Smoking and health-related quality of life in English general population: implications for economic evaluations

EQ-5D-5L Population Norms and Quality-Adjusted Life Expectancy by Sociodemographic Characteristics and Modifiable Risk Factors for Adults in Queensland, Australia

OBJECTIVES

Over half of Australia's disease burden is due to morbidity, predominantly chronic conditions. Health-related quality of life instruments provide measures of morbidity and health status across different dimensions with EQ-5D being one of the most widely used. This study reports EQ-5D-5L general population norms for Queensland, Australia using the recently published Australian value set.

METHODS

Population survey results from cross-sectional computer-assisted telephone interviews for Queensland adults in 2022 and 2023 were analyzed. EQ-5D-5L, as well as modifiable risk factors and sociodemographic data were collected. Using the recently published final Australian EQ-5D-5L value set, mean utility scores were calculated for Queensland, as well as by sociodemographic characteristics, including remoteness and socioeconomic area-based measures, and modifiable risk factors, such as smoking and body mass index. Results were combined with life tables to estimate quality-adjusted life expectancy (QALE) for subgroups with different lifestyles.

RESULTS

The EQ-5D utility score for the Queensland adult population was 0.916. Smoking daily, being obese or older in age, or living in the most disadvantaged socioeconomic area were associated with lower mean scores. QALE was 6.1 and 7.9 years shorter than the life expectancy for Queensland males and females, respectively, but generally, those who reported having healthier lifestyles had higher mean utility scores and thus longer QALE.

CONCLUSIONS

In addition to reporting Queensland EQ-5D-5L general population norms, these results demonstrate potential QALE gains in people following healthier lifestyles. The results support investment in prevention and may motivate further studies in this important area.

Incremental net monetary benefit of using varenicline for smoking cessation: A systematic review and meta-analysis of economic evaluation studies

AIMS

To conduct a systematic review and meta-analysis and pool the incremental net benefits (INBs) of varenicline compared with behaviour support with bupropion or nicotine replacement therapy (NRT), behaviour support alone and unaided cessation in adult smokers making a first-time attempt to quit.

METHODS

A search for economic evaluation studies was conducted from inception to 30 September 2022, on PubMed, Embase, Cost-Effectiveness Analysis (CEA) Registry by Tufts Medical Centre, EconLit and the NHS Economic Evaluation Database (NHS EED). Eligible studies were included if they were (1) conducted among adults ages 18 years old and older who were smokers attempting to quit for the first time; (2) compared varenicline to behaviour support with bupropion or NRT, behaviour support alone and unaided cessation; and (3) performed a CEA or cost-utility analysis. The INBs were calculated and pooled across studies stratified by country income level and study perspective using the random-effects model. Statistical heterogeneity between studies was assessed using the I2 statistic and Cochrane Q statistic.

RESULTS

Of the 1433 identified studies, 18 studies were included in our review. Our findings from healthcare system/payer perspective suggested that the use of varenicline is statistically significantly cost-effective compared with bupropion (pooled INB, $830.75 [95% confidence interval, $208.23, $1453.28]), NRTs ($636.16 [$192.48, $1079.84]) and unaided cessation ($4212.35 [$1755.79, $6668.92]) in high-income countries. Similarly, varenicline is also found to be cost-effective compared to bupropion ($2706.27 [$1284.44, $4128.11]), NRTs ($3310.01 [$1781.53, $4838.50]) and behavioural support alone ($5438.22 [$4105.99, $6770.46]) in low- and middle-income countries.

CONCLUSION

Varenicline is cost-effective as a smoking cessation aid when compared with behavioural support with bupropion or nicotine replacement therapies and behavioural support alone in both high-income countries and low- and middle-income countries, from the healthcare system/payer perspective in adult smokers who attempt to quit for the first time.

Immediate, Short-term, Medium-term, and Long-term effects of Acceptance and Commitment Therapy for Smoking Cessation: A Systematic Review and Meta-Analysis

INTRODUCTION

Acceptance and commitment therapy (ACT) is increasingly being studied as a treatment for smoking cessation. However, its immediate, short-, and long-term effects have rarely been reviewed.

METHODS

This systematic review aimed to evaluate the effectiveness of immediate, short-, medium-, and long-term smoking cessation rates in ACT and comparators at less than 3-month, 3 to 4-month, 6-, and 12-month follow-ups. Randomized controlled trials (RCTs) were searched in eight databases until April 20, 2023. We assessed the quality of RCTs and the certainty of evidence of outcomes.

RESULTS

Nineteen RCTs involving 7885 smokers across six countries were included. The majority (72.81%) of RCTs were graded as low risk across six domains. For complete-case outcomes, meta-analyses were conducted, and the results revealed a significant effect in favor of ACT [risk ratio: 1.70-1.80 at <3-month, 3 to 4-month, and 6 months follow-up] compared with comparators. For outcomes using missing data management, meta-analyses found an overall effect in favor of ACT, but a significant effect was found at 3 to 4-months only. However, 12-month follow-ups revealed no significant reduction in smoking cessation for both outcomes. Moderate and substantial heterogeneities were found among four meta-analyses that may lead to inaccurate estimates of effects. The certainty of evidence of all outcomes was rated as low and very low.

CONCLUSION

ACT may be an effective intervention for smoking cessation with immediate, short-term, and medium-term effects. Caution must be applied in the interpretation of the results due to the limited trials and low certainty of evidence.

IMPLICATION

ACT can be implemented adjuvant to the usual treatment for smoking cessation. Additional RCTs with follow-up data using biochemically verified measures in non-US countries are warranted.

Health-related quality of life and associated factors in elderly individuals with dyslipidemia in rural Northern China

PURPOSE

The purpose of the study was to investigate health-related quality of life (HRQOL) and its associated factors among elderly individuals with dyslipidemia in rural Northern China.

METHODS

A cross-sectional study was conducted on 457 elderly individuals. The EQ-5D-5L questionnaire was used to assess HRQOL. Sociodemographic, anthropometric, lifestyle and health information was collected using a structured and standardized questionnaire. The Tobit regression model and multiple linear regression analysis were used to assess factors associated with HRQOL parameters including utility index and visual analogue score (EQ-VAS).

RESULTS

The mean age of the participating individuals was 68.04 ± 5.98 years. The median utility index and EQ-VAS scores were 0.942 (P25-P75: 0.876-1.000) and 80 (P25-P75: 70-90), respectively. Pain/discomfort was the most frequently reported complaint among the five health dimensions (50.5%). Illiterate and primary education levels, unemployed, widowed, smoking, secondhand smoke exposure, with hypertension or DM, chronic disease core knowledge scores < 8, and daily sedentary time ≥ 6 h were associated with lower HRQOL.

CONCLUSION

Pain/discomfort dimension was the most affected problems. Education, occupation, marital status, smoking, secondhand smoke exposure, chronic disease core knowledge, comorbidities, and daily sedentary time were significantly associated with HRQOL in the present study.

Symptomatic benefits of testosterone treatment in patient subgroups: a systematic review, individual participant data meta-analysis, and aggregate data meta-analysis

BACKGROUND

Testosterone replacement therapy is known to improve sexual function in men younger than 40 years with pathological hypogonadism. However, the extent to which testosterone alleviates sexual dysfunction in older men and men with obesity is unclear, despite the fact that testosterone is being increasingly prescribed to these patient populations. We aimed to evaluate whether subgroups of men with low testosterone derive any symptomatic benefit from testosterone treatment.

METHODS

We did a systematic review and meta-analysis to evaluate characteristics associated with symptomatic benefit of testosterone treatment versus placebo in men aged 18 years and older with a baseline serum total testosterone concentration of less than 12 nmol/L. We searched major electronic databases (MEDLINE, Embase, Science Citation Index, and the Cochrane Central Register of Controlled Trials) and clinical trial registries for reports published in English between Jan 1, 1992, and Aug 27, 2018. Anonymised individual participant data were requested from the investigators of all identified trials. Primary (cardiovascular) outcomes from this analysis have been published previously. In this report, we present the secondary outcomes of sexual function, quality of life, and psychological outcomes at 12 months. We did a one-stage individual participant data meta-analysis with a random-effects linear regression model, and a two-stage meta-analysis integrating individual participant data with aggregated data from studies that did not provide individual participant data. This study is registered with PROSPERO, CRD42018111005.

FINDINGS

9871 citations were identified through database searches. After exclusion of duplicates and publications not meeting inclusion criteria, 225 full texts were assessed for inclusion, of which 109 publications reporting 35 primary studies (with a total 5601 participants) were included. Of these, 17 trials provided individual participant data (3431 participants; median age 67 years [IQR 60-72]; 3281 [97%] of 3380 aged ≥40 years) Compared with placebo, testosterone treatment increased 15-item International Index of Erectile Function (IIEF-15) total score (mean difference 5·52 [95% CI 3·95-7·10]; τ2=1·17; n=1412) and IIEF-15 erectile function subscore (2·14 [1·40-2·89]; τ2=0·64; n=1436), reaching the minimal clinically important difference for mild erectile dysfunction. These effects were not found to be dependent on participant age, obesity, presence of diabetes, or baseline serum total testosterone. However, absolute IIEF-15 scores reached during testosterone treatment were subject to thresholds in patient age and baseline serum total testosterone. Testosterone significantly improved Aging Males' Symptoms score, and some 12-item or 36-item Short Form Survey quality of life subscores compared with placebo, but it did not significantly improve psychological symptoms (measured by Beck Depression Inventory).

INTERPRETATION

In men aged 40 years or older with baseline serum testosterone of less than 12 nmol/L, short-to-medium-term testosterone treatment could provide clinically meaningful treatment for mild erectile dysfunction, irrespective of patient age, obesity, or degree of low testosterone. However, due to more severe baseline symptoms, the absolute level of sexual function reached during testosterone treatment might be lower in older men and men with obesity.

FUNDING

National Institute for Health and Care Research Health Technology Assessment Programme.

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.

Factors associated with health-related quality of life among people with visual impairments living in nursing homes in Armenia: a cross-sectional study

PURPOSE

The study aimed to examine the effect of visual impairment (VI), eye diseases, and other risk factors on health-related quality of life (HRQoL) in nursing home residents in Armenia.

METHODS

This cross-sectional study administered an interviewer-administered structured questionnaire to collect information about socio-demographics, chronic diseases, HRQoL, smoking, receiving and giving instrumental/emotional social support, and sleeping disorders among 313 nursing home residents. An ophthalmic examination of the participants was conducted.

RESULTS

The mean age was 72.5 years, ranging from 45.5 to 91.4. Women constituted 50% of the sample. The prevalence of normal vision by presenting visual acuity with available correction was 55.3%, while VI and blindness were present in 40.8% and 3.9%, respectively. Uncorrected refractive error (URE) was found in 20% of participants. The mean HRQoL score was 51.3, ranging from 7.9 to 95.0. In the adjusted analysis, having at least one chronic non-communicable disease, sleeping disorders, eye diseases, URE, VI, blindness, and giving instrumental social support were associated with HRQoL.

CONCLUSIONS

Regular eye care services could improve the eye health and HRQoL of nursing home residents. Interventions addressing vision loss and chronic non-communicable diseases could enhance the functioning and overall well-being of the target population.

Wellbeing in Addiction Recovery: Does It Differ across Addictions?

Limited research has been conducted on the experiences of individuals in long-term recovery from addiction, and addictions are usually studied in isolation. However, no theories of addiction differentiate between addictions or assume that individuals will experience only one addiction. This study aimed to compare affect between individuals with addictions to drugs and alcohol and to explore how QoL changes in long-term recovery from addiction. Individuals in recovery from addiction (n = 115; 52.2% male) were recruited via snowball sampling on social media signposted by an addiction rehabilitation charity. Participants completed questionnaires about QoL (WHOQOL-Bref) and positive and negative affect (PANAS-X). The main primary addictions were drugs (76.5%) and alcohol (21.7%), with 69.7% reporting multiple addictions including food, sex, internet, and gambling. Affect and coping strategies did not differ by addiction. QoL appeared to improve with time in recovery. The high percentage of multiple addictions and greater similarities than differences between individuals with drug and alcohol addictions suggest that addictions should not be studied in isolation when studying psychological health during long-term recovery.

Tobacco impact on quality of life, a cross-sectional study of smokers, snuff-users and non-users of tobacco

BACKGROUND

Tobacco smoking is a major public health issue, and also affects health-related quality of life. There has been considerable debate as to whether oral moist snuff, a form of tobacco placed in the oral cavity between the upper lip and gum as in sublabial administration, can be considered a safe alternative to smoking. The aim of this study was to investigate the association between health-related quality of life and smoking, snuff use, gender and age.

METHOD

This cross-sectional study included 674 women and 605 men aged 18 to 65 recruited through a Swedish population database. Subjects completed a questionnaire about tobacco use and the 36-item Short Form Health Survey (SF-36). Multivariable logistic regression analyses were performed for the association between health-related quality of life and tobacco use, gender and age. The median perceived health-related quality of life (SF-36) for an age-matched Swedish population was used as the cutoff: above the cutoff indicated better-than-average health coded as 1, or otherwise coded as 0. The independent variables were smoking (pack-decades), snuff-use (box-decades), gender and age in decades. The outcome was presented as the Odds Ratio (OR) with a 95% confidence interval (CI) for each independent variable.

RESULTS

The experience of cigarette smoking is associated with decreased physical functioning (PF), general health (GH), vitality (VT), social functioning (SF) and mental health (MH) as well as both lower physical component summary (PCS) and mental component summary (MCS). Further, the experience of snuff use is associated with bodily pain (BP), lower VT, and lower PCS. In the study population older age is associated with lower PF,GH, VT, MH, PCS and MCS. Female gender is associated with lower PF and VT.

CONCLUSION

This study shows that smoking is associated with lower health-related quality of life. The results also illuminate the detrimental health effects of using snuff, implying that snuff too is a health hazard. As studies on the bodily effects of snuff are relatively scarce, it is imperative that we continue to address and investigate the impact on the population using snuff on a regular basis.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT05409963 05251022 08/06/22.

Medication Adherence and Contraceptive Counseling

Combined oral contraceptives (COC) are a very popular form of birth control. Incorrect use and lack of adherence to treatment reduce the effectiveness of this method. Having a standard tool to identify poor-adherence profiles quickly and objectively can be helpful for midwives and potentially for COC users. The MMAS-4 adherence scale has been used in various medical fields, but there is little evidence of its potential in contraceptive consultation. This paper presents a piece of multicenter observational research based on a sample of 327 women who had attended contraceptive counselling in Spain and were COC users or had informed the midwife that they want to start to use this method. Two interviews were conducted: at the time of consultation and after one year. In our research, the MMAS-4 identified high-risk behaviors: during the 1-year follow-up period, COC users classified as poorly adherent had a significantly higher risk of missed contraceptive pills, more incidents and problems related to the method of contraception, as well as a lower degree of satisfaction with the contraceptive method. One case of unplanned pregnancy and two cases of emergency contraception were identified, all of them corresponding to poorly adherent women. The use of MMAS-4 in consultation can improve midwives' contraceptive counselling.

Motivational support intervention to reduce smoking and increase physical activity in smokers not ready to quit: the TARS RCT

Background

Physical activity can support smoking cessation for smokers wanting to quit, but there have been no studies on supporting smokers wanting only to reduce. More broadly, the effect of motivational support for such smokers is unclear.

Objectives

The objectives were to determine if motivational support to increase physical activity and reduce smoking for smokers not wanting to immediately quit helps reduce smoking and increase abstinence and physical activity, and to determine if this intervention is cost-effective.

Design

This was a multicentred, two-arm, parallel-group, randomised (1 : 1) controlled superiority trial with accompanying trial-based and model-based economic evaluations, and a process evaluation.

Setting and participants

Participants from health and other community settings in four English cities received either the intervention (n = 457) or usual support (n = 458).

Intervention

The intervention consisted of up to eight face-to-face or telephone behavioural support sessions to reduce smoking and increase physical activity.

Main outcome measures

The main outcome measures were carbon monoxide-verified 6- and 12-month floating prolonged abstinence (primary outcome), self-reported number of cigarettes smoked per day, number of quit attempts and carbon monoxide-verified abstinence at 3 and 9 months. Furthermore, self-reported (3 and 9 months) and accelerometer-recorded (3 months) physical activity data were gathered. Process items, intervention costs and cost-effectiveness were also assessed.

Results

The average age of the sample was 49.8 years, and participants were predominantly from areas with socioeconomic deprivation and were moderately heavy smokers. The intervention was delivered with good fidelity. Few participants achieved carbon monoxide-verified 6-month prolonged abstinence [nine (2.0%) in the intervention group and four (0.9%) in the control group; adjusted odds ratio 2.30 (95% confidence interval 0.70 to 7.56)] or 12-month prolonged abstinence [six (1.3%) in the intervention group and one (0.2%) in the control group; adjusted odds ratio 6.33 (95% confidence interval 0.76 to 53.10)]. At 3 months, the intervention participants smoked fewer cigarettes than the control participants (21.1 vs. 26.8 per day). Intervention participants were more likely to reduce cigarettes by ≥ 50% by 3 months [18.9% vs. 10.5%; adjusted odds ratio 1.98 (95% confidence interval 1.35 to 2.90] and 9 months [14.4% vs. 10.0%; adjusted odds ratio 1.52 (95% confidence interval 1.01 to 2.29)], and reported more moderate-to-vigorous physical activity at 3 months [adjusted weekly mean difference of 81.61 minutes (95% confidence interval 28.75 to 134.47 minutes)], but not at 9 months. Increased physical activity did not mediate intervention effects on smoking. The intervention positively influenced most smoking and physical activity beliefs, with some intervention effects mediating changes in smoking and physical activity outcomes. The average intervention cost was estimated to be £239.18 per person, with an overall additional cost of £173.50 (95% confidence interval -£353.82 to £513.77) when considering intervention and health-care costs. The 1.1% absolute between-group difference in carbon monoxide-verified 6-month prolonged abstinence provided a small gain in lifetime quality-adjusted life-years (0.006), and a minimal saving in lifetime health-care costs (net saving £236).

Conclusions

There was no evidence that behavioural support for smoking reduction and increased physical activity led to meaningful increases in prolonged abstinence among smokers with no immediate plans to quit smoking. The intervention is not cost-effective.

Limitations

Prolonged abstinence rates were much lower than expected, meaning that the trial was underpowered to provide confidence that the intervention doubled prolonged abstinence.

Future work

Further research should explore the effects of the present intervention to support smokers who want to reduce prior to quitting, and/or extend the support available for prolonged reduction and abstinence.

Trial registration

This trial is registered as ISRCTN47776579.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 4. See the NIHR Journals Library website for further project information.

The cost-effectiveness of tailored smoking cessation interventions for people with severe mental illness: a model-based economic evaluation

BACKGROUND

Tailored smoking cessation interventions, which combine behavioural and pharmaceutical support, are effective in populations with severe mental illness (SMI). We establish the cost-effectiveness of two tailored interventions in the UK: (i) a bespoke smoking cessation intervention (BSCI) versus usual care, and (ii) integrated tobacco cessation and mental health care (IC) versus standard smoking cessation clinic (SCC) referral.

METHODS

This economic evaluation was conducted between January 15th 2019 and August 4th 2022. We adapted a Markov model estimating smoking status, healthcare costs and quality-adjusted life years (QALYs) across the lifetime. Intervention effectiveness and costs were obtained from a systematic review and a meta-analysis. We obtained specific parameter values for populations with SMI for mortality, risk of smoking related comorbidities, and health utility. Uncertainty was analysed in deterministic and probabilistic sensitivity analysis (PSA).

FINDINGS

The BSCI was cost-effective versus usual care with an incremental cost-effectiveness ratio (ICER) of £3145 per QALY (incremental costs: £165; incremental QALYs: 0.05). Integrated care was cost-effective versus SCC with an ICER of £6875 per QALY (incremental costs: £292; incremental QALYs: 0.04). The BSCI and IC were cost-effective in 89% and 83% of PSA iterations respectively. The main area of uncertainty related to relapse rates.

INTERPRETATION

Our findings suggested that the tailored interventions were cost-effective and could increase QALYs and decrease expenditure on treating smoking related morbidities if offered to people with SMI.

FUNDING

York Health Economics Consortium was funded by the National Institute for Health and Care Excellence to produce economic evaluations to inform public health guidelines.

Translating an Economic Analysis into a Tool for Public Health Resource Allocation in Cancer Survivorship

Background. The complexity of decision science models may prevent their use to assist in decision making. User-centered design (UCD) principles provide an opportunity to engage end users in model development and refinement, potentially reducing complexity and increasing model utilization in a practical setting. We report our experiences with UCD to develop a modeling tool for cancer control planners evaluating cancer survivorship interventions. Design. Using UCD principles (described in the article), we developed a dynamic cohort model of cancer survivorship for individuals with female breast, colorectal, lung, and prostate cancer over 10 y. Parameters were obtained from the National Program of Cancer Registries and peer-reviewed literature, with model outcomes captured in quality-adjusted life-years and net monetary benefit. Prototyping and iteration were conducted with structured focus groups involving state cancer control planners and staff from the Centers for Disease Control and Prevention and the American Public Health Association. Results. Initial feedback highlighted model complexity and unclear purpose as barriers to end user uptake. Revisions addressed complexity by simplifying model input requirements, providing clear examples of input types, and reducing complex language. Wording was added to the results page to explain the interpretation of results. After these updates, feedback demonstrated that end users more clearly understood how to use and apply the model for cancer survivorship resource allocation tasks. Conclusions. A UCD approach identified challenges faced by end users in integrating a decision aid into their workflow. This approach created collaboration between modelers and end users, tailoring revisions to meet the needs of the users. Future models developed for individuals without a decision science background could leverage UCD to ensure the model meets the needs of the intended audience.

Highlights

Model complexity and unclear purpose are 2 barriers that prevent lay users from integrating decision science tools into their workflow.Modelers could integrate the user-centered design framework when developing a model for lay users to reduce complexity and ensure the model meets the needs of the users.

Association of lifestyle behaviors with health-related quality of life among patients with hematologic diseases

PURPOSE

Health-related quality of life (HRQoL) is a multi-dimensional construct used to assess the impact of health status on quality of life, and it is known to be affected by lifestyle behaviors. This study focused on multiple lifestyle behaviors among patients with hematologic diseases, including physical activity, dietary intake, sleep quality, occupational exposure, alcohol consumption and smoking. The main objective was to investigate the association of both individual and clustering of health behaviors with HRQoL among the population with hematologic diseases based on a comprehensive lifestyle survey.

METHODS

A total of 539 patients with hematologic diseases aged over 18 years were enrolled in this cross-sectional study. Latent class analysis was used to identify homogeneous, mutually exclusive lifestyle classes, and multinomial logistic regression was then performed to explore the association of lifestyle classes membership with HRQoL. Meanwhile, multiple linear regression and quantile regression were used to identify the relationship between individual lifestyle behaviors and HRQoL.

RESULTS

A three-class model was selected based on conceptual interpretation and model fit. We found no association between multiple lifestyle behaviors and HRQoL in the 3-class model, either in the whole patients or in subgroups stratified by hematological malignancies. Further research on each lifestyle found that physical activity, dietary intake, occupational exposure, alcohol consumption or smoking were independent of HRQoL. Sleep quality was positively associated with HRQoL.

CONCLUSION

Our findings suggested that clustering of lifestyle behaviors may not be an indicator to reflect the health quality of patients with hematologic diseases. Sleep represents a viable intervention target that can confer health benefits on the hematologic patients.

The Cost-Effectiveness of Nicotine Replacement Therapy Sampling in Primary Care: a Markov Cohort Simulation Model

BACKGROUND

Pharmacotherapies remain a central focus of successful tobacco control, but uptake remains very low.

OBJECTIVE

To estimate the cost effectiveness of a primary care nicotine replacement therapy (NRT) sampling intervention.

DESIGN

A Markov cohort simulation model was constructed to conduct cost-effectiveness analyses. Clinical trial results were used to initialize the Markov model. All other model parameters were derived from the literature. The study was conducted over a lifetime horizon, from the payers' budgetary perspective.

PARTICIPANTS

Smokers with a primary care visit.

INTERVENTION

Medication sampling, which provided short, starter packets of NRT (nicotine patch and lozenge) to smokers in the primary care setting.

MAIN MEASURES

Lifetime healthcare expenditures, quality-adjusted life years, and life years.

KEY RESULTS

Medication sampling was the dominant strategy compared to standard care. Our intervention cost $75, yielding a discounted lifetime savings of $1065 in healthcare expenditures, and increased both discounted quality-adjusted life years and discounted life years by 0.01. One-way sensitivity analyses showed that medication sampling remained dominant in plausible ranges except when it failed to increase cessation relative to standard care. Probabilistic sensitivity analyses confirmed that medication sampling was dominant in 94.1% of the simulated cases, with an implementation cost of $74 (95% CI $73-$76) and discounted lifetime savings in health expenditures of $1061 (- $1106 to - $1,017), increasing quality-adjusted life years by 0.008 (0.0085-0.0093) and life years by 0.008 (0.0081-0.0089).

CONCLUSION

Medication sampling, an easily implementable, scalable and low-cost intervention to encourage smoking cessation, is cost saving and improves quality of life.

Socioeconomic status and self-rated health in Iran: findings from a general population study

Background

There are large gaps in health and well-being among different groups of the society. Socioeconomic factors play a significant role in determining the health status of the society. The present study was conducted to examine socioeconomic inequality in health status among the adult population of Khorramabad city, the capital of Lorestan province, wester part of Iran.

Methods

A cross-sectional study was conducted on 1348 participants selected through multistage sampling. A valid and reliable questionnaire was used for data collection. The wealth index as an indicator of the socioeconomic status (SES) was used to categorize the subjects in terms of the SES. The concentration index and concentration curve was used to measure socioeconomic inequity in poor self-rated health (SRH) of population. Finally, after determine the status of inequity in poor SRH, a decomposition analysis approach was used to identify the most important determinants of this inequity.

Results

The prevalence of poor SRH was 18.91% in all subjects, 38.52% in the lowest SES group, and 11.15% in the highest SES group. The value of the concentration index for poor SRH was − 0.3243 (95% CI − 0.3996 to − 0.2490), indicating that poor SRH was more concentrated among the poor. The results of decomposition analysis showed that SES (41.2%), higher body mass index (28.6%) and lack of physical activity (26.9%) were the most important factors associated with the concentration of poor SRH in the poor groups.

Conclusion

Identification of socioeconomic factors affecting on health status is the first step for proper policymaking. Policymakers and health system managers at the national and subnational levels can use the results of this study as well as other similar domestic studies to design and implement proper interventions to promote equity and improve the health status of population.

Worse health‐related quality of life, impaired functioning and psychiatric comorbidities are associated with excess mortality in patients with severe chronic pain

Background

Severe chronic pain that interferes with daily activities is associated with an increased risk of mortality. We assessed the overall mortality of tertiary chronic pain patients in comparison with the general population, with a special aim to analyse the association of health‐related quality of life (HRQoL) and its dimensions with the risk of death.

Methods

In this prospective observational follow‐up study, patients with non‐cancer chronic pain attended an outpatient multidisciplinary pain management (MPM) episode in a tertiary pain clinic in 2004–2012 and were followed until May 2019. Mortality between the patients and the general population was compared with standardized mortality ratios (SMR) in different age groups. Causes of death and comorbidities were compared among the deceased. Association of mortality and HRQoL and its dimensions, measured with the 15D instrument, was studied with Cox proportional hazards model.

Results

During a mean of 10.4‐year follow‐up of 1498 patients, 296 died. The SMR in the youngest age group (18–49 years) was significantly higher than that of the general population: 2.6 for males and 2.9 for females. Even elderly females (60–69 years) had elevated mortality (SMR 2.3). Low baseline HRQoL at the time of MPM, as well as poor ratings in the psychosocial dimensions of HRQoL, was associated with an increased risk of death.

Conclusions

Our results support the role of HRQoL measurement by a validated instrument such as the 15D in capturing both the physical and the psychological symptom burden, and consequently, an elevated risk of death, in patients with chronic pain.

Significance

Severe chronic pain is associated with elevated mortality. In patients in chronic pain under 50 years old, the mortality was 2.5–3 times higher than in the general population. Psychological distress appears to contribute to the increased mortality. Regular follow‐up by health‐related quality of life (HRQoL) measurement could be useful in identifying patients in chronic pain who are in need of intensive symptom management and to prevent early death.

The Association Between Smoking and Health-Related Quality of Life Among Chinese Individuals Aged 40 Years and Older: A Cross-Sectional Study

Objective

The purpose of this study was to investigate the association between smoking and health-related quality of life among Chinese individuals aged 40 years and older.

Method

Using a stratified multistage sampling method, data from 1,543 adults aged 40 years and older were obtained from a household survey conducted in eight provinces in China. The health-related quality of life was quantified based on the utility index obtained using a standardized instrument entitled “The European Five-Dimensional Health Scale (EQ-5D-5L).” Descriptive statistics were used to summarize the demographic characteristics and social factors of the sample according to smoking status. An instrumental variable (IV) probit model was used to estimate the association between smoking status and health-related quality of life.

Results

Of the 1,543 participants, 485 (31.43%) were smokers and 1,058 (68.57%) were non-smokers. Smoking was negatively associated with the probability of having a higher quality of life (p < 0.01). For smokers, the average probability of having a higher quality of life was 11.65% lower than when they did not smoke.

Conclusions

These findings suggest that smoking reduces health-related quality of life among Chinese individuals aged 40 years and older. Anti-smoking programs should consider this factor.

Assessment of the real-world impact of the Thai smoking cessation programme on clinical outcomes: protocol for a multicentre prospective observational study

Background:

Tobacco smoking is the most common preventable cause of morbidity and mortality in the world. In an effort to counteract the harmful consequences of smoking, various tobacco control measures have been implemented, including the use of smoking cessation programmes to reduce the number of new smokers as well as helping current smokers to quit smoking. In Thailand, the SMART Quit Clinic Program (FAH-SAI Clinics) was launched in 2010 to provide smoking cessation services by a multidisciplinary team. There are currently 552 FAH-SAI Clinics established across all 77 provinces of Thailand.

Aim:

This protocol describes a study aiming to evaluate the SMART Quit Clinic Program (FAH-SAI Clinics) in terms of programme performance and clinical outcomes. We hope that the results of the study could be used to improve the current service model and the programme’s success.

Method:

A multicentre prospective observational study will be conducted. The study will focus on 24 FAH-SAI Clinics across 21 provinces of Thailand. The primary outcomes are seven-day point prevalence abstinence rate and continuous abstinence rate at three and six months. The outcomes will be measured using a self-reported questionnaire and biochemical validated by exhaled carbon monoxide.

Discussion:

This study will be the first real-world study that reports the effectiveness of the well-established smoking cessation programme in Thailand. Findings from this study can help improve the quality of smoking cessation services provided by multidisciplinary teams and other smoking cessation services, especially those implemented in low- and middle-income countries.

Pain During Sex Before and After Decompressive Surgery for Lumbar Spinal Stenosis: A Multicenter Observational Study

STUDY DESIGN

Observational multicenter study.

OBJECTIVE

The aim of this study was to evaluate changes in pain during sexual activity after surgery for lumbar spinal stenosis (LSS).

SUMMARY OF BACKGROUND DATA

There are limited data available on sexual function in patients undergoing surgery for LSS.

METHODS

Data were retrieved from the Norwegian Registry for Spine Surgery. The primary outcome was change in pain during sexual activity at 1 year, assessed by item number eight of the Oswestry disability index questionnaire. Secondary outcome measures included Oswestry Disability Index, EuroQol-5D, and numeric rating scale scores for back and leg pain.

RESULTS

Among the 12,954 patients included, 9908 (76.5%) completed 1-year follow-up. At baseline 9579 patients (73.9%) provided information about pain during sexual activity, whereas 7424 (74.9%) among those with complete follow-up completed this item. Preoperatively 2528 of 9579 patients (26.4%) reported a normal sex-life without pain compared with 4294 of 7424 patients (57.8%) at 1 year. Preoperatively 1007 (10.5%) patients reported that pain prevented any sex-life, compared with 393 patients (5.3%) at 1 year. At baseline 7051 of 9579 patients (73.6%) reported that sexual activity caused pain, and among these 3145 of 4768 responders (66%) reported an improvement at 1 year. A multivariable regression analysis showed that having a life partner, college education, and working until time of surgery were predictors of improvement in pain during sexual activity. Current tobacco smoking, pain duration >12 months, previous spine surgery, and complications occurring within 3 months were negative predictors.

CONCLUSION

This study clearly demonstrates that a large proportion of patients undergoing surgery for LSS experienced an improvement in pain during sexual activity at 1 year.Level of Evidence: 2.

Interactions of Comorbidity and Five Simple Environmental Unhealthy Habits Concerning Physical and Mental Quality of Life in the Clinical Setting

The objective of this study was to examine the interactions between comorbidity and five lifestyle single habits concerning different subscales of quality of life (QoL). For the study, 302 patients were consecutively recruited at the internal medicine department of a tertiary teaching hospital. Lifestyle habits, comorbidities and QoL were recorded according to validated questionnaires. Five single unhealthy habits, such as tobacco consumption, dietary intake of ultra-processed pastries, raw nuts or carbonated drinks, sleep time and physical activity patterns were selected according to previously published data. The main outcomes of the study were the scores of the eight subscales of the SF-36 QoL survey. The aggregate of unhealthy habits showed statistically significant association to every category in the SF-36 questionnaire, both in the univariate and the multivariate analysis when adjusting by age, sex and comorbidity. An interaction was found between comorbidity and unhealthy habits in both physical and mental summaries of SF-36. In conclusion, the lifestyle assessment according to five unhealthy habits is associated with a worse QoL. The interaction between comorbidity and unhealthy habits is especially clear in diseased patients due to the interplay between illness and lifestyle in the prediction of QoL.

Long-Term Cost-Effectiveness of Smoking Cessation Interventions in People With Mental Disorders: A Dynamic Decision Analytical Model

OBJECTIVES

People with mental disorders are more likely to smoke than the general population. The objective of this study is to develop a decision analytical model that estimates long-term cost-effectiveness of smoking cessation interventions in this population.

METHODS

A series of Markov models were constructed to estimate average lifetime smoking-attributable inpatient cost and expected quality-adjusted life-years. The model parameters were estimated using a variety of data sources. The model incorporated uncertainty through probabilistic sensitivity analysis using Monte Carlo simulations. It also generated tables presenting incremental cost-effectiveness ratios of the proposed interventions with varying incremental costs and incremental quit rates. We used data from 2 published trials to demonstrate the model's ability to make projections beyond the observational time frame.

RESULTS

The average smoker's smoking-attributable inpatient cost was 3 times higher and health utility was 5% lower than ex-smokers. The intervention in the trial with a statistically insignificant difference in quit rate (19% vs 25%; P=.2) showed a 45% to 49% chance of being cost-effective compared with the control at willingness-to-pay thresholds of £20 000 to £30 000/quality-adjusted life-years. The second trial had a significant outcome (quit rate 35.9% vs 15.6%; P<.001), and the corresponding probability of the intervention being cost-effective was 65%.

CONCLUSIONS

This model provides a consistent platform for clinical trials to estimate the potential lifetime cost-effectiveness of smoking cessation interventions for people with mental disorders and could help commissioners direct resources to the most cost-effective programs. However, direct comparisons of results between trials must be interpreted with caution owing to their different designs and settings.

Facebook usage, participation patterns, and social support from Facebook activity among smokers with mobility impairments

People with mobility impairments (MIs; use assistive devices to ambulate) have twice the smoking prevalence versus the general population. A Facebook intervention could improve reach to smokers with MIs, but use and patterns of use are unknown. The study examined: (a) Facebook use and relationship with Facebook-based social support and (b) whether Facebook use differs by motivation to quit smoking. Participants (N = 510; 56.3% female, mean age = 42.4 years) were recruited via a recruitment company to complete a one-time online survey assessing motivation to quit within 30 days, Facebook use (Facebook Activities Scale), reasons for use (Facebook Motives Scale), attitudes (Facebook Intensity Scale), and social support (Facebook Measure of Social Support). The vast majority said that Facebook is part of their daily routine (92.9%), 83% checked Facebook >once a day, and 69% spent >30 min/day on Facebook. Facebook was used to connect with similar others (68.4%), participate in groups (72.9%), decrease loneliness (69.2%), and obtain health information (62.5%); 88% said that they would join a Facebook program to help them quit smoking. A greater number of Facebook friends (rs = .18-.22, p < .001) and greater Facebook use (rs = .20 to rs = .59; p < .001) were correlated with greater perceived social and emotional support. Those motivated to quit posted more frequently (odds ratio [OR] = 1.56, 95% confidence interval [CI] = 1.10, 2.22) and were more likely to indicate that they would join a Facebook group for smoking cessation (OR = 4.15, 95% CI = 2.05, 8.38) than those not motivated. Facebook could circumvent disability and environmental barriers to accessing cessation among this health disparity population.

Evaluation of an integrated treatment to address smoking cessation and anxiety/depressive symptoms among people living with HIV: Study protocol for a randomized controlled trial

BACKGROUND

Interventions that target anxiety/depressive symptoms in the context of smoking treatment have shown promise irrespective of psychiatric diagnosis. Yet, these tailored treatments are largely absent for persons who smoke and are living with HIV (SLWH).

OBJECTIVE

To evaluate a novel, smoking cessation intervention that addresses anxiety/depression and HIV-related health (QUIT) against a time-matched control (TMC) and a standard of care (SOC) condition.

METHODS

SLWH (N = 180) will be recruited and enrolled from 3 medical clinics in Boston, MA, and Houston, TX. The trial will consist of a baseline assessment, a 10-week intervention/assessment period, and follow-up assessments, accounting for a total study duration of approximately 8 months. All participants will complete a baseline visit and a pre-randomization standardized psychoeducation visit, and will then be randomized to one of three conditions: QUIT, TMC, or SOC. QUIT and TMC will consist of nine 60-min, cognitive behavioral therapy-based, individual weekly counseling sessions using standard smoking cessation counseling; additionally, QUIT will target anxiety and depressive symptoms by addressing underlying mechanisms related to mood and quit difficulty. SOC participants will complete weekly self-report surveys for nine weeks. All participants will be encouraged to quit at Session 7 and will be offered nicotine replacement therapy to help.

CONCLUSIONS

QUIT is designed to improve smoking cessation in SLWH by addressing anxiety and depression and HIV-related health issues. If successful, the QUIT intervention would be ready for implementation and dissemination into "real-world" behavioral health and social service settings consistent with the four objectives outlined in NIDA's Strategic Plan.

Smoking, Obesity, and Disability Benefits or Litigation Are Not Associated with Clinically Important Reductions in Physical Functioning After Intramedullary Nailing of Tibial Shaft Fractures: A Retrospective Cohort Study

BACKGROUND

Forty percent of long bone fractures involve the tibia. These fractures are associated with prolonged recovery and may adversely affect patients' long-term physical functioning; however, there is limited evidence to inform what factors influence functional recovery in this patient population.

QUESTION/PURPOSE

In a secondary analysis of a previous randomized trial, we asked: What fracture-related, demographic, social, or rehabilitative factors were associated with physical function 1 year after reamed intramedullary nailing of open or closed tibial shaft fractures?

METHODS

This is a secondary (retrospective) analysis of a prior randomized trial (Trial to Re-evaluate Ultrasound in the Treatment of Tibial Fractures; TRUST trial). In the TRUST trial, 501 patients with unilateral open or closed tibial shaft fractures were randomized to self-administer daily low-intensity pulsed ultrasound or use a sham device, of which 15% (73 of 501) were not followed for 1 year due to early study termination as a result of futility (no difference between active and sham interventions). Of the remaining patients, 70% (299 of 428) provided full data. All fractures were fixed using reamed (298 of 299) or unreamed (1 of 299) intramedullary nailing. Thus, we excluded the sole fracture fixed using unreamed intramedullary nailing. The co-primary study outcomes of the TRUST trial were time to radiographic healing and SF-36 physical component summary (SF-36 PCS) scores at 1-year. SF-36 PCS scores range from 0 to 100, with higher scores being better, and the minimum clinically important difference (MCID) is 5 points. In this secondary analysis, based on clinical and biological rationale, we selected factors that may be associated with physical functioning as measured by SF-36 PCS scores. All selected factors were inserted simultaneously into a multivariate linear regression analysis.

RESULTS

After adjusting for potentially confounding factors, such as age, gender, and injury severity, we found that no factor showed an association that exceeded the MCID for physical functioning 1 year after intramedullary nailing for tibial shaft fractures. The independent variables associated with lower physical functioning were current smoking status (mean difference -3.0 [95% confidence interval -5 to -0.5]; p = 0.02), BMI > 30 kg/m2 (mean difference -3.0 [95% CI -5.0 to -0.3]; p = 0.03), and receipt of disability benefits or involvement in litigation, or plans to be (mean difference -3.0 [95% CI -5.0 to -1]; p = 0.007). Patients who were employed (mean difference 4.6 [95% CI 2.0 to 7]; p < 0.001) and those who were advised by their surgeon to partially or fully bear weight postoperatively (mean difference 2.0 [95% CI 0.1 to 4.0]; p = 0.04) were associated with higher physical functioning. Age, gender, fracture severity, and receipt of early physical therapy were not associated with physical functioning at 1-year following surgical fixation.

CONCLUSION

Among patients with tibial fractures, none of the factors we analyzed, including smoking status, receipt of disability benefits or involvement in litigation, or BMI, showed an association with physical functioning that exceeded the MCID.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Health-related quality of life in women after colposcopy: results from a longitudinal patient survey

BACKGROUND

Information concerning the health-related quality-of-life (HRQoL) consequences of colposcopy is limited, particularly over time. In a longitudinal study, we investigated women's HRQoL at 4, 8 and 12 months post colposcopy and the factors associated with this.

METHODS

Women attending colposcopy at two large hospitals affiliated with the national screening programme in Ireland were invited to complete questionnaires at 4, 8 and 12 months post colposcopy. HRQoL was measured using the EQ-5D-3L and compared across a range of socio-demographic, clinical and attitudinal variables. A mixed-effects logistic multivariable model was employed to investigate associations between these variables and low HRQoL.

RESULTS

Of 584 women initially recruited, 429, 343 and 303 completed questionnaires at 4, 8 and 12 months, respectively. The mean overall HRQoL score for the sample across all time points was 0.90 (SD 0.16). Approximately 18% of women experienced low HRQoL at each of the three time points. In multivariable testing, over the entire 12-month follow-up period, non-Irish nationals (OR 8.99, 95% CI 2.35-34.43) and women with high-grade referral cytology (OR 2.78, 95% CI 1.08-7.13) were at higher odds of low HRQoL. Women who were past (OR 0.20, 95% CI 0.07-0.58) or never (OR 0.42, 95% CI 0.16-1.12) smokers were at lower odds of low HRQoL than current smokers. As women's satisfaction with their healthcare increased their odds of experiencing low HRQoL fell (OR per unit increase 0.51, 95% CI 0.34-0.75).

CONCLUSIONS

Women's HRQoL did not change over the 12 months post colposcopy, but some subgroups of women were at higher risk of experiencing low HRQoL. These subgroups may benefit from additional support.

The Impact of Psychiatric Disorder Diagnosis on Motivation to Quit and Stage of Change Among Patients at a Hospital-Based Outpatient Smoking Cessation Clinic

Smoking is among the greatest international public health concerns, causing excessive levels of preventable premature death, disability, and economic costs. The prevalence of tobacco use among people with psychiatric disorders (PDs) remains persistently high relative to the general population, highlighting the need to improve smoking cessation (SC) strategies in this group. We aimed to assess the associations between having a PD and baseline motivation to quit (MtQ) smoking and Prochaska's stage of change (SoC), two clinically important metrics linked to SC outcomes. Methods: This retrospective chart review included patients who completed a baseline visit at a hospital-based outpatient SC clinic (N = 896). Multivariate hierarchical logistic and linear regression models were developed to assess variables associated with MtQ (importance and confidence in quitting) and SoC, primarily PD category (externalizing, internalizing, externalizing/internalizing, psychotic or no PD) and secondarily, demographics, physical health history, and tobacco use/dependence metrics. Results: The variables negatively associated with MtQ were female sex (p = .011), older age (p = .038), deriving income from social assistance (p < .001), and age at smoking initiation (p = .005), whereas ≥ 1 quit attempt in the past year predicted higher MtQ (p < .0001). Being in the preparative/action SoC (versus the pre-contemplative/contemplative) was associated with income from social assistance (OR 0.39, p = .001), more daily cigarettes smoked (OR 0.98, p = .005) and ≥ 1 past-year quit attempt (OR 1.69, p = .013). Conclusions: Having a PD was not associated with either MtQ or SoC. Deriving income from social assistance predicted lower MtQ and SoC. Having made ≥ 1 quit attempt in the past year was associated with higher MtQ and SoC. Our study suggests that people with PDs are as motivated to quit smoking and ready for change as people without PDs, and smoking cessation efforts should be amplified in this group to address the disproportionately high level of tobacco use, especially because having at least one quit attempt may enhance MtQ and SoC.

Health-related quality of life in pilots of a Chinese commercial airline

Health-related quality of life (HRQOL) is currently an important issue in the medical industry. However, data on HRQOL in commercial airline pilots are lacking. This study aimed to investigate HRQOL and its related factors in a sample of commercial pilots. A purposive sample of 373 participants was recruited from a Chinese Commercial Airline. The median (IQR) score for physical health, psychological health and social relationship were 64.3 (75-53.6), 62.5 (70.8-54.2) and 75 (75-58.3), respectively. The mean (SD) score for Environment was 62.2 (16). After controlling for demographics, the multiple linear regression analyses showed that physical activity, fruit intake and vegetable intake were positively correlated with HRQOL score (p < .05), while time-zone flights, smoking, alcohol drinking and being dyslipidemic showed a negative correlation with HRQOL score (p < .05). Healthcare providers should consider time-zone flights, behavioral factors and dyslipidemia when planning related health promotion and disease prevention programs for commercial pilots in the future.

Pain During Sex Before and After Surgery for Lumbar Disc Herniation: A Multicenter Observational Study

STUDY DESIGN

Observational multicenter study.

OBJECTIVE

The aim of this study was to evaluate changes in pain during sexual activity after surgery for lumbar disc herniation (LDH).

SUMMARY OF BACKGROUND DATA

There are limited data available on sexual function in patients undergoing surgery for LDH.

METHODS

Data were retrieved from the Norwegian Registry for Spine Surgery. The primary outcome was change in pain during sexual activity at one year, assessed by item number eight of the Oswestry disability index (ODI) questionnaire. Secondary outcome measures included ODI, EuroQol-5D (EQ-5D), and numeric rating scale (NRS) scores for back and leg pain.

RESULTS

Among the 18,529 patients included, 12,103 (64.8%) completed 1-year follow-up. At baseline, 16,729 patients (90.3%) provided information about pain during sexual activity, whereas 11,130 (92.0%) among those with complete follow-up completed this item. Preoperatively 2586 of 16,729 patients (15.5%) reported that pain did not affect sexual activity and at 1 year, 7251 of 11,130 patients (65.1%) reported a normal sex-life without pain. Preoperatively, 2483 (14.8%) patients reported that pain prevented any sex-life, compared to 190 patients (1.7%) at 1 year. At baseline, 14,143 of 16,729 patients (84.5%) reported that sexual activity caused pain, and among these 7232 of 10,509 responders (68.8%) reported an improvement at 1 year. A multivariable regression analysis showed that having a life partner, college education, working until time of surgery, undergoing emergency surgery, and increasing ODI score were predictors of improvement in pain during sexual activity. Increasing age, tobacco smoking, increasing body mass index, comorbidity, back pain >12 months, previous spine surgery, surgery in two or more lumbar levels, and complications occurring within 3 months were negative predictors.

CONCLUSION

This study clearly demonstrates that a large proportion of patients undergoing surgery for LDH experienced an improvement in pain during sexual activity at 1 year.

LEVEL OF EVIDENCE

2.

Impacts and interactions of COVID-19 response involvement, health-related behaviours, health literacy on anxiety, depression and health-related quality of life among healthcare workers: a cross-sectional study

OBJECTIVES

We examined impacts and interactions of COVID-19 response involvement, health-related behaviours and health literacy (HL) on anxiety, depression, and health-related quality of life (HRQoL) among healthcare workers (HCWs).

DESIGN

A cross-sectional study was conducted. Data were collected 6 April to 19 April 2020 using online-based, self-administered questionnaires.

SETTING

19 hospitals and health centres in Vietnam.

PARTICIPANTS

7 124 HCWs aged 21-60 years.

RESULTS

The COVID-19 response-involved HCWs had higher anxiety likelihood (OR (95% CI)=4.41 (3.53 to 5.51)), higher depression likelihood (OR(95% CI)=3.31 (2.71 to 4.05)) and lower HRQoL score (coefficient, b(95% CI)=-2.14 (-2.89 to -1.38)), compared with uninvolved HCWs. Overall, HCWs who smoked or drank at unchanged/increased levels had higher likelihood of anxiety, depression and lower HRQoL scores; those with unchanged/healthier eating, unchanged/more physical activity and higher HL scores had lower likelihood of anxiety, depression and higher HRQoL scores. In comparison to uninvolved HCWs who smoked or drank at never/stopped/reduced levels, involved HCWs with unchanged/increased smoking or drinking had lower anxiety likelihood (OR(95% CI)=0.34 (0.14 to 0.83)) or (OR(95% CI)=0.26 (0.11 to 0.60)), and lower depression likelihood (OR(95% CI)=0.33 (0.15 to 0.74)) or (OR(95% CI)=0.24 (0.11 to 0.53)), respectively. In comparison with uninvolved HCWs who exercised at never/stopped/reduced levels, or with those in the lowest HL quartile, involved HCWs with unchanged/increased exercise or with one-quartile HL increment reported lower anxiety likelihood (OR(95% CI)=0.50 (0.31 to 0.81)) or (OR(95% CI)=0.57 (0.45 to 0.71)), lower depression likelihood (OR(95% CI)=0.40 (0.27 to 0.61)) or (OR(95% CI)=0.63 (0.52 to 0.76)), and higher HRQoL scores (b(95% CI)=2.08 (0.58 to 3.58)), or (b(95% CI)=1.10 (0.42 to 1.78)), respectively.

CONCLUSIONS

Physical activity and higher HL were found to protect against anxiety and depression and were associated with higher HRQoL. Unexpectedly, smoking and drinking were also found to be coping behaviours. It is important to have strategic approaches that protect HCWs' mental health and HRQoL.

A Cost-Effectiveness Analysis of Smoking-Cessation Interventions Prior to Posterolateral Lumbar Fusion

BACKGROUND

Smoking cessation represents an opportunity to reduce both short and long-term effects of smoking on complications after lumbar fusion and smoking-related morbidity and mortality. However, the cost-effectiveness of smoking-cessation interventions prior to lumbar fusion is not fully known.

METHODS

We created a decision-analytic Markov model to evaluate the cost-effectiveness of 5 smoking-cessation strategies (behavioral counseling, nicotine replacement therapy [NRT], bupropion or varenicline monotherapy, and a combined intervention) prior to single-level, instrumented lumbar posterolateral fusion (PLF) from the health payer perspective. Probabilities, costs, and utilities were obtained from published sources. We calculated the costs and quality-adjusted life years (QALYs) associated with each strategy over multiple time horizons and accounted for uncertainty with probabilistic sensitivity analyses (PSAs) consisting of 10,000 second-order Monte Carlo simulations.

RESULTS

Every smoking-cessation intervention was more effective and less costly than usual care at the lifetime horizon. In the short term, behavioral counseling, NRT, varenicline monotherapy, and the combined intervention were also cost-saving, while bupropion monotherapy was more effective but more costly than usual care. The mean lifetime cost savings for behavioral counseling, NRT, bupropion monotherapy, varenicline monotherapy, and the combined intervention were $3,291 (standard deviation [SD], $868), $2,571 (SD, $479), $2,851 (SD, $830), $6,767 (SD, $1,604), and $34,923 (SD, $4,248), respectively. The minimum efficacy threshold (relative risk for smoking cessation) for lifetime cost savings varied from 1.01 (behavioral counseling) to 1.15 (varenicline monotherapy). A PSA revealed that the combined smoking-cessation intervention was always more effective and less costly than usual care.

CONCLUSIONS

Even brief smoking-cessation interventions yield large short-term and long-term cost savings. Smoking-cessation interventions prior to PLF can both reduce costs and improve patient outcomes as health payers/systems shift toward value-based reimbursement (e.g., bundled payments) or population health models.

LEVEL OF EVIDENCE

Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

Association of smoking status and health-related quality of life: difference among young, middle-aged, and older adults in Shandong, China

PURPOSE

Few studies explored the relationship between smoking status and health-related quality of life (HRQOL) among adults in China. This study aims to explore the relationship between smoking status and HRQOL among adults (18 +) and examine whether there is a difference in this relationship among young, middle-aged, and older adults in China.

METHODS

A total of 23,021 respondents were included in this study. The HRQOL is measured by EQ-5D-3L. The smoking status is divided into never smokers, current smokers, and former smokers. Tobit regression and Logistic regression are employed to explore the association between smoking status and HRQOL. The interaction term is included to explore the difference among young, middle-aged, and older adults.

RESULTS

This study finds smoking status is significantly associated with HRQOL. An interaction analysis shows that the association between smoking status and HRQOL is significantly different among young, middle-aged, and older adults (P < 0.05). The smoking status is only significantly associated with HRQOL in middle-aged and older adults, but not for young adults. Compared with never smokers, former smokers report significantly lower EQ-5D-3L utility value in middle-aged adults (coefficient =  - 0.089; 95%CI - 0.128 to - 0.050), current smokers report significantly higher EQ-5D-3L utility value in older adults (coefficient = 0.041; 95%CI 0.005 to 0.076).

CONCLUSIONS

This study demonstrates a significant association between smoking status and HRQOL among adults in China, and there is a difference in this relationship among young, middle-aged, and older adults. The government should take efforts to formulate a variety of measures to control tobacco use among adults.

Alcohol drinking as a mediator of the influence of smoking prevalence on second-hand smoke exposure in workplaces: a mediation analysis

Objective

Both alcohol drinking and second-hand smoke (SHS) exposure have shown a strong association with smoking behaviour. This study uses mediation analysis to clarify the process underlying the relationship between smoking prevalence and SHS exposure and the extent to which this relationship is mediated by alcohol use in the workplace.

Method

A total of 14,195 employees from 81 companies in China participated in this survey. Mediation analysis was used to establish the mediation effect of alcohol drinking. Structural equation modelling (SEM) was used to evaluate the role of alcohol drinking when a smoke-free (SF) workplace policy was imposed.

Results

For males, approximately 6.3% of the effects on SHS exposure were mediated through the channel of alcohol use. For females, this channel mediated 14.1% of the total effects. SF policy was negatively associated with smoking prevalence and SHS exposure. The indirect effect of the SF policy on reducing SHS exposure by controlling smoking behaviour was significant. For smokers, worksite smoking bans were negatively associated with the smoking amount and drinking behaviour, and the indirect effect of this policy on promoting smokers’ intention to quit by reducing the smoking amount and controlling drinking behaviour was significant.

Conclusion

This study confirmed that alcohol drinking is among the channels that mediate the association between smoking prevalence and SHS exposure in workplaces. Our results also find a spillover effect of SF workplace policy and call for effective interventions for alcohol use, which may influence the outcomes of SF policy implementation.

Health benefits and economic advantages associated with increased utilization of a smoking cessation program

Rationale, aim & objective: The goal of this study was to examine the health and economic impacts related to increased utilization of the Duke Smoking Cessation Program resulting from the addition of two relatively new referral methods - Best Practice Advisory and Population Outreach. Materials & methods: In a companion paper 'Comparison of Referral Methods into a Smoking Cessation Program', we report results from a retrospective, observational, comparative effectiveness study comparing the impact of three referral methods - Traditional Referral, Best Practice Advisory and Population Outreach on utilization of the Duke Smoking Cessation Program. In this paper we take the next step in this comparative assessment by developing a Markov model to estimate the improvement in health and economic outcomes when two referral methods - Best Practice Advisory and Population Outreach - are added to Traditional Referral. Data used in this analysis were collected from Duke Primary Care and Disadvantaged Care clinics over a 1-year period (1 October 2017-30 September 2018). Results: The addition of two new referral methods - Best Practice Advisory and Population Outreach - to Traditional Referral increased the utilization of the Duke Smoking Cessation Program in Primary Care clinics from 129 to 329 smokers and in Disadvantaged Care clinics from 206 to 401 smokers. The addition of these referral methods was estimated to result in 967 life-years gained, 408 discounted quality-adjusted life-years saved and total discounted lifetime direct healthcare cost savings of US$46,376,285. Conclusion: Health systems may achieve increased patient health and decreased healthcare costs by adding Best Practice Advisory and Population Outreach strategies to refer patients to smoking cessation services.

Cost-effectiveness of e-cigarettes compared with nicotine replacement therapy in stop smoking services in England (TEC study): a randomized controlled trial

AIM

To evaluate the cost-effectiveness of e-cigarettes as a smoking cessation aid used in routine stop smoking services in England.

DESIGN

Cost-effectiveness analysis was performed from the National Health Service (NHS) and Personal Social Services (PSS) perspective for 12-month periods and life-time. Costs, including that of both treatments, other smoking cessation help and health-care services, and health benefits, estimated from EQ-5D-5L and measured in quality-adjusted life-years (QALYs), for the 12-month analysis, came from a randomized controlled trial. Life-time analysis was model-based with input from both trial data and published secondary data sources. Cost-effectiveness was measured by an incremental cost-effectiveness ratio (ICER).

SETTING

Three stop-smoking service sites in England.

PARTICIPANTS

Adult smokers (n = 886) who sought help to quit in the participating sites.

INTERVENTION AND COMPARATOR

An e-cigarette (EC) starter kit versus provision of nicotine replacement therapy (NRT) for up to 3 months, both with standard behavioural support. A total of 886 participants were randomized (439 in the EC arm, 447 in the NRT arm). Excluding one death in each arm, the 1-year quit rate was 18.0 and 9.9%, respectively.

MEASUREMENTS

Cost of treatments was estimated from the treatment log. Costs of other smoking cessation help and health-care services and EQ-5D-5 L were collected at baseline, 6- and 12-month follow-ups. Incremental costs and incremental QALYs were estimated using regression adjusting for baseline covariates and their respective baseline values.

FINDINGS

The ICER was £1100 per QALY gained at the 12 months after quit date (87% probability below £20 000/QALY). Markov model estimated the life-time ICER of EC to be £65 per QALY (85% probability below £20 000/QALY).

CONCLUSION

Using e-cigarettes as a smoking cessation aid with standard behavioural support in stop-smoking services in England is likely to be more cost-effective than using nicotine replacement therapy in the same setting.

Tobacco smoking and health-related quality of life among university students: Mediating effect of depression

The aim of this study was to assess the association between cigarette smoking and health-related quality of life (HRQoL) among students in two different universities, and the potential mediating effect of depression. Participants were students who came for mandatory check-ups at Student Health Care Centers in two Universities in Serbia, differing by socio-politically and economically environments. Students completed socio-demographic questionnaire, Beck Depression Inventory (BDI) and the SF-36 questionnaire for assessment of HRQoL. In both populations, after adjustment for socio-demographic, behavioral and health factors, smoking was associated with poorer Mental Composite Score (MCS) and Physical Composite Score (PCS) (Belgrade 1,624 students: MCS β = 3.38, 95% confidence interval [CI] 1.31, 5.44, PCS β = 1.01, 95% CI -0.50, 2.52; Kosovska Mitrovica 514 students: MCS β = 5.06, 95% CI 1.74, 8.37, PCS β = 3.29, 95% CI 0.75, 5.83). After additional adjustment for BDI score, the observed associations were lost (Belgrade: MCS β = 1.12, 95% CI -0.57, 2.80, PCS β = -0.40, 95% CI -1.71, 0.92; Kosovska Mitrovica: MCS β = 0.77, 95% CI -2.06, 3.60, PCS β = 0.56, 95% CI -1.75, 2.87). Higher BDI score was associated with poorer PCS and MCS across all quintiles. The association of smoking with impairment of HRQoL among university students in two different settings was mediated by higher levels of depressive symptoms. These findings highlight the need for further research on the interaction between smoking, mental health and quality of life, with implications for prevention, diagnosis and treatment.

Health-Related Quality of Life and Associated Factors among Oldest-Old in China

OBJECTIVES

The oldest old population has become the fastest growing segment with excess need of care and social support, it is crucial to improve the health-related quality of life (HRQoL) of these populations. This study seeks to evaluate the health status and to investigate modifiable factors associated with health-related quality of life for oldest old adults in China.

DESIGN

A cross-sectional population-based study.

SETTING

Hainan Province in the south of China.

PARTICIPANTS

1,278 adults aged 80 years or older.

METHODS

HRQoL was assessed by three-level EuroQol-5D scale (EQ-5D-3L) and a visual analogue scale (VAS). Demographic and health-related variables were analysed by estimating mean values and standard deviations for continuous variables, percentages and standard deviations for categorical variables. Tobit regressions, ordinary least Squared (OLS) regressions and ordered probit regressions were adopted to determine the associated factors for overall HRQoL and for each health dimension.

RESULTS

Anxiety/depression was the least reported problem while mobility was the most frequently reported with problem. Female respondents had lower EQ-5D score (0.76 vs. 0.86) and VAS score (66.55 vs. 69.84) than male respondents. Better health-related quality of life was significantly associated with higher BMI, no drinking habit, more leisure activities, living with family members, good sleeping quality, closer social and family connections, fewer numbers of drugs consumed per day, without having hearing or visual impairment, and fewer chronic conditions, after controlling for potential confounders.

CONCLUSION

Findings from this study suggested that quality of life was not only associated with age-related diseases, but also correlated with a range of health-related lifestyles, and factors indicating social and family support.

Cigarette Smoking and Health-related Quality of Life in the General Population of Iran: Independent Associations According to Gender

Background:

Associations between smoking and health-related quality of life (HRQoL) in the general population remain unclear. The aim of the study was to quantify the independent associations between smoking and HRQoL.

Methods:

A cross-sectional population-based study was conducted on a total sample of 2197 participants obtained by multistage sampling to investigate the associations between smoking and HRQoL in the general population of southeast and southwest of Iran, aged 18–100 years in 2012–2013. Data were collected using a self-administrated of the 36-Item Short Form Survey (SF-36) questionnaire. Linear regression analyses were used to evaluate the associations between HRQoL and smoking while adjusting for various socioeconomic variables. In this study, P < 0.05 was considered a significant difference.

Results:

Out of the total of 2197 participants, current smokers and never smokers accounted for 13% and 87%, respectively. The mean HRQoL indices were for the current smokers 66.66 ± 17.86, and never smokers 71.35 ± 18.47 (P < 0.001). Independent associations between smoking and HRQoL were found, including negative associations (P < 0.001). The multivariate associations between smoking status and HRQoL, male smokers had a lower physical functioning, mental health, and total SF-36 score.

Conclusions:

Smoking was independently related to HRQoL, with large differences according to the gender. This study showed that there is a significant difference in the quality of life related to health in male smokers compared to male nonsmokers.

Cost-effectiveness of population-level proactive tobacco cessation outreach among socio-economically disadvantaged smokers: evaluation of a randomized control trial

AIMS

To estimate the cost-effectiveness at population-level of the OPT-IN proactive tobacco cessation outreach program for adult smokers enrolled in publicly funded health insurance plans for low-income persons (e.g. Medicaid).

DESIGN

Cost-effectiveness analysis using a state transition model based on data from the Offering Proactive Treatment Intervention (OPT-IN) randomized control trial.

SETTING

The trial was conducted in Minnesota, USA, and the economic analysis was conducted from the Medicaid program perspective.

PARTICIPANTS

Data were used from 2406 smokers who were randomized into the intervention or comparator groups.

INTERVENTION AND COMPARATOR

The intervention was comprised of proactive outreach (mailed invitation and telephone calls) and free cessation treatment (nicotine replacement therapy and intensive telephone counseling). The comparator was usual care, which comprised access to a primary care physician, insurance coverage of Food and Drug Administration (FDA)-approved smoking cessation medications and the state's telephone quitline.

MEASUREMENTS

Smoking status, quality of life and health-care use at varying times, including at baseline and 1 year.

FINDINGS

The OPT-IN program cost an average of $84 per participant greater than the comparator. One year after randomization, the population-level, 6-month prolonged smoking abstinence rate was 16.5% in the proactive outreach intervention group and 12.1% in the usual care group (P < 0.05). The model projected that the proactive outreach intervention added $78 in life-time cost and generated 0.005 additional quality-adjusted life-years (QALYs), with an expected incremental cost-effectiveness ratio of $4231 per QALY. Probabilistic sensitivity analysis found that the proactive outreach intervention would be cost-effective against a willingness-to-pay threshold of $50 000/QALY approximately 68% of the time.

CONCLUSIONS

Population-level proactive tobacco treatment with personal telephone outreach was effective in achieving higher population-level quit rates and was cost-effective at various willingness-to-pay thresholds, compared with usual care (i.e. reactive treatment). Taken together with prior research, population-level proactive tobacco cessation outreach programs are judged to be highly cost-effective over the long term.

Health-related quality of life and economic burden to smoking behaviour among Canadians

OBJECTIVES

The objectives of this study were to: (1) examine whether the smoking status of the Canadian population is associated with a reduction in health-related quality of life (HRQoL); (2) calculate the overall economic burden of loss in HRQoL using a commonly accepted $100,000 willingness-to-pay (WTP) threshold to gain one quality-adjusted life year (QALY); and (3) calculate the loss of HRQoL over a lifetime.

METHODS

We used the 2015 Canadian Community Health Survey. The variations in HRQoL were estimated using a multivariable generalized linear model. Total expected lifetime QALYs lost due to smoking were calculated by compounding the annual adjusted health utility loss associated with smoking across a respondent's remaining years of life expectancy stratified by age. A discount rate of 1.5% was applied to the analysis based on recent analysis of the costs of borrowing in Canada.

RESULTS

Smoking is significantly associated with HRQoL loss. This study demonstrated that smoking is associated with a 0.05 and 0.01 reduction in Health Utilities Index Mark 3 (HUI3) score for current and former smokers, which also corresponds to a loss of 0.66 quality-adjusted life years in average, and also is associated with substantial individual and societal economic cost. The total lifetime economic burden of HUI3 loss per smoker was $65,935, yielding in the aggregate a societal burden of $1068.88 billion in the study population.

CONCLUSION

Tobacco control, prevention and intervention not only will improve HRQoL but also will generate social returns on investment.

E-cigarettes compared with nicotine replacement therapy within the UK Stop Smoking Services: the TEC RCT

BACKGROUND

Over the past few years, a large number of smokers in the UK have stopped smoking with the help of e-cigarettes. So far, UK Stop Smoking Services (SSSs) have been reluctant to include e-cigarettes among their treatment options because data on their efficacy compared with the licensed medications are lacking.

OBJECTIVE

The objective was to compare the efficacy of refillable e-cigarettes and nicotine replacement therapy (NRT) products, when accompanied by weekly behavioural support.

DESIGN

A randomised controlled trial comparing e-cigarettes and NRT.

SETTING

Three sites that provide local SSSs.

PARTICIPANTS

The participants were 886 smokers seeking help to quit smoking, aged ≥ 18 years, not pregnant or breastfeeding, with no strong preference to use or not to use NRT or e-cigarettes in their quit attempt, and currently not using NRT or e-cigarettes. A total of 886 participants were randomised but two died during the study (one in each study arm) and were not included in the analysis.

INTERVENTIONS

The NRT arm (n = 446) received NRT of their choice (single or combination), provided for up to 12 weeks. The e-cigarette arm (n = 438) received an e-cigarette starter pack and were encouraged to buy addtional e-liquids and e-cigarette products of their choice. Both arms received the same standard behavioural support. Participants attended weekly sessions at their SSS and provided outcome data at 4 weeks. They were then followed up by telephone at 6 and 12 months. Participants reporting abstinence or at least 50% reduction in cigarette consumption at 12 months were invited to attend for carbon monoxide (CO) validation. Participants/researchers could not be blinded to the intervention.

MAIN OUTCOME MEASURES

The primary outcome was CO-validated sustained abstinence rates at 52 weeks. Participants lost to follow-up or not providing biochemical validation were included as non-abstainers. Secondary outcomes included abstinence at other time points, reduction in smoke intake, treatment adherence and ratings, elicited adverse reactions, and changes in self-reported respiratory health. A cost-efficacy analysis of the intervention was also conducted.

RESULTS

The 1-year quit rate was 9.9% in the NRT arm and 18.0% in the e-cigarette arm (risk ratio 1.83, 95% confidence interval 1.30 to 2.58; p < 0.001). The e-cigarette arm had significantly higher validated quit rates at all time points. Participants in the e-cigarette arm showed significantly better adherence and experienced fewer urges to smoke throughout the initial 4 weeks of their quit attempt than those in the NRT arm, and gave their allocated product more favourable ratings. They were also more likely to be still using their allocated product at 1 year (39.5% vs. 4.3%, χ2 = 161.4; p < 0.001). Participants assigned to e-cigarettes reported significantly less coughing and phlegm at 1 year than those assigned to NRT (controlling for smoking status). A detailed economic analysis confirmed that, because e-cigarettes incur lower NHS costs than NRT and generate a higher quit rate, e-cigarette use is more cost-effective.

LIMITATIONS

The results may not be generalisable to other types of smokers or settings, or to cartridge-based e-cigarettes.

CONCLUSIONS

Within the context of multisession treatment for smokers seeking help, e-cigarettes were significantly more effective than NRT. If SSSs provide e-cigarette starter packs, it is likely to boost their success rates and improve their cost-efficacy.

FUTURE WORK

The efficacy of e-cigarettes provided with different levels of support will show whether smokers should be encouraged to switch to vaping within support services or whether e-cigarettes can be recommended with less intensive or no support.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN60477608.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 43. See the NIHR Journals Library website for further project information. The trial was supported by the Cancer Research UK Prevention Trials Unit (grant A16893).

The Iranian version of geriatric anxiety inventory (GAI-P): a validation study

Background

Anxiety is one of the most common mental health problems experienced by the elderly that affects quality of life. This study aimed to assess the psychometric properties of the Persian version of the Geriatric Anxiety Inventory (GAI-P) in order to provide a valid instrument for measuring anxiety in this population.

Methods

Forward-backward translation was used to translate the Geriatric Anxiety Inventory from English into Persian and was tested by 10 elderly to assess its face validity. Then a sample of elderly people attending health centers in Dezful, Iran completed the questionnaire. Validity was assessed using both exploratory and confirmatory factors analysis, known-groups comparison (abused and non-abused elderly) also was administered. The internal consistency of the instrument was assessed using Kuder-Richardson 20 coefficients (KR-20). Afterwards, the reliability and validity through assessing the correlation between the Persian version of the GAI-P and the SF-36, were measured.

Results

In all 720 elderly completed the questionnaire. Of these data from 420 elderly were used for exploratory factor analysis and the data from the remaining 300 elderly were used for confirmatory factor analysis. The exploratory factor analysis showed a three-factor solution (cognitive, arousal and somatic) for the questionnaire that jointly explained 59.48% of the overall variance observed. The confirmatory factor analysis supported the three-factor solution and the second-order latent factor model. The findings indicated a positive and significant correlation between the two measures lending support to its concurrent validity (r = 0.67, p < .001).Ultimately, the Geriatric Anxiety Inventory was found to have a favorable internal consistency.

Conclusion

This study confirmed that the GAI-P is a valid measure of anxiety in elderly population and now can be used in geriatric studies in Iran.

Nicotine preloading for smoking cessation: the Preloading RCT

BACKGROUND

Nicotine preloading means using nicotine replacement therapy prior to a quit date while smoking normally. The aim is to reduce the drive to smoke, thereby reducing cravings for smoking after quit day, which are the main cause of early relapse. A prior systematic review showed inconclusive and heterogeneous evidence that preloading was effective and little evidence of the mechanism of action, with no cost-effectiveness data.

OBJECTIVES

To assess (1) the effectiveness, safety and tolerability of nicotine preloading in a routine NHS setting relative to usual care, (2) the mechanisms of the action of preloading and (3) the cost-effectiveness of preloading.

DESIGN

Open-label randomised controlled trial with examination of mediation and a cost-effectiveness analysis.

SETTING

NHS smoking cessation clinics.

PARTICIPANTS

People seeking help to stop smoking.

INTERVENTIONS

Nicotine preloading comprised wearing a 21 mg/24 hour nicotine patch for 4 weeks prior to quit date. In addition, minimal behavioural support was provided to explain the intervention rationale and to support adherence. In the comparator group, participants received equivalent behavioural support. Randomisation was stratified by centre and concealed from investigators.

MAIN OUTCOME MEASURES

The primary outcome was 6-month prolonged abstinence assessed using the Russell Standard. The secondary outcomes were 4-week and 12-month abstinence. Adverse events (AEs) were assessed from baseline to 1 week after quit day. In a planned analysis, we adjusted for the use of varenicline (Champix^®; Pfizer Inc., New York, NY, USA) as post-cessation medication. Cost-effectiveness analysis took a health-service perspective. The within-trial analysis assessed health-service costs during the 13 months of trial enrolment relative to the previous 6 months comparing trial arms. The base case was based on multiple imputation for missing cost data. We modelled long-term health outcomes of smoking-related diseases using the European-study on Quantifying Utility of Investment in Protection from Tobacco (EQUIPT) model.

RESULTS

In total, 1792 people were eligible and were enrolled in the study, with 893 randomised to the control group and 899 randomised to the intervention group. In the intervention group, 49 (5.5%) people discontinued preloading prematurely and most others used it daily. The primary outcome, biochemically validated 6-month abstinence, was achieved by 157 (17.5%) people in the intervention group and 129 (14.4%) people in the control group, a difference of 3.02 percentage points [95% confidence interval (CI) -0.37 to 6.41 percentage points; odds ratio (OR) 1.25, 95% CI 0.97 to 1.62; p = 0.081]. Adjusted for use of post-quit day varenicline, the OR was 1.34 (95% CI 1.03 to 1.73; p = 0.028). Secondary abstinence outcomes were similar. The OR for the occurrence of serious AEs was 1.12 (95% CI 0.42 to 3.03). Moderate-severity nausea occurred in an additional 4% of the preloading group compared with the control group. There was evidence that reduced urges to smoke and reduced smoke inhalation mediated the effect of preloading on abstinence. The incremental cost-effectiveness ratio at the 6-month follow-up for preloading relative to control was £710 (95% CI -£13,674 to £23,205), but preloading was dominant at 12 months and in the long term, with an 80% probability that it is cost saving.

LIMITATIONS

The open-label design could partially account for the mediation results. Outcome assessment could not be blinded but was biochemically verified.

CONCLUSIONS

Use of nicotine-patch preloading for 4 weeks prior to attempting to stop smoking can increase the proportion of people who stop successfully, but its benefit is undermined because it reduces the use of varenicline after preloading. If this latter effect could be overcome, then nicotine preloading appears to improve health and reduce health-service costs in the long term. Future work should determine how to ensure that people using nicotine preloading opt to use varenicline as cessation medication.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN33031001.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 41. See the NIHR Journals Library website for further project information.

Clustering of Health-Related Behavior Patterns and Demographics. Results From the Population-Based KORA S4/F4 Cohort Study

Background: Health behaviors are of great importance for public health. Previous research shows that health behaviors are clustered and do not occur by chance. The main objective of this study was to investigate and describe the clustering of alcohol consumption, nutrition, physical activity and smoking while also considering the influence of sex, age and education. Methods: Using data from the population-based KORA S4/F4 cohort study, latent class regression analysis was undertaken to identify different clusters of health behavior patterns. The clusters were described according to demographics. Furthermore, the clusters were described regarding health-related quality of life at baseline and at a 7 year follow-up. Results: Based on a sample of 4,238 participants, three distinct classes were identified. One overall healthy class and two heterogeneous classes. Classes varied especially according to sex, indicating a healthier behavior pattern for females. No clear association between healthier classes and age, education or physical and mental health-related quality of life was found. Discussion: This study strengthens the literature on the clustering of health behaviors and additionally describes the identified clusters in association with health-related quality of life. More research on associations between clustering of health behaviors and important clinical outcomes is needed.

Protocol for an Economic Evaluation of the Quitlink Randomized Controlled Trial for Accessible Smoking Cessation Support for People With Severe Mental Illness

Introduction: Smoking is a major cause of disease burden and reduced quality of life for people with severe mental illness (SMI). It places significant resource pressure on health systems and financial stress on smokers with SMI (SSMI). Telephone-based smoking cessation interventions have been shown to be cost effective in general populations. However, evidence suggests that SSMI are less likely to be referred to quitlines, and little is known about the effectiveness and cost effectiveness of such interventions that specifically target SSMI. The Quitlink randomized controlled trial for accessible smoking cessation support for SSMI aims to bridge this gap. This paper describes the protocol for evaluating the cost effectiveness of Quitlink. Methods: Quitlink will be implemented in the Australian setting, utilizing the existing mental health peer workforce to link SSMI to a tailored quitline service. The effectiveness of Quitlink will be evaluated in a clustered randomized controlled trial. A cost-effectiveness evaluation will be conducted alongside the Quitlink clustered randomized controlled trial (RCT) with incremental cost-effectiveness ratios (ICERs) calculated for the cost (AUD) per successful quit and quality adjusted life year (QALY) gained at 8 months compared with usual care from both health care system and limited societal perspectives. Financial implications for study participants will also be investigated. A modeled cost-effectiveness analysis will also be conducted to estimate future costs and benefits associated with any treatment effect observed during the trial. Results will be extrapolated to estimate the cost effectiveness of rolling out Quitlink nationally. Sensitivity analyses will be undertaken to assess the impact on results from plausible variations in all modeled variables. Discussion: SSMI require additional support to quit. Quitlink utilizes existing peer worker and quitline workforces and tailors quitline support specifically to provide that increased cessation support. Given Quitlink engages these existing skilled workforces, it is hypothesized that, if found to be effective, it will also be found to be both cost effective and scalable. This protocol describes the economic evaluation of Quitlink that will assess these hypotheses. Ethics and dissemination: Full ethics clearances have been received for the methods described below from the University of Newcastle (Australia) Human Research Ethics Committee (H-2018-0192) and St Vincent's Hospital, Melbourne (HREC/18/SVHM/154). The trial has been registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12619000244101). Participant consent is sought both to participate in the study and to have the study data linked to routine health administrative data on publicly subsidized health service and pharmaceutical use, specifically the Medicare Benefits and Pharmaceutical Benefits Schemes (MBS/PBS). Trial findings (including economic evaluation) will be published in peer reviewed journals and presented at international conferences. Collected data and analyses will be made available in accordance with journal policies and study ethics approvals. Results will be presented to relevant government authorities with an interest in cost effectiveness of these types of interventions.

Cost-effectiveness of enhancing a Quit-and-Win smoking cessation program for college students

OBJECTIVES

We conducted a cost-effectiveness analysis and model-based cost-utility and cost-benefit analysis of increased dosage (3 vs. 1 consecutive contests) and enhanced content (supplemental smoking-cessation counseling) of the Quit-and-Win contest using data from a randomized control trial enrolling college students in the US.

METHODS

For the cost-utility and cost-benefit analyses, we used a microsimulation model of the life course of current and former smokers to translate the distribution of the duration of continuous abstinence among each treatment arm's participants observed at the end of the trial (N = 1217) into expected quality-adjusted life-years (QALYs) and costs and an incremental net monetary benefit (INMB). Missing observations in the trial were classified as smoking. For our reference case, we took a societal perspective and used a 3% discount rate for costs and benefits. A probabilistic sensitivity analysis (PSA) was performed to account for model and trial-estimated parameter uncertainty. We also conducted a cost-effectiveness analysis (cost per additional intermediate cessation) using direct costs of the intervention and two trial-based estimates of intermediate cessation: (a) biochemically verified (BV) 6-month continuous abstinence and (b) BV 30-day point prevalence abstinence at 6 months.

RESULTS

Multiple contests resulted in a significantly higher BV 6-month continuous abstinence rate (RD 0.04), at a cost of $1275 per additional quit, and increased the duration of continuous abstinence among quitters. In the long run, multiple contests lead to an average gain of 0.03 QALYs and were cost saving. Incorporating parameter uncertainty into the analyses, the expected INMB was greater than $1000 for any realistic willingness to pay (WTP) for a QALY.

CONCLUSIONS

Assuming missing values were smoking, multiple contests appear to dominate a single contest from a societal perspective. Funding agencies seeking to promote population health by funding a Quit-and-Win contest in a university setting should strongly consider offering multiple consecutive contests. Further research is needed to evaluate multiple contests compared to no contest.

Relapse to smoking and health-related quality of life: Secondary analysis of data from a study of smoking relapse prevention

Background

Previous studies have shown that smoking and smoking cessation may be associated with health-related quality of life (HRQoL). In this study, we compared changes in HRQoL in people who maintained abstinence with people who had relapsed to smoking.

Methods

This was a secondary analysis of data from a trial of a relapse prevention intervention in 1,407 short-term quitters. The European Quality of Life -5 Dimensions (EQ-5D) measured HRQoL at baseline, 3 and 12 months. Smoking outcome was continuous abstinence from 2 to 12 months, and 7-day smoking at 3 and 12 months. We used nonparametric test for differences in EQ-5D utility scores, and chi-square test for dichotomised response to each of the five EQ-5D dimensions. Multivariable regression analyses were conducted to evaluate associations between smoking relapse and HRQoL or anxiety/depression problems.

Results

The mean EQ-5D tariff score was 0.8252 at baseline. People who maintained abstinence experienced a statistically non-significant increase in the EQ-5D score (mean change 0.0015, P = 0.88), while returning to smoking was associated with a statistically significant decrease in the EQ-5D score (mean change -0.0270, P = 0.004). After adjusting for multiple baseline characteristics, the utility change during baseline and 12 months was statistically significantly associated with continuous abstinence, with a difference of 0.0288 (95% CI: 0.0006 to 0.0571, P = 0.045) between relapsers and continuous quitters. The only difference in quality of life dimensions between those who relapsed and those who maintained abstinence was in the proportion of participants with anxiety/depression problems at 12 months (30% vs. 22%, P = 0.001). Smoking relapse was associated with a simultaneous increase in anxiety/depression problems.

Conclusions

People who achieve short-term smoking abstinence but subsequently relapse to smoking have a reduced quality of life, which appears mostly due to worsening of symptoms of anxiety and depression. Further research is required to more fully understand the relationship between smoking and health-related quality of life, and to develop cessation interventions by taking into account the impact of anxiety or depression on smoking.

Quality of Life for 19,114 participants in the ASPREE (ASPirin in Reducing Events in the Elderly) study and their association with sociodemographic and modifiable lifestyle risk factors

PURPOSE

To explore the relationship between sociodemographic and lifestyle variables with health-related quality of life (HRQoL) of a large cohort of 'healthy' older individuals.

METHODS

The sample included individuals aged 65+ years from Australia (N = 16,703) and the USA (N = 2411) enrolled in the ASPirin in Reducing Events in the Elderly (ASPREE) multicentre placebo-controlled trial study and free of cardiovascular disease, dementia, serious physical disabilities or 'fatal' illnesses. The associations with the physical (PCS) and mental component scores (MCS) of HRQoL (SF-12 questionnaire) were explored using multiple linear regression models from data collected at baseline (2010-2014).

RESULTS

The adjusted PCS mean was slightly higher in the USA (49.5 ± 9.1) than Australia (48.2 ± 11.6; p < 0.001), but MCS was similar in both samples (55.7 ± 7.5 and 55.7 ± 9.6, respectively; p = 0.603). Males, younger participants, better educated, more active individuals, or those currently drinking 1-2 alcoholic drinks/day showed a better HRQoL (results more evident for PCS than MCS), while current heavy smokers had the lowest physical HRQoL in both countries. Neither age, walking time, nor alcohol intake was associated with MCS in either cohort.

CONCLUSIONS

Baseline HRQoL of ASPREE participants was higher than that reported in population-based studies of older individuals, but the associations between sociodemographic and lifestyle variables were consistent with the published literature. As the cohort ages and develops chronic diseases, ASPREE will be able to document HRQoL changes.

Smoking Cessation: A Comparison of Two Model Structures

BACKGROUND

Most economic evaluations of smoking cessation interventions have used cohort state-transition models. Discrete event simulations (DESs) have been proposed as a superior approach.

OBJECTIVE

We developed a state-transition model and a DES using the discretely integrated condition event (DICE) framework and compared the cost-effectiveness results. We performed scenario analysis using the DES to explore the impact of alternative assumptions.

METHODS

The models estimated the costs and quality-adjusted life years (QALYs) for the intervention and comparator from the perspective of the UK National Health Service and Personal Social Services over a lifetime horizon. The models considered five comorbidities: chronic obstructive pulmonary disease, myocardial infarction, coronary heart disease, stroke and lung cancer. The state-transition model used prevalence data, and the DES used incidence. The costs and utility inputs were the same between two models and consistent with those used in previous analyses for the National Institute for Health and Care Excellence.

RESULTS

In the state-transition model, the intervention produced an additional 0.16 QALYs at a cost of £540, leading to an incremental cost-effectiveness ratio (ICER) of £3438. The comparable DES scenario produced an ICER of £5577. The ICER for the DES increased to £18,354 when long-term relapse was included.

CONCLUSIONS

The model structures themselves did not influence smoking cessation cost-effectiveness results, but long-term assumptions did. When there is variation in long-term predictions between interventions, economic models need a structure that can reflect this.