have policies that prohibit all forms of tobacco use (for example, cigarette smoking, little cigars, chewing tobacco) in the following locations? a. School grounds during school hours Yes No b. School grounds outside of school hours Yes No c. Off school grounds but within a specified distance of the boundary Yes No d. School buses or other vehicles used to transport students Yes No e. Private vehicles parked on school grounds Yes No f. School events off school grounds Yes No continued on next page CIM of Youth Tobacco Control 4

Topics Select those relevant to your data collection objective(s) 2. Increased enforcement of policies prohibiting tobacco use Indicators For each topic selected, report all where possible 3. Proportion of schools with policies that prohibit all forms of tobacco use, in all locations, whose policies apply to everyone including students, staff, families and visitors 4. Proportion of schools with policies that prohibit all forms of tobacco use, in all locations, whose policies apply 24 hours per day, 356 days per year. 1. Proportion of schools that have at least one person with responsibility to actively enforce policies prohibiting tobacco use Measures For each topic selected, include all questions in your data collection tool 2. Do these policies apply to everyone including students, staff, families and visitors? Yes No Our school does not have policies that prohibit all forms of tobacco use 3. Do these policies apply 24 hours per day, 365 days per year, even if enforcement is not always feasible? Yes No Our school does not have policies that prohibit all forms of tobacco use 1. Policies include management practices, decisionmaking processes, procedures and rules at any level. * Does your school have at least one person with responsibility to actively enforce policies prohibiting tobacco use, at least while students are in school? Yes No Our school does not have policies prohibiting tobacco use *If definition already included as part of the measures from topic 1, it does not need to be repeated. 3. Health curriculum is supplemented with additional opportunities for learning about tobacco control issues 1. Proportion of schools whose health curriculum is supplemented with opportunities for learning about tobacco use and control issues (e.g. prevention of tobacco use, stopping tobacco use, protection from secondhand smoke) 1. Do students at your school have opportunities to learn about the following tobacco control issues in subjects other than health or physical education, or through programs or activities outside the curriculum? Yes No Prevention of tobacco use Quitting tobacco use Protection from secondhand smoke Advocacy or youth empowerment 4. Schools have partnerships and resources that help students remain or become tobacco free 1. Proportion of schools that have at least one effective partnership to help students remain or become tobacco free continued on next page 1. Effective partnerships are based on effective communication and strong interpersonal relationships, have common goals, value the roles of each member and evolve over time. continued on next page CIM of Youth Tobacco Control 5

Topics Select those relevant to your data collection objective(s) Indicators For each topic selected, report all where possible 2. Proportion of schools that have at least one effective partnership with an external organization (e.g. NGO, business, government, public health, police) to help students remain or become tobacco free 3. Proportion of schools that have a. funding to help students remain or become tobacco free b. services to help students remain or become tobacco free c. material resources to help students remain or become tobacco free Measures For each topic selected, include all questions in your data collection tool Does your school have at least one effective partnership with the following individuals or groups to help students remain or become tobacco free? Yes No Families Community group(s) or nongovernmental organization(s) Business(es) Government at any level Public health or regional/local health authorities Law enforcement or police 2. Does your school have any of the following supports to help students remain or become tobacco free? Yes No Funding, grants or donations Services (e.g. programs, youth advocacy activities, guest speakers, teacher training, counseling) Material resources (e.g. handouts, signs, equipment) School Characteristic Variables Variable For each indicator, report by Measures Include all or obtain data from other sources 1. Grades taught at the school What grades are taught at your school? Open ended range response OR list each relevant grade as a separate response option 2. Number of students enrolled at the school 3. School socioeconomic status (as indicated by postal code) How many students are enrolled at your school? Open ended response What is your school s postal code? Open ended response CIM of Youth Tobacco Control 6

1.0 Vision Individuals and organizations in Canada who conduct, or make use of, surveillance and evaluation data will voluntarily and consistently adopt the Core Indicators and Measures (CIM) of Youth Health using the Tobacco Control, Physical Activity & Sedentary Behaviour, and/or Nutrition modules as they were developed, each time measurement occurs. 2.0 Why Core Indicators and Measures? Across Canada, there is strong interest in tracking a common, comparable set of indicators over time for both student health and comprehensive school health. 1,2 Use of consistent measures to generate and report comparable indicators can more rapidly advance our knowledge of what types of interventions work in different settings with different populations, and help inform change (for example, program and policy decisions). Adopting CIM can minimize duplication and reduce burden on respondents by coordinating our efforts (i.e., if two groups need information on the same topic, using common measures and sharing the data can reduce the number of survey requests made to a school). Use of CIM can help us coordinate our efforts and progress faster towards our goal of improving youth health. Previous work has been conducted to develop a core set of indicators and measures for tobacco control suitable for national use 3,4,5,6,7 yet adoption has been limited and inconsistent. In only one case were the measures specific to the youth population. Never have core indicators or measures been developed for assessing the school setting as it relates to youth tobacco use. This report describes the output of a renewed attempt to develop a set of core indicators and measures (CIM) for use with youth respondents, plus CIM for use when assessing aspects of school settings related to tobacco control. Separate reports address Core Indicators and Measures of youth physical activity/sedentary behaviour and nutrition. 3.0 What are the Core Indicators and Measures of Youth Tobacco Control? A group of tobacco control experts developed two separate sets of core indicators and measures: 1) for use with youth respondents aged 10-19 and 2) for use with school health teams/administrators when assessing aspects of school setting related to tobacco control. In this report, we refer to these as the individual-level CIM and the school-level CIM. They can be implemented independently. For example, you do not have to implement the school-level CIM if your surveillance or evaluation objectives do not include measuring aspects of the school setting. While we view the individual-level CIM and the school-level CIM as separate entities, in this report we sometimes use the singular term CIM to refer to both sets of core indicators and measures at once for simplicity. 1 Joint Consortium on School Health (2007, February). Data Monitoring and Surveillance Meeting Report. Toronto, Ontario. 2 Strachan-Tomlinson, Manske S, Russell E, Wong K. (2010). Comprehensive School Health Roundtable Report, May 13-14, 2010. Waterloo, Ontario: Propel Centre for Population Health Impact, University of Waterloo. 3 University of Waterloo (1997). Assessment of Youth Smoking: Summary Workshop Report. Waterloo, Ontario. 4 Manske S, Maule C, O Connor S, Lovato C, Harvey D. A call for action to support best practices in evaluation of comprehensive tobacco control evaluation strategies. Chronic Diseases in Canada, 2003; 24 (1). 5 Copley TT, Lovato C, O Connor S. (2006). Indicators for Monitoring and Evaluating Tobacco Control: A Resource for Decision-Makers, Evaluators, and Researchers. On behalf of the National Advisory Group on Monitoring and Evaluation. Toronto, Ontario: Canadian Tobacco Control Research Initiative. 6 Copley TT, Lovato CY, Manske S (2006).Indicators and measurement items for outcome evaluation of youth smoking cessation interventions: background paper. Toronto, Ontario: Report from the Canadian Tobacco Control Research Initiative to the Office of Programs and Mass Media, Tobacco Control Programme, Health Canada. 7 Manske S, Cressman Zehr W, Lovato CY, Copley T.T. (2007). Indicators and measurement items for outcome evaluation of youth smoking cessation interventions: Phase II Youth Consultation Sessions and Expert Review Panel. Toronto, Ontario: Report from the Canadian Tobacco Control Research Initiative to the Office of Programs and Mass Media, Tobacco Control Programme, Health Canada. CIM of Youth Tobacco Control 7

The individual-level CIM set contains 10 indicators measured by 9 questions about tobacco use behaviour, tobacco use intentions and exposure to secondhand smoke, plus 5 demographic questions. The individual-level CIM are designed to be used with youth respondents aged 10-19, regardless of their living, working and playing environment(s). For example, implementation of the CIM is not intended to be limited to students attending school. The school-level CIM set contains 9 indicators measured by 7 questions about the existence and enforcement of rules prohibiting tobacco use, extra-curricular activities and community partnerships designed to reduce tobacco use among youth, plus 3 school characteristic variables. The school-level CIM are designed to be used with respondents (as individuals or a team) who can accurately report on various aspects of their school setting. We limited the scope of the school-level CIM to processes, programs and structures which educators and their community partners can reasonably be expected to influence. The Core Indicators and Measures were designed... to capture a minimal amount of information to be used as standardized sets of measures (questions) and indicators that would be reported on publicly to enable comparison to be used on their own or integrated into other data collection tools to be suitable for multiple implementation methods to have some flexibility At each level, the CIM were designed to capture a minimal amount of information related to youth tobacco use; the number of indicators and measures were intentionally limited to those deemed most critical for routine assessment. Within each indicator profile (sections 5.0 and 6.0), topics for expansion are suggested in the event that more complete data on a topic is desired. The CIM can be used on their own or integrated into more detailed data collection tools, including instruments that assess more than just tobacco-related topics. Equal attention was paid to making the CIM suitable for surveillance and evaluation, although the CIM were designed primarily for use with population-based surveys as opposed to clinical use or small-scale program evaluations. The measures (questions) were designed to be appropriate for a variety of data collection tools including questionnaires, interviews, social media applications, etc. The CIM are organized by topics (e.g., reduced uptake; increased desired to quit). Indicators provide a measure of progress towards an ideal outcome. The measures (questions) collect the data required to calculate the indicators. Some topics are informed by multiple indicators, and some indicators are informed by multiple measures (questions). Demographic or school characteristic variables are also included. Standardization is the key benefit of using CIM as it ensures comparability across implementations. However, flexibility is also important as there is no need for an implementer to collect data that is not relevant to their specific objectives. To balance these needs, we have structured the CIM for Youth Tobacco Control so that the topics can be assessed independently, but hope that all the indicators associated with a particular topic will be reported publicly (where possible) and that all the measures (questions) associated with these indicators will be included in the data collection tool exactly as they appear in this report. For example, if only Individual-level Topic 4 (increased desire to quit) is relevant to your particular data collection needs then just include the question listed for that topic in your data collection tool. As more and more people use the question as presented, without modification, and report all the indicators for Topic 4 publicly where possible, we can build a better understanding of what policy or program contexts maximize desire to quit. Section 7.0 specifies how to calculate and report the CIM of Youth Tobacco Control 8

indicators (plus descriptions of key survey design variables) to ensure comparability across implementations. 3.1 Guiding Framework The individual-level CIM are organized around the tobacco control framework used by Canada s Federal Tobacco Control Strategy and most provinces and territories. The CIM includes indicators for three components of the framework: prevention of tobacco use initiation; cessation of tobacco use; and protection from secondhand smoke. The school-level CIM are organized around the comprehensive school health framework. Comprehensive school health is an internationally recognized framework for supporting improvements in students educational outcomes while addressing school health in a planned, integrated and holistic way. It goes beyond the classroom to encompass the whole school setting. Research has shown that comprehensive school health is an effective way to improve both health 8 and educational outcomes 9 and encourage healthy behaviours that last a lifetime. Comprehensive school health is an extension of several behaviour change theories that specify environment as an important influence on individual behaviour. The comprehensive school health concept is expressed through a variety of terms (e.g. health promoting schools; coordinated school health) and while each specific framework differs in how its pillars are defined, the underlying concepts are the same; they are all based on the World Health Organization s Ottawa Charter for Health Promotion (1986). The school-level CIM were guided by the comprehensive school health framework used by the Joint Consortium for School Health, a partnership of federal, provincial, and territorial governments from across Canada. 10 The framework outlines four distinct but inter-related pillars: healthy school policy. Management practices, decision-making processes, rules, procedures and policies promote tobacco-free living and shape a respectful, welcoming and caring school environment social and physical environment. The social environment (e.g. relationships between staff and students) and the physical environment (e.g. buildings and grounds) support tobacco-free living teaching and learning. Resources, activities and provincial/territorial curriculum enable students to gain age-appropriate knowledge and experiences, helping to build the skills to live tobacco-free partnerships and services. Partnerships (between schools and families, between and within schools, and between health and education sectors) and community and school-based services support tobaccofree living 8 Stewart-Brown, S. (2006). What is the evidence on school health promotion in improving health or preventing disease and, specifically, what is the effectiveness of the health promoting schools approach? Copenhagen, Denmark: WHO Regional Office for Europe (Health Evidence Network report). 9 Murray ND, Low BJ, Hollis C, Cross A, Davis S. Coordinated school health programs and academic achievement: a systematic review of the literature. Journal of School Health 2007; 77 (9), 589-599. 10 Joint Consortium for School Health. Comprehensive School Health Framework. Available www.jcshcces.ca/index.php?option=com_content&view=article&id=40&itemid=62, January 31, 2011. CIM of Youth Tobacco Control 9

3.2 Definitions The CIM development process was guided by the following definitions: Indicator: A specific item of information that describes measurable characteristics in a corresponding outcome. For example, if the objective is that less than ten percent of the population smoke cigarettes, the indicator would be the proportion of participants who report that they smoke cigarettes. 11 Measures: Each indicator requires a way of classifying or estimating, in relation to a scale or standard, the degree of quality or quantity of the indicator. 11 These estimates are measures, e.g. tobacco-related attitudes, knowledge or behaviour being considered. They are the specific questions to which responses are made. 4.0 Development Process Development of the Core Indicators and Measures (CIM) of Youth Tobacco Control was a multi-stage process beginning in January 2010 and building on previous work. Throughout the development process, attempts were made to include a range of sectors (policy, practice, research), disciplines (health, education), jurisdictions (national, provincial), and geography (provinces, territories). Detailed reports of each phase of the CIM development process are available at www.propel.uwaterloo.ca/youthexcel. Step one involved a review of past reports outlining work towards a common set of indicators and measures. For the individual-level, the indicators developed by the National Advisory Group on Monitoring and Evaluation (NAGME) 11 were selected as a starting point and modified where applicable for use with the youth population. At the school-level, the indicators from the Joint Consortium for School Health (JCSH) Healthy School Planner Tobacco Use Assessment Feedback Report 12 provided a starting point. A scan of recent national and provincial surveys was conducted to identify potential measures each indicator (see Appendices A and B). A workshop was held in March 2010 to refine the intended use of CIM of Youth Tobacco Control and work towards can live with consensus as to what indicators and measures should be included. Nineteen individuals from across Canada representing research, policy, and practice disciplines from academia, government, education and public health sectors attended. Prior to the workshop, invitees were asked to comment on the initial list of indicators, indicating the extent to which each indicator had an impact on decisions related to tobacco control. These data were summarized and used in combination with the NAGME and Healthy School Planner indicators and scan of potential measures to inform workshop discussions. The main outcome of the workshop was a revised list of indicators intended to undergo further review. The review and refinement phase began with a series of workbooks aimed to refine the indicator selection criteria, and solicit input on which indicators were critical to include in the CIM, and why. Indicator selection was based on criteria similar to those in the Centers for Disease Control and Prevention report on Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs (2005). 13 Five criteria were used to guide indicator selection: 11 Copley TT, Lovato C, O Connor S. (2006). Indicators for Monitoring and Evaluating Tobacco Control: A Resource for Decision-Makers, Evaluators, and Researchers. On behalf of the National Advisory Group on Monitoring and Evaluation. Toronto, Ontario: Canadian Tobacco Control Research Initiative. 12 Available at http://www.healthyschoolplanner.uwaterloo.ca, January 31, 2011. 13 Starr G, Rogers T, Schooley M, Porter S, Wiesen E, Jamison N. (2005). Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs. Atlanta, Georgia: Centers for Disease Control and Prevention. CIM of Youth Tobacco Control 10

1. Feasibility. The indicator is feasible to measure in a population of interest. The amount of resources (funds, time and effort) required to collect and analyze data on the indicator can be realistically applied to collect data from a sufficient sample. 2. Strength of evidence. Evidence supports the assumption that implementing interventions to effect change in a given indicator will lead to measureable outcome. 3. Relevance/utility. Indicator informs decisions relevant to surveillance and evaluation (taking priority over answering research questions). There should be a rational connection between the indicator and what we need/want to measure. 4. Accepted practice. Degree to which indicator is consistent with/reflective of current accepted practice. Where warranted, there should be comparability to indicators currently used, collected and reported on. This criterion acknowledges value in both using existing data sources, but developing new indicators where needed. 5. Face validity. The indicator appears to be valid to tobacco control stakeholders. Through a series of teleconferences the most critical indicators were refined and measures were selected to form the CIM. An average of 6 individuals representing a mix of practice, policy and surveillance/research perspectives participated in each workbook or teleconference. Targeted literature searches, a review of federal, provincial and territorial tobacco control strategies, and focus groups with youth investigating how they define smokers were also conducted to inform the process. In June, 2011, the Propel Centre for Population Health Impact hosted a meeting 14 to engage community monitoring stakeholders across Canada in developing an implementation plan for the CIM of Youth Tobacco Control. Participants supported processes used to develop the CIM of Youth Tobacco Control, but identified the need for an additional section in this report that outlines what methodological aspects should be reported to ensure proper comparison across implementation (i.e. basic information on sampling, data quality, data collection mode and response rate). A small working group developed Section 7.3, Survey Design Variables to Report in response to this request. 4.1 Pilot testing The initial CIM of Youth Tobacco Control were made public in April 2011. Pilot testing was conducted during the Spring of 2012, in combination with the CIM of Youth Physical Activity & Sedentary Behaviour. A detailed report of pilot test results can be accessed at www.propel.uwaterloo.ca/youthexcel. This version of the CIM of Youth Tobacco Control replaces all previously published versions. The indicators and measures presented in this report have been updated based on pilot test results. 4.2 Ongoing Maintenance The CIM require regular review and updating as the evidence base is more fully developed. Expansion of the CIM to other environments (e.g. community or neighbourhood) is ideal, but was beyond the scope of initial development efforts. Propel convened a multi-organization Steering Committee to provide strategic direction on an ongoing basis for the CIM of Youth Health. The CIM of Youth Health Steering Committee held their inaugural meeting in September, 2011. The Propel Centre for Population Health Impact serves as the secretariat. 14 Meeting funding was supplied by CIHR and the Propel Centre for Population Health Impact. CIM of Youth Tobacco Control 11

5.0 Core Indicators and Measures for Youth Respondents ( Individual-level ) The individual-level CIM are designed for use with respondents age 10-19 regardless of their living, working, and playing environment(s). The measures can be used with any data collection tool, on their own or integrated with additional questions. Topics Select those relevant to your data collection objective(s) 1. Reduced susceptibility to experimentation with cigarettes 2. Reduced use of cigarettes 3. Reduced use of tobacco products (excluding cigarettes) Indicators For each topic selected, report all indicators where possible 1. Proportion of youth who have never had a puff of a cigarette 2. Proportion of youth who have never had a puff of a cigarette who are susceptible to cigarette smoking 1. Proportion of youth who smoked cigarettes a. every day for the past 30 days b. almost every day for the past 30 days c. on some of the past 30 days 2. Proportion of youth who did not smoke cigarettes at all in the past 30 days 1. Proportion of youth who used tobacco (excluding cigarettes) a. every day for the past 30 days b. almost every days for the past 30 days c. on some of the past 30 days 2. Proportion of youth who did not use tobacco (excluding cigarettes) at all during the past 30 days Measures For each topic selected, include all questions in your data collection tool 1. Have you ever tried cigarette smoking, even just a few puffs? Yes No 2. At any time during the next year do you think you will smoke a cigarette? Definitely yes Probably yes Probably not Definitely not 3. Do you think in the future you might try smoking cigarettes? Definitely yes Probably yes Probably not Definitely not 4. If one of your best friends was to offer you a cigarette would you smoke it? Definitely yes Probably yes Probably not Definitely not 1. During the past 30 days, did you smoke a cigarette, even just a few puffs? Yes, every day (30 days) Yes, almost every day (15-29 days) Yes, some days (1-14 days) No (0 days) 1. During the past 30 days, did you use any form of tobacco other than cigarettes? (for example, cigars or little cigars or chew) Yes, every day (30 days) Yes, almost every day (15-29 days) Yes, some days (1-14 days) No (0 days) CIM of Youth Tobacco Control 12

Topics Select those relevant to your data collection objective(s) 4. Increased desire to quit using tobacco 5. Reduced exposure to secondhand smoke Indicators For each topic selected, report all indicators where possible 1. Proportion of youth that want to quit using tobacco a. in the next 30 days b. in the next 6 months 2. Proportion of youth that do not want to quit using tobacco 1. Proportion of youth that report being exposed to secondhand smoke a. daily b. almost every day c. some days d. never 2. Proportion of youth reporting exposure to secondhand smoke a. in their home in the past 30 days b. on school grounds in the past 30 days c. while at work in the past 30 days d. in a vehicle in the past 30 days Measures For each topic selected, include all questions in your data collection tool 1. Do you want to quit using tobacco (both cigarettes and other tobacco)? I have never used tobacco I have already quit for at least 30 days Yes, within 30 days Yes, within 6 months Yes, but I am not sure when No, I do not want to quit 1. During the past 30 days, how often did you breathe in secondhand smoke, meaning the smoke from someone else s cigarette? If you smoke, do not include your own cigarette smoke in your answer. Every day (30 days) Almost every day (15-29 days) Some days (1-14 days) Never (0 days) 2. During the past 30 days, did you breathe in secondhand smoke, meaning the smoke from someone else s cigarette (If you smoke, do not include your own cigarette smoke in your answer) a. in your home? Yes No I do not have a home (exclude if sample will not contain homeless youth) b. on school grounds? Yes No I do not go to school (exclude if entire sample attends school) c. while at work? Yes No I do not work d. in a vehicle? Yes No I have not been in a a vehicle in the past 30 days Demographic Variables Variables For each indicator, report by Measures Include all if possible 1. Age 1. How old are you today? (Response options can be customized for sample) 10 years or younger 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years or older CIM of Youth Tobacco Control 13

Variables For each indicator, report by 2. Grade Exclude if the entire sample does not attend school Measures Include all if possible 1. What grade are you in? List each relevant grade as a separate response option. If sample may contain youth that do not attend school, include I do not go to school as a response option. 3. Gender 1. Are you OR 2. Are you a Male? Boy? Female? Girl? 4. Disposable income of youth respondent 1. About how much money do you usually get each week to spend on yourself or to save? (remember to include all money from allowances and jobs like babysitting, delivering papers ) Zero $1 to $5 $6 to $10 $11 to $20 $21 to $40 $41 to $100 More than $100 I do not know how much money I get each week 5. Recent immigration 1. Did you move to Canada for the first time in the last 5 years? Yes No I do not know CIM of Youth Tobacco Control 14

5.1 Indicator Profiles Topic 1: Reduced susceptibility to experimentation with cigarettes Tobacco Framework Area Indicators Why these indicators are important Prevention 1. Proportion of youth who have never had a puff of a cigarette 2. Proportion of youth who have never had a puff of a cigarette who are susceptible to cigarette smoking Susceptibility to smoking, defined as the absence of a firm decision not to smoke, is a strong predictor of experimentation with cigarettes. 15 One-third (33%) of Canadian youth in grades 6-12 have tried cigarette smoking, at least a puff (22% grades 6-9; 49% grades 10-12). 16 Approximately 66% of smokers have their first cigarette by age 15. 17 Individuals that do not start smoking cigarettes during their adolescent years will probably never smoke. 18 Cigarettes are the most common form of tobacco used by youth, although not necessarily the first type tried. 16 Monitoring susceptibility is important so that prevention efforts can be targeted appropriately and occur before the onset of smoking behaviour. Measures to use From QTSS 19, TAYES 20, NTSTS 21, YSS 22 and adapted from GYTS 23, MB-YHS 24 1. Have you ever tried cigarette smoking, even just a few puffs? Yes No From YSS 2. At any time during the next year do you think you will smoke a cigarette? Definitely yes Probably yes Probably not Definitely not 3. Do you think in the future you might try smoking cigarettes? Definitely yes Probably yes Probably not Definitely not 15 Pierce JP, Choi WS, Gilpin EA, Farkas AJ, Merritt RK. Validation of susceptibility as a predictor of which adolescents take up smoking in the United States. Health Psychology. 1996; 15(5): 355-361. 16 Controlled Substances and Tobacco Directorate, Health Canada. Supplementary tables, Youth Smoking Survey 2008-2009. Available http://www.yss.uwaterloo.ca/results/yss2008-2009_supplementary_tables_en.pdf, January 17, 2011. 17 Health Canada. Smoking in Canada: Young adults. Available http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/_ctumsesutc_fs-if/2003-youn-jeun-eng.php, January 17, 2011. 18 Maggi, S. Change in smoking behaviours from late childhood to adolescence: 4 years later. Drug & Alcohol Dependence, 2008; 94:251-53. 19 Quebec Survey of Tobacco, Alcohol, Drug use, and Gambling in High School Students (2004), Institute de la statistique du Québec, Direction Santé Québec. 20 The Alberta Youth Experience Survey (2008). The Alberta Alcohol and Drug Abuse Commission & Alberta Health Services. 21 Northwest Territories School Tobacco Survey (2002), Northwest Territories Bureau of Statistics & Department of Health and Social Services. 22 Youth Smoking Survey (2010-2011), Health Canada & University of Waterloo. 23 Global Youth Tobacco Survey (2008), World Health Organization & Centers for Disease Control and Prevention. 24 [Manitoba] Youth Health Survey (2008), Manitoba Partners in Planning for Healthy Living & Health in Common. CIM of Youth Tobacco Control 15

4. If one of your best friends was to offer you a cigarette would you smoke it? Definitely yes Probably yes Probably not Definitely not Why the measures were selected What we know about the measures Analytical notes For more complete data When used in combination, the measures provide a validated source of data on susceptibility, although specific to cigarette smoking. More research is needed to explore susceptibility in relation to other tobacco products. On its own, the question Have you ever tried cigarette smoking, even just a few puffs?, provides a measure of lifetime ever-use of cigarettes, useful for assessing 100% abstinence rates and/or typical age of initiation at a population level. Predictive validity of the questions has been established 25 although wording of questions 2 and 3 have been changed slightly. Response options for question 3 have been changed to a four point scale from the binary yes/no response originally tested. Each question has demonstrated good test-retest reliability and face validity with youth aged 10 to 19. 26 The susceptibility algorithm is only applied to youth who have never tried cigarette smoking, not even a puff. To be considered not susceptible to cigarette smoking, youth must answer no to question 1 and definitely not to questions 2, 3 and 4. Any other combination of responses to questions 2, 3 and 4 indicates susceptibility. See section 7.0 for guidelines on how to calculate and report these indicators, as well as what survey design variables to report to enable comparison across implementations. You may also want to ask questions about exposure to social models (e.g. family, friends, movies), attitudes towards tobacco use, beliefs about tobacco use, attitudes towards tobacco-control related policies and programs, and awareness of and attitudes towards tobacco industry tactics to promote use. See Appendix A for questions recently used by recent Canadian surveys of youth. 25 Pierce JP, Choi WS, Gilpin EA, Farkas AJ, Merritt RK. Validation of susceptibility as a predictor of which adolescents take up smoking in the United States. Health Psychology. 1996; 15(5): 355-361. 26 Kroeker C, Manske S, & Smith E, on behalf of Youth Excel (2012). Validity and Reliability of the Measures for Youth Respondents from the Core Indicators and Measures of Youth Health Tobacco Control & Physical Activity and Sedentary Behaviour Modules. Waterloo, Ontario: Propel Centre for Population Health Impact, University of Waterloo. CIM of Youth Tobacco Control 16