Int. J. Environ. Res. Public Health 2011, 8 255 0.5 persons/km2 compared to 12.5 persons/km2 provincially [10]. One of the hospitals was the regional tertiary hospital located in an urban centre (Thunder Bay); the other 10 hospitals were in the rural communities of Atikokan, Dryden, Fort Frances, Geraldton, Marathon, Manitouwadge, Nipigon, Red Lake, Sioux Lookout, and Terrace Bay. All 11 hospitals have recently become affiliated with a new medical school as northern, rural, and remote teaching sites for undergraduate and graduate learners. The study received ethics clearance through the regional hospital institutional review board (IRB), which also served as the IRB for 8 of the community hospitals; 2 of the community hospitals provided individualized clearance from their own IRBs. 2.2. Measures Tobacco use status was defined as 30-day point prevalence: “Have you smoked or used any tobacco products in the last 30 days?” (yes, no, not asked, not able [to answer], and refused). Thirty days allows comparison to inpatient studies [11,12]. Although the question was phrased as “smoked or used any tobacco products”, previous studies have showed that 97–99% of hospital patients who report using tobacco smoke cigarettes [12]. Demographic data that were part of the regular ED registration process were extracted for analyses to characterize the population—gender, age, hospital site, and date. To protect confidentiality, patient age instead of the more specific birth date was extracted and names were not recorded. Hospital-assigned medical record numbers were extracted to enable statistical control for repeat visits; the researchers had no way to track these numbers to patient names or other personally-identifying information. Statistics Canada and Health Canada cross-sectional survey data were used for comparative tobacco use prevalence data for the general population—community level prevalence data were not available but national, provincial, and regional data were. The regional data were available by public health district; there are two public health districts in NW Ontario—Northwestern District Public Health (NWDPH) and Thunder Bay District Public Health (TBDPH). The most recent and complete population data were used for population comparisons—Health Canada’s 2007 Canadian Tobacco Use Monitoring Survey for national and provincial rates [7], and Statistics Canada 2009 socioeconomic database CANSIM for regional rates [13]. The general population data are specific to smoking prevalence, not all tobacco use. 2.3. Procedure The Chief Executive Officer and senior management team in each hospital in LHIN 14 were approached with the opportunity to participate in the research project. A presentation was made that included: (1) what adding a tobacco use question to the admitting records would involve; (2) clinical practice guideline recommendations for institutionalizing tobacco use identification and documentation [2]; (3) the type of data and reports that would be available to the hospitals resulting from the systematic tracking of tobacco use; and, (4) accreditation benefits to the hospitals for research participation and disease surveillance activities. Hospitals agreed to add the tobacco use question on the admitting records to be asked by admitting staff and agreed to allow the data to be extracted and analyzed for research purposes. They also arranged for the admitting staff to be trained by the principal investigator (PI).