Are patients truthful about their smoking habits? A validation of self-report about smoking cessation with biochemical markers of smoking activity amongst patients with ischaemic heart disease

Smoking data quality of primary care practices in comparison with smoking data from the New Zealand Māori and Pacific abdominal aortic aneurysm screening programme: an observational study

BACKGROUND

Quality smoking data is crucial for assessing smoking-related health risk and eligibility for interventions related to that risk. Smoking information collected in primary care practices (PCPs) is a major data source; however, little is known about the PCP smoking data quality. This project compared PCP smoking data to that collected in the Māori and Pacific Abdominal Aortic Aneurysm (AAA) screening programme.

METHODS

A two stage review was conducted. In Stage 1, data quality was assessed by comparing the PCP smoking data recorded close to AAA screening episodes with the data collected from participants at the AAA screening session. Inter-rater reliability was analysed using Cohen's kappa scores. In Stage 2, an audit of longitudinal smoking status was conducted, of a subset of participants potentially misclassified in Stage 1. Data were compared in three groups: current smoker (smoke at least monthly), ex-smoker (stopped > 1 month ago) and never smoker (smoked < 100 cigarettes in lifetime).

RESULTS

Of the 1841 people who underwent AAA screening, 1716 (93%) had PCP smoking information. Stage 1 PCP smoking data showed 82% concordance with the AAA data (adjusted kappa 0.76). Fewer current or ex-smokers were recorded in PCP data. In the Stage 2 analysis of discordant and missing data (N = 313), 212 were enrolled in the 29 participating PCPs, and of these 13% were deceased and 41% had changed PCP. Of the 93 participants still enrolled in the participating PCPs, smoking status had been updated for 43%. Data on quantity, duration, or quit date of smoking were largely missing in PCP records. The AAA data of ex-smokers who were classified as never smokers in the Stage 2 PCP data (N = 27) showed a median smoking cessation duration of 32 years (range 0-50 years), with 85% (N = 23) having quit more than 15 years ago.

CONCLUSIONS

PCP smoking data quality compared with the AAA data is consistent with international findings. PCP data captured fewer current and ex-smokers, suggesting ongoing improvement is important. Intervention programmes based on smoking status should consider complementary mechanisms to ensure eligible individuals are not missed from programme invitation.

Clinical challenges facing patient participation in cardiac rehabilitation: cigarette smoking

INTRODUCTION

Cardiac rehabilitation (CR) is highly effective at reducing morbidity and mortality. However, CR is underutilized, and adherence remains challenging. In no group is CR attendance more challenging than among patients who smoke. Despite being more likely to be referred to CR, they are less likely to enroll, and much more likely to drop out. CR programs generally do not optimally engage and treat those who smoke, but this population is critical to engage given the high-risk nature of continued smoking in those with cardiovascular disease.

AREAS COVERED

This review covers four areas relating to CR in those who smoke. First, we review the evidence of the association between smoking and lack of participation in CR. Second, we examine how smoking has historically been identified in this population and propose objective screening measures for all patients. Third, we discuss the optimal treatment of smoking within CR. Fourth, we review select populations within those who smoke (those with lower-socioeconomic status, females) that require additional research and attention.

EXPERT OPINION

Smoking poses a challenge on multiple fronts, being a significant predictor of future morbidity and mortality, as well as being strongly associated with not completing the secondary prevention program (CR) that could benefit those who smoke the most.

Perceptions of COVID-related risks among people who smoke: A mediation model

The COVID-19 pandemic provides both reasons to quit smoking as well as stress that may promote increased cigarette consumption. Perceptions of COVID-19 risk related to smoking may motivate cessation among smokers. At the same time, other evidence shows that affective perceptions (i.e., worry) could lead to increased smoking as a coping mechanism. Using a sample drawn from a rural region of California (N = 295), we examined the relationship between perceptions about health risks for smokers during the pandemic and both reported increases in smoking frequency and intentions to quit smoking. We also examined whether worry about health risks mediated these relationships. High perceived risk was associated both with reported increases in smoking frequency as well as greater intentions to quit smoking. Worry partially mediated both these relationships, with worry accounting for 29.11% of the variance in the relationship between high risk perceptions and increased smoking as well as 20.17% of the relationship between risk perceptions and intentions to quit smoking. These findings suggest that while smokers' awareness about their increased risk of COVID-19 can motivate intent to quit smoking in the future, smokers may require greater support to act on these intentions.

Objective measure of smoking status highlights disparities by sex

Current smoking is the strongest predictor of future morbidity and mortality in those with cardiovascular disease, yet clinically, smoking status is usually ascertained through self-report. We objectively measured smoking status, using exhaled carbon monoxide (CO), for 1122 consecutive patients entering cardiac rehabilitation. Within those with elevated CO levels (≥4 ppm), females had CO levels almost twice that of males (20.4 vs. 11.6), suggesting higher amounts of smoking.

Impact of smoking on dendritic cells in patients with oral squamous cell carcinoma

Smoking has been shown to alter innate and adaptive immune responses and is directly associated with the onset of oral squamous cell carcinoma (OSCC). The purpose of this study was to evaluate the effect of cigarette smoke exposure on dendritic cells (DCs) from OSCC patients. CD1a and CD83 antibodies were used to identify immature and mature DCs, respectively, by immunohistochemistry in OSCC samples of 24 smokers and 24 non-smokers. Density of DCs was calculated in intra and peritumoral areas. Clinical and microscopic findings were reviewed and analyzed for all patients. Smokers with OSCC had a lower density of intra and peritumoral DCs when compared to non-smokers. Tumors classified as moderately/poorly differentiated had lower peritumoral CD1a+ DCs than well-differentiated tumors (p < 0.001). Smoking contributed to a depletion of immature and mature DCs in the OSCC.

Assessing the evidence on the differential impact of menthol versus non-menthol cigarette use on smoking cessation in the U.S. population: a systematic review and meta-analysis

Background

The potential impact of menthol versus non-menthol cigarette use on smoking behaviors is an intensely scrutinized topic in the public health arena. To date, several general literature reviews have been conducted, but findings and conclusions have been discordant. This systematic review followed PRISMA guidelines to examine the Key Question, “Does menthol cigarette use have a differential impact on smoking cessation compared with non-menthol cigarette use?”

Methods

Six databases—Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, MEDLINE, Embase and PsycInfo—were queried from inception to June 12, 2020. Articles comparing menthol versus non-menthol cigarette smokers in terms of at least one predefined smoking cessation outcome were included. Risk of bias was assessed using the Agency for Healthcare Research and Quality Evidence-Based Practice Center approach. A random-effects model utilizing the DerSimonian and Laird method to pool adjusted odds ratio was applied. Variations among pooled studies were assessed using Cochran’s Q statistic, and heterogeneity was quantified using the inconsistency index (I²).

Results

Forty-three demographically adjusted studies (22 rated “good”, 20 rated “fair”, and one study rated “poor” individual study quality) comparing menthol and non-menthol smokers were qualitatively synthesized across the following measures (study count; strength of evidence): duration of abstinence (2; low); quit attempts (15; insufficient); rate of abstinence/quitting (29; moderate); change in smoking quantity/frequency (5; insufficient); and, return to smoking/relapse (2; insufficient). Overall, the qualitative synthesis failed to show a consistent trend for an association between menthol cigarette use and smoking cessation across outcomes. Meta-analyses found no difference between menthol and non-menthol cigarette use and either quit attempts or abstinence.

Conclusions

Given the lack of consistency or statistical significance in the findings—combined with a “low” overall strength of evidence grade, based on deficiencies of indirectness and inconsistency—no consistent or significant associations between menthol cigarette use and smoking cessation were identified. Recommendations for future studies include increased focus on providing longitudinal, adjusted data collected from standardized outcome measures of cessation to better inform long-term smoking cessation and menthol cigarette use. Such improvements should also be further considered in more methodologically rigorous systematic reviews characterized by objectivity, comprehensiveness, and transparency with the ultimate objective of better informing public health and policy decision making.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-021-00397-4.

Impact of tobacco smoking on the patient's outcome after (chemo)radiotherapy for anal cancer

PURPOSE

Anal squamous cell carcinoma is associated with multiple risk factors, including infection with human papillomavirus and human immunodeficiency virus, immunosuppression, multiple sex partners, receptive anal sex and tobacco smoking. The aim of our study was to identify prognostic factors associated with poor outcomes after radiotherapy for anal cancer.

METHODS

We analysed retrospectively the medical records of 171 patients treated by (chemo)radiotherapy for non-metastatic anal cancer in our institution from 2000 to 2015. Patients and tumour characteristics, treatments (chemotherapy, radiotherapy [RT] and surgery) and outcomes were reported. Colostomy-free survival (CRF), disease-free survival and overall survival (OS) at 5 years were studied. Univariate and multivariate analyses were performed by logistic regression to determine factors associated with poor progression-free survival (PFS).

RESULTS

Patients' characteristics were as follows: median age, 62 years (range = 36-89); gender, 45 men (26%) and 126 women (74%); HIV serology, positive: 21 patients (12%); tobacco smoking, 86 patients (50%), among whom 28 patients and 58 patients were current and former smokers, respectively. Tumours were classified as locally limited (T1-2, N0, M0) for 86 patients (50%) and locally advanced (T3-4 or N+, M0) for 85 patients (50%). The median total dose was 64.4 Gy (range = 54-76.6), and 146 patients were treated by concurrent chemoradiotherapy. Factors associated with poor PFS in univariate analysis were as follows: tumour size >4 cm, lymph node involvement, tobacco smoking, no initial surgical excision and anal warts at diagnosis. In multivariate analysis, only tobacco smoking status was significantly associated with poor PFS (hazard ratio = 2.85, 95% confidence interval [1.25-6.50], p = 0.013). Five-year PFS for non-smokers, former smokers and current smokers was 88.1%, 76.7% and 73.8%, respectively (p = 0.038). Tobacco smoking was also associated with poor overall survival (p = 0.03), locoregional relapse-free survival (LRFS; p = 0.05) and CFS (p = 0.02).

CONCLUSIONS

Tobacco smoking status is associated with poor OS, LRFS, PFS and CFS in patients treated for anal cancer by high RT dose ± chemotherapy.

A health coach-led smoking cessation program for Chinese Americans at a community health center in New York City

Introduction

A health coach-led smoking cessation program was implemented in a community of immigrant Chinese Americans. Follow-up was provided face-to-face or over-the-phone to provide support and address barriers. Free nicotine replacement treatment was provided for eligible participants.

Aim

The aim is to assess smoking cessation outcome by program components.

Methods

Quitting was defined as self-reported smoking abstention for at least 3 months. Factors contributing to successful cessation were evaluated using chi-squared tests and regression analysis. Participants were randomly surveyed to measure the helpfulness of and satisfaction with the program.

Results/Findings

The program enrolled 184 participants from November 2015 to January 2017. Participants were mostly men (89%) with a mean age of 44. An intent-to-treat analysis found that 19% quit. Phone counseling had the same success as face-to-face counseling. Each additional session attended was associated with 2.1 times the odds of quitting, P < 0.001. Among the participants who quit, 70% reported the health coach was helpful in their cessation.

Conclusions

A health coach-led smoking cessation program that offered phone-based counseling was successful in reducing smoking. Future programs should consider using a health coach to reduce physician burden and phone-based counseling for difficult-to-access patients to increase program reach.

Impact of active smoking on the immature platelet fraction and its relationship with the extent of coronary artery disease

INTRODUCTION

Smoking represents a major cardiovascular risk factor, due to the induction of oxidative stress and low-grade, continuous, inflammation that contribute to promote atherothrombosis. However, the mechanisms leading to increased platelet aggregability associated with smoking are only partially defined. A potential role has been hypothesized for immature platelets, a younger and potentially more reactive fraction, previously associated with the main determinants of coronary artery disease (CAD). Therefore, the aim of our study was to define the impact of smoking on the immature platelet fraction (IPF) and its relationship with prevalence and extent of coronary artery disease.

METHODS

We enrolled a cohort of consecutive patients undergoing coronary angiography in a single centre. Significant CAD was defined as at least 1 vessel stenosis >50%, while severe CAD was defined as left main and/or three-vessel disease. IPF was measured at admission by routine blood cell count (Sysmex XE-2100).

RESULTS

We included in our study 2553 patients who were divided according to smoking status (active smokers: 512; nonactive smokers: 2041). Smokers were younger, more frequent males, with lower rate of diabetes mellitus, previous PCI and previous CABG (P < .001, respectively) and were in treatment less often with ARB, BB, nitrates, statins, ASA, clopidogrel, CCB and diuretics (P < .001, respectively) as compared to nonactive smokers. Higher percentage of smokers was observed in patients with higher IPF values, and at multivariate analysis, active smoking resulted as an independent predictor of higher IPF (adjusted OR [95% CI] = 1.59[1.03-2.45], P = .035). Among smokers, higher IPF was associated with lower ejection fraction (P = .034), percentage of acute coronary syndrome (P = .002) and platelet count (P < .001) compared to ones with lower IPF. However, the IPF (according to quartiles values) was not associated with the prevalence and extent of CAD (82.5%, 80.4%, 86.1% and 80.9%, from 1st to 4th quartile, respectively, adjusted OR[95% CI] = 0.98[0.79-1.23], P = .89) and severe CAD (31%, 31.1%, 39.1% and 35.2%, from 1st to 4th quartile, respectively, adjusted OR[95% CI] = 1.03[0.86-1.23], P = .76).

CONCLUSION

The present study shows an independent association between active smoking and the levels of immature platelet fraction in patients undergoing coronary angiography. However, among active smokers, IPF did not result as an independent predictor of CAD or severe CAD.

Impact of oral and oropharyngeal cancer diagnosis on smoking cessation patients and cohabiting smokers

INTRODUCTION

Our aim was to determine the influence of oral and oropharyngeal (OOP) cancer diagnosis on smoking cessation in patients and/or cohabiting smokers. We also aimed to determine whether OOP cancer patients received smoking-cessation advice and evaluated the factors that were influential in aiding them to quit or decrease smoking.

METHODS

This study was conducted at King Fahad Medical City, Saudi Arabia from March 2015 to May 2017. A pre-validated self-administered questionnaire was administered to OOP cancer patients visiting the Dentistry and Head & Neck Oncology outpatient clinics. Sociodemographics and baseline information were obtained from electronic medical records. Data were collected from 203 patients; 88 were ever-smokers and 115 were never-smokers.

RESULTS

Among patients who were smoking at the time of the OOP cancer diagnosis, 47.7% continued to smoke after the diagnosis. OOP cancer diagnosis was influential in smoking cessation in ever-smoker patients and their cohabiting smokers. The apparent influence of OOP cancer diagnosis was different between cohabiting smokers of ever-smoker patients (n=21/25; 84%) and those of never-smokers (n=10/21; 47.6%). Former-smokers (n=16/19; 84.2%) were less likely to remember receiving smoking-cessation advice than current-smokers (n=17/39; 43.6%). Pressure from family and friends, adverse impact on cancer prognosis, and adverse impact of cancer treatment were influential factors for smoking cessation. Among treatment modalities, combined chemoradiotherapy had the greatest impact (n=10/21; 47.6%) on smoking cessation among patients who stated that oncology treatment was influential in causing them to quit or decrease smoking.

CONCLUSIONS

A substantial number of patients continued to smoke after the OOP cancer diagnosis; however, diagnosis facilitated smoking cessation in many cases. Current smoking status should be reviewed throughout the OOP cancer patient’s disease course, and smoking-cessation assistance should be provided where necessary.

Outcome of intramedullary nailing treatment for intertrochanteric femoral fractures

INTRODUCTION

The OTA/AO type 31 A3 intertrochanteric fracture has a transverse or reverse oblique fracture at the lesser trochanteric level, which accentuates the varus compressive stress in the region of the fracture and the implant. Intramedullary fixation using different types of nails is commonly preferred. The purpose of this study is to evaluate intertrochanteric femoral fractures with intramedullary nail treatment in regard to surgical procedure, complications, and clinical outcomes.

METHODS

From one level 1 trauma center, 216 consecutive adult intertrochanteric femoral fractures (OTA/AO type 31 A3) were retrospectively identified with intramedullary nail fixation from 2004 through 2013. Of these, 193 patients (58.5% female) met the inclusion criteria. The average age was 70 years (range 19-96 years).

RESULTS

Cephalomedullary nails were utilized in 176 and reconstruction nails in 17 patients. After the index procedure, 86% healed uneventfully. Nonunion development was observed in 6% and 5% had an unscheduled reoperation due to implant or fixation failure. Active smoking was reported in 16.6%. Current smokers had an increased nonunion risk compared to those who do not currently smoke (15.6% vs. 4.3%; p = 0.016). The femoral neck angle averaged 128.0° ± 5°. Fixation failure occurred in 11.1% of patients with a neck-shaft-angle < 125° compared to 2.6% (4/155) of patients with a neck-shaft angle ≥125° (p = 0.021). Patients treated with a reconstruction nail required a second surgical intervention in 23.5%, which was no different compared to 25.0% in the cephalomedullary group (p = 0.893). In the cephalomedullary group, 4.5% developed a nonunion compared to 23.5% in the reconstruction group (p = 0.002). Painful hardware led to hardware removal in 8.8%. All of them were treated with a cephalomedullary device (p = 0.180). During the last office visit, two-thirds of the patients reported no or only mild pain but most patients had reduced hip range of motion.

CONCLUSION

Intramedullary nailing is a reliable surgical technique when performed with adequate reduction. Varus reduction with a neck-shaft angle < 125° resulted in an increase in fixation failures. Patient and implant factors affected nonunion formation. Smoking increased nonunion formation. Utilization of a cephalomedullary device reduced the nonunion rate, but had higher rates of painful prominent hardware compared to reconstruction nailing.

Use of electronic cigarettes in the perioperative period: A mixed-method study exploring perceptions of cardiothoracic patients in Australia

INTRODUCTION

Electronic cigarettes (e-cigarettes) may reduce tobacco use and achieve tobacco abstinence in the perioperative period of cardiothoracic surgery for patients who smoke. However, research on patients' views on the role of e-cigarettes as a smoking cessation tool is lacking. This mixed-methods study explored perceptions on the use of e-cigarettes among current smokers and ex-smokers awaiting cardiothoracic surgery in Australia.

METHODS

A cross-sectional study and semi-structured interviews were conducted with 62 patients who were diagnosed with coronary artery disease or lung cancer and were scheduled for elective cardiothoracic surgery at six metropolitan hospitals in Sydney. Data were collected on demographic characteristics, smoking history, surgical risk index, self-efficacy, interest in, perceived benefits of, and barriers to using e-cigarettes in the perioperative period.

RESULTS

Current smokers reported significantly higher interest in the use of e-cigarettes (p=0.008), and perceived fewer barriers (p=0.048) and more health benefits (p=0.079), compared to ex-smokers. Current smokers considered e-cigarettes to be either a safer alternative to tobacco or a novel method for quitting. Recent ex-smokers, defined as those who quit 2-8 weeks, were a distinct group with high nicotine dependency, a long history of smoking, and multiple failed quit attempts. Compared to longer-term ex-smokers (8-52 weeks quit), recent ex-smokers were more interested in e-cigarettes (p=0.029) and considered e-cigarettes a useful aid to prevent relapse in the lead up to surgery and to manage their nicotine cravings.

CONCLUSIONS

E-cigarettes may be considered a short-term novel aid and a bridge to evidence-based methods to reduce harm from continued tobacco use for some patients awaiting cardiothoracic surgery for coronary artery disease or lung cancer. This study presents reasons why patients awaiting cardiothoracic surgery may enquire about or use e-cigarettes, which will help clinicians identify those who need more consistent, sustained cessation support.

Consistency and reliability of smoking-related variables: longitudinal study design in asthma and COPD

Introduction: Smoking has a significant impact on the development and progression of asthma and chronic obstructive pulmonary disease (COPD). Self-reported questionnaires and structured interviews are usually the only way to study patients' smoking history. In this study, we aim to examine the consistency of the responses of asthma and COPD patients to repeated standardised questions on their smoking habits over the period of 10 years. Methods: The study population consisted of 1329 asthma and 959 COPD patients, who enrolled in the study during years 2005-2007. A follow-up questionnaire was mailed to the participants 1, 2, 4, 6, 8, and 10 years after the recruitment. Results: Among the participants who returned three or more questionnaires (N = 1454), 78.5 % of the patients reported unchanged smoking status (never smoker, ex-smoker or current smoker) across the time. In 4.5% of the answers, the reported smoking statuses were considered unreliable/conflicting (first never smoker and, later, smoker or ex-smoker). The remainder of the patients changed their status from current smoker to ex-smoker and vice versa at least once, most likely due to struggling with quitting. COPD patients were more frequently heavy ex- or current smokers compared to the asthma group. The intraclass coefficient correlations between self-reported starting (0.85) and stopping (0.94) years as well as the consumption of cigarettes (0.74) over time showed good reliability among both asthma and COPD patients. Conclusion: Self-reported smoking data among elderly asthma and COPD patients over a 10-year follow-up is reliable. Pack years can be considered a rough estimate for their comprehensive consumption of tobacco products over time. We also observed that the questionnaire we used was not designed for dynamic changes in smoking which are rather common among heavy smokers especially when the follow-up time is several years, as in our study.

Tobacco Dependence Predicts Higher Lung Cancer and Mortality Rates and Lower Rates of Smoking Cessation in the National Lung Screening Trial

BACKGROUND

Incorporating tobacco treatment within lung cancer screening programs has the potential to influence cessation in high-risk smokers. We aimed to better understand the characteristics of smokers within a screening cohort, correlate those variables with downstream outcomes, and identify predictors of continued smoking.

METHODS

This study is a secondary analysis of the National Lung Screening Trial randomized clinical study. Tobacco dependence was evaluated by using the Fagerstrӧm Test for Nicotine Dependence, the Heaviness of Smoking Index, and time to first cigarette (TTFC); descriptive statistics were performed. Clinical outcomes (smoking cessation, lung cancer, and mortality) were assessed with descriptive statistics and χ² tests stratified according to nicotine dependence. Logistic and Cox regression models were used to study the influence of dependence on smoking cessation and mortality, respectively.

RESULTS

Patients with high dependence scores were less likely to quit smoking compared with low dependence smokers (TTFC OR, 0.50 [95% CI, 0.42-0.60]). Indicators of high dependence, as measured according to all three metrics, were associated with worsening clinical outcomes. TTFC showed that patients who smoked within 5 min of waking (indicating higher dependence) had higher rates of lung cancer (2.07% for > 60 min after waking vs 5.92% ≤ 5 min after waking; hazard ratio [HR], 2.56 [95% CI, 1.49-4.41]), all-cause mortality (5.38% for > 60 min vs 11.21% ≤ 5 min; HR, 2.19 [95% CI, 1.55-3.09]), and lung cancer-specific mortality (0.55% for > 60 min vs 2.92% for ≤ 5 min; HR, 4.46 [95% CI, 1.63-12.21]).

CONCLUSIONS

Using TTFC, a one-question assessment of tobacco dependence, at the time of lung cancer screening has implications for personalizing tobacco treatment and improving risk assessment.

Sensitivity of Claims-Based Algorithms to Ascertain Smoking Status More Than Doubled with Meaningful Use

BACKGROUND

The "meaningful use of certified electronic health record" policy requires eligible professionals to record smoking status for more than 50% of all individuals aged 13 years or older in 2011 to 2012.

OBJECTIVES

To explore whether the coding to document smoking behavior has increased over time and to assess the accuracy of smoking-related diagnosis and procedure codes in identifying previous and current smokers.

METHODS

We conducted an observational study with 5,423,880 enrollees from the year 2009 to 2014 in the Truven Health Analytics database. Temporal trends of smoking coding, sensitivity, specificity, positive predictive value, and negative predictive value were measured.

RESULTS

The rate of coding of smoking behavior improved significantly by the end of the study period. The proportion of patients in the claims data recorded as current smokers increased 2.3-fold and the proportion of patients recorded as previous smokers increased 4-fold during the 6-year period. The sensitivity of each International Classification of Diseases, Ninth Revision, Clinical Modification code was generally less than 10%. The diagnosis code of tobacco use disorder (305.1X) was the most sensitive code (9.3%) for identifying smokers. The specificities of these codes and the Current Procedural Terminology codes were all more than 98%.

CONCLUSIONS

A large improvement in the coding of current and previous smoking behavior has occurred since the inception of the meaningful use policy. Nevertheless, the use of diagnosis and procedure codes to identify smoking behavior in administrative data is still unreliable. This suggests that quality improvements toward medical coding on smoking behavior are needed to enhance the capability of claims data for smoking-related outcomes research.

STOP smoking and alcohol drinking before OPeration for bladder cancer (the STOP-OP study), perioperative smoking and alcohol cessation intervention in relation to radical cystectomy: study protocol for a randomised controlled trial

Background

To evaluate the effect of a smoking-, alcohol- or combined-cessation intervention starting shortly before surgery and lasting 6 weeks on overall complications after radical cystectomy. Secondary objectives are to examine the effect on types and grades of complications, smoking cessation and alcohol cessation, length of hospital stay, health-related quality of life and return to work or habitual level of activity up to 12 months postoperatively.

Methods/design

The study is a multi-institutional randomised clinical trial involving 110 patients with a risky alcohol intake and daily smoking who are scheduled for radical cystectomy. Patients will be randomised to the 6-week Gold Standard Programme (GSP) or treatment as usual (control). The GSP combines patient education and pharmacologic strategies. Smoking and alcohol intake is biochemically validated (blood, urine and breath tests) at the weekly meetings and at follow-up.

Discussion

Herein, we report the design of the STOP-OP study, objectives and accrual up-date. This study will provide new knowledge about how to prevent smoking and alcohol-related postoperative complications at the time of bladder cancer surgery. Till now 77 patients have been enrolled. Patient accrual is expected to be finalised before the end of 2017 and data will be published in 2018.

Trial registration

ClinicalTrials.gov, ID: NCT02188446. Registered on 28 May 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2065-6) contains supplementary material, which is available to authorized users.

Telephone-Based Coaching

PURPOSE

Many Americans continue to smoke, increasing their risk of disease and premature death. Both telephone-based counseling and in-person tobacco cessation classes may improve access for smokers seeking convenient support to quit. Little research has assessed whether such programs are effective in real-world clinical populations.

DESIGN

Retrospective cohort study comparing wellness coaching participants with two groups of controls.

SETTING

Kaiser Permanente Northern California, a large integrated health care delivery system.

SUBJECTS

Two hundred forty-one patients who participated in telephonic tobacco cessation coaching from January 1, 2011, to March 31, 2012, and two control groups: propensity-score-matched controls, and controls who participated in a tobacco cessation class during the same period. Wellness coaching participants received an average of two motivational interviewing-based coaching sessions that engaged the patient, evoked their reason to consider quitting, and helped them establish a quit plan.

MEASURES

Self-reported quitting of tobacco and fills of tobacco cessation medications within 12 months of follow-up.

ANALYSIS

Logistic regressions adjusting for age, gender, race/ethnicity, and primary language.

RESULTS

After adjusting for confounders, tobacco quit rates were higher among coaching participants vs. matched controls (31% vs. 23%, p < .001) and comparable to those of class attendees (31% vs. 29%, p = .28). Coaching participants and class attendees filled tobacco-cessation prescriptions at a higher rate (47% for both) than matched controls (6%, p < .001).

CONCLUSION

Telephonic wellness coaching was as effective as in-person classes and was associated with higher rates of quitting compared to no treatment. The telephonic modality may increase convenience and scalability for health care systems looking to reduce tobacco use and improve health.

Smoking and heavy drinking patterns in rural, urban and rural-to-urban migrants: the PERU MIGRANT Study

Background

Previous studies have found mixed results about cigarette and alcohol consumption patterns among rural-to-urban migrants. Moreover, there are limited longitudinal data about consumption patterns in this population. As such, this study aimed to compare the smoking and heavy drinking prevalence among rural, urban, and rural-to-urban migrants in Peru, as well as the smoking and heavy drinking incidence in a 5-year follow-up.

Methods

We analyzed the PERU MIGRANT Study data from rural, urban, and rural-to-urban migrant populations in Peru. The baseline study was carried out in 2006–2007 and follow-up was performed five years later. For the baseline data analysis, the prevalence of lifetime smoking, current smokers, and heavy drinking was compared by population group using prevalence ratios (PR) and 95% confidence intervals (95% CI). For the longitudinal analysis, the incidence of smoking and heavy drinking was compared by population group with risk ratios (RR) and 95% CI. Poisson regression with robust variance was used to calculate both PRs and RRs.

Results

We analyzed data from 988 participants: 200 rural dwellers, 589 migrants, and 199 urban dwellers. Compared with migrants, lifetime smoking prevalence was higher in the urban group (PR = 2.29, 95% CI = 1.64–3.20), but lower in the rural group (PR = 0.55, 95% CI = 0.31–0.99). Compared with migrants, the urban group had a higher current smoking prevalence (PR = 2.29, 95% CI = 1.26–4.16), and a higher smoking incidence (RR = 2.75, 95% CI = 1.03–7.34). Current smoking prevalence and smoking incidence showed no significant difference between rural and migrant groups. The prevalence and incidence of heavy drinking was similar across the three population groups.

Conclusions

Our results show a trend in lifetime smoking prevalence (urban > migrant > rural), while smoking incidence was similar between migrant and rural groups, but higher in the urban group. In addition, our results suggest that different definitions of smoking status could lead to different smoking rates and potentially different measures of association. The prevalence and incidence of heavy drinking were similar between the three population groups.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4080-7) contains supplementary material, which is available to authorized users.

Substance Use Disorders among Patients with Type 2 Diabetes: a Dangerous but Understudied Combination

PURPOSE OF REVIEW

This paper reviews research on substance use and disorders (SUDs) among adults with diabetes. It describes epidemiological data on SUDs in persons with type 2 diabetes, overviews effects of substance use on diabetes outcomes, and discusses treatments for SUDs in patients with diabetes.

RECENT FINDINGS

Rates of current smoking range from 10 to 26% and alcohol use disorders are 0-5%. Rates of illicit SUDs are 3-4%, but there are no population-based studies using nationally representative samples. Smoking increases the risk for long-term diabetes complications and premature death. Alcohol and illicit drug use can also impact long-term diabetes complications by impairing glucose homeostasis and adversely influencing self-management behaviors. There is mixed evidence about psychosocial smoking cessation interventions in adults with diabetes and little on alcohol and illicit SUD interventions. Limited data exist on pharmacotherapies for SUDs in this population, but a recent study suggests that varenicline is safe and effective for treating smoking in patients with diabetes. Substance use is an understudied problem in type 2 diabetes, and addressing substance use holds potential for improving outcomes. Additional large population-based epidemiological studies in those with type 2 diabetes are needed, particularly for alcohol and illicit SUDs. Longitudinal studies should be conducted to better understand the time course of diabetes onset and outcomes in relation to SUDs. Randomized controlled trials are needed to assess safety and efficacy of promising psychosocial and pharmacological interventions.

Self-Reporting of Smoking Cessation in Cardiac Patients: How Reliable Is It and Is Reliability Associated With Patient Characteristics?

OBJECTIVES

The objectives of this study were to determine the accuracy of smoking cessation self-reports by cardiac patients who participated in a smoking cessation program, and to determine which patient characteristics are associated with an inaccurate self-report during a follow-up interview 12 months after the start of the program.

METHODS

Smoking cessation self-reports (point prevalence abstinence) were validated against salivary cotinine levels. Using χ analyses, patients who reported accurately being a nonsmoker were compared with those who reported inaccurately being a nonsmoker (biochemically verified as smokers) on factors the literature has indicated to be associated with inaccurate self-report in smoking. Potential predictors of inaccurate self-report of smoking (P ≤ 0.20 in univariate analyses) were subsequently tested in a multivariate logistic regression analysis.

RESULTS

Of the 95 patients tested, almost 25% inaccurately reported having quit smoking at a cutoff of 10-ng/mL cotinine in saliva. The data show more underreporting of smoking among patients who received a face-to-face counseling intervention and among patients with an intermediate education level. There was significantly less underreporting among patients characterized as having a Type D personality.

CONCLUSIONS

These findings suggest that underreporting of smoking status in cardiac patients who participate in a smoking cessation program is high, especially in those who receive intensive face-to-face counseling. Having a Type D personality seems to be a protective factor, whereas having an intermediate level of education is a risk factor for inaccurate reporting. Biochemical validation in high-risk populations is highly needed, ideally accompanied by alternative forms of verification. Optimal validation testing in smoking cessation studies of cardiac patients is difficult because of high refusal rates, no-show, and organizational difficulties.

Research Priorities, Measures, and Recommendations for Assessment of Tobacco Use in Clinical Cancer Research

There is strong evidence that cigarette smoking causes adverse outcomes in people with cancer. However, more research is needed regarding those effects and the effects of alternative tobacco products and of secondhand smoke, the effects of cessation (before diagnosis, during treatment, or during survivorship), the biologic mechanisms, and optimal strategies for tobacco dependence treatment in oncology. Fundamentally, tobacco is an important source of variation in clinical treatment trials. Nevertheless, tobacco use assessment has not been uniform in clinical trials. Progress has been impeded by a lack of consensus regarding tobacco use assessment suitable for cancer patients. The NCI-AACR Cancer Patient Tobacco Use Assessment Task Force identified priority research areas and developed recommendations for assessment items and timing of assessment in cancer research. A cognitive interview study was conducted with 30 cancer patients at the NIH Clinical Center to evaluate and improve the measurement items. The resulting Cancer Patient Tobacco Use Questionnaire (C-TUQ) includes "Core" items for minimal assessment of tobacco use at initial and follow-up time points, and an "Extension" set. Domains include the following: cigarette and other tobacco use status, intensity, and past use; use relative to cancer diagnosis and treatment; cessation approaches and history; and secondhand smoke exposure. The Task Force recommends that assessment occur at study entry and, at a minimum, at the end of protocol therapy in clinical trials. Broad adoption of the recommended measures and timing protocol, and pursuit of the recommended research priorities, will help us to achieve a clearer understanding of the significance of tobacco use and cessation for cancer patients.

The effect of smoking on carotid intima-media thickness progression rate and rate of lumen diameter reduction

OBJECTIVE

The purpose of the study was to investigate the long-term associations between smoking habits, environmental tobacco smoke exposure (ETS), carotid intima-media thickness (IMT) progression rate, and rate of lumen diameter reduction in the carotid artery during a 16-year follow-up. Another objective was to investigate if an effect of smoking on progression rate could be explained by increased low grade inflammation.

METHODS

The study population included 2992 middle-aged men and women in the 1991-1994 (baseline) and the 2007-2012 (re-examination) investigation of the Malmö Diet and Cancer Study cardiovascular cohort. Associations between smoking, progression of carotid IMT and lumen diameter reduction due to plaque protrusion were assessed by linear regression.

RESULTS

IMT progression rates and rate of lumen diameter reduction increased from never smokers with no ETS through former, moderate and heavy smokers, even after adjustment for traditional risk factors (e.g., differences in yearly progression rates (mm/year) of maximal IMT in the carotid bifurcation compared to never smokers; former smokers 0.0074 (95% CI: 0.0018-0.0129), moderate smokers 0.0106 (95% CI: 0.0038-0.0175), and heavy smokers 0.0146 (95% CI: 0.0061-0.0230)). Former smokers showed distinct lowering of progression rates after more than five years since smoking cessation. Smoking and former smoking was associated with increased low grade inflammation, however, the effect of smoking on atherosclerotic progression rate remained fairly unchanged after such adjustment.

CONCLUSION

The effect of smoking and former smoking on carotid IMT progression rates and change in lumen reduction due to plaque protrusion could not be explained by differences in traditional risk factors or low grade inflammation.

Continued Smoking in Lung Transplant Patients: A Cross Sectional Survey

Introduction

Smoking is associated with a higher incidence of post-lung transplantation complications and mortality. Prior to inclusion on the lung transplant waiting list in the Czech Republic, patients are supposed to be tobacco free for at least 6 months. Our aim was to determine the prevalence of smoking, validated by urinary cotinine, among patients post lung transplantation and prior to inclusion on the transplant waiting list.

Methods

Between 2009 and 2012, we conducted a cross-sectional survey of urinary cotinine to assess tobacco exposure in 203 patients in the Lung Transplant Program in the Czech Republic. We measured urinary cotinine in 163 patients prior to inclusion on the transplantation waiting list, and 53 patients post bilateral lung transplantation.

Results

15.1% (95% CI 0.078 to 0.269) of all lung transplant recipients had urinary cotinine levels corresponding to active smoking; and a further 3.8% (95% CI 0.007 to 0.116) had borderline results. Compared to patients with other diagnoses, patients with COPD were 35 times more likely to resume smoking post- transplantation (95% CI 1.92 to 637.37, p-value 0.016). All patients who tested positive for urinary cotinine levels were offered smoking cessation support. Only one Tx patient sought treatment for tobacco dependence, but was unsuccessful.

Conclusion

Smoking resumption may be an underrecognized risk for lung transplantation recipients, particularly among patients with chronic obstructive pulmonary disease. More rigorous screening, as well as support and treatment to stop smoking among these patients are needed.

A quantitative epigenetic approach for the assessment of cigarette consumption

Smoking is the largest preventable cause of morbidity and mortality in the world. Despite the development of numerous preventive and treatment interventions, the rate of daily smoking in the United States is still approximately 22%. Effective psychosocial interventions and pharmacologic agents exist for the prevention and treatment of smoking. Unfortunately, both approaches are hindered by our inability to accurately quantify amount of cigarette consumption from the point of initial experimentation to the point of total dependency. Recently, we and others have demonstrated that smoking is associated with genome-wide changes in DNA methylation. However, whether this advance in basic science can be employed as a reliable assay that is useful for clinical diagnosis and treatment has not been shown. In this communication, we determine the sensitivity and specificity of five of the most consistently replicated CpG loci with respect to smoking status using data from a publically available dataset. We show that methylation status at a CpG locus in the aryl hydrocarbon receptor repressor, cg05575921, is both sensitive and specific for smoking status in adults with a receiver operated curve characteristic area under the curve of 0.99. Given recent demonstrations that methylation at this locus reflects both intensity of smoking and the degree of smoking cessation, we conclude that a methylation-based diagnostic at this locus could have a prominent role in understanding the impact of new products, such as e-cigarettes on initiation of cigarette smoking among adolescents, while improving the prevention and treatment of smoking, and smoking related disorders.

Treatment Outcome Assessment of the Pharmacist-Managed Quit Smoking Clinic in Malaysia

Introduction: Evaluating a new health service is different from evaluating a new drug, as the former depends on the local delivery structure and culture. No data are available on the effectiveness of the existing pharmacist-managed quit smoking clinic (PM-QSC) in Malaysia. We evaluated the effectiveness in terms of the quit and default rate, the cost per quitter, cost per patient and the number of days of the patient remained in the managed care of the pharmacist.

Methods: The patients’ medical records at the PM-QSC in a tertiary hospital in Melaka, Malaysia, were examined retrospectively from January 2009 to December 2010. Patients were grouped into current smokers, attempted to quit and quitters. Costs were calculated per patient visit on the basis of resource used (smoking cessation agents (SCAs)) and the personnel involved (time spent by the pharmacist). This study was reviewed and approved by the Malaysia Research Ethics Committee (MREC).

Results: The quit rate between January 2009 and December 2010 was 5.8%, and the default rate was 71.8%. The average quit period for all smokers enrolled was 298 days. From the health provider perspective, the average costs per quitter, per patient and per quit attempt were MYR 953.28 (USD 308), MYR 55.71 (USD 18) and MYR 34.74 (USD 11), respectively.

Conclusion: The pharmacist delivery of cessation services at a public-funded QSC was associated with a high default rate. The pharmacist could not be dismissed entirely as an ineffective health care professional (HCP) for the provision of the cessation service based solely on this preliminary data, but these findings stress the need to address the high default rate prior to the expansion of the service.

Validation of self-reported smokeless tobacco use by measurement of serum cotinine concentration among US adults

Although investigators have assessed the relationship between self-reported cigarette smoking and biomarker levels, the validity of self-reported information on smokeless tobacco (SLT) use is uncertain. We used aggregated data from the 2003-2004, 2005-2006, 2007-2008, and 2009-2010 administrations of the National Health and Nutrition Examination Survey (NHANES) to compare self-reported SLT use with serum concentrations of cotinine, a metabolite of nicotine, among US adults aged ≥18 years. Receiver operating characteristic analysis was used to determine the optimal serum cotinine cutpoint for discriminating SLT users from nonusers of tobacco, and concordance analysis was used to compare self-reported SLT use with cotinine levels. Among the 30,298 adult respondents who completed the NHANES during 2003-2010, 418 reported having exclusively used SLT and no other type of tobacco (cigarettes, cigars, or pipes) during the past 5 days, while 23,457 reported not using any tobacco. The optimal cotinine cutpoint for discriminating SLT users from non-tobacco users was 3.0 ng/mL (sensitivity=97.0%, specificity=93.0%), which was comparable to a revised cutpoint recommended for identifying adult cigarette smokers. Concordance with cotinine was 96.4% and 93.7% for self-reported SLT use and tobacco nonuse, respectively. These findings indicate that self-reported SLT use among adults correlates highly with serum cotinine levels and that the optimal cutpoint for minimizing misclassification of self-reported use is a serum cotinine concentration of 3.0 ng/mL.

Self-report of tobacco use status: comparison of paper-based questionnaire, online questionnaire, and direct face-to-face interview--implications for meaningful use

Identifying tobacco use status is essential to address use and provide resources to help patients quit. Being able to collect this information in an electronic format will become increasingly important, as the Centers for Medicare and Medicaid Services has included the assessment of tobacco use as part of its Stage 1 Meaningful Use criteria. The objective was to compare the accuracy of online vs. paper assessment methods to ascertain cigarette smoking status using a face-to-face structured interview as the gold standard. This was a retrospective analysis of a stratified opportunity sample of consecutive patients, reporting in 2010 for a periodic health evaluation, who completed either a scannable paper-based form or an online questionnaire and underwent a standardized rooming interview. Compared with face-to-face structured interview, the overall observed agreement and kappa coefficient for both methods combined (paper and online) were 97.7% and 0.69 (95% confidence interval (CI) 0.51-0.86) . For the online form they were 97.4% and 0.61 (95% CI 0.33-0.90), and for the paper form they were 97.9% and 0.75 (95% CI 0.54-0.96). There was no statistically significant difference in agreement between the online and paper-based methods (P=0.76) compared with a face-to-face structured interview. Online assessment of tobacco use status is as accurate as a paper questionnaire, and both methods have greater than 97% observed agreement with a face-to-face structured interview. The use of online assessment of tobacco use status has several advantages and more widespread use should be explored.

Smoking cessation in Taiwanese male smokers with coronary artery disease: influencing factors and policy implications

AIM

To investigate factors affecting smoking cessation in male smokers with coronary artery disease.

DESIGN

A descriptive, correlation, cross-sectional study was conducted.

METHODS

Data were collected using a questionnaire constructed by a literature review of research on smoking cessation in male smokers including demographics and smoking background, as well as psychological, interpersonal and environmental factors. A total of 130 male patients with coronary artery disease were recruited from the cardiac clinic at a regional hospital in Taiwan from August to December 2008. The response rate was 93% (n = 121). Descriptive statistics, chi-square, t-tests and logistic regression analysis were conducted.

RESULTS

During the survey, 64.5% of the respondents reported that they had stopped smoking after a coronary event. Five factors were significantly associated with smoking cessation after diagnosis of coronary artery disease: age, the severity of heart diagnoses, antismoking norms (perceived that smoking was against the social norms), nicotine dependence level, and contrary views of smoking (perceived negative expectancy of smoking). Multivariate analysis revealed antismoking norms to be the most important predictor (AOR = 4.27; P < .05) after adjusting age.

CONCLUSION

The study highlights the need to develop smoking cessation interventions that specifically counsel patients with coronary artery disease about these information, such as the disease risk and development, health consequences of smoking, and dependence therapy. Additionally, government support for tobacco control programmes in hospitals and elsewhere is designed to have a beneficial effect on patients' smoking behaviours primarily by increasing antismoking norms.

Impact of smoking status on cardiovascular outcomes following percutaneous coronary intervention

BACKGROUND

Many military veterans in the United States with coronary artery disease continue to smoke despite undergoing percutaneous coronary intervention (PCI). Previous studies have described improved cardiovascular outcomes in smokers, the so-called "smokers' paradox." In this study, we examined the effects of smoking on cardiovascular outcomes following PCI.

HYPOTHESIS

Do patients who smoke have different post-PCI outcomes than nonsmokers?

METHODS

All patients who underwent PCI at a single US Veterans Administration hospital from 2004 to 2009 were followed. Outcomes of interest included myocardial infarction, unplanned coronary intervention, unplanned cardiac hospitalization, death, and a composite of events for 6 months after PCI. Changes in traditional risk factors were also assessed.

RESULTS

Unadjusted analysis revealed that in almost all categories, smokers had lower incidence of adverse events than nonsmokers. However, after adjusting for the older age of the nonsmokers, no favorable statistical trend toward smokers was seen. Significant improvement in blood pressure and lipid levels were seen in both groups.

CONCLUSIONS

After adjusting for differences in age, there did not appear to be any protective effect of smoking on cardiovascular outcomes following PCI. Smokers achieved similar degrees of risk factor optimization during the follow-up period as their nonsmoker counterparts. Aggressive efforts to decrease the prevalence of smoking must be maintained.

Accuracy of self-reported tobacco use in newly diagnosed cancer patients

PURPOSE

Accurate identification of tobacco use is critical to implement evidence-based cessation treatments in cancer patients. The purpose of this study is to evaluate the accuracy of self-reported tobacco use in newly diagnosed cancer patients.

METHODS

Tobacco use questionnaires and blood samples were collected from 233 newly diagnosed cancer patients (77 lung, 77 breast, and 79 prostate cancer). Blood was analyzed for cotinine levels using a commercially available enzyme-linked immunosorbent assay. Patients with cotinine measurements exceeding 10 ng/mL were categorized as current smokers. Smoking status based upon cotinine levels was contrasted with self-report in current smokers, recent quitters (1 or less year since quit), non-recent quitters (>1 year since quit), and never smokers. Multivariate analyses were used to identify potential predictors of discordance between self-reported and biochemically confirmed smoking.

RESULTS

Cotinine confirmed 100 % accuracy in self-reporting of current and never smokers. Discordance in cotinine and smoking status was observed in 26 patients (15.0 %) reporting former tobacco use. Discordance in self-reported smoking was 12 times higher in recent (35.4 %) as compared with non-recent quitters (2.8 %). Combining disease site, pack-year history, and employment status predicted misrepresentation of tobacco use in 82.4 % of recent quitters.

CONCLUSIONS

Self-reported tobacco use may not accurately assess smoking status in newly diagnosed cancer patients. Patients who claim to have recently stopped smoking within the year prior to a cancer diagnosis and lung cancer patients may have a higher propensity to misrepresent tobacco use and may benefit from biochemical confirmation.

Utility of biochemical verification of tobacco cessation in the Department of Veterans Affairs

Research on the validity of self-report tobacco use has varied by the population studied and has yet to be examined among smokers serviced by the Department of Veterans Affairs (VA). The purpose of this study was to determine the predictors of returning a biochemical urine test and the specificity and sensitivity of self-reported tobacco use status compared to biochemical verification. This was a sub-analysis of the larger Tobacco Tactics research study, a pre-/post-non-randomized control design study to implement and evaluate a smoking cessation intervention in three large VA hospitals. Inpatient smokers completed baseline demographic, health history and tobacco use measures. Patients were sent a follow-up survey at six-months to assess tobacco use and urine cotinine levels. A total of 645 patients returned six-month surveys of which 578 also returned a urinary cotinine strip at six-months. Multivariate analysis of the predictors of return rate revealed those more likely to return biochemical verification of their smoking status were younger, more likely to be thinking about quitting smoking, have arthritis, and less likely to have heart disease. The sensitivity and specificity of self-report tobacco use were 97% (95% confidence interval=0.95-0.98) and 93% (95% confidence interval=0.84-0.98) respectively. The misclassification rate among self-reported quitters was 21%. The misclassification rate among self-reported tobacco users was 1%. The sensitivity and specificity of self-report tobacco use were high among veteran smokers, yet among self-report quitters that misclassification rate was high at 21% suggesting that validating self-report tobacco measures is warranted in future studies especially in populations that are prone to misclassification.

[Factors associated with smoking in the elderly: a health survey in São Paulo (ISA-SP)]

This article reports on smoking prevalence and associated factors in the elderly, based on a population-based cross-sectional study with multi-stage sampling including 1,954 individuals 60 years or older living in four areas of São Paulo State, Brazil. Overall smoking prevalence was 12.2%, and higher rates were associated with male gender, age 60-69 years, not belonging to an Evangelical church, lower income, low body weight, lack of leisure-time physical activity, depression/anxiety, and hypertension. There was a high prevalence of smokers among individuals with a history of stroke, cancer, and chronic obstructive pulmonary disease. The results point to the need for effective interventions in healthcare services to promote smoking cessation among the elderly, since many are unable to stop on their own, even when they have tobacco-related illnesses. Special attention should be paid to individuals that depend on the National Health System, since smoking prevalence is higher in underprivileged socioeconomic groups.

Reliability of self-reported tobacco use in bipolar disorder: an exploratory study of euthymic patients visiting a tertiary care hospital in India

BACKGROUND

Unlike schizophrenia, only a little attention has been paid to tobacco dependence in patients with bipolar disorder despite a similarly high prevalence and predisposition to health risks. The euthymic phase is especially suitable for tobacco screening by the treating psychiatrist. However, the validity of self-report for tobacco use in this patient population remains undetermined.

AIM

The current study aims to assess the validity of self-reported tobacco use in euthymic bipolar disorder.

METHOD

The psychiatric out-patients with DSM-IV TR diagnosis of bipolar type-I in remission who were males, > or =18 years, and euthymic as established by current scores of <7 on HAM-D and <4 on YMRS. Patients were specifically asked for the recent use of tobacco in any form. Ten ml urine sample was obtained after informed consent and subjected to a quantitative cotinine estimation by direct enzyme-linked immunosorbent assay.

RESULTS

A total of 100 patients were screened, of which 79 were finally included. The self-report for recent tobacco use showed only a moderate concordance with urinary cotinine (k = 0.518) and cotinine-creatinine ratio (k = 0.492). Over 15% patients had denied the use of tobacco, but tested positive on urinary cotinine assessment. The sensitivity of self-report was 73.3% compared to urinary cotinine. The denial among users was 26.7% and denial among those with negative self-report was 30.8%.

CONCLUSION

Mental health professionals should be vigilant for detection of tobacco dependence among remitted bipolar patients, who may not be so forthcoming about their tobacco use.

Folate status and health behaviours in two Australian Indigenous populations in north Queensland

OBJECTIVE

To assess nutritional status using red-cell folate (RCF) and associated health behaviours including fruit and vegetable intake, smoking, drinking and physical activity in two Indigenous populations living in remote northern Australia.

DESIGN

A cross-sectional survey conducted during 1998-2000.

SETTING

Twenty-six rural communities in north Queensland, Australia.

SUBJECTS

A total of 2524 Indigenous people aged 15 years and over was included in the study. Self-reported fruit and vegetable intake, tobacco smoking, alcohol intake and physical activity were recorded. RCF was measured using the Bayer Advia Centaur automated immunoassay system. The association between low RCF (RCF<295 nmol/l) and risk factors was analysed using general linear models adjusted for demographic factors and covariates, namely BMI, diabetes and dyslipidaemia.

RESULTS

The prevalence of RCF deficiency was higher in Aboriginal participants compared with Torres Strait Islanders (25.6 % v. 14.8 %, P < 0.001). Young women of childbearing age were more likely to have low RCF. Among Aboriginal adults, smoking was strongly associated with low RCF (risk ratio = 1.9, 95 % CI 1.5, 2.5 in females and risk ratio = 2.9, 95 % CI 1.9, 4.2 in males).

CONCLUSIONS

Indigenous Australians, especially women of childbearing age, had high prevalence of low RCF. Smoking was associated with insufficient folate independent of fruit and vegetable intake and alcohol consumption in the Aboriginal population. This population with an already higher risk of obesity and higher rate of tobacco smoking should be targeted to improve nutrition status to prevent ill health such as diabetes and CVD.

Parental smoking cessation and child daily smoking: A 9-year longitudinal study of mediation by child cognitions about smoking

OBJECTIVE

This study investigated to what extent the prospective relationship between parental smoking cessation and child daily smoking is mediated by child cognitions about smoking.

DESIGN

The study drew its sample from the 40 Washington State school districts involved in the Hutchinson Smoking Prevention Project. The predictor variable of parental smoking cessation was measured during third grade. The mediator measures, consistent with the Theory of Planned Behavior and Social Cognitive Theory, were measured during ninth grade, and the smoking status outcome was measured during twelfth grade.

MAIN OUTCOME MEASURES

Smoking status at twelfth grade.

RESULTS

Negative general attitudes toward smoking, attitude that cigarette smoke is bothersome, and tobacco refusal self-efficacy together significantly mediated 49% of the prospective relationship between parental smoking cessation and child daily smoking.

CONCLUSION

Parental smoking cessation before children reach third grade may lead children to develop more negative cognitions about smoking, and, in turn, reduce their risk of smoking.

Secondary prevention in coronary artery disease. Achieved goals and possibilities for improvements

AIM

To describe presence of risk indicators of recurrence 6 months after hospitalisation due to coronary artery disease at a university clinic.

METHODS

The presence of risk indicators, including tobacco use, lipid levels, blood pressure and glucometabolic status, including 24-hour blood pressure monitoring and an oral glucose-tolerance test, was analysed.

RESULTS

Of 1465 patients who were screened, 402 took part in the survey (50% previous myocardial infarction and 50% angina pectoris). Mean age was 64 years (range 40-85 years) and 23% were women. Present medications were: lipid lowering drugs (statins; 94%), beta-blockers (85%), aspirin or warfarin (100%) and ACE-inhibitors or angiotensin II blockers (66%). Values above target levels recommended in guidelines were: a) low density lipoprotein (LDL) in 40%; b) mean blood pressure (day or night) in 38% and c) smoking in 13%. Of all patients, 66% had at least one risk factor (LDL or blood pressure above target levels or current smoking). An abnormal glucose-tolerance test was found in 59% of patients without known diabetes. If no history of diabetes, 85% had either LDL or blood pressure above target levels, current smoking or an abnormal glucose-tolerance test. However, with treatment intensification to patients with elevated risk factors 56% reached target levels for blood pressure and 79% reached target levels for LDL.

CONCLUSION

Six months after hospitalisation due to coronary artery disease, despite the high use of medication aimed at prophylaxis against recurrence, the majority were either above target levels for LDL or blood pressure or continued to smoke.

The effect of smoking on survival and bone loss of implants with a fluoride-modified surface: a 2-year retrospective analysis of 1106 implants placed in daily practice

AIM

To compare the survival and peri-implant bone loss of implants with a fluoride-modified surface in smokers and nonsmokers.

MATERIALS AND METHODS

Patient files of all patients referred for implant treatment from November 2004 to 2007 were scrutinized. All implants were placed by the same experienced surgeon (B. C.). The only inclusion criterion was a follow-up time of at least 2 years. Implant survival and bone loss were assessed by an external calibrated examiner (S. V.) comparing digital peri-apical radiographs taken during recall visits with the post-operative ones. Implant success was determined according to the international success criteria (Albrektsson et al. 1986). Survival of implants installed in smokers and nonsmokers was compared using the log-rank test. Both nonparametric tests and fixed model analysis were adopted to evaluate bone loss in smokers and nonsmokers.

RESULTS

One-thousand one-hundred and six implants in 300 patients (186 females; 114 males) with a mean follow-up of 31 months (SD 7.15; range 24-58) were included. Nineteen implants in 17 patients failed, resulting in an overall survival rate of 98.3% at the implant level and 94.6% at the patient level. After a follow-up period of 2 years, the cumulative survival rates was 96.7% and 99.1% with the patient and implant as the statistical unit, respectively. Implant survival was significantly higher for nonsmokers compared with smokers (implant level P=0.025; patient level P=0.017). The overall mean bone loss was 0.34 mm (n=1076; SD 0.65; range 0-7.1). Smokers lost significantly more bone compared with nonsmokers in the maxilla (0.74 mm; SD 1.07 vs. 0.33 mm; SD 0.65; P<0.001), but not in the mandible (0.25 mm; SD 0.65 vs. 0.22 mm; SD 0.5; P=0.298).

CONCLUSION

The present study is the first to compare peri-implant bone loss in smokers and nonsmokers from the time of implant insertion (baseline) to at least 2 years of follow-up. Implants with a fluoride-modified surface demonstrated a high survival rate and limited bone loss. However, smokers are at a higher risk of experiencing implant failure and more prone to show peri-implant bone loss in the maxilla. Whether this bone loss is predicting future biological complications remains to be evaluated.

Differences in cardiovascular mortality in smokers, past-smokers and non-smokers: findings from the FRENA registry

BACKGROUND

The influence of smoking on outcome in patients with coronary artery disease (CAD) is controversial. Even less is known about its influence in patients with cerebrovascular (CVD), or peripheral artery (PAD) disease.

PATIENTS AND METHODS

FRENA is an ongoing, observational registry of consecutive outpatients with symptomatic CAD, CVD, or PAD. We reviewed their cardiovascular mortality according to smoking status.

RESULTS

As of May 2008, 2501 patients had been enrolled in FRENA. Of these, 439 (18%) were current smokers, 1086 (43%) past-smokers, 976 (39%) had never smoked. Current- and past-smokers were 10 years younger, more often males, and more likely to have chronic lung disease, but had diabetes, hypertension, heart failure, or renal insufficiency less often than non-smokers. Over a mean follow-up of 14 months, 123 patients died (cardiovascular death, 68). On univariate analysis, current smokers had a significantly lower rate of cardiovascular death: 1.1 (95% CI: 0.4-2.4) per 100 patient-years in current smokers; 1.9 (95% CI: 1.2-2.8) in past-smokers; 3.5 (95% CI: 2.5-4.7) in non-smokers, with no differences between patients with CAD, CVD or PAD. Mean age at cardiovascular death was 82+/-6.4; 70+/-9.9 and 67+/-15 years, respectively. On multivariate analysis, smoking status was not independently associated with a lower risk for cardiovascular death.

CONCLUSIONS

Current and past-smokers with CAD, CVD or PAD had a less than half cardiovascular mortality than those who never smoked, but this may be explained by the confounding effect of additional variables. They died over 10 years younger than non-smokers.

Do patient characteristics, disease, or treatment explain social inequality in survival from colorectal cancer?

This paper investigates the association between individually measured socioeconomic status (SES) and all-cause survival in colorectal cancer patients, and explores whether factors related to the patient, the disease, or the surgical treatment mediate the observed social gradient. The data were derived from a nationwide clinical database of all adenocarcinomas of the colon or rectum diagnosed in Denmark between 2001 and 2004 (inclusive). These data were linked to those from several central registries providing information on income, education, and housing status, as well as to data on comorbidity from previous hospitalizations and use of medication. Only patients with colorectal cancer as their first primary tumour and those born after 1920 were included. A total of 8763 patients were included in the study. Cox proportional hazard regression models revealed a positive social gradient in survival for increasing levels of education and income, and in owners versus renters of housing. A series of regression analyses were used to test potential mediators of the association between the socioeconomic indicators and survival by stepwise inclusion of lifestyle factors (smoking, alcohol intake, body mass index), comorbidity, stage of disease, mode of admission, type of operation, specialization of the surgeon, and curative versus palliative resection. A causal diagram guided the analyses. Inclusion of comorbidity, and to a lesser extent lifestyle, reduced the variation associated with SES, while no evidence of a mediating effect was found for disease or surgical treatment factors. This indicates that the difference in survival among colorectal cancer patients from different social groups was probably not caused by unintentional differences in treatment factors related to surgery, and suggests that primary prevention of chronic diseases among the socially deprived might be one way to reduce social differences in prognosis.

Emergency department-initiated tobacco control: a randomised controlled trial in an inner city university hospital

Objectives:

Emergency department (ED) patients show high smoking rates. The effects of ED-initiated tobacco control (ETC) on 7-day abstinence at 12 months were investigated.

Methods:

A randomised controlled intention-to-treat trial (trials registry no.: ISRCTN41527831) was conducted with 1044 patients in an urban ED. ETC consisted of on-site counselling plus up to four telephone booster sessions. Controls received usual care. Analysis was by logistic regression.

Results:

In all, 630 (60.7%) participants were males, the median age was 30 years (range 18–81) and the median smoking intensity was 15 (range 1–60) cigarettes per day. Overall, 580 study participants (55.6%) were unmotivated, 331 (31.7%) were ambivalent and 133 (12.7%) were motivated smokers. ETC (median time 30 (range 1–99) min) was administered to 472 (91.7% out of 515) randomised study participants. At follow-up, 685 study participants (65.6% of 1044) could be contacted. In the ETC group, 73 out of 515 (14.2%) in the ETC group were abstinent, whereas 60 out of 529 (11.3%) controls were abstinent (OR adjusted for age and gender = 1.31 (95% CI 0.91 to 1.89, p = 0.15). Stratified for motivation to change behaviour, the adjusted ORs for ETC versus usual care were OR = 1.00 (95% CI 0.57 to 1.76) in unmotivated smokers, respectively OR = 1.37 (95% CI 0.73 to 2.58) in ambivalent smokers and OR = 2.19 (95% CI 0.98 to 4.89) in motivated smokers, p for trend = 0.29.

Conclusions:

ETC, in the form of on-site counselling with up to four telephone booster sessions, showed no overall effect on tobacco abstinence after 12 months. A non-significant trend for a better performance of ETC in more motivated smokers was observed.