Validation of self reported smoking by serum cotinine measurement in a community-based study

Methods for quantification of exposure to cigarette smoking and environmental tobacco smoke: focus on developmental toxicology

Active and passive smoking have been associated with an array of adverse effects on health. The development of valid and accurate scales of measurement for exposures associated with health risks constitutes an active area of research. Tobacco smoke exposure still lacks an ideal method of measurement. A valid estimation of the risks associated with tobacco exposure depends on accurate measurement. However, some groups of people are more reluctant than others to disclose their smoking status and exposure to tobacco. This is particularly true for pregnant women and parents of young children, whose smoking is often regarded as socially unacceptable. For others, recall of tobacco exposure may also prove difficult. Because relying on self-report and the various biases it introduces may lead to inaccurate measures of nicotine exposure, more objective solutions have been suggested. Biomarkers constitute the most commonly used objective method of ascertaining nicotine exposure. Of those available, cotinine has gained supremacy as the biomarker of choice. Traditionally, cotinine has been measured in blood, saliva, and urine. Cotinine collection and analysis from these sources has posed some difficulties, which have motivated the search for a more consistent and reliable source of this biomarker. Hair analysis is a novel, noninvasive technique used to detect the presence of drugs and metabolites in the hair shaft. Because cotinine accumulates in hair during hair growth, it is a unique measure of long-term, cumulative exposure to tobacco smoke. Although hair analysis of cotinine holds great promise, a detailed evaluation of its potential as a biomarker of nicotine exposure, is needed. No studies have been published that address this issue. Because the levels of cotinine in the body are dependent on nicotine metabolism, which in turn is affected by factors such as age and pregnancy, the characterization of hair cotinine should be population specific. This review aims at defining the sensitivity, specificity, and clinical utilization of different methods used to estimate exposure to cigarette smoking and environmental tobacco smoke.

The accuracy of self-reported smoking: a systematic review of the relationship between self-reported and cotinine-assessed smoking status

INTRODUCTION

Smoking is a leading cause of premature mortality and preventable morbidity. Surveillance is most often based on self-reported data, but studies have shown that self-reports tend to underestimate smoking status.

METHODS

This study systematically reviewed the literature to measure the concordance between self-reported smoking status and smoking status determined through measures of cotinine in biological fluids. Four electronic databases were searched to identify observational and experimental studies on adult populations over the age of 18 years.

RESULTS

Searching identified 67 studies that met the eligibility criteria and examined the relationship between self-reported smoking and smoking confirmed by cotinine measurement. Overall, the data show trends of underestimation when smoking prevalence is based on self-report and varying sensitivity levels for self-reported estimates depending on the population studied and the medium in which the biological sample is measured. Sensitivity values were consistently higher when cotinine was measured in saliva instead of urine or blood. Meta-analysis was not appropriate because of the substantial heterogeneity among the cutpoints used to define smokers and the poor reporting on outcomes of interest.

DISCUSSION

Further research in this field would benefit from the standardization of cutpoints to define current smokers and the implementation of standard reporting guidelines to enhance comparability across studies. Accurate estimation of smoking status is important as data from population studies such as those included in this review are used to generate regional and national estimates of smoking status and in turn are used to allocate resources and set health priorities.

The association of active and passive smoking with peripheral arterial disease: results from NHANES 1999-2004

We aim to quantify the association between different forms of tobacco use and peripheral arterial disease (PAD) and to characterize the association between secondhand smoke exposure and PAD in a large nationally representative sample of the US population. We observed significant associations between current and former cigarette smoking and PAD. The association between noncigarette forms of tobacco and PAD was not significant even after adjustment for clinical and demographic variables. Secondhand smoke was not significantly associated with PAD. Interestingly, a ;;threshold phenomenon'' for tobacco exposure was demonstrated for PAD occurrence. Individuals with serum cotinine >155 ng/ mL were at significantly higher risk of having PAD as compared with a nonexistent or a minimal risk below this threshold value. Lack of association between PAD and secondhand smoke exposure in conjunction with the threshold phenomenon described above leads us to speculate existence of striking differences between the systemic circulation and lower extremity vasculature in terms of pathogenesis of atherosclerosis.

Association of smoking in adolescence with abdominal obesity in adulthood: a follow-up study of 5 birth cohorts of Finnish twins

OBJECTIVES

We studied the association of adolescent smoking with overweight and abdominal obesity in adulthood.

METHODS

We used the FinnTwin16, a prospective, population-based questionnaire study of 5 consecutive and complete birth cohorts of Finnish twins born between 1975 and 1979 (N = 4296) and studied at four points between the ages of 16 and 27 years to analyze the effect of adolescent smoking on abdominal obesity and overweight in early adulthood.

RESULTS

Smoking at least 10 cigarettes daily when aged 16 to 18 years increased the risk of adult abdominal obesity (odds ratio [OR]=1.77; 95% confidence interval [CI] = 1.39, 2.26). After we adjusted for confounders, the OR was 1.44 (95% CI = 1.11, 1.88), and after further adjustment for current body mass index (BMI), the OR was 1.34 (95% CI = 0.95, 1.88). Adolescent smoking significantly increased the risk of becoming overweight among women even after adjustment for possible confounders, including baseline BMI (OR = 1.74; 95% CI = 1.06, 2.88).

CONCLUSIONS

Smoking is a risk factor for abdominal obesity among both genders and for overweight in women. The prevention of smoking during adolescence may play an important role in promoting healthy weight and in decreasing the morbidity related to abdominal obesity.

Work-place social capital and smoking cessation: the Finnish Public Sector Study

AIMS

To examine whether high social capital at work is associated with an increased likelihood of smoking cessation in baseline smokers.

DESIGN

Prospective cohort study.

SETTING

Finland.

PARTICIPANTS

A total of 4853 employees who reported to be smokers in the baseline survey in 2000-2002 (response rate 68%) and responded to a follow-up survey on smoking status in 2004-2005 (response rate 77%).

MEASUREMENTS

Work-place social capital was assessed using a validated and psychometrically tested eight-item measure. Control variables included sex, age, socio-economic position, marital status, place of work, heavy drinking, physical activity, body mass index and physician-diagnosed depression.

FINDINGS

In multi-level logistic regression models adjusted for all the covariates, the odds for being a non-smoker at follow-up were 1.26 [95% confidence interval (CI)=1.03-1.55] times higher for baseline smokers who reported high individual-level social capital than for their counterparts with low social capital. In an analysis stratified by socio-economic position, a significant association between individual-level social capital and smoking cessation was observed in the high socio-economic group [odds ratio (OR) (95% CI)=1.63 (1.01-2.63)], but not in intermediate [(OR=1.10 (0.83-1.47)] or low socio-economic groups [(OR=1.28 (0.86-1.91)]. Work unit-level social capital was not associated with smoking cessation.

CONCLUSIONS

If the observed associations are causal, these findings suggest that high perceived social capital at work may facilitate smoking cessation among smokers in higher-status jobs.

Tobacco smoking and chewing as risk factors for multiple human papillomavirus infections and cervical squamous intraepithelial lesions in two countries (Côte d'Ivoire and Finland) with different tobacco exposure

Our objective was to compare the association between tobacco smoking and chewing and the risk of multiple human papillomavirus (HPV) infections and cervical squamous intraepithelial lesions (SILs) in two populations with different tobacco exposure. We studied 2,162 women from Côte d'Ivoire, West Africa, and 419 women from Finland, Northern Europe, with baseline data on cervical screening, HPV DNA status and smoking and chewing habits. The proportion of women who smoked and/or chewed tobacco was higher in Finland (36.8%) than in Côte d'Ivoire (3.7%), where tobacco chewing (2.6%) was more common than tobacco smoking (1.4%). Having multiple HPV infections was common in HPV16 and/or 18-infected women (60.4% in Finland and 47.2% in Côte d'Ivoire). There was no increased risk of multiple HPV infections among tobacco consumers. We found that women >or=30 years of age exposed to tobacco through smoking in Finland (OR: 2.2, 95% CI: 0.5-8.7) and chewing in Côte d'Ivoire (OR: 5.5, 95% CI: 2.1-14) had a moderately or highly increased risk of high-grade SIL, respectively. In the latter, the risk was statistically significant. Our findings emphasize the need for health initiatives targeted to prevent tobacco smoking or chewing among women especially in less industrialized countries.

Linkage of nicotine dependence and smoking behavior on 10q, 7q and 11p in twins with homogeneous genetic background

The significant worldwide health burden introduced by tobacco smoking highlights the importance of studying the genetic determinants of smoking behavior and the key factor sustaining compulsive smoking, that is, nicotine dependence (ND). We have here addressed the genetic background of smoking in a special study sample of twins, harmonized for early life events and specifically ascertained for smoking from the nationwide twin cohort of the genetically unique population of Finland. The twins and their families were carefully examined for extensive phenotype profiles and a genome-wide scan was performed to identify loci behind the smoking status, ND and the comorbid phenotype of ND and alcohol use in 505 individuals from 153 families. We replicated previous linkage findings on 10q (max logarithm of the odds (LOD) 3.12) for a smoker phenotype, and on 7q and 11p (max LOD 2.50, and 2.25, respectively) for the ND phenotype. The loci linked for ND also showed evidence for linkage for the comorbid phenotype. Our study provides confirmatory evidence for the involvement of these genome regions in the genetic etiology of smoking behavior and ND and for the first time associates drinking and smoking to a shared locus on 10q.

The collective dynamics of smoking in a large social network

BACKGROUND

The prevalence of smoking has decreased substantially in the United States over the past 30 years. We examined the extent of the person-to-person spread of smoking behavior and the extent to which groups of widely connected people quit together.

METHODS

We studied a densely interconnected social network of 12,067 people assessed repeatedly from 1971 to 2003 as part of the Framingham Heart Study. We used network analytic methods and longitudinal statistical models.

RESULTS

Discernible clusters of smokers and nonsmokers were present in the network, and the clusters extended to three degrees of separation. Despite the decrease in smoking in the overall population, the size of the clusters of smokers remained the same across time, suggesting that whole groups of people were quitting in concert. Smokers were also progressively found in the periphery of the social network. Smoking cessation by a spouse decreased a person's chances of smoking by 67% (95% confidence interval [CI], 59 to 73). Smoking cessation by a sibling decreased the chances by 25% (95% CI, 14 to 35). Smoking cessation by a friend decreased the chances by 36% (95% CI, 12 to 55 ). Among persons working in small firms, smoking cessation by a coworker decreased the chances by 34% (95% CI, 5 to 56). Friends with more education influenced one another more than those with less education. These effects were not seen among neighbors in the immediate geographic area.

CONCLUSIONS

Network phenomena appear to be relevant to smoking cessation. Smoking behavior spreads through close and distant social ties, groups of interconnected people stop smoking in concert, and smokers are increasingly marginalized socially. These findings have implications for clinical and public health interventions to reduce and prevent smoking.

Continued smoking exacerbates but cessation ameliorates progression of early type 2 diabetic nephropathy

PURPOSE

We tested the hypothesis that continued cigarette smoking exacerbates and its cessation ameliorates progression of the early nephropathy of type 2 diabetes mellitus (DM2) from microalbuminuria to macroalbuminuria.

METHODS

We recruited 91 DM2 subjects with microalbuminuria, 39 nonsmokers and 52 smokers. Smokers underwent smoking cessation intervention with 11 of the 52 smokers quitting, yielding 3 groups: nonsmokers (NS, n = 39), continued smokers (S, n = 41), and quitting smokers (Quit, n = 11), all on angiotensin converting enzyme inhibition (ACEI), treated toward recommended BP and glycemic targets, and followed prospectively for 5 years. Subjects had yearly measurements of estimated glomerular filtration rate (eGFR) and albumin (mg)-to-creatinine (g) ratios (alb/cr) in spot morning urines. Comparison of changes in characteristics was done using analysis of variance, with all pair wise multiple comparison procedure at alpha = 0.05.

RESULTS

Although average urine alb/cr was not different among groups at recruitment, 7 of the 41 S (17%) but none of the 50 NS or Quit progressed to macroalbuminuria (P < 0.003). eGFR decline rate was faster in S (-1.79 +/- 0.35 mL/min/yr) than in NS or Quit (-1.30 +/- 0.43 and -1.54 +/- 0.37 mL/min/yr, respectively, P < 0.001). Multivariate analysis revealed smoking to be the only measured baseline factor that influenced eGFR decline rate (P < 0.041).

CONCLUSION

Smoking exacerbates progression of early to advanced DM2 nephropathy and its cessation is an effective kidney-protective intervention in the early nephropathy of DM2.

Impact of the 1976 Tobacco Control Act in Finland on the proportion of ever daily smokers by socioeconomic status

OBJECTIVE

To assess the impact of the 1976 Tobacco Control Act (TCA) on smoking initiation across socioeconomic groups.

METHODS

Nationwide data from independent annual cross-sectional postal surveys in 1978-2002 in Finland. Subjects were 25-64-year-old men and women born 1926-1975 (n=68 071). Socioeconomic status was derived individually from population census data. Logistic regression was applied to assess the impact of the 1976 TCA on the prevalence of ever daily smoking in birth cohorts and socioeconomic groups.

RESULTS

Clear socioeconomic differences in ever daily smoking among men and women were found. In all socioeconomic groups a declining cohort trend was observed among men whereas women showed an increasing trend in early cohorts and a declining one thereafter. A statistically significant decline in the proportion of ever daily smokers compatible with the impact of the TCA was found in all socioeconomic groups except farmers. Among women the decline was roughly similar in each socioeconomic group, while among men it varied and was most pronounced among white collar employees.

CONCLUSIONS

The impact of the 1976 TCA was less pronounced among male lower socioeconomic groups. In spite of the even impact of the TCA on female smoking across socioeconomic groups, large socioeconomic disparities remain. Tobacco control policy measures specifically directed at lower socioeconomic groups are needed.

Characteristics of physically active smokers and implications for harm reduction

OBJECTIVES

We sought to establish the prevalence of physical activity among smokers, whether or not physically active smokers were more likely to attempt cessation, and who these physically active smokers were.

METHODS

We used logistic regression to contrast physically active and inactive smokers in a secondary data analysis of the Canadian Community Health Survey Cycle 1.1.

RESULTS

Physically active smokers represented almost one quarter of the smoking population. Compared with physically inactive smokers, physically active smokers were more likely to have attempted cessation in the past year. Physically active smokers were more likely to be young, single, and men compared with their inactive counterparts. Income had no influence in distinguishing physically active and inactive smokers.

CONCLUSIONS

Skepticism persists regarding the practicality and potential risks of promoting physical activity as a harm-reduction strategy for tobacco use. We found that a modest proportion of the daily smoking population was physically active and that engagement in this behavior was related to greater cessation attempts. Interventions could be developed that target smokers who are likely to adopt physical activity.

Serum cotinine concentration and wound complications in head and neck reconstruction

BACKGROUND

The authors examined whether the preoperative serum concentrations of cotinine accurately predict the risk of complications in patients undergoing flap reconstruction of head and neck cancer defects.

METHODS

Patients with incident stage III or IV squamous cell carcinoma of the head and neck undergoing resection with pedicled or free flap reconstruction were selected from an existing database of 500 patients with squamous cell carcinoma of the head and neck who participated in a prospective epidemiologic study and were reviewed retrospectively. Preoperative serum cotinine concentrations were determined using a competitive microplate immunoassay. Complications were defined as any adverse postoperative wound outcome at either the donor or recipient site.

RESULTS

Eighty-nine patients underwent 101 flap reconstructions. Thirty-seven wound complications occurred in 33 patients. Forty of the 89 patients had a serum cotinine concentration greater than 10 ng/ml; twenty (50 percent) developed postoperative complications, whereas only 13 of 49 patients (27 percent) with a serum cotinine concentration of 10 ng/ml or less developed complications (p = 0.028). The relative risk of wound complications for those with a cotinine concentration greater than 10 ng/ml was approximately double that of patients with a lower cotinine concentration (relative risk, 1.9; 95 percent CI, 1.1 to 3.3). Patients with a cotinine concentration greater than 50 ng/ml had a particularly high risk (relative risk, 2.3; 95 percent CI, 1.1 to 16.7; p = 0.024). The relative risk of wound complications was not significantly associated with self-reported smoking status or history.

CONCLUSION

A serum cotinine concentration greater than 10 ng/ml may predict an increased risk of wound complication in head and neck flap reconstruction and may serve as an objective, easily measured variable with which to identify patients who may benefit from an aggressive smoking cessation program before surgery.

Acceptability and effectiveness of opportunistic referral of smokers to telephone cessation advice from a nurse: a randomised trial in Australian general practice

BACKGROUND

GPs often lack time to provide intensive cessation advice for patients who smoke. This study aimed to determine the effectiveness of opportunistic referral of smokers by their GP for telephone cessation counselling by a trained nurse.

METHODS

Adult smokers (n = 318) attending 30 GPs in South Western Sydney, Australia were randomly allocated to usual care or referral to a telephone-based program comprising assessment and stage-based behavioural advice, written information and follow-up delivered by a nurse. Self-reported point prevalence abstinence at six and 12 months was compared between groups. Characteristics of patients who accepted and completed the intervention were investigated.

RESULTS

Of 169 smokers randomised to the intervention, 76 (45%) consented to referral. Compared with smokers in 'pre-contemplation', those further along the stage-of-change continuum were significantly more likely to consent (p = 0.003). Those further along the continuum also were significantly more likely to complete all four calls of the intervention (OR 2.6, 95% CI: 0.8-8.1 and OR 8.6, 95% CI: 1.7-44.4 for 'contemplation' and 'preparation' respectively). At six months, there was no significant difference between groups in point prevalence abstinence (intention to treat) (9% versus 8%, p = 0.7). There was no evidence of differential intervention effectiveness by baseline stage-of-change (p = 0.6) or patient sex (p = 0.5). At 12 months, point prevalence abstinence in the intervention and control groups was 8% and 6% respectively (p = 0.6).

CONCLUSION

Acceptance of opportunistic referral for nurse delivered telephone cessation advice was low. This trial did not demonstrate improved quit rates following the intervention. Future research efforts might better focus support for those patients who are motivated to quit. AUSTRALIAN CLINICAL TRIALS REGISTRY NUMBER: ACTRN012607000091404.

Proactive interventions for smoking cessation in general medical practice: a quasi-randomized controlled trial to examine the efficacy of computer-tailored letters and physician-delivered brief advice

AIMS

To test the efficacy of (i) computer-generated tailored letters and (ii) practitioner-delivered brief advice for smoking cessation against an assessment-only condition; and to compare both interventions directly.

DESIGN

Quasi-randomized controlled trial.

SETTING

A total of 34 randomly selected general practices from a German region (participation rate 87%).

PARTICIPANTS

A total of 1499 consecutive patients aged 18-70 years with daily cigarette smoking (participation rate 80%).

INTERVENTIONS

The tailored letters intervention group received up to three individualized personal letters. Brief advice was delivered during routine consultation by the practitioner after an onsite training session. Both interventions were based on the Transtheoretical Model of behaviour change.

MEASUREMENTS

Self-reported point prevalence and prolonged abstinence at 6-, 12-, 18- and 24-month follow-ups.

FINDINGS

Among participants completing the last follow-up, 6-month prolonged abstinence was 18.3% in the tailored letters intervention group, 14.8% in the brief advice intervention group and 10.5% in the assessment-only control group. Assuming those lost to follow-up to be smokers, the rates were 10.2%, 9.7% and 6.7%, respectively. Analyses including all follow-ups confirmed statistically significant effects of both interventions compared to assessment only. Using complete case analysis, the tailored letters intervention was significantly more effective than brief advice for 24-hour [odds ratio (OR) = 1.4; P = 0.047] but not for 7-day point prevalence abstinence (OR = 1.4; P = 0.068) for prolonged abstinence, or for alternative assumptions about participants lost to follow-up.

CONCLUSIONS

The study demonstrated long-term efficacy of low-cost interventions for smoking cessation in general practice. The interventions are suitable to reach entire populations of general practices and smoking patients. Computer-generated letters are a promising option to overcome barriers to provide smoking cessation counselling routinely.

Educational attainment and cigarette smoking: a causal association?

BACKGROUND

Despite abundant evidence that lower education is associated with a higher risk of smoking, whether the association is causal has not been convincingly established.

METHODS

We investigated the association between education and lifetime smoking patterns in a birth cohort established in 1959 and followed through adulthood (n = 1311). We controlled for a wide range of potential confounders that were measured prior to school entry, and also estimated sibling fixed effects models to control for unmeasured familial vulnerability to smoking.

RESULTS

In the full sample of participants, regression analyses adjusting for multiple childhood factors (including socioeconomic status, IQ, behavioural problems, and medical conditions) indicated that the number of pack-years smoked was higher among individuals with less than high school education [rate ratio (RR) = 1.58, confidence interval (CI) = 1.31, 1.91]. However, in the sibling fixed effects analysis the RR was 1.23 (CI = 0.80, 1.93). Similarly, adjusted models estimated in the full sample showed that individuals with less than high school education had fewer short-term (RR = 0.40; CI = 0.23, 0.69) and long-term (RR = 0.59; CI = 0.42, 0.83) quit attempts, and were less likely to quit smoking (odds ratio = 0.34; CI = 0.19, 0.62). The effects of education on quitting smoking were attenuated in the sibling fixed effects models that controlled for familial vulnerability to smoking.

CONCLUSIONS

A substantial portion of the education differential in smoking that has been repeatedly observed is attributable to factors shared by siblings that contribute to shortened educational careers and to lifetime smoking trajectories. Reducing disparities in cigarette smoking, including educational disparities, may therefore require approaches that focus on factors early in life that influence smoking risk over the adult life span.

Tobacco smoking by occupation in Australia and the United States: a review of national surveys conducted between 1970 and 2005

Tobacco use represents a key issue in workplace health, and much can be learned from countries where occupational smoking data has been regularly collected on a national basis. This article reviews national smoking surveys previously conducted in Australia and the United States between 1970 and 2005, and examines their relevance to the field of occupational tobacco control. When the first preliminary research was undertaken over 35 years ago, tobacco smoking was a regular feature in the general population of both countries, albeit with higher rates often documented among blue collar workers. Recent national investigations however, suggest that certain historical differences in smoking prevalence rates by occupation are persisting as we enter the 21st century. Detailed examination also indicates that employee sub-groups, such as cleaners and construction workers, are now bearing much of the occupational smoking burden in Australia and the United States. As such, there is an urgent need for more aggressive and finely targeted tobacco control activities in the workplace, as well as increased cooperation between tobacco control organizations, labor unions and other stakeholders, so that they may more effectively combat this ongoing threat to workers' health.

Occasional tobacco use among young adult women: a longitudinal analysis of smoking transitions

OBJECTIVE

To describe prospective transitions in smoking among young adult women who were occasional smokers, and the factors associated with these transitions, by comparing sociodemographic, lifestyle and psychosocial characteristics of those who changed from occasional smoking to daily smoking, non-daily smoking or non-smoking.

DESIGN

Longitudinal study with mailed questionnaires.

PARTICIPANTS/SETTING

Women aged 18-23 years in 1996 were randomly selected from the Medicare Australia database, which provides the most complete list of people in Australia.

MAIN OUTCOME MEASURES

Self-reported smoking status at survey 1 (1996), survey 2 (2000) and survey 3 (2003), for 7510 participants who took part in all three surveys and who had complete data on smoking at survey 1.

RESULTS

At survey 1, 28% (n = 2120) of all respondents reported smoking. Among the smokers, 39% (n = 829) were occasional smokers. Of these occasional smokers, 18% changed to daily smoking at survey 2 and remained daily smokers at survey 3; 12% reported non-daily smoking at surveys 2 and 3; 36% stopped smoking and remained non-smokers; and 33% moved between daily, non-daily and non-smoking over surveys 2 and 3. Over the whole 7-year period, approximately half stopped smoking, one-quarter changed to daily smoking and the remainder reported non-daily smoking. Multivariate analysis identified that a history of daily smoking for > or = 6 months at baseline predicted reversion to daily smoking at follow-up. Being single and using illicit drugs were also associated with change to daily or non-daily smoking, whereas alcohol consumption was associated with non-daily smoking only. Compared with stopping smoking, the change to daily smoking was significantly associated with having intermediate educational qualifications. No significant associations with depression and perceived stress were observed in the multivariate analysis.

CONCLUSIONS

Interventions to reduce the prevalence of smoking among young women need to take account of occasional smokers, who made up 39% of all smokers in this study. Targeted interventions to prevent the escalation to daily smoking and to promote cessation should allow for the social context of smoking with alcohol and other drugs, and social and environmental influences in vocational education and occupational settings.

Association of smoking cessation with financial stress and material well-being: results from a prospective study of a population-based national survey

OBJECTIVES

We used 4 waves of prospective data to examine the association of smoking cessation with financial stress and material well-being.

METHODS

Data (n = 5699 at baseline) came from 4 consecutive waves (2001-2005) of the Household Income and Labour Dynamics in Australia survey. We used mixed models to examine the participant-specific association of smoking cessation with financial stress and material well-being.

RESULTS

On average, a smoker who quits is expected to have a 25% reduction (P<.001; odds ratio [OR]=0.75; 95% confidence interval [CI]=0.69, 0.81) in the odds of financial stress. Similarly, the data provided strong evidence (P<.001) that a smoker who quits is likely to experience an enhanced level of material well-being.

CONCLUSIONS

Our findings indicate that interventions to encourage smoking cessation are likely to improve standards of living and reduce deprivation. The findings provide grounds for encouraging the social services sector to incorporate smoking cessation efforts into their programs to enhance the material or financial conditions of disadvantaged groups. The findings also provide additional incentives for smokers to stop smoking and as such can be used in antismoking campaigns and by smoking cessation services.

Sedative, hypnotic, anxiolytic and opioid medicament use and its co-occurrence with tobacco smoking and alcohol risk drinking in a community sample

Background

Sedative, hypnotic, anxiolytic and opioid medicament (SO) use and its relation to tobacco smoking and alcohol risk drinking is largely unknown. Prevalence data for SO intake and its co-occurrence with tobacco smoking and alcohol risk drinking considering age are presented.

Methods

Random general population sample of individuals aged 20–79 drawn from a mixed rural and urban area in Germany (Study of Health in Pomerania, SHIP). All medicament intake during the past 7 days prior to the interview was assessed according to the Anatomical Therapeutic Chemical classification as part of an interview conducted in a health examination center.

Results

Among men, 3.0%, and among women 5.0% took SO. The proportion of SO users was higher (odds ratio 1.9; 95% confidence interval 1.1–3.4) whereas the proportions of current cigarette smokers and alcohol risk drinkers without SO use were lower among individuals aged 60–79 compared to those aged 20–39. The proportion of individuals with smoking, alcohol risk drinking or SO use was also lower among those aged 60–79 compared to the 20–39 year olds.

Conclusion

Although proportions of SO users in older adult age are higher than in younger adult age there are less subjects with any of the 3 substance use behaviors at older adult age compared to age 20–39.

GC-MS determined cotinine in an epidemiological study on smoking status at delivery

The objective of this study was to measure the plasma cotinine levels in pregnant women and their newborns using a gas chromatography-mass spectrometry (GC-MS) method in an epidemiological-delivered population with a wide range of tobacco intakes. Nearly 1000 pregnant women from regional maternity wards (n=1007) were selected for the study. Each patient kept a tobacco diary and underwent a blood test to assess cotinine levels and at the same time that the newborns' cordonal plasma was taken. These values were then cross-checked. Cotinine was estimated using a selected-ion monitoring mode with a 1.5 ng/ml quantification limit. The cotinine levels in mothers and newborns were highly correlated, whatever the mother's smoking status, with a calculated cut-off for cotinine levels in active smokers of 21.5 ng/ml. Finally, the cotinine determined through this GC-MS method offered a sensitive and accurate measure of tobacco exposition of the pregnant women and their babies.

Did the Tobacco Control Act Amendment in 1995 affect daily smoking in Finland? Effects of a restrictive workplace smoking policy

BACKGROUND

This study examined changes in adult daily smoking in 1981-2005 in Finland, in order to evaluate the impact of the 1995 Tobacco Control Act Amendment (TCAA) and accompanying measures on the proportion of daily smokers. The main focus of the TCAA was to prohibit smoking at workplaces (designated rooms excluded) in order to protect workers from environmental tobacco smoke.

METHODS

The study was based on data from annual postal surveys among 15- to 64-year-olds in 1981-2005 (average response rate 73%). The data set for this study comprised men and women aged 25-64 years (n = 73 471). Logistic models were used to test the effect of the 1995 TCAA across employment status while controlling for the effect of changes in the real price of tobacco and in gross domestic product per capita, and adjusting for age, education, secular trend and prevalence of ever-smokers in each birth cohort.

RESULTS

Controlling for confounding factors, the odds ratio (OR) for daily smoking after 1995 among employed men was 0.83 (95% CI 0.73-0.94) compared with the OR (1.0) for the period ending 1994. The corresponding figure for employed women was 0.78 (95% CI 0.68-0.91). The results can be interpreted as a positive effect of the 1995 TCAA on employees' daily smoking. Moreover, a similar decrease in daily smoking was not seen among those not targeted by the TCAA (including farmers, students, housewives, pensioners and the unemployed).

CONCLUSION

Smoking behaviour was and can be influenced by national tobacco policy measures.

Associations of carotid intima-media thickness, tobacco smoking and overweight with hearing disorder in a general population sample

It has been argued that smoking or overweight might contribute to hearing disorder by atherogenic narrowing of the nutrient arteries to the cochlea. The carotid intima-media thickness (CIMT) is a surrogate marker for generalized atherosclerosis. We analyzed a subgroup (n=2619) from a general population sample in north-eastern Germany aged 45-81 years (Study of Health in Pomerania, SHIP). Assessments included self-statements about hearing disorder and medical examinations of CIMT. Using ordinal logistic regression for data analysis and after adjustment for cigarettes per day, waist circumference, diabetes, exposure to noise, age and sex, we found CIMT remained a predictor of hearing disorder (odds ratio 1.8, 95% confidence interval 1.0-3.2). Cigarettes per day and waist circumference were related to CIMT but not to hearing disorder. The findings suggest a positive association between CIMT and hearing disorder.

Job stress and other working conditions: Relationships with smoking behaviors in a representative sample of working Australians

OBJECTIVES

To assess the relationships between current smoking status and psychosocial working conditions.

METHODS

A cross-sectional population-based telephone survey was conducted (66% response rate, N = 1,101). Job stress was measured using the demand/control, effort/reward imbalance (ERI), and job pressure models. Multiple regression modelling was conducted for smoking status (current versus non-smokers, and a more restricted analysis of current versus former-smokers) and daily smoking intensity outcomes in relation to job stress measures, working hours, shift work, and other independent variables.

RESULTS

After adjustment for age, education, martial status, and hostility, high job strain was positively associated with current smoking in men only. Employment in active jobs was associated with decreased odds of smoking among women only. High strain jobs were associated with decreased odds of current smoking compared to former smoking in women. In men, extreme and moderate job pressure were related to current smoking compared to current non-smoking, and moderate job pressure was associated with current smoking compared with former smokers. Other working conditions associated with smoking were excessive working hours in men and physical demand in women. Daily smoking intensity in current smokers was associated with high psychological demand and with ERI in women.

CONCLUSIONS

These results suggest that job stress is related to smoking status at the population level, with different patterns in men and women.

Recurrent dieting and smoking among Finnish men and women

OBJECTIVE

To examine the association of smoking with recurrent dieting and BMI among Finnish adults.

RESEARCH METHODS AND PROCEDURES

We used questionnaire data from 1990 on 11,055 subjects from the Finnish Twin Cohort who were 33 to 61 years of age. Multinomial logistic regression analysis was carried out using lifetime dieting as the outcome variable and smoking as the main explanatory variable, adjusted for BMI and age. Twin pairs discordant for dieting and smoking were studied to examine the effect of environmental and genetic factors.

RESULTS

Among women, current smokers [odds ratio (OR), 1.09 to 1.41 at different ages] and former smokers (OR, 1.52 to 2.82) were more likely to have dieted recurrently than never smokers. Among men, current smokers were less likely (OR, 0.69; 95% confidence interval, 0.55, 0.87) and former smokers were more likely (OR, 1.30; 95% confidence interval, 1.05, 1.61) to have dieted recurrently at different ages. The differences between the discordant pairs were consistent with this, although not statistically significant.

DISCUSSION

Recurrent dieting was associated with former smoking in both sexes and with current smoking in women.

Parental smoking behaviour and effects of tobacco smoke on children's health in Finland and Russia

BACKGROUND

There is little information on potential differences in smoking behaviour of parents between Finland and Russia and on the effects of environmental tobacco smoke (ETS) exposure on allergic and respiratory diseases among Finnish and Russian children. The aim of the study was to compare the smoking behaviour of parents and school children and to assess the relations of tobacco smoke exposure during pregnancy and childhood with occurrence of allergic diseases and respiratory infections among school children.

METHODS

We conducted a population-based cross-sectional study in the neighbour towns across the border of Imatra in Finland and Svetogorsk in Russia. The study population consisted of 512 Finnish and 581 Russian school children aged 7-16 years (response rate 79%).

RESULTS

Children's tobacco smoke exposure differed markedly between Finland and Russia. The risk of asthma was particularly related to high maternal smoking exposure during pregnancy (adjusted OR 3.51, 95% CI 1.00-12.3), infancy (3.34, 1.23-9.07) and currently (3.27, 1.26-8.48), and the risk of common cold was related to high combined parental smoking during infancy (1.83, 1.06-3.17) in Finnish children. Among Russian children allergic conjunctivitis was related to maternal smoking during infancy (4.53, 1.49-13.8) and currently (2.82, 1.07-7.44).

CONCLUSIONS

Smoking behaviour of parents and ETS exposure during childhood differed markedly between Finland and Russia. Asthma was particularly increased in relation to high exposure to maternal smoking in Finland. The results suggest that more efforts should be directed to reducing tobacco smoke exposure of children in both Finland and Russia. (250 words).

Can we trust national smoking prevalence figures? Discrepancies between biochemically assessed and self-reported smoking rates in three countries

BACKGROUND

National smoking prevalence estimates are the primary basis for assessing progress in tobacco control across the world. They are based on surveys of self-reported cigarette smoking. It has been assumed that this is sufficiently accurate for policy purposes, but this assumption has not been adequately tested.

METHODS

We report data from the 2003 Health Survey for England, the U.S. National Health and Nutrition Examination Survey for 2001-2002, and the 2004 national smoking behaviors survey in Poland as examples of countries at different stages in the "tobacco epidemic." Self-reported cigarette and total tobacco smoking prevalence were assessed by means of the standard questions used in each country. In subsamples, specimens were collected for analysis of cotinine (saliva, N = 1,613 in England; serum, N = 4,687 in the United States; and saliva, N = 388 in Poland) providing an objective means of determining active smoking. A cut point of 15 ng/mL was used to discriminate active smoking from passive smoke exposure.

RESULTS

Self-reported cigarette smoking prevalence using the standard methods underestimated true tobacco smoking prevalence by an estimated 2.8% in England, 0.6% in the United States, and 4.4% in Poland. Cotinine concentrations in those misclassified as nonsmokers were indicative of high levels of smoke intake.

INTERPRETATION

Underestimation of smoking prevalence was minimal in the United States but significant in England and Poland. A review of methodologies for assessing tobacco smoking prevalence worldwide is urgently needed.

Smoking interacts with family history with regard to change in knee cartilage volume and cartilage defect development

OBJECTIVE

To describe the effects of smoking on change in knee cartilage volume and increases in knee cartilage defects, and to test for interaction between smoking and family history of osteoarthritis (OA).

METHODS

Subjects with at least 1 parent having severe primary knee OA (offspring) and randomly selected controls without this history (a total of 325 subjects with a mean age of 45 years) were measured at baseline and 2.3 years later. Knee cartilage volume and defect score (on a 0-4 scale) were determined using T1-weighted fat-saturated magnetic resonance imaging. Smoking status and duration and number of cigarettes were recorded by questionnaire.

RESULTS

In offspring, smoking was associated with annual change in medial and lateral tibial cartilage volume (beta = -2.20% and beta = -1.45%, respectively, for current smokers versus former smokers and those who had never smoked; beta = -0.07%/pack-year at both tibial sites, for smoking severity) in multivariate analysis. Smoking was also associated with increases (change >or=1) in medial and lateral tibiofemoral cartilage defect scores (odds ratio [OR] 4.91 and OR 2.98, respectively, for current smokers versus those who had never smoked; OR 9.90 and OR 12.98, respectively, for heavy smoking [total of >20 pack-years] versus never smoking) (all P < 0.05). In contrast, smoking was not associated with any of the above in controls except for change in lateral tibial cartilage volume. There was significant interaction between smoking and offspring-control status for change in medial tibial cartilage volume (P = 0.047) and increases in medial (P = 0.03) and lateral (P = 0.049) tibiofemoral cartilage defects.

CONCLUSION

Smoking leads to knee cartilage loss and defect development primarily in individuals with a family history of knee OA. This provides evidence for a gene-environment interaction in the etiology of knee OA.

Putative biases in estimating mortality attributable to obesity in the US population

BACKGROUND

A recent analysis concluded that there were fewer excess deaths attributable to obesity in the US population than previously believed. This analysis may not have fully corrected for two putative biases, the regression-dilution and the reverse-causation biases. It is not presently known whether correcting for these biases would increase estimates of excess deaths attributable to obesity.

METHODS

All-cause mortality hazard ratios (HRs) for different body mass index (BMI) categories were calculated and adjusted for confounding factors, using data from the prospective Atherosclerosis Risk in Communities Study. The analysis was based on 12 457 individuals aged 51-70 years and 606 all-cause deaths during a 5.3-year follow-up. The HRs were corrected for the regression-dilution and reverse-causation biases, and compared with data from a previously published study to evaluate the effects of correcting for these putative biases on estimates of excess deaths attributable to obesity in the US population.

RESULTS

The uncorrected all-cause mortality HR for obesity (BMI>/=30) was 1.26 (95% confidence interval (95% CI)=1.01-1.58), using the 21-25 kg/m(2) as ideal-weight category. Correcting for regression dilution increased the HR to 1.46 (95% CI=1.17-1.83). Correcting for both putative biases increased it further to 2.70 (95% CI=1.31-5.57). Such increases in HRs are consonant with increases of several hundred percent in estimates of deaths attributable to obesity in the US.

CONCLUSIONS

Correcting for putative biases yielded increases in all-cause mortality HRs for obesity that correspond to substantial increases in estimates of excess deaths attributable to obesity in the US population.

Tobacco Smoking by Occupation in Australia: Results from the 2004 to 2005 National Health Survey

OBJECTIVE

This study presents the most recent estimates of Australia's national tobacco smoking rates by occupation.

METHODS

Smoking data was extracted from the 2004 to 2005 National Health Survey, which captured approximately 26,000 persons and achieved a response rate of around 90%. Participants were limited to those of working age (18 to 64 years), with data stratified by job category and gender during the analysis.

RESULTS

The prevalence of smoking among Australian workers is estimated to be 25% (28% among males and 21% among females). Tobacco usage is considerably less common among those who are employed compared with the unemployed. By job category, smoking was most common among laborers and the least common among professionals, managers, or administrators.

CONCLUSIONS

Overall, this study suggests that Australian rates of tobacco smoking vary widely depending on occupation. Effective tobacco-control strategies targeting vulnerable sections of the workforce, particularly blue-collar workers, are clearly needed.

Sociodemographic characteristics and diabetes predict invalid self-reported non-smoking in a population-based study of U.S. adults

Background

Nearly all studies reporting smoking status collect self-reported data. The objective of this study was to assess sociodemographic characteristics and selected, common smoking-related diseases as predictors of invalid reporting of non-smoking. Valid self-reported smoking may be related to the degree to which smoking is a behavior that is not tolerated by the smoker's social group.

Methods

True smoking was defined as having serum cotinine of 15+ng/ml. 1483 "true" smokers 45+ years of age with self-reported smoking and serum cotinine data from the Mobile Examination Center were identified in the third National Health and Nutrition Examination Survey. Invalid non-smoking was defined as "true" smokers self-reporting non-smoking. To assess predictors of invalid self-reported non-smoking, odds ratios (OR) and 95% confidence intervals (CI) were calculated for age, race/ethnicity-gender categories, education, income, diabetes, hypertension, and myocardial infarction. Multiple logistic regression modeling took into account the complex survey design and sample weights.

Results

Among smokers with diabetes, invalid non-smoking status was 15%, ranging from 0% for Mexican-American (MA) males to 22%–25% for Non-Hispanic White (NHW) males and Non-Hispanic Black (NHB) females. Among smokers without diabetes, invalid non-smoking status was 5%, ranging from 3% for MA females to 10% for NHB females. After simultaneously taking into account diabetes, education, race/ethnicity and gender, smokers with diabetes (OR_Adj = 3.15; 95% CI: 1.35–7.34), who did not graduate from high school (OR_Adj = 2.05; 95% CI: 1.30–3.22) and who were NHB females (OR_Adj = 5.12; 95% CI: 1.41–18.58) were more likely to self-report as non-smokers than smokers without diabetes, who were high school graduates, and MA females, respectively. Having a history of myocardial infarction or hypertension did not predict invalid reporting of non-smoking.

Conclusion

Validity of self-reported non-smoking may be related to the relatively slowly progressing chronic nature of diabetes, in contrast with the acute event of myocardial infarction which could be considered a more serious, major life changing event. These data also raise questions regarding the possible role of societal desirability in the validity of self-reported non-smoking, especially among smokers with diabetes, who did not graduate from high school, and who were NHB females.

Dose dependency between cigarette consumption and reduced maternal serum PAPP-A levels at 11–13+6 weeks of gestation

OBJECTIVE

To examine whether in smokers there is a significant dose dependency between the number of cigarettes per day and levels of free ss-hCG and pregnancy-associated plasma protein A (PAPP-A) at 11-13(+6) weeks of gestation.

METHODS

This was a retrospective analysis of the maternal serum free ss-hCG and PAPP-A levels in relation to the maternal smoking status in 109 263 chromosomally normal singleton pregnancies that had undergone first-trimester screening for Down syndrome by a combination of fetal nuchal translucency thickness and maternal serum biochemistry.

RESULTS

There were 95 287 nonsmokers and 13 976 cigarette smokers. The overall median PAPP-A MoM among cigarette smokers was 0.827, which was 19.6% lower than the value of 1.029 in nonsmokers (p < 0.0001 for log(10) MoM). The respective values for beta-hCG MoM were 1.003 for smokers and 1.035 for nonsmokers (p < 0.0001 for log(10) MoM) which corresponds to a reduction of 3.1%. There was a significant inverse relationship between the number of cigarettes per day and the level of PAPP-A MoM (r = 0.989, p < 0.0001) but not the level of free beta-hCG MoM (r = 0.733; p = 0.098). Using a statistical modeling approach we found that the screen-positive rate when correcting the PAPP-A MoM by an all or nil smoking factor was reduced by only 0.1% (3.75 vs 3.85%) when compared to correcting with a factor related to the smoking dose per day.

CONCLUSION

In first-trimester screening for Down syndrome by maternal serum PAPP-A and free beta-hCG the impact of correcting for the dose dependant rather than the all or nil effect of smoking is marginal. However, a dose dependent correction improves the accuracy of the individual patient-specific risk.

Association of smoking status with obesity and diabetes among elderly people

The present study was aimed to examine associations of current and ex-smoking status with obesity and diabetes among elderly people. Nationwide study of Finnish elderly people based on biennial surveys from 1985 to 1995, were used to study 7482 people aged 65-79 years. Smoking status included non-, ex-light, ex-heavy, current light, and current heavy smokers. Obesity was set as body mass index (BMI) > or = 30. Information of smoking, BMI, and diabetes was based on self-reports. Logistic regression was used as the main method of analyses. Compared to non-smokers (reference category), ex-heavy smokers had higher (odds ratio, 1.42; 95% confidence interval: 1.09, 1.85) and current light smokers (OR, 0.46; 95% CI: 0.31, 0.69) lower relative risk of obesity. Current light smokers had also lower and ex-heavy smokers higher rate of diabetes than non-smokers. Ex-heavy smokers had a higher risk of obesity (OR, 1.75; 95% CI: 1.30, 2.36) and diabetes (OR, 1.48; 95% CI: 1.10, 2.01) than ex-light smokers. Same pattern for current smokers was found. Heavy ex- and current elderly smokers are at risk of obesity and diabetes. Thus, heavy smokers should be emphasized in programs promoting smoking cessation.

Socioeconomic gradients in smoking among young women: A British survey

Marked and increasing socioeconomic gradients in cigarette smoking are well established. Tracking these differentials among women requires appropriate measures of their socioeconomic position (SEP) which are equivalent across older and younger age groups. This study examines socioeconomic gradients in cigarette smoking by age among women aged 20-34, using a standard indicator of SEP (age left full-time education) and alternative indicators which take account of changes in women's educational levels across age cohorts. The study is based on a large cross-sectional British data set (n = 12,398), the Southampton Women's Survey, conducted 1998-2002. Poisson log-linear regression with adjusted variance was used to predict smoking status (ever smoked > or =1 cigarette a day for 1 year, currently smoking > or =1 cigarette a day, and ex-smoker - ever-smoker not currently smoking > or =1 cigarette a day) in models which controlled for SEP, age and year of interview. Socioeconomic gradients in ever-smoking were marked but stable across age groups. With quitting more prevalent in the higher than lower socioeconomic groups, gradients in current smoking steepened across age groups, with significant age/SEP interactions. The socioeconomic patterning of ever, ex and current smoking was similar using both the standard and alternative measures of education, but interactions were less pronounced with the alternative measures. Socioeconomic indicators which take account of the recent and rapid increase in women's educational participation rates may provide a more reliable indication of age-related differentials in smoking status than standard measures. Nonetheless, both conventional and alternative measures point to stable socioeconomic differentials in rates of ever-smoking and widening differentials in current smoking across age groups. Our study confirms that addressing the link between socioeconomic disadvantage and tobacco use remains a major challenge for the tobacco control community.

The activity of the immunoregulatory enzyme indoleamine 2,3-dioxygenase is decreased in smokers

Indoleamine 2,3-dioxygenase (IDO), an enzyme involved in the degradation of the essential amino acid tryptophan (trp) to its main metabolite kynurenine (kyn), suppresses T cell activity. Smoking has marked immunomodulatory effects, above all immunosuppressive, causing a reduction in the levels of immunoglobulins and an increased risk of infections. The immunostimulatory effects of smoking are manifested, for example, in increased autoantibody production. We sought to establish whether IDO activity is involved in the immunomodulatory effects of smoking. To this end we measured the ratio of kyn to trp, reflecting IDO activity, by reverse-phase high-performance liquid chromatography (HPLC) in 784 (464 female, 230 male) subjects of a population-based sample of the adult Finnish population. Serum cotinine concentration as an indicator of active smoking was measured in the patients by radioimmunoassay and detailed data gathered on smoking habits. IDO activity was lower in smokers in this population-based sample compared with non-smokers when active smoking was classified according to serum cotinine concentration or history of smoking habits. Moreover, serum IDO activity correlated inversely with serum cotinine concentration. In conclusion, the activity of the IDO enzyme is decreased in smoking subjects, and the reduction in IDO-dependent immunosuppression could thus be responsible for the known immunostimulatory effects of smoking.

Serum cotinine level as predictor of lung cancer risk

BACKGROUND

No prospective studies are available on serum cotinine level as a marker of lung cancer risk.

METHODS

We analyzed serum cotinine level among 1,741 individuals enrolled since the 1970s in a prospective study of Norwegian volunteers who developed lung cancer during the follow-up and 1,741 matched controls free from lung cancer. Serum cotinine was measured with a competitive immunoassay. Regression dilution was corrected for based on repeated measures on samples from 747 subjects.

RESULTS

Mean serum cotinine level was higher in cases than in controls. Compared with subjects with a cotinine level of < or = 5 ng/mL, the odds ratio of lung cancer was increasing linearly, reaching 55.1 (95% confidence interval, 35.7-85.0) among individuals with a serum cotinine level of > 378 ng/mL. There was no clear suggestion of a plateau in risk at high exposure levels. Odds ratios were very similar in men and women. We found no association between serum cotinine level (range, 0.1-9.9 ng/mL) and lung cancer risk among self-reported nonsmokers and long-term quitters (79 cases and 350 controls).

DISCUSSION

The association between tobacco smoking and lung cancer risk might be stronger than is estimated from questionnaire-based studies. Serum cotinine level is a predictor of risk of lung cancer among smokers. The reported plateau in risk at high doses is likely due mainly to artifacts. There is no difference between men and women in the carcinogenicity of tobacco smoking.

Tobacco smoking in relation to analgesic drug use in a national adult population sample

BACKGROUND

Nicotine is known to produce pain-inhibitory effects. Here, we examine whether there is a relation between tobacco smoking and analgesic drug use (ADU).

METHODS

A probability sample of the German national population aged 18-79 with 7124 participants (participation rate: 61.4%) was used. All individuals underwent a health examination and ADU was assessed as part of an interview conducted by a study physician.

RESULTS

Current and former smokers had higher odds for ADU than never smokers. Current heavy smokers (>20 cigarettes per day) had an odds ratio (OR) of 1.8 (95% confidence interval, CI, 1.4-2.3) for ADU three times per month or less and an OR of 3.1 (CI 2.0-4.8) for ADU once a week to daily, with never smokers as the reference group. Former heavy smokers had an OR of 2.0 (CI 1.3-3.2) for ADU once a week to daily compared to never smokers.

CONCLUSION

The findings suggest that current and former smokers, particularly current and former heavy smokers, are more likely to use analgesic drugs than never smokers.

Expired carbon monoxide levels in self‐reported smokers and nonsmokers in prison

Breath carbon monoxide (CO) is a convenient, widely used method for abstinence validation, with cutoffs of 8-10 ppm commonly employed. The goal of the present study was to determine an appropriate CO cutoff to differentiate nonsmokers and smokers within a large sample (N = 374) of female prisoners incarcerated at a correctional facility in Virginia. Mean age of the population was 34.5 years, 49.2% were White, and 29% had less than a high school education. Smoking prevalence was 74.1% within the prison population. Examination of CO levels versus smoking self-report using a receiver operator characteristic (ROC) analysis revealed that a CO cutoff of 3 ppm resulted in the best sensitivity (98.1%) and specificity (95.8%). Overall ROC area under the curve was 99% (95% CI = 98.2%-99.9%). This same cutoff was optimal for smoking subgroups including Black and light (<10 cigarettes/day) smokers. Results suggest that CO cutoffs higher than 3 ppm may misclassify some smokers as nonsmokers and underestimate the prevalence of smoking.

Validity of Self-reported Smoking Status among Participants in a Lung Cancer Screening Trial

Lung cancer remains a devastating disease associated with substantial morbidity and mortality. Recent research has suggested that lung cancer screening with spiral computed tomography scans might reduce lung cancer mortality. Studies of lung cancer screening have also suggested that significant numbers of participants quit smoking after screening. However, most have relied solely on self-reported smoking behavior, which may be less accurate among participants in lung cancer screening. To assess the validity of self-reported smoking status among participants in a lung cancer screening trial, this study compared self-reported smoking status against urinary cotinine levels. The sample included 55 consecutive participants enrolled in a randomized clinical trial comparing annual spiral computed tomography and chest X-ray for lung cancer screening. Participants were a mean of 59 years of age and predominantly Caucasian (96%) and male (55%). Self-reported smoking status was assessed before and after participants learned of the purpose of the biochemical verification study. Using urinary cotinine as the "gold standard," the sensitivity and specificity of self-reported smoking status were 91% and 95%, respectively (kappa = 0.85, P < 0.001, 95% confidence interval = 0.71-0.99). Total misclassification rate was 7%. However, three of the four misclassified participants reported concurrent use of nicotine replacement strategies. Eliminating these cases from the analysis revealed sensitivity of 100% and specificity of 95% (kappa = 0.96, P < 0.001, 95% confidence interval = 0.88-1.00). In conclusion, self-reported smoking status among participants in a lung cancer screening trial was highly consistent with urinary cotinine test results.

The association of smoking with perception of income inequality, relative material well-being, and social capital

The aim of this study is to examine the association of smoking status with income inequality, relative deprivation, perception of relative material well-being and community-level social capital, controlling for individual-level indicators of social capital, and common socio-economic variables. Data were from telephone interviews of approximately 126 residents selected at random (using the Electronic White Pages) from each of 22 local government areas (LGAs) in the Melbourne metropolitan region, Victoria, Australia (total n = 2762). We used logistic regression to assess the association of covariates with smoking status. Being a smoker was associated with a higher level of perceived income inequality, lower perception of relative material well-being and living in a community with a lower degree of trust and safety. While the cross-sectional design of the study does not allow causal inferences, the results imply that smoking is less prevalent in communities that are more egalitarian and have a higher stock of social capital.

Pathways of disadvantage and smoking careers: evidence and policy implications

OBJECTIVES

To investigate in older industrialised societies (a) how social disadvantage contributes to smoking risk among women (b) the role of social and economic policies in reducing disadvantage and moderating wider inequalities in life chances and living standards.

METHODS

Review and analysis of (a) the effects of disadvantage in childhood and into adulthood on women's smoking status in early adulthood (b) policy impacts on the social exposures associated with high smoking risk.

MAIN RESULTS

(a) Smoking status--ever smoking, current smoking, heavy smoking, and cessation--is influenced not only by current circumstances but by longer term biographies of disadvantage (b) social and economic policies shape key social predictors of women's smoking status, including childhood circumstances, educational levels and adult circumstances, and moderate inequalities in the distribution of these dimensions of life chances and living standards. Together, the two sets of findings argue for a policy toolkit that acts on the distal determinants of smoking, with interventions targeting the conditions in which future and current smokers live.

CONCLUSIONS

An approach to tobacco control is advocated that combines changing smoking habits with reducing inequalities in the social trajectories in which they are embedded. Policies to level up opportunities and living standards across the lifecourse should be championed as part of an equity oriented approach to reducing the disease burden of cigarette smoking.

Urinary point-of-care test for smoking in the pre-operative assessment of patients undergoing elective plastic surgery

Self-reported information about smoking habit and cigarette consumption can be inaccurate and subject to bias in the clinical setting. Accurate assessment of a given smoking history at point-of-care is valuable. We describe the use of a comprehensive smoking questionnaire and the use of a disposable biomarker test to verify and quantify the exposure to tobacco smoke. This point-of-care test (SmokeScreen) is a 6-min, easy-to-use urine test that measures nicotine and its breakdown products. One hundred consecutive patients attending plastic surgery pre-assessment clinic filled in the questionnaire and gave a consented urine sample. Qualitative and semi-quantitative assessment of tobacco consumption was observed by a simple sample colour change set against a standardised colorimetric chart for nicotine metabolite containing urine. The questionnaire self-reported smoking prevalence was 30% with 98% test specificity. The cotinine validated smoking prevalence was 54% with a 26% self-denial rate. Half the patients (n = 15) who admitted smoking on the questionnaire underreported the amount they smoked daily, as quantified by biochemical measurement. Objective biochemical assessment shows that 26% of self-reporting non-smokers via self-completed questionnaire studies are actual smokers attending this pre-assessment clinic. When patients did report smoking there was consistent underreporting of cigarette consumption.

Smoking cessation in patients with diabetes mellitus: results from a controlled study of an intervention programme in primary healthcare in Sweden

OBJECTIVE

To evaluate an intervention programme on smoking cessation in patients with diabetes mellitus in primary healthcare.

DESIGN

Regional controlled intervention study.

SETTING

Seventeen primary healthcare centres in Sweden.

INTERVENTION

In the intervention centres, nurses with education in diabetes were given one half-day of training in motivational interviewing and smoking cessation. An invitation to participate in a smoking cessation group was mailed to patients from the intervention centres followed by a telephone call from the patient's diabetes nurse. The nurses who intervened were specially educated in smoking cessation. The control group received a letter containing advice to stop smoking and information about a one-year follow-up.

PATIENTS

Daily smokers with diabetes mellitus, 30-75 years of age. In the intervention centres 241 patients fulfilled the criteria and in the control centres 171 patients.

MAIN OUTCOME MEASURES

Self-reported smoking habits after one year.

RESULTS

In total, 21% of the smokers accepted group treatment. After 12 months, 20% (42/211) in the intervention centres reported that they had stopped smoking and 7% (10/140) in the control centres; 40% (19/47) of the smokers who had participated in group treatment reported that they had stopped smoking.

CONCLUSION

A computerized record system for patients in primary healthcare was used to identify diabetic patients who were smokers. The selected group was invited to a stop smoking programme. At a one-year follow-up significantly more patients in the intervention centres had stopped smoking compared with patients in the control centres.

Associations of perceived work strain with nicotine dependence in a community sample

BACKGROUND

Little is known about work strain and smoking, and even less about work strain and nicotine dependence.

AIM

To investigate the relations of perceived work strain with nicotine dependence among an adult general population sample.

METHOD

Cross sectional survey with a probability sample of residents of a northern German area with 4075 participants, aged 18-64 years (participation rate 70.2%). The current study is based on 2549 participants who were working 15 or more hours per week. Face to face at-home computer aided interviews (World Health Organization Composite International Diagnostic Interview) were carried out. Work strain, defined as high work demand and low work control, was assessed with a questionnaire. Nicotine dependence was diagnosed according to the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association. In addition, the Fagerström Test for Nicotine Dependence (FTND) was used.

RESULTS

Subjects with work strain had an odds ratio of 1.6 (95% CI 1.2 to 2.3) for nicotine dependence compared to those who had no work strain. In a general linear model, higher work strain was associated with a stronger relation between work demand and work control and the FTND. The findings were adjusted for alcohol use disorders, occupational status, age, and sex.

CONCLUSION

Perceived work strain is related to nicotine dependence in this general adult population.

Socioeconomic lifecourse influences on women's smoking status in early adulthood

STUDY OBJECTIVE

To incorporate women's domestic trajectories and circumstances into analyses of the socioeconomic influences on women's smoking status (current and former smoking) in early adulthood.

DESIGN

Cross sectional survey.

SETTING

Southampton, UK.

PARTICIPANTS

8437 women aged 25-34 recruited from 1998-2002 via patient lists of general practices.

MAIN RESULTS

Domestic lifecourse factors contributed to the odds of being a current smoker and former smoker in models that included conventional measures of the socioeconomic lifecourse. Early motherhood, non-cohabitation, and lone motherhood increased the odds of smoking; early motherhood and non-cohabitation reduced the odds of former smoking. For example, relative to childless women, odds ratios (OR) for women who had become mothers <20 years were 1.71 for smoking and 0.76 for former smoking. The effects of education and current SEP remained strong with the inclusion of childbearing and cohabitation variables for both outcomes. For instance, compared with women in education to age > or =22, the odds ratio for smoking for those leaving school < or =16 was 3.37 and for former smoking was 0.42.

CONCLUSIONS

Both the conventionally measured socioeconomic lifecourse and the domestic lifecourse contributed separately to the odds of smoking and former smoking, suggesting that lifecourse analyses should incorporate women's domestic circumstances as an important pathway of influence on their smoking status in early adulthood.