Stealing a march in the 21st century: accelerating progress in the 100-year war against tobacco addiction in the United States

Mortality trends and disparities for coexisting chronic obstructive pulmonary disease and cardiovascular disease: A retrospective analysis of deaths in the United States from 1999-2020

BACKGROUND

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) greatly influence morbidity and mortality, with COPD patients frequently suffering from cardiovascular comorbidities like coronary heart disease and stroke. This study analyzes mortality trends and disparities among individuals in the United States (US) affected by both CVD and COPD.

METHODS

This study analyzed death certificates from the CDC WONDER database for individuals aged 25 and older who died between 1999 and 2020 with both CVD (ICD I00-I99) and COPD (ICD J41-J44). Age-adjusted mortality rates (AAMRs) and annual percent change (APC) were calculated by year, sex, age group, race/ethnicity, geographic region, and urbanization status.

RESULTS

Between 1999 and 2020, there were 3,590,124 reported deaths due to coexisting CVD and COPD, with overall AAMR slightly changing from 82.2 to 81.2 per 100,000 population, and a notable rise from 2018 to 2020 (APC: 5.28; 95% CI: 1.83 to 7.22) coinciding with the onset of COVID-19 pandemic. A similar surge in mortality was observed across multiple demographic subgroups, particularly among older adults. Disparities across age groups, sex, race, and geographic location were also observed in the mortality rates due to CVD and COPD. When analyzed by age group, older adults exhibited the highest AAMR at 824.1. Men had higher AAMRs than women (96.5 vs. 60.7). Ethnoracial analysis showed that non-Hispanic (NH) White individuals had the highest AAMRs (82.0), followed by NH American Indian or Alaska Native (74.5), NH Black (63.6), Hispanic (38.1), and NH Asian or Pacific Islander (25.1) individuals. Additionally, non-metropolitan areas had higher AAMRs compared to metropolitan areas (96.2 vs. 70.9).

CONCLUSIONS

The findings suggest that mortality rates for CVD and COPD have increased in recent years, coinciding with the onset of the COVID-19 pandemic, which may have exacerbated outcomes in vulnerable populations. The study highlights the need for targeted interventions to address the overlapping impacts of CVD and COPD, especially in high-risk groups.

A roadmap of six different pathways to improve survival in laryngeal cancer patients

PURPOSE OF REVIEW

Laryngeal cancer continues to require improvement in earlier stage diagnosis and better imaging delineation of disease, and hence 'more evidence-based' selection of treatment, as recent evidence suggests that related mortality, in the last decades, has not significantly decreased worldwide. Even though the reasons are not fully understood, there persists an urgency for a review and development of future strategies to embrace such clinical and diagnostic challenges from a political, societal, as well as scientific and clinical points of view.

RECENT FINDINGS

This review of the published literature suggests that survival improvement in laryngeal cancer may be achieved by fuelling and combining at least some or all of six targeted agendas: documentation of disease global incidence and national burden monitoring; development and implementation of high-quality cancer registries; education on risk factors and hazardous habits associated with laryngeal cancer for the general population; active modification of proven at-risk population lifestyles; centralization of treatment; and use of machine learning of gathered 'big data' and their integration into approaches for the optimization of prevention and treatments strategies.

SUMMARY

Laryngeal cancer should be tackled on several fronts, commencing with disease monitoring and prevention, up to treatment optimisation. Available modern resources offer the possibility to generate significant advances in laryngeal cancer management. However, each nation needs to develop a comprehensive approach, which is an essential prerequisite to obtain meaningful improvement on results.

The role of demographic and behavioural change for the long-term decline in daily smoking in Norway

Background

The aim of this paper was to compare the effects of demography (population aging and the increasing fraction of tertiary educated) and behaviour (intra-cohort ageing and inter-cohort change) on long-term change in the fraction of daily smokers (FrS), using a counterfactual framework.

Methods

Using aggregated data on smoking prevalence, education and population size from Norway 1978 to 2017, the probabilities of smoking for men and women were calculated using a pseudo-panel approach. From these estimates, four counterfactual scenarios of FrS were constructed by holding the age effect, the cohort effect and the distribution of age and education constant over time.

Results

FrS decreased from 45 to 14% among men, and from 33 to 14% among women over the study period. Holding the age distribution constant did not have any substantial effect on FrS. Holding the distribution of education constant led to a five percentage points increase in FrS among women, but not among men. In the case of no intra-cohort ageing, FrS would have been 11/12 percentage points higher among women/men. The corresponding figures for no inter-cohort change were 13 points for women and 27 points for men.

Conclusions

If the age distribution had remained stable over time, FrS would have been almost identical to the current level. In contrast, if smoking behaviour had remained stable over the life course or between birth cohorts, FrS would have been substantially higher than it is today. These results highlight the large cumulative effect of reducing smoking uptake in successive cohorts.

Portion size and later food intake: evidence on the "normalizing" effect of reducing food portion sizes

Background

Historical increases in the size of commercially available food products have been linked to the emergence of a worldwide obesity crisis. Although the acute effect that portion size has on food intake is well established, the effect that exposure to smaller portion sizes has on future portion size selection has not been examined.

Objective

We tested whether reducing a food portion size "renormalizes" perceptions of what constitutes a normal amount of that food to eat and results in people selecting and consuming smaller portions of that food in the future.

Design

Across 3 experiments, participants were served a larger or smaller portion of food. In experiments 1 and 2, participants selected and consumed a portion of that food 24 h later. In experiment 3, participants reported on their preferred ideal portion size of that food after 1 wk.

Results

The consumption of a smaller, as opposed to a larger, portion size of a food resulted in participants believing a "normal"-sized portion was smaller (experiments 1-3, P ≤ 0.001), consuming less of that food 1 d later (experiments 1-2, P ≤ 0.003), and displaying a tendency toward choosing a smaller ideal portion of that food 1 wk later (experiment 3, P = 0.07), although the latter finding was not significant.

Conclusion

Because consumer preferences appear to be driven by environmental influences, reducing food portion sizes may recalibrate perceptions of what constitutes a "normal" amount of food to eat and, in doing so, decrease how much consumers choose to eat. This trial was registered at www.clinicaltrials.gov as NCT03241576.

mGluR2/3 mediates short-term control of nicotine-seeking by acute systemic N-acetylcysteine

Chronic self-administration of nicotine induces maladaptive changes in the cortico-accumbal glutamate (Glu) network. Consequently, re-exposure to nicotine-associated cues raises extracellular Glu in the nucleus accumbens reinstating drug-seeking. Restoring basal concentrations of extracellular Glu, thereby increasing tonic activation of the presynaptic group II metabotropic Glu receptors (mGluR2/3) with N-acetylcysteine (N-AC), might offer a valid therapeutic approach for maintaining smoking abstinence. Although N-AC modulates nicotine-seeking behavior by drug-associated stimuli in abstinent rats, it is still unclear whether it occurs through activation of mGluR2/3. Male Wistar rats were trained to associate discriminative stimuli (S^D s) with the availability of intravenous nicotine (0.03 mg/kg/65 µl/2-second/infusion) or oral saccharin (100 µl of 50 mg/l) self-administration versus non-reward. Reinforced response was followed by a cue signaling 20-second time-out (CSs). Once the training criterion was met, rats underwent lever press extinction, without reinforcers, S^D s and CSs. Re-exposure to nicotine or saccharin S^D+ /CS⁺ , but not non-reward S^D- /CS^- , revived responding on the previously reinforced lever. Acute N-AC, 100 but not 60 or 30 mg/kg i.p., reduced cue-induced nicotine-seeking. N-AC 100 mg/kg did not modify cue-induced saccharin-seeking behavior or influenced locomotor activity. Blocking mGluR2/3 with the selective antagonist LY341495, 1 mg/kg i.p., completely prevented the antirelapse activity of N-AC. The finding that N-AC prevents cue-induced nicotine-seeking by stimulating mGluR2/3 might indicate a therapeutic opportunity for acute cue-controlled nicotine-seeking. Future studies could evaluate the persistent effects of chronic N-AC in promoting enduring suppression of nicotine-cue conditioned responding.

Two-Year Therapeutic Effectiveness of Varenicline for Smoking Cessation in a Real World Setting

BACKGROUND

Varenicline is an effective smoking cessation therapy in clinical trials. However, its effectiveness might vary in a real world setting and its long term effectiveness (2-year) has not been reported yet.

OBJECTIVE

The objective was ascertaining the effectiveness of varenicline in the treatment of tobacco consumption in Primary Care settings.

METHODS

Observational, multicenter, retrospective study using medical records of smokers followed for 24 months. Sociodemographic characteristics, comorbidity, type of treatment (varenicline with or without group therapy), and smoking characteristics (Fageström and Richmond tests, starting age, number of cigarettes, cessation attempts, and initial CO-oximeter measurements) were evaluated.

RESULTS

773 smokers treated with varenicline (72.4%) or varenicline combined with group therapy (27.6%) were included. Mean age was 43.6 years [51.7% male (n = 400)]. Continuous abstinence rate at 24 months was 44.4%, with no significant gender or age differences. Median cessation time was 398 days (95%CI: 376-421). A clear association was detected between the probability of remaining abstinent at 24 months and participation in group therapy (OR: 1.877, 95%CI: 1.362-2.589), as well as treatment adherence (compliance >80%) (OR: 6.556, 95%CI: 5.870-7.242), but not with co-financing of treatment (observed in 77% of patients). For every day that varenicline was taken, abstinence increased by an average of 6.6 days.

CONCLUSIONS

This retrospective cohort study suggests that 2-year effectiveness of varenicline might be substantial in a real world setting. The abstinence rate was higher for those who also receive group therapy.

The tobacco endgame: a qualitative review and synthesis

The tobacco endgame concept reorients discussion away from the persistent control of tobacco toward plans for ending the tobacco epidemic, and envisions a tobacco-free future. A variety of policy approaches have been proposed, with many offered prior to the introduction of the unifying term ‘endgame’. We conducted a qualitative synthesis of the literature on tobacco control endgames, and drew on media accounts and discussion of analogous ideas for illustrative purposes. We identified proposals focused on the product, user, market/supply or larger institutional structures. Research on public support for these proposals was limited, but suggestive of some public appetite for endgame ideas. Advocates should be encouraged to explore new policy options and consider the goal of a tobacco-free future.

Cohort changes in educational disparities in smoking: France, Germany and the United States

This study investigates the evolution of educational disparities in smoking uptake across cohorts for men and women in three countries. Nationally representative surveys of adults in France, Germany and the United States in 2009-2010 include retrospective measures of age of uptake that are compared for three cohorts (born 1946-1960, 1961-1975, and 1976-1992). Discrete logistic regressions and a relative measure of education are used to model smoking histories until age 34. The following patterns are found: a strengthening of educational disparities in the timing of uptake from older to younger cohorts; an earlier occurrence of the strengthening for men than women and for the United States than France or Germany; a faster pace of the epidemic in France than in the United States, and; a divide between the highest level of education and the others in the United States, as opposed to a gradient across categories in France. Those differences in smoking disparities across cohorts, genders and countries help identify the national and temporal circumstances that shape the size and direction of the relationship between education and health and the need for policies that target educational disparities.

Polygenic risk and the developmental progression to heavy, persistent smoking and nicotine dependence: evidence from a 4-decade longitudinal study

IMPORTANCE

Genome-wide hypothesis-free discovery methods have identified loci that are associated with heavy smoking in adulthood. Research is needed to understand developmental processes that link newly discovered genetic risks with adult heavy smoking.

OBJECTIVE

To test how genetic risks discovered in genome-wide association studies of adult smoking influence the developmental progression of smoking behavior from initiation through conversion to daily smoking, progression to heavy smoking, nicotine dependence, and struggles with cessation.

DESIGN

A 38-year, prospective, longitudinal study of a representative birth cohort.

SETTING

The Dunedin Multidisciplinary Health and Development Study of New Zealand.

PARTICIPANTS

The study included 1037 male and female participants.

EXPOSURE

We assessed genetic risk with a multilocus genetic risk score. The genetic risk score was composed of single-nucleotide polymorphisms identified in 3 meta-analyses of genome-wide association studies of smoking quantity phenotypes.

MAIN OUTCOMES AND MEASURES

Smoking initiation, conversion to daily smoking, progression to heavy smoking, nicotine dependence (Fagerström Test of Nicotine Dependence), and cessation difficulties were evaluated at 8 assessments spanning the ages of 11 to 38 years.

RESULTS

Genetic risk score was unrelated to smoking initiation. However, individuals at higher genetic risk were more likely to convert to daily smoking as teenagers, progressed more rapidly from smoking initiation to heavy smoking, persisted longer in smoking heavily, developed nicotine dependence more frequently, were more reliant on smoking to cope with stress, and were more likely to fail in their cessation attempts. Further analysis revealed that 2 adolescent developmental phenotypes-early conversion to daily smoking and rapid progression to heavy smoking-mediated associations between the genetic risk score and mature phenotypes of persistent heavy smoking, nicotine dependence, and cessation failure. The genetic risk score predicted smoking risk over and above family history.

CONCLUSIONS AND RELEVANCE

Initiatives that disrupt the developmental progression of smoking behavior among adolescents may mitigate genetic risks for developing adult smoking problems. Future genetic research may maximize discovery potential by focusing on smoking behavior soon after smoking initiation and by studying young smokers.

Behavioral medicine and the health of our nation: accelerating our impact

PURPOSE

A key goal of this paper is to illustrate the impact of behavioral medicine on the factors that influence population health. A second goal is to consider the delicate balance between relevance and excellence as we bring our science to bear on important social and public health problems. If we are to increase the translation of our evidence and accelerate our impact, we must increase our relevance while maintaining excellence in our scientific methods.

METHODS

What are the pressing questions facing those that we would like to use our work, and how we can increase our relevance to theirs? We must work on the marriage of relevance and excellence-use rigorous methodologies, but be flexible in our approach, using study designs and methods that will get rapid yet rigorous answers to the questions that are facing practice and policy settings.

CONCLUSION

We have the tools and the knowledge to impact the health of our nation.

Population composition, public policy, and the genetics of smoking

In this article, we explore the effect of public policy on the extent to which genes influence smoking desistance. Using a sample of adult twins (n(mz) = 363, n(dz) = 233) from a large population registry, we estimate Cox proportional hazards models that describe similarity in the timing of smoking desistance among adult twin pairs. We show that identical twin pairs are significantly more likely to quit smoking within a similar time frame compared with fraternal twin pairs. Importantly, we then show that genetic factors for smoking desistance increase in importance following restrictive legislation on smoking behaviors that occurred in the early and mid-1970s. These findings support the social push perspective and make important contributions to the social demography and genetic epidemiology of smoking as well as to the gene-environment interaction literatures.

Parental smoking cessation to protect young children: a systematic review and meta-analysis

BACKGROUND

Young children can be protected from much of the harm from tobacco smoke exposure if their parents quit smoking. Some researchers encourage parents to quit for their children's benefit, but the evidence for effectiveness of such approaches is mixed.

OBJECTIVE

To perform a systematic review and meta-analysis to quantify the effects of interventions that encourage parental cessation.

METHODS

We searched PubMed, the Cochrane Library, Web of Science, and PsycINFO. Controlled trials published before April 2011 that targeted smoking parents of infants or young children, encouraged parents to quit smoking for their children's benefit, and measured parental quit rates were included. Study quality was assessed. Relative risks and risk differences were calculated by using the DerSimonian and Laird random-effects model.

RESULTS

Eighteen trials were included. Interventions took place in hospitals, pediatric clinical settings, well-baby clinics, and family homes. Quit rates averaged 23.1% in the intervention group and 18.4% in the control group. The interventions successfully increased the parental quit rate. Subgroups with significant intervention benefits were children aged 4 to 17 years, interventions whose primary goal was cessation, interventions that offered medications, and interventions with high follow-up rates (>80%).

CONCLUSIONS

Interventions to achieve cessation among parents, for the sake of the children, provide a worthwhile addition to the arsenal of cessation approaches, and can help protect vulnerable children from harm due to tobacco smoke exposure. However, most parents do not quit, and additional strategies to protect children are needed.

Correlates of chilean adolescents' negative attitudes toward cigarettes: the role of gender, peer, parental, and environmental factors

INTRODUCTION

We examined the association of peer, parental, and environmental factors with negative attitudes toward cigarettes among youth from Santiago, Chile.

METHODS

A total of 860 youth from Santiago, Chile, completed questions regarding their lifetime use of cigarettes, intentions to smoke, attitudes toward cigarettes, and questions that assessed peer, parental, and environmental factors.

RESULTS

For both boys and girls, peer disapproval of smoking was associated with more negative attitudes toward cigarettes and peer smoking was associated with less negative attitudes toward cigarettes. Peer pressure was significantly associated with more negative attitudes toward cigarettes for girls only. Parental smoking was associated with less negative attitudes and parental control with more negative attitudes, but these associations were significant in the overall sample only. School prevention efforts and exposure to cigarette ads were not associated with cigarette attitudes. Difficulty in accessing cigarettes was positively associated with negative attitudes for boys and girls.

CONCLUSION

Smoking prevention efforts focus on attitude change, but scant information is available about the experiences that influence Chilean youth's attitudes toward cigarettes. Results from the current study suggest that prevention efforts could benefit from gender-specific strategies. Girls' but not boys' attitudes were influenced by peer pressure. Moreover, negative attitudes toward cigarettes were associated with lower current smoking in girls only. Parental smoking was an important influence on youth's attitudes toward cigarettes. Efforts to reduce smoking among Chilean youth may benefit from concurrently reducing parental smoking.

Smoking behavior of US youths: a comparison between child welfare system and community populations

OBJECTIVES

We compared rates of smoking for 2 groups of youths aged 12 to 14 years: those involved in the child welfare system (CW) and their counterparts in the community population. We then investigated factors associated with smoking for each group.

METHODS

We drew data from 2 national-level US sources: the National Survey of Child and Adolescent Well-Being and the National Longitudinal Study of Adolescent Health. We estimated logistic regression models for 3 binary outcome measures of smoking behavior: lifetime, current, and regular smoking.

RESULTS

CW-involved youths had significantly higher rates of lifetime smoking (43% vs 32%) and current smoking (23% vs 18%) than did youths in the community population. For CW-involved youths, delinquency and smoking were strongly linked. Among youths in the community population, multiple factors, including youth demographics and emotional and behavioral health, affected smoking behavior.

CONCLUSIONS

Smoking prevalence was notably higher among CW-involved youths than among the community population. In light of the persistent public health impact of smoking, more attention should be focused on identification of risk factors for prevention and early intervention efforts among the CW-involved population.

Public health clinical demonstration project for smoking cessation in american veterans who served since september 11, 2001

OBJECTIVE

The purpose of this clinical demonstration project was to increase the reach of effective treatments, such as pharmacotherapy and telephone or web-based support, by offering these treatments in a low cost and convenient manner to a population of Veterans.

METHODS

Six hundred nine veteran smokers who had served in the military since September 11, 2001 were contacted by invitational letters. Veterans indicating interest in further contacts received telephone calls using standardized scripts that offered referral to the National Cancer Institute's Smoking QuitLine, web-based counseling, and local Department of Veteran Affairs pharmacologic treatment for smoking cessation.

RESULTS

Seven percent of survey recipients participated in the clinical program. At follow-up, 23% of participants providing follow-up information reported maintaining smoking abstinence. This clinical demonstration project was associated with a reach of 8.6% (number of smokers who accessed the intervention/the number of targeted smokers), an efficacy of 26% (number of abstinent smokers at follow-up/number who accessed the intervention), and a 24-hour abstinence impact rate of 2.2% (number of smokers with 24-hour abstinence/number of targeted smokers).

CONCLUSIONS

Results suggested that this project enhanced access to care and promoted short-term smoking cessation in Veterans who have served since September 11. 2001.

Does Gender Moderate Associations Between Social Capital and Smoking? An Asian American Study

Growing research finds that social capital is associated with smoking. However, most studies focus on white populations and do not take into account potential differences between genders. The present study examines the associations between social capital and self-report smoking status and assesses the moderating role of gender among a national representative sample of Asian American adults. Social capital consisted of measures of individual social connectedness (i.e. social ties with relatives and friends) and subjective evaluation of family and neighborhood environment (i.e. family and neighborhood cohesion, family conflict). Asian men were almost three times more likely to be current smokers than women (20.1% vs. 7.0%). Results of multivariate logistic regression analyses showed that family conflicts or higher levels of connectedness with family members were associated with increased odds of being a current smoker among Asian Americans as a whole. Further stratified analysis revealed significant gender differences in several aspects of social capital: there were stronger effects of social connectedness with family members on increasing the odds of smoking for women than for men. In addition, women who had closer connections to friends had greater odds of being current smokers, whereas the opposite was true for men. The findings of this study provide new evidence for the differential effects of social capital by gender, suggesting that more studies are needed to understand social capital's effects in different racial/ethnic populations and the mechanisms by which the effects vary with gender.

Electronic medical records to increase the clinical treatment of tobacco dependence: a systematic review

CONTEXT

The expanded use of electronic medical records (EMRs) may provide an opportunity to increase the use and impact of clinical guidelines to promote tobacco-cessation treatment in primary care settings. The objective of this systematic review is to evaluate the evidence for such an effect.

EVIDENCE ACQUISITION

After a systematic search of the English-language literature regarding an EMR effect on either smoking cessation or clinician behavior, relevant articles were abstracted and findings summarized from both observational studies and RCTs.

EVIDENCE SYNTHESIS

Of ten identified studies of EMRs and tobacco, only two RCTs were found. Adding tobacco status as a vital sign resulted in an increase in some clinical guideline recommended actions, particularly documentation of smoking status. There was insufficient evidence to quantify the effect of an EMR on changes in patient smoking behaviors.

CONCLUSIONS

While the use of EMRs to prompt or provide feedback on the clinical treatment of tobacco dependence demonstrates some promising results, substantial additional research is needed to understand the effects of EMRs on provider and patient behavior.

Power of the process: evaluating the impact of the Framework Convention on Tobacco Control negotiations

OBJECTIVE

Evaluate the impact of the FCTC negotiations on the diffusion of tobacco control policies.

METHODS

Analyzed country characteristics to determine their effects on the frequency, type and strength of tobacco control policies adopted among WHO Member States. Bivariate analyses were conducted for each characteristic to compare the frequency and strength of control policies adopted between pre-negotiation and negotiation periods. Multivariate regression analyses were performed to determine the predictive nature of these variables.

RESULTS

The frequency of policy adoption intensified during the years the FCTC negotiations were most intense. The strength of policies adopted also shifted significantly towards policies promoted by WHO. The average strength of policies adopted varied significantly according to country characteristics. All characteristics, with the exception of total and male smoking prevalence, were significantly associated with the number of policy types adopted.

CONCLUSIONS

This study suggests that investments in international legal processes can be effective, even when the outcomes are unclear from the start. The FCTC negotiation process coincided with a rise in domestic policy adoption in the direction advocated by WHO. However, there remains a need to improve outreach and diffusion to lower-income countries in tobacco control, as well as other areas of chronic disease control.

A framework for developing an evidence-based, comprehensive tobacco control program

Background

Tobacco control is an area where the translation of evidence into policy would seem to be straightforward, given the wealth of epidemiological, behavioural and other types of research available. Yet, even here challenges exist. These include information overload, concealment of key (industry-funded) evidence, contextualization, assessment of population impact, and the changing nature of the threat.

Methods

In the context of Israel's health targeting initiative, Healthy Israel 2020, we describe the steps taken to develop a comprehensive tobacco control strategy. We elaborate on the following: a) scientific issues influencing the choice of tobacco control strategies; b) organization of existing evidence of effectiveness of interventions into a manageable form, and c) consideration of relevant philosophical and political issues. We propose a framework for developing a plan and illustrate this process with a case study in Israel.

Results

Broad consensus exists regarding the effectiveness of most interventions, but current recommendations differ in the emphasis they place on different strategies. Scientific challenges include integration of complex and sometimes conflicting information from authoritative sources, and lack of estimates of population impact of interventions. Philosophical and political challenges include the use of evidence-based versus innovative policymaking, the importance of individual versus governmental responsibility, and whether and how interventions should be prioritized.

The proposed framework includes: 1) compilation of a list of potential interventions 2) modification of that list based on local needs and political constraints; 3) streamlining the list by categorizing interventions into broad groupings of related interventions; together these groupings form the basis of a comprehensive plan; and 4) refinement of the plan by comparing it to existing comprehensive plans.

Conclusions

Development of a comprehensive tobacco control plan is a complex endeavour, involving crucial decisions regarding intervention components. "Off the shelf" plans, which need to be adapted to local settings, are available from a variety of sources, and a multitude of individual recommendations are available. The proposed framework for adapting existing approaches to the local social and political climate may assist others planning for smoke-free societies. Additionally, this experience has implications for development of evidence-based health plans addressing other risk factors.