Misclassification rates for current smokers misclassified as nonsmokers

Self-reported smoking, urine cotinine, and risk of type 2 diabetes: Findings from the PREVEND prospective cohort study

BACKGROUND

Smoking is a major risk factor for type 2 diabetes (T2D), but the evidence has mostly relied on self-reports. We aimed to compare the associations of smoking exposure as assessed by self-reports and urine cotinine with T2D.

METHODS

Using the PREVEND prospective study, smoking status was assessed at baseline by self-reports and urine cotinine in 4708 participants (mean age, 53 years) without a history of diabetes. Participants were classified as never, former, light current and heavy current smokers according to self-reports and analogous cut-offs for urine cotinine. Hazard ratios (HRs) with 95% CIs were estimated for T2D.

RESULTS

During a median follow-up of 7.3 years, 259 participants developed T2D. Compared with self-reported never smokers, the multivariable adjusted HRs (95% CI) of T2D for former, light current, and heavy current smokers were 1.02 (0.75-1.4), 1.41 (0.89-2.22), and 1.30 (0.88-1.93), respectively. The corresponding adjusted HRs (95% CI) were 0.84 (0.43-1.67), 1.61 (1.12-2.31), and 1.58 (1.08-2.32), respectively, as assessed by urine cotinine. Urine cotinine-assessed but not self-reported smoking status improved T2D risk prediction beyond established risk factors.

CONCLUSION

Urine cotinine assessed smoking status may be a stronger risk indicator and predictor of T2D compared to self-reported smoking status.

Marital status and cause-specific mortality: A population-based prospective cohort study in southern Sweden

The aim was to investigate associations between marital status and mortality with a prospective cohort study design. A public health survey including adults aged 18-80 was conducted with a postal questionnaire in southern Sweden in 2008 (54.1% participation). The survey formed a baseline that was linked to 8.3-year follow-up all-cause, cardiovascular (CVD), cancer and other cause mortality. The present investigation entails 14,750 participants aged 45-80. Associations between marital status and mortality were investigated with multiple Cox-regression analyses. A 72.8% prevalence of respondents were married/cohabitating, 9.1% never married, 12.2% divorced and 5.9% widows/widowers. Marital status was associated with age, sex, socioeconomic status (SES) by occupation, country of birth, chronic disease, Body Mass Index (BMI), health-related behaviors and generalized trust covariates. Never married/single, divorced, and widowed men had significantly higher hazard rate ratios (HRRs) of all-cause mortality than the reference category married/cohabitating men throughout the multiple analyses. For men, CVD and other cause mortality showed similar significant results, but not cancer. No significant associations were displayed for women in the multiple analyses. Associations between marital status and mortality are stronger among men than women. Associations between marital status and cancer mortality are not statistically significant with low effect measures throughout the multiple analyses among both men and women.

Religious service attendance and mortality: A population-based prospective cohort study in southern Sweden

Aims

The aim is to investigate associations between attendance in religious service during the past year and all-cause, cardiovascular (CVD), cancer and other cause mortality.

Study design

Prospective cohort study.

Methods

A public health survey with three reminders was sent to a stratified random sample of the adult 18-80 population in southernmost Sweden in 2008. The response rate was 54.1%, and 24,855 participants were included in this study. The cross-sectional baseline survey was connected to mortality data with 8.3-year follow-up. Analyses were conducted in Cox regression models.

Results

13.9% had attended religious service at least once during the past year, and 86.1% had not attended. The group with religious attendance contained significantly higher proportions of women, high and medium position non-manual employees, participants born abroad, never alcohol consumers, respondents with high trust in others and respondents with high social participation. It also contained significantly lower proportions with low leisure-time physical activity (LTPA) and daily smokers. Religious service attendance during the past year was significantly associated with lower hazard rate ratios (HRRs) of all-cause mortality compared to non-attendance until social participation items were introduced in the final model. HRRs of CVD mortality were significantly lower for religious attendance in the multiple models until BMI and health-related behaviors were introduced. No significant results were observed for cancer and other cause mortality.

Conclusions

The results suggest that religious service attendance in a highly secularized country such as Sweden is significantly associated with lower all-cause mortality, which may be explained by a social network pathway in this highly secularized population.

Smoking status and the association between patient-level factors and survival among lung cancer patients

BACKGROUND

Declines in the prevalence of cigarette smoking, advances in targeted therapies, and implementation of lung cancer screening have changed the clinical landscape for lung cancer. The proportion of lung cancer deaths is increasing in those who have never smoked cigarettes. To better understand contemporary patterns in survival among patients with lung cancer, a comprehensive evaluation of factors associated with survival, including differential associations by smoking status, is needed.

METHODS

Patients diagnosed with lung cancer between January 1, 2010, and September 30, 2019, were identified. We estimated all-cause and lung cancer-specific median, 5-year, and multivariable restricted mean survival time (RMST) to identify demographic, socioeconomic, and clinical factors associated with survival, overall and stratified by smoking status (never, former, and current).

RESULTS

Analyses included 6813 patients with lung cancer: 13.9% never smoked, 54.2% formerly smoked, and 31.9% currently smoked. All-cause RMST through 5 years for those who never, formerly, and currently smoked was 32.1, 25.9, and 23.3 months, respectively. Lung cancer-specific RMST was 36.3 months, 30.3 months, and 26.0 months, respectively. Across most models, female sex, younger age, higher socioeconomic measures, first-course surgery, histology, and body mass index were positively associated, and higher stage was inversely associated with survival. Relative to White patients, Black patients had increased survival among those who formerly smoked.

CONCLUSIONS

We identify actionable factors associated with survival between those who never, formerly, and currently smoked cigarettes. These findings illuminate opportunities to address underlying mechanisms driving lung cancer progression, including use of first-course treatment, and enhanced implementation of tailored smoking cessation interventions for individuals diagnosed with cancer.

Smoking quit rates among patients receiving pharmacotherapy who received general practitioner counselling versus intensive counselling: a retrospective cohort study

BACKGROUND

Behavioral treatments can augment the success of pharmacotherapy in smoking cessation. The aim of this study was to compare smoking quit rates between patients receiving individual counseling with their general practitioner during office visits or intensive counselling with behavioral support, both augmented by varenicline.

METHODS

A nationwide retrospective cohort study conducted in a large Healthcare Maintenance Organization in Israel. We selected randomly patients who filled a prescription for varenicline and received either individual consulting by their general practitioner or intensive counselling with behavioural support, and asked them to answer a questionnaire. The outcome variables were smoking cessation 26-52 weeks following the beginning of treatment and satisfaction with the process.

RESULTS

870 patients were contacted and 604 agreed to participate (a response rate of 69%); 301 patients in the general practitioner group, 300 in the intensive counselling group and 3 were excluded due to missing date. The quit rate was 36.5% in the general practitioner group and 42.3% in the intensive counselling group (P = 0.147). In a logistic regression analysis, controlling for age, gender, socioeconomic status, ischemic heart disease, chronic obstructive pulmonary disease, pack years and duration of varenicline consumption, the adjusted OR for quitting in the general practitioner group was 0.79 (95% CI 0.56,1.13). The adjusted OR was higher in the group with the highest socioeconomic status at 2.06 (1.39,3.07) and a longer period of varenicline consumption at 1.30 (1.15,1.47). Age, gender and cigarette pack-years were not associated with quit rate. In the general practitioner group 68% were satisfied with the process, while 19% were not. In the intensive counselling group 64% were satisfied and 14% were not (P = 0.007).

CONCLUSION

We did not detect a statistically significant difference in smoking quit rates, though there was a trend towards higher quit rates with intensive counselling.

Lung cancer in never smokers: Distinct population-based patterns by age, sex, and race/ethnicity

OBJECTIVES

Epidemiological patterns for lung cancer among never smokers (LCNS) are largely unknown, even though LCNS cases comprise 15% of lung cancers. Past studies were based on epidemiologic or health system cohorts, and not fully representative of the underlying population. The objective was to analyze rates (and trends) of LCNS by sex, age group, and race and ethnicity based on all-inclusive truly population-based sources.

MATERIALS AND METHODS

Individual-level data from 2014 to 2018 on smoking status among microscopically-confirmed lung cancer cases from Florida's cancer registry were combined with population denominators adjusted with NHIS data on smoking prevalence to compute population-based LCNS incidence rates and rate ratios. Incidence rates and proportional mortality were ranked against other cancers. Joinpoint regression analyses examined trends.

RESULTS

Proportions of LCNS ranged from 9% among White men to 83% among Chinese women. Overall, LCNS was 13% (IRR 1.13, 95%CI 1.08-1.17) more common among men than women, but variation occurred by age group, with female rates exceeding male in younger ages. Age-adjusted rates per 100,000 were highest among Asian/Pacific Islander (API) men and women (15.3 and 13.5, respectively) and Black populations (14.6, 12.9), intermediate for White (13.2, 11.8) and lowest among the Hispanic population (12.1, 10.6). Among API women, LCNS was the second leading cause of cancer death, surpassed only by breast cancer. LCNS trends were stable over time.

CONCLUSION

LCNS is the 11th most frequently occurring cancer in men and 8th in women. LCNS differences by race/ethnicity are small, within a 15% range of the White population's rates. Surprisingly, API men and women have the highest LCNS rates and proportional mortality. As smoking prevalence decreases in the US, LCNS cases will inevitably increase, warranting inquiry into risk factors across the lifespan.

Smoking and Radiation-induced Skin Injury: Analysis of a Multiracial, Multiethnic Prospective Clinical Trial

INTRODUCTION

Smoking during breast radiotherapy (RT) may be associated with radiation-induced skin injury (RISI). We aimed to determine if a urinary biomarker of tobacco smoke exposure is associated with increased rates of RISI during and after breast RT.

PATIENTS AND METHODS

Women with Stage 0-IIIA breast cancer treated with breast-conserving surgery or mastectomy followed by RT to the breast or chest wall with or without regional nodal irradiation were prospectively enrolled on a multicenter study assessing acute/late RISI. 980 patients with urinary cotinine (UCot) measurements (baseline and end-RT) were categorized into three groups. Acute and late RISI was assessed using the ONS Acute Skin Reaction scale and the LENT-SOMA Criteria.

RESULTS

Late Grade 2+ and Grade 3+ RISI occurred in 18.2% and 1.9% of patients, respectively-primarily fibrosis, pain, edema, and hyperpigmentation. Grade 2+ late RISI was associated with UCot group (P= 006). Multivariable analysis identified UCot-based light smoker/secondhand smoke exposure (HR 1.79, P= .10) and smoking (HR 1.60, p = .06) as non-significantly associated with an increased risk of late RISI. Hypofractionated breast RT was associated with decreased risk of late RISI (HR 0.51, P=.03). UCot was not associated with acute RISI, multivariable analysis identified race, obesity, RT site/fractionation, and bra size to be associated with acute RISI.

CONCLUSIONS

Tobacco exposure during breast RT may be associated with an increased risk of late RISI without an effect on acute toxicity. Smoking cessation should be encouraged prior to radiotherapy to minimize these and other ill effects of smoking.

Associations among vitamin D, tobacco smoke, and hypertension: A cross-sectional study of the NHANES 2001-2016

The interrelationships among vitamin D, tobacco smoking, and hypertension are currently unknown. This study was conducted to determine the relationship between vitamin D levels and hypertension and the effect of tobacco smoke exposure levels on this relationship among US adults. We performed a cross-sectional analysis of adult participants from the 2001-2016 National Health and Nutrition Examination Survey (NHANES). Serum 25-hydroxyvitamin D concentration was used as a biomarker of vitamin D status, and tobacco smoke exposure levels were objectively evaluated by serum cotinine levels. Among 22,875 eligible adults who were not receiving antihypertensive medications, the prevalence of hypertension, vitamin D deficiency (<50 mmol/L), and cotinine ≥3 ng/mL was 13.9%, 34.9%, and 29.4%, respectively. Serum cotinine and vitamin D levels were independently associated with hypertension risk after controlling for confounders (P < 0.05). When stratified by the cotinine group (<0.05, 0.05-3 and ≥3 ng/mL), we found that the risk of hypertension associated with vitamin D deficiency was higher among subjects with cotinine levels ≥3 ng/mL compared with the other strata [OR (95% CI) 1.30 (1.09, 1.54) vs. 1.53 (1.19, 1.96) vs. 1.64 (1.30, 2.06); P for heterogeneity test <0.05]. Furthermore, serum cotinine levels were negatively correlated with vitamin D levels. These findings suggested that the increased risk of hypertension could be partly attributed to low vitamin D levels induced by tobacco smoke exposure, in addition to the effects of tobacco smoke exposure and vitamin D deficiency themselves.

The Association Between Smoking Status and Breast Cancer Recurrence: A Systematic Review

PURPOSE

To determine whether smoking status (active/passive) affects recurrence events after breast cancer (BC) diagnosis among women.

METHODS

A comprehensive literature search of MEDLINE, Cochrane Central, EMBASE, and Web of Science databases on smoking status and BC outcomes retrieved 5,940 articles. After reviewing the inclusion and exclusion criteria, we selected 14 articles for a full review and synthesis.

RESULTS

Five studies were cohort retrospective, 6 were case-control, 2 were prospective cohort studies, and 1 was a secondary analysis of a randomized control trial. Among the 8 articles that focused on active smoking, 6 showed an increased risk of BC recurrence, and 2 showed no evidence of such an association. Studies that examined former smokers found little evidence of an increased risk of BC recurrence. This association may be dose-dependent.

CONCLUSION

Given the current evidence, although limited, active smokers should quit smoking after BC diagnosis as trends indicate a positive association between active and BC recurrence. More robust evidence is needed to assess such associations and examine the outcomes of quitting smoking in such patients.

Trust in the healthcare system and mortality: A population-based prospective cohort study in southern Sweden

Aims

To investigate associations between trust in the healthcare system and all-cause, cardiovascular, cancer and other causes mortality.

Study design

Prospective cohort study.

Methods

A public health questionnaire was conducted in 2008 in Scania, the southernmost part of Sweden, with a 54.1% participation rate with a postal questionnaire and three reminders. In this study 24,833 respondents were included. The baseline questionnaire study was linked to prospective 8.3-year follow-up cause-specific mortality register data. Survival (Cox) regression analyses were conducted.

Results

A 15.2% proportion of respondents reported very high, 59.1% rather high, and 21.7% not particularly high trust in the healthcare system, while 3.2% reported no trust at all and 0.9% did not know. The groups with rather high and not particularly high trust in the healthcare system had significantly lower all-cause mortality than the reference group with very high trust in the healthcare system. These statistically significant results remained throughout the multiple analyses, and were explained by lower cancer mortality in both the rather high and not particularly high trust respondent groups, and lower cardiovascular mortality in the not particularly high trust respondent group. No significant results were observed in the adjusted models for other causes mortality. No significant results were observed for the no trust and don't know categories in the multiple adjusted models, but these groups are small.

Conclusions

The results suggest a comparative advantage of moderate trust compared to very high trust in this setting of long waiting times for cancer and CVD treatment.

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Trust in the healthcare system and mortality was investigated.

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Rather high and not particularly high trust groups had lower all-cause mortality than the very high trust group.

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The lower mortality was mainly explained by lower cancer mortality.

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The lower mortality was partly explained by lower CVD mortality.

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The findings are associated with long-term queueing for particularly cancer treatment.

Social capital, the miniaturization of community, traditionalism and mortality: A population-based prospective cohort study in southern Sweden

Objectives

To investigate associations between social capital, miniaturization of community and traditionalism and all-cause, cardiovascular (CVD), cancer and other causes mortality.

Study design

Prospective cohort study.

Methods

The 2008 public health survey in Scania in the southernmost part of Sweden was conducted with a postal questionnaire posted to a stratified random sample aged 18–80. The response rate was 54.1%. The baseline survey was linked to 8.3-year prospective public death register data. Analyses were conducted with survival analyses, adjusting for relevant factors.

Results

Among women 37.9% had low social participation and 37.8% low trust. Among men 40.9% had low social participation and 35.7% low trust. Low social capital (low social participation/low trust) and traditionalism (low social participation/high trust) have significantly higher total and cardiovascular mortality among women and men combined and among men, but not among women in the final models. The results for women are not significant in the full models for all-cause, CVD, cancer and all other causes mortality. Miniturization of community (high social participation/low trust) displays no statistically significant associations in the adjusted models. Social participation and trust, respectively, and total mortality show consistent Schoenfeld residuals over 8.3 years.

Conclusions

The associations between low social capital, traditionalism and mortality are stronger for men than for women, and may be partly mediated by health-related behaviors.

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Combinations of cognitive (trust) and structural (social participation) social capital were analyzed.

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Traditionalism and low social capital are associated higher all-cause and CVD mortality among men.

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High social participation/low trust combination does not differ mortality from high social capital combination.

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It may be possible to analyze social capital using intersectional statistical aproaches.

Effect of smoking on periodontal health and validation of self-reported smoking status with serum cotinine levels

OBJECTIVE

To investigate whether self-reported smoking and serum cotinine levels associate with periodontal pocket development and to determine the accuracy of self-reported smoking using serum cotinine.

MATERIALS AND METHODS

This 4-year prospective cohort study included data from 294 dentate adults, aged ≥30 years, who participated in both the Health 2000 Survey and the Follow-up Study of Finnish Adults' Oral Health. Subjectively reported smoking status (daily smokers n = 62, occasional smokers n = 12, quitters n = 49, and never-smokers n = 171), serum cotinine levels, demographic factors, education level, dental behaviours and medical history were collected at baseline. The outcome measure was the number of teeth with periodontal pocketing ≥4 mm over 4 years.

RESULTS

Self-reported daily smokers had 1.82 (95% CI: 1.32-2.50) higher incidence of deepened periodontal pockets than never-smokers. A positive association was observed between serum cotinine (≥42.0 μg/L) and the development of periodontal pockets. The misclassification rate of self-reported smoking was 6%.

CONCLUSIONS

Both self-reported daily smoking and higher serum cotinine were associated with periodontal pocket development. Self-reported smoking was fairly accurate in this study. However, higher cotinine levels among a few self-reported never-smokers indicated misreporting or passive smoking. Thus, self-reports alone are not enough to assess the smoking-attributable disease burden.

Isotope dilution-LC-MS/MS method for quantification of the urinary cotinine-to-creatinine ratio

Background

Appropriate monitoring of tobacco smoking is extremely important in several areas of medicine, e.g. management of chronic obstructive pulmonary disease (COPD), epidemiological surveys, and allocation of heart or lung transplants. The major metabolite of nicotine is cotinine that is increasingly used as a laboratory parameter for assessing tobacco smoke exposure.

Methods

Creatinine and cotinine were analyzed simultaneously in urine by ultra-high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) in one run within 3 min using a biphenyl column. For quantification, the respective stable-isotope-labeled standards were used.

Results

Detuning and measuring a natural isotope of creatinine as precursor and product ion allowed a simultaneous quantification of creatinine and cotinine. The method revealed robust validation results. For both analytes, inaccuracy and imprecision of the quality control and external quality assessment (EQA) samples were ≤-11.1%.

Conclusions

One essential novelty of the method presented here is the simultaneous quantification of creatinine and cotinine covered by one analytical method. Despite the very different natural concentrations of creatinine and cotinine, this allows the immediate reporting of the cotinine-to-creatinine ratio without the need for a separate creatinine analysis.

Investigating the added value of biomarkers compared with self-reported smoking in predicting future e-cigarette use: Evidence from a longitudinal UK cohort study

Biomarkers can be used to assess smoking behaviour more accurately and objectively than self-report. This study assessed the association between cotinine (a biomarker of smoke exposure) and later e-cigarette use among a population who were unexposed to e-cigarettes in youth. Young people in the Avon Longitudinal Study of Parents and Children took part in the study. We observed associations between cotinine at 15 years (measured between 2006 and 2008 before the wide availability of e-cigarettes) and self-reported ever use of e-cigarettes at 22 (measured between 2014 and 2015 when e-cigarettes were widely available) using logistic regression. A range of potential confounders were adjusted for (age, sex, body mass index, alcohol use and passive smoke exposure). Additionally, we adjusted for the young people's self-reported smoking status/history to explore potential misreporting and measurement error. In a sample of N = 1,194 young people, cotinine levels consistent with active smoking at 15 years were associated with increased odds of e-cigarette ever use at 22 years (Odds Ratio [OR] = 7.24, 95% CI 3.29 to 15.93) even when self-reported active smoking status at age 16 (OR = 3.14, 95% CI 1.32 to 7.48) and latent classes of smoking behaviour from 14 to 16 (OR = 2.70, 95% CI 0.98 to 7.44) were included in the model. Cotinine levels consistent with smoking in adolescence were strongly associated with increased odds of later e-cigarette use, even after adjusting for reported smoking behaviour at age 16 and smoking transitions from 14 to 16.

Cotinine Testing Improves Smoking Cessation Before Total Joint Arthroplasty

BACKGROUND

Patients who are actively smoking at the time of primary total joint arthroplasty (TJA) are at an increased risk of perioperative complications. Serum cotinine testing is a sensitive and specific method to verify abstinence from smoking and may therefore improve a patient's chance of smoking cessation. The primary purpose of this study was to assess whether cotinine testing improves the self-reported quit rate among smokers before TJA.

METHODS

Our hospital performs a high volume of TJAs and documents smoking status at each clinic visit (at 6-month intervals), as well as at the time of surgery through an institutional total joint registry. As part of a retrospective analysis, this information was used to identify all self-reported smokers (regularly cigarette smoking within 1 year of TJA) who underwent unilateral TJA from 2007 to 2018. The cohort had a mean age of 66 years, 55% were female, and the mean body mass index was 31 kg/m². Patients whose serum cotinine was obtained within 1 month before surgery were then separated from the cohort and compared to the smokers who did not undergo cotinine testing.

RESULTS

Of the 28,758 primary TJAs identified, 8.8% (2514) were smokers. Serum cotinine testing was obtained on 103 of these patients. The abstinence rate (by means of self-reporting) before surgery significantly improved from 15.8% to 28.2% in the untested vs cotinine-tested groups, respectively (P = .005). Among all patients who underwent cotinine testing, 77% were negative (abstinent) and an additional 15% had cotinine levels between 3 and 8 ng/mL representing passive tobacco exposure. Among patients who stated they had quit smoking, 15% still had positive cotinine tests.

CONCLUSION

Smoking cessation remains a major challenge in contemporary TJA practices despite a concerted effort to help patients quit. Our findings suggest that cotinine testing significantly improves the self-reported quit rates of smokers before surgery and helps identify the 15% who falsely report abstinence to ensure appropriate counseling of inherent risks.

LEVEL OF EVIDENCE

Therapeutic level III.

Parental separation/divorce in childhood and tobacco smoking in adulthood: A population-based study

Aims: The aim was to investigate associations between the experience of parental separation/divorce in childhood and tobacco smoking in adulthood, adjusting for economic stress in childhood and adulthood and psychological health (General Health Questionnaire GHQ12). Methods: The 2012 public-health survey in Skåne, southern Sweden, is a cross-sectional postal questionnaire population-based study with 28,029 participants aged 18-80 (51.7% response rate). Associations between parental separation/divorce in childhood and tobacco smoking were investigated in multiple logistic regression models, with adjustments for economic stress in childhood and adulthood and psychological health. Results: A 17.6% weighted prevalence of men and 17.1% of women reported tobacco smoking. Significantly higher odds ratios of tobacco smoking were observed for men who had experienced parental separation/divorce in childhood at ages 0-4, 5-9 and 15-18 years and for women with this experience in childhood at ages 0-4, 5-9, 10-14 and 15-18 years, even after inclusion of economic stress in childhood in the final multiple models. No effect modification was observed for parental separation and psychological health and for parental separation and economic stress in childhood with regard to smoking. Conclusions: Experience of parental separation/divorce in childhood was significantly associated with tobacco smoking in adulthood for both sexes. There seems to be no specific critical period.

Misclassification of smoking habits: An updated review of the literature

BACKGROUND

Misclassification of smoking habits leads to underestimation of true relationships between diseases and active smoking, and overestimation of true relationships with passive smoking. Information on misclassification rates can be obtained from studies using cotinine as a marker.

AIM

To estimate overall misclassification rates based on a review and meta-analysis of the available evidence, and to investigate how misclassification rates depend on other factors.

METHODS

We searched for studies using cotinine as a marker which involved at least 200 participants and which provided information on high cotinine levels in self-reported non-, never, or ex-smokers or on low levels in self-reported smokers. We estimated overall misclassification rates weighted on sample size and investigated heterogeneity by various study characteristics. Misclassification rates were calculated for two cotinine cut points to distinguish smokers and non-smokers, the higher cut point intended to distinguish regular smoking.

RESULTS

After avoiding double counting, 226 reports provided 294 results from 205 studies. A total of 115 results were from North America, 128 from Europe, 25 from Asia and 26 from other countries. A study on 6.2 million life insurance applicants was considered separately. Based on the lower cut point, true current smokers represented 4.96% (95% CI 4.32-5.60%) of reported non-smokers, 3.00% (2.45-3.54%) of reported never smokers, and 10.92% (9.23-12.61%) of reported ex-smokers. As percentages of true current smokers, non-, never and ex-smokers formed, respectively, 14.50% (12.36-16.65%), 5.70% (3.20-8.20%), and 8.93% (6.57-11.29%). Reported current smokers represented 3.65% (2.84-4.45%) of true non-smokers. There was considerable heterogeneity between misclassification rates. Rates of claiming never smoking were very high in Asian women smokers, the individual studies reporting rates of 12.5%, 22.4%, 33.3%, 54.2% and 66.3%. False claims of quitting were relatively high in pregnant women, in diseased individuals who may recently have been advised to quit, and in studies considering cigarette smoking rather than any smoking. False claims of smoking were higher in younger populations. Misclassification rates were higher in more recently published studies. There was no clear evidence that rates varied by the body fluid used for the cotinine analysis, the assay method used, or whether the respondent was aware their statements would be validated by cotinine - though here many studies did not provide relevant information. There was only limited evidence that rates were lower in studies classified as being of good quality, based on the extent to which other sources of nicotine were accounted for.

CONCLUSION

It is important for epidemiologists to consider the possibility of bias due to misclassification of smoking habits, especially in circumstances where rates are likely to be high. The evidence of higher rates in more recent studies suggests that the extent of misclassification bias in studies relating passive smoking to smoking-related disease may have been underestimated.

Two theoretical strands of social capital, and total, cardiovascular, cancer and other mortality: A population-based prospective cohort study

The aim is to prospectively investigate both the “cohesion” and “network” perspectives of social capital in relation to total, cardiovascular (CVD), cancer and all other causes mortality. The 2008 public health survey in Scania was a postal questionnaire with three letters of reminder, and it was answered in the Autumn by 28,198 respondents (55% participation) aged 18–80 from a stratified random sample of the population register. This baseline was connected with the national causes of death registry (Dödsorsaksregistret) with a more than five-year follow-up August 27- November 14 (depending on individual response) to December 31, 2013 (946 deaths). The analyses were performed in multiple adjusted survival (Cox-) regression models. Results show that low social participation, common to both theoretical perspectives, had consistently high hazard rate ratios (HRRs) of total, CVD, cancer and other morality, and that HRRs of total and CVD mortality remained statistically significant even after adjustments for all covariates including health behaviors, BMI, unmet healthcare needs and self-rated health, HRR 1.28 (1.08–1.52) and HRR 1.79 (1.28–2.50), respectively. In contrast, low social support, specific to the “network” perspective, showed no significant associations with mortality, except for low emotional and instrumental support and other causes mortality for which HRRs remained significant adjusted for demographics and socioeconomic status (SES). Generalized trust in other people, specific to the “cohesion” perspective, showed statistically significant HRRs for total and other causes mortality until adjustments for health-related behaviours and BMI, although not after complete adjustments, and significant HRRs for CVD and cancer mortality before adjustment for health behaviours. In conclusion, low social participation is consistently associated with all forms of mortality, and particularly total and CVD mortality. Social participation represents a strong core of social capital theory, and items should measure both variety of social contact surfaces and intensity.

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There is no consensus regarding the definition of social capital.

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The “network” and “cohesion” approaches are discussed in the public health literature.

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Generalized trust is specific to the cohesion approach also including social participation.

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Social support is sometimes defined as an aspect of network which also includes social participation.

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Social participation was the strongest predictor of total and cause-specific mortality.

A quantitative method for assessing smoke associated molecular damage in lung cancers

BACKGROUND

While tobacco exposure is the cause of the vast majority of lung cancers, an important percentage arise in lifetime never smokers. Documenting the precise extent of tobacco induced molecular changes may be of importance. Also, the contribution of environmental tobacco smoke (ETS) is difficult to assess.

METHODS

We developed and validated a quantitative method to assess the extent of tobacco related molecular damage by combing the most characteristic changes associated with tobacco smoke, the tumor mutation burden (TMB) and type of molecular changes present in lung cancers. Using maximum entropy (MaxEnt) as a classifier, we developed a F score. F score values >0 were considered to show evidence of tobacco related molecular damage, while values ≤0 were considered to lack evidence of tobacco related molecular damage. Compared to the stated patient tobacco exposure histories, the F scores had sensitivity, specificity and accuracy values of 85-87%. Using this method, we analyzed public data sets of lung adenocarcinoma (LUAD), lung squamous cell (LUSC) and small cell lung cancer (SCLC).

RESULTS

Less than 10% of LUSCs and SCLCs had negative F scores, while 27% to 35% of LUADs had positive scores. The F score showed a highly significant downward trend when LUADs were subdivided into the following categories: ever, reformed ≤15 years, reformed >15 years and never smokers. Most of the examined bronchial carcinoids (a lung cancer type not associated with smoke exposure) had negative F scores. In addition, most LUADs with EGFR mutations had negative F scores, while almost all with KRAS mutations had positive scores.

CONCLUSIONS

We have established and validated a quantitative assay that will be of use in assessing the presence and degree of smoke associated molecular damage in lung cancers arising in ever and never smokers.

[Biomarkers of Smoking - Which Cut-Off Values Should be Used?]

Biomarkers of Smoking - Which Cut-Off Values Should be Used? Abstract. Verification of smoking status by means of biomarkers is important for treatment decisions of patients with smoking-related diseases. Cotinine is currently the best biomarker to document nicotine consumption. A low cost alternative method to determine smoking status is by measurement of carboxyhemoglobin (CO-Hb) in the exhaled breath. The main disadvantage of CO-Hb is the short half-life. The appropriate cut-off value for active nicotine consumption in Switzerland is 50 ng/ml or higher cotinine in the urine or 10 ng/ml and 12 ng/ml in serum and saliva, respectively. CO-Hb levels greater than 2 % indicate smoking with high probability, levels above 3 % with very high probability.

The prevalence of and factors associated with urinary cotinine-verified smoking in Korean adults: The 2008-2011 Korea National Health and Nutrition Examination Survey

Background

Smoking rate based on self-reporting questionnaire might be underestimated. Cotinine is the principal metabolite of nicotine and is considered an accurate biomarker of exposure to cigarette smoke.

Objectives

This study evaluated the prevalence of and factors associated with urinary cotinine-verified smoking in Korean adults.

Methods

We analyzed data from 12,110 adults in the 2008–2011 Korea National Health and Nutrition Examination Survey (KNHANES), using three threshold levels of urinary cotinine ≥100ng/ml, ≥50ng/ml, and ≥30ng/ml.

Results

The weighted prevalence of urinary cotinine levels of ≥100, ≥50, and ≥30 ng/mL in the whole study population was 34.7%, 37.1%, and 41.1%, respectively. Male sex, younger age, elementary school graduation, household income in the ≤24th percentile, service and sales workers and assembly workers, and high-risk alcohol drinking were associated with a higher prevalence of urinary cotinine level of ≥ 50 or 30 ng/mL, after we adjusted for age, sex, education level, number of family members, household income, occupation, and alcohol drinking.

Logistic regression analyses were performed using the aforementioned variables as covariates to identify factors independently associated with cotinine-verified smoking. Men had a higher risk than women of having a urinary cotinine level of ≥50 ng/mL (OR 4.67, 95% CI 4.09–5.32, p < 0.001). When subjects ages 19–29 years were used as controls, adults ages 30–39 years had a 1.19-fold (CI 1.02–1.39, p = 0.026) higher risk of having a urinary cotinine level of ≥50 ng/mL. College graduates had a 32% lower risk of having a urinary cotinine level of ≥50 ng/mL than elementary school graduates (p < 0.001).

A household income in the 25–49th percentile (OR 0.82, 95% CI 0.69–0.98, p = 0.026), 50–74th percentile (OR 0.64, 95% CI 0.53–0.76, p < 0.001), or ≥75th percentile (OR 0.64, 95% CI 0.53–0.77, p < 0.001) was associated with a lower risk of having a urinary cotinine level of ≥50 ng/mL compared to a household income in the ≤24th percentile. High-risk (OR 2.75, 95% CI 2.37–3.18, p < 0.001) and intermediate-risk (OR 2.04, 95% CI 1.82–2.30, p < 0.001) alcohol drinking were associated with having a urinary cotinine level of ≥50 ng/mL compared to low-risk alcohol drinking. Similar to the results of the logistic regression analyses of urinary cotinine ≥50 ng/mL, male sex, younger age, elementary school education, household income in the ≤24th percentile, and high-risk alcohol drinking were significantly associated with having a urinary cotinine level of ≥30 ng/mL. Service and sales workers (OR 1.22, 95% CI 1.01–1.48, p = 0.041) had a significantly higher risk of having a urinary cotinine level of ≥30 ng/mL.

Conclusions

Based on a threshold urinary cotinine level of 50 ng/mL, the prevalence of cotinine-verified smoking in a representative sample of Korean adults was 37.1% (men 52.7%, women 15.4%). Younger age, male sex, low education level, service and sales workers, low household income, and high-risk alcohol drinking were associated with the risk of smoking.

Self-Reported Smoking, Urine Cotinine, and Risk of Cardiovascular Disease: Findings From the PREVEND (Prevention of Renal and Vascular End-Stage Disease) Prospective Cohort Study

BACKGROUND

We aimed to compare the associations of smoking exposure as assessed by self-reports and urine cotinine with cardiovascular disease (CVD) risk and determine the potential utility of cotinine for CVD risk prediction.

METHODS AND RESULTS

Smoking status by self-reports and urine cotinine were assessed at baseline in 4737 participants (mean age, 53 years) of the PREVEND (Prevention of Renal and Vascular End-Stage Disease) prospective study. Participants were classified as never, former, light current (≤10 cigarettes/day), and heavy current smokers (>10 cigarettes/day) according to self-reports and analogous cutoffs for urine cotinine. During a median follow-up of 8.5 years, 296 first CVD events were recorded. Compared with self-reported never smokers, the hazard ratios (95% confidence interval) of CVD for former, light current, and heavy current smokers were 0.86 (0.64-1.17), 1.28 (0.83-1.97), and 1.80 (1.27-2.57) in multivariate analysis. Compared with urine cotinine-assessed never smokers, the corresponding hazard ratios of CVD for urine cotinine-assessed former, light current, and heavy current smokers were 1.70 (1.03-2.81), 1.62 (1.15-2.28), and 1.95 (1.39-2.73) respectively. The C-index change on adding urine cotinine-assessed smoking status to a standard CVD risk prediction model (without self-reported smoking status) was 0.0098 (0.0031-0.0164; P=0.004). The corresponding C-index change for self-reported smoking status was 0.0111 (0.0042-0.0179; P=0.002).

CONCLUSIONS

Smoking status as assessed by self-reports and urine cotinine is associated with CVD risk; however, the nature of the association of urine cotinine with CVD is consistent with a dose-response relationship. The ability of urine cotinine to improve CVD risk assessment is similar to that of self-reported smoking status.

Perinatal Biochemical Confirmation of Smoking Status by Trimester

Introduction:

Tobacco use during pregnancy is the most modifiable risk factor associated with poor pregnancy outcomes. Self-reported tobacco use has been demonstrated to have high misclassification rates. The aims were to examine misclassification rates of perinatal tobacco use during each trimester of pregnancy and 8 weeks postpartum, and to evaluate characteristics associated with misclassification of tobacco use status.

Methods:

This is secondary analysis of a prospective, multicenter trial of pregnant women, and it includes participants who were biochemically identified as tobacco users during their first trimester (N = 103). Each trimester and once postpartum, tobacco use was assessed via self-report and validated using a cutoff of 100 ng/mL for urine cotinine via NicAlert test strips to indicate current use. Those who self-reported as nonusers but were identified as users via urine cotinine were considered misclassified; misclassification rates were determined for each time period. Logistic regression assessed maternal factors associated with misclassification status.

Results:

Misclassification rates declined from 35.0% at first trimester to 31.9% and 26.6% at the second and third; the postpartum rate was 30.4%. These rates did not differ significantly from each other at the 0.05 level. Race/ethnicity was associated with misclassification status; white/non-Hispanic women were 87% less likely to be misclassified (p < .001).

Conclusion:

Misclassification of prenatal smoking status decreases as pregnancy progresses, though the observed rate change was not significant. Minority women may be at particular risk for non-disclosure of tobacco use. Biochemical validation should be considered when assessing perinatal tobacco use via self-report, given high misclassification rates throughout the perinatal period.

Implications:

These results demonstrate that regardless of trimester, more than one-quarter of tobacco-using pregnant women may not disclose tobacco use throughout pregnancy and early postpartum. Although the rate of misclassification decreased from first to third trimester and then increased in the immediate postpartum, these changes in misclassification rates were not significant. Minority groups may be at particular risk of misclassification compared with white/non-Hispanic women. Biochemical validation is warranted throughout pregnancy to encourage cessation as tobacco use is one of the most easily-modified risk factors for poor birth outcomes.

Childhood cognitive ability and smoking initiation, relapse and cessation throughout adulthood: evidence from two British cohort studies

AIMS

To test the relationship between early cognitive ability and major changes in smoking habits across adulthood, and test whether educational attainment mediates these associations.

DESIGN

Prospective observational study to examine the link between cognitive ability and smoking initiation, relapse and cessation at multiple time-points throughout adulthood in a pooled analysis of two cohorts.

SETTING

Great Britain 1981-2013.

PARTICIPANTS

A total of 16 653 participants from two British cohorts; 7191 from the 1970 British Cohort Study (BCS) and 9462 from the 1958 National Child Development Study (NCDS). Participants were 52.9% female and 27.3% were smokers, 24.8% were ex-smokers and 47.9% reported never smoking.

MEASUREMENTS

Cognitive ability was assessed at age 10 years in the BCS and 11 years in the NCDS. Outcomes were smoking initiation, relapse and cessation derived from changes in smoking status observed across five time-points between ages 26-42 in the BCS and six time-points between ages 23-55 in the NCDS. Educational attainment was examined as a mediating variable. Controls were age, gender, social class, self-control, psychological distress, parental smoking and a study indicator (BCS/NCDS).

FINDINGS

In adjusted regression models, a 1 standard deviation increase in cognitive ability predicted a 0.5 percentage point (95% CI = -0.9 to -0.1) reduced probability of smoking and a 2.9 percentage point (95% CI = 2.1-3.7) higher probability of smoking cessation throughout adulthood, but did not change the likelihood of smoking relapse significantly. Differences in educational attainment explained approximately half the association between childhood cognitive ability and smoking initiation/cessation.

CONCLUSIONS

Lower cognitive ability, measured in childhood before smoking is initiated, appears to predict a higher likelihood of taking up smoking and a lower likelihood of quitting in adulthood. Educational attainment appears to mediate this effect: children with higher cognitive ability tend to become more highly educated adults which, in turn, predicts lower rates of smoking initiation and increased rates of smoking cessation.

Overview of Cotinine Cutoff Values for Smoking Status Classification

While cotinine is commonly used as a biomarker to validate self-reported smoking status, the selection of an optimal cotinine cutoff value for distinguishing true smokers from true nonsmokers shows a lack of standardization among studies. This review describes how the cutoff values have been derived, and explains the issues involved in the generalization of a cutoff value. In this study, we conducted an English-language literature search in PubMed using the keywords “cotinine” and “cutoff” or “self-reported” and “smoking status” and “validation” for the years 1985–2014. We obtained 104 articles, 32 of which provided (1) sensitivity and specificity of a cutoff value and (2) determination methods for the given cutoff value. We found that the saliva cotinine cutoff value range of 10–25 ng/mL, serum and urine cotinine cutoff of 10–20 ng/mL and 50–200 ng/mL, respectively, have been commonly used to validate self-reported smoking status using a 2 × 2 table or a receiver operating characteristics (ROC) curve. We also found that recent large population-based studies in the U.S. and UK reported lower cutoff values for cotinine in serum (3 ng/mL) and saliva (12 ng/mL), compared to the traditionally accepted ones (15 and 14 ng/mg, respectively).

Biomonitoring of tobacco smoke exposure and self-reported smoking status among general population of Tehran, Iran

The present study aimed to find a correlation between the self-reported smoking status of the residents of Tehran, Iran, and the urine cotinine as a biomarker of exposure to tobacco smoke. The self-reported data was collected from 222 participants who were living in the urban area of Tehran. The urine samples of participants were collected for cotinine analysis. Urine cotinine was measured by an enzymatic immunoassay technique. Tobacco smoking was reported by 76 (34.23 %) participants as the self-reported data, and the number of males in this report was higher than of females (p < 0.001). By adding the number of the self-reported non-smokers with cotinine levels above the cutoff value of >100 ng/ml to self-reported smokers, the smoking prevalence increased from 34.23 % (95 % CI 28.01-40.88 %) to 36.48 % (95 % CI 30.14-43.19 %). Using the cutoff value, sensitivity and specificity of the self-reported smoking status were respectively 90.12 % (95 % CI 81.46-95.64 %) and 98 % (95 % CI 93.91-99.55 %). The levels of agreement between self-reported tobacco smoking and urinary cotinine concentrations was 95.1 % (k = 0.89, p < 0.001, 95 % CI = 0.81-0.95). Based on the results, self-reported smoking can be a valid marker for assessing the tobacco exposure, and it can be of use in large epidemiological studies.

Socioeconomic differences in smoking cessation: the role of social participation

Objectives: The aim of this study was to investigate whether psychosocial resources explain socioeconomic differences in smoking cessation and its maintenance. Methods: A subpopulation of 11,837 individuals from the Malmö Diet and Cancer Study interviewed in 1992-94, age range 45-64 years, was investigated in this cross-sectional study. A multivariate logistic regression model was used to assess relative risks of having stopped smoking, adjusting for age, country of origin, previous/ current diseases, and marital status. Results: An odds ratio of 1.9 (1.4-2.5; 95% CI) for men and 2.0 (1.4-2.7; 95% CI) for women of having stopped smoking was found for higher non-manual employees when compared with unskilled manual workers. A decrease in these odds ratios was found when social participation was introduced into the model. The other three social network and social support variables were non-significant. Conclusion: High social participation is a predictor of maintenance of smoking cessation. It seems possible to interpret parts of the socioeconomic differences in smoking cessation and its maintenance as a consequence of differing social network resources and social capital between socioeconomic groups.

The association between smoking and the prevalence of intermittent claudication

The objective of this study was to investigate the association between smoking and the prevalence of intermittent claudication (IC). Between 1995 and 1997, all residents aged 20 years or older in Nord-Trøndelag County, Norway, were invited to take part in the Nord-Trøndelag Health Study (Helseundersøkelsen i Nord-Trøndelag: HUNT 2). A total of 19 748 participants aged 40-69 years attended. Responses to 12 questions on IC (including a Norwegian translation of the Edinburgh Claudication Questionnaire) had been previously tested against the ankle-brachial pressure index (ABPI < 0.9), and an algorithm of the best test properties was used to identify people with IC. Using logistic regression analysis we computed age-adjusted prevalence odds ratios (OR) for the association between smoking and IC. Both current (ORmen = 3.8, confidence interval (CI) 2.1-6.7, ORwomen = 2.2, CI 1.4-3.4) and former smokers (ORmen = 1.7, CI 0.9-3.2, ORwomen = 1.7, CI 1.1-2.7) had a higher prevalence of IC compared with those who had never smoked, and individuals who had stopped smoking more than 20 years previously had a substantially lower prevalence of IC (ORmen = 0.2, CI 0.1-0.5, ORwomen = 0.4, CI 0.2-0.8) than current smokers. We found no association between passive smoking and IC in either men or women. Current and previous smoking habits were positively associated with the prevalence of IC, and smoking cessation was negatively associated in men and women. Passive smoking was not associated with IC in this study.

Accelerometer-determined physical activity and mortality in a national prospective cohort study: Considerations by visual acuity

BACKGROUND

Previous research demonstrates that visual impairment (VI) is associated with increased all-cause mortality risk and is also associated with reduced physical activity participation. Although physical activity is reduced among those with VI, no studies have examined the relationship between physical activity and all-cause mortality across different visual function statuses, which is noteworthy of investigation as physical activity is linked with greater survival.

METHODS

Data from the 2003-2006 NHANES were employed, with physical activity assessed via accelerometry and visual function assessed using the ARK-760 autorefractor.

RESULTS

For those with normal vision, and after adjustments, for every 60min increase in physical activity, normal-sighted adults had an 18% (HR=0.82; 95% CI: 0.72-0.93) reduced risk of all-cause mortality. Similarly, after adjustments and for every 60min increase in physical activity for those with uncorrected refractive error and VI, respectively, there was a 15% (HR=0.85; 95% CI: 0.72-1.00) and 35% (HR=0.65; 95% CI: 0.43-0.98) reduced risk of all-cause mortality. Among all three visual status groups, sedentary behavior was not associated with mortality status.

CONCLUSION

Among those with varying degrees of visual loss, sedentary behavior was not associated with mortality, but physical activity demonstrated survival benefits.

Lung Cancer in Never Smokers

Lung cancer is predominantly associated with cigarette smoking; however, a substantial minority of patients with the disease have never smoked. In the US it is estimated there are 17,000-26,000 annual deaths from lung cancer in never smokers, which as a separate entity would be the seventh leading cause of cancer mortality. Controversy surrounds the question of whether or not the incidence of lung cancer in never-smokers is increasing, with more data to support this observation in Asia. There are several factors associated with an increased risk of developing lung cancer in never smokers including second hand smoke, indoor air pollution, occupational exposures, and genetic susceptibility among others. Adenocarcinoma is the most common histology of lung cancer in never smokers and in comparison to lung cancer in smokers appears less complex with a higher likelihood to have targetable driver mutations.

Coffee Drinking and Risk of Lung Cancer-A Meta-Analysis

BACKGROUND

Previous epidemiologic results on coffee consumption and lung cancer risk have not been consistent. Furthermore, not all studies have addressed the potential role of tobacco as a confounder in this association. A meta-analysis was conducted to assess the effect of coffee consumption on lung cancer risk independent of tobacco use.

METHODS

A systematic review and a meta-analysis based on random effects models were performed using studies from the PubMed and EMBASE databases, and the references from the retrieved articles. Included were 8 prospective cohorts and 13 case-control studies, which provided data for 19,892 cases and 623,645 non-cases, timeframe 1986-2015.

RESULTS

The meta-relative risk (RR) for coffee drinking, not controlling for tobacco smoking, was 1.09 [95% confidence interval (CI), 1.00-1.19], the reference group was never drinkers. There was significant heterogeneity among the study results (Q = 84.39, I² = 75.1%, Pheterogeneity < 0.001). Among non-smokers, coffee was not associated with lung cancer risk (RR, 0.92; 95% CI, 0.75-1.10), the reference group was never drinkers. The meta-RR for 1 cup per day increase, unadjusted for smoking, was 1.04 (95% CI, 1.03-1.05); the corresponding RR for non-smokers was 0.95 (95% CI, 0.83-1.09).

CONCLUSIONS

The pooled estimates indicated that when the potential confounding effect from smoking is controlled for, coffee drinking does not appear to be a lung cancer risk factor. Further pooled analyses, with larger non-smokers population size, are encouraged to confirm these results.

IMPACT

This study illustrates that the association between coffee consumption and lung cancer can be confounded by tobacco smoking. Cancer Epidemiol Biomarkers Prev; 25(6); 951-7. ©2016 AACR.

Assessment of Cotinine Reveals a Dose-Dependent Effect of Smoking Exposure on Long-term Outcomes After Renal Transplantation

BACKGROUND

Smoking is a risk factor for poor late outcomes in renal transplant recipients (RTR). Smoking exposure can be assessed by self-report and cotinine measurements. We investigated whether use of cotinine as a biomarker for smoking exposure can serve as an alternative for self-report and to compare associations of smoking exposure by self-report and cotinine with outcomes in RTR and assess dose dependency.

METHODS

Renal transplant recipients were classified as never, former, light (≤10 cigarettes/day), and heavy smokers (>10 cigarettes/day) according to self-report and analogous categories for urine and plasma cotinine. First, we assessed agreement of self-reported smoking exposure with smoking exposure according urine and plasma cotinine. Second, we compared the associations with graft failure and mortality.

RESULTS

Of 603 RTR (age 51.5 ± 12.1 years, 55% men), 36.0% RTR were never, 42.3% former, 10.6% light, and 11.1% heavy smokers according to self-report. The majority (98.6%) of never smokers had nondetectable cotinine. However, 14 and 13 RTR reporting no active smoking had respective urine or plasma cotinine consistent with active smoking. Cotinine-based measurements were dose-dependently associated with mortality and graft failure.

CONCLUSIONS

Plasma and urine cotinine can serve as an alternative to self-report and were dose-dependently associated with poor late outcomes in RTR.

Smoking may modify the association between neoadjuvant chemotherapy and survival from ovarian cancer

OBJECTIVE

Tobacco smoking by cancer patients is associated with increased mortality. Less is known of the impact of smoking on recurrence risk and interaction with chemotherapy treatment. We examined these associations in ovarian cancer.

METHODS

Patients were identified from the Alberta Cancer Registry between 1978 and 2010 and were oversampled for less-common histologic ovarian tumor types. Medical records were abstracted for 678 eligible patients on lifestyle, medical and cancer treatment, and review of pathology slides was performed for 605 patients. We estimated hazard ratios (HR) and 95% confidence intervals (CI) using Cox proportional hazard models adjusted for age at diagnosis, race, stage and residual disease.

RESULTS

Among patients receiving adjuvant chemotherapy (N=432), current smoking was significantly associated with shorter duration of overall (OS; HR, 8.56; 95% CI, 1.50-48.7) and progression-free (PFS; HR, 5.74; 95% CI, 1.05-31.4) survival from mucinous ovarian cancer only. There was no significant association between neoadjuvant chemotherapy and survival. However, among patients receiving neoadjuvant chemotherapy (N=44), current smokers had shorter PFS (HR, 4.32; 95% CI, 1.36-13.8; N=32 progressed/9 censored events) compared to never smokers, but the HRs were not statistically different across smoking categories (P interaction=0.87).

CONCLUSIONS

Adverse associations were observed between smoking status and OS or PFS among patients with mucinous ovarian cancer receiving adjuvant chemotherapy. No significant effect was found from neoadjuvant chemotherapy on PFS overall; however, smoking may modify this association. Although needing replication, these findings suggest that patients may benefit from smoking cessation interventions prior to treatment with chemotherapy.

Is Smoking a Predictor for Acute Mountain Sickness? Findings From a Meta-Analysis

AIM

Studies of the potential association between cigarette smoking and acute mountain sickness (AMS) have reached contradictory conclusions. Our aim was to perform a meta-analysis of studies across a range of populations to ascertain better the true relationship between cigarette smoking and AMS.

MATERIALS AND METHODS

We used the PRISMA protocol to identify and screen eligible studies of smoking and AMS. Databases including Pubmed and Google Scholar were searched, using the terms "smoking" and "acute mountain sickness." We conducted a meta-analysis of the selected studies in order to evaluate causal inference, evaluate potential biases, and investigate possible sources of heterogeneity across studies.

RESULTS

We identified 3907 publications, of which 29 were eligible for inclusion by reporting smoking status and AMS. Of these, eight publications were excluded because they were duplicative or were lacking quantitative data. The 21 studies analyzed included 16 566 subjects. These fell into two groups: occupational/military (n = 8) or volunteers/trekkers/mixed (n = 13). Study heterogeneity was high (X (2) = 55.5, P < .001). Smoking was not statistically associated with increased risk of AMS: pooled OR = 0.88 (95% CI = 0.74-1.05). Stratification yielded similar risk estimates among the occupational/military studies versus all others and studies at relatively higher and lower altitudes.

CONCLUSIONS

Overall, smoking was not statistically significantly associated with AMS: there is no consistent effect of cigarette smoking acting as either a protective factor against or a risk factor for AMS.

IMPLICATIONS

This is the first quantitative assessment of published studies on smoking and AMS, which shows smoking to be neither a risk, nor protective. Studies specifically focusing on smoking as a risk factor, should guide further research on this issue. Although all smokers should be strongly advised to quit, studies on risk factors for AMS focusing on other exposures could shed light on the full range of risks for AMS.

Sedentary behavior and medical multimorbidity

Emerging research demonstrates that sedentary behavior is associated with various individual chronic conditions, independent of physical activity. Despite multimorbidity (having at least 2 chronic diseases) being highly prevalent (≥ 23% of adults) and associating with premature mortality, limited research has examined the association between sedentary behavior and multimorbidity, which was the purpose of this research letter. Data from the 2005-2006 NHANES were used (analyzed in 2015). A multimorbidity index variable was created indicating the number of 14 morbidities each patient had; sedentary behavior and physical activity were assessed via accelerometry. For every 60 min/day increase in sedentary behavior, participants had a higher multimorbidity index (β(adjusted) = 0.08; 95% CI: 0.04-0.11, p<0.001) and had an 11% (OR(adjusted) = 1.11; 95% CI: 1.01-1.21; p = 0.03) increased odds of being multimorbid (i.e., having ≥ 2 morbidities). Sedentary behavior is associated with multimorbidity (independent of light-intensity physical activity and adherence to moderate-to-vigorous physical activity guidelines), which underscores the importance of minimizing prolonged sedentary behavior (in addition to promoting physical activity) among adults.

Second hand smoke exposure in public venues and mental disorder: a representative nationwide study of China

INTRODUCTION

Many studies have clearly linked exposure to Second Hand Smoke (SHS) to various somatic diseases, however, few studies have examined the relationship between SHS and mental disorders and those that have were only conducted with specific groups. The purpose of this study was to examine the association between SHS exposure and mental disorders among Chinese residents in both worksites and public places.

METHODS

A cross-sectional multistage sampling design was used to interview subjects from 21 selected cities in China. Using a standardized questionnaire including demographic characteristics, SHS exposure, and mental health information was collected. Multiple logistic regression analysis was used to assess the association between SHS exposure and mental disorders.

RESULTS

Sixteen-thousand-eight-hundred-sixty-six valid questionnaires were collected and utilized in this study. Of 11,206 non-smokers, SHS exposure prevalence in workplaces and public places were respectively 78.4 % (95 % C.I.:74.3-82.5 %) and 80.7 % (95 % C.I.:74.6-86.5 %). Multiple logistic regressions showed SHS exposures in these venues were positively related to mental disorder.

CONCLUSIONS

These findings further support the health hazards of SHS exposure. Findings underscore the importance of controlling SHS exposure, and can be used to inform future SHS control policies and reinforce the need for public education in China.

Association of active and passive smoking with occupational injury in manual workers: a cross-sectional study of the 2011 Korean working conditions survey

This study was conducted to investigate the relationship of active and passive smoking with occupational injury among manual workers. Data from the 2011 Korean Working Conditions Survey were analyzed for 12,507 manual workers aged ≥15 yr. Overall, 60.4% of men and 5.8% of women were current smokers. The prevalence of injury was higher among never smokers who were exposed to secondhand smoke (SHS) (7.7% in men and 8.1% in women) than current smokers (4.2% in men and 4.1% in women). After controlling for potential confounders, in men, compared to those who never smoked and were not exposed to SHS, people who never smoked and were exposed to SHS (adjusted odds ratio (aOR)=3.7, 2.2-6.4) and current smokers (aOR=2.5, 1.6-3.8) were more likely to experience injury. Among women, the aORs of occupational injury were 8.4 (4.2-16.7) for never smoking women with occasional exposure to SHS and 3.5 (95% CI: 1.4-8.7) for current smokers, in comparison to never smoking women who were never exposed to SHS at work (reference group). The present study suggests that exposure to SHS is a possible risk factor of occupational injury for never smoking men and women.

Health-enhancing multibehavior and medical multimorbidity

OBJECTIVE

To examine the association of multibehavior on multimorbidity.

PATIENTS AND METHODS

Data from the 2005-2006 National Health and Nutrition Examination Survey were used. The study duration was from October 20, 2013, through December 16, 2014. A multimorbidity index variable was created that indicated the number of 14 morbidities that each patient had. A multibehavior index variable was created that indicated the number of 4 health-enhancing behaviors each participant had; physical activity was assessed via accelerometry, dietary behavior was assessed via an interview, smoking was determined via cotinine levels, and sleep duration was self-reported.

RESULTS

For the entire sample of 2048 participants, those with 1, 2, 3, and 4 health behaviors, compared with 0 health behaviors, had a 35% (odds ratio [OR], 0.65; 95% CI, 0.47-0.90; P=.01), 44% (OR, 0.56; 95% CI, 0.38-0.82; P=.006), 63% (OR, 0.37; 95% CI, 0.26-0.51; P<.001), and 69% (OR, 0.31; 95% CI, 0.19-0.52; P<.001) reduced odds of being multimorbid, respectively. Only physical activity (β=-.46) and sleep (β=-.23) were independently associated with multimorbidity, and only 2 health behavior combinations were associated with multimorbidity: physical activity and sleep (β=-.17) and physical activity and nonsmoking (β=-.16).

CONCLUSIONS

Americans engaging in more health behaviors were less likely to be multimorbid. Physical activity was independently, as well is in combination with other health behaviors, associated with multimorbidity. Implications for developing a multibehavior-multimorbidity framework to treat the patients' holistic needs is discussed.

Factors influencing the disconnect between self-perceived health status and actual health profile: implications for improving self-awareness of health status

OBJECTIVE

Self-perceived health is an often used proxy measure for disease and health behavior status. Due to its convenience in clinical and epidemiological contexts, it is of interest to examine factors that may help to explain the potential disconnect between perceived and actual health, which was the purpose of this study.

METHODS

Data from the 2005-2006 NHANES were used (n=1,999 adults). Perceived health status was self-reported, with the following 6 health characteristics assessed: 1) physical activity; 2) healthy eating, 3) smoking status; 4) sleep duration; 5) depression status; and 6) weight status.

RESULTS

For every 5year increase in age, participants had a 7% reduced odds of having a discrepancy between perceived and actual health; Mexican Americans (vs. non-Hispanic Whites) had a 49% reduced odds of discrepancy; non-Hispanic Blacks (vs. non-Hispanic Whites) had a 40% increased odds of discrepancy, and individuals with a higher SES had a 12% increased odds of discrepancy.

CONCLUSION

Targeted public health and educational messages to young adults, non-Hispanic Blacks, and those with a higher SES may be needed to help prevent discrepancies between perceived and actual health. Preventing this disconnect may help to, for example, improve individual health awareness, and ultimately, improve health outcomes.

Agreement between exhaled breath carbon monoxide threshold levels and self-reported cigarette smoking in a sample of male adolescents in Jordan

This study aimed to measure the percent agreement between Exhaled Breath Carbon Monoxide (eBCO) measure using a piCO+ smokerlyzer® and self-reported cigarette smoking status and to determine the optimal thresholds for definite identification of cigarette smokers of male school students in Jordan. A descriptive, cross sectional, study of a random sample of male adolescents in grades 7 and 8 from four public high schools in Irbid, completed an adaptation of a standardized Arabic-language tobacco smoking questionnaire and an eBCO measure. Sensitivity and specificity of the eBCO were calculated against self-reported cigarette smoking. Participants (n = 439) had a mean age of 12.5 years (SD = 0.50) and 174 (39.9%) reported being an ever smoker of whom 59 (33.9%) reported being a recent (30-day) smoker. The optimal eBCO cut-off point for recent smoking was 4.5 ppm with a sensitivity of 84.7% and specificity of 65.5%. Overall, eBCO can accurately identify recent smokers and distinguish them from non-smokers. The eBCO use enables healthcare professionals and researchers to assess efficacy of smoking cessation and prevention programs without necessarily relying on self-report. Further research is indicated to validate our findings and should be expanded to include females, detailed characteristics of cigarette and waterpipe smoking.

Psychological, social and familial factors associated with tobacco cessation among young adults

BACKGROUND/AIMS

The younger individuals quit smoking, the greater the health benefits. We studied the role of adolescent and concurrent psychological, social and familial factors in successful tobacco cessation in a general population sample of French young adults.

METHODS

Our data came from participants of the TEMPO cohort study and their parents (members of the GAZEL cohort study) in France. Among regular smokers (n = 678), Cox proportional hazards models were used to estimate hazard ratios of self-reported tobacco cessation of at least 12 months in relation to individual and socioenvironmental variables.

RESULTS

On average, participants (mean: 28.9 years) smoked for 10.51 years (SD = 5.9); the majority had attempted to quit smoking at least once (59.5%). In multiple regression analyses, cannabis use in the preceding year and recent financial difficulties were both negatively associated with successful smoking cessation. Conversely, living with a partner and, for women only, recent pregnancy or childbirth were associated with an increased likelihood of tobacco cessation.

CONCLUSIONS

This study highlights the importance of young adults' cannabis use, family situation and socioeconomic context with regard to their smoking behavior. Physicians and public health decision makers aiming to decrease the burden of tobacco smoking should take into consideration these social and behavioral factors.

Sexual orientation, social capital and daily tobacco smoking: a population-based study

Background

Studies have suggested poorer health in the homosexual and bisexual groups compared to heterosexuals. Tobacco smoking, which is a health-related behavior associated with psychosocial stress, may be one explanation behind such health differences. Social capital, i.e. the generalized trust in other people and social participation/social networks which decreases the costs of social interaction, has been suggested to affect health through psychosocial pathways and through norms connected with health related behaviours, The aim of this study is to investigate the association between sexual orientation and daily tobacco smoking, taking social capital into account and analyzing the attenuation of the logit after the introduction of social participation, trust and their combination in the models.

Methods

In 2008 a cross-sectional public health survey was conducted in southern Sweden with a postal questionnaire with 28,198 participants aged 18–80 (55% participation rate). This study was restricted to 24,348 participants without internally missing values on all included variables. Associations between sexual orientation and tobacco smoking were analyzed with logistic regression analysis.

Results

Overall, 11.9% of the men and 14.8% of the women were daily tobacco smokers. Higher and almost unaltered odds ratios of daily smoking compared to heterosexuals were observed for bisexual men and women, and for homosexual men throughout the analyses. The odds ratios of daily smoking among homosexual women were not significant. Only for the “other” sexual orientation group the odds ratios of daily smoking were reduced to not significant levels among both men and women, with a corresponding 54% attenuation of the logit in the “other” group among men and 31.5% among women after the inclusion of social participation and trust. In addition, only the “other” sexual orientation group had higher odds ratios of low participation than heterosexuals.

Conclusions

Bisexual men and women and homosexual men, but not homosexual women, are daily smokers to a higher extent than heterosexuals. Only for the “other” sexual orientation group the odds ratios of daily smoking were reduced to not significant levels after adjustments for covariates including trust and social participation.

Treatment modality: a predictor of continued tobacco use after treatment in patients with laryngeal cancer

Background:

Laryngeal cancer patients who continue to smoke after treatment are at an elevated risk of mortality and morbidity. This study aimed to identify factors associated with continued tobacco use following treatment in patients with laryngeal cancer.

Methods:

A smoking behaviour questionnaire, a self-report measure, was sent to 112 patients who were diagnosed with laryngeal cancer during 2006–2011 at the Brighton and Sussex University Hospitals, Brighton, UK. Patient demographics, tumour and treatment-related variables, comorbidity and socio-economic status were obtained from the medical records.

Results:

Eighty-one per cent of patients responded to the survey; 22 per cent of these reported continued tobacco use after treatment. Treatment modality was found to be a predictor of post-therapeutic smoking (odds ratio: 4.9, p = 0.01); patients who received less invasive therapy (transoral laser microsurgery) were more likely to smoke after treatment.

Conclusions:

The findings of this preliminary study suggest that treatment modality influences smoking behaviour in patients with laryngeal cancer, which may have important implications for the design of anti-smoking interventions.

Smoking denial in cardiovascular disease studies

Assessment of self-reported smoking behavior in cardiovascular studies may lead to inaccurate measures of nicotine exposure. A more objective measurement of nicotine exposure can be done by measurement of plasma cotinine levels. The aim of the present study was to define the rate of discordance between the self-reported smoking behavior and biochemically defined smoking status. Data from 3,316 patients hospitalized for coronary angiography, who completed a questionnaire on smoking behavior, were analyzed. As a biochemical assessment of smoking status we used a cut-off serum cotinine level of 15 μg/l. Smoking denial, defined as a discrepancy between high cotinine levels and self-reported never- or ex-smoking status, was observed in 3.7 % of the study participants. In a logistic regression analysis with a step-wise inclusion of sex, age, CAD, previous MI, and educational level, only male sex (odds ratio male/female: 2.00, 95 % CI 1.22-3.33; p = 0.007) and age (odds ratio per year: 0.79, 95 % confidence interval 0.66-0.94, p = 0.008) were associated with smoking denial. In conclusion, a misclassification rate of 3.7 % in the evaluation of such an important risk factor may lead to blurred effects and favor false negative results. The results of the present study substantiate the importance of biochemical markers for smoking assessment in cardiovascular studies.

Association between tobacco smoking and cognitive functioning in young adults

BACKGROUND

Tobacco smoking represents a considerable public health burden globally. Smoking in older adults is associated with cognitive impairment and more rapid age-associated cognitive decline, but there is a paucity of studies in younger people.

METHOD

Adults aged 18-29 years were recruited from a longitudinal study investigating impulsivity in young people. Exclusion criteria were presence of any axis-I morbidity or cannabis use. Subjects undertook neurocognitive assessment using the Cambridge Neuropsychological Test Automated Battery (CANTAB). Demographic, clinical, and cognitive differences between smokers (N = 37) and nonsmokers (N = 177) were characterized.

RESULTS

Groups were well matched in terms of age, education, income, and gender. In comparison to nonsmokers, nicotine users showed significant cognitive impairments on sustained attention (target detection: p= .005), spatial working memory (errors: p= .023, strategy use: p= .004), executive planning (p= .002), and did not appropriately adjust behavior as a function of risk (Gamble task risk adjustment: p= .004). Smokers were intact on general response speeds and response inhibition.

CONCLUSIONS

These data, using objective translational paradigms, support an association between tobacco smoking and cognitive problems in young people, with implications for such individuals and for society. Future studies should extend these results longitudinally to explore causality, and evaluate effects of nicotinic agents (including anti-smoking medications) on cognition.

A life-course perspective on economic stress and tobacco smoking: a population-based study

AIMS

To investigate the associations between economic stress in childhood and adulthood and tobacco smoking, with reference to the accumulation, critical period and social mobility hypotheses from life-course epidemiology.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

The 2008 public health survey in Skåne, Sweden is a cross-sectional postal questionnaire study based on a random sample which yielded 28 198 participants aged 18-80 years (55% participation). Logistic regression models were used to investigate associations between economic stress in childhood and adulthood and tobacco smoking.

FINDINGS

A 17.4% prevalence of men and 19.1% of women reported tobacco smoking. Tobacco smoking was more prevalent among middle-aged men and young women, among those born outside Sweden, with low occupational status, low social support, low trust, economic stress in childhood and adulthood. The accumulation hypothesis was confirmed because combined childhood and adulthood exposures to economic stress were associated (P < 0.001) with tobacco smoking in a graded manner. The critical period hypothesis was not supported because the associations between economic stress in childhood as well as adulthood, respectively, and tobacco smoking were significant (P = 0.004 and P < 0.001) throughout the analyses. The social mobility hypothesis was confirmed because upward social mobility was associated significantly (P < 0.001) with lower odds of smoking, while downward social mobility was associated significantly (P < 0.001) with higher odds of smoking.

CONCLUSIONS

Downward social mobility and economic stress in both childhood and adulthood should be considered as risk factors for tobacco smoking over the life-course.

Public place smoke-free regulations, secondhand smoke exposure and related beliefs, awareness, attitudes, and practices among Chinese urban residents

Objective: To evaluate the association between smoke-free regulations in public places and secondhand smoke exposure and related beliefs, awareness, attitudes, and behavior among urban residents in China. Methods: We selected one city (Hangzhou) as the intervention city and another (Jiaxing) as the comparison. A structured self-administered questionnaire was used for data collection, and implemented at two time points across a 20-month interval. Both unadjusted and adjusted logistic methods were considered in analyses. Multiple regression procedures were performed in examining variation between final and baseline measures. Results: Smoke-free regulations in the intervention city were associated with a significant decline in personal secondhand smoke exposure in government buildings, buses or taxis, and restaurants, but there was no change in such exposure in healthcare facilities and schools. In terms of personal smoking beliefs, awareness, attitudes, and practices, the only significant change was in giving quitting advice to proximal family members. Conclusions: There was a statistically significant association between implementation of smoke-free regulations in a city and inhibition of secondhand tobacco smoking exposure in public places. However, any such impact was limited. Effective tobacco control in China will require comprehensive laws implemented fully and supported by penalties and a combination of strong public health education.

Environmental tobacco smoke exposure at home and smoking prevalence in the general Portuguese population--the INAsma study

BACKGROUND

We aimed to: 1) estimate the prevalence of exposure to environmental tobacco smoke (ETS) at home in the Portuguese population; 2) estimate tobacco smoking prevalence in Portugal; 3) identify social and personal characteristics associated with smoking or exposure to ETS.

METHODS

Nationwide, cross-sectional, population-based telephone survey. Overall, 6003 individuals completed the interview. ETS exposure at home was defined as exposure to at least one current smoker at home. A smoker was defined as someone with 15 years or older, smoking at least 1 cigarette per day during a year; a current smoker (CS) smoked in the last month.

RESULTS

Exposure to ETS at home was reported by 26.6% (95%CI 25.5-27.7) of the participants. Living in households with ≥4 persons (OR=2.31; 95%CI[1.81-2.96]), being a current smoker (OR=7.29; 95%CI[5.74-9.26]) or having current asthma (OR=2.06; 95%CI[1.45-2.94]) were factors positively associated with ETS exposure. When analyzed by gender, the effect of current asthma was only relevant to females. Currently 19.0% (95%CI 18.0-20.0) of the Portuguese population smokes tobacco and 17.2% (95%CI 16.2-18.2) are ex-smokers. CS prevalence is higher in males than females (26.5%versus 12.2%, p<0,001). The odds of being a CS were higher for males, the more educated, and those exposed to ETS at home. When analyzed by gender, school education only affected females.

CONCLUSION

Exposure to ETS at home was higher than previously reported. Children/adolescents and asthma patients may have a higher risk of exposure. This report endorses a decreasing trend in the prevalence of tobacco smoking in Portuguese males, but a tendency to increase in females.

Optimum cutoff value of urinary cotinine distinguishing South Korean adult smokers from nonsmokers using data from the KNHANES (2008-2010)

INTRODUCTION

Cutoff values for distinguishing smokers from nonsmokers have generally been derived from studies in White populations. Even though recent population-based studies have demonstrated that cutoff values can differ by race and ethnicity, few studies have explored cutoff values among Asian populations. We established the cutoff values for urinary cotinine and cotinine:creatinine ratio (CCR) using a nationally representative South Korean adult population sample.

METHODS

Data were obtained from the Korea National Health and Nutrition Examination Survey (KNHANES) 2008-2010 with pooled sampling weights. Adult participants (n = 11,629) aged ≥19 were included. Optimal cutoff values were determined by performing receiver operating characteristic curve analysis.

RESULTS

The optimum cutoff values for urinary cotinine and CCR for Korean adults were found to be 164ng/mL and 1122ng/mg, respectively. The application of these urinary cotinine and CCR cutoff values for the female subpopulations aged 19-34, 35-54, and ≥55 years provided sensitivities ranging from 87.1% to 93.8% and from 82.9% to 94.9%, respectively, while maintaining specificity of ≥92%. For the 3 male age-based subpopulations, we obtained sensitivities and specificities for cotinine ranging from 93.1% to 94.5% and from 92.8% to 97.0%, respectively, and for CCR ranging from 90.0% to 96.9% and from 92.2% to 96.8%, respectively.

CONCLUSIONS

Our cutoff values should allow researchers conducting environmental epidemiological or clinical studies in South Korea to distinguish adult smokers from nonsmokers effectively. However, different values may be applicable for subpopulations with different smoking prevalence rates or higher exposure levels to secondhand smoke.