Background and Purpose:
You are taking part in the Smoking Treatment for Ontario Patients on the Net (STOP on the Net) Program. This program is funded by the Government of Ontario and led by Dr. Peter Selby and Dr. Laurie Zawertailo at the Centre for Addiction and Mental Health (CAMH). This program is designed to support adults (aged 18 years and older) in Ontario to initiate an attempt to quit smoking, and it is offered free of charge. If you smoke cigarettes and pass eligibility criteria, you can join the program. If you are pregnant or breastfeeding, have a generalized skin disorder (e.g., eczema, rash), or have any known hypersensitivity or allergy to nicotine or adhesives (e.g. medical tape) you are not eligible for this program; please consult your health care provider if you are seeking support to quit or reduce smoking.
Procedures:
If you consent to enroll in the STOP on the Net Program, you will be asked to complete a brief survey about your health, tobacco use, and personal information such as income and job status. There are no right or wrong answers and you do not have to answer a question if that is your choice. Based on how many cigarettes you currently smoke, you will be mailed a kit containing Nicotine Replacement Therapy (NRT) to aid in your quit attempt. You will receive ten boxes of transdermal patches in one of the following kits: Kit A: 6 boxes of Step 1 (21mg nicotine) + 2 boxes of Step 2 (14mg nicotine) + 2 boxes of Step 3 (7mg nicotine) patches
Kit B: 6 boxes of Step 2 (14mg nicotine) + 4 boxes of Step 3 (7mg nicotine) patches and your choice of five boxes of gum (2 mg nicotine) OR lozenge (2 mg nicotine; contains aspartame).
The NRT will be mailed to the address you provide in the survey. You will be contacted by email and/or text message to complete follow-up surveys about your smoking and related behaviours at 12 weeks and 6 months after your enrollment. The surveys only take a few minutes and it is important for you to complete these surveys so we can assess the impact of the program.
Withdrawal from the Program:
Your involvement with the program is voluntary and you may withdraw at any time by contacting StopOnTheNet@camh.ca. If you choose to withdraw, you will not be contacted for the follow-up surveys. The information you have provided up to that point will be kept to analyze in the future. For other treatment options, please contact your health care provider.
Benefits:
The benefit of joining this program is that it may help you quit smoking by helping you initiate an attempt to quit. Quitting smoking is one of the most important things you can do to improve your health.
Risks:
One risk of using the NRT provided by this program is that you may develop some mild side effects from the NRT, such as skin rash, itching, or burning from patches; other side effects may include nausea, dizziness or headache. Please consult your health care provider before joining the program if you: are already using NRT medication; have/had heart, thyroid, circulation or stomach problems, stroke or high blood pressure; take insulin or any prescription medications; have ever experienced seizures.
Confidentiality:
The information you provide as part of this program will be kept confidential to the extent permitted by law, and will only be available to the program investigators and authorized project staff. Your contact information will be used to mail your NRT to you, and for follow-up purposes. Data you provide on enrollment and follow-up surveys will be collected by the STOP Program’s electronic database. The information you provide will be linked using a unique identifier automatically generated by the STOP Program’s electronic database. You may also be contacted by text message to complete a shorter version of the program follow-up surveys. These data will be collected by the Research Electronic Data Capture (REDCap) platform and the information you provide will be linked to your other program data using your phone number and a temporary unique identifier. The information you provide will be used to evaluate and improve the program. Any reports or publications based on this program will not identify you in any way. Data you provide will be exported and stored in a password-protected database on a secure CAMH server. All data are encrypted and protected with security features during data collection and transmission. The program investigators will be responsible for protecting and keeping all information confidential to the greatest extent possible. All data will be destroyed 10 years after the end of the project, as per CAMH policy.
Contacts:
If you have any questions about the program you can contact Dr. Laurie Zawertailo, Senior Scientist, at 416-535-8501 ext. 77422 or Dr. Peter Selby, Clinician Scientist at 416-535-8501 ext. 36859.
* I consent to participate in the STOP on the Net Program and to provide information on my smoking behaviour and other health information to researchers at CAMH. I verify that I have read the information provided in this form. I understand the procedures and my questions, if any, have been answered to my satisfaction. I understand that some of my personal health information may be used to evaluate and improve the quality of the STOP on the Net Program. I understand that I may be contacted by email and/or text message for program and evaluation purposes. I understand that my mobile telephone number may be used to link my data between surveys as part of the evaluation of this program. I understand that my personal information will be protected and my confidentiality maintained. I understand that providing my consent does not waive my legal rights or relieve the legal responsibilities of the investigators, program sponsors or institutions; it also does not affect any care I am currently receiving or am eligible to receive at CAMH. I understand that a copy of this consent form will become available to me via email for my records.
Optional: I consent to being contacted for future research participation
Thank you for your interest in the Smoking Treatment for Ontario Patients on the Net (STOP on the Net) Program. The following questions are important in helping us understand what influences someone’s chances of quitting. It is important to answer these questions truthfully to make sure the treatment offered by this program is safe and appropriate for you to use. Please complete every question. Your answers will be kept completely confidential, including within the evaluation team at the STOP on the Net program.
Note: As part of program eligibility to receive free NRT, you must provide your complete first and last names.
Please check your email spelling carefully. If you enter an invalid email address, you will not receive a confirmation email and will not be enrolled in the program.
* Mobile telephone number:
Please enter the address that you want your nicotine replacement therapy (NRT) to be delivered to. Please ensure all details are accurate and provided in full in order to ensure timely delivery.
PLEASE NOTE: This program is only available to residents of Ontario. If you do not live in Ontario you will not be eligible for this program.
* What is your date of birth?
* What is your current age?
* Which best describes your current gender identity? (select all that apply)
* What was your sex at birth?
* Are you pregnant or breastfeeding?
* How tall are you without your shoes on?
* How would you like to report your weight?
* How much do you weigh (lbs)?
* How much do you weigh (kgs)?
The first section of questions is about cigarette smoking. Include cigarettes that are bought ready-made as well as cigarettes that you make yourself.
* At the present time, do you smoke cigarettes daily, occasionally or not at all? By daily, we mean one or more cigarettes every day. By occasionally, we mean non-daily.
* On the days that you smoke, how many cigarettes do you usually smoke?
* In the past 30 days, on how many days did you smoke 1 or more cigarettes?
* How many cigarettes do you smoke each day now?
* How soon after you wake up do you smoke your first cigarette?
* At what age did you begin to smoke cigarettes daily?
PLEASE NOTE: This program is designed for individuals that want to make a quit attempt within 30 days of enrollment. If you do not feel ready to make a quit attempt within the next 30 days, please return to our site at a later date when you feel ready.
* Are you willing to set a quit date (make a quit attempt) within the next 30 days?
* Do you know your quit date?
* What is your quit date?
* On a scale of 1 to 10, where 10 means this is the most important thing you have to do and 1 is the least important, how important is it for you to quit smoking?
* On a scale of 1 to 10, where 10 means you are very confident that you can quit smoking and 1 means you have very little confidence, how confident are you that you can quit smoking?
* In the past year, how many times did you stop smoking for at least 24 hours because you were trying to quit?
* In your whole life, how many times did you stop smoking for at least 24 hours because you were trying to quit?
Electronic cigarettes are electronic devices that create an inhaled mist from cartridges of solution called e-liquids or e-juices. Electronic cigarettes are also referred to as e-cigarettes, vape pens, vapes, mods, hookah pens or e-hookahs, among other terms. For the remainder of this survey, we will refer to electronic cigarettes and vaping devices as "e-cigarettes”.
* Have you ever taken at least one puff from an e-cigarette?
* Have you used an e-cigarette in the past 30 days?
* How often did you use an e-cigarette in the past 30 days?
* Are you currently using e-cigarettes to quit smoking?
* Do you use an e-cigarette that contains nicotine?
* On the days you vape, how many times do you usually pick up or take out your e-cigarette to vape?
* Each time you picked up or took out your e-cigarette to vape, how many puffs did you usually take before putting it away?
* On days that you can use your e-cigarette freely, how soon after you wake up do you first use your e-cigarette?
The next section of questions is about alcohol, caffeine, and other drugs. Please remember, your answers will be kept completely confidential.
First, some questions about your alcohol consumption. When we use the word ‘drink’ it means one: 12 oz bottle of beer, or 1.5 oz shot of liquor, or 5 oz glass of wine.
* During the past 12 months, have you had a drink of beer, wine, liquor or any other alcoholic beverage?
* How often do you have a drink containing alcohol?
* How many drinks containing alcohol do you have on a typical day when you are drinking?
* How often do you have 5 or more drinks on one occasion?
* How often during the last year have you found that you were not able to stop drinking once you had started?
* How often during the last year have you failed to do what was normally expected of you because of drinking?
* How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
* How often during the last year have you had a feeling of guilt or remorse after drinking?
* How often during the last year have you been unable to remember what happened the night before because of your drinking?
* Have you or someone else been injured because of your drinking?
* Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?
* How many caffeinated beverages (e.g., coffee, tea, cola) do you drink per day?
When you stop smoking, your body does not break down caffeine as much. You may need to reduce your caffeine intake. Talk to your health care provider if you have any concerns or notice any symptoms such as anxiety.
* In the past 30 days, have you used marijuana, cannabis, or hashish?
* In the past 30 days, have you used opioids such as codeine or oxycodone?
This section of the survey deals with various aspects of your health. By health, we mean not only the absence of disease or injury but also physical, mental and social well-being.
* In the past 30 days, have you received treatment or counselling for any problem you were having with your emotions, nerves, or mental health?
* In the past 30 days, have you received treatment or counselling for your use of alcohol or any other drug, not including tobacco?
The following questions ask about certain chronic health conditions which you may have. We are interested in conditions that have ever been diagnosed by a health professional. We are also interested in whether you are currently taking any medication for a diagnosed condition. Have you ever been diagnosed with any of the following?
* If yes, are you currently taking medication for high blood pressure?
* If yes, are you currently taking medication for heart disease?
* If yes, are you currently taking medication for stroke?
* If yes, are you currently taking medication for diabetes?
* e. Chronic bronchitis, emphysema or COPD
* If yes, are you currently taking medication for chronic bronchitis, emphysema or COPD?
* If yes, are you currently taking medication for chronic pain?
* If yes, are you currently taking medication for cancer?
* If yes, are you currently taking medication for depression?
* If yes, are you currently taking medication for anxiety?
* If yes, are you currently taking medication for schizophrenia?
* If yes, are you currently taking medication for bipolar disorder?
* l. Substance use disorder (drug addiction other than tobacco or caffeine)
* If yes, are you currently taking medication for substance use disorder?
* m. Alcohol use disorder (alcoholism)
* If yes, are you currently taking medication for alcohol use disorder?
* If yes, are you currently taking medication for problem gambling?
* Do you have any generalized skin disorders that would affect your ability to use the nicotine patch (e.g., eczema, rash)?
* Do you have any allergies to nicotine or adhesives (e.g., medical tape) that would affect your ability to use the nicotine patch?
This section asks you some questions about your mood. When answering these questions, please think about how many days each of the following has occurred in the past 2 weeks.
Over the last 2 weeks, how often have you been bothered by any of the following problems?
* a. Little interest or pleasure in doing things
* b. Feeling down, depressed, or hopeless
* On average, how many days per week do you engage in moderate-to-strenuous (vigorous) exercise (like a brisk walk)?
* On these days, for how many minutes do you typically exercise at this level?
* In a typical day, how many total servings of fruits and vegetables do you eat? (1 serving is ½ cup of fresh, frozen or canned fruits or vegetables, or ½ cup of 100% juice. Please DO NOT include potatoes.)
* What is the highest level of education you have completed?
* What is your approximate total household income for the past year before income tax deduction (from all sources)?
* What is your marital status?
* Are you receiving Ontario Drug Benefits?
* In our society, people are often described by their race or racial background. Our race may influence the way we are treated by individuals and institutions, and this may affect our health. Which category(ies) best describes you? Select all that apply:
* Last week, did you work at a job or a business? Please include part-time jobs, seasonal work, contract work, self-employment, baby-sitting and any other paid work, regardless of the number of hours worked.
* Last week, did you have a job or business from which you were absent?
* How did you find out about this program? (select one response)
* If you are determined to be eligible to participate in the STOP on the Net Program, would you prefer to receive nicotine gum or nicotine lozenges (contains aspartame) with your nicotine patches?
