Smoking prevalence in US birth cohorts: the influence of gender and education

Age-period-cohort analysis and projection of cancer mortality in Hong Kong, 1998-2030

OBJECTIVES

To explore the relationship between immigration groups and cancer mortality, this study aimed to explore age, period, birth cohort effects and effects across genders and immigration groups on mortality rates of lung, pancreatic, colon, liver, prostate and stomach cancers and their projections.

DESIGN, SETTING, AND PARTICIPANTS

Death registry data in Hong Kong between 1998 and 2021, which were stratified by age, sex and immigration status. Immigration status was classified into three groups: locals born in Hong Kong, long-stay immigrants and short-stay immigrants.

METHODS

Age-period-cohort (APC) analysis was used to examine age, period, and birth cohort effects for genders and immigration groups from 1998 to 2021. Bayesian APC models were applied to predict the mortality rates from 2022 to 2030.

RESULTS

Short-stay immigrants revealed pronounced fluctuations of mortality rates by age and of relative risks by cohort and period effects for six types of cancers than those of long-stay immigrants and locals. Immigrants for each type of cancer and gender will be at a higher mortality risk than locals. After 2021, decreasing trends (p<0.05) or plateau (p>0.05) of forecasting mortality rates of cancers occur for all immigration groups, except for increasing trends for short-stay male immigrants with colon cancer (p<0.05, Avg+0.30 deaths/100 000 per annum from 15.47 to 18.50 deaths/100 000) and long-stay male immigrants with pancreatic cancer (p<0.05, Avg+0.72 deaths/100 000 per annum from 16.30 to 23.49 deaths/100 000).

CONCLUSIONS

Findings underscore the effect of gender and immigration status in Hong Kong on mortality risks of cancers that immigrants for each type of cancer and gender will be at a higher mortality risk than locals.

Smoking Disparities by Level of Educational Attainment and Birth Cohort in the U.S

INTRODUCTION

Little is known about how U.S. smoking patterns of initiation, cessation, and intensity vary by birth cohort across education levels or how these patterns may be driven by other demographic characteristics.

METHODS

Smoking data for adults aged ≥25 years was obtained from the National Health Interview Surveys 1966-2018. Age-period-cohort models were developed to estimate the probabilities of smoking initiation, cessation, intensity, and prevalence by age, cohort, calendar year, and gender for education levels: ≤8th grade, 9th-11th grade, high school graduate or GED, some college, and college degree or above. Further analyses were conducted to identify the demographic factors (race/ethnicity and birthplace) that may explain the smoking patterns by education. Analyses were conducted in 2020-2021.

RESULTS

Smoking disparities by education have increased by birth cohort. In recent cohorts, initiation probabilities were highest among individuals with 9th-11th-grade education and lowest among individuals with at least a college degree. Cessation probabilities were higher among those with higher education. Current smoking prevalence decreased over time across all education groups, with important differences by gender. However, it decreased more rapidly among individuals with ≤8th grade education, resulting in this group having the second lowest prevalence in recent cohorts. This may be driven by the increasing proportion of non-U.S. born Hispanics in this group.

CONCLUSIONS

Although smoking is decreasing by cohort across all education groups, disparities in smoking behaviors by education have widened in recent cohorts. Demographic changes for the ≤8th-grade education group need special consideration in analyses of tobacco use by education.

Mortality Relative Risks by Smoking, Race/Ethnicity, and Education

INTRODUCTION

The impact of cigarette smoking on mortality is well studied, with estimates of the relative mortality risks for the overall population widely available. However, age-specific mortality estimates for different sociodemographic groups in the U.S. are lacking.

METHODS

Using the 1987-2018 National Health Interview Survey Linked Mortality Files through 2019, all-cause mortality relative risks (RRs) were estimated for current smokers or recent quitters and long-term quitters compared with those for never smokers. Stratified Cox proportional hazards regression models were used to estimate RRs by age, gender, race/ethnicity, and educational attainment. RRs were also assessed for current smokers or recent quitters by smoking intensity and for long-term quitters by years since quitting. The analysis was conducted in 2021-2022.

RESULTS

All-cause mortality RRs among current smokers or recent quitters were generally highest for non-Hispanic White individuals than for never smokers, followed by non-Hispanic Black individuals, and were lowest for Hispanic individuals. RRs varied greatly by educational attainment; generally, higher-education groups had greater RRs associated with smoking than lower-education groups. Conversely, the RRs by years since quitting among long-term quitters did not show clear differences across race/ethnicity and education groups. Age-specific RR patterns varied greatly across racial/ethnic and education groups as well as by gender.

CONCLUSIONS

Age-specific all-cause mortality rates associated with smoking vary considerably by sociodemographic factors. Among high-education groups, lower underlying mortality rates for never smokers result in correspondingly high RR estimates for current smoking. These estimates can be incorporated in modeling analyses to assess tobacco control interventions' impact on smoking-related health disparities between different sociodemographic groups.

Patterns of Birth Cohort‒Specific Smoking Histories by Race and Ethnicity in the U.S

INTRODUCTION

U.S. smoking prevalence varies greatly by race/ethnicity. However, little is known about how smoking initiation, cessation, and intensity vary by birth cohort and race/ethnicity.

METHODS

Adult smoking data were obtained from the 1978-2018 National Health Interview Surveys. Age‒period‒cohort models with constrained natural splines were developed to estimate historical smoking patterns among non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian and Pacific Islander, and non-Hispanic American Indian and Alaskan Native individuals. Annual smoking prevalence and probabilities of smoking initiation, cessation, and intensity by age, year, gender, and race/ethnicity were estimated for the 1900 to 2000 birth cohorts. Analysis was conducted in 2020-2021.

RESULTS

Smoking initiation probabilities were highest for the American Indian and Alaskan Native population, second highest among the non-Hispanic White population, and lowest among Asian and Pacific Islander and Hispanic populations across birth cohorts. Historically, initiation probabilities among non-Hispanic Black populations were comparable with those among non-Hispanic White populations but have decreased since the 1970 birth cohort. Cessation probabilities were lowest among American Indian and Alaskan Native and non-Hispanic Black populations and highest among non-Hispanic White and Asian and Pacific Islander populations across cohorts and ages. Initiation and cessation probabilities produce observed patterns of smoking where prevalence among American Indian and Alaskan Native populations is highest across all ages and cohorts. Across cohorts, smoking prevalence among non-Hispanic Black populations, particularly males, is lower than among non-Hispanic White populations at younger ages but higher at older ages.

CONCLUSIONS

There are important and persistent racial/ethnic differences in smoking prevalence, initiation, cessation, and intensity across U.S. birth cohorts. Targeted interventions should address widening smoking disparities by race/ethnicity, particularly for American Indian and Alaskan Native and non-Hispanic Black populations.

Birth Cohort‒Specific Smoking Patterns by Family Income in the U.S

INTRODUCTION

In the U.S., low-income individuals generally smoke more than high-income individuals. However, detailed information about how smoking patterns differ by income, especially differences by birth cohort, is lacking.

METHODS

Using the National Health Interview Survey 1983-2018 data, individual family income was calculated as a ratio of the federal poverty level. Missing income data from 1983 to 1996 were imputed using sequential regression multivariate imputation. Age‒period‒cohort models with constrained natural splines were used to estimate annual probabilities of smoking initiation and cessation and smoking prevalence and intensity by gender and birth cohort (1900-2000) for 5 income groups: <100%, 100%-199%, 200%-299%, 300%-399%, and ≥400% of the federal poverty level. Analysis was conducted in 2020-2021.

RESULTS

Across all income groups, smoking prevalence and initiation probabilities are decreasing by birth cohort, whereas cessation probabilities are increasing. However, relative differences between low- and high-income groups are increasing markedly, such that there were greater declines in prevalence among those in high-income groups in more recent cohorts. Smoking initiation probabilities are lowest in the ≥400% federal poverty level group for males across birth cohorts, whereas for females, this income group has the highest initiation probabilities in older cohorts but the lowest in recent cohorts. People living below the federal poverty level have the lowest cessation probabilities across cohorts.

CONCLUSIONS

Smoking prevalence has been decreasing in all income groups; however, disparities in smoking by family income are widening in recent birth cohorts. Future studies evaluating smoking disparities should account for cohort differences. Intervention strategies should focus on reducing initiation and improving quit success among low-income groups.

Beliefs about harms of cigarette smoking among Norwegian adults born from 1899 to 1969. Do variations across education, smoking status and sex mirror the decline in smoking?

Background and aim

Smoking is one of the most important causes of socioeconomic disparities in morbidity and mortality. The aim of this study was to examine if beliefs about harms of smoking differed across gender, smoking status and education among Norwegian adults born between 1899 and 1969.

Methods

Using data from a nationally representative survey of smoking habits and a multinomial logit/negative binomial two-stage hurdle model design, we examined (first hurdle) the associations between birth cohort, gender, education and smoking status and four beliefs about cigarette smoking: i) smoking is not harmful, ii) do not know if smoking is harmful, iii) any number of cigarettes per day (CPD) is harmful and iv) smoking more than a given nonzero number of CPD is harmful, and (second hurdle) the predicted number of CPD that could be smoked without causing harm (from outcome iv).

Results

The probability of believing that smoking was not harmful was close to zero, regardless of birth cohort, sex, education and smoking status. The probability of not knowing if smoking was harmful decreased from around 0.7 to almost zero across cohorts. The probability of believing that smoking more than zero CPD was harmful increased from less than 0.1 to around 0.7, while the probability of believing that there is some safe level of smoking increased with cohorts born from 1900 to 1930 before declining. Respondents with primary/secondary education consistently believed smoking to be less harmful compared to respondents with tertiary education, but cohort trajectories were similar.

Discussion

The similar birth cohort trajectories in beliefs about the harms of smoking do not support the idea that Norwegian adults with lower education has had qualitatively different beliefs about the harmfulness of smoking compared to those with higher education. The persistent and large socioeconomic gradient is likely a result of other factors.

Diverging Trends and Expanding Educational Gaps in Smoking in China

Introduction: The male smoking rate in China declined moderately through the 1990s and early 2000s, but the decline has since stagnated. It is unclear why the decline stalled and whether it stalled uniformly across all social strata. Theories that view socioeconomic status as a fundamental cause of health predict that socioeconomic gaps in smoking may widen, but theories emphasizing the cultural context of health behavior cast doubt on the prediction. We investigated changes in the socioeconomic gaps in smoking during recent decades in China. Methods: We applied growth-curve models to examine inter- and intra-cohort changes in socioeconomic gaps in male smoking in China using data from a national longitudinal survey spanning 25 years. Results: We found diverging trends in smoking in men with different education levels among the post-1980 cohorts; for high-education men, smoking participation consistently declined, but for low-education men, the decline stopped and possibly reversed. The stagnation in the decline in overall smoking rate since 2010 was mostly due to the stalling of the decline of smoking among low-education men in the most recent cohorts. The diverging trends were a continuation of a general trend in expanding educational gaps in smoking that emerged in the cohorts born after 1960. Our analysis also identified widening educational gaps over age within each cohort. Conclusion: We identified a long-term widening in educational gaps in smoking in China. An effective way to reduce smoking, social inequality in smoking and possibly health disparities in China is to target the smoking behavior of vulnerable groups.

Fertility trends and comparisons in a historical cohort of US women with primary infertility

BACKGROUND

There is growing interest in long-term outcomes following infertility and infertility treatment. However, there are few detailed longitudinal cohorts available for this work. This study aimed to assemble a historical cohort of women with primary infertility and age-matched controls to evaluate fertility trends, sequelae, and sociodemographic differences. Described here are cohort group characteristics and associated reproductive trends over time.

METHODS

A population-based historical cohort was created using the Rochester Epidemiology Project (REP) record-linkage system (Olmsted County, MN). The cohort included women aged 18-50 with a diagnosis of primary infertility between January 1, 1980, and December 31, 1999. As part of a case-control study, we identified 1:1 age-matched female controls from the same community and era.

RESULTS

A total of 1001 women with primary infertility and 1001 age-matched controls were identified. The women with primary infertility were significantly more likely to be married, college educated, use barrier contraception, and non-smokers compared to age-matched controls. The incidence of primary infertility increased from 14 to 20 per 10,000 person years from 1980-1985 to 1995-1999. Ovulatory dysfunction and unexplained infertility were the most common causes of primary infertility and clomiphene was the most widely used fertility medication. Rates of in vitro fertilization (IVF) increased from 1.8% during 1980-1985 to 26.0% during 1995-1999.

CONCLUSION

Women with primary infertility were found to have unique sociodemographic characteristics compared to age-matched control women, which is consistent with previous research. The incidence of diagnosed primary infertility increased from 1980 to 1999, as did use of IVF.

The impact of an unequal distribution of education on inequalities in life expectancy

Prior research has found socio-economic determinants such as education to affect health outcomes. Yet, education is not distributed equally among the population. This article attempts to quantify the impact of unequal distribution of education on inequalities in life expectancy. We calculate a Gini coefficient of longevity from the life tables provided by the Human Mortality Database and a Gini coefficient of education using data on educational attainment from Barro and Lee (2013). We estimate linear regression models to examine the relationship between inequality in education and inequality in life expectancy at the country level for up to 31 European countries between 1970 and 2010. Results provide empirical evidence for a statistically significant positive association between educational inequality and inequalities of longevity. Confounding factors reflecting individual health behaviour such as cigarette or alcohol consumption do not exert a separate statistically significant effect on inequality in life expectancy. Findings are robust to alternative calculation of key variables, dropping a potential outlier, and an alternative estimation approach. These findings suggest that not only education, but also equality in education is a crucial factor for health outcomes. Continuing efforts should be directed towards the reduction of educational inequality in order to reduce inequality in longevity within a country.

The Effects of Education on Mortality: Evidence From Linked U.S. Census and Administrative Mortality Data

Does education change people's lives in a way that delays mortality? Or is education primarily a proxy for unobserved endowments that promote longevity? Most scholars conclude that the former is true, but recent evidence based on Danish twin data calls this conclusion into question. Unfortunately, these potentially field-changing findings-that obtaining additional schooling has no independent effect on survival net of other hard-to-observe characteristics-have not yet been subject to replication outside Scandinavia. In this article, we produce the first U.S.-based estimates of the effects of education on mortality using a representative panel of male twin pairs drawn from linked complete-count census and death records. For comparison purposes, and to shed additional light on the roles that neighborhood, family, and genetic factors play in confounding associations between education and mortality, we also produce parallel estimates of the education-mortality relationship using data on (1) unrelated males who lived in different neighborhoods during childhood, (2) unrelated males who shared the same neighborhood growing up, and (3) non-twin siblings who shared the same family environment but whose genetic endowments vary to a greater degree. We find robust associations between education and mortality across all four samples, although estimates are modestly attenuated among twins and non-twin siblings. These findings-coupled with several robustness checks and sensitivity analyses-support a causal interpretation of the association between education and mortality for cohorts of boys born in the United States in the first part of the twentieth century.

Role of sex hormones in lung cancer

Lung cancer represents the world's leading cause of cancer deaths. Sex differences in the incidence and mortality rates for various types of lung cancers have been identified, but the biological and endocrine mechanisms implicated in these disparities have not yet been determined. While some cancers such as lung adenocarcinoma are more commonly found among women than men, others like squamous cell carcinoma display the opposite pattern or show no sex differences. Associations of tobacco product use rates, susceptibility to carcinogens, occupational exposures, and indoor and outdoor air pollution have also been linked to differential rates of lung cancer occurrence and mortality between sexes. While roles for sex hormones in other types of cancers affecting women or men have been identified and described, little is known about the influence of sex hormones in lung cancer. One potential mechanism identified to date is the synergism between estrogen and some tobacco compounds, and oncogene mutations, in inducing the expression of metabolic enzymes, leading to enhanced formation of reactive oxygen species and DNA adducts, and subsequent lung carcinogenesis. In this review, we present the literature available regarding sex differences in cancer rates, associations of male and female sex hormones with lung cancer, the influence of exogenous hormone therapy in women, and potential mechanisms mediated by male and female sex hormone receptors in lung carcinogenesis. The influence of biological sex on lung disease has recently been established, thus new research incorporating this variable will shed light on the mechanisms behind the observed disparities in lung cancer rates, and potentially lead to the development of new therapeutics to treat this devastating disease.

The Acceptability and Effectiveness of Videos Promoting Smoking Cessation Among Australians Experiencing Mental Illness

There are high rates of tobacco smoking among people who experience mental illness (MI). While videos are an effective method of disseminating health-related information, there is limited research investigating the effectiveness of video-delivered education promoting smoking cessation among people living with MI. This formative study aimed to investigate the effectiveness and acceptability of targeted video resources providing smoking cessation information and advice to smokers with MI. This study used a mixed-method design; 29 Australian smokers living with MI completed a preinterview survey including 12 questions assessing knowledge about smoking cessation, watched six videos developed by the research team providing information about smoking cessation, took part in semistructured interviews about the videos' quality, content, and format, and then completed a postinterview survey identical to the preinterview survey to assess changes in smoking cessation-related knowledge. A Wilcoxon signed rank test was used to calculate changes in cessation-related knowledge, and thematic analysis was used to identify common themes in qualitative data. We found a statistically significant increase in participants' smoking cessation-related knowledge scores after watching the videos. Participants indicated an overall high level of acceptability of the videos' quality, content, and format, and findings from the semistructured interviews reflected these favorable views. This study's findings provide a new understanding of the effectiveness and acceptability of customized video-based education to promote smoking cessation among people living with MI, and can be used to inform the content and focus of video resources aimed at increasing knowledge about smoking cessation for people experiencing MI.

The Greek smoking epidemic from a life-course perspective

BACKGROUND

Smoking rates in Greece are the highest recorded among OECD countries, but the historical and life-course evolution of smoking patterns is largely unknown. The present paper addresses this gap.

METHODS

We produce nationally representative life-course trajectories of smoking and related mortality of eight generations of Greek men and women. We estimate the smoking-mortality correlation conditional on several confounders and project the estimates forward.

RESULTS

We show that smoking prevalence among Greek men has plateaued at >60% for all but the youngest generation. For women, smoking prevalence is relatively lower, lags by several generations and follows a hump-shaped pattern. Smoking-attributable mortality is currently peaking for men (nearing 40% of total deaths) and is rising for women. We estimate that it takes ~20 years of smoking to maximize the smoking-mortality correlation (at 0.48 for men and 0.32 for women). Based on this estimation, we forecast that mortality rates will begin falling within the current decade.

CONCLUSIONS

The breadth of the Greek smoking epidemic has been high by international standards, reflecting the ineffective tobacco control efforts in the country. While smoking popularity fell during the Great Recession, policy vigilance is necessary to prevent a relapse once the economy recovers.

Polygenic scores for smoking and educational attainment have independent influences on academic success and adjustment in adolescence and educational attainment in adulthood

Educational success is associated with greater quality of life and depends, in part, on heritable cognitive and non-cognitive traits. We used polygenic scores (PGS) for smoking and educational attainment to examine different genetic influences on facets of academic adjustment in adolescence and educational attainment in adulthood. PGSs were calculated for participants of the Minnesota Twin Family Study (N = 3225) and included as predictors of grades, academic motivation, and discipline problems at ages 11, 14, and 17 years-old, cigarettes per day from ages 14 to 24 years old, and educational attainment in adulthood (mean age 29.4 years). Smoking and educational attainment PGSs had significant incremental associations with each academic variable and cigarettes per day. About half of the adjusted effects of the smoking and education PGSs on educational attainment in adulthood were mediated by the academic variables in adolescence. Cigarettes per day from ages 14 to 24 years old did not account for the effect of the smoking PGS on educational attainment, suggesting the smoking PGS indexes genetic influences related to general behavioral disinhibition. In sum, distinct genetic influences measured by the smoking and educational attainment PGSs contribute to academic adjustment in adolescence and educational attainment in adulthood.

Sex and Gender Differences in Lung Disease

Sex differences in the anatomy and physiology of the respiratory system have been widely reported. These intrinsic sex differences have also been shown to modulate the pathophysiology, incidence, morbidity, and mortality of several lung diseases across the life span. In this chapter, we describe the epidemiology of sex differences in respiratory diseases including neonatal lung disease (respiratory distress syndrome, bronchopulmonary dysplasia) and pediatric and adult disease (including asthma, cystic fibrosis, idiopathic pulmonary fibrosis, chronic obstructive pulmonary disease, lung cancer, lymphangioleiomyomatosis, obstructive sleep apnea, pulmonary arterial hypertension, and respiratory viral infections such as respiratory syncytial virus, influenza, and SARS-CoV-2). We also discuss the current state of research on the mechanisms underlying the observed sex differences in lung disease susceptibility and severity and the importance of considering both sex and gender variables in research studies' design and analysis.

Pathways to Educational Disparities in Disability Incidence: The Contributions of Excess Body Mass Index, Smoking, and Manual Labor Involvement

OBJECTIVES

In the United States, educational disparities in disability are large and increasing, but the mechanisms underlying them are not well understood. We estimate the proportion of population-level educational disparities in disability incidence explained by excess body mass index (BMI), smoking, and manual labor.

METHOD

We use waves 2003-2015 of the nationally representative Panel Study of Income Dynamics to calculate observed disability incidence and counterfactual incidence absent the key mediators (3,129 individuals; 13,168 observations). We take advantage of earlier-life measures, including childhood socioeconomic status, 1986 BMI, and occupational history between 1968 and 2001. To account for distinct processes in women and men at middle versus older ages, we stratify by gender and at age 65.

RESULTS

Educational disparities in disability incidence were evident in women and men at younger and older ages, and were largest among older women. Together, the mediators of interest were estimated to explain roughly 60% of disparities in younger women, 65%-70% in younger men, 40% in older women, and 20%-60% in older men. The main contributors to disparities appeared to be excess BMI and smoking in younger women; manual labor and smoking in younger men; excess BMI in older women; and smoking in older men.

DISCUSSION

These mediators explain much of disparities in earlier-age disability; successful interventions to address these factors may substantially reduce them. However, a considerable proportion of disparities remained unexplained, particularly at older ages, reflecting the myriad pathways by which educational attainment can influence disability status.

A Complex Systems Model of Breast Cancer Etiology: The Paradigm II Conceptual Model

BACKGROUND

The etiology of breast cancer is a complex system of interacting factors from multiple domains. New knowledge about breast cancer etiology continues to be produced by the research community, and the communication of this knowledge to other researchers, practitioners, decision makers, and the public is a challenge.

METHODS

We updated the previously published Paradigm model (PMID: 25017248) to create a framework that describes breast cancer etiology in four overlapping domains of biologic, behavioral, environmental, and social determinants. This new Paradigm II conceptual model was part of a larger modeling effort that included input from multiple experts in fields from genetics to sociology, taking a team and transdisciplinary approach to the common problem of describing breast cancer etiology for the population of California women in 2010. Recent literature was reviewed with an emphasis on systematic reviews when available and larger epidemiologic studies when they were not. Environmental chemicals with strong animal data on etiology were also included.

RESULTS

The resulting model illustrates factors with their strength of association and the quality of the available data. The published evidence supporting each relationship is made available herein, and also in an online dynamic model that allows for manipulation of individual factors leading to breast cancer (https://cbcrp.org/causes/).

CONCLUSIONS

The Paradigm II model illustrates known etiologic factors in breast cancer, as well as gaps in knowledge and areas where better quality data are needed.

IMPACT

The Paradigm II model can be a stimulus for further research and for better understanding of breast cancer etiology.

Temporal Trends and Familial Clustering of Ideal Cardiovascular Health in Parents and Offspring Over the Life Course: An Investigation Using The Framingham Heart Study

Background

Evidence suggests familial aggregation and intergenerational associations for individual cardiovascular health (CVH) metrics. Over a 53‐year life course, we examined trends and association of CVH between parents and their offspring at similar mean ages.

Methods and Results

We conducted a series of cross‐sectional analyses of the FHS (Framingham Heart Study). Parent‐offspring pairs were assessed at exams where their mean age distributions were similar. Ideal CVH was defined using 5 CVH metrics: blood pressure (<120/<80 mm Hg), fasting blood glucose (<100 mg/dL), blood cholesterol (<200 mg/dL), body mass index (<25 kg/m²), and non‐smoking. Joinpoint regression and Chi‐squared test were used to assess linear trend; proportional‐odds regression was used to examine the association between parents and offspring CVH. A total of 2637 parents were paired with 3119 biological offspring throughout 6 exam cycles. Similar patterns of declining ideal CVH with advancing age were observed in parents and offspring. Small proportions of parents (4%) and offspring (17%) achieved 5 CVH metrics at ideal levels (P‐trend <0.001). Offspring of parents with poor CVH had more than twice the odds of having poor CVH (pooled odds ratio, 2.59; 95% CI, 1.98–3.40). Over time, elevated glucose levels and obesity doubled among the offspring and were the main drivers for declining ideal CVH trends.

Conclusions

Parental CVH was positively associated with offspring CVH. However, intergenerational CVH gains from declining smoking rates, cholesterol, and blood pressure were offset by rising offspring obesity and elevated glucose levels. This suggests an intergenerational phenotypic shift of risk factors and the need for a family‐centered approach to cardiovascular care.

Gender differential secular trend in lifetime smoking prevalence among adolescents: an age-period-cohort analysis

Background

There has been a gender difference in adolescents’ lifetime smoking prevalence trends over the last 10 years. This study aimed to explain the gender differential secular trend in adolescents’ lifetime smoking prevalence using age-period-cohort (APC) analysis and suggests possible causes for this trend, including Korean tobacco control policies during the last 10 years.

Methods

We utilized the 2006–2017 Korea Youth Risk Behavior Web-based Survey enrolling grades 7 to 12. Using year of survey and year of entry into middle school, we classified 859,814 students who had ever smoked into 6 age groups, 12 periods, and 17 school admission cohorts. Using APC analysis with the intrinsic estimator method, the effects of age, period, and school admission cohort on lifetime smoking prevalence were analyzed according to gender.

Results

Overall, there was a similar tendency of all the three effects on lifetime smoking prevalence between genders: an increasing age effect with grade, negative period effect with survey period, and similar pattern of school admission cohort groups. However, compared to boys, girls experienced reduction in the increasing age effect in the 12th grade, consistent and steeper decreasing trend in the period effect from 2006 to 2016, and shorter and lower school admission cohort effect.

Conclusions

Gender differential response to chronological changes in lifetime smoking prevalence was measured by the APC effect, which affected the gender differential secular trend in lifetime smoking prevalence. Therefore, considering the APC effect could help us understand the trend in smoking rates, as well as the contextual factors that affect it.

Examining sex differences in pleiotropic effects for depression and smoking using polygenic and gene-region aggregation techniques

Sex differences in rates of depression are thought to contribute to sex differences in smoking initiation (SI) and number of cigarettes smoked per day (CPD). One hypothesis is that women smoke as a strategy to cope with anxiety and depression, and have difficulty quitting because of concomitant changes in hypothalamic-pituitary-adrenocortical (HPA) axis function during nicotine withdrawal states. Despite evidence of biological ties, research has not examined whether genetic factors that contribute to depression-smoking comorbidity differ by sex. We utilized two statistical aggregation techniques-polygenic scores (PGSs) and sequence kernel association testing-to assess the degree of pleiotropy between these behaviors and moderation by sex in the Health and Retirement Study (N = 8,086). At the genome-wide level, we observed associations between PGSs for depressive symptoms and SI, and measured SI and depressive symptoms (all p < .01). At the gene level, we found evidence of pleiotropy in FKBP5 for SI (p = .028), and sex-specific pleiotropy in females in NR3C2 (p = .030) and CHRNA5 (p = .025) for SI and CPD, respectively. Results suggest bidirectional associations between depression and smoking may be partially accounted for by shared genetic factors, and genetic variation in genes related to HPA-axis functioning and nicotine dependence may contribute to sex differences in SI and CPD.

The Prevalence of Smoking, Determinants and Chance of Psychological Problems among Smokers in an Urban Community Housing Project in Malaysia

Objective: This study was conducted to assess the prevalence, pattern of smoking and sociodemographic factors among Kerinchi residents in Kuala Lumpur, as well as to identify the association between smoking, stress, anxiety and depression. Methods: This study was carried out at four community housing projects in the Lembah Pantai area in Kuala Lumpur. Data was collected between 3 February 2012, and 29 November 2012. Data collectors made house visits and used interviewer administered questionnaires containing questions on demographic data and smoking patterns. Depression anxiety stress scale (DASS) was used to assess psychological symptoms. Alcohol smoking and substance involvement screening tool (ASSIST) scale was used to assess nicotine use. Results: Data from 1989 individuals (833 households) showed the age of respondents ranged from 18 to 89 years and the mean age was 39.12 years. There were 316 smokers indicating the prevalence of smoking was 15.85%, with 35.5% among males and 1.8% among females. Further, 86.6% of smokers were Malay and 87% were Muslims. Divorce was associated with smoking. Unemployment and housewives were less associated with smoking. Depression and anxiety were significantly associated with smoking (OR = 1.347. 95% CI: 1.042–1.741) and (OR = 1.401. 95% CI: 1.095–1.793) respectively. Conclusion: Screening for depression and anxiety should be routinely performed in the primary care setting and in population-based health screening to intervene early in patients who smoke.

Longitudinal effects of race, ethnicity, and psychosocial disadvantage on systemic inflammation

Objective

Psychosocial factors likely contribute to racial and ethnic inequalities in cardiovascular diseases (CVDs). However, precise social, psychological, and physiological pathways linking race and ethnicity to the development of CVDs are not well understood. Systemic inflammation, commonly indexed by C-reactive protein (CRP), is a biomarker for CVD risk and progression. The objective of this study was to identify mediating pathways from race and ethnicity to CRP through social, psychological, and behavioral variables.

Methods

Using data from 12,382 participants aged 51 and older in the Health and Retirement Study, structural equation models tested for direct and indirect effects of race and ethnicity on CRP measured over four years through educational disadvantage, everyday discrimination, depressive symptoms, external locus of control, and smoking.

Results

Educational disadvantage mediated Black-White and Hispanic-White disparities in baseline CRP directly, as well as indirectly through elevated depressive symptoms, higher external locus of control, and smoking. Educational disadvantage also mediated Black-White and Hispanic-White disparities in CRP change directly, as well as indirectly through higher external locus of control and smoking. Independent of education, discrimination mediated Black-White differences in baseline CRP via elevated depressive symptoms, higher external locus of control, and smoking. Discrimination also mediated Black-White disparities in CRP change via external locus of control.

Conclusions

Results from this population-based, longitudinal study support the view that racially patterned social disadvantage is prospectively associated with longitudinal inflammatory processes, and some of these effects are independently mediated by psychological and behavioral factors. Biopsychosocial pathways to health disparities also differ between minority groups.

Feasibility of lung cancer prediction from low-dose CT scan and smoking factors using causal models

Introduction

Low-dose CT (LDCT) is currently used in lung cancer screening of high-risk populations for early lung cancer diagnosis. However, 96% of individuals with detected nodules are false positives.

Methods

In order to develop an efficient early lung cancer predictor from clinical, demographic and LDCT features, we studied a total of 218 subjects with lung cancer or benign nodules. Probabilistic graphical models (PGMs) were used to integrate demographics, clinical data and LDCT features from 92 subjects (training cohort) from the Pittsburgh Lung Screening Study cohort.

Results

Learnt PGMs identified three variables directly (causally) linked to malignant nodules and the largest benign nodule and used them to build the Lung Cancer Causal Model (LCCM), which was validated in a separate cohort of 126 subjects. Nodule and vessel numbers and years since the subject quit smoking were sufficient to discriminate malignant from benign nodules. Comparison with existing predictors in the training and validation cohorts showed that (1) incorporating LDCT scan features greatly enhances predictive accuracy; and (2) LCCM improves cancer detection over existing methods, including the Brock parsimonious model (p<0.001). Notably, the number of surrounding vessels, a feature not previously used in predictive models, significantly improves predictive efficiency. Based on the validation cohort results, LCCM is able to identify 30% of the benign nodules without risk of misclassifying cancer nodules.

Discussion

LCCM shows promise as a lung cancer predictor as it is significantly improved over existing models. Validated in a larger, prospective study, it may help reduce unnecessary follow-up visits and procedures.

Correlates of smoking status in cancer survivors

PURPOSE

To determine the characteristics associated with cancer survivors which indicate continued cigarette smoking at or around the time of cancer diagnosis.

METHODS

A total of 631 survivors were recruited in four cancer centers in Memphis, TN, between March 2015 and June 2016. To increase the probability of accurate reporting, surveys were conducted anonymously. A total of 112 respondents reported they were current smokers and 202 reported they were former smokers (n = 314), who comprised the sample.

RESULTS

We found that the rate of daily e-cigarette use among cancer survivors who smoked was 15.2% versus 3.9% in cancer survivors who no longer smoked. The national rate of adult e-cigarette use is 3.5%. Multivariate models correlated the characteristics of current versus former smokers and revealed that increasing age (aOR = 0.97, p < .0001), decreasing education (aOR = 2.39, p < .02), and current use of e-cigarettes (aOR = 3.74, p < .00045) were frequently associated with current cigarette smoking.

CONCLUSIONS

While age and gender were associated with continued smoking, current use of e-cigarettes was associated with almost four times higher odds of being a current smoker. Further research is needed to determine if use of e-cigarettes deters or promotes the smoking cessation process, at least in cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Among cancer survivors who continue to smoke after a cancer diagnosis, use of e-cigarettes is highly prevalent; research is needed to determine whether use of e-cigarettes promotes, has no effect, or hinders smoking cessation efforts among this vulnerable population.

Use of age-period-cohort analysis in cancer epidemiology research

PURPOSE OF REVIEW

Age-period-cohort (APC) models simultaneously estimate the effects of age - biological process of aging; time period - secular trends that occur in all ages simultaneously; and birth cohort - variation among those born around the same year or from one generation to the next. APC models inform understanding of cancer etiology, natural history, and disparities. We reviewed findings from recent studies (published 2008-2018) examining age, period, and cohort effects and summarized trends in age-standardized rates and age-specific rates by birth cohort. We also described prevalence of cancer risk factors by time period and birth cohort, including obesity, current smoking, human papilloma virus (HPV), and hepatitis C virus (HCV).

RECENT FINDINGS

Studies (n=29) used a variety of descriptive analyses and statistical models to document age, period, and cohort trends in cancer-related outcomes. Cohort effects predominated, particularly in breast, bladder, and colorectal cancers, whereas period effects were more variable. No effect of time period was observed in studies of breast, bladder, and oral cavity cancers. Age-specific prevalence of obesity, current smoking, HPV, and HCV also varied by birth cohort, which generally paralleled cancer incidence and mortality rates.

SUMMARY

We observed strong cohort effects across multiple cancer types and less consistent evidence supporting the effect of time period. Birth cohort effects point to exposures early in life - or accumulated across the life course - that increase risk of cancer. Birth cohort effects also illustrate the importance of reconsidering the timing and duration of well-established risk factors to identify periods of exposure conferring the greatest risk.

Using the emergency department to investigate smoking in young adults

PURPOSE

Smoking in young adults identifies the population at risk for future tobacco-related disease. We investigated smoking in a young adult population and within high-risk groups using emergency department (ED) data in a metropolitan area.

METHODS

Using the electronic health record, we performed a retrospective study of smoking in adults aged 18-30 years presenting to the ED.

RESULTS

Smoking status was available for 55,777 subjects (90.9% of the total ED cohort); 60.8% were women, 55.0% were black, 35.3% were white, and 8.1% were Hispanic; 34.4% were uninsured. Most smokers used cigarettes (95.1%). Prevalence of current smoking was 21.7% for women and 42.5% for men. The electronic health record contains data about diagnosis and social history that can be used to investigate smoking status for high-risk populations. Smoking prevalence was highest for substance use disorder (58.0%), psychiatric illness (41.3%) and alcohol use (39.1%), and lowest for pregnancy (13.5%). In multivariable analyses, male gender, white race, lack of health insurance, alcohol use, and illicit drug use were independently associated with smoking. Smoking risk among alcohol and drug users varied by gender, race, and/or age.

CONCLUSIONS

The ED provides access to a large, demographically diverse population, and supports investigation of smoking risk in young adults.

A structural equation modeling approach to understanding pathways that connect socioeconomic status and smoking

The inverse association between socioeconomic status and smoking is well established, yet the mechanisms that drive this relationship are unclear. We developed and tested four theoretical models of the pathways that link socioeconomic status to current smoking prevalence using a structural equation modeling (SEM) approach. Using data from the 2013 National Health Interview Survey, we selected four indicator variables (poverty ratio, personal earnings, educational attainment, and employment status) that we hypothesize underlie a latent variable, socioeconomic status. We measured direct, indirect, and total effects of socioeconomic status on smoking on four pathways through four latent variables representing social cohesion, financial strain, sleep disturbance, and psychological distress. Results of the model indicated that the probability of being a smoker decreased by 26% of a standard deviation for every one standard deviation increase in socioeconomic status. The direct effects of socioeconomic status on smoking accounted for the majority of the total effects, but the overall model also included significant indirect effects. Of the four mediators, sleep disturbance and psychological distress had the largest total effects on current smoking. We explored the use of structural equation modeling in epidemiology to quantify effects of socioeconomic status on smoking through four social and psychological factors to identify potential targets for interventions. A better understanding of the complex relationship between socioeconomic status and smoking is critical as we continue to reduce the burden of tobacco and eliminate health disparities related to smoking.

Smoking Predicting Physical Activity in an Aging America

OBJECTIVES

Tobacco smoking and physical inactivity are among leading behavioral risk factors for ill health in older adults. This study considers how smoking is associated with physical activity.

DESIGN

Using a Life-Course model, data are analyzed regarding this relationship, controlling for, and interacted with, life-course and other factors. Daily smokers and sometimes smokers were hypothesized to engage in less leisure-time physical activity than those who never smoked, while those who stopped smoking were expected to do more than never smokers. Analyses were performed using SAS-Callable SUDAAN.

SETTING AND PARTICIPANTS

Secondary data from ten years of a national sample of adults aged 18 and over of the National Health Interview Survey, 2001-2010, are used (N = 264,945, missing data excluded, of 282,313 total cases).

MEASUREMENTS

Daily smokers, occasional smokers, and smoking quitters are compared to never smokers with regard to requisite physical activity (150 minutes per week of moderate, 100 of vigorous, and/or 50 of strengthening activity). Life-course measures include birth cohorts, age, and year of survey, as well as gender, race/ethnicity, and education.

RESULTS

Overall, hypotheses are supported regarding daily smokers and quitters; but the hypothesis is strongly rejected among sometimes smokers, who are much more likely to do requisite physical activity. Findings differ by age, sometimes smokers age 65 and over being less likely to do physical activity. Findings among all men are similar to the overall findings, while those among all women are similar to those for older respondents. Associations of smoking status with physical activity vary greatly by race/ethnicity.

CONCLUSIONS

Daily smokers may be most in need of both smoking cessation and leisure-time physical activity interventions. Smoking-cessation efforts may pay greater physical activity benefits among women and the aged, while smoking-reduction efforts may provide better outcomes among men. Smoking reduction efforts may pay more exercise benefits among African-Americans and Hispanics.

Prevalence and Correlates of Smoking among Low-Income Adults Residing in New York City Public Housing Developments-2015

To guide targeted cessation and prevention programming, this study assessed smoking prevalence and described sociodemographic, health, and healthcare use characteristics of adult smokers in public housing. Self-reported data were analyzed from a random sample of 1664 residents aged 35 and older in ten New York City public housing developments in East/Central Harlem. Smoking prevalence was 20.8%. Weighted log-binomial models identified to be having Medicaid, not having a personal doctor, and using health clinics for routine care were positively associated with smoking. Smokers without a personal doctor were less likely to receive provider quit advice. While most smokers in these public housing developments had health insurance, a personal doctor, and received provider cessation advice in the last year (72.4%), persistently high smoking rates suggest that such cessation advice may be insufficient. Efforts to eliminate differences in tobacco use should consider place-based smoking cessation interventions that extend cessation support beyond clinical settings.

The German East-West Mortality Difference: Two Crossovers Driven by Smoking

Before the fall of the Berlin Wall, mortality was considerably higher in the former East Germany than in West Germany. The gap narrowed rapidly after German reunification. The convergence was particularly strong for women, to the point that Eastern women aged 50-69 now have lower mortality despite lower incomes and worse overall living conditions. Prior research has shown that lower smoking rates among East German female cohorts born in the 1940s and 1950s were a major contributor to this crossover. However, after 1990, smoking behavior changed dramatically, with higher smoking intensity observed among women in the eastern part of Germany. We forecast the impact of this changing smoking behavior on East-West mortality differences and find that the higher smoking rates among younger East German cohorts will reverse their contemporary mortality advantage. Mortality forecasting methods that do not account for smoking would, perhaps misleadingly, forecast a growing mortality advantage for East German women. Experience from other countries shows that smoking can be effectively reduced by strict anti-smoking policies. Instead, East Germany is becoming an example warning of the consequences of weakening anti-smoking policies and changing behavioral norms.

Time Trends in the Incidence of Parkinson Disease

IMPORTANCE

Changes over time in the incidence of parkinsonism and Parkinson disease (PD) remain uncertain.

OBJECTIVE

To investigate secular trends (period effects) and birth cohort trends in the incidence of parkinsonism and PD over 30 years in a geographically defined American population.

DESIGN, SETTING, AND PARTICIPANTS

We used the medical records-linkage system of the Rochester Epidemiology Project to identify incidence cases of PD and other types of parkinsonism in Olmsted County, Minnesota, from 1976 to 2005. All cases were classified by a movement disorder specialist using defined criteria through the review of the complete medical records within the system. The analyses for this study were conducted between May 2015 and January 2016.

MAIN OUTCOMES AND MEASURES

Incidence rates of parkinsonism and PD over 30 years. We tested for secular trends (period effects) using negative binomial regression models and for birth cohort effects using age-period-cohort models.

RESULTS

Of 906 patients with parkinsonism, 501 were men, and the median age at onset was 74 years (interquartile range, 66-81 years). Of the 464 patients with PD, 275 were men, and the median age at onset was 73 years (interquartile range, 64-80 years). The overall incidence rates increased significantly over 30 years in men for both parkinsonism (relative risk [RR], 1.17 per decade; 95% CI, 1.03-1.33) and PD (RR, 1.24 per decade; 95% CI, 1.08-1.43). These trends were driven primarily by the older age groups. In particular, for men 70 years or older, incidence rates increased for both parkinsonism (RR, 1.24 per decade; 95% CI, 1.07-1.44) and PD (RR, 1.35 per decade; 95% CI, 1.10-1.65). The secular trends were not significant for women overall or in age strata. We observed an increased risk for both men and women born in the 1920 cohort (1915-1924). However, this birth cohort effect was significant only for PD and only in men.

CONCLUSIONS AND REVELANCE

Our study suggests that the incidence of parkinsonism and PD may have increased between 1976 and 2005, particularly in men 70 years and older. These trends may be associated with the dramatic changes in smoking behavior that took place in the second half of the 20th century or with other lifestyle or environmental changes. However, the trends could be spurious and need to be confirmed in other populations.

Population health in an era of rising income inequality: USA, 1980-2015

Income inequality in the USA has increased over the past four decades. Socioeconomic gaps in survival have also increased. Life expectancy has risen among middle-income and high-income Americans whereas it has stagnated among poor Americans and even declined in some demographic groups. Although the increase in income inequality since 1980 has been driven largely by soaring top incomes, the widening of survival inequalities has occurred lower in the distribution-ie, between the poor and upper-middle class. Growing survival gaps across income percentiles since 2001 reflect falling real incomes among poor Americans as well as an increasingly strong association between low income and poor health. Changes in individual risk factors such as smoking, obesity, and substance abuse play a part but do not fully explain the steeper gradient. Distal factors correlated with rising inequality including unequal access to technological innovations, increased geographical segregation by income, reduced economic mobility, mass incarceration, and increased exposure to the costs of medical care might have reduced access to salutary determinants of health among low-income Americans. Having missed out on decades of income growth and longevity gains, low-income Americans are increasingly left behind. Without interventions to decouple income and health, or to reduce inequalities in income, we might see the emergence of a 21st century health-poverty trap and the further widening and hardening of socioeconomic inequalities in health.

Cigarette Smoking and Mortality in Adults Aged 70 Years and Older: Results From the NIH-AARP Cohort

INTRODUCTION

Tobacco use remains a leading modifiable cause of cancer incidence and premature mortality in the U.S. and globally. Despite increasing life expectancy worldwide, less is known about the effects of cigarette smoking on older populations. This study sought to determine the effects of smoking on mortality in older age.

METHODS

Associations of mortality with self-reported age at smoking cessation, age at smoking initiation, and amount smoked after age 70 years were examined in 160,113 participants of the NIH-AARP Diet and Health Study aged >70 years. Participants completed a questionnaire detailing their smoking use in 2004-2005, and were followed for mortality through December 31, 2011. Analyses were conducted between 2014 and 2016.

RESULTS

Relative to never smokers, current smokers were more likely to die during follow-up (hazard ratio, 3.18; 95% CI=3.04, 3.31). Furthermore, former smokers had lower risks than current smokers (hazard ratios for quitting between ages 30-39, 40-49, 50-59, and 60-69 years were 0.41 [95% CI=0.39, 0.43], 0.51 [95% CI=0.49, 0.54], 0.64 [95% CI=0.61, 0.67], and 0.77 [95% CI=0.73, 0.81], respectively). Among current smokers, mortality was inversely associated with age at initiation, but directly associated with the number of cigarettes smoked per day at age >70 years.

CONCLUSIONS

As among younger people, lifetime cigarette smoking history is a key determinant of mortality after age 70 years.

Peer Influence on Aggressive Behavior, Smoking, and Sexual Behavior: A Study of Randomly-assigned College Roommates

Identifying casual peer influence is a long-standing challenge to social scientists. Using data from a natural experiment of randomly-assigned college roommates (N = 2,059), which removes the threat of friend selection, we investigate peer effects on aggressive behavior, smoking, and concurrent sexual partnering. The findings suggest that the magnitude and direction of peer influence depend on predisposition, gender, and the nature of the behavior. Peer effects on individuals predisposed toward a given behavior tend to be larger than peer effects on individuals without such a predisposition. We find that the influence of roommates on aggressive behavior is more pronounced among male students than among female students; roommate effects on smoking are negative among female students and male students who did not smoke before college. For concurrent sexual partnering, a highly private behavior, we find no evidence of peer effects.

Appeal of electronic cigarettes in smokers with serious mental illness

INTRODUCTION

Up to 75% of people with serious mental illness (SMI) smoke, and most are highly dependent on nicotine, consuming more cigarettes per day than smokers without mental illness. Even with evidence-based treatment, relapses are common, resulting in high morbidity and early mortality from tobacco-related diseases. Electronic cigarettes (e-cigarettes) are theoretically safer because they deliver no tar or carbon monoxide; however, their appeal is largely untested in people with SMI.

METHODS

We enrolled 21 chronic smokers with SMI who had failed a quit attempt and were not engaged in cessation treatment. Research staff provided e-cigarettes and instructions on how to use them, and assessed participants weekly for 4weeks.

RESULTS

Of the enrolled participants, 19 completed weekly assessments. From baseline to the final study visit, mean self-reported use of combustible tobacco declined from 192 to 67cigarettes/week (t=3.62, df=17, p=0.005), confirmed by reduction in breath carbon monoxide from 27ppm to 15ppm (t=3.246, df=18, p=0.004). Use of e-cigarettes did not escalate over the 4weeks. Temporary and mild side effects, including dry/sore throat, nausea, dizziness, and cough, were reported by 58% of participants. End of trial ratings of enjoyment, satisfaction compared to regular cigarettes, and willingness to buy e-cigarettes were high (ranging from 3.82-4.51 on a 5-point scale).

CONCLUSIONS

Results of this study suggest that people with SMI may find e-cigarettes an appealing substitute for combustible cigarettes. We found no evidence of increasing nicotine dependence. Further randomized studies are needed to better assess e-cigarette appeal and toxicity.

A Novel Indicator of Life-Course Smoking Prevalence in the United States Combining Popularity, Duration, Quantity, and Quality of Smoking

OBJECTIVES

To develop a smoking indicator that combines the popularity and duration of smoking and the quantity and quality of consumed cigarettes, factors that vary dramatically over time and across generations.

METHODS

We used retrospective reports on smoking behavior and a time series of cigarette tar yields to standardize nationally representative life-course smoking prevalence rates of 11 generations of US men and women, spanning 120 years. For each generation and gender, we related the standardized data with the corresponding rates of smoking-attributable mortality.

RESULTS

Our indicator suggests that US cigarette consumption spread, peaked, and contracted faster than commonly perceived; predicts a significantly stronger smoking-mortality correlation than unadjusted smoking prevalence; and reveals the emergence of a delay (by up to 8 years) in premature death from smoking that is consistent with increasing population access to effective treatments. In fact, we show that, among recent cohorts, smoking health-risk exposure is at a historic low and will account for less than 5% of deaths.

CONCLUSIONS

Relative to unstandardized measures, our novel, standardized indicator of smoking prevalence describes a different history of smoking diffusion in the United States, and more strongly predicts later-life mortality.

Parental and adolescent health behaviors and pathways to adulthood

This paper examines associations among parental and adolescent health behaviors and pathways to adulthood. Using data from the National Longitudinal Study of Adolescent to Adult Health, we identify a set of latent classes describing pathways into adulthood and examine health-related predictors of these pathways. The identified pathways are consistent with prior research using other sources of data. Results also show that both adolescent and parental health behaviors differentiate pathways. Parental and adolescent smoking are associated with lowered probability of the higher education pathway and higher likelihood of the work and the work & family pathways (entry into the workforce soon after high school completion). Adolescent drinking is positively associated with the work pathway and the higher education pathway, but decreases the likelihood of the work & family pathway. Neither parental nor adolescent obesity are associated with any of the pathways to adulthood. When combined, parental/adolescent smoking and adolescent drinking are associated with displacement from the basic institutions of school, work, and family.

Emotion dysregulation explains relations between sleep disturbance and smoking quit-related cognition and behavior

Poor sleep quality and tobacco use are common and co-occurring problems, although the mechanisms underlying the relations between sleep disturbance and smoking are poorly understood. Sleep disturbance lowers odds of smoking cessation success and increases odds of relapse. One reason may be that sleep loss leads to emotion dysregulation, which in turn, leads to reductions in self-efficacy and quit-related problems. To address this gap, the current study examined the explanatory role of emotion dysregulation in the association between sleep disturbance and smoking in terms of (1) self-efficacy for remaining abstinent in relapse situations, (2) the presence of a prior quit attempt greater than 24h, and (3) the experience of quit-related problems among 128 adults (Mage=40.2; SD=11.0; 52.3% female) seeking treatment for smoking cessation. Results suggested that increased levels of sleep disturbance are related to emotion dysregulation which, in turn, may lead to lower levels of self-efficacy for remaining abstinent, more quit-related problems, and being less likely to have had a quit attempt of 24h or greater. Further, these indirect effects were present above and beyond variance accounted for by theoretically-relevant covariates (e.g., gender and educational attainment), suggesting that they may maintain practical significance. These findings suggest that this malleable emotional risk factor (emotion dysregulation) could serve as a target for intervention among those with poor sleep and tobacco use.

Development and usability testing of a web-based smoking cessation treatment for smokers with schizophrenia

INTRODUCTION

Over half of people with schizophrenia and other psychotic disorders smoke tobacco. Web-based approaches to cessation have been effective for the general population, but are not usable by many with schizophrenia disorders due to cognitive impairments and low computer experience. We developed a prototype smoking cessation treatment website for this group of smokers with features to reduce cognitive load. Here we report results from initial office-based usability testing and home-based field testing.

METHOD

Five people were observed using the prototype website in the office with think-aloud cognitive interviewing. The website was modified based on these data. Six people then used the website on a home laptop after a single training session, with further coaching if needed.

RESULTS

Office-based testing showed that the website was usable, but required minor modifications. Further editing provided labels that were more explicit and concrete, limited the conceptual content on each page, and modified features of the support group forum. Home-based field-testing identified further functionality issues that were rapidly modified. Over half of users needed more than a single session of training to use the computer and website. Eighty three then used it independently and were very satisfied with the web-based program. Among the five smokers who field tested the prototype, 60% cut down and 20% had quit smoking after three weeks of home use.

CONCLUSION

The prototype website was usable and satisfactory. With training and support, home use of this cessation website appears to be feasible and promising for cessation among smokers with schizophrenia. Further research is needed to evaluate web-based cessation treatment in people with psychotic disorders.

Long-term effects of mental disorders on educational attainment in the National Comorbidity Survey ten-year follow-up

PURPOSE

The study sought to examine the association of mental disorders with educational attainment in a community sample.

METHODS

Data were from 5001 respondents aged 15-54 in the 1990-1992 National Comorbidity Survey (NCS), re-interviewed in the 2001-2003 NCS follow-up (NCS-2). Discrete-time survival analysis was used to examine the association of disorders present at baseline (NCS) or having first onset after the baseline (assessed in NCS-2) with educational outcomes among 3954 eligible respondents. Mental disorders were categorized into internalizing fear disorders (simple phobia, social phobia, panic disorder with/without agoraphobia and agoraphobia without panic disorder), internalizing anxiety-misery disorders (major depressive disorder, generalized anxiety disorder and post-traumatic stress disorder), externalizing disorders (alcohol and drug use disorders, conduct disorder) and bipolar disorder. Analyses were conducted separately in students and non-students at baseline.

RESULTS

Among students, baseline bipolar and externalizing disorders, as well as fear, anxiety-misery and externalizing disorders with onset after baseline were associated with lower odds of high school graduation; baseline anxiety-misery disorders with lower odds of going to college; and baseline externalizing disorders and bipolar disorder with onset after baseline with lower odds of college graduation. Among non-students, baseline fear disorders were associated with lower odds of high school graduation and bipolar disorder with lower odds of going to college. Assuming that the regression coefficients represent causal effects, mental disorders accounted for 5.8-11.0% of high school and 3.2-11.4% of college non-completion.

CONCLUSIONS

Expanding access to mental health services for youth might have a net positive societal value by helping to prevent some of these adverse educational outcomes.

Decomposing Black-White Disparities in Heart Disease Mortality in the United States, 1973-2010: An Age-Period-Cohort Analysis

Against the backdrop of late 20th century declines in heart disease mortality in the United States, race-specific rates diverged because of slower declines among blacks compared with whites. To characterize the temporal dynamics of emerging black-white racial disparities in heart disease mortality, we decomposed race-sex-specific trends in an age-period-cohort (APC) analysis of US mortality data for all diseases of the heart among adults aged ≥35 years from 1973 to 2010. The black-white gap was largest among adults aged 35-59 years (rate ratios ranged from 1.2 to 2.7 for men and from 2.3 to 4.0 for women) and widened with successive birth cohorts, particularly for men. APC model estimates suggested strong independent trends across generations ("cohort effects") but only modest period changes. Among men, cohort-specific black-white racial differences emerged in the 1920-1960 birth cohorts. The apparent strength of the cohort trends raises questions about life-course inequalities in the social and health environments experienced by blacks and whites which could have affected their biomedical and behavioral risk factors for heart disease. The APC results suggest that the genesis of racial disparities is neither static nor restricted to a single time scale such as age or period, and they support the importance of equity in life-course exposures for reducing racial disparities in heart disease.

Cohort Effects in the Genetic Influence on Smoking

We examine the hypothesis that the heritability of smoking has varied over the course of recent history as a function of associated changes in the composition of the smoking and non-smoking populations. Classical twin-based heritability analysis has suggested that genetic basis of smoking has increased as the information about the harms of tobacco has become more prevalent-particularly after the issuance of the 1964 Surgeon General's Report. In the present paper we deploy alternative methods to test this claim. We use data from the Health and Retirement Study to estimate cohort differences in the genetic influence on smoking using both genomic-relatedness-matrix restricted maximum likelihood and a modified DeFries-Fulker approach. We perform a similar exercise deploying a polygenic score for smoking using results generated by the Tobacco and Genetics consortium. The results support earlier claims that the genetic influence in smoking behavior has increased over time. Emphasizing historical periods and birth cohorts as environmental factors has benefits over existing GxE research. Our results provide additional support for the idea that anti-smoking policies of the 1980s may not be as effective because of the increasingly important role of genotype as a determinant of smoking status.

Grandmothers' smoking in pregnancy and grandchildren's birth weight: comparisons by grandmother birth cohort

This study examined whether grandmothers' smoking behavior during pregnancy was associated with birth weights in their grandchildren, considering possible birth cohort effects in the grandmothers' generation. The birth weights of 935 singleton children were compared by grandmothers' and mothers' smoking status during pregnancy. In 2008, women (n = 397) from the Michigan Bone Health and Metabolism Study were interviewed about their own birth history, including whether their own mother smoked while pregnant with them, and the birth histories of their offspring. While also accounting for family clustering, linear mixed models were used to evaluate whether birth weight differences in the grandchildren were associated with grandmothers' and mothers' smoking behavior during pregnancy. Associations were compared among grandmothers born from 1904 to 1928 versus grandmothers born from 1929 to 1945 to determine potential birth cohort effects. Forty-six (5 %) grandchildren had grandmothers and mothers who smoked while pregnant, while 455 (49 %) had grandmothers and mothers who did not smoke during pregnancy. After adjustment, birth weight was an average of 346 (95 % confidence interval 64-628) grams higher in grandchildren whose grandmother and mother both smoked during pregnancy relative to grandchildren whose grandmother and mother both did not smoke during pregnancy, but only among grandmothers who were born from 1929 to 1945. For grandmothers born from 1904 to 1928, grandchildren birth weights did not differ by grandmother and mother smoking status. Birth weight may be associated with grandmother and mother smoking behaviors during pregnancy, but birth cohort effects should be considered.

Comparison of smoking cessation between education groups: findings from 2 US National Surveys over 2 decades

OBJECTIVES

We examined smoking cessation rate by education and determined how much of the difference can be attributed to the rate of quit attempts and how much to the success of these attempts.

METHODS

We analyzed data from the National Health Interview Survey (NHIS, 1991-2010) and the Tobacco Use Supplement to the Current Population Survey (TUS-CPS, 1992-2011). Smokers (≥ 25 years) were divided into lower- and higher-education groups (≤ 12 years and >12 years).

RESULTS

A significant difference in cessation rate between the lower- and the higher-education groups persisted over the last 2 decades. On average, the annual cessation rate for the former was about two thirds that of the latter (3.5% vs 5.2%; P<.001, for both NHIS and TUS-CPS). About half the difference in cessation rate can be attributed to the difference in quit attempt rate and half to the difference in success rate.

CONCLUSIONS

Smokers in the lower-education group have consistently lagged behind their higher-education counterparts in quitting. In addition to the usual concern about improving their success in quitting, tobacco control programs need to find ways to increase quit attempts in this group.

Potentially preventable premature lung cancer deaths in the USA if overall population rates were reduced to those of educated whites in lower-risk states

PURPOSE

Death rates for lung cancer, the leading cause of cancer death in the USA, vary substantially by the level of education at the national level, but this has not previously been analyzed by state.

METHODS

We examined age-standardized lung cancer death rates by educational attainment, race/ethnicity, and state in men and women (aged 25-64 years) in the USA in 2008-2010 and estimated the proportion of potentially avoidable premature lung cancer deaths for each state if rates were reduced to those achieved among more educated non-Hispanic whites in five states with low lung cancer rates, using data on 134,869 lung cancer deaths.

RESULTS

Age-standardized lung cancer mortality rates differed substantially by state and education level. Among non-Hispanic white men, for example, rates per 100,000 ranged from below 6 in more educated men (≥16 years of education) in Utah, Colorado, and Montana to >75 in less educated men (≤12 years of education) in Mississippi, Oklahoma, and Kentucky. An estimated 73 % of lung cancer deaths in the USA (32,700 deaths annually in 25- to 64-year-old individuals alone) would be prevented. This proportion was ≥85 % among men in Arkansas, Alabama, Kentucky, and Mississippi, and ≥80 % among women in West Virginia and Kentucky.

CONCLUSION

Most premature lung cancer deaths in the USA are potentially avoidable. As most of these deaths can be attributed to smoking, our findings underscore the importance of increasing tobacco control measures in high-risk states and targeting tobacco control interventions to less educated populations in all states.

Generation shifts in smoking over 20 years in two Dutch population-based cohorts aged 20-100 years

BACKGROUND

Younger and older generations may differ substantially in their lifetime smoking habits, which may result in generation-specific health challenges. We aimed to quantify generation shifts in smoking over a period of 25 years.

METHODS

We used the Doetinchem Cohort Study (baseline 1987-1991; 7768 individuals; 20-60 years; follow-up 1993-2012) and the Longitudinal Aging Study Amsterdam (baseline 1992-1993; 3017 individuals; 55-85 years; follow-up 1995-2009). Generation shifts were studied between 10-year generations (age range: 20-100 years). Generation shifts were examined graphically and by using logistic random effect models for men and women.

RESULTS

Among men, significant generation shifts in current smoking were found between two non-successive generations: for instance men in their 40s at baseline smoked much more than men in their 40s at follow-up (33.6% vs. 23.1%, p < 0.05). Among women, the most recently born generation showed a favourable significant generation shift in current smoking (-7.3%) and ever smoking (-10.1%). For all other generations, the prevalence of ever smoking among women was significantly higher in every more recently born generation, whereas no other generation shifts were observed for current smoking. The unfavourable generation shifts were mainly found among the lower educated.

CONCLUSIONS

The future burden of disease due to smoking is expected to be reduced among men, but not yet among women. Educational differences in smoking-related health problems are expected to increase.

A pre-post pilot study of a brief, web-based intervention to engage disadvantaged smokers into cessation treatment

BACKGROUND

People with low education and/or income are more likely to smoke, less likely to quit, and experience disparately poor health outcomes compared to those with education and income advantage. Cost-effective strategies are needed to inform and engage this group into effective cessation treatments. We developed a novel, web-based, motivational, decision-support system that was designed to engage disadvantaged smokers into tobacco cessation treatment. We piloted the system among smokers in a primary care safety net clinic.

METHODS

Thirty-nine eligible subjects were assessed at baseline and used the decision-support system; 38 were assessed 2 months later. Chi-square or Fisher's exact tests were used to assess whether participants who used the program were more likely to use cessation treatment than a randomly selected group of 60 clinic patients.

RESULTS

Thirty-nine percent of smokers initiated cessation treatment after using the decision-support system, compared to 3 percent of the comparison group (Fisher's exact = 21.2; p = 0.000). Over 10 percent achieved continuous abstinence over the 2-month follow-up. Users were satisfied with the program - 100 percent stated they would recommend it to a friend.

CONCLUSIONS

Our data indicate that this web-based, motivational, decision-support system is feasible, satisfactory, and promising in its ability to engage smokers into cessation treatment in a primary care safety net clinic. Further evaluation research is warranted.