Health consequences of sustained smoking cessation

Co-action and changes in alcohol use during a smoking cessation attempt

AIMS

Three smoking cessation studies (CARE, Break Free, Por Nuestra Salud [PNS]) were used to measure changes in average alcohol consumption, binge drinking and alcohol-related problems during a smoking cessation attempt and to explore co-action with smoking abstinence.

DESIGN

CARE and PNS were longitudinal cohort cessation studies; Break Free was a two-arm randomized clinical trial.

SETTING

Texas, USA.

PARTICIPANTS

Participants were current smokers who were recruited from the community and received smoking cessation interventions. All participants received nicotine replacement therapy and smoking cessation counseling. CARE included 424 smokers (1/3 White, 1/3 African American and 1/3 Latino); Break Free included 399 African American smokers; PNS included 199 Spanish-speaking Mexican-American smokers.

MEASUREMENTS

Weekly alcohol consumption was collected multiple times pre and post-quit, and binge drinking and alcohol-related problems were collected at baseline and 26 weeks post-quit. Analyses included only those who indicated current alcohol use.

FINDINGS

Average alcohol consumption decreased from baseline to 26 weeks post-quit in CARE (F = 17.09, P < 0.001), Break Free (F = 12.08, P < 0.001) and PNS (F = 10.21, P < 0.001). Binge drinking decreased from baseline to 26 weeks post-quit in CARE (F = 3.94, P = 0.04) and Break Free (F = 10.41, P < 0.001) but not PNS. Alcohol-related problems decreased from baseline to 26 weeks post-quit in CARE (Chi-sq = 6.41, P = 0.010) and Break Free (Chi sq = 14.44, P = 0.001), but not PNS.

CONCLUSIONS

Among current drinkers, alcohol use/problems appear to decrease during a smoking cessation attempt and remain low through 26 weeks after the quit attempt. Little evidence was found for co-action, with smoking abstainers and relapsers showing similar change in alcohol use/problems.

Should Nicotine Replacement Therapy be Provided Free of Charge? A Cost-Utility Analysis in Sweden

INTRODUCTION

Treatment with nicotine replacement therapy (NRT) during an attempt to quit smoking increases the likelihood of success by about 55%. However, out-of-pocket payment for NRT can hinder its use.

AIMS AND METHODS

This study aims therefore to assess the cost-effectiveness of subsidizing NRT in Sweden. A homogeneous cohort-based Markov model was used to assess the lifetime costs and effects of subsidized NRT from a payer and societal perspective. Data to populate the model were retrieved from the literature, and selected parameters were varied in deterministic and probabilistic sensitivity analyses to assess robustness of model outputs. Costs are presented in USD, year 2021.

RESULTS

A 12-week treatment with NRT was estimated to cost USD 632 (474-790) per person. From a societal perspective, subsidized NRT was a cost-saving alternative in 98.5% of the simulations. NRT is cost-saving across all ages, but the health and economic gains are somewhat larger among younger smokers from a societal perspective. When a payer perspective was used, the incremental cost-effectiveness ratio was estimated at 14 480 (11 721-18 515) USD per QALY which was cost-effective at a willingness to pay of 50 000 USD per QALY in 100 % of the simulations. Results were robust with realistic changes in the inputs during scenario and sensitivity analyses.

CONCLUSIONS

Subsidizing NRT is potentially a cost-saving smoking cessation strategy from a societal perspective and cost-effective from a payer perspective.

IMPLICATIONS

This study found that subsidizing NRT is potentially a cost-saving smoking cessation policy alternative compared to current practice from a societal perspective. From a healthcare payer perspective, subsidizing NRT is estimated to cost USD 14 480 to gain an extra QALY. NRT is cost-saving across all ages, but the health and economic gains are somewhat larger among younger smokers from a societal perspective. Moreover, subsidizing NRT removes the financial barriers that are mostly faced by socioeconomically disadvantaged smokers which might reduce health inequalities. Thus, future economic evaluations should further investigate the health inequality impacts with methods that are more suitable for this.

Clustering and trajectories of key noncommunicable disease risk factors in Norway: the NCDNOR project

Noncommunicable diseases (NCDs) are a leading cause of premature death globally and have common preventable risk factors. In Norway, the NCDNOR-project aims at establishing new knowledge in the prevention of NCDs by combining information from national registries with data from population-based health studies. In the present study, we aimed to harmonize data on key NCD risk factors from the health studies, describe clustering of risk factors using intersection diagrams and latent class analysis, and identify long-term risk factor trajectories using latent class mixed models. The harmonized study sample consisted of 808,732 individuals (1,197,158 participations). Two-thirds were exposed to ≥ 1 NCD risk factor (daily smoking, physical inactivity, obesity, hypertension, hypercholesterolaemia or hypertriglyceridaemia). In individuals exposed to ≥ 2 risk factors (24%), we identified five distinct clusters, all characterized by fewer years of education and lower income compared to individuals exposed to < 2 risk factors. We identified distinct long-term trajectories of smoking intensity, leisure-time physical activity, body mass index, blood pressure, and blood lipids. Individuals in the trajectories tended to differ across sex, education, and body mass index. This provides important insights into the mechanisms by which NCD risk factors can occur and may help the development of interventions aimed at preventing NCDs.

Evaluating an alcohol harm-reduction campaign advising drinkers of the alcohol-cancer link

INTRODUCTION

Public awareness of the alcohol-cancer link is low. Provision of this information could reduce alcohol consumption and related harms. The Spread campaign is a multi-media education campaign implemented in Western Australia to inform people about the carcinogenic properties of alcohol and associated harms. The aims of the present study were to (i) examine attitudinal and behavioural outcomes of the Spread campaign and (ii) identify demographic and drinking status factors associated with enactment of harm-reduction behaviours resulting from exposure.

METHOD

A cross sectional survey of Western Australian drinkers (consumed alcohol at least a few times in the previous 12 months, n = 760) examined campaign recognition, campaign perceptions, and behaviours resulting from campaign exposure. Chi-square analyses and a generalised linear model were used to identify demographic and alcohol-related factors associated with behavioural outcomes.

RESULTS

Around two-thirds of respondents recognised the campaign (65%), and of these, 22% reported successfully reducing how often or how much they drank due to seeing the campaign. Three quarters (73%) of all respondents considered the campaign message about the alcohol-cancer link to be believable. Respondents drinking at levels above the Australian guideline were less likely to have positive perceptions of the campaign than those complying with the guideline, but were more likely to report enacting the assessed harm-reduction behaviours as a result of campaign exposure.

DISCUSSION AND CONCLUSION

The results suggest that provision of information about the alcohol-cancer link has the potential to motivate reduced alcohol consumption. Implementing such campaigns could constitute an effective alcohol harm-reduction strategy.

The Use of Biomarkers to Guide Precision Treatment for Tobacco Use

This review summarizes the evidence to date on the development of biomarkers for personalizing the pharmacological treatment of combustible tobacco use. First, the latest evidence on FDA-approved medications is considered, demonstrating that, while these medications offer real benefits, they do not contribute to smoking cessation in approximately two-thirds of cases. Second, the case for using biomarkers to guide tobacco treatment is made based on the potential to increase medication effectiveness and uptake and reduce side effects. Next, the FDA framework of biomarker development is presented along with the state of science on biomarkers for tobacco treatment, including a review of the nicotine metabolite ratio, electroencephalographic event-related potentials, and other biomarkers utilized for risk feedback. We conclude with a discussion of the challenges and opportunities for the translation of biomarkers to guide tobacco treatment and propose priorities for future research.

Tools for Assessing Cardiovascular Disease Risk Factors in Underserved Young Adult Populations: A Systematic Review

Cardiovascular disease (CVD, i.e., disease of the heart and blood vessels) is a major cause of death globally. Current assessment tools use either clinical or non-clinical factors alone or in combination to assess CVD risk. The aim of this review was to critically appraise, compare, and summarize existing non-clinically based tools for assessing CVD risk factors in underserved young adult (18–34-year-old) populations. Two online electronic databases—PubMed and Scopus—were searched to identify existing risk assessment tools, using a combination of CVD-related keywords. The search was limited to articles available in English only and published between January 2008 and January 2019. Of the 10,383 studies initially identified, 67 were eligible. In total, 5 out of the 67 articles assessed CVD risk in underserved young adult populations. A total of 21 distinct CVD risk assessment tools were identified; six of these did not require clinical or laboratory data in their estimation (i.e., non-clinical). The main non-clinically based tools identified were the Heart Disease Fact Questionnaire, the Health Beliefs Related to CVD-Perception measure, the Healthy Eating Opinion Survey, the Perception of Risk of Heart Disease Scale, and the WHO STEPwise approach to chronic disease factor surveillance (i.e., the STEPS instrument).

Quality of smoking cessation advice in guidelines of tobacco-related diseases: An updated systematic review

Tobacco smoking is a major risk factor for a wide range of diseases, and smoking cessation significantly reduces these risks. Clinical guidelines for diseases associated with smoking should therefore include guidance on smoking cessation. This review updated evidence on the proportion of clinical guidelines that do so. We conducted a systematic review investigating clinical guidelines and recommendations developed by UK national or European transnational medical specialty associations and societies between January 2014 and October 2019 on 16 diseases to be at least twice as common among smokers than non-smokers. Outcomes of interest were the reporting of smoking as a risk factor, and the inclusion either of smoking cessation advice or referral to other cessation guidance. We compared our findings with an earlier review of guidelines published between 2000 and 2013. We identified 159 clinical guidelines/recommendations. Over half (51%) made no mention of smoking, while 43% reported smoking as a risk factor for the development of the disease, 31% recommended smoking cessation and 19% provided detailed information on how to deliver smoking cessation support. These proportions were similar to those in our earlier review. Smoking cessation continues to be neglected in clinical management guidance for diseases caused by smoking.

Evaluation of the Taking Texas Tobacco Free Workplace Program within behavioral health centers

Despite the health benefits of tobacco control and cessation initiatives, tobacco users with behavioral health disorders (BHDs) have less access to evidence-based tobacco dependence treatment. Academic-community partnerships can help guide the translation of tobacco-related research findings and evidence-based guidelines into real-world applications. Through a comprehensive, evidence-based, multilevel, and multicomponent program, Taking Texas Tobacco Free (TTTF) facilitated the implementation of tobacco-free workplaces at 18 local mental health authorities in Texas, comprising over 250 individual community behavioral health centers. Compared with preprogram implementation, key accomplishments postimplementation include: (1) educated over 5,000 employees (nonclinical staff and providers) on the hazards of tobacco use and benefits of quitting, particularly among people with BHD; providers were additionally trained on the use of evidence based practices (EBPs; i.e. 5A's model, use of pharmacotherapy) to identify and treat tobacco use among people with BHD; (2) providers' significant increase in conducting tobacco-use assessments and using EBPs; (3) significant decrease in nonclinical staff tobacco use; (4) increase in quit attempts among consumers as evidenced by the demand for nicotine replacement therapy; and (5) reach to over 115,000 community members through outreach and education about the benefits of quitting tobacco use and maintaining a healthy lifestyle. TTTF demonstrated that the implementation of a comprehensive tobacco-free workplace program in behavioral health settings is feasible and beneficial, facilitating the capacity building of healthcare professionals and enhancing their resulting engagement in EBPs, and promoting healthier lifestyles among employees, consumers, and community members as a whole.

Discussions of Alcohol Use in an Online Social Network for Smoking Cessation: Analysis of Topics, Sentiment, and Social Network Centrality

BACKGROUND

Few Internet smoking cessation programs specifically address the impact of alcohol use during a quit attempt, despite its common role in relapse. This study used topic modeling to describe the most prevalent topics about alcohol in an online smoking cessation community, the prevalence of negative sentiment expressed about alcohol use in the context of a quit attempt (i.e., alcohol should be limited or avoided during a quit attempt) within topics, and the degree to which topics differed by user social connectivity within the network.

METHODS

Data were analyzed from posts from the online community of a larger Internet cessation program, spanning January 1, 2012 to May 31, 2015 and included records of 814,258 online posts. Posts containing alcohol-related content (n = 7,199) were coded via supervised machine learning text classification to determine whether the post expressed negative sentiment about drinking in the context of a quit attempt. Correlated topic modeling (CTM) was used to identify a set of 10 topics of at least 1% prevalence based on the frequency of word occurrences among alcohol-related posts; the distribution of negative sentiment and user social network connectivity was examined across the most salient topics.

RESULTS

Three salient topics (with prevalence ≥10%) emerged from the CTM, with distinct themes of (i) cravings and temptations; (ii) parallel between nicotine addiction and alcoholism; and (iii) celebratory discussions of quit milestones including "virtual" alcohol use and toasts. Most topics skewed toward nonnegative sentiment about alcohol. The prevalence of each topic differed by users' social connectivity in the network.

CONCLUSIONS

Future work should examine whether outcomes in Internet interventions are improved by tailoring social network content to match user characteristics, topics, and network behavior.

Smoking as a risk factor for lung cancer in women and men: a systematic review and meta-analysis

OBJECTIVES

To investigate the sex-specific association between smoking and lung cancer.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched PubMed and EMBASE from 1 January 1999 to 15 April 2016 for cohort studies. Cohort studies before 1 January 1999 were retrieved from a previous meta-analysis. Individual participant data from three sources were also available to supplement analyses of published literature.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Cohort studies reporting the sex-specific relative risk (RR) of lung cancer associated with smoking.

RESULTS

Data from 29 studies representing 99 cohort studies, 7 million individuals and >50 000 incident lung cancer cases were included. The sex-specific RRs and their ratio comparing women with men were pooled using random-effects meta-analysis with inverse-variance weighting. The pooled multiple-adjusted lung cancer RR was 6.99 (95% Confidence Interval (CI) 5.09 to 9.59) in women and 7.33 (95% CI 4.90 to 10.96) in men. The pooled ratio of the RRs was 0.92 (95% CI 0.72 to 1.16; I2=89%; p<0.001), with no evidence of publication bias or differences across major pre-defined participant and study subtypes. The women-to-men ratio of RRs was 0.99 (95% CI 0.65 to 1.52), 1.11 (95% CI 0.75 to 1.64) and 0.94 (95% CI 0.69 to 1.30), for light, moderate and heavy smoking, respectively.

CONCLUSIONS

Smoking yields similar risks of lung cancer in women compared with men. However, these data may underestimate the true risks of lung cancer among women, as the smoking epidemic has not yet reached full maturity in women. Continued efforts to measure the sex-specific association of smoking and lung cancer are required.

Implementation of a tobacco-free workplace program at a local mental health authority

Tobacco-free workplace policies that incorporate evidence-based practices can increase the reach and effectiveness of tobacco dependence treatment among underserved populations but may be underutilized due to limited knowledge about implementation processes. This paper describes the implementation of a comprehensive tobacco-free workplace program at a behavioral healthcare community center in Texas. The center participated in a tobacco-free workplace program implementation project that provided guidance and resources and allowed center autonomy in implementation. Six employee-based subcommittees guided implementation of program components including consumer and staff surveys, policy development, signage, tobacco use assessments, communication, and nicotine replacement distribution. Timeline development, successes, challenges, lessons learned, and sustainability initiatives are delineated. Concerns about the tobacco-free workplace policy from the center's staff and consumers were gradually replaced by strong support for the initiative. Program success was enabled by consistent support from the center's leadership, publicity of program efforts, and educational campaigns. The center surpassed the program expectations when it adopted a tobacco-free hiring policy, which was not an initial program goal. This center's path to a tobacco-free workplace provides an implementation and sustainability model for other behavioral health community centers and other organizations to become tobacco free.

Reconceptualizing motivation for smoking cessation among people with rheumatoid arthritis as incentives and facilitators

OBJECTIVES

Smokers with rheumatoid arthritis (RA) may have different motivations for, and barriers to, quitting. Understanding the motivations of smokers and ex-smokers with RA will help in the design and implementation of targeted smoking cessation interventions for people with RA that are not based solely on extrapolation from the general population or populations with other chronic illnesses.

METHODS

Twenty-nine smokers and 10 recent ex-smokers with RA participated in semi-structured interviews via telephone 18 months after being offered a smoking cessation intervention in Aotearoa/New Zealand. The sample consisted of 27 women and 12 men (age range 32-78 years), of whom 14 had received the intervention, 14 had been in the control group and 11 had declined participation in the trial.

RESULTS

Thematic analysis led to the formulation of four "incentives" to quit and five "facilitators" of quitting for people with RA. Desiring improvements to health (overall and specific to arthritis), social relationships and avoiding costs were incentives to quit. Coping with stress without smoking, commitment, mental preparedness, willpower and interventions were facilitators of quitting.

CONCLUSIONS

Becoming aware of the effects of smoking on arthritis provides an important motivation to quit smoking that may counter RA-specific barriers to smoking cessation. Further research is needed to test whether similar incentives and facilitators of smoking cessation exist in other chronic illnesses, and how to develop interventions to address these motivational processes.

Combined treatment for at-risk drinking and smoking cessation among Puerto Ricans: A randomized clinical trial

Tobacco and alcohol use are linked behaviors that individually and synergistically increase the risk for negative health consequences. This study was a two-group, randomized clinical trial evaluating the efficacy of a behavioral intervention, "Motivation And Problem Solving Plus" (MAPS+), designed to concurrently address smoking cessation and the reduction of at-risk drinking. Targeted interventions may promote coaction, the likelihood that changing one behavior (smoking) increases the probability of changing another behavior (alcohol use). Puerto Ricans (N=202) who were smokers and at-risk drinkers were randomized to standard MAPS treatment focused exclusively on smoking cessation (S-MAPS), or MAPS+, focused on cessation and at-risk drinking reduction. Drinking outcomes included: number of at-risk drinking behaviors, heavy drinking, binge drinking, and drinking and driving. MAPS+ did not have a significant main effect on reducing at-risk drinking relative to S-MAPS. Among individuals who quit smoking, MAPS+ reduced the number of drinking behaviors, the likelihood of meeting criteria for heavy drinking relative to S-MAPS, and appeared promising for reducing binge drinking. MAPS+ did not improve drinking outcomes among individuals who were unsuccessful at quitting smoking. MAPS+ showed promise in reducing at-risk drinking among Puerto Rican smokers who successfully quit smoking, consistent with treatment enhanced coaction. Integrating an alcohol intervention into cessation treatment did not reduce engagement in treatment, or hinder cessation outcomes, and positively impacted at-risk drinking among individuals who quit smoking. Findings of coaction between smoking and drinking speak to the promise of multiple health behavior change interventions for substance use treatment and chronic disease prevention.

Pharmacotherapy for smoking cessation: pharmacological principles and clinical practice

Strategies for assisting smoking cessation include behavioural counselling to enhance motivation and to support attempts to quit and pharmacological intervention to reduce nicotine reinforcement and withdrawal from nicotine. Three drugs are currently used as first line pharmacotherapy for smoking cessation, nicotine replacement therapy, bupropion and varenicline. Compared with placebo, the drug effect varies from 2.27 (95% CI 2.02, 2.55) for varenicline, 1.69 (95% CI 1.53, 1.85) for bupropion and 1.60 (95% CI 1.53, 1.68) for any form of nicotine replacement therapy. Despite some controversy regarding the safety of bupropion and varenicline, regulatory agencies consider these drugs as having a favourable benefit/risk profile. However, given the high rate of psychiatric comorbidity in dependent smokers, practitioners should closely monitor patients for neuropsychiatric symptoms. Second-line pharmacotherapies include nortriptyline and clonidine. This review also offers an overview of pipeline developments and issues related to smoking cessation in special populations such as persons with psychiatric comorbidity and pregnant and adolescent smokers.

Cost-effectiveness of extended cessation treatment for older smokers

AIMS

We examined the cost-effectiveness of extended smoking cessation treatment in older smokers.

DESIGN

Participants who completed a 12-week smoking cessation program were factorial randomized to extended cognitive behavioral treatment and extended nicotine replacement therapy.

SETTING

A free-standing smoking cessation clinic.

PARTICIPANTS

A total of 402 smokers aged 50 years and older were recruited from the community.

MEASUREMENTS

The trial measured biochemically verified abstinence from cigarettes after 2 years and the quantity of smoking cessation services utilized. Trial findings were combined with literature on changes in smoking status and the age- and gender-adjusted effect of smoking on health-care cost, mortality and quality of life over the long term in a Markov model of cost-effectiveness over a lifetime horizon.

FINDINGS

The addition of extended cognitive behavioral therapy added $83 in smoking cessation services cost [P = 0.012, confidence interval (CI) = $22-212]. At the end of follow-up, cigarette abstinence rates were 50.0% with extended cognitive behavioral therapy and 37.2% without this therapy (P < 0.05, odds ratio 1.69, CI 1.18-2.54). The model-based incremental cost-effectiveness ratio was $6324 per quality-adjusted life year (QALY). Probabilistic sensitivity analysis found that the additional $947 in lifetime cost of the intervention had a 95% confidence interval of -$331 to 2081; the 0.15 additional QALYs had a confidence interval of 0.035-0.280, and that the intervention was cost-effective against a $50 000/QALY acceptance criterion in 99.6% of the replicates. Extended nicotine replacement therapy was not cost-effective.

CONCLUSIONS

Adding extended cognitive behavior therapy to standard cessation treatment was cost-effective. Further intensification of treatment may be warranted.

[Consequences of hospitalisations on smoking behaviour in psychiatric and somatic inpatients]

BACKGROUND

To examine the differences and potential changes that occur in smoking habits among psychiatric and somatic patients due to and during their hospital stay in a general hospital.

METHODS

Inpatients of three departments (psychiatry,cardiology, pulmology) were given a questionnaire that asked for epidemiologic data and their smoking habits,including the Fagerstrom-Test. In order to achieve sufficient data, the questionnaire was administered twice on two different dates. Primary goal of this examination was to determine a potential change in smoking behaviour whereas the secondary goal was to check for differences between psychiatric and somatic inpatients and within the psychiatric diagnostic groups according to their smoking habits respectively. According to a lack of normal distribution of the data non parametric tests undvisual classifying were used for statistical analysis.

RESULTS

A substantial proportion (26.4 %) of psychiatric inpatients reported an increase in cigarette consumption or have restarted or newly started smoking cigarettes are due to their admission. On the other hand, none of the somatic patients did so, actually they showed higher proportion of being non-smokers. There were statistically significant differences between psychiatric and somatic patients in two age-groups due to their change in smoking habits and severity of nicotine dependence as measured by the Fagerstrom-test. Among the psychiatric patients sampled, those with schizophrenia and affective disorders showed high prevalence of being highly addicted smokers in 85.7 and 44.4 % respectively.

CONCLUSIONS

As a result of this small sample and hindered comparability of somatic and psychiatric groups of inpatients further investigations are needed to evaluate the influence of hospitalisations on smoking behaviour and to tailor suitable actions

The hazards of death by smoking in middle-aged women

Recent studies have found that the risk of death continues to increase among female smokers, as compared with women who have never smoked. We wanted to examine the effect of smoking on all-cause and cause-specific mortality and calculate the corresponding population attributable fraction (PAF) of mortality in the Norwegian women and cancer study; a nationally representative prospective cohort study. We followed 85,320 women, aged 31–70 years, who completed a questionnaire in 1991–1997, through linkages to national registries through December 2008. Questionnaire data included information on lifestyle factors, including lifetime history of smoking. Poisson regression models were fitted to estimate relative risks (RRs) with 95 % confidence intervals (CIs) adjusting for age, birth cohort, education, postmenopausal status, alcohol consumption and body mass index, all at enrollment. During a mean follow-up time of 14 years 2,842 deaths occurred. Compared with that of never smokers, current smokers had a mortality rate that was double (RR = 2.34; 95 % CI 2.13–2.62) from deaths overall, triple (RR = 3.30; 95 % CI 2.21–4.82) from cerebrovascular disease and myocardial infarction (RR = 3.65; 95 % CI 2.18–6.15), 12 times (RR = 12.16; 95 % CI 7.80–19.00) from lung cancer and seventeen times (RR = 17.00; 95 % CI 5.90–48.78) from chronic obstructive pulmonary diseases. The PAF of mortality due to smoking was 34 % (CI 30–39). In summary, one in three deaths among middle aged women in Norway could have been prevented if the women did not smoke. More middle-aged women, than ever before, are dying prematurely due to smoking in Norway.

Estimating the decline in excess risk of cerebrovascular disease following quitting smoking--a systematic review based on the negative exponential model

We attempted to quantify the decline in stroke risk following quitting using the negative exponential model, with methodology previously employed for IHD. We identified 22 blocks of RRs (from 13 studies) comparing current smokers, former smokers (by time quit) and never smokers. Corresponding pseudo-numbers of cases and controls/at risk formed the data for model-fitting. We tried to estimate the half-life (H, time since quit when the excess risk becomes half that for a continuing smoker) for each block. The method failed to converge or produced very variable estimates of H in nine blocks with a current smoker RR <1.40. Rejecting these, and combining blocks by amount smoked in one study where problems arose in model-fitting, the final analyses used 11 blocks. Goodness-of-fit was adequate for each block, the combined estimate of H being 4.78(95%CI 2.17-10.50) years. However, considerable heterogeneity existed, unexplained by any factor studied, with the random-effects estimate 3.08(1.32-7.16). Sensitivity analyses allowing for reverse causation or differing assumed times for the final quitting period gave similar results. The estimates of H are similar for stroke and IHD, and the individual estimates similarly heterogeneous. Fitting the model is harder for stroke, due to its weaker association with smoking.

Alcohol and smoking consumption behaviours in older Australian adults: prevalence, period and socio-demographic differentials in the DYNOPTA sample

PURPOSE

Alcohol consumption and tobacco use are key risk factors for chronic disease and health burden across the adult lifespan. We estimate the prevalence of alcohol consumption and smoking by age and time period in adults from mid to old age.

METHODS

Participants (n = 50,652) were drawn from the Dynamic Analyses to Optimise Ageing (DYNOPTA) project and were compared with Australian National Health Survey data. Alcohol and smoking consumption DYNOPTA data were weighted to the estimated resident population of the sampling frame for each contributing study according to age and sex distributions within major statistical regions.

RESULTS

Comparisons in the rates of smoking and alcohol consumption between DYNOPTA and other national surveys were comparable. Males were more likely to be (RRR = 2.12) or have been smokers (RRR = 2.97), whilst females were more likely to be non-drinkers (RRR = 2.52). Period effects were also identified; higher prevalence rates in consumption of alcohol (RRR = 3.21) and smoking (RRR = 1.67) for those contributing studies from the early 1990's, in comparison with those studies from the latter half of the decade, were reported.

CONCLUSIONS

Over a decade, prevalence rates for high-risk consumption of alcohol and current smoking behaviour declined and suggest the possible impact of government health policy, with targeted-health policies, that included bans on public smoking, and a toughening of legislation against alcohol-related crime.

Predictors of smoking patterns after first stroke

Persistent smoking following stroke is associated with poor outcomes including development of secondary stroke and increased mortality risk. This study uses longitudinal data from the U.S. Health and Retirement Study (1992-2008) to investigate whether depression and duration of inpatient hospital care impact smoking outcomes among stroke survivors (N = 745). Longer duration of care was associated with lower likelihood of persistent smoking. Depression was associated with greater cigarette consumption. Interaction effects were also significant, indicating that for survivors who experienced longer inpatient care there was a weaker association between depression and cigarette consumption. Implications for practice and research are discussed.

From 'omics' to complex disease: a systems biology approach to gene-environment interactions in cancer

Background

Cancer is a complex disease that involves a sequence of gene-environment interactions in a progressive process that cannot occur without dysfunction in multiple systems, including DNA repair, apoptotic and immune functions. Epigenetic mechanisms, responding to numerous internal and external cues in a dynamic ongoing exchange, play a key role in mediating environmental influences on gene expression and tumor development.

Hypothesis

The hypothesis put forth in this paper addresses the limited success of treatment outcomes in clinical oncology. It states that improvement in treatment efficacy requires a new paradigm that focuses on reversing systemic dysfunction and tailoring treatments to specific stages in the process. It requires moving from a reductionist framework of seeking to destroy aberrant cells and pathways to a transdisciplinary systems biology approach aimed at reversing multiple levels of dysfunction.

Conclusion

Because there are many biological pathways and multiple epigenetic influences working simultaneously in the expression of cancer phenotypes, studying individual components in isolation does not allow an adequate understanding of phenotypic expression. A systems biology approach using new modeling techniques and nonlinear mathematics is needed to investigate gene-environment interactions and improve treatment efficacy. A broader array of study designs will also be required, including prospective molecular epidemiology, immune competent animal models and in vitro/in vivo translational research that more accurately reflects the complex process of tumor initiation and progression.

Genetic variants and risk of lung cancer in never smokers: a genome-wide association study

BACKGROUND

Lung cancer in individuals who have never smoked tobacco products is an increasing medical and public-health issue. We aimed to unravel the genetic basis of lung cancer in never smokers.

METHODS

We did a four-stage investigation. First, a genome-wide association study of single nucleotide polymorphisms (SNPs) was done with 754 never smokers (377 matched case-control pairs at Mayo Clinic, Rochester, MN, USA). Second, the top candidate SNPs from the first study were validated in two independent studies among 735 (MD Anderson Cancer Center, Houston, TX, USA) and 253 (Harvard University, Boston, MA, USA) never smokers. Third, further replication of the top SNP was done in 530 never smokers (UCLA, Los Angeles, CA, USA). Fourth, expression quantitative trait loci (eQTL) and gene-expression differences were analysed to further elucidate the causal relation between the validated SNPs and the risk of lung cancer in never smokers.

FINDINGS

44 top candidate SNPs were identified that might alter the risk of lung cancer in never smokers. rs2352028 at chromosome 13q31.3 was subsequently replicated with an additive genetic model in the four independent studies, with a combined odds ratio of 1.46 (95% CI 1.26-1.70, p=5.94x10(-6)). A cis eQTL analysis showed there was a strong correlation between genotypes of the replicated SNPs and the transcription level of the gene GPC5 in normal lung tissues (p=1.96x10(-4)), with the high-risk allele linked with lower expression. Additionally, the transcription level of GPC5 in normal lung tissue was twice that detected in matched lung adenocarcinoma tissue (p=6.75x10(-11)).

INTERPRETATION

Genetic variants at 13q31.3 alter the expression of GPC5, and are associated with susceptibility to lung cancer in never smokers. Downregulation of GPC5 might contribute to the development of lung cancer in never smokers.

FUNDING

US National Institutes of Health; Mayo Foundation.

Tobacco smoking in older people

Smoking remains prevalent in elderly people in the UK and similar countries. The adverse health effects of current smoking continue to accumulate in old age and stopping smoking in old age confers benefits on function, morbidity and mortality. Many elderly people wish to stop smoking and many are successful. Structured support from health and social care workers improves quit rates and nicotine replacement therapy can be an effective aid to smoking cessation in old age. Doctors and other healthcare staff should use the opportunities of patient contact to encourage older smokers to quit. Cognitive impairment is a barrier to successful smoking cessation.