Smoking Cessation – Smoking Treatment for Ontario Patients (STOP) Program

Our group decided on the topic “Smoking Cessation” due to the dangers of smoking and

second-hand smoke. Every day tobacco kills more Ontarians than alcohol, illicit substances,

accidents, suicide and homicides combined. People who use tobacco are more likely to go to

the hospital and stay longer. They are likely to die younger. Tobacco products contain

nicotine, which is a substance that makes them highly addictive. In Canada, tobacco use is the

greatest preventable cause of illness, disability and premature death, causing more than

45,000 deaths per year. As well links between health problems such as cancer, heart disease

and respiratory disease, and exposure to second-hand smoke are well established. Tobacco

smoke contains more than 7,000 chemicals, of which more than 50 known to cause cancer.

The magnitude of the excess morbidity, mortality and healthcare usage caused by tobacco

addiction is immense. Tobacco can be used in various ways, but smoking remains the most

common method.

Despite the availability of smoking cessation treatments that increase long-term quit success,

a majority of quit attempts are made unassisted. Low rates of treatment utilization have

prompted various strategies to increase demand and reduce disparities in access to

pharmacotherapy and behavioral support.

A broadly shared goal of public policy toward cigarettes and other tobacco products is to

reduce their health burden (IOM 1994, 1998). That health burden is minimized if no

individual begins smoking and those who are currently smoking quit promptly (U.S. DHHS,

1988). However, quitting is difficult for most smokers and many adolescents will experiment

with smoking; experimentation predictably leads a substantial fraction to become regular

smokers (U.S. DHHS, 1994). Thus, in addition to interventions aimed at prevention and at

promoting immediate quitting, it is appropriate to consider interventions that aim to reduce

the harm that the remaining population of smokers cause themselves and others by continued

smoking. This is the underlying concept of harm reduction or harm minimization.

The term “harm reduction” has a variety of applications. It can refer to a policy or strategy (a

set of laws and programs) or to specific interventions (e.g., an individual product innovation

or dissemination effort). A harm reduction policy or intervention (a) explicitly assumes

continuation of the undesired behavior as a possibility and (b) aims to lower the total adverse

consequences, including those arising from continuation. In this use, the term describes an

assumption and a goal rather than a result. It can also be used as a criterion for evaluating

results; an intervention or policy is harm-reducing if it does in fact reduce the total adverse

consequences. Finally, harm reduction can also be viewed as a framework, a way of thinking

about dealing with a harmful behavior, since it requires analysis of a broader set of outcome

measures than would otherwise be considered. One cannot usually determine in advance, on

theoretical grounds, whether a particular policy or intervention is harm-reducing. For

example, it may turn out that a policy which aims to minimize prevalence (i.e., addresses

only abstinence) reduces total harm as compared to any other policy. But the framework

allows consideration of alternatives to reduction in the number of users as a complement to

abstinence.

The Smoking Treatment for Ontario Patients (STOP) Program is a province-wide initiative

delivering smoking cessation treatment (up to 26 weeks of NRT) and counselling support to

people who want to reduce/quit their tobacco use. These supports are available free of charge,

through partnerships with community health care organizations. Importantly, STOP has been

able to reach and successfully be implemented within vulnerable communities that face

barriers in accessing care. Clinics that have implemented the STOP Program include team-

based primary care settings and addictions agencies. Although STOP does not directly

operate participating clinics, it does provide training and web-based computerized care
pathways, and it supplies long-and short-acting nicotine replacement therapy at no cost.

Between 2014 and 2019, over 20,000 people enrolled in the STOP Program each year, at

approximately 450 clinics across Ontario. STOP largely treats people of lower socioeconomic

status: 60% report an annual total household income of less that $40,000, and 50% report

having no postsecondary education. The STOP Program is funded by the Ontario Ministry of

Health.

STOP is an interdisciplinary team with focus on developing and testing innovative methods

for treating tobacco smoking addictions. With STOP and the Portal software, they are able to:

assess patients in and outside of healthcare settings; produce insights to highlight diagnoses

and modifiable risk factors with data evidence; and automate workflows to treat or provide

recommendations for treatment and self-management of care.

STOP has been in service for 15 years. Their previous implementations include tertiary care

centers, public health units, mass distribution, community pharmacies, community health

centres, STOP on the road, internet-based enrolment, family health teams, family physicians,

workplace project and hospital project. Their currently active programs are family health

teams, community health centres, murse practitioner-led clinics, aboriginal health access

centres and STOP on the net.

Ontario declared a state of emergency as a result of the COVID-19 pandemic on March 17,

2020. On and shortly after this date, restrictions were implemented that mandated the closure

of schools, business, indoor public spaces and nonessential workspaces. Similar to other

health services that were offered only remotely during this time, many STOP sites

transitioned from in-person to virtual care, including enrolment and follow-up visits.

Clinics enroll people in the STOP Program using a centralized online portal, which prompts

providers to administer a digital bassline questionnaire that includes questions about the
person’s current tobacco use, health and sociodemographic characteristics. All STOP

providers complete a STOP operations training webinar, during which general documentation

procedures are covered.

They extracted data from the electronic database of STOP enrolments and clinical visits, and

analyze baseline questionnaires from all participating clinics. To provide a sufficient

historical comparison and permit the testing of seasonal effects, they included STOP

enrolments and clinical visits from January 1, 2018 to December 7, 2020.

They examined total enrolments and total clinical visits over time. Given the substantial

decrease they observed in program enrolments following the declaration of a state of

emergency on March 17, 2020, they used this single date in subsequent analyses as the point

separating the pre and post-restriction eras. To analyze participant characteristics, they

included all sociodemographic and health-related variables that are routinely collected at

intake. These included previous diagnoses of a number of health conditions, which we

combined into 3 binary outcomes indicating the presence of any physical health (heart

disease, diabetes, chronic obstructive pulmonary disease, cancer or stroke), mental health

(depression, anxiety, bipolar disorder or schizophrenia), or substance use (alcohol or other

drugs) diagnoses. If the prevalence of any indicator changed significantly at our break point,

we further explored differences in individual diagnoses.

They produced descriptive statistics to characterize participants, and then undertook an

exploratory, segmented, mixed-effects regression analysis to test whether participants who

enrolled on or after Mar. 17, 2020, differed from those who enrolled before that date in terms

of each of the variables, because participants were nested within clinics, they included a

random intercept for clinic in all models.

The STOP Program permits people to re-enroll after their initial 1-year treatment period has

expired. To evaluate the effect of repeated enrolments, we conducted a sensitivity analysis

using probabilistic deduplication to identify repeat enrolments, randomly selecting 1

enrolment per individual and rerunning the main analysis.

The STOP Program is funded by the Ontario Ministry of Health, and its procedures were

approved by the Research Ethics Board at the Centre for Addiction and Mental Health

(protocol numbers 058-2011 and 154-2012). Participants provided written informed consent

at baseline for the use of their data for research and publications.

When public health restrictions were implemented in Ontario as a result of the COVID-19

pandemic, a province-wide smoking cessation program experienced sharp decreases in new

enrolments. Visits were less affected at first because of ongoing care for existing enrolments,

but they took much longer to begin recovering. As participants completed treatment, visits

became a reflection of enrolments over the immediately preceding period. With minor

exceptions, the characteristics of people who enrolled in the STOP Program were quite

similar before and after implementation of the state of emergency. The change in enrolments

in the STOP Program and their subsequent slow recovery might be attributable to the fact that

many primary care sites were partially closed for nonurgent matters at the beginning of the

lockdown, consistent with reductions in other in-person health care services in Ontario and

beyond

The changes they observed for STOP participants’ employment in the previous week may

have reflected layoffs related to COVID-19. The increased number of STOP participants who

reported physical health, mental health and substance use diagnoses might have reflected a

referral effect, because about 70% of participants are referred by other health care providers.

Although the use of nonurgent health care services fell sharply early in the pandemic, those
who required continuous management for pre-existing health conditions were likely to have

continued accessing care after Mar. 17, 2020. As a result, they would have had greater

opportunities for referral.

STOP Program is funded by the Ontario Ministry of Health and provides tobacco cessation

treatment either through local Ontario-based healthcare providers, or online via STOP on the

Net program.

The percentage of people who smoke in Ontario has decreased over the years. The provincial

smoking rate is the third lowest in all of Canada with roughly one in five Ontarians who

smoke. Over the past decade, Ontario has worked hard to reduce tobacco use in the province

and has established itself as both a national and international leader in tobacco control. In

2005, the government created Smoke-Free Ontario encompassing Ontario’s actions and

investments in tobacco control, and combining evidence-based approaches to prevent

children and young people from starting to smoke, helping Ontarians quit smoking and

protecting Ontarians from exposure to second-hand smoke. Ontario’s previous efforts, in

partnership with Public Health Units, non-governmental organizations, health professionals

and institutions, have provided people with the programs and services to live smoke-free.

Some key achievements of the STOP program and services that Ontario, together with other

partners, have been able to deliver include helping people who smoke access: counselling and

supports in hospitals and community health care settings to help quit smoking, phone

counselling and online resources to help quit smoking and no-cost nicotine replacement

therapy in combination with counselling.

For over a decade, Ontario has been putting policies in place to reduce tobacco use in Ontario

and these policies have provided the legislative force needed to further protect the health of

Ontarians. The Smoke-Free Ontario Act (SFOA), which came into force in 2006, is an
example of ground-breaking legislation that helps to reduce access to tobacco products and to

protect workers and the public from the hazards of second-hand smoke. The SFOA imposes

strict

controls on the sale of tobacco to young people, restricts the display and promotion of

tobacco at point-of-sale, and prohibits smoking in enclosed workplaces and enclosed public

places, as well as other designated places.

Health Canada provides funding to support that pan-Canadian toll-free Quitline initiative.

This means that STOP Program is supported by law enforcement and those who access

services. Provincial and territorial governments ensure their citizens have access to this free,

confidential and convenient support. Trained specialists can provide counselling, help

develop a quit smoking plan, answer questions and provide referrals to the program and

services available in communities across Canada.

The Tobacco Control Liaison Committee is comprised of federal, provincial and territorial

government representatives who are focused on tobacco and vaping policy and programming

in Canada. TCLC provides a forum for discussion and collaboration directed at improving

policy coherence and programming efficiency to reduce the death and disease burden of

tobacco in Canada.

Each jurisdiction (federal / territorial / provincial) is represented on the committee. The

federal government is represented by officials from Health Canada (including the Tobacco

Control Directorate and the Regulatory Operations and Enforcement Branch), Indigenous

Services Canada and the Public Health Agency of Canada. The committee is co-chaired by a

federal and a provincial/territorial representative.

Efforts to address tobacco and vaping product use are not limited to government action.

Advocates including community leaders and non-governmental organizations, academics and

health professionals, all play an important role in building evidence to inform new tobacco

and vaping policies and programs and educating the public about the relative risks of using

tobacco and vaping products. The Tobacco Control Directorate meets with stakeholders

regularly to discuss tobacco and vaping policy and programming in Canada.

Adopting healthy public policies is critical to maintaining and improving the health of all

Canadians. A strong relationship between federal, provincial and territorial governments

ensures tobacco control takes place on a national scale.

References

Dobrescu A, Bhandari A, Sutherland G, et al. The costs of tobacco use in Canada, 2012.

Ottawa: Conference Board of Canada; 2017.

West R. The clinical significance of “small” effects of smoking cessation treatments.

Addiction. 2007;102:506–9.

CAN-ADAPTT practice-informed guidelines. Toronto: Canadian Action Network for the

Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre

for Addiction and Mental Health; 2011.

Glazier RH, Green ME, Wu FC, et al. Shifts in office and virtual primary care during the

early COVID-19 pandemic in Ontario, Canada. CMAJ. 2021;193:E200–10.

https://www.health.gov.on.ca/en/common/ministry/publications/reports/SmokeFreeOntario/

SFO_The_Next_Chapter.pdf