Introduction

Tobacco use, risky or problem drinking, and the abuse of women are all serious health and social concerns for Canadian women. Smoking, drinking and abuse can lead to grave health consequences for women and their children, including unborn children. Therefore, it is critical to identify at-risk women so that they can receive the advice and assistance necessary to reduce the risk to themselves and their children.

In the KFL&A area, 17.5% of women are daily smokers; of these, two-thirds (64.3%) smoke more than ten cigarettes per day and one-third (35.8%) smoke 20 or more cigarettes¹. Of particular concern, 21.2% of KFLA women who gave birth in 2008 reported smoking during pregnancy². More than half of all women (53.6%) drink alcohol more often than once a month, of whom 5.2% drink daily. One-third of women in KFL&A (32.5%) drink beyond the low risk drinking guidelines, meaning that, at least on occasion, they consume more than two drinks on a day or more than 10 drinks in a week³. During pregnancy, 9% of Ontario women drink alcohol, with the majority of these women drinking two to three times per month or less⁴.

Statistics on the abuse of women are more difficult to obtain, and local statistics are not available. In Ontario, the rate of reported spousal violence against women is 225/100,000 population. However, it is estimated that police-reported incidents represent only 36% of spousal violence against women, which in turn, represents only a proportion of cases of abuse⁵.

Physicians, midwives and nurse practitioners are well positioned to identify tobacco use, problem drinking and abuse, since most Canadians consult their family doctor or family health team at least once a year. Recent data indicate, for example, that approximately 79% of KFL&A residents report consulting a medical doctor in the previous 12 months⁶ and 92% of pregnant women in KFL&A attend an antenatal visit during their first trimester². Although health professionals customarily take a patient's medical history, they vary in the questions they ask.  Routine use of screening instruments for tobacco use, problem drinking and domestic abuse provides a structured, consistent means to detect individuals at risk.

Clinical guidelines published by leading Canadian health authorities advocate universal screening for tobacco and alcohol use and abuse. Clinical Practice Guidelines from the Ontario Medical Association⁷, Canadian Paediatric Society⁸ and Registered Nurses of Ontario (RNAO)⁹ all recommend screening patients for smoking and providing advice and assistance with cessation. Due to low rates of alcohol screening among pregnant women, the Society of Obstetricians and Gynaecologists of Canada, along with other health agencies, recently issued consensus clinical guidelines that recommend periodic universal screening for alcohol in all women of childbearing age and pregnant women¹⁰. The SOGC¹¹ and others¹² also recommend screening for woman abuse during pregnancy as a routine part of prenatal care.

Although family physicians report a belief that screening for health risk behaviours including alcohol and tobacco use is their responsibility, they cite many barriers to effective screening. These include a lack of time, cultural and language barriers, insufficient knowledge and skills, a belief that screening is not ultimately beneficial, and lack of knowledge of where to refer patients¹³.

Barriers to effective screening may be most pronounced for woman abuse. Few health professionals report routine screening for abuse, and among Canadian women who have experienced abuse, only 61.0% reported discussing or receiving information about what to do if they were experiencing abuse⁴. A study of medical residents suggests incorrect knowledge of the epidemiology of abuse, a lack of mentorship during medical education and low awareness of referral sources contribute to low rates of screening for abuse¹⁴. Routine screening is a primary starting point for early identification of domestic violence, and will increase the opportunities for identification and brief intervention with women presenting symptoms not generally associated with domestic violence¹².

It appears many physicians and other primary care providers are reluctant to screen for health risk behaviours and woman abuse; however, evidence suggests most patients do not object to screening. Indeed, in a study of alcohol screening, the majority of patients said they expected their family doctor to ask about lifestyle factors that influence their health, and to provide advice on these issues¹⁵. Similarly, it appears most women are comfortable being screened in family practice for abuse¹⁶.

It has been demonstrated that brief interventions by physicians are effective in reducing tobacco use^17,18,19, alcohol use20 and in assisting women who are experiencing abuse^11,21. The fact that women are willing to discuss these issues with their physician or other health professional^15,22 underlines the importance of valid, brief screening tools as the first step towards reducing the effects of tobacco, alcohol and abuse on women's health.

Kingston, Frontenac and Lennox & Addington (KFL&A) Public Health has compiled three valid screening tools - one for smoking, one for alcohol use (T-ACE) and one for woman abuse (RUCS) - into one tool entitled the Alcohol, Tobacco and Abuse Screening Tool for Women. This tool uses the ASK, ADVISE, and ASSIST philosophy. In the ASK section, health professionals are prompted to ask patients screening questions. If the patient uses tobacco, is at risk for problem drinking or is experiencing abuse, the ADVISE section provides health professionals with information to share with patients on the health impact of these behaviours and how to reduce tobacco or alcohol use. In the ASSIST section, community resources are listed to which health professionals can refer patients who require or would like further assistance. Patients may also use these community resources for self-referral.