HEALTH PROFILE FOR PRINCE EDWARD ISLAND

HEALTH PROFILE FOR PRINCE EDWARD ISLAND

Suggested Citation: Cumming, T., Patton, R., Rynard, V., Munro-Bernard, M., Manske, S. 16 (October). 14/15 Canadian Tobacco, Alcohol and Drugs Survey: Health Profile for Prince Edward Island. Waterloo (ON): Propel Centre for Population Health Impact, 1-14.

PRINCE EDWARD ISLAND HEALTH PROFILE This Health Profile for Prince Edward Island (PEI) details results from Health Canada s 14/15 Canadian Student Tobacco, Alcohol and Drugs Survey (CSTADS). Grade 6-12 students with parental permission from randomly selected schools in each province were invited to participate in the pan-canadian survey. Participating students were asked questions about tobacco, alcohol and drug use, in addition to questions about bullying, school connectedness and mental wellness. Note: Only students in grades 7-12 were asked questions about alcohol and drug use. In Prince Edward Island, 2256 students from 53 schools participated in the survey. Health Canada has contracted the Propel Centre for Population Health Impact at the University of Waterloo to centrally coordinate the implementation of CSTADS across Canada biennially since 4. For the 14/15 CSTADS the survey was implemented in collaboration with the following provincial partners: Memorial University of Newfoundland Dalhousie University University of Prince Edward Island New Brunswick Health Council Université du Québec à Montréal University of Waterloo University of Manitoba University of Saskatchewan University of Alberta University of Victoria For more information regarding this profile or the research project associated with it, visit www.cstads.ca or contact: Dr. Jo-Ann MacDonald Dr. Donna Murnaghan PEI Provincial Co-Investigators Comprehensive School Health Research Group University of Prince Edward Island (92) 566-771 jammacdonald@upei.ca Steve Manske, CSTADS Principal Investigator Senior Scientist Propel Centre for Population Health Impact University of Waterloo (519) 888-4518 manske@uwaterloo.ca CSTADS data is collected on behalf of Health Canada to understand Canadian trends in tobacco, alcohol and drug use, and to effectively develop, implement, and evaluate strategies, policies and programs aimed at youth substance use and abuse. The results of the survey will be provided to Health Canada in a manner that will not identify any participants in the survey.

TABLE OF CONTENTS THE ISSUE... 2 MENTAL WELLNESS IN PRINCE EDWARD ISLAND... 3 SCHOOL ENVIRONMENT... 4 SCHOOL CONNECTEDNESS...4 BULLYING... 5 STUDENTS WHO ARE BEING BULLIED IN PRINCE EDWARD ISLAND... 5 How Students Report Being Bullied in Prince Edward Island... 5 STUDENTS WHO BULLY OTHERS IN PRINCE EDWARD ISLAND... 6 How Students Report Bullying Others in Prince Edward Island... 6 SMOKING IN PRINCE EDWARD ISLAND... 7 OBTAINING AND SHARING CIGARETTES... 7 STUDENT SUSCEPTIBILITY TO SMOKING... 8 TRENDS IN TOBACCO USE... 9 ELECTRONIC CIGARETTES (E-CIGARETTES, VAPES, PENS)... 9 FLAVOURED TOBACCO PRODUCTS... 1 SUBSTANCE USE AND ABUSE IN STUDENTS...11 MARIJUANA USE... 11 Frequency of use... 11 ALCOHOL USE... 12 Frequency of use... 12 Trends in Alcohol Use and Binge Drinking... 12 Caffeinated Alcoholic Beverages... 13 HEALTH RISK BEHAVIOUR IN VEHICLES... 14 EXPOSURE TO SECOND HAND SMOKE AND IMPAIRED OR HIGH DRIVING... 14 REFERENCES... 15 PLEASE NOTE: 1. The graphs and tables in this profile represent student self-reported data. 2. In some cases, the results in table columns or rows and graphs may not add to 1% due to rounding. 3. * indicates that data are NOT reportable due to low numbers or high variability. 4. indicates estimates should be interpreted with caution because of moderate sampling variability. PAGE 1

THE ISSUE This profile presents results for Prince Edward Island on 5 interconnected issues facing students that impact their well-being. The following table shares information about the impact and prevalence of these issues for students. Mental Wellness Mental wellness is the capacity of each and all of us to feel, think, act in ways that enhance our ability to enjoy life and deal with the challenges we face 1. Approximately % of people with a mental disorder also have a substance use problem 2. Bullying In Canada, 36% of students in grades 6-12 reported being bullied (14/15 CSTADS). Effective bullying prevention programs involve the whole school and focus not only on reducing incidents of bullying, but also on promoting a positive school climate 3. Tobacco Use Everyday 1 Canadians (2 school buses full of people) die from tobacco use that s 37, people each year 4. In Canada, 31% of students who have never smoked a cigarette reported not being confident in their ability to remain smoke free (14/15 CSTADS). Alcohol Use Alcohol is involved in more regrettable moments, crimes and traffic fatalities than all other drugs of abuse combined 5. In Canada, 24% of students in grades 7-12 reported binge drinking (5 or more drinks on one occasion) in the past 12 months (14/15 CSTADS). Marijuana Use Despite the health risks, marijuana use has become more normative and is the most common substance of daily use by adolescents 6. In Canada, 22% of students in grades 7-12 reported that they have tried marijuana before (14/15 CSTADS). PAGE 2

MENTAL WELLNESS IN PRINCE EDWARD ISLAND Mental wellness is the ability to think, feel and act in ways that strengthen our capacity to enjoy life and deal with challenges as they arise. 1 Students with higher levels of mental wellness tend to report higher levels of school connectedness and exhibit more prosocial behaviours such as helping people or sharing things without being asked. Alternatively, students with lower levels of mental wellness tend to report more oppositional behaviours 7. Schools can develop targeted programs, policies, curricula, and environments (that is, a culture) that fosters mentally well students by supporting their relatedness, competency and autonomy.. STUDENT MENTAL WELLNESS IN PEI Canada 14 CSTADS PEI 14 My family and friends like and care about me (Relatedness) 88 87 I like to spend time with my parents and friends (Relatedness) 81 78 I feel I do things well (Competency) 82 81 I feel that my family and friends think I am good at things (Competency) 83 84 I feel free to express myself to family and friends (Autonomy) 79 78 I feel like I am given the opportunity to make choices with my family and friends (Autonomy) 66 67 5 1 % OF STUDENTS RESPONDING "SORT OF TRUE FOR ME" OR "REALLY TRUE FOR ME" PAGE 3

SCHOOL ENVIRONMENT Schools, homes, and community are key environments influencing student wellness. We know that schools influence wellness independent of family, economic, and community factors 8. Schools hold a unique position to create a culture of wellness, ideally in partnership with parents and community members/ organizations. This culture embraces the physical and social environment within the school. This culture is foundational to healthy behaviour choices and academic success. SCHOOL CONNECTEDNESS Students who feel an attachment to their school and who consider their teachers to be supportive are less likely to engage in unhealthy or risky behaviours 8. SCHOOL CONNECTEDNESS_IN PEI PEI 14 PEI 12 YSS Canada 14 CSTADS I feel close to people at my school I feel I am part of my school I am happy to be at my school I feel the teachers at my school treat me fairly I feel safe at my school 81 83 82 8 83 82 79 8 8 86 87 85 89 91 89 5 1 % OF STUDENTS RESPONDING "STRONGLY AGREE" OR "AGREE" Schools Can Make Mental Wellness a Priority Schools can try and ensure every student is connected with an adult at the school. For example, schools can post all student names on a wall and ask staff to mark who they know. Schools can then plan to build connections with students who are not linked in. Schools can foster positive mental wellness habits through physical activity, journaling, learning to cope with negative thoughts, setting goals and sharing humour 9. Schools can involve staff in identifying and fostering students innate strengths by providing opportunities for student leadership in activities such as tutoring, mentoring and peer lunch-mate programs. Schools can establish awards that honour pro-social behaviour (behaviour that is intended to help other people). Schools can also ensure that students are included in decision making processes for setting rules and consequences. PAGE 4

BULLYING STUDENTS WHO ARE BEING BULLIED IN PRINCE EDWARD ISLAND Bullying is a form of abuse at the hands of peers that takes different forms at different ages. Bullying is often an aggressive behaviour imposed from a position of power, which is repeated over time. With each repeated bullying incident, the student who is bullying increases in power while the student being victimized loses power 1. In Prince Edward Island, 37% of students reported being bullied by other students in the last month, compared to 36% of students in Canada (14/15 CSTADS). Note: Bullying rates may be higher in 14 due to the addition of nonverbal attacks as a form of bullying. % OF STUDENTS 6 STUDENTS WHO REPORT BEING BULLIED IN THE LAST MONTH PEI 14 PEI 12 YSS Canada 14 CSTADS 37 44 36 42 24 29 3 22 27 Total Males Females How Students Report Being Bullied in Prince Edward Island In Prince Edward Island, non-verbal attacks are the most common form of bullying. The table to the right displays the forms of bullying reported by Prince Edward Island students. Across Canada, non-verbal attacks are the most common form of bullying reported by Canadian students who were bullied. MOST COMMON FORMS OF BULLYING IN PEI %of students who reported being bullied by others Non-verbal attacks (ignored, being left out or 26% excluded ) Verbal attacks (teased, threatened, rumours spread 23% about you ) Cyber attacks (mean text messages, rumours spread 11% on internet ) 9% Had someone steal from you or damage your things 6% Physical attacks (beaten up, pushed or kicked ) PAGE 5

STUDENTS WHO BULLY OTHERS IN PRINCE EDWARD ISLAND Research shows that bullies and the victims of bullying report the highest levels of substance use 11. In Prince Edward Island, 19% of students reported bullying others in the last month. The graph to the right displays the percentage of students at in Prince Edward Island who bully others, in comparison to the rest of Canada and data from 12 YSS. Note: Bullying rates may be higher in 14 due to the addition of non-verbal attacks as a form of bullying. % OF STUDENTS 6 STUDENTS WHO REPORT BULLYING OTHERS IN THE LAST MONTH PEI 14 PEI 12 YSS Canada 14 CSTADS 19 11 17 14 19 8 Total Males Females How Students Report Bullying Others in Prince Edward Island In Prince Edward Island, bullies report non-verbal attacks as the most common way they bully others. This is consistent with the form of bullying reported most by those being bullied above. The table to the right displays the most common form of bullying, as reported by students who report bullying others in PEI. MOST COMMON FORMS OF BULLYING IN PEI % of students who reported bullying others Non-verbal attacks (ignoring, leaving someone out 12% or excluding them, giving dirty looks ) Verbal attacks (teased, threatened, rumours spread 1% about them ) Cyber attacks (sent mean text messages or spread 4% rumours about them on the internet ) 3% Physical attacks (beaten up, pushed or kicked ) 2% Stole from them or damaged their things Schools Can Provide Safe Environments and Address Bullying Many organizations are dedicated to ensuring that children grow up in safe and secure school environments. These groups recognize that the issue of student violence is a societal problem; schools cannot resolve it on their own. Shared responsibility is fundamental to the achievement of safe learning environments. Schools may well be addressing bullying already. Here are ideas that schools may add to their kits: Teach students how to identify bullying, particularly attacks that are non-physical. Enable students to report bullying anonymously on the school website or other means. Train school staff to recognize target behaviour as it emerges so that intervention occurs early and works to prevent anti-social behaviour from escalating. Provide whole classroom consequences when bullying occurs. For example, remove a classroom peace banner (a student created emblem of the classroom agreement), to communicate that bullying is everyone s issue. Ask community youth workers to run restorative justice programs when incidents occur. PAGE 6

SMOKING IN PRINCE EDWARD ISLAND In Prince Edward Island, 25% of students (28% of males and 22% of females) report ever having tried a cigarette, even a few puffs. The graph below compares Prince Edward Island to the 14/15 CSTADS national results and the 12/13 YSS Prince Edward Island results. While rates of use have slowly declined over time, many students remain at risk to experimenting and starting new habits. The next page reports on the susceptibility of students to start smoking. 5 STUDENTS WHO REPORT EVER TRYING A CIGARETTE PEI 14 PEI 12 YSS Canada 14 CSTADS % OF STUDENTS 3 1 51 48 41 34 34 36 31 23 22 22 3 13 15 * * 9 * * 4 * 6 7 8 9 1 11 12 GRADE OBTAINING AND SHARING CIGARETTES Smoking is a social activity and as a result, students often obtain their cigarettes from social sources in addition to retail outlets. In Prince Edward Island: 35% of students who are smoking report being given cigarettes by someone else. % of students who are smoking report buying cigarettes from a store. PAGE 7

STUDENT SUSCEPTIBILITY TO SMOKING Most established smokers began experimenting with cigarettes between the ages of 1 and 18. Some students become nicotine dependent within a day of first inhaling cigarette smoke 12. People who become dependent can find it very difficult to quit. Therefore, we need to intervene before students become dependent. In Prince Edward Island, 29% of students who have never smoked a cigarette have low confidence in their ability to remain smoke-free in the future. These students are at high risk to begin smoking. Students in PEI were asked the following questions: Do you think in the future you might try smoking cigarettes? At any time during the next year do you think you will smoke a cigarette? If one of your best friends were to offer you a cigarette, would you smoke it? The graph displays the percentage of students who answered Yes to any of the above questions. Rates of susceptibility typically decline with increased grade, because more students have smoked. % OF STUDENTS SUSCEPTIBLE 8 6 21 22 24 25 25 29 SUSCEPTIBILITY TO SMOKING (of students who have never smoked) PEI 14 PEI 12 YSS Canada 14 CSTADS 32 36 37 3 34 3 35 34 26 27 31 27 17 21 27 6 7 8 9 1 11 12 GRADE Did You Know? Students are less likely to begin smoking in the future if they have made a firm decision not to try smoking and if they have the resources to resist pressures to start 13. PAGE 8

TRENDS IN TOBACCO USE Students use tobacco products other than cigarettes including: cigarillos, little cigars, cigars, e-cigarettes, water-pipes, and smokeless tobacco (i.e. chewing tobacco). The growing popularity of these products is concerning because students commonly misconceive alternate forms of tobacco as not being as bad for them as cigarettes. Research shows that these alternative forms of tobacco may be worse than cigarettes in some cases 14,15. In Canada, 18% of Canadian students have tried cigarettes, and another 5% have not tried cigarettes but have tried other tobacco products (14/15 CSTADS). The following graph displays the number of students in Prince Edward Island who have ever tried products as compared to the 14/15 CSTADS Canadian results and the 12/13 YSS Prince Edward Island results. EVER USE OF ALTERNATE FORMS OF_TOBACCO PEI 14 PEI 12 YSS Canada 14 CSTADS Cigarillos, Little Cigars, Cigars 14 14 19 E-cigarettes 18 22 Water-Pipe 7 11 1 Smokeless Tobacco 5 7 11 Cigarettes 18 25 25 1 3 STUDENTS (%) E-cigarette use not collected in the 12/13 YSS. In 14/15 CSTADS the format of the questions changed from a mark all that apply to a series of yes/no responses. ELECTRONIC CIGARETTES (E-CIGARETTES, VAPES, PENS) The jury is still out on e-cigarettes. While some argue it is a way to reduce harm, e-cigarettes may promote continuation of an addiction in adults, or promote trying nicotine products in students. In Prince Edward Island, 1% of students report having used e- cigarettes in the last 3 days. It is also interesting to note that 26% of Prince Edward Island students report trying e-cigarettes before trying cigarettes. PAGE 9

FLAVOURED TOBACCO PRODUCTS Flavoured tobacco has appeal among students: they perceive them as less risky, and perceive the smoke as causing less irritation. Several provinces are working to strengthen legislation that bans adding flavours to tobacco products, since availability of flavoured tobacco may be stalling progress in decreasing tobacco initiation and use among Canadian youth 16. The graph below shows the percentage of students who used flavoured products among those that have used tobacco products in the last month. The current Prince Edward Island results are compared to the 14/15 CSTADS national results and 12/13 YSS Prince Edward Island results. FLAVOURED PRODUCT USE IN THE LAST MONTH * (of students who use tobacco products) % OF STUDENTS 7 6 5 3 1 65 55 38 PEI 14 PEI 12 YSS Canada 14 CSTADS In 14/15 CSTADS the format of the questions changed from a mark all that apply to a series of yes/no. * Flavoured products include: flavoured cigarettes, cigarillos, cigars and water-pipe. 14/15 CSTADS also includes flavoured smokeless tobacco. Schools Can Help Keep Students from Smoking Even when smoking rates are low, efforts need to focus on preventing susceptible students from experimenting with smoking. Schools can support established smokers and those experimenting with using tobacco products in the following ways. Brainstorm with students and staff about ways to re-purpose areas students use for smoking (both on and off school property) for more positive uses. Partner with the community to make changes feasible. Make sure students are aware that all tobacco products (e.g., cigarillos, little cigars, cigars, smokeless tobacco [snuff] and flavoured tobacco) have the same level of health risk. E-cigarettes also have risk. Use persuasive writing development or civics lessons to write to persuade local merchants and their staff to not sell or promote tobacco products to youth. Flavoured tobacco products are often targeted at youth. Engage local public health for support. PAGE 1

SUBSTANCE USE AND ABUSE IN STUDENTS In Prince Edward Island, students in grades 7 and above were asked about marijuana and alcohol use. It is startling to note the young age at which students first engage in these risky behaviours. Besides being illegal, students are making decisions to engage in these behaviours before they are developmentally capable of fully understanding the consequences. The table below shows the average age at which grade 12 students in Prince Edward Island reported having first tried alcohol and marijuana. SUBSTANCE AVERAGE AGE OF FIRST USE EVER USED OR TRIED MARIJUANA 15 HAVING A DRINK OF ALCOHOL THAT WAS MORE THAN A SIP 14 HAVING 5 OR MORE DRINKS OF ALCOHOL ON ONE OCCASION 15 MARIJUANA USE In Prince Edward Island, 3% of students reported having tried marijuana (33% of males, 26% of females). Comparatively, 22% of Canadian students reported having tried marijuana (22% of males, 21% of females). 6 FREQUENCY OF MARIJUANA USE (of students who use marijuana) PEI 14 PEI 12 YSS Canada 14 CSTADS Frequency of use The social acceptance of marijuana has increased over time 17. The graph to the right displays the frequency of marijuana use among PEI students who reported using marijuana in the past 12 months. The graph also compares the current results to the national 14 CSTADS results and the 12 YSS results. % OF STUDENTS 39 33 22 25 25 39 42 34 < Once/Month 1-3 Times/Month Once/Week Or More Schools Can Help Prevent Marijuana Use Schools can create class projects (e.g., in health class, or English class) that explore the long-term and short-term health risks of and social influences on marijuana use. Among youth, immediate social influences (rather than health) are more likely to motivate behaviour. Schools can ask community resource people (former drug user, clinician) to paint a picture of drug use consequences. Ensure that there are options to deal with issues that surface for students at a later date. Don t rely only on testimonials for long-term culture change. Schools can equip students with skills to recognize and avoid situations where they may feel obligated to use marijuana. Where students can t avoid it (e.g., if a joint is passed to them at a party), they should commit in advance to a friend not to use marijuana. Schools can have a student success teacher identify habitual users and then arrange to offer special programming for them during the school day. PAGE 11

ALCOHOL USE In Prince Edward Island, 43% of students reported having a drink of alcohol that was more than just a sip in the last 12 months. Of those who had more than just a sip of alcohol in the last 12 months, 76% report having 5 drinks or more on one occasion (binge drinking). 6 FREQUENCY OF_ALCOHOL USE (of students who use alcohol) PEI 14 PEI 12 YSS Canada 14 CSTADS Frequency of use In Prince Edward Island, 28% of students reported consuming alcohol at least once a month in the last 12 months. Students who reported using alcohol were also asked how often they engaged in this behaviour. The graph to the right shows the reported frequency of alcohol use in the last 12 months, among PEI students who report using alcohol. These results are compared to the 12 YSS results and the national 14 CSTADS results. % OF STUDENTS 44 42 35 35 41 < Once/Month 1-3 Times/Month 22 26 15 Once/Week or More Trends in Alcohol Use and Binge Drinking Binge drinking can be defined as drinking five or more drinks on a single occasion and it is the most common pattern of consumption among students who drink alcohol 18. In Prince Edward Island, 19% of students reported binge drinking at least once a month in the past year. 6 FREQUENCY OF BINGE DRINKING (of students who binge drink) PEI 14 PEI 12 YSS Canada 14 CSTADS Binge drinking at this age may hinder important developmental changes. The potential for serious and unpredictable consequences are well known. % OF STUDENTS 48 39 42 44 36 < Once/Month 1-3 Times/Month 18 12 Once/Week or More Did You Know? Tobacco, alcohol and marijuana use are strongly related. Of students who smoked in the last 3 days, 93% drank alcohol and 77% used marijuana in the past 12 months. Among non-smokers, only 36% and 12% used these substances in the last year respectively (14/15 CSTADS). PAGE 12

Caffeinated Alcoholic Beverages Caffeinated alcoholic beverages (CABs) are drinks that contain both alcohol and caffeine. In Prince Edward Island, 21% of students have consumed an energy drink (e.g., such as Rockstar and Red Bull ) with alcohol. 6 ALCOHOL AND ENERGY DRINK CONSUMPTION in the last year Consuming energy drinks (i.e., Red Bull) in combination with alcohol is common among Canadian students. The caffeine in the energy drinks keeps the consumer awake and able to party for a longer period of time. In the 14/15 CSTADS, 34% of grades 7-12 students who reported drinking alcohol in the last 12 months also reported consuming an energy drink on the same occasion as drinking alcohol. % OF STUDENTS PEI 14 21 16 Energy Drinks with Alcohol Canada 14 CSTADS 32 31 Energy Drinks 43 Alcohol Did You Know? People who consume alcohol mixed with energy drinks are: 3 times as likely to binge drink compared to people who do not mix their alcohol with energy drinks 19. 2 times more likely to report being taken advantage of sexually or to report taking advantage of someone else sexually when compared to drinkers who do not report mixing their alcohol with energy drinks. 2 times more likely to report riding with a driver who is impaired by alcohol when compared to drinkers who do not mix their alcohol with energy drinks. Schools Can Take Action to Prevent Alcohol Abuse Schools can aim to have staff connected to student life so they are aware of and comfortable to address events (May 24, prom) that typically involve binge drinking so that students have thought of strategies to minimize risk. Schools can provide students with the opportunity to discuss the pros and cons of using binge drinking to put people at ease in social situations. Then schools can have students brainstorm heathier ways to have fun on weekends. Schools can have students work with local/provincial advocacy groups to identify how to put the issue of energy drinks and pre-mixed caffeinated alcoholic beverages in the government s eye. For instance, promote more prominent warnings about the risks. Schools can energy drinks from school property. Schools can find ways to address common beliefs that can lead to alcohol abuse (e.g., everyone does it and YOLO [you only live once] ). PAGE 13

HEALTH RISK BEHAVIOUR IN VEHICLES EXPOSURE TO SECOND HAND SMOKE AND IMPAIRED OR HIGH DRIVING Evidence shows that children are particularly vulnerable to the adverse health impacts associated with exposure to second-hand smoke 21. Across Canada, all provinces have legislated a ban on smoking tobacco in cars when children are present. Nationally, 26% of students reported riding in a vehicle with someone who was smoking in the past month (14/15 CSTADS). In Prince Edward Island, 35% of students reported having been exposed to second hand smoke in a vehicle in the last 3 days. According to the 14/15 CSTADS, 33% of Canadian students in grades 7-12 reported riding in a vehicle with someone who had been consuming alcohol and 15% reported riding in a vehicle with a driver who had used marijuana. Unfortunately, many young people and some adults have the misperception that driving while high on cannabis is safer than driving under the influence of alcohol 22. The following graph shows the percentage of students in Prince Edward Island and Canada who were at risk in a vehicle with someone who was smoking, or had been drinking alcohol or using marijuana. EXPOSURE TO HEALTH RISKS IN A VEHICLE PEI 14 Canada 14 In a vehicle with someone who was smoking cigarettes in the last 3 days 26 35 Ever in a vehicle driven by someone who had one or more drinks of alcohol in the last hour 33 33 Ever in a vehicle driven by someone who had been using marijuana in the last 2 hours 15 23 1 3 5 6 % OF STUDENTS REPORTING EXPOSURE Did You Know? The 14/15 CSTADS revealed that 5.6% of Canadian students in grades 7-12 have driven a vehicle (e.g., car, snowmobile, motorboat or ATV) after drinking alcohol and 4.8% have driven a vehicle while under the influence of marijuana. PAGE 14

REFERENCES 1 Public Health Agency of Canada, (14). Mental Health Promotion. Retrieved from http://www.phac-aspc.gc.ca/mh-sm/mhppsm/index-eng.php 2 Rush, B., Urbanoski, K., Bassani, D., Castels, S., Wild, TC., Strike, C., Kimberley, D., & Somers, J. (8). Prevalence of co-occurring substance use and other mental disorders in the Canadian population. Can J Psychiatry, 53(12),8-9. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/1987478# 3 PREV Net. (n.d.).bullying and School Climate. Retrieved from http://www.prevnet.ca/sites/prevnet.ca/files/fact-sheet/prevnet- SAMHSA-Factsheet-Bullying-and-School-Climate.pdf 4 Rehm, J., Baliunas, D., Brochu, S., Fischer, B., Gnam, W., Patra, J., et al. (6). The Costs of Substance Abuse in Canada 2. Ottawa: Canadian Centre on Substance Abuse. 5 Centre for Addiction and Mental Health. (12). Alcohol. Retrieved from http://www.camh.ca/en/hospital/health_information/a_z_mental_health_and_addiction_information/alcohol/pages/alcohol. aspx 6 Milin, R. (14). Demystifying marijuana dependence in youth. Retrieved from the Partnership For a Drug Free Canada website: http://www.canadadrugfree.org/wp-content/uploads/14/4/demystifying-marijuana-dependence-in-youth-ccsa-jan-14- Milin.pdf 7 Joint Consortium for School Health. (n.d.). Pan-Canadian joint consortium for school health: Positive Mental Health Toolkit. Retrieved from http://www.jcshpositivementalhealthtoolkit.com 8 Bond L., Butler, H., Thomas, L., Carlin, J., Glover, S., Bowes, G., Patton, G. (7). Social and school connectedness in early secondary school as predictors of late teenage substance use, mental health, and academic outcomes. Journal of Adolescent Health, (4), 357.e9-357.e18. Retrieved from http://www.sciencedirect.com/science/article/pii/s154139x64228 9 Canadian Mental Health Association. (14). Mental fitness tips. Retrieved from http://www.cmha.ca/mental_health/mentalfitness-tips/ 1 Craig WM., & Pepler DJ. (7). Understanding bullying: from research to practice. Canadian Psychological Association, 48(2), 86-93. http://dx.doi.org/1.137/cp71 11 Radiff, K.M., Wheaton, J.E., Robinson, K., & Morris, J. (12). Illuminating the relationship between bullying and substance use among middle and high school youth. Addictive Behaviour, 37(4), 569-572. http://dx.doi.org/1.116/j.addbeh.12.1.1 12 Kaai, S.C., Manske, S.R., Leatherdale, S.T., Brown, K.S., & Murnaghan, D. (14). Are experimental smokers different from their never-smoking classmates? A multilevel analysis of Canadian youth in grades 9 to 12. Chronic Diseases and Injuries in Canada, 34(2-3), 121-131. Retrieved from http://www.phac-aspc.gc.ca/publicat/cdic-mcbc/34-2-3/ar-7-eng.php 13 Pierce, J.P., Choi, W.S., Gilpin, E.A., & Farkas, A.J. (1996). Validation of susceptibility as a predictor of which adolescents take up smoking in the United States. Health Psychology, 15 (5), 355-361. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8891714 14 Raad D., Gaddam, S., Schunemann, H. J., Irani, J., Abou Jaoude, P., Honeine, R & Akl, EA. (11). Effects of waterpipe tobacco smoking on lung function: A systematic review and meta-analysis. Chest, 139(4), 764-74. Retrieved from http://journal.publications.chestnet.org/article.aspx?articleid=187831 15 Cobb C., Ward, DK., Maziak, W., Shihadeh, AL., & Eissenberg, T. (1). Waterpipe tobacco smoking: An emerging health crisis in the United States. American Journal of Health Behaviour, 3(3), 275-285. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3215592/ 16 Minaker L, Manske S, Rynard VL, Reid JL & Hammond D. (14). Tobacco use in Canada: patterns and trends- special supplement: flavoured tobacco use-14 edition. Retrieved from http://www.mantrainc.ca/assets/tobaccouseincanada_14_flavoursupplement.pdf 17 Webster, L., Chaiton, M., & Kirst M. (14). The co-use of tobacco and cannabis among adolescents over a 3-year period. J Sch Health, 84 (3), 151-9. doi: 1.1111/josh.12137 18 Miller JW., Naimi TS., Brewer RD. & Jones ES. (7). Binge drinking and associated health risk behaviours among high school students. Pediatrics, 119(1), 76-85. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17273 19 Thombs DL, O Mara RJ, Tsukamoto M, Rossheim ME, Weiler RM, Merves ML, & Goldberger BA. (1). Event-level analyses of energy drink consumption and alcohol intoxication in bar patrons. Addictive Behaviors, 35 (4),325-33. doi: 1.116/j.addbeh.9.11.4 O Brien MC, McCoy TP, Rhode SD, Wagoner A, & Wolfson M. (8). Caffeinated cocktails; energy drink consumption, high-risk drinking, and alcohol-related consequences among college students. Acad Emerg Med, 15(5):453-46. doi: 1.1111/j.1553-2712.8.85.x PAGE 15

21 Barisic, A., Leatherdale, S.T., Burkhalter, R., & Ahmed, R. (14). Are Canadian youth still exposed to second-hand smoke in homes and in cars? Chronic Diseases and Injuries in Canada, 34(2-3), 113-1. Retrieved from http://www.phacaspc.gc.ca/publicat/cdic-mcbc/34-2-3/ar-6-eng.php 22 MADD. (n.d.).youth services-statistics &links. Retrieved from http://www.madd.ca/madd2/en/services/youth_services_statistics.html PAGE 16