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STOP on the Net - baseline

CF • Consent Form

STOP PROGRAM PRIVACY STATEMENT AND CONSENT TO PARTICIPATE, AND INFORMATION COLLECTION, USE AND DISCLOSURE

You are taking part in the STOP on the Net Program, which is part of the Smoking Treatment for Ontario Patients (STOP) Program. This program is designed to help support your decision to quit using tobacco cigarettes through the provision of Nicotine Replacement Therapy (NRT) and access to informational and educational resources through an online portal (STOP Portal). This program is administered by the Centre for Addiction and Mental Health (CAMH) and is funded by the Ontario Ministry of Health, and is free of cost to you.

If you take part in the STOP on the Net Program, CAMH collects certain information, including personal information, from you. This form explains the purposes for which CAMH collects, uses, and discloses your information and our management of that information for the STOP Program.
ELIGIBILITY AND ENROLLMENT

You may take part in the STOP on the Net program if you smoke cigarettes, are 18 years of age or older, are a resident of Ontario, and meet other eligibility criteria. If you are pregnant or breastfeeding, you are not eligible for this program; please consult your health care provider if you are seeking support to quit or reduce smoking. If you have a generalized skin disorder (e.g., eczema, rash), or have any known hypersensitivity or allergy to adhesives (e.g. medical tape) you are not eligible to receive NRT patches; however you may be eligible to receive other types of NRT products (gum or lozenges). If you have experienced an adverse reaction from using NRT patches, or have had difficulty using NRT patches in the past, you may also be eligible to receive other NRT products (gum or lozenges).

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 (described in the next section), 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, and other information reported, you will be mailed a kit containing Nicotine Replacement Therapy (NRT) to aid in your quit attempt. You will receive one of the following kits:

Kit A (combination of nicotine patches and gum or lozenges): 4 boxes of Step 1 (21mg nicotine) + 1 box of Step 2 (14mg nicotine) + 1 box of Step 3 (7mg nicotine) patches, and your choice of 3 boxes of gum (2mg nicotine) OR lozenge (2mg nicotine; contains aspartame)

Kit B (combination of nicotine patches and gum or lozenges): 4 boxes of Step 2 (14mg nicotine) + 2 boxes of Step 3 (7mg nicotine) patches, and your choice of 3 boxes of gum (2mg nicotine) OR lozenge (2mg nicotine; contains aspartame)

Kit C (nicotine patches only): 4 boxes of Step 1 (21mg nicotine) + 1 box of Step 2 (14mg nicotine) + 1 box of Step 3 (7mg nicotine) patches

Kit D (nicotine patches only): 4 boxes of Step 2 (14mg nicotine) + 2 boxes of Step 3 (7mg nicotine) patches

Kit E (nicotine gum or lozenges only): 6 boxes of gum (2mg nicotine) OR 5 boxes of lozenge (2mg nicotine; contains aspartame)

The NRT will be mailed to the address you provide in the survey. You will be contacted by email, phone and/or text message to complete follow-up surveys about your smoking and related behaviours at 8 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.

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.

Re-enrollment in the STOP on the Net Program is possible after 6 months from the previous enrollment.

If you previously participated in STOP including when it was a research study, CAMH will link your information from these previous enrollment(s) to your information from this current enrollment for STOP Program planning, evaluation, and research on nicotine use and quitting or reducing nicotine use. This means if you ever participated in STOP previously, including when it was a research study, CAMH will look into your information from those enrollment(s) and put it together with information from your current enrollment. By consenting to the STOP on the Net Program, you are agreeing to this data transfer. You cannot participate in the STOP on the Net Program if you do not agree to have data transferred if you were a STOP participant or past STOP Program user.

Any information provided to you by CAMH in connection with the STOP on the Net Program, either directly or indirectly (including any resources provided through the STOP Portal), is not a substitute for professional medical advice, diagnosis or treatment. If you require medical advice, diagnosis or treatment, please contact a qualified health care professional. No physician-patient or other health care provider relationship is created between you and CAMH as a result of your enrollment in the STOP on the Net Program.

INFORMATION COLLECTED BY CAMH
  • Full name: first name and last name.
  • Contact information, for example, your mailing address including postal code, e-mail address, telephone numbers.
  • Nicotine use information, for example, your cigarette use, e-cigarette use.
  • Other substance use information, for example, cannabis use, alcohol use, caffeine use.
  • Behavioural information, for example, physical activity, fruit and vegetable intake.
  • Physical and mental health information, for example, past and current diagnosis of high blood pressure, pain, mood, and related medication use.
  • Sociodemographic information, for example, your date of birth, sex, gender, employment, education.
  • Technical information, for example, your internet browser type, operating system, date and time of STOP Portal access, IP address.
  • OHIP number (optional)
REQUIRED AND OPTIONAL INFORMATION
Some information that you are asked to provide when completing the STOP on the Net Program questionnaires, such as your name and address, are required to participate in the STOP on the Net Program to ensure safe and effective program delivery; these questions are marked with an asterisk (*). Other information you are asked to provide is not required; these questions do not have an asterisk. However, the optional information is extremely valuable to help evaluate the STOP on the Net Program for the purpose of improving it for others trying to quit or reduce their tobacco cigarette use. Please complete all questionnaires as best as you can.
METHODS OF COLLECTING YOUR INFORMATION

CAMH collects most information directly from you online using the STOP Portal, CAMH’s web application for the STOP on the Net Program. Other times we collect your information when you speak with a CAMH STOP Team member by phone. You may also be contacted by text message to complete follow-up surveys. These follow-up data will be collected by the Research Electronic Data Capture (REDCap) platform at CAMH and the information you provide will be linked to your other program data collected using the STOP Portal, using your phone number and a temporary unique identifier.

Other information is collected when you access the STOP Portal. When you access the STOP Portal it will automatically collect some standard types of technical information such as the types and versions of internet browser and operating system used to access the STOP Portal, the Internet Protocol (IP) address of the device being used to access the STOP Portal, dates and times users access the STOP Portal, etc. This information is collected to support troubleshooting of the STOP Portal software program and for traffic monitoring and statistical purposes. The STOP Portal also uses cookies. Cookies are small pieces of data stored by an internet browser on your device when you visit the STOP Portal. Cookies are often used to retain information about preferences and pages you have visited. The STOP Portal uses cookies for a few functions, such as to authenticate users, manage the online session, and prevent multiple logins and duplicate records.

INFORMATION USED USE OF YOUR INFORMATION BY CAMH
Full name and contact information
  • Deliver NRT to you
  • Conduct STOP follow-up surveys
  • Ask if you are interested in learning about other CAMH offerings that may be beneficial to you
  • Data quality checks, such as finding duplicate entries and/or errors in the program database
Tobacco use
Nicotine use
Other substance use
Behavioural
Physical and mental health
Sociodemographic
Location data (postal code)
  • Evaluate and improve the program, identify where we need to improve access to services. STOP Program progress, outcomes, and findings (using aggregate data that does not identify you) are shared with our funder, the Ontario Ministry of Health, health care and scientific communities, as well as policy makers (e.g., publications, presentations, media updates)
  • Research about tobacco and nicotine use, quitting or reducing tobacco and nicotine use, and factors related to health and health outcomes of individuals who smoke or use nicotine. Your de-identified STOP information also may be combined with information collected from other people in other programs and studies.
Technical information
  • Find and fix issues / bugs in the STOP Portal and other troubleshooting
  • Monitor STOP Portal traffic
DISCLOSURE OF YOUR INFORMATION BY CAMH
CAMH will not sell your information. It will share your information only with the parties listed below.
  • Researchers: CAMH may share your de-identified information (meaning it cannot be used to identify you) with researchers within and outside of CAMH for specific research or evaluation projects. Your information may be combined with information collected from other people in other programs and studies.
  • Institute for Clinical Evaluative Sciences (ICES): We will share your questionnaire answers with ICES so they can link it with your publicly-funded health care information held by ICES. If you agree to the Optional Consent below, CAMH will share your OHIP number with ICES for the purposes of facilitating this linkage; if you do not wish to provide your OHIP number for this purpose, CAMH will share your full name and date of birth with ICES instead. The data ICES gives back to CAMH is aggregated (grouped by age groups, for example) to help CAMH measure the impact of the STOP Program on the future health of its participants.
COMMERCIALIZATION
The results of the STOP on the Net Program, or in the course of designing and delivering the STOP on the Net Program, CAMH may create methods, tools, software and other products with commercial value. You will have no rights to any of these tools, programs or products created as a result of the STOP on the Net Program or any future programs/studies that may use your de-identified information. You will not receive money or other compensation or benefits from these tools, programs or other products.
CONFIDENTIALITY AND PROTECTION OF YOUR INFORMATION
The information you provide as part of the STOP on the Net Program will be kept for as long as required by the Ministry of Health and CAMH retention policies. Information will be kept confidential to the extent permitted by law, and will only be available to CAMH and the parties mentioned above. The STOP Portal is a secure electronic database that encrypts information in transit and at rest. The CAMH STOP Team also stores a copy of STOP on the Net participants’ information in a password-protected database on a secure CAMH server. Any paper documentation will be kept in locked cabinets with limited access to the STOP Team only. CAMH conducts periodic privacy reviews and Technical Vulnerability or Threat Risk Assessments to safeguard all information against unauthorized access.
WITHDRAWING YOUR CONSENT
You may withdraw from the STOP on the Net Program 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 remain available to be used by CAMH for program reporting, evaluation, improvement, and research purposes as described above.
QUESTIONS ABOUT THE STOP PROGRAM?
Before you consent to the STOP on the Net Program and at any time after you have provided your consent, if you have any questions about the NRT provided, you can ask your health care provider. If you have questions about how your information is collected, used, or disclosed by CAMH, you can contact StopOnTheNet@camh.ca or 416-535-8501 ext. 34455. If you have questions about the privacy of your information in the STOP on the Net Program, then please reach out to privacy@camh.ca or 416-535-8501 x33314.
CONSENT

I understand that my participation in the STOP on the Net Program is voluntary. I may refuse to participate in the STOP on the Net Program without any impact on any other care I am currently receiving or am eligible to receive at CAMH. If I consent to participate in the STOP on the Net Program and change my mind, I understand I may withdraw my consent at any time without any impact to any other care I am currently receiving or am eligible to receive at CAMH.

By clicking “I Agree”, I hereby:

  • Agree to participate in the STOP on the Net Program and consent to the collection, use, and disclosure of my information by CAMH for the STOP on the Net Program.
  • Confirm that I have read the information provided in this form and understand how the information I provide will be used and shared by CAMH.
  • Understand that if I previously participated in STOP on the Net, CAMH will link information from this enrollment with my previous enrollment(s) to answer new research and evaluation questions to better understand factors that influence tobacco and/or nicotine use and quitting or reducing tobacco and/or nicotine use.

If you do not agree with any of the above, click “I do not agree”

*
Optional Consent: You have the option of consenting to allow CAMH to collect your OHIP number to link your STOP information (as set out above) to your publicly-funded health care information at ICES for STOP Program planning and evaluation. You can refuse to provide your OHIP number without any impact on your eligibility to participate in the STOP Program.
Optional Consent: You have the option of consenting to allow CAMH to contact you about future research studies, programs, or resources on smoking and other factors that may be relevant to you based on your STOP information. You can refuse to consent to being contacted without any impact on your eligibility to participate in the STOP Program. If you consent to be contacted, CAMH will use the CONTACT INFORMATION you have provided below (or any updated or subsequent contact information you provide) to contact you.

BQ • Baseline Questionnaire

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.
* First Name:
* Last Name:
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.
* Email:
* 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.
* Street Address:
Unit:
Buzzer code:
* City/Town:
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.
* Province:
* Postal Code:
* 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?

A • CIGARETTE USE HISTORY

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.
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.
* 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?

E-CIG • E-CIGARETTES

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?

OS • OTHER SUBSTANCES

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 many caffeinated beverages (e.g., coffee, tea, cola) do you drink per day?
* 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?

GH • GENERAL HEALTH

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?
* a. High blood pressure
* b. Heart disease
* c. Stroke
* d. Diabetes
* e. Chronic bronchitis, emphysema or COPD
* f. Chronic pain
* g. Cancer
* h. Depression
* i. Anxiety
* j. Schizophrenia
* k. Bipolar disorder
* l. Substance use disorder (drug addiction other than tobacco or caffeine)
* m. Alcohol use disorder (alcoholism)
* n. 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 adhesives (e.g., medical tape) that would affect your ability to use the nicotine patch, and/or have you experienced challenges/an adverse reaction when trying to use nicotine patches in the past (e.g., could not get the patch to stick)?
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)?
* 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.)

D • DEMOGRAPHICS

* 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:
* Where were you born?
* 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.
* 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?

End • End of survey

End of survey. Please click the Finish button to receive an email with further instructions. Thank you for participating.