Low cigarette consumption and risk of coronary heart disease and stroke: meta-analysis of 141 cohort studies in 55 study reports

Characterization and stratification of risk factors of stroke in people living with HIV: A theory-informed systematic review

BACKGROUND

Identification and stratification of risk factors for stroke among individuals living with HIV (PLWH) will facilitate primary prevention and prognostication, as well as strategies aimed at optimizing neurorehabilitation. This review sought to characterize and stratify the risk factors associated with stroke in PLWH.

METHODS

The review was structured in accordance with the preferred items for reporting systematic reviews and meta-analysis (PRISMA) checklist. The epidemiological triangle, Bradford criteria, and Rothman causality model further informed the review. The review outcomes encompassed cardiovascular factors, HIV-related factors, and personal and extrinsic factors associated with stroke in PLWH. We conducted searches in PubMed, Scopus, Medline, Web of Science, Cumulative Index for Nursing and Allied Health Literature, and African Journal (SABINET). Data screening and extraction were independently performed utilizing predefined eligibility criteria and a data-extraction template. Narrative synthesis and risk stratification were employed to analyze the results.

RESULTS

Thirty studies (22 cohorts and eight case-control) with a sample size of 353,995 participants were included in this review. The mean age of the participants was 45.1 ± 10.7 years. The majority of the participants (72.4%) were male. Risk factors for stroke in PLWH include cardiovascular factors (advanced age, tobacco use, hypertension, diabetes, atrial fibrillation, etc.), HIV-related factors (high viral load and low nadir CD4 count), personal factors (advanced age and female sex), and comorbidities (hepatitis C virus infection, chronic kidney disease, coronary artery disease, and liver fibrosis or cirrhosis). Diabetes, atrial fibrillation, smoking habits, hypertension, age, and viral load demonstrated a high likelihood of association with stroke in PLWH and should be prioritized when constructing clinical prediction algorithms for HIV-related stroke.

CONCLUSIONS

The most important factors were hypertension and chronic kidney disease, followed by smoking, dyslipidemia, diabetes, HCV, HBV, CD4 count, use of ART, TB, and substance use (cocaine). The least important factors were age, sex, ethnicity, obesity, alcohol use, ART duration, and viral load. The predictive significance of these factors is still evolving, given the average moderate certainty of evidence. Predictive and preventative models should target factors with a high causality index and low investigative costs.

TRIAL REGISTRATION

The review is part of a larger review registered with the PROSPERO (ID: CRD42024524494).

Associations of DNA Methylation Algorithms of Aging With Cardiovascular Disease and Mortality Risk Among US Older Adults

BACKGROUND

Several DNA methylation (DNAm) algorithms have recently emerged as robust predictors of aging and adverse health outcomes in older adults, offering valuable insights into cardiovascular disease (CVD) risk stratification. However, their predictive performance for CVD varies significantly. This study aimed to systematically investigate the associations of 12 widely used DNAm algorithms with CVD and mortality risk.

METHODS

Data from the NHANES (National Health and Nutrition Examination Survey) 1999 to 2002 were used to assess 12 DNAm algorithms (eg, HannumAgeacc, PhenoAgeacc, GrimAgeMortacc, GrimAge2Mortacc) in relation to CVD risk and mortality. Two cohorts were analyzed: one for CVD risk (n=1230) and another for CVD mortality risk (n=1606). DNAm was measured using the Infinium Methylation EPIC BeadChip kit (Illumina). Odds ratios (ORs) and hazard ratios (HRs), along with 95% CIs per SD increase of these DNAm algorithms, were calculated.

RESULTS

Significant associations were observed for GrimAgeMortacc and GrimAge2Mortacc with coronary heart disease and heart attack, with multivariable-adjusted ORs per SD increase ranging from 2.15 to 2.76. However, several algorithms exhibited no significant association with self-reported prevalent CVD. For mortality risk, HannumAgeacc, PhenoAgeacc, ZhangAgeacc, GrimAgeMortacc, and GrimAge2Mortacc were significantly associated with CVD mortality. The multivariable-adjusted HRs per SD increase were 1.19 (95% CIs, 1.05-1.34), 1.13 (95% CIs, 1.01-1.26), 1.63 (95% CI, 1.08-2.47), 1.90 (95% CIs, 1.51-2.40), and 1.87 (95% CIs, 1.51-2.32), respectively. These associations were consistent across biological sex, age (≥50 and <65 versus ≥65 years), and race and ethnicity groups.

CONCLUSIONS

DNAm algorithms, particularly GrimAgeMortacc and GrimAge2Mortacc, may serve as valuable tools for CVD risk stratification and mortality risk assessment.

Misperceptions About the Effectiveness of Cutting Down and Low-Rate Daily Smoking for Reducing the Risk of Tobacco-Caused Harm

INTRODUCTION

Reducing the amount smoked per day, or smoking at a low rate, confers limited protection from smoking harms. We aimed to quantify the prevalence of misperceptions about cutting down and low-rate smoking among Australian adults who smoke.

METHODS

Cross-sectional online survey in April/May 2022 (N = 2740). Participants were asked whether they agreed (misperception) or disagreed that "Reducing the number of cigarettes smoked per day is an effective way to reduce the risk of experiencing the health harms of smoking." They were also asked whether the statement "Smoking 1 cigarette per day is about 1/20th as dangerous as smoking a pack of 20 cigarettes per day" sounded about right (misperception) or if it was less dangerous (misperception) or more dangerous than that.

RESULTS

The misperception that reducing the number of cigarettes smoked is an effective way to reduce risk was held by 72.0% of people who smoke overall, but was more common among those who smoked ≤5 cigarettes daily (76.3%; Adj PR = 1.11 [95% CI 1.01 to 1.21]) or only occasionally (79.7%; Adj PR = 1.14 [1.06 to 1.23]) compared with those who smoked >5 cigarettes daily (66.7%). Over two-thirds (67.9%) underestimated the dangers of smoking one cigarette per day, and this misperception was also more common among low-rate smokers (77.6%, Adj PR = 1.14 [95% CI 1.04 to 1.26]) compared to those who smoked >5 cigarettes daily (63.1%).

CONCLUSIONS

Misperceptions about the value of cutting down and low-rate smoking for reducing the risk of tobacco-caused harm are pervasive, especially among those who currently smoke at a low rate or only occasionally.

IMPLICATIONS

Recent epidemiological evidence confirms that the risks of harm associated with low-rate smoking and cutting down are much higher than would be expected if the relationship between consumption and harm was linear. Findings from this study indicate that misperceptions about the benefits conferred by these smoking patterns are pervasive among people who smoke, particularly among those who currently smoke at a low rate. Corrective education that explains the mechanisms for the increased risk posed by these behaviors could be delivered via package health warnings and/or public health campaigns and may provide low-rate and occasional smokers with additional reasons to quit.

Associations of Blood Lipid-Related Polygenic Scores, Lifestyle Factors and Their Combined Effects with Risk of Coronary Artery Disease in the UK Biobank Cohort

Circulating lipids play a crucial role in the development of coronary artery disease (CAD). However, it is unclear whether the genetic susceptibility to hyperlipidemia may interact with lifestyle factors in CAD risk. Using UK Biobank data from 328,606 participants, we evaluated combined effects of genetic susceptibility to hyperlipidemia and lifestyle factors with risk of CAD. We found that both blood lipid-related polygenic score (PGS) and healthy lifestyle score (HLS) are independently associated with CAD risk, and individuals with the highest-risk lipid-related PGS and the least healthy HLS had the highest CAD risk. This association was stronger in younger (< 60 years, hazard ratio: 4.46, 95% confidence interval: 3.44-5.78) than older adults (2.54, 2.13-3.03). Our study suggests that individuals, particularly younger adults, with higher-risk PGSs of blood lipid traits would benefit more substantially by adherence to a healthy lifestyle than those with lower PGSs.

Assessing Cigarette Reduction Tax-Effectiveness in Low Tobacco Expenditure Contexts: An Application to Bolivia

In this research we show that ambitious increases in tobacco tax rates can substantially reduce tobacco consumption, increase fiscal revenue, and provide net positive social benefits even in contexts of low consumption prevalence and intensity. Low nicotine intake still constitutes a grave disease risk factor, and the effectiveness of tax increases might be questioned if income effects are small. We adapt spatial variation of price methodologies to deal with low prevalence and intensity, censored data, and small samples using the Bolivian case as an illustration. We find an average price elasticity of demand of- 0.69 ${-}0.69$ to- 0.76 ${-}0.76$ . Using our estimates of elasticities, we develop a simulation to anticipate the effects of a 35% yearly increase of the Bolivian specific excise on tobacco starting in 2025. Our estimates show that by 2030, this reform could reduce the consumption of cigarettes by 52.6%, diminish the prevalence of smoking by 30.6%, and increase fiscal revenue by $123 million over six years. Moreover, we estimate that the abated direct medical costs of reduced consumption net of the deadweight loss associated with a tax increase would generate a net social gain of over $100 million in five years.

Smoking history and all-cause, ischaemic heart disease and lung cancer mortality: follow-up study of 358 551 men and women aged 40-43 years

AIMS

We studied the health consequences of quitting smoking before age 43 by time since quitting, number of years smoked and cigarettes smoked per day. The outcomes were all-cause, ischaemic heart disease and lung cancer mortality.

DESIGN

Prospective study.

SETTING

Norwegian counties.

PARTICIPANTS

Men and women aged 40-43 years who participated in a national cardiovascular screening programme and who were followed from 1985 to 2018.

MEASUREMENTS

Self-reports from questionnaire on time since quitting smoking, years smoked and number of cigarettes per day, and measurements of height, weight and blood pressure, and a blood sample where serum was analysed for total serum cholesterol and triglycerides.

FINDINGS

The all-cause mortality rate was 30% higher among quitters less than 1 year ago compared with never smokers (adjusted HR=1.30, 95% CI 1.18-1.43 in men and HR=1.31, 95% CI 1.16 to 1.50 in women). Quitters who had smoked longer than 20 years had 23% higher mortality in men (HR=1.23, 95% CI 1.14 to 1.34) and 32% higher mortality in women (HR=1.32, 95% CI 1.18 to 1.49). Past smoking of more than 20 cigarettes/day was associated with HR=1.14 (1.05-1.23) in men and HR=1.16 (1.01-1.32) in women. The HR for lung cancer was 6.77 (95% CI 4.86 to 9.45) for quitting men who had smoked for more than 20 years compared with never smokers. The corresponding figure for women was 5.75 (95% CI 4.08 to 8.09).

CONCLUSIONS

The mortality among quitters was close to that of never smokers, except for a higher mortality for lung cancer, which on the other hand was much lower than the lung cancer mortality in current smokers.

[Update on cardiovascular prevention 2025]

Despite an expensive healthcare system Germany performs poorly with respect to life-expectancy compared to other countries, for which cardiovascular diseases and deficits in cardiovascular prevention in particular are responsible. The basis of cardiovascular prevention is a healthy lifestyle with regular physical exercise, a predominantly plant-based diet, nonsmoking, good sleep and mental health. In many cases additional lipid-lowering, antidiabetic and antihypertensive medications are necessary. Recent studies have proven the prognostic effects of different groups of medications, such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, sodium-glucose transporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 (GLP-1) receptor agonists, in the appropriate indication areas. To improve the cardiovascular prevention in Germany, intensified public efforts are crucial. In addition, individual support of patients is effective for long-term preventive measures. To achieve this healthcare professionals must be trained (physicians, cardiovascular prevention assistants), who can sustainably support patients in lifestyle modifications and medicinal prevention.

Sex-Specific Multimorbidity-Multibehaviour Patterns in Primary Care Populations

BACKGROUND

A conceptual shift in healthcare emphasises multimorbidity and multibehaviours as interconnected phenomena, highlighting dose-response associations and sex-specific differences. Data-driven approaches have been suggested for overcoming methodological challenges, of multimorbidity research. By using exploratory factor analysis, this study aimed to identify sex specific lifestyle associative multimorbidity patterns, providing valuable evidence to primary care providers and informing future multimorbidity guidelines.

METHODS

A retrospective observational study examined the electronic health records of three general practices in the UK between 2015 and 2018. The participants were aged 18+ with lifestyle multimorbidity, having engaged with multiple health risk behaviours. Stratified exploratory factor analysis with oblique rotation was used to identify sex specific lifestyle associative multimorbidity patterns.

RESULTS

The study included N = 7560 patients, with females comprising 53.9%. Eight independent lifestyle associative multimorbidity patterns were identified and distributed as follows. For females, three patterns emerged: cardiometabolic-neurovascular spectrum disorders (42.97% variance), respiratory conditions (8.08%), and sensory impairment (5.63%), with 25.4% assigned to these patterns. For males, five patterns were revealed: cardiometabolic-vascular spectrum disorders (34.10%), genitourinary (9.19%), respiratory-vision (8.20%), ocular (5.70%), and neurovascular-gastro-renal syndrome (4.54%), with 43%.

CONCLUSIONS

We revealed eight different sex-specific lifestyle-associated patterns, implying the need for tailored clinical approaches. The application of exploratory factor analysis yielded clinically valuable and scientifically rigorous multimorbidity patterns. Clinically, the findings advocate for a paradigm shift towards person-centred care, integrating multimorbidity and SNAP multibehaviours to enhance the complexity of inquiry and treatment of high-risk populations.

Trends in Daily Cigarette Consumption Among Smokers: A Population Study in England, 2008-2023

INTRODUCTION

This study aimed to estimate time trends in cigarette consumption among smokers in England between 2008 and 2023 and to explore differences by key potential moderators.

AIMS AND METHODS

We used data from 57 778 adult cigarette smokers participating in a nationally representative monthly cross-sectional survey between January 2008 and September 2023. We estimated monthly time trends in mean daily consumption of (1) any, (2) manufactured, and (3) hand-rolled cigarettes among all smokers and by main type of cigarettes smoked, smoking frequency, age, gender, occupational social grade, region, nicotine replacement therapy use, and vaping status.

RESULTS

Overall cigarette consumption fell from 13.6 [95% CI = 13.3 to 13.9] to 10.6 [10.5 to 10.8] per day between January 2008 and October 2019 (a 22% decrease), then remained stable up to September 2023. Over this period, the proportion mainly or exclusively smoking hand-rolled cigarettes increased (from 30.6% [29.1%-32.1%] in 2008 to 52.1% [49.7%-54.5%] in 2023). As a result, manufactured cigarette consumption fell by 47%, from 9.5 [9.2-9.8] per day in January 2008 to 5.0 [4.7-5.3] in September 2023, while hand-rolled cigarette consumption increased by 35%, from 4.2 [3.9-4.4] to 5.6 [5.3-5.9], respectively. The decline in overall cigarette consumption was observed across all subgroups, but was greater among non-daily smokers, younger smokers, and those who vaped.

CONCLUSIONS

Over the last 15 years, the average number of cigarettes consumed each day by smokers in England has fallen by almost a quarter, but has plateaued since October 2019. There has been a sharp decline in the number of manufactured cigarettes consumed and an increase in the number of hand-rolled cigarettes consumed, as smokers have increasingly shifted towards using hand-rolled tobacco.

IMPLICATIONS

While average cigarette consumption in England has fallen over the past 15 years, this declining trend has stalled (and reversed in some population groups) since 2019. The availability of cheap, hand-rolled tobacco appears to be undermining policies that aim to reduce smoking by raising the price of tobacco (eg, through taxation) and could be targeted to reignite the decline in cigarette consumption.

Patterns of Use of e-Cigarettes and Their Respiratory Effects: A Critical Umbrella Review

E-cigarettes (ECs) are a well-established consumer product. To study their respiratory health effects, there is the issue of heterogenous patterns of use: concurrently with cigarette smoking (dual use), exclusive use after smoking cessation (exclusive use), or use initiated without any prior or current use of cigarettes (naïve use). Our primary goal was to synthesize the evidence on the respiratory effects of ECs use in adults, categorized by their pattern of use. Additionally, we identified the highest quality systematic reviews and critically evaluated the current literature on this topic. The review was developed with published umbrella review guidelines. The database searches were Medline, Scopus, Cochrane, Epistemonikos, LILACS, and grey literature databases. The criterion for inclusion of systematic reviews was analyses of respiratory tests from randomized controlled trials or cohort studies. Quality assessments were performed with AMSTAR2 and a checklist of reporting biases. A narrative analysis was synthesized by test method: spirometry, impulse oscillometry, breath gasses, biomarkers, and clinical serious adverse events. Twelve systematic reviews were included. The findings on respiratory functioning were statistically non-significant across all patterns of use. Reporting bias was frequently observed. Based on the current research, there is no evidence of significant change in the short or medium term in respiratory function with any pattern of ECs use. We attribute the null findings to the weaknesses of acute studies, the participants' smoking history masking testing, and the inclusion of participants with a low frequency of use.

Effects of very low nicotine cigarettes, e-cigarettes, and nicotine patches on daily own-cigarette abstinence in a randomized controlled switching trial

INTRODUCTION

This research investigated the extent to which three nicotine products promote day-level cigarette substitution during a 1-week switch attempt METHODS: Adults who smoked daily but were not motivated to quit were randomized to 4 weeks using: 1) very low nicotine cigarettes (VLNCs), 2) e-cigarettes, or 3) no product. During two separate switch weeks, participants were instructed to abstain from their own cigarettes and switch to using their study product (if assigned one). Participants were also assigned to use active nicotine patches during one switch week and placebo patches during the other. Nightly smartphone surveys assessed use of participants' own-brand cigarettes. Average marginal effects from a logistic regression model characterized effects of trial design variables on day-level own-cigarette abstinence.

RESULTS

Participants (N = 196) recorded 4998 evening reports. Switch weeks were associated with an average marginal increase in abstinence rate by 27.9 percentage points (p < .001). The switch week effect was significantly larger in the VLNC (35.9 percentage points), and e-cigarette (31.2) groups compared to the no product group (16.4; ps < .05). Use of active patches during the first switch week increased abstinence by 6.9 percentage points on average (p = .010), but use of active patches during the second switch week decreased abstinence probability by 9.6 percentage points (p = .032, difference p = .010) CONCLUSIONS: VLNCs and e-cigarettes meaningfully and equivalently increase the probability of day-level abstinence from one's own cigarettes. Transdermal nicotine promotes cigarette substitution, but only when provided early in the switching process.

Comparison of the associations between life's essential 8 and life's simple 7 with stroke: NHANES 1999-2018

OBJECTIVE

This study aims to explore the association between Life's Essential 8 (LE8) and stroke and all-cause mortality, and compare whether it has an advantage over Life's Simple 7 (LS7).

METHODS

This study investigated data from NHANES spanning from 1999 to 2018. The LE8 was categorized as low, moderate and high cardiovascular health (CVH). LS7 score was categorized as inadequate, average, or optimal. Weighted logistic regression and restricted cubic spline (RCS) were used to examin correlations. Receiver operating characteristic (ROC) curves were employed to detect the accuracy in predicting stroke. The stratified and sensitivity analyses were conducted along with mediation analysis. In addition, a longitudinal cohort was constructed by combining the mortality data, and Cox regression models were utilized to determine the association between CVH and the mortality rate.

RESULTS

For LE8, compared to low CVH, moderate CVH was associated with a 41 % lower risk of stroke, and high CVH was associated with a 71 % lower prevalence of stroke. For LS7, compared to inadequate CVH, average CVH was associated with a 24 % lower prevalence of stroke, and optimal CVH was associated with a 39 % lower prevalence of stroke. RCS showed inverse dose-response relationships of both LE8 and LS7 with stroke. In unweighted ROC, LE8 (AUC = 0.702, 95 % CI: 0.685-0.718, P < 0.001) has a stronger ability to discriminate stroke than LS7 (0.677, 95 % CI: 0.658-0.696, P < 0.001) (PDeLong = 0.046). Sensitivity analyses demonstrated robustness of LE8 in predicting stroke. GGT and WBC mediated 4.92 % and 4.58 % of the association, respectively. Cox regression showed neither LE8 nor LS7 were predictive of mortality risk among stroke survivor.

CONCLUSIONS

LE8 outperformed LS7 in classifying stroke. Oxidative stress and inflammation mediated the association between LE8 and stroke.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Cigarette Smoking and Structural Brain Deficits in Patients With Atrial Fibrillation

Cigarette smoking and atrial fibrillation (AF) are associated with impaired brain health. We investigated the association between smoking habits and brain lesions and volume in patients with AF. In patients with AF from a multicenter cohort study, we assessed smoking status (never, ex-, active), number of cigarettes smoked per day, smoking duration (years), pack-years, and time since smoking cessation. On brain magnetic resonance imaging, the prevalence and volumes of white matter lesions (WML) and small noncortical infarcts, and the volumes of gray matter and white matter were evaluated. Logistic and linear regression analyses were used to analyze the association between smoking habits and brain lesions and volumes. A total of 1,728 patients were enrolled (mean age 72.6 years, 27.5% female); 7.5% were active smokers; 48.5% were ex-smokers, and 44% had never smoked. We found linear associations of number of cigarettes smoked per day, pack-years, and older age at smoking cessation with reduced gray matter volume (p for linear trend <0.01, 0.02, and 0.01, respectively). Patients with a smoking duration in the second and third tertile had a greater risk for WML Fazekas ≥2 (odds ratio 1.86, 95% confidence interval 1.29 to 2.69, p <0.01 and 1.47 [1.02 to 2.12], p = 0.04), and exhibited larger WML volumes. Patients who had stopped smoking ≥16 years before enrollment were less likely to have small noncortical infarcts (odds ratio 0.46, 0.25 to 0.88, p = 0.02) and had smaller WML volumes (β: -0.451 mm3, -0.8 to -0.11, p = 0.01). In conclusion, smoking intensity and time since smoking cessation were associated with the presence and volume of brain lesions and with brain volumes in patients with AF.

Smoking-attributable neurological health loss: age-specific burden and health disparities

BACKGROUND

Smoking is a significant risk factor for neurological disorders, yet its global impact on these conditions remains underexplored.

METHODS

Using Global Burden of Diseases 2021 data, we analysed trends in age-standardised disability-adjusted life-years (DALYs) and deaths attributable to smoking from 1990 to 2021 for three neurological disorders: stroke, Alzheimer's disease and other dementias, and Multiple Sclerosis. Socioeconomic disparities were assessed using the lope index of inequality and the relative concentration index. Bayesian age-period-cohort models were employed to forecast smoking-attributable burden through 2050.

RESULTS

Between 1990 and 2021, annual smoking-attributable DALYs and death rates slightly declined by -1.93% and -1.92%, respectively, but absolute numbers continued to rise, from 26.10 million to 30.18 million DALYs and from 0.93 million to 1.15 million deaths. Older adults (aged 60 and above) experienced the greatest burden, contributing 58.15% of DALYs and 75.57% of deaths in 2021. Smoking-attributable stroke was increasingly concentrated in low sociodemographic index regions, whereas disparities in dementias and multiple sclerosis were more pronounced in socioeconomically advantaged regions, particularly for multiple sclerosis.

CONCLUSIONS

This study identified an age-specific burden and widening disparities for neurological disorders attributable to smoking, with older adults disproportionately experiencing an escalating impact. Targeted prevention and equitable healthcare access tailored for older adults are critical to mitigating smoking-attributable neurological health loss.

Relationship between sleep disorders and depressive symptoms among young women in Japan: a web-based cross-sectional study

OBJECTIVES

Japanese people are known to get the least amount of sleep in the world, and in particular, the increase in sleep deprived young women is a serious problem. Sleep deprivation is considered to be associated with depression, but the factors involved in this problem are unclear. This study aimed to examine the association between sociodemographic factors, lifestyle choices, sleep-related characteristics and depressive symptoms in young Japanese women.

DESIGN

Web-based cross-sectional study.

PARTICIPANTS

We distributed an online survey aiming to recruit young Japanese women ages 18 to 29 from 8 November 2022 to 2 February 2023.

PRIMARY AND SECONDARY OUTCOME MEASURES

Sociodemographic, lifestyle, health, and sleep characteristics were compared among participants according to the presence or absence of depressive symptoms, as assessed by the Patient Health Questionnaire 2 (Cut-off value: 3 points).

RESULTS

Overall, 540 participants aged between 19 and 29 years were enrolled in the study. The overall prevalence of depressive symptoms was 15.6%. The group with depressive symptoms had a higher rate of current smoking status at 38.5% (unadjusted OR 3.716, 95% CI 1.624 to 8.502). Multiple logistic analyses revealed that depressive symptoms were associated with increased sleep onset latency (β=0.282; p=0.048; OR, 1.325; 95% CI, 1.003 to 1.752) and daytime dysfunction (β=0.550; p<0.001; OR, 1.733; 95% CI, 1.281 to 2.343) after adjusting for the effects of smoking habits.

CONCLUSIONS

Depressive symptoms were found to be associated with sleep disorders in young Japanese women, and paying attention to sleep onset latency and daytime dysfunction which are one of the strongest related factors to depressive symptoms could be a clue to improving sleep disorders and depressive symptoms.

Psychosocial interventions for smoking cessation in people with coronary heart disease

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: Primary objective To examine the benefits and harms of different types of psychosocial interventions for smoking cessation in people with CHD. Secondary objectives To examine the benefits and harms of psychosocial interventions aimed solely at smoking cessation compared with multi-risk factor interventions for smoking cessation in people with CHD. To examine the benefits and harms of brief (duration of < one month) compared to extended (duration of ≥ one month) psychosocial interventions for smoking cessation in people with CHD. To explore whether using a validated biochemical assessment versus a self-report of abstinence moderates the effectiveness of smoking cessation interventions in people with CHD. To assess the equity of psychosocial interventions for smoking cessation in people with CHD.

A missing link: The interdependence between sugar-sweetened beverage and cigarette consumption from China

Sugar-sweetened beverages (SSBs) and cigarettes are addictive substances and addictive substances are often related in consumption with each other. However, the potential interdependence between SSB and cigarette consumption has not been explored in the literature. As SSB and cigarette consumption have posed a great threat to individual health, the knowledge of such interdependence is critical for policymakers to design and coordinate government interventions. We thus employed Heckman sample selection model and simultaneous equation model to identify and validate the interdependence between SSB and cigarette consumption across subgroups exhibiting different smoking behaviors with individual-level data from the China Health and Nutrition Survey (CHNS) during the period from 2004 to 2011. We find that SSBs and cigarettes are complements in that individuals who ever smoked are more likely to consume SSBs frequently with higher level of SSB intake eventually and SSB intake of current smokers increases along with the amount of cigarettes smoked. SSBs and cigarettes are also substitutes in that former smokers are more likely to consume SSBs compared with current smokers. The complementary relation observed among current smokers implies that government interventions targeting one of the two goods may yield a double dividend effect on health whereas the substitutable relation displayed by former smokers suggests that the health effect of interventions designed to reduce the consumption of one good may be tempered by an elevated demand for the other.

Occupational exposures and coronary heart disease in the Hamburg City Health Study (HCHS) - a cross-sectional study

BACKGROUND

Coronary heart disease (CHD) is the leading cause of death among adults in Germany. There is evidence that occupational exposure to particulate matter, noise, psychosocial stressors, shift work and high physical workload are associated with CHD. The aim of this study is to identify occupations that are associated with CHD and to elaborate on occupational exposures associated with CHD by using the job exposure matrix (JEM) BAuA-JEM ETB 2018 in a German study population.

METHODS

Cross-sectional data from 8,070 participants, members of the first sub-cohort of the Hamburg City Health Study (HCHS), was used. To classify occupations, we rely on standard occupational titles (ISCO-08). The level of exposure is assigned to each job using a JEM. CHD is measured by self-reported diagnosis. Absolute and relative frequencies were calculated. Using logistic regression, the association of CHD and standard occupation titles via ISCO-08 and the association of CHD and occupational exposures via JEM were calculated and adjusted for potentially confounding covariates. Multiple imputations with chained equations (MICEs) were applied for missing values. Sensitivity analyses were performed.

RESULTS

The CHD prevalence in the study population was 4.6% (95% CI 4.2-5.1). Occupations associated with CHD were Physical and Engineering Science Technicians, Other Health Associate Professionals, General Office Clerks, Secretaries (general), Material Recording and Transport Clerks, Hairdressers, Beauticians and Related Workers, Electronics and Telecommunications Installers and Repairers, Other Craft and Related Workers, Car, Van and Motorcycle Drivers, Mobile Plant Operators and Domestic, Hotel and Office Cleaners and Helpers. Among occupational exposures retrieved from the JEM, Environmental Demands showed an association with CHD in the crude model but not after adjustment. The results remained robust in sensitivity analyses.

CONCLUSIONS

This study is the first to assess the association of a wide range of occupations and occupational exposures with CHD in a German study population. We found no association between occupational exposures and CHD after adjustment, but 11 occupations associated with CHD were identified. The results are limited by cross-sectional design, healthy worker effect (HWE), and small group sizes. Further studies with a larger sample and longitudinal design containing data on occupational history, occupational exposures and time of CHD diagnosis are needed.

Association of remote work with tobacco and alcohol use: a cross-sectional study in Japan

BACKGROUND

Remote work allows one to work free from workplace policy, but it may negatively affect health-related behaviors such as tobacco product use and alcohol drinking. Our study aimed to investigate the association of remote work with tobacco dependence and hazardous alcohol use.

METHODS

This nationwide Internet-based survey was conducted in Japan in February 2023. Using the data of 8,292 workers aged 18 - 64, frequency of remote work (0, < 1, ≥ 1 day per week), tobacco dependence based on the scores of the Tobacco Dependence Screener ≥ 5, hazardous alcohol use based on the scores of the Alcohol Use Disorders Identification Test ≥ 8 were assessed. Then, the associations of frequency of remote work with tobacco dependence and hazardous alcohol use were examined using a multivariable Poisson regression model.

RESULTS

The percentages of remote work 0, < 1, ≥ 1 day per week were 56.6%, 9.9%, and 33.5%, respectively, whereas those of tobacco dependency and hazardous alcohol use were 11.3% and 17.9%, respectively. Remote work < 1 day per week (adjusted prevalence ratio [aPR] 1.30, 95%CI 1.07 - 1.57), and ≥ 1 per week (aPR 1.29, 95%CI 1.13 - 1.47) were associated with tobacco dependence. Further, remote work < 1 day per week (aPR 1.43, 95%CI 1.25 - 1.65), and ≥ 1 per week (aPR 1.40, 95%CI 1.27 - 1.55) were associated with hazardous alcohol use.

CONCLUSIONS

Remote workers showed higher prevalence of tobacco dependence and hazardous alcohol use. The health behavior of remote workers should be carefully monitored.

Cigar, Pipe, and Smokeless Tobacco Use and Cardiovascular Outcomes From Cross Cohort Collaboration

Importance

Cardiovascular health outcomes associated with noncigarette tobacco products (cigar, pipe, and smokeless tobacco) remain unclear, yet such data are required for evidence-based regulation.

Objective

To investigate the association of noncigarette tobacco products with cardiovascular health outcomes.

Design, Setting, and Participants

This cohort study was conducted within the Cross Cohort Collaboration Tobacco Working Group by harmonizing tobacco-related data and conducting a pooled analysis from 15 US-based prospective cohorts with data on the use of at least 1 noncigarette tobacco product ranging between 1948 and 2015. The analysis for this study was conducted between September 2023 and February 2024. The median (IQR) follow-up time for the all-cause mortality outcome was 13.8 (10.2-19.2) years.

Exposure

Current, sole, and exclusive use of noncigarette tobacco products. Sole use refers to using a noncigarette tobacco product without currently smoking cigarettes. Exclusive use means using only the noncigarette tobacco product and never having smoked cigarettes.

Main Outcomes and Measures

Myocardial infarction, stroke, heart failure, atrial fibrillation, total coronary heart disease, total cardiovascular disease (CVD), coronary heart disease mortality, CVD mortality, and all-cause mortality.

Results

Of 103 642 participants (mean [SD] age, 55.7 [13.2] years; 49 550 female [47.8%] and 54 092 male [52.2%]), current use rates were 26 962 participants (26.3%) for cigarettes, 1147 participants (2.1%) for cigars, 530 participants (1.2%) for pipes, and 1410 participants (2.1%) for smokeless tobacco. Current cigar use was associated with stroke (hazard ratio [HR], 1.25; 95% CI, 1.01-1.55), atrial fibrillation (HR, 1.32; 95% CI, 1.13-1.53), and heart failure (HR, 1.29; 95% CI, 1.10-1.51) compared with never using cigars in the model adjusted for demographic and socioeconomic factors, cardiovascular risk factors, and cohort. Sole (HR, 1.34; 95% CI, 1.12-1.62) and exclusive (HR, 1.53; 95% CI, 1.20-1.96) cigar use was associated with stroke compared with never using cigars or cigarettes. Current pipe use was associated with heart failure (HR, 1.23; 95% CI, 1.01-1.49) compared with never using pipes, and sole pipe use was associated with myocardial infarction (HR, 1.43; 95% CI, 1.17-1.74) compared with never using pipes or cigarettes. Current use of smokeless tobacco was associated with coronary heart disease mortality (HR, 1.31; 95% CI, 1.08-1.59) and myocardial infarction (HR, 1.20; 95% CI, 1.03-1.39) compared with never using smokeless tobacco. Sole and exclusive smokeless tobacco use demonstrated associations with total CVD (HR, 1.34; 95% CI, 1.19-1.50 and HR, 1.34; 955 CI, 1.13-1.59, respectively), total coronary heart disease (HR, 1.41; 95% CI, 1.21-1.64 and HR, 1.36; 95% CI, 1.08-1.70, respectively), heart failure (HR, 1.41; 95% CI, 1.22-1.64 and HR, 1.70; 95% CI, 1.40-2.06, respectively), and cardiovascular (HR, 1.41; 95% CI, 1.20-1.65 and HR, 1.54; 95% CI, 1.24-1.91, respectively) and all-cause (HR, 1.46; 95% CI, 1.34-1.60 and HR, 1.39; 95% CI, 1.22-1.58, respectively) mortality compared with never using smokeless tobacco or cigarettes.

Conclusions and Relevance

In this study, there were distinct risk patterns associated with the use of noncigarette tobacco products. These findings may carry implications for public health and regulation of noncigarette tobacco products.

Quantitative assessment of lung structure changes in low-intensity smokers: a retrospective study in a Chinese male cohort

Background

With an increasing number of smokers who consume fewer cigarettes, it is crucial to understand the lung structure changes of low-intensity smoking. This study aimed to investigate the lung structure changes in low-intensity smokers in a Chinese male cohort.

Methods

Chest computed tomography (CT) examinations of 465 asymptomatic healthy male participants were divided into non-smoking (n=256), light-smoking (n=84), intermediate-smoking (n=85), and heavy-smoking (n=40) groups. Low-intensity smokers (fewer than 10 cigarettes per day) were included (n=32), and a new group of non-smokers was generated using propensity score matching according to age. Quantitative CT parameters, including the volume of the intrapulmonary vessel (IPVV), the volume of the lung, mean lung density (MLD), the low-attenuation areas below -910 Hounsfield units (LAA-910), and the volume ratio of intrapulmonary vessel to the lung for the total lung and each lobe were measured. Quantitative CT parameters were compared among the four smoking groups and also between the low-intensity smokers and non-smokers. Binary logistic regression was used to determine the independent quantitative CT measurements of smoking intensity.

Results

Compared with that in non-smokers, the IPVV and the MLD of the total lung and five lobes was significantly higher in light smokers (P<0.05); meanwhile, the LAA-910 of the total lung and five lobes of the light and intermediate smokers were significantly lower (P<0.05). The IPVV of the total lung and five lobes was significantly higher in the low-intensity smoking group (P<0.05). The IPVV of the total lung was the independent factor for discriminating between the non-smokers and light smokers (odds ratio =1.040; 95% confidence interval: 1.027-1.053) and between the non-smokers and low-intensity smokers (odds ratio =1.034; 95% confidence interval: 1.013-1.055).

Conclusions

CT-quantified measurements of the IPVVs and MLD increased in light and intermediate smokers. The IPVV of the total lung was selected as the independent factor between non-smokers and light smokers and between non-smokers and low-intensity smokers.

Cigarette smoking extract induces mitochondrial dysfunction and apoptosis in HUVECs via the Sirt1-SHH axis

IntroductionCigarette smoking extract (CSE) can cause endothelial cell (EC) dysfunction, and then promote the occurrence and development of atherosclerosis. However, the molecular mechanisms underlying CSE-induced EC dysfunction are unknown. Sirt1, as a deacetylase, is involved in various biological processes of ECs. Therefore, this study investigated whether CSE induces apoptosis and mitochondrial dysfunction in human umbilical vein endothelial cells (HUVECs) via Sirt1-dependent mechanisms.MethodsHUVEC activity was assessed using MTT and crystal violet staining following treatment with different concentrations of CSE. Lentiviral transfection technology was used to generate HUVECs overexpressing Sirt1. Apoptosis was detected by Tunnel staining. MitoTracker™ Deep Red FM and JC-1 were used to assess mitochondrial structure and membrane potential. ELISA was used to detect the expression of superoxide dismutase (SOD) and malondialdehyde (MDA). qPCR was used to determine mRNA expression. Atherosclerosis was evaluated by oil red O staining in ApoE-KO mice after cigarette smoke exposure.ResultsCSE decreased Sirt1 and sonic hedgehog (SHH) expression, leading to mitochondrial dysfunction and apoptosis in HUVECs. Overexpressing Sirt1 or activating the SHH signaling pathway attenuated CSE-induced apoptosis and mitochondrial dysfunction. However, inhibiting the SHH signaling axis attenuated the protective effect of Sirt1 overexpression on CSE-induced apoptosis and mitochondrial dysfunction. In vivo studies also showed that cigarette smoke exacerbated atherosclerosis in ApoE-KO mice, downregulating Sirt1, SHH, and Gli1 expression in the aorta. Additionally, cigarette smoke increased Bax expression and decreased Bcl-2 expression in ApoE-KO mice aortas.DiscussionsSmoking can affect all stages of the atherosclerosis process, and the specific mechanism remains unclear. This study confirms that CSE can induce mitochondrial dysfunction and apoptosis of HUVECs by reducing Sirt1 expression and inhibiting SHH signaling activation. These findings provide new insights into the prevention and treatment of smoking-induced atherosclerosis.

Insulin resistance, vulnerable plaque and stroke risk in patients with carotid artery stenosis

Insulin resistance (IR) is linked to both the vulnerable plaque and the stroke risk. However, the precise extent of this correlation and its impact on stroke risk in carotid artery stenosis patients remain unclear. Therefore, this study aims to investigate the relationship between vulnerable plaque and IR and stroke risk and the mediating role of vulnerable plaque in patients with carotid artery stenosis. This study included 505 patients with carotid artery stenosis. IR was assessed using the triglyceride-glucose (TyG) index. The association of the TyG index and vulnerable plaque with stroke risk was investigated using the restricted cubic splines (RCS)and adjusted Logistic regression. Additionally, the mediation analysis was used to explore the mediating impact of the vulnerable plaque on the association between the TyG index and stroke risk. A total of 184 (36.4%) stroke events were recorded. The RCS curves revealed a positive linear association between TyG index and risk events among patients with carotid artery stenosis (P-value < 0.001 and P for nonlinear = 0.860). After fully adjusting for covariates, both the TyG index and vulnerable plaque emerged as significant predictors of stroke events. Mediation analysis indicated that the vulnerable plaque mediated 18.3%, 15.8%, 13.9%, and 11.6% of the correlation between the TyG index and stroke risk in different adjusted models, respectively. TyG index and vulnerable plaque are associated with a higher risk of stroke in patients with carotid artery stenosis. In addition, vulnerable plaques partially mediated the relationship between TyG index and stroke risk.

The Proper Calculation of Risk Ratios: How and Why

A recent article (Joslyn, P. R., & Morris, S. L. in Perspectives on Behavior Science, 47(1), 167-196, 2024) advocates the use of risk ratios, or relative risk, in behavior analysis. The authors present a strong case for the use of risk ratios and how they might improve the science and application of behavior analysis. Unfortunately, their computation of the risk ratio is incorrect and their examples gloss over important nuances in how risk ratios should be used. The present article corrects the calculations, describes how to determine whether a particular risk ratio differs from a reference group, comments on the importance of stability of the data entering the calculation, and demonstrates approaches to presenting them visually, such as Forest plots.

Network analysis of smoking-related sleep characteristics in Chinese adults

The associations between multiple sleep characteristics and smoking behavior are inconsistent, and it is unclear which sleep characteristics are most crucial for tobacco prevention. This study aimed to explore the associations between smoking status/intensity and multiple sleep characteristics and to identify the potential core domain of smoking-related sleep using network analysis. Data were obtained from a survey of cancer-related risk factors among Chinese adults. Logistic regression models were used to quantify the associations between sleep characteristics and smoking status/intensity. Network analyses were employed to identify the core sleep characteristics. A total of 5,228 participants with a median age of 44 years old were included in the study. Current smoking was significantly positively associated with long nap time, difficulty falling asleep, late bedtime, getting up after 7 am, and waking up earlier than expected. There was significant positive association between current smoking and short sleep duration in young adults under 45 years old. Late bedtime and getting up after 7 am were only associated with current heavy smoking, but not current light smoking. Network analyses showed that multiple smoking-related sleep characteristics were interconnected, with difficulty falling asleep and late bedtime as central characteristics in the network. The study found that the associations between sleep characteristics and smoking varied by age and smoking intensity and highlights the potential benefits of sleep health promotion in smoking cessation, with a particular focus on difficulty falling asleep and late bedtime.

2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2024 Guideline for the Primary Prevention of Stroke" replaces the 2014 "Guidelines for the Primary Prevention of Stroke." This updated guideline is intended to be a resource for clinicians to use to guide various prevention strategies for individuals with no history of stroke.

METHODS

A comprehensive search for literature published since the 2014 guideline; derived from research involving human participants published in English; and indexed in MEDLINE, PubMed, Cochrane Library, and other selected and relevant databases was conducted between May and November 2023. Other documents on related subject matter previously published by the American Heart Association were also reviewed.

STRUCTURE

Ischemic and hemorrhagic strokes lead to significant disability but, most important, are preventable. The 2024 primary prevention of stroke guideline provides recommendations based on current evidence for strategies to prevent stroke throughout the life span. These recommendations align with the American Heart Association's Life's Essential 8 for optimizing cardiovascular and brain health, in addition to preventing incident stroke. We also have added sex-specific recommendations for screening and prevention of stroke, which are new compared with the 2014 guideline. Many recommendations for similar risk factor prevention were updated, new topics were reviewed, and recommendations were created when supported by sufficient-quality published data.

Pragmatic Application of Risk Ratios in Behavior Analysis

Joslyn and Morris (2024) recently published a tutorial on adapting and applying risk ratios to within-subject behavioral data. Newland (2024; this issue) offers a commentary on Joslyn and Morris that expands the discussion of risk ratios and how they are typically applied in group comparison research. He is also critical of the approach described by Joslyn and Morris, and advocates against its use primarily because it differs from the traditional calculation. Although we agree with many of Newland's assertions about the benefits of the traditional approach, we disagree that it is the only method of evaluating relative risk that may be useful to behavior analysts. In this response to Newland, we summarize and respond to his concerns, discuss our own concerns with his perspective, consider variables that may affect the relative utility of the two approaches, and provide concluding remarks.

Poor sleep duration and E-cigarette/Cigarette use among US adults with cardiovascular diseases: findings from the 2022 BRFSS cross-sectional study

BACKGROUND

Studies have explored the connections between tobacco use, sleep and cardiovascular disease (CVD) risks in adults, but no study has examined the link between tobacco use and sleep among adults with CVDs. This study explores the association between tobacco use (cigarette only, e-cigarette only, and dual use) and poor sleep duration among adults with CVDs.

METHODS

A sample of 47,180 US adults with CVDs (myocardial infarction, coronary heart disease, or stroke) was drawn from the 2022 Behavioral Risk Factor Surveillance System (BRFSS) cross-sectional survey. Poor/inadequate sleep (< 7 h/24-hour) was defined based on National Sleep Foundation recommendations. Logistic regression models assessed tobacco use status across seven categories (i.e., non-use [reference], current [past-month use] cigarette only, current e-cigarettes only, current dual use, former cigarette only, former e-cigarette only, and former dual use) with inadequate sleep, adjusting for demographics and health conditions.

RESULTS

Overall, 40% of US adults with a history of CVD reported inadequate sleep. Current cigarette, e-cigarette, and dual use were associated with a relatively higher proportion of inadequate sleep duration. Unweighted findings revealed a significant association between current cigarette use (OR = 1.35, 95%CI: 1.26-1.44), e-cigarette use (1.40 [1.19-1.63]) and dual use (1.50 [1.27-1.77]) and increased odds of reporting inadequate sleep among adults with CVDs. Weighted analysis showed only a significant link between current cigarette use and inadequate sleep (1.34 [1.17-1.54]).

CONCLUSIONS

Current cigarette use is associated with poor sleep in adults with CVDs. Unweighted findings suggested a similar association for e-cigarettes. Interventions targeting smoking cessation may offer promising avenues for improving sleep health and reducing the burden on adults with CVDs.

A Narrative Review of the Best Anesthesia Care for Endovascular Thrombectomy: Early Diagnosis of the Ischemic Stroke and Evaluation of Risk Factors in Female Population

Background: The increasing incidence of cerebrovascular accidents represents an emerging problem. The rise in risk factors such as lifestyle choices—smoking, poor nutrition, and metabolic diseases—poses a significant challenge for the global healthcare system. The female population, due to physiological conditions and iatrogenic risks, may be at a greater risk of developing ischemic accidents. In addition to these acquired conditions, life phases such as pregnancy or puerperium, and medical conditions like surgical treatments and hormone therapy, may elevate this risk. Methods: This narrative aims to assess the various risk factors specific to the female population and evaluate the appropriate management strategies, including anesthetic support. Anesthesia plays a crucial role in enabling pharmacological procedures, such as thrombolysis, or surgical procedures like thrombectomy, in the management of ischemic cerebrovascular events. Results: The review emphasizes the importance of early recognition of risk factors to ensure prompt diagnosis and the most appropriate treatment options for ischemic events. Anesthesia support has become essential for carrying out necessary medical interventions effectively. Choosing the right anesthesia technique for endovascular thrombectomy is particularly significant, requiring consideration of the patient’s characteristics, the timing of diagnosis, and the preferences of the interventional neuroradiologists. Conclusions: It is vital to identify risk factors in the female population early to facilitate timely diagnosis and optimize treatment outcomes. Anesthetic support plays a key role in ensuring that critical procedures, such as thrombolysis and thrombectomy, are carried out effectively. Tailoring anesthesia choices to the patient’s individual needs is critical for a successful intervention.

Modeling the determinants of smoking behavior among young adults in Khuzestan province: a two-level count regression approach

Purpose

This study investigates the determinants of smoking behavior among young adults in Khuzestan province, southwest Iran, using two-level count regression models. Given the high prevalence of smoking-related diseases and the social impact of smoking, understanding the factors influencing smoking habits is crucial for effective public health interventions.

Methods

We conducted a cross-sectional analysis of 1,973 individuals aged 18-35 years, using data from the Daily Smoking Consumption Survey (DSCS) in Khuzestan province collected in 2023. A variety of count regression models, including Poisson, Negative Binomial, Conway-Maxwell Poisson, and their zero-inflated counterparts, were evaluated. The best-fitting model was selected based on goodness-of-fit indices.

Results

Approximately 90% of participants were non-smokers. Among smokers, the prevalence of light, moderate, and heavy smoking was 47.7, 19.0, and 33.3%, respectively. The two-level Zero-Inflated Conway-Maxwell Poisson (ZICMP) model provided the appropriate fit for the data. Key determinants of daily cigarette consumption included gender, age, education, and Body Mass Index (BMI). Men consumed 3.24 times more cigarettes per day than women. Higher education levels were inversely related to smoking intensity, with MSc/PhD holders having significantly lower smoking rates. Age and BMI also significantly influenced smoking behavior, with younger and obese individuals showing lower smoking rates.

Conclusion

The use of advanced count models capable of handling numerous zeros and overdispersion is crucial for accurately analyzing trends in cigarette consumption across different population groups. The results indicate that factors such as older age, lower education levels, and gender differences influence smoking behavior. Therefore, prevention strategies aimed at delaying the onset of smoking, particularly among men, and promoting education among adolescents can effectively reduce smoking rates. However, further research should consider additional socioeconomic variables and encompass a broader age range to enhance the understanding of smoking behavior.

The impact of behavioral risks on cardiovascular disease mortality in China between 1990 and 2019

Aims

Behavioral risks including tobacco use, alcohol use, low physical activity and dietary risks had been proven to contribute to the pathological process in cardiovascular diseases (CVD). Herein the lethal effects attributable to behavioral risks on CVD in China were investigated.

Methods

Data were obtained from the Global Burden of Disease Study 2019. Joinpoint regression analyses and age-period-cohort models were applied.

Results

In China, the total number of CVD deaths attributable to tobacco use, alcohol use, low physical activity and dietary risks in 2019 was 0.98, 0.19, 0.13 and 1.76 million, with an age-standardized rate of 51.2, 9.9, 8.9 and 101.9 per 100 000 people, respectively. Joinpoint analyses suggested a general favorable trend in age-standardized rate of attributable CVD mortality for tobacco use (average annual percent change [AAPC]: -0.9 %, P < 0.001), alcohol use (AAPC: -0.8 %, P < 0.001) and dietary risks (AAPC: -1.3 %, P < 0.001), but unchanged trend for low physical activity (AAPC: 0.2 %, P = 0.525) since 1990. Period effects suggested an improvement in attributable CVD mortality rate across the study period for alcohol use and dietary risks, but more favorable period trends were observed over the past 15 years for tobacco use and before the period 2000-2004 for low physical activity. The patterns for cohort effects differed markedly between men and women. In women, cohort effects revealed an inverted hook-shaped pattern for all these behavioral risks, with the highest risk in cohort born around 1915. In men, the improvement was mainly observed in cohorts born before 1980 for tobacco use and dietary risks, in cohorts born before 1965 for alcohol use, and in cohorts born between 1925 and 1955 for low physical activity.

Conclusion

Behavioral risks, especially the dietary risks, brought out huge burden of CVD in China, and their trajectories differed along with time and genders. Much more priorities should be established to ameliorate the impact of behavioral risks on CVD in China.

E-cigarettes, synthetic nicotine, heated-tobacco and smokeless nicotine delivery products: the nicotine landscape beyond combustible cigarettes

Cigarette smoking remains an enormous public health problem causing millions of preventable deaths annually worldwide. Although safe and efficient smoking cessation pharmacotherapies such as nicotine replacement products and the medications varenicline and bupropion are available, long-term abstinence rates remain low and new approaches to help smokers successfully quit smoking are needed. In recent years, electronic nicotine delivery systems such as e-cigarettes and heated-tobacco products, and novel smokeless nicotine delivery products like nicotine pouches have gained widespread popularity. These products can deliver nicotine without combustion of tobacco and might thus present an alternative to the currently available smoking cessation methods if they prove able to help smokers quit smoking conventional cigarettes while decreasing their exposure to toxicants. In this narrative review, we provide a summary of the characteristics of these novel nicotine delivery products and the available data regarding their efficacy as smoking cessation tools and safety profile with a focus on the current situation in Switzerland.

Aryl hydrocarbon receptor repressor ( AHRR ) methylation predicts risk of vascular disease: A cohort study of the general population

AIMS

Smoking is a risk factor for cardiovascular disease, but there is currently no clinically established biomarker for its cardiovascular damage. We aimed to investigate the hypothesis that aryl hydrocarbon receptor repressor ( AHRR ) methylation at CpG site cg05575921, a biomarker of smoking behavior, is associated with the risk of peripheral artery disease (PAD) and aortic aneurysm (AA) in the general population.

METHODS AND RESULTS

In this prospective cohort study of the general population, we measured AHRR methylation in individuals from three visits to the Copenhagen City Heart Study. Information on risk factors was collected at visits with 10 years intervals; visit 1 (1991-1994), visit 2 (2001-2003), and visit 3 (2011-2015). Individuals were followed up in the Danish National Patient Register for PAD and AA until December 2018. Subhazard ratios were calculated using Fine and Gray competing risk regression. In 11 332 individuals from visit 1 ( n =9234), visit 2 ( n =5384), and visit 3 ( n =4387), there were 613 and 219 events of PAD and AA during up to 26.5 years of follow-up. AHRR hypomethylation was associated with a higher risk of PAD and AA with multivariable-adjusted subhazard ratios of 2.82 (1.91; 4.15) for PAD and 2.88 (1.42; 5.88) for AA in individuals within the lowest versus highest methylation quintile.

CONCLUSIONS

We found that AHRR methylation, a strong biomarker for smoking, was associated with the risk of PAD and AA. AHRR methylation could be a useful tool in more personalized risk prediction of PAD and AA.

Risk factors for stroke-related pneumonia in patients with ischaemic stroke: A systematic evaluation and meta-analysis

BACKGROUND

Stroke-associated pneumonia (SAP) is a frequent and severe complication occurring within the first week after a stroke, particularly in ischemic stroke (IS) patients. SAP is primarily driven by stroke-induced immune suppression, dysphagia, and impaired consciousness, leading to aspiration and subsequent pneumonia. Its incidence ranges from 3.9 % to 12 %, making it a leading cause of mortality and morbidity in stroke survivors. Despite previous studies identifying risk factors such as age, and dysphagia, the results have often been inconsistent due to methodological differences and the inclusion of both ischemic and hemorrhagic stroke patients.

OBJECTIVE

This study aims to provide a comprehensive and targeted analysis of SAP risk factors specific to IS patients through a systematic review and meta-analysis, with the goal of enhancing clinical risk assessment and prevention strategies.

METHODS

This study searched eight databases-PubMed, EMBASE, Web of Science, Cochrane Library, CNKI, VIP, CBM, and Wanfang-for literature on risk factors for SAP in IS patients, with a timeframe of January 1, 2014, to April 6, 2024. Using Revman 5.4, the odds ratio values and 95 % confidence intervals for each collected risk factor were combined and analysed to explore the risk factors for the development of SAP in patients with ischemic stroke.

RESULTS

A total of 25 studies were included, involving 4,251,064 patients and 153,431 SAP patients. We identified 68 potential risk factors for SAP in IS patients from 25 studies, with detailed analysis performed on 13 factors. The remaining factors were not included in the combined analysis due to insufficient supporting literature (fewer than five studies). Out of 13 risk factors, 11 were determined to be associated with the occurrence of SAP, including age, gender, smoking, diabetes, swallowing disorders, with a timeframe of January 1, 2014, to April 6, 2024. chronic lung disease, consciousness disorders, a high NIHSS score, elevated white blood cell count, elevated CRP, and nasogastric tube.

CONCLUSION

This study identified major risk factors for SAP in IS patients, confirming some existing factors in current assessment scales, such as advanced age, impaired consciousness, and dysphagia. Additionally, new risk factors were identified, including nasogastric tube use, and diabetes. These findings will help improve risk assessment tools, facilitate early identification of SAP risk factors, and prevent SAP occurrence, thereby improving outcomes for IS patients.

REGISTRATION

This systematic review according to the Preferred Reporting Items for Systematic Evaluation and Meta-Analysis (PRISMA) guidelines [1] and is registered in PROSPERO (Registration No: CRD42024548441).

Joint Modifiable Risk Factor Control and Incident Stroke in Hypertensive Patients

Recent guidelines have recognized several factors, including blood pressure (BP), body mass index (BMI), low-density lipoprotein cholesterol (LDL-C), hemoglobin A1c (HbA1c), smoking, and physical activity, as key contributors to stroke risk. However, the impact of simultaneous management of these risk factors on stroke susceptibility in individuals with hypertension remains ambiguous. This study involved 238 388 participants from the UK Biobank, followed up from their recruitment date until April 1, 2023. Cox proportional hazard models with hazard ratios (HRs) and 95% confidence intervals (CIs) were used to illustrate the correlation between the joint modifiable risk factor control and the stroke risk. As the degree of risk factor control increased, a gradual reduction in stroke risk was observed. Hypertensive patients who had the optimal risk factor control (≥5 risk factor controls) had a 14.6% lower stroke risk than those who controlled 2 or fewer (HR: 0.854; 95% CI: 804-0.908; p < 0.001). The excess risk of stroke linked to hypertension slowly diminished as the number of controlled risk factors increased. However, the risk was still 25.1% higher for hypertensive patients with optimal risk factor control as compared to the non-hypertensive population (HR: 1.251; 95% CI: 1.100-1.422; p < 0.001). The protective effect of joint risk factor control against the stroke risk due to hypertension was stronger in medicated hypertensive patients than in those not medicated. This finding leads to the conclusion that joint risk factor control combined with pharmacological treatment could potentially eliminate the excess risk of stroke associated with hypertension.

Associations between daytime napping, sleep duration, and depression and 15 cardiovascular diseases: a Mendelian randomization study

Background

Numerous studies have documented the effects of daytime napping, sleep duration, and depression on cardiovascular diseases (CVDs). However, the evidence has been gleaned from observational studies that might be riddled with confounding variables and the possibility of reverse causation bias. Therefore, the present study employed a Mendelian randomization (MR) methodology to meticulously explore the relationships between daytime napping, sleep duration, and depression, and the risk profiles of CVDs.

Methods

Genome-wide significant genetic variants associated with daytime napping, sleep duration, and depression were used as the instrumental variables (IVs). Data on the genetic correlations between these IVs and 15 CVDs were derived from the United Kingdom (UK) Biobank, Finnish Genome Studies, and other large-scale collaborations. We conducted both univariate and multivariate MR analyses to assess the overall effects and mediated relationships after adjusting for potential confounders, including body mass index (BMI), smoking status, and type 2 diabetes. The effect sizes were estimated using inverse variance-weighted (IVW) regression.

Results

The MR analysis revealed that an increased risk of heart failure (HF) [odds ratio (OR): 1.366; 95% confidence interval (CI): 1.013-1.842; P=0.04], coronary atherosclerosis (OR: 1.918; 95% CI: 1.257-2.927; P=0.003), myocardial infarction (MI) (OR: 1.505; 95% CI: 1.025-2.211; P=0.04), and coronary artery disease (CAD) (OR: 1.519; 95% CI: 1.130-2.043; P=0.006) was significantly associated with genetically predicted daytime napping. Prolonged sleep duration was found to be related to a reduced risk of HF (OR: 0.995; 95% CI: 0.993-0.998; P=2.69E-04), peripheral vascular disease (PVD) (OR: 0.984; 95% CI: 0.971-0.997; P=0.02), and CAD (OR: 0.997; 95% CI: 0.994-0.999; P=0.006). Additionally, a statistically significant positive relationship was observed between depressive disorders and the occurrence of atrial fibrillation (AF) (OR: 1.298, 95% CI: 1.065-1.583, P=0.01), indicating a heightened susceptibility. The multivariable MR analyses substantiated the reliability of the observed associations between daytime napping and the incidence of HF and CAD, following adjustments for genetically predicted BMI and smoking. The sensitivity analysis did not reveal any evidence of horizontal pleiotropy or heterogeneity, thus supporting the validity of the study's results.

Conclusions

This MR investigation posits a potential causal nexus between daytime napping, sleep duration, and depression, and the genesis of CVDs, offering new perspectives on the prevention and management of CVDs.

Low-intensity daily smoking and mortality risk among Mexican women

OBJECTIVE

To examine the association between low-intensity smoking (10 or less cigarettes per day) and all-cause and cause-specific mortality risk among women who smoke and by age at cessation among women who previously smoked.

METHODS

In this study, 104 717 female participants of the Mexican Teachers' Cohort Study were categorised according to self-reported smoking status at baseline (2006/2008) and were followed for mortality through 2019. We estimated HRs and 95% CIs for all-cause and cause-specific mortality using multivariable Cox proportional hazards regression models with age as the underlying time metric.

RESULTS

Smoking as few as one to two cigarettes per day was associated with higher mortality risk for all causes (HR: 1.36; 95% CI 1.10 to 1.67) and all cancers (HR: 1.46; 95% CI 1.05 to 2.02), compared with never smoking. Similarly, slightly higher HRs were observed among participants smoking ≥3 cigarettes per day (all causes HR: 1.43; 95% CI 1.19 to 1.70; all cancers HR: 1.48; 95% CI 1.10 to 1.97; cardiovascular disease HR: 1.58; 95% CI 1.09 to 2.28).

CONCLUSIONS

In this large study of Mexican women, low-intensity smoking was associated with higher mortality risk for all causes and all cancers. Interventions are needed to promote cessation among women who smoke at low-intensity in Mexico, regardless of how few cigarettes they smoke per day.

Lifestyle and cardiovascular risk in working young adults: insights from a nationwide Spanish cohort

INTRODUCTION AND OBJECTIVES

This study aimed to describe the cardiovascular risk profile of working young adults from Spain and its association with lifestyle.

METHODS

Participants (18-30 years) were recruited from a nationwide cohort of economically active adults insured by a large occupational risk prevention company, with data obtained from routine medical assessments. The participants were categorized as having an "unhealthy" cardiovascular risk profile based on the presence of prediabetes/diabetes, prehypertension/hypertension, or hypercholesterolemia, or a "healthy" profile if these conditions were completely absent. The association with lifestyle factors (weight, physical activity, sleeping characteristics, alcohol consumption, smoking) was assessed.

RESULTS

A total of 78 421 young adults (27±2 years, 36% female) were evaluated at baseline. The "unhealthy" cardiovascular risk profile was prevalent (18%) and inversely associated (OR, 0.64; 95%CI, 0.57-0.80) with an optimal lifestyle (normal weight, regular physical activity, no drinking/smoking, and good sleep). The latter condition was found in only 3.5% of the participants. On the other hand, prospective analyses in 44 776 participants (median follow-up=2 [range 2-5] years) showed that 2.0% transitioned from a "healthy" to an "unhealthy" profile. Being physically active (OR, 0.95; 95%CI, 0.81-0.99) and having a normal weight (OR, 0.61; 95%CI, 0.51-0.70) were associated with a lower likelihood of this transition. No consistent associations were found for other lifestyle factors.

CONCLUSIONS

The prevalence of cardiovascular risk factors is high in economically active young Spanish adults. An unhealthy cardiovascular risk profile is inversely associated with an optimal lifestyle, but the latter is highly infrequent in this population.

Patterns of Use of e-Cigarettes and Their Respiratory Effects: Protocol for an Umbrella Review

BACKGROUND

Electronic nicotine delivery systems (ENDS)-e-cigarettes or vapes-have been shown to substantially reduce or eliminate many toxins compared with cigarette smoke, but simultaneously ENDS use also produces their own unique toxins. Yet the patterns of use among people who use ENDS are not homogeneous. Some people who use ENDS also smoke cigarettes (dual use). Other people who formerly smoked cigarettes are completely substituting ENDS (exclusive use). A small number of people who have never smoked cigarettes are using ENDS (naïve use of nicotine). Each of these patterns of use results in different exposures to toxins. Unfortunately, epidemiological studies routinely group together any ENDS use regardless of other tobacco use.

OBJECTIVE

This umbrella review primarily aims to present all the evidence available on the respiratory effects of ENDS use by adults based on their pattern of use: dual use, exclusive use, and naïve use. With each of these patterns of use, are there benefits, no changes, or harmful effects on respiratory functioning? Our objective is to provide clinicians with a detailed analysis of how different patterns of ENDS use impact respiratory functioning and to point to the best sources of evidence.

METHODS

This umbrella review follows the Methods for Overviews of Reviews framework and the PRIOR (Preferred Reporting Items for Overviews of Reviews) statement. Systematic reviews published since 2019 will be searched across 4 databases and 3 gray literature sources. Additional searches will include citation chasing, references lists, and referrals from respiratory specialists. The quality of included reviews will be evaluated using the AMSTAR2 (A Measurement Tool to Assess Systematic Reviews) checklist. We will document biases in 3 areas: protocol deviations, biases from the Oxford Catalogue of Bias, and internal data discrepancies. Two reviewers will independently conduct the search and quality assessments. Our analysis will focus on reviews rated as moderate or high confidence by AMSTAR2. We will use the Vote Counting Direction of Effect method to manage expected data heterogeneity, assessing whether ENDS use is beneficial or detrimental, or has no effect on respiratory functions based on the pattern of use.

RESULTS

The review is expected to be completed by December 2024. The database search was concluded in April 2024, and data extraction and bias assessment were completed in June 2024. The analysis phase is planned to be completed by October 2024.

CONCLUSIONS

A thorough and comprehensive assessment of the evidence will better inform the contentious debate over the respiratory effects of ENDS providing much needed clarity by linking their effects to specific usage patterns. This analysis is particularly crucial in understanding the risks associated with continued cigarette smoking.

TRIAL REGISTRATION

PROSPERO CRD42024540034; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=540034.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/60325.

E-Cigarette Use in Adults

This JAMA Insights explores the adverse effects and health outcomes of e-cigarettes vs combusted cigarettes and the effectiveness of using e-cigarettes as a smoking cessation aid among US adults.

Association between baseline levels of muscular strength and risk of stroke in later life: The Cooper Center Longitudinal Study

BACKGROUND

Muscular strength is an important component of physical fitness. We evaluated the relationship between baseline muscular strength and risk of stroke among adults who were aged ≥65 years during follow-up.

METHODS

We included 7627 healthy adults (mean age = 43.9 years, 86.0% male) underwent a baseline physical examination between 1980 and 1989. Muscular strength was determined by 1-repetition maximum measures for bench press and leg press and categorized into age- and sex-specific tertiles for each measure. Cardiorespiratory fitness (CRF) was assessed via a maximal treadmill exercise test. Those enrolled in fee-for-service Medicare from 1999 to 2019 were included in the analyses. Associations between baseline strength and stroke outcomes were estimated using a modified Cox proportional hazards model. In a secondary analysis, we examined stroke risk by categories of CRF where Quintile 1 = low, Quintiles 2-3 = moderate, and Quintiles 4-5 = high CRF based on age and sex.

RESULTS

After 70,072 person-years of Medicare follow-up, there were 1211 earliest indications of incident stroke. In multivariable analyses, the hazard ratio (95% confidence interval (95%CI)) for stroke across bench press categories were 1.0 (referent), 0.96 (0.83-1.11), and 0.89 (0.77-1.04), respectively (p trend = 0.14). The trend across categories of leg press was also non-significant (p trend = 0.79). Adjusted hazard ratio (95%CI) for stroke across ordered CRF categories were 1.0 (referent), 0.90 (0.71-1.13), and 0.72 (0.57-0.92) (p trend < 0.01).

CONCLUSION

While meeting public health guidelines for muscular strengthening activities is likely to improve muscular strength as well as many health outcomes in older adults, performing such activities may not be helpful in preventing stroke. Conversely, meeting guidelines for aerobic activity is likely to improve CRF and lower stroke risk.

Cardiovascular disease and cancer: shared risk factors and mechanisms

Cardiovascular disease (CVD) and cancer are among the leading causes of morbidity and mortality globally, and these conditions are increasingly recognized to be fundamentally interconnected. In this Review, we present the current epidemiological data for each of the modifiable risk factors shared by the two diseases, including hypertension, hyperlipidaemia, diabetes mellitus, obesity, smoking, diet, physical activity and the social determinants of health. We then review the epidemiological data demonstrating the increased risk of CVD in patients with cancer, as well as the increased risk of cancer in patients with CVD. We also discuss the shared mechanisms implicated in the development of these conditions, highlighting their inherent bidirectional relationship. We conclude with a perspective on future research directions for the field of cardio-oncology to advance the care of patients with CVD and cancer.

2024 Guidelines of the Taiwan Society of Cardiology on the Primary Prevention of Atherosclerotic Cardiovascular Disease --- Part I

Atherosclerotic cardiovascular disease (ASCVD) is one of the leading causes of death worldwide and in Taiwan. It is highly prevalent and has a tremendous impact on global health. Therefore, the Taiwan Society of Cardiology developed these best-evidence preventive guidelines for decision-making in clinical practice involving aspects of primordial prevention including national policies, promotion of health education, primary prevention of clinical risk factors, and management and control of clinical risk factors. These guidelines cover the full spectrum of ASCVD, including chronic coronary syndrome, acute coronary syndrome, cerebrovascular disease, peripheral artery disease, and aortic aneurysm. In order to enhance medical education and health promotion not only for physicians but also for the general public, we propose a slogan (2H2L) for the primary prevention of ASCVD on the basis of the essential role of healthy dietary pattern and lifestyles: "Healthy Diet and Healthy Lifestyles to Help Your Life and Save Your Lives". We also propose an acronym of the modifiable risk factors/enhancers and relevant strategies to facilitate memory: " ABC2D2EFG-I'M2 ACE": Adiposity, Blood pressure, Cholesterol and Cigarette smoking, Diabetes mellitus and Dietary pattern, Exercise, Frailty, Gout/hyperuricemia, Inflammation/infection, Metabolic syndrome and Metabolic dysfunction-associated fatty liver disease, Atmosphere (environment), Chronic kidney disease, and Easy life (sleep well and no stress). Some imaging studies can be risk enhancers. Some risk factors/clinical conditions are deemed to be preventable, and healthy dietary pattern, physical activity, and body weight control remain the cornerstone of the preventive strategy.

Associations between dimensions of the social environment and cardiometabolic health outcomes: a systematic review and meta-analysis

OBJECTIVES

The social environment (SE), that is, the social relationships and social context in which groups of people live and interact, is an understudied element of the broader living environment which impacts health. We aim to summarise the available evidence on the associations between SE and cardiometabolic disease (CMD) outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Scopus and Web of Science Core Collection were searched from inception to 28 February 2024.

ELIGIBILITY CRITERIA

We included studies for which determinants were SE factors such as area-level deprivation and social network characteristics and outcomes were type 2 diabetes mellitus and cardiovascular diseases incidence and prevalence.

DATA EXTRACTION AND SYNTHESIS

Titles and abstracts and full text were screened in duplicate. Data appraisal and extraction were based on the study protocol published in PROSPERO. Methodological quality was assessed with the Newcastle-Ottawa Scale. We synthesised the data through vote counting and meta-analyses.

RESULTS

From 10 143 records screened, 281 studies reporting 1108 relevant associations are included in this review. Of the 384 associations included in vote counting, 271 (71%) suggested that a worse SE is associated with a higher risk of CMD. 14 meta-analyses based on 180 associations indicated that worse SE was associated with increased odds of CMD outcomes, with 4 of them being statistically significant. For example, more economic and social disadvantage was associated with higher heart failure risk (OR 1.58, 95% CI 1.08 to 1.61; n=18; I2=95%). With the exception of two meta-analyses for men, meta-analysed sex-specific associations consistently showed results in the same direction as the overall meta-analyses.

CONCLUSION

Worse SE seems to be associated with increased odds of CMD outcomes, although certain SE dimensions are underexplored in relation to CMD.

PROSPERO REGISTRATION NUMBER

CRD42021223035.

Effects of smoking cessation on endothelial function as assessed by flow-mediated total dilation

BACKGROUND

In assessing the effects of smoking cessation on endothelial function, low-flow-mediated constriction (L-FMC) may provide complementary information to flow-mediated dilation (FMD). However, the value of flow-mediated total dilation (FMTD), an index that incorporates L-FMC into FMD, remains underreported. We aimed to evaluate the effect of smoking cessation on endothelial function, as assessed by FMD and FMTD, and clarify its associated clinical factors.

METHODS

We enrolled 118 consecutive current smokers without previous coronary artery disease (72.9% were men; age: 59 ± 11 years) who underwent smoking cessation treatment. The clinical variables %FMD, %L-FMC, and %FMTD were examined before and 20 weeks after treatment initiation. A multivariate linear regression model was used to investigate the effects of smoking cessation on %FMD and %FMTD and the interaction between smoking cessation and baseline clinical variables.

RESULTS

After 20 weeks, 85 smokers (69.4% were men; age: 59 ± 12 years) ceased smoking (abstainers), whereas 33 smokers (81.8% were men; age: 58 ± 11 years) did not (continued smokers). The estimated group differences (abstainers - continued smokers) in changes in the %FMD and %FMTD were 0.77% (95% confidence interval [CI], -0.22-1.77%; p = 0.129) and 1.17% (95% CI, 0.16-2.18%; p = 0.024), respectively. Smoking cessation-associated improvement in %FMTD was greater in women than in men (5.41% [95% CI, 3.15-7.67%] versus 0.24% [95% CI, -0.81-1.28%]; p-value for interaction, < 0.001). Additionally, a greater %FMTD improvement was observed in patients who smoked fewer cigarettes per day (p-value for interaction, 0.042) and those who had a smaller resting baseline lumen diameter (Dbase) (p-value for interaction, 0.023).

CONCLUSIONS

Smoking cessation was associated with an improvement in %FMTD. Sex, cigarettes smoked per day, and Dbase significantly affected this improvement. The FMTD may help in risk stratification after smoking cessation.

Lifestyle-Related Risk Factors and Primary Prevention Strategies for Cardiovascular Diseases in a Middle-Income Country: A Scoping Review and Implication for Future Research

Cardiovascular diseases are the leading cause of death in middle-income countries such as Malaysia. There is a significant gap in knowledge between cardiovascular disease-related risk assessments and interventions in the Malaysian population. In this scoping review, we have determined the status of cardiovascular research in Malaysia by prioritising lifestyle-related risk assessments and interventions. We searched five electronic databases (Ovid MEDLINE, Cochrane Central Register of Controlled Trials, APA PsychINFO, Embase and Scopus) to identify relevant research articles that had been published. The Joanna Briggs Institute and the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews served as a guide for the scoping review. Study selection was made using the Covidence platform, screened, and extracted. Thirty-one studies were included in this review. Studies reviewed reported a significant positive association between physical inactivity, smoking, poor dietary patterns, working hours, clustering of lifestyle risk, and cardiovascular disease risk. Most interventions focused on physical activity and a multimodal lifestyle approach, significantly improving primary and secondary cardiovascular disease-related outcomes. The findings suggest improving lifestyle-related risk assessments and interventions to prevent cardiovascular diseases in this population. It is unclear if these outcomes can translate to higher effectiveness in preventing cardiovascular disease. Nevertheless, intervention using the multifaceted lifestyle approach can improve cardiovascular disease-related outcomes.

The correlation between smoking cumulative dose based on Brinkman Index with peak expiratory flow rate

Background

Indonesia is the country with the highest prevalence of smokers above 15 years old according to WHO, with a percentage of 76.2%. Smoking-induced lung damage is characterized by inflammation, leading to the destruction of lung parenchyma and airway obstruction, ultimately worsening lung function parameters. This study aims to find correlation between cumulative dose of smoking based on Brinkman index (BI) with Peak Expiratory Flow Rate (PEFR).

Methods

This is a cross-sectional correlative study conducted on January-March 2020. Data were collected through history taking and PEFR measured with a peak flowmeter by taking the average of three peak flowmeter measurements, each separated by a 2-min interval. Inclusion criteria include male active smokers, aged 30 to 40 years, who have had a smoking history for at least 1 year. Exclusion criteria are as follows: uses e-cigarretes for smoking, has a history of chronic lung diseases such as tuberculosis, pneumonia, post-COVID-19 syndrome, asthma, and has not smoked in the last 28 days.

Results

A total of 48 male smokers are included in this study. The mean age of participants was 35.91 years, with a history of smoking of 18.12 years, and 12.5 cigarettes smoked daily. Patients included in this study had BI classified as mild (47.91%), moderate (47.91%), and severe (4.16%). PEFR in patients was classified into green (10.41%), yellow (83.33%), and red (6.25%). Analysis showed significant negative correlation between BI and PEFR (r = -0.721; p < 0.001) suggesting that increasing Brinkman Index may lead to a decrease in PEFR.

Conclusion

Higher BI correlates with a decrease in PEFR. PEFR may prove to be useful in early detection of reduced pulmonary function. Further trials conducted on larger sample sizes and evaluating other lung function parameters are recommended.

Impact of switching from cigarette smoking to tobacco heating system use on biomarkers of potential harm in a randomized trial

BACKGROUND

Smoking cessation reduces the risk of developing smoking-related diseases. Although smoking prevalence has declined, many continue smoking cigarettes. Switching completely to smoke-free alternatives like the Tobacco Heating System (THS) 2.2-a heated tobacco product for which there is evidence demonstrating significantly reduced formation and exposure to harmful chemicals compared to cigarettes-has the potential to reduce the harm caused by continuing to smoke cigarettes.

METHODS

We conducted a 6-month clinical study (NCT02396381) with a 6-month extension (NCT02649556), initially randomizing 984 adult smokers to continue smoking or switch to THS (non-mentholated), of which 672 continued into the extension study. Endpoints were evaluated at baseline and at 3, 6, and 12 months. We longitudinally assessed biomarkers of potential harm (BoPHs) known to be reversible upon smoking cessation as indicators of pathways involved in the pathogenesis of cardiovascular or respiratory diseases and carcinogenicity. The need to cough and safety profile were also assessed. Impact on eight key BoPHs was used as a proxy to evaluate harm reduction potential.

RESULTS

At 12 months, comparison of BoPH levels between the predominant THS use and cigarette smoking groups showed a positive effect in favor of switching, partially or in full, to THS.

CONCLUSION

These results provide additional evidence of the harm reduction potential of THS for smokers who would otherwise continue smoking, but they need to be verified in long-term confirmatory studies.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT0264955. Date of registration: January 7, 2016 https://clinicaltrials.gov/ct2/show/NCT02649556.