Smoking and All-cause Mortality in Older Adults: Results From the CHANCES Consortium

Life's Essential 8: Optimizing Health in Older Adults

The population worldwide is getting older as a result of advances in public health, medicine, and technology. Older individuals are living longer with a higher prevalence of subclinical and clinical cardiovascular disease (CVD). In 2010, the American Heart Association introduced a list of key prevention targets, known as "Life's Simple 7" to increase CVD-free survival, longevity, and quality of life. In 2022, sleep health was added to expand the recommendations to "Life's Essential 8" (eat better, be more active, stop smoking, get adequate sleep, manage weight, manage cholesterol, manage blood pressure, and manage diabetes). These prevention targets are intended to apply regardless of chronologic age. During this same time, the understanding of aging biology and goals of care for older adults further enhanced the relevance of prevention across the range of functions. From a biological perspective, aging is a complex cellular process characterized by genomic instability, telomere attrition, loss of proteostasis, inflammation, deregulated nutrient-sensing, mitochondrial dysfunction, cellular senescence, stem cell exhaustion, and altered intercellular communication. These aging hallmarks are triggered by and enhanced by traditional CVD risk factors leading to geriatric syndromes (eg, frailty, sarcopenia, functional limitation, and cognitive impairment) which complicate efforts toward prevention. Therefore, we review Life's Essential 8 through the lens of aging biology, geroscience, and geriatric precepts to guide clinicians taking care of older adults.

Predictors of changes in running and smoking identity among individuals in the Run to Quit smoking cessation program

OBJECTIVES

Multiple health behaviour change is a viable strategy to promote health outcomes. An example is the use of running behaviour to support smoking cessation in the group-mediated Run to Quit program. On the basis that changes in running and smoking identity were related to changes in running and smoking behaviour among individuals in the Run to Quit program, the purpose of this study was to extend these findings by examining key predictors of change in both running and smoking identity.

METHODS

We analyzed data collected from 450 adult individuals (70.67% female, and 92.44% white) during the program evaluation of Run to Quit from 2016 to 2018. Participants completed assessments at week 1 (baseline), week 3 (mid-program), and week 10 (follow-up) of the program. Relevant predictor variables for change in identity were identified by drawing from theory (identity theory, identity control theory, physical activity self-definition model, social identity theory) and past research regarding exercise and smoking identity. Potential predictors of changes in running and smoking identity included changes in behaviour, self-efficacy, perceptions of the social environment (task and social cohesion, descriptive norms), as well as smoking identity and running identity, respectively. Two regression models, using residualized change scores (for each variable) and relative Pratt indices, were constructed for both running and smoking identity.

RESULTS

Changes in running self-efficacy, running frequency, and individual attractions to the group exercise tasks were significant and meaningful predictors of change in running identity, whereas changes in objectively measured smoking behaviour and running identity were significant and meaningful predictors of change in smoking identity.

CONCLUSION

Consistent with identity theories and past research, ensuring individuals develop a sense of efficacy and enjoy group exercise tasks both represent viable strategies to enhance exercise identity. Including an exercise component within smoking cessation programs may help individuals replace their existing smoking identity with a healthier exercise identity.

Cytisine Therapy Improved Smoking Cessation in the Randomized Screening and Multiple Intervention on Lung Epidemics Lung Cancer Screening Trial

INTRODUCTION

Cytisine, a partial agonist-binding nicotine acetylcholine receptor, is a promising cessation intervention. We conducted a single-center, randomized, controlled trial (RCT) in Italy to assess the efficacy and tolerability of cytisine as a smoking cessation therapy among lung cancer screening participants.

METHODS

From July 2019 to March 2020, the Screening and Multiple Intervention on Lung Epidemics RCT enrolled 869 current heavy tobacco users in a low-dose computed tomography screening program, with a randomized comparison of pharmacologic intervention with cytisine plus counseling (N = 470) versus counseling alone (N = 399). The primary outcome was continuous smoking abstinence at 12 months, biochemically verified through carbon monoxide measurement.

RESULTS

At the 12-month follow-up, the quit rate was 32.1% (151 participants) in the intervention arm and 7.3% (29 participants) in the control arm. The adjusted OR of continuous abstinence was 7.2 (95% confidence interval: 4.6-11.2). Self-reported adverse events occurred more frequently in the intervention arm (399 events among 196 participants) than in the control arm (230 events among 133 participants, p < 0.01). The most common adverse events were gastrointestinal symptoms, comprising abdominal swelling, gastritis, and constipation.

CONCLUSIONS

The efficacy and safety observed in the Screening and Multiple Intervention on Lung Epidemics RCT indicate that cytisine, a very low-cost medication, is a useful treatment option for smoking cessation and a feasible strategy to improve low-dose computed tomography screening outcomes with a potential benefit for all-cause mortality.

Behavioural programmes for cigarette smoking cessation: investigating interactions between behavioural, motivational and delivery components in a systematic review and component network meta-analysis

AIMS

To investigate the comparative and combined effectiveness of four types of components of behavioural interventions for cigarette smoking cessation: behavioural (e.g. counselling), motivational (e.g. focus on reasons to quit), delivery mode (e.g. phone) and provider (e.g. nurse).

DESIGN

Systematic review and component network meta-analysis of randomised controlled trials identified from Cochrane reviews. Interventions included behavioural interventions for smoking cessation (including all non-pharmacological interventions, e.g. counselling, exercise, hypnotherapy, self-help materials), compared with another behavioural intervention or no support. Building on a 2021 review (CD013229), we conducted three analyses, investigating: comparative effectiveness of the components, whether models that allowed interactions between components gave different results to models assuming additivity, and predicted effect estimates for combined effects of components that had showed promise but where there were few trials.

SETTING

Community and health-care settings.

PARTICIPANTS

Adults who smoke tobacco.

MEASUREMENTS

Smoking cessation at ≥6 months, preferring sustained, biochemically validated outcomes where available.

FINDINGS

Three hundred and twelve trials (250 563 participants) were included. Fifty were at high risk of bias using Cochrane risk of bias tool, V1 (ROB1); excluding these studies did not change findings. Head-to-head comparisons of components suggested that support via text message (SMS) compared with telephone (OR 1.48, 95% CrI 1.13-1.94) or print materials (OR 1.44, 95% CrI 1.14-1.83) was more effective, and individual delivery was less effective than delivery as part of a group (OR 0.78, 95% CrI 0.64-0.95). There was no conclusive evidence of synergistic or antagonistic interactions when combining components that were commonly used together. Adding multiple components that are commonly used in behavioural counselling suggested clinically relevant and statistically conclusive evidence of benefit. Components with the largest effects that could be combined, but rarely have been, were estimated to increase the odds of quitting between two and threefold. For example, financial incentives delivered via SMS, with tailoring and a focus on how to quit, had an estimated OR of 2.94 (95% CrI 1.91-4.52).

CONCLUSIONS

Among the components of behavioural support for smoking cessation, behavioural counselling and guaranteed financial incentives are associated with the greatest success. Incorporating additional components associated with effectiveness may further increase benefit, with delivery via text message showing particular promise.

Incidence and Predictors of Mortality among Community-Dwelling Older Adults in Malaysia: A 5 Years Longitudinal Study

With older adults accounting for 10.7% of the Malaysian population, determining the predictors of mortality has now become crucial. Thus, this community-based longitudinal study aimed to investigate the predictors for mortality among community-dwelling older adults using a wide range of factors, including clinical or subclinical. A total of 2322 older adults were interviewed and assessed by trained fieldworkers using validated structured questionnaires. The questionnaire consisted of information on socio-demographic characteristics, health status, neuropsychological and psychosocial functions, lifestyle, dietary intake and biophysical measures. The incidence rate of mortality was 2.9 per 100 person-years. Cox regression analysis indicated that advancing age (Adjusted Hazard Ratio, Adj HR = 1.044, 95% CI: 1.024–1.064), male (Adj HR = 1.937, 95% CI: 1.402–2.675), non-married status (Adj HR = 1.410, 95% CI: 1.078–1.843), smoking (Adj HR = 1.314, 95% CI: 1.004–1.721), a higher fasting blood sugar (Adj HR = 1.075, 95% CI: 1.029–1.166), a lower serum albumin (Adj HR = 0.947, 95% CI: 0.905–0.990), a longer time to complete the TUG test (Adj HR = 1.059, 95% CI: 1.022–1.098), and a lower intake of total dietary fibre (Adj HR = 0.911, 95% CI: 0.873–0.980) were the predictors of mortality in this study. These findings provide an estimated rate of multiethnic mortality in middle-income countries and diet is one of the predictors. These predictors of mortality could be a reference in identifying new public health strategies to ensure longer healthier life spans with lower disability rate among community-dwelling older adults in Malaysia.

Assessment of association between smoking and all-cause mortality among Malaysian adult population: Findings from a retrospective cohort study

INTRODUCTION

Smoking is a known risk factor for many chronic diseases. Illness and death due to smoking are a significant public health burden in many countries. This study aims to address the information gap in smoking-related mortality in Malaysia by estimating the risk of cardiovascular disease and all-cause mortalities due to smoking among Malaysian adults.

METHODS

We analyzed data on 2525 respondents, aged 24–64 years, of the Malaysian Non-Communicable Disease Surveillance survey conducted September 2005 to February 2006. Mortality records from the Malaysian National Registration Department were linked to the MYNCDS-1 data to determine respondents’ mortality status over 12 years from 2006 to 2018. Associations between smoking and all-cause mortalities were assessed using Cox proportional hazards regression with adjustments for non-communicable disease and sociodemographic and lifestyle factors.

RESULTS

The prevalence of daily smoking was 21.2% (95% CI: 19.0–23.7). During the 31668 person-years follow-up, 213 deaths from all causes occurred, where 68 deaths were among smokers (13.2%), and 452 were among non-smokers (6.3%). Smoking was associated with a significantly increased risk of all-cause mortality (adjusted hazard ration, AHR=1.79; 95% CI: 1.12– 2.97). These associations remained significant after excluding mortalities in the first two years of follow-up.

CONCLUSIONS

Daily smoking is associated with a significantly higher risk of all-cause death. Behavioral and pharmacological smoking cessation interventions should be intensified among smokers to reduce the risk of mortality.

Changes in Attitudes toward Tobacco Smoking and Factors Associated with Quitting in 9-Year Observation of PURE Poland Cohort Study

(1) Background: This study aims to examine changes in tobacco smoking prevalence in the PURE Poland cohort study over the 9-year follow-up period. Moreover, it attempts to identify socio-demographic factors that affect changes in attitudes towards tobacco smoking. (2) Methods: The PURE Poland cohort study—baseline was performed in 2007–2010 and covered 2036 participants, including urban (59.4%) and rural (40.6%) residents of Lower Silesia, Poland. The following study reports the results of 1690 participants who took part in both the baseline (2007–2010) study and 9-year follow-up (2016–2019). (3) Results: There was a 3.5% decrease in current smokers during the analyzed period (from 20.2% at the baseline study to 16.7% in the 9-year follow-up). Living in rural area increased the likelihood of being a current smoker by more than 1.5-fold (OR = 1.65 CI = 1.26–2.14) and decreased the likelihood of being a former smoker (OR = 0.70 CI = 0.57–0.86). In the 9-year follow-up period, more women were current smokers than men (17.2% vs. 16.0%) and women had lower chances of being former smokers than men (OR = 0.77 CI = 0.62–0.95). People with a primary education had 1.5-fold higher likelihood of being a current smoker (OR = 1.45 CI = 1.03–2.05). Nearly 11% significant increase in the percentage of current smokers was observed in the oldest age group (1.9% in the baseline study vs. 12.6% in the follow-up period). (4) Conclusions: The results obtained during 9 years of observation indicate the necessity of intensifying anti-tobacco programs especially targeting women, elderly population, people with lower level of education, rural residents, and the unemployed.

Late-life drinking and smoking in primary care users in Brazil

To estimate the prevalence of at-risk drinking and smoking and associated factors among older adults in primary care in Brazil. A cross-sectional study carried out in seven primary care units with 503 older adults (60+), in a city in the state of Sao Paulo, Brazil. At-risk drinking was defined by AUDIT-C and by consumption of units per week. Poisson regression was used to assess the association between the sociodemographic and health characteristics and smoking and at-risk drinking. The median age of the 503 participants was 69.6 (SD ± 6.7; range:60-93). One third of participants (33.6%) were current drinkers, 16% were at-risk drinkers (AUDIT-C), 4% at-risk drinkers (units per week), and 13% of the sample were regular smokers. The prevalence of at-risk drinking (AUDIT-C) was higher for males (RP: 4.89; 95% CI: 2.52-9.49) and for those with higher levels of education (RP: 1,861.85 95% CI: 1.08-3.14), and lower for those over the age of 70 (RP: 0.50; 95% CI: 0.30-0.84). The prevalence of smoking was higher for those with depressive symptoms (RP: 1.95; 95% CI: 1.03-3.66), and lower for those over age 70 (RP: 0.52; 95% CI: 0.29-0.94). The results point to a set of factors associated with at-risk drinking (being male, younger and having a higher education), and with smoking (being younger and having depressive symptoms). Our findings could help health professionals to identify at-risk drinkers and smokers, as well as support strategies for future interventions by the identification of the groups most vulnerable to these behaviors.

The need for long-term personalized management of frail CVD patients by rehabilitation and telemonitoring: a framework

Due to advances in cardiovascular medicine and preventive cardiology, patients benefit from a better prognosis, even in case of significant disease burden such as acute and chronic coronary syndromes, advanced valvular heart disease and chronic heart failure. These advances have allowed CVD patients to increase their life expectancy, but on the other hand also experience aging-related syndromes such as frailty. Despite being underrecognized, frailty is a critical, common, and co-existent condition among older CVD patients, leading to exercise intolerance and compromised adherence to cardiovascular rehabilitation. Moreover, frail patients need a different approach for CR and are at very high risk for adverse events, but yet are underrepresented in conventional CR. Fortunately, recent advances have been made in technology, allowing remote monitoring, coaching and supervision of CVD patients in secondary prevention programs with promising benefits. Similarly, we hypothesized that such programs should also be implemented to treat frailty in CVD patients. However, considering frail patients' particular needs and challenges, telerehabilitation interventions should thus be appropriately adapted. Our purpose is to provide, for the first time and based on expert opinions, a framework of how such a cardiac telerehabilitation program could be developed and implemented to manage a prevention and rehabilitation program for CVD patients with frailty.

Smoking and loneliness in older adults: a population-based study in Campinas, São Paulo State, Brazil

This study aims to analyze the relationship between social isolation and loneliness with smoking in older adults. This is a cross-sectional, population-based study performed with 986 individuals aged 60 years or older. Data were collected from the Health Survey of the Municipality of Campinas (ISACamp 2014/2015), state of São Paulo, Brazil. We estimated the prevalence of smoking and smoking cessation according to independent variables and tested the associations using the chi-square test, considering a 5% significance level. Adjusted prevalence ratios were calculated using simple and multiple Poisson regression. Smoking and smoking cessation were not associated with most variables that indicate objective social isolation. “Often or always” loneliness was related to a higher prevalence of smoking (PR = 2.25; 95%CI: 1.38-3.66) whereas loneliness accompanied of self-reported emotional problems or common mental disorders was strongly associated with smoking and with lower smoking cessation (PR = 6.24; 95%CI: 1.37-28.47 and PR = 0.46; 95%CI: 0.28-0.77, respectively). These findings indicate that loneliness is a psychosocial aspect related to tobacco use which hinders smoking cessation in older adults, emphasizing the importance of emotional problems in this association.

Quality of life of tobacco users- A correlation with duration of use and nicotine dependence

BACKGROUND

Few studies have investigated the relationship between health-related quality of life and nicotine dependence, while none are from India. This study aims to explore the quality of life among patients with nicotine dependence and examine the clinical and demographic correlates of quality of life.

METHOD

This was a cross-sectional study in which 130 active nicotine dependence individuals were interviewed. Participants were selected using random sampling from the various clinical department of a tertiary health care setting of Northern India. Information about the quality of life and severity of nicotine dependence was assessed using SF-12 and Fagerstrom test for Nicotine Dependence questionnaire. One way ANOVA test compared the means among different tobacco users, while Pearson or Spearman tests assessed the correlation between the quality of life and nicotine dependence.

RESULTS

The mean age of the respondents in the study was 42.72 (SD = 15.68); with 66% using smoking tobacco, 53.07% had a high dependence towards tobacco. We observed a negative correlation between the physical health component and years of regular use (r = -0.503, p < .001). There was also a negative correlation between FTND score and physical health component (r = -.180, p = .049).

CONCLUSION

Duration of tobacco use and the severity of nicotine dependence negatively influence health-related quality of life in treatment-naive individuals.

Antioxidants in smokers

Cigarette smoke (CS) is likely the most common preventable cause of human morbidity and mortality worldwide. Consequently, inexpensive interventional strategies for preventing CS-related diseases would positively impact health systems. Inhaled CS is a powerful inflammatory stimulus and produces a shift in the normal balance between antioxidants and oxidants, inducing oxidative stress in both the respiratory system and throughout the body. This enduring and systemic pro-oxidative state within the body is reflected by increased levels of oxidative stress and inflammation biomarkers seen in smokers. Smokers might benefit from consuming antioxidant supplements, or a diet rich in fruit and vegetables, which can reduce the CS-related oxidative stress. This review provides an overview of the plasma profile of antioxidants observable in smokers and examines the heterogeneous literature to elucidate and discuss the effectiveness of interventional strategies based on antioxidant supplements or an antioxidant-rich diet to improve the health of smokers. An antioxidant-rich diet can provide an easy-to-implement and cost-effective preventative strategy to reduce the risk of CS-related diseases, thus being one of the simplest ways for smokers to stay in good health for as long as possible. The health benefits attributable to the intake of antioxidants have been observed predominantly when these have been consumed within their natural food matrices in an optimal antioxidant-rich diet, while these preventive effects are rarely achieved with the intake of individual antioxidants, even at high doses.

Clinical characteristics of late-life depression predicting mortality

OBJECTIVE

Depression has been associated with increased mortality rates, and modifying mechanisms have not yet been elucidated. We examined whether specific subtypes or characteristics of late-life depression predict mortality.

METHODS

A cohort study including 378 depressed older patients according to DSM-IV criteria and 132 never depressed comparisons. The predictive value of depression subtypes and characteristics on the six-year mortality rate, as well as their interaction with somatic disease burden and antidepressant drug use, were studied by Cox proportional hazard analysis adjusted for demographic and lifestyle characteristics.

RESULTS

Depressed persons had a higher mortality risk than non-depressed comparisons (HR = 2.95 [95% CI: 1.41-6.16], p = .004), which lost significance after adjustment for age, sex, education, smoking, alcohol, physical activity, number of prescribed medications and somatic comorbidity. Regarding depression subtypes and characteristics, only minor depression was associated with a higher mortality risk when adjusted for confounders (HR = 6.59 [95% CI: 1.79-24.2], p = .005).

CONCLUSIONS

Increased mortality rates of depressed older persons seem best explained by unhealthy lifestyle characteristics and multiple drug prescriptions. The high mortality rate in minor depression, independent of these factors, might point to another, yet unknown, pathway towards mortality for this depression subtype. An explanation might be that minor depression in later life reflects depressive symptoms due to underlying aging-related processes, such as inflammation-based sickness behavior, frailty, and mild cognitive impairment, which have all been associated with increased mortality.

Changes over 15 years in the contribution of adiposity and smoking to deaths in England and Scotland

BACKGROUND

For many years smoking has been the major threat to public health in developed countries. However, smoking prevalence has declined over a period when adiposity has increased. The aim of this study was to determine whether adiposity now accounts for more deaths than smoking in the general population as a whole or sub-groups of it.

METHODS

This is a comparative risk assessment study using Health Surveys for England and Scottish Health Surveys from 2003 to 2017. Annual prevalence of overweight, obesity, current and former smoking were obtained and combined using population-based weights. Sex-specific risk ratios for all-cause mortality were obtained from the most recently published meta-analyses. Population attributable fractions across yeas were then estimated.

FINDINGS

Overall, deaths attributable to current/former smoking declined from 23.1% (95% CI 20.6-25.8%) in 2003 to 19.4% (95% CI 17.3-21.6%) in 2017, whilst those attributable to adiposity (overweight or obesity) increased from 17.9% (95% CI 17.3-18.4%) in 2003 to 23.1% (95% CI 22.3-23.8%) in 2017 with cross-over occurring in 2013. Cross-over occurred earlier in men (2011) than women (2014). It occurred in 2006 for those aged over 65 years of age and in 2012 for those aged 45-64 years. Below 45 years, smoking remained the larger contributor to mortality.

INTERPRETATION

Adiposity now accounts for more deaths in England and Scotland than smoking among people in middle- and old-age. National strategies to address adiposity should be a public health priority.

Estimated global cancer incidence in the oldest adults in 2018 and projections to 2050

Using GLOBOCAN estimates, we describe the estimated cancer incidence among adults aged 80 years or older at the regional and global level in 2018, reporting the number of new cancer cases, and the truncated age-standardised incidence rates (per 100 000) for all cancer sites combined for this age group. We also presented the five most frequent cancers diagnosed by region and globally among females and males aged 65 to 79 years old and 80 years or older. We, finally, estimated the number of new cancer cases in 2050, the proportion of cases aged 80 years or older, and the proportional increase between 2018 and 2050 by region, by applying population projections to the 2018 incidence rates. In 2018, an estimated 2.3 million new cancer cases (excluding nonmelanoma skin cancers) were aged 80 years or older worldwide (13% of all cancer cases), with large variation in the profiles at regional levels. Globally, breast, lung and colon were the most common cancer sites diagnosed in the oldest females, while prostate, lung and colon were most frequent in the oldest males. In 2050, an estimated 6.9 million new cancers will be diagnosed in adults aged 80 years or older worldwide (20.5% of all cancer cases). Due to the complexity of cancer management in the oldest patients, the expected increase will challenge healthcare systems worldwide, posing a tangible economic and social impact on families and society. It is time to consider the oldest population in cancer control policies.

Association of smoking reduction and mortality: protocol for a systematic review and meta-analysis of longitudinal observational studies

INTRODUCTION

Strong evidence shows that smoking cessation decreases mortality. Much less is known regarding the association between reduction in cigarettes per day (CPD) and mortality. The primary aim of this systematic review is to compare the mortality risk between smokers achieving a sustained reduction of CPD and smokers maintaining their smoking rate. The secondary aims are to compare the mortality risk between smokers achieving complete, sustained smoking cessation and (1) smokers maintaining their smoking rate and (2) smokers who achieved a sustained reduction in smoking rate.

METHODS AND ANALYSIS

MEDLINE, Web of Sciences and Embase will be searched using a prespecified search strategy, up to 23 November 2020, and will be limited to studies published in English and in French. Longitudinal observational studies using individual data including smokers with at least two distant CPD assessments and a follow-up period of systematic mortality data recording will be included. The main outcome will be the all-cause mortality. The secondary outcome will be specific mortality. The Newcastle-Ottawa Scale will be used to assess the risk of bias of individual studies. Outcomes will be analysed using HRs. All other outcomes' effect size reported in included studies will be converted in HRs using validated methods.

ETHICS AND DISSEMINATION

We intend to publish the results of our review in a peer-reviewed journal and to present the findings at national and international meetings and conferences.

PROSPERO REGISTRATION NUMBER

CRD42019138354.

Changes in physical activity and mortality risk among an adult Lithuanian urban population: results from a cohort study

OBJECTIVES

The purpose of this study was to investigate changes in physical activity and the association of these changes with the risk of all-cause mortality and mortality from cardiovascular disease (CVD) among an adult and elderly Lithuanian urban population.

STUDY DESIGN

Prospective cohort study.

METHODS

Data from four surveys are presented. In total, there were 2416 participants (1071 men and 1345 women) who took part in one of the initial three surveys in the framework of the Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) study since 1986 and also in the follow-up survey in 2006 (with follow-up over 15 years). Study participants were followed-up for mortality events from 2006 until 31 December 2017. The mean duration of the follow-up for endpoints period was 10.55 (standard deviation 2.33) years.

RESULTS

Over 15 years of follow-up, 50.9% of men and 56.7% of women were physically active at initial and follow-up surveys, and approximately 10.0% of respondents were physically inactive. Over this period, 22.8% of men and 24.8% of women increased their physical activity level, and 14.1% of men and 10.1% of women decreased their physical activity level. The findings from the Cox proportional hazards regression multivariable analysis showed that a decrease in physical activity level during the follow-up period was related to a higher risk for all-cause mortality and mortality from CVD risk in women (hazard ratio [HR] = 1.82, P = 0.039; and HR = 5.40, P = 0.014, respectively). In men, a clear association of physical inactivity was ascertained only to all-cause mortality risk and only for non-smokers (HR = 2.07, P = 0.013).

CONCLUSIONS

A decrease in physical activity levels in women is a strong predictor for all-cause mortality risk and mortality from CVD risk. Physical inactivity in male non-smokers is a strong predictor for all-cause mortality risk.

Behavioural interventions for smoking cessation: an overview and network meta-analysis

BACKGROUND

Smoking is a leading cause of disease and death worldwide. In people who smoke, quitting smoking can reverse much of the damage. Many people use behavioural interventions to help them quit smoking; these interventions can vary substantially in their content and effectiveness.

OBJECTIVES

To summarise the evidence from Cochrane Reviews that assessed the effect of behavioural interventions designed to support smoking cessation attempts and to conduct a network meta-analysis to determine how modes of delivery; person delivering the intervention; and the nature, focus, and intensity of behavioural interventions for smoking cessation influence the likelihood of achieving abstinence six months after attempting to stop smoking; and whether the effects of behavioural interventions depend upon other characteristics, including population, setting, and the provision of pharmacotherapy. To summarise the availability and principal findings of economic evaluations of behavioural interventions for smoking cessation, in terms of comparative costs and cost-effectiveness, in the form of a brief economic commentary.

METHODS

This work comprises two main elements. 1. We conducted a Cochrane Overview of reviews following standard Cochrane methods. We identified Cochrane Reviews of behavioural interventions (including all non-pharmacological interventions, e.g. counselling, exercise, hypnotherapy, self-help materials) for smoking cessation by searching the Cochrane Library in July 2020. We evaluated the methodological quality of reviews using AMSTAR 2 and synthesised data from the reviews narratively. 2. We used the included reviews to identify randomised controlled trials of behavioural interventions for smoking cessation compared with other behavioural interventions or no intervention for smoking cessation. To be included, studies had to include adult smokers and measure smoking abstinence at six months or longer. Screening, data extraction, and risk of bias assessment followed standard Cochrane methods. We synthesised data using Bayesian component network meta-analysis (CNMA), examining the effects of 38 different components compared to minimal intervention. Components included behavioural and motivational elements, intervention providers, delivery modes, nature, focus, and intensity of the behavioural intervention. We used component network meta-regression (CNMR) to evaluate the influence of population characteristics, provision of pharmacotherapy, and intervention intensity on the component effects. We evaluated certainty of the evidence using GRADE domains. We assumed an additive effect for individual components.

MAIN RESULTS

We included 33 Cochrane Reviews, from which 312 randomised controlled trials, representing 250,563 participants and 845 distinct study arms, met the criteria for inclusion in our component network meta-analysis. This represented 437 different combinations of components. Of the 33 reviews, confidence in review findings was high in four reviews and moderate in nine reviews, as measured by the AMSTAR 2 critical appraisal tool. The remaining 20 reviews were low or critically low due to one or more critical weaknesses, most commonly inadequate investigation or discussion (or both) of the impact of publication bias. Of note, the critical weaknesses identified did not affect the searching, screening, or data extraction elements of the review process, which have direct bearing on our CNMA. Of the included studies, 125/312 were at low risk of bias overall, 50 were at high risk of bias, and the remainder were at unclear risk. Analyses from the contributing reviews and from our CNMA showed behavioural interventions for smoking cessation can increase quit rates, but effectiveness varies on characteristics of the support provided. There was high-certainty evidence of benefit for the provision of counselling (odds ratio (OR) 1.44, 95% credibility interval (CrI) 1.22 to 1.70, 194 studies, n = 72,273) and guaranteed financial incentives (OR 1.46, 95% CrI 1.15 to 1.85, 19 studies, n = 8877). Evidence of benefit remained when removing studies at high risk of bias. These findings were consistent with pair-wise meta-analyses from contributing reviews. There was moderate-certainty evidence of benefit for interventions delivered via text message (downgraded due to unexplained statistical heterogeneity in pair-wise comparison), and for the following components where point estimates suggested benefit but CrIs incorporated no clinically significant difference: individual tailoring; intervention content including motivational components; intervention content focused on how to quit. The remaining intervention components had low-to very low-certainty evidence, with the main issues being imprecision and risk of bias. There was no evidence to suggest an increase in harms in groups receiving behavioural support for smoking cessation. Intervention effects were not changed by adjusting for population characteristics, but data were limited. Increasing intensity of behavioural support, as measured through the number of contacts, duration of each contact, and programme length, had point estimates associated with modestly increased chances of quitting, but CrIs included no difference. The effect of behavioural support for smoking cessation appeared slightly less pronounced when people were already receiving smoking cessation pharmacotherapies.

AUTHORS' CONCLUSIONS

Behavioural support for smoking cessation can increase quit rates at six months or longer, with no evidence that support increases harms. This is the case whether or not smoking cessation pharmacotherapy is also provided, but the effect is slightly more pronounced in the absence of pharmacotherapy. Evidence of benefit is strongest for the provision of any form of counselling, and guaranteed financial incentives. Evidence suggested possible benefit but the need of further studies to evaluate: individual tailoring; delivery via text message, email, and audio recording; delivery by lay health advisor; and intervention content with motivational components and a focus on how to quit. We identified 23 economic evaluations; evidence did not consistently suggest one type of behavioural intervention for smoking cessation was more cost-effective than another. Future reviews should fully consider publication bias. Tools to investigate publication bias and to evaluate certainty in CNMA are needed.

Assessment of Current Mental Health Status in a Population-Based Sample of Canadian Men With and Without a History of Prostate Cancer Diagnosis: An Analysis of the Canadian Longitudinal Study on Aging (CLSA)

Background: Small-scale studies indicate an increase in mental health disorders among prostate cancer survivors compared to the general population, but large population-based data assessing this relationship are scarce. The present study examined the prevalence of lifetime history of prostate cancer in a cross-sectional sample of Canadian men and assessed the contribution of lifetime history of a prostate cancer diagnosis, multimorbidity, and current alcohol and smoking status to the association with current mental health outcomes in this population. Methods: The analytical sample included 25,183 men (aged 45 to 85 years old), who completed a survey as part of the Canadian Longitudinal Study on Aging (CLSA). The Center for Epidemiological Studies Depression Scale (CES-D10), Kessler's Psychological Distress Scale (K10), and self-reported mental health were mental health outcomes. Multiple logistic regression analyses, and controlling for the complexity of the design and covariates, evaluated the association between prostate cancer survivorship, multimorbidity, alcohol and smoking status, and current mental health outcomes. Results: The prevalence of lifetime history of prostate cancer diagnosis in this population-based sample of men was 4% (95% CI: 3.7, 4.4). Our results indicate statistically significantly higher odds of current psychological distress (aOR = 1.52, 95% CI: 1.09, 2.11) and screening positive for depression (aOR = 1.24; 95% CI: 1.02, 1.51) among survivors of prostate cancer, compared to men without a history of prostate cancer diagnosis in demographics controlled analyses. After addition of multimorbidity and substance use, the odds of screening positive for depression among survivors of prostate cancer are 1.32 (95% CI: 1.06, 1.64) higher compared to men who never had a history of prostate cancer diagnosis. Interpretation: Patient education and empowerment programs aimed at addressing concerns during the diagnosis and treatment and enhancing survivorship care plans by adding routine screening for mental distress to help survivors overcome poor mental health during the cancer survivorship journey, are warranted.

Functional and Structural Changes of the Retinal Nerve Fiber Layer and Ganglion Cell Complex in Heavy Smokers

Purpose

To assess the functional and structural changes in the retinal nerve fiber layer (RNFL) and the ganglion cell complex (GCC) in heavy smokers using pattern electroretinogram (PERG), photopic negative response(PhNR) and spectral domain optical coherence tomography (SD-OCT).

Patients and Methods

Sixty eyes of 30 heavy smokers (at least 15 cigarettes/day for 10 years) (study group) and 60 eyes of 30 age and gender-matched healthy non-smoker subjects (control group) were included. After full ophthalmologic examination (PERG), (PhNR) using RETI-port/scan 21 (Roland Consult, Brandenburg, Germany) and (SD-OCT using Topcon 3D OCT model 2000 FA version.8.30) were tested for all participants. Statistical analysis was performed to compare GCC, RNFL thicknesses, PERG and phNR values between groups.

Results

The mean age was 36.67±4.13 years in the study group and 36.0±4.76 years in the control group. There were no statistical significant differences between the two groups regarding intraocular pressure (p=0.43), axial length (p=0.37), and central corneal thickness (p=0.86). There were significant differences of GCC thickness values between the study group (88.4±6.6 µm) and control group (94.83±5.25 µm) (p<0.001). The mean RNFL values of study and control groups were 97.87±5.88 and 106.43±6.59 µm, respectively (p<0.001). In the study group the superior and inferior quadrants of RNFL were significantly thinner, but there were no significant differences between the two groups in nasal and temporal quadrants. There were no significant differences of PERG-P50 amplitude (p=0.49) and latency (p=0.71); however, PERG-N95 amplitude and latency showed significant differences between the two groups (p<0.001).There were significant differences of phNR amplitude and latency between the two groups (p<0.001). Multiple regression analyses demonstrated that the PhNR, PERG amplitude and latency are the most important determinants for both RNFL and GCC thicknesses.

Conclusion

In heavy smokers RNFL thickness was decreased, the PhNR, PERG-N95 amplitudes were diminished and the implicit times were prolonged compared to non-smokers. PhNR and PERG reflect both dysfunction and loss of ganglion cells and their axons.

Smoking cessation behaviors among older U.S. adults

Smoking cessation is a critical component of cancer prevention among older adults (age ≥ 65 years). Understanding smoking cessation behaviors among older adults can inform clinical and community efforts to increase successful cessation. We provide current, national prevalence estimates for smoking cessation behaviors among older adults, including interest in quitting, quitting attempts, quitting successes, receiving advice to quit from a healthcare provider, and use of evidence-based tobacco cessation treatments. The 2015 National Health Interview Survey and Cancer Control Supplement were used to estimate cigarette smoking status and cessation behaviors among older US adults across selected socio-demographic and health characteristics. We found that four in five older adults who had ever smoked cigarettes had quit and more than half who currently smoked were interested in quitting but fewer than half made a past-year quit attempt. Two-thirds of older adults said that a healthcare provider advised them to quit smoking, but just over one-third who tried to quit used evidence-based tobacco cessation treatments and only one in 20 successfully quit in the past year. Prevalence estimates for smoking cessation behaviors were similar across most characteristics. Our study demonstrates that few older adults, across most levels of characteristics examined, successfully quit smoking, underscoring the importance of assisting smoking cessation efforts. Healthcare providers can help older adults quit smoking by offering or referring evidence-based cessation treatments. States and communities can implement population-based interventions including tobacco price increases, comprehensive smoke-free policies, high-impact tobacco education media campaigns, and barrier-free access to evidence-based tobacco cessation counseling and medications.

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Smoking cessation among older adults (age ≥ 65 years) is key to cancer prevention.

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More than half of older adults who currently smoked were interested in quitting.

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Only one in 20 older adults successfully quit smoking in the past year.

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Only a third of older adults who tried to quit used a proven cessation treatment.

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Clinical and community efforts can boost successful cessation among older adults.

[Trends in smoking among adults in Germany : Evidence from seven population-based health surveys from 1991-2015]

BACKGROUND

Despite decreasing smoking prevalence, tobacco use remains a key public health problem in Germany. For planning, managing, and evaluating tobacco control measures, regular data collection on smoking behavior in the population is essential. The aim of this article is to present trends in adult tobacco use since the early 1990s based on data from the health monitoring of the Robert Koch-Institute (RKI).

METHODS

Analyses are based on data from 106,158 individuals aged 18 to 79 years, who participated in seven RKI health surveys from 1991-2015. Trends in tobacco consumption were analyzed using different indicators of smoking behavior, stratified by age, cohort, and gender.

RESULTS

An overall falling smoking prevalence can be attributed primarily to a significant decline in the younger age groups since the early 2000s. Trend analysis by cohort reveals a declining prevalence for almost all cohorts over time from 1991-2015. Historically there has been is a sharp increase in the prevalence of women who have ever smoked between the 1930-1934 and 1950-1959 cohorts. The proportion of men who have ever smoked slightly decreased between the 1930-1934 and 1980-1984 cohorts.

DISCUSSION

The shown overall decline happened concurrently with various tobacco prevention measures implemented during this period in Germany. If present trends related to continuous high smoking rates are sustained, it can be assumed that the tobacco consumption of the population will remain the source of adverse health outcomes. Accordingly, tobacco prevention measures and the promotion of smoking cessation in all age groups should be a public health priority.

Dose-response effect of smoking status on quality-adjusted life years among U.S. adults aged 65 years and older

Background

To estimate the impact of smoking on quality-adjusted life years (QALY) for US adults aged 65 years and older.

Methods

Using the 2003-08 National Health and Nutrition Examination Survey Linked Mortality File, we estimated the mean QALY throughout the remaining lifetime by participants' smoking status as well as smoking intensity and time since cessation.

Results

Never, former and current smokers had a mean QALY of 16.1, 12.7 and 7.3 years, respectively. Among current smokers, those who started smoking before age 18 had fewer QALYs than those who started at or after age 18 (6.0 and 8.5 years, respectively) and those smoking ≥20 cigarettes per day had fewer QALYs than those smoking <20 cigarettes per day (6.6 and 8.1 years, respectively). QALYs also declined with a longer duration of smoking and a shorter time since cessation. The potential gains if a person quit smoking would be 5.4 QALYs, and the gains would increase with a longer time since quitting as well as quitting at a younger age.

Conclusions

This study demonstrated the dose-response effect of smoking status on QALY. The results indicate the health benefits of tobacco cessation at any age and sizeable losses for former or current smokers.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of telephone support to help smokers quit, including proactive or reactive counselling, or the provision of other information to smokers calling a helpline.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2018.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which offered proactive or reactive telephone counselling to smokers to assist smoking cessation.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We pooled studies using a random-effects model and assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I² statistic. In trials including smokers who did not call a quitline, we used meta-regression to investigate moderation of the effect of telephone counselling by the planned number of calls in the intervention, trial selection of participants that were motivated to quit, and the baseline support provided together with telephone counselling (either self-help only, brief face-to-face intervention, pharmacotherapy, or financial incentives).

MAIN RESULTS

We identified 104 trials including 111,653 participants that met the inclusion criteria. Participants were mostly adult smokers from the general population, but some studies included teenagers, pregnant women, and people with long-term or mental health conditions. Most trials (58.7%) were at high risk of bias, while 30.8% were at unclear risk, and only 11.5% were at low risk of bias for all domains assessed. Most studies (100/104) assessed proactive telephone counselling, as opposed to reactive forms.Among trials including smokers who contacted helplines (32,484 participants), quit rates were higher for smokers receiving multiple sessions of proactive counselling (risk ratio (RR) 1.38, 95% confidence interval (CI) 1.19 to 1.61; 14 trials, 32,484 participants; I² = 72%) compared with a control condition providing self-help materials or brief counselling in a single call. Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate.In studies that recruited smokers who did not call a helpline, the provision of telephone counselling increased quit rates (RR 1.25, 95% CI 1.15 to 1.35; 65 trials, 41,233 participants; I² = 52%). Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate. In subgroup analysis, we found no evidence that the effect of telephone counselling depended upon whether or not other interventions were provided (P = 0.21), no evidence that more intensive support was more effective than less intensive (P = 0.43), or that the effect of telephone support depended upon whether or not people were actively trying to quit smoking (P = 0.32). However, in meta-regression, telephone counselling was associated with greater effectiveness when provided as an adjunct to self-help written support (P < 0.01), or to a brief intervention from a health professional (P = 0.02); telephone counselling was less effective when provided as an adjunct to more intensive counselling. Further, telephone support was more effective for people who were motivated to try to quit smoking (P = 0.02). The findings from three additional trials of smokers who had not proactively called a helpline but were offered telephone counselling, found quit rates were higher in those offered three to five telephone calls compared to those offered just one call (RR 1.27, 95% CI 1.12 to 1.44; 2602 participants; I² = 0%).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that proactive telephone counselling aids smokers who seek help from quitlines, and moderate-certainty evidence that proactive telephone counselling increases quit rates in smokers in other settings. There is currently insufficient evidence to assess potential variations in effect from differences in the number of contacts, type or timing of telephone counselling, or when telephone counselling is provided as an adjunct to other smoking cessation therapies. Evidence was inconclusive on the effect of reactive telephone counselling, due to a limited number studies, which reflects the difficulty of studying this intervention.

Smoking and cancer, cardiovascular and total mortality among older adults: The Finrisk Study

Little information is available about the deleterious effect of smoking in older adults The objective of this study was to assess the relationship of smoking habits with cancer, CVD and all-cause mortality in late middle-age (45–64 years) and older (65–74) people. This cohort study of 6516 men and 6514 women studied the relationship of smoking habits with cancer, cardiovascular disease (CVD) and all-cause mortality among middle-aged and older Finnish men and women during 1997–2013. The study cohort was followed up until the end of 2013 (median follow-up time was 11.8 years). Mortality data were obtained from the National Causes of Death Register and data on incident stroke events from the National Hospital Discharge Register. Adjusted Hazard ratios (HR) for total mortality were 2.61 (95% Confidence interval 2.15–3.18) among 45–64 years-old men and 2.59 (2.03–3.29) in 65–74 years-old men. The corresponding HRs for women 45–64 years-of-age were 3.21 (2.47–4.19) and 3.12 (2.09–4.68) for those 65–74 years-old, respectively. Adjusted HRs for CVD mortality in the 45–64 years-old and 65–74 years-old groups were 2.67 (1.92–2.67) and 1.95 (1.33–2.86) in men, and 4.28 (2.29–7.99) and 2.67 (1.28–5.58) in women, respectively. Among men, the risk difference between never and current smokers was 108/100.000 in the age-group 45–64 years, and 324/100.000 in the age group 65–74 years. Among women the differences were 52/100.000 and 196/100.000, respectively. In conclusion, absolute risk difference between never and current smokers are larger among the older age group. Smoking cessation counseling should routinely target also older adults in primary health-care.

The effects of cigarette smoking on the associations between sitting time and all-cause mortality: a meta-analysis

BACKGROUND

Sedentary behavior is recognized as an independent risk factor for mortality, but it remains unclear whether cigarette smoking will aggravate the detrimental effects of prolonged sitting on mortality. This study examined the impact of cigarette smoking on the relationship between sitting time and all-cause mortality in adults.

METHODS

Electronic database searches were conducted in PubMed, Web of Science, and the EMBASE up to 1 June 2017. Prospective studies that reported sitting time, percent of current smokers, and all-cause mortality were included. Data were extracted independently by two authors.

RESULTS

Ten prospective studies met the inclusion criteria. These studies included 850990 adults who were followed up for 2-15.7 years, during which 64 781 died (7.6%). Generally, during follow-up sitting time showed a dose-response relationship with all-cause mortality, with each 1 h increment of sitting time per day accounting for hazard ratio (HR) of mortality 1.02 (95%CI, 1.02-1.03). The relationship remained significant when stratified by the quartiles of smoking populations (≤8.4%, 8.5%-12.6%, 12.7%-27.9%, and ≥28.0%), and the risk of sitting time-related mortality increased parallel to the increment of the percent of smoking populations, with HRs 1.02 (95%CI, 1.02-1.03), 1.03 (95%CI, 1.02-1.03), 1.04 (95%CI, 1.03-1.04) and 1.06 (95%CI, 1.06-1.06), respectively. The associations between the risk of prolonged sitting-related mortality and the percent of smoking populations were linear (P = 0.032).

CONCLUSIONS

Cigarette smoking significantly aggravated the detrimental effects of sitting time on all-cause mortality. Our findings provided further evidence on the harmful effects of smoking combing prolonged sitting on adult health.

Inflammatory status and lung function predict mortality in lung cancer screening participants

Supplemental Digital Content is available in the text.

Low-dose computed tomography (LDCT) screening trials have based their risk selection algorithm on age and tobacco exposure, but never on pulmonary risk-related biomarkers. In the present study, the baseline inflammatory status, measured by C-reactive protein (CRP) level, and lung function, measured by forced expiratory volume in 1 s (FEV₁), were tested as independent predictors of all-cause mortality in LDCT-screening participants. Between 2000 and 2010, 4413 volunteers were enrolled in two LDCT-screening trials, with evaluable baseline CRP and FEV₁ values: 2037 were included in the discovery set and 2376 were included in the validation set. The effect of low FEV₁ or high CRP alone or combined was evaluated by Kaplan–Meier mortality curves and hazard ratio (HR) with 95% confidence interval (CI) by fitting Cox proportional hazards models. The overall mortality risk was significantly higher in participants with FEV₁ of up to 90% (HR: 2.13, CI: 1.43–3.17) or CRP more than 2 mg/l (HR: 3.38, CI: 1.60–3.54) and was still significant in the fully adjusted model. The cumulative 10-year probability of death was 0.03 for participants with FEV₁ of more than 90% and CRP up to 2 mg/l, 0.05 with only FEV₁ of up to 90% or CRP above 2 mg/l, and 0.12 with FEV₁ of up to 90% and CRP above 2 mg/l. This predictive performance was confirmed in the two external validation cohorts with 10-year mortality rates of 0.06, 0.12, and 0.14, and 0.03, 0.07, and 0.14, respectively. Baseline inflammatory status and lung function reduction are independent predictors of all-cause long-term mortality in LDCT-screening participants. CRP and FEV₁ could be used to select higher-risk individuals for future LDCT screening and preventive programs.

Impact of tobacco use on health and work productivity in Malaysia

Background

The loss of productivity arising from tobacco use in low/middle-income countries has not been well described. We sought to examine the impact of cigarette smoking on population health and work productivity in Malaysia using a recently published measure, the productivity-adjusted life year (PALY).

Methods

A life table model was constructed using published Malaysian demographic and mortality data. Our analysis was limited to male smokers due to the low smoking prevalence in females (1.1%). Male smokers aged 15–64 years were followed up until 65 years or until death. The population attributable risk, health-related quality of life decrements and relative reduction in productivity due to smoking were sourced from published data. The analysis was repeated assuming the cohorts were never smokers, and the differences in outcomes represented the health and productivity burden conferred by smoking. The cost of productivity loss was estimated based on the gross domestic product per equivalent full-time worker in Malaysia.

Results

Tobacco use is highly prevalent among working-age males in Malaysia, with 4.2 million (37.5%) daily smokers among men aged between 15 and 64 years. Overall, our model estimated that smoking resulted in the loss of over 2.1 million life years (2.9%), 5.5 million (8.2%) quality-adjusted life years (QALYs) and 3.0 million (4.8%) PALYs. Smoking was estimated to incur RM275.3 billion (US$69.4 billion) in loss of productivity.

Conclusion

Tobacco use imposes a significant public health and economic burden among working-age males in Malaysia. This study highlights the need of effective public health interventions to reduce tobacco use.

[Characteristics of non-pharmacological interventions in the elderly with COPD. Smoking cessation, pulmonary rehabilitation, nutritional management and patient education]

Chronic obstructive pulmonary disease (COPD) is a respiratory disorder responsible for a high mortality and disability. People older than 65 years are more commonly affected than younger people and tend to present with more symptoms and a greater level of disability. Non-pharmacological interventions play an important role in the management of all patients with COPD and this is particularly true in the elderly. Given the improvement in quality of life and risk of hospitalization, smoking cessation should be promoted to patients of all ages. Increased physical activity is associated with reduced respiratory symptoms. Tests such as the "Short Physical Performance Battery" can be useful in frailer older people with COPD, while walking tests such as the 6-minute walk test are used as an assessment before pulmonary rehabilitation. Increased physical activity should be combined with nutritional management. Screening for undernutrition by questionnaire, body mass index and albumin quantification is recommended in the elderly. In case of undernutrition, oral supplementation seems to reduce the risk of re-admission. All these measures must be included in an education program adapted to the elderly comorbidities (hearing loss, isolation…).

Combined effect of silica dust exposure and cigarette smoking on total and cause-specific mortality in iron miners: a cohort study

BACKGROUND

Both cigarette smoking and long-term exposure to crystalline silica dust were reported to be associated with increased mortality. However, the combined effect of both factors has not been well evaluated.

METHODS

We investigated a retro-prospective cohort of 7,665 workers from one Chinese iron mine with a median follow-up of 42.8 years. Cumulative silica exposure was estimated for each worker by linking work histories with a job-exposure matrix. Cigarette smoking information was collected through face-to-face questionnaires. Hazard ratios (HRs) for total and cause-specific mortality due to silica exposure and smoking were estimated using Cox proportional hazards models.

RESULTS

A total of 2,814 deaths occurred during 315,772.9 person-years of follow-up. Significantly elevated mortality from all causes, cardiovascular disease, non-malignant respiratory disease and lung cancer was observed among silica-exposed workers, while elevated mortality from non-malignant respiratory disease and lung cancer was observed among smokers. Combined exposure to silica dust and cigarette smoking elevated the proportion of mortality and accounted for 21.2, 76.0, 35.7 and 81.4% of all causes, non-malignant respiratory disease, cardiovascular disease, and lung cancer, respectively. Significant additive joint effects of silica exposure and cigarette smoking on mortality from lung cancer (HR 1.893, 95% CI 0.628 to 3.441) and pneumoconiosis (6.457, 0.725 to 39.114), together with a significant multiplicative joint effect from all causes (1.002, 1.000 to 1.004) were observed.

CONCLUSIONS

The present findings indicated that silica exposure in combination with cigarette smoking accounted for a fraction of extra deaths in our cohort. Our research showed the urgent need for smoking cessation and silica control among iron miners.

Drinking Level Versus Drinking Pattern and Cigarette Smoking Among Older Adults

BACKGROUND

There is a lack of research on the role of alcohol consumption in cigarette smoking among older adults, and the few studies on alcohol use and smoking with older adults have failed to distinguish between average level and pattern of drinking as predictors of smoking. The main purpose of this study was to examine the independent contributions of average level versus pattern of drinking as predictors of cigarette smoking among older adults. A subsidiary purpose was to examine the link between continued smoking and mortality among older smokers.

METHODS

We investigated average level and pattern of drinking as predictors of current smoking among 1,151 older adults at baseline and of continued smoking and mortality among the subset of 276 baseline smokers tracked across 20 years. We used multiple linear and logistic regression analyses and, to test mediation, bias-corrected bootstrap confidence intervals.

RESULTS

A high level of average drinking and a pattern of episodic heavy drinking were concurrently associated with smoking at baseline. However, only episodic heavy drinking was prospectively linked to continued smoking among baseline smokers. Continued smoking among baseline smokers increased the odds of 20-year mortality and provided an indirect pathway through which heavy episodic drinking related to mortality.

CONCLUSIONS

Smokers who misuse alcohol are a challenging population for smoking cessation efforts. Older adults who concurrently misuse alcohol and smoke cigarettes provide a unique target for public health interventions.

The earlier the better: health-related quality of life is inversely related to age of smoking cessation in older former Italian smokers

BACKGROUND

Quitting smoking has several health benefits, including an improvement in health-related quality of life. It is not well established if there is a relationship between the age when people stop smoking and health-related quality of life in older adults.

AIMS

The primary aim was to investigate the relationship between health-related quality of life and the age when people quit smoking in a national representative sample of community-dwelling older Italian adults. The secondary aim was to describe the characteristics of older former smokers according to their age when they stopped smoking.

METHODS

Data were drawn from the "Health and use of health care in Italy", a national cross-sectional survey (2004-2005). Seven thousand five hundred and sixty-two former smokers, aged 65 years and older, were evaluated by age of smoking cessation. Socio-demographic characteristics, physical activity, the 12-Item Short-Form Health Survey (SF-12) score and its physical (PCS-12) and mental (MCS-12) component summary scores, disability and comorbidities were analyzed.

RESULTS

Educational level, marital status and area of residence were associated with a different age of smoking cessation, as a higher level of disability and comorbidity. PCS-12 (β -0.144; p < 0.001) and MCS-12 (β -0.077; p < 0.001) component scores were lower in subjects who quit smoking later. The relationship was confirmed for the PCS-12 score even after adjustment for socio-demographic, disability and clinical variables (β -0.031; p < 0.001), while it disappeared for the MCS-12 score (β -0.010, p = 0.307), after adjustment for comorbidities.

CONCLUSION

Physical and mental health-related quality of life is influenced by the age of smoking cessation in older individuals, but this relationship is influenced by comorbidities, particularly depression. Some individual characteristics are related to the age of the person when he/she quit smoking.

Preventive Interventions for the Second Half of Life: A Systematic Review

OBJECTIVE

Recent improvements in life expectancy globally require intensified focus on noncommunicable diseases and age-related conditions. The purpose of this article is to inform the development of age-specific prevention guidelines for adults aged 50 and above, which are currently lacking.

DATA SOURCE

PubMed, Cochrane database, and Google Scholar and explicit outreach to experts in the field.

STUDY INCLUSION AND EXCLUSION CRITERIA

Meta-analyses, intervention-based, and prospective cohort studies that reported all-cause mortality, disease-specific mortality, or morbidity in adults were included.

DATA EXTRACTION

A systematic review was undertaken in 2015 using search terms of a combination of <risk factor> and "intervention," "mortality," "reduction," "improvement," "death," and "morbidity."

DATA SYNTHESIS

Interventions were categorized according to the Center for Evidence-Based Medicine Level of Evidence framework.

RESULTS

A summary table reports for each intervention the impact, strength of evidence, initiation, duration, and details of the intervention. Age-decade-specific preventive recommendations have been proposed relating to physical activity, diet, tobacco and alcohol use, medication adherence, screening and vaccination, and mental and cognitive health.

CONCLUSION

Clear recommendations have been made according to the existing evidence base, but further research investment is needed to fill the many gaps. Further, personalized approaches to healthy aging complemented by population-wide approaches and broader cross-sector partnerships will help to ensure greater longevity is an opportunity, rather than a burden, for society.

Smoking cessation and receipt of cessation advice from health professionals among older smokers in Taiwan

OBJECTIVES

To examine the prevalence and correlates of smoking cessation and receiving professional cessation advice among older smokers in Taiwan.

METHODS

Cross-sectional data from the 2008-2010 and 2012 Taiwan Adult Smoking Behavior Survey was used to form a sample of 4081 recent active smokers aged 50+, comprising current smokers and former smokers who quit smoking within the past 12months. We examined three outcome variables: quit attempt in the past 12months, successful cessation for at least 3months, and receipt of health professional cessation advice. Multivariate logistic regressions were used to identify significant correlates.

RESULTS

During the study period, the annual quit attempt rate was 41.4%, annual successful cessation rate was 4.7%, and prevalence of receiving cession advice among smokers who visited health professionals within the past 12months was 72.3%. After controlling for other covariates, quit attempts were significantly higher in 2009 and positively associated with higher education, poorer health status, smoke-free homes, and receipt of cessation advice. Successful cessation was significantly higher in 2009, positively associated with older age, higher income, and smoke-free homes, and negatively associated with receiving cessation advice. Receipt of cessation advice was significantly lower in 2010 and 2012, positively associated with male gender, older age, and poorer health status, and negatively associated with higher education.

CONCLUSIONS

Our results suggest that targeting lower educated and lower income subgroups, adopting effective strategies to increase voluntary smoke-free home rules, and improving professional cessation advice will have great potential to further reduce smoking prevalence in older smokers.

Adherence to the cancer prevention recommendations of the World Cancer Research Fund/American Institute for Cancer Research and mortality: a census-linked cohort

BACKGROUND

Modifiable lifestyle factors linked to cancer offer great potential for prevention. Previous studies suggest an association between adherence to recommendations on healthy lifestyle and cancer mortality.

OBJECTIVES

The aim of this study was to examine whether adherence to the cancer prevention recommendations of the World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR) is associated with reduced all-cause, total cancer, and specific cancer type mortality.

DESIGN

We built a lifestyle score that included 3 categories, based on the recommendations of the WCRF/AICR. Applying Cox regression models, we investigated the association with all-cause, total cancer, and specific cancer type mortality; in addition, we included cardiovascular disease (CVD) mortality. We used census- and death registry-linked survey data allowing a mortality follow-up for ≤32 y. Our analysis included 16,722 participants. Information on lifestyle score components and confounders was collected at baseline.

RESULTS

Over a mean follow-up of 21.7 y, 3730 deaths were observed (1332 cancer deaths). Comparing best with poorest category of the lifestyle score showed an inverse association with all-cause (HR: 0.82; 95% CI: 0.75, 0.89) and total cancer (men only, HR: 0.69; 95% CI: 0.57, 0.84) mortality. We estimated that ∼13% of premature cancer deaths in men would have been preventable if lifestyle score levels had been high. Inverse associations were observed for lung, upper aerodigestive tract, stomach, and prostate cancer mortality [men and women combined, HR: 0.72; 95% CI: 0.51, 0.99; HR: 0.49; 95% CI: 0.26, 0.92; HR: 0.34; 95% CI: 0.14, 0.83; HR: 0.48; 95% CI: 0.28, 0.82 (men only), respectively]. CVD mortality was not associated with the lifestyle score (men and women combined, HR: 0.96; 95% CI: 0.82, 1.13).

CONCLUSIONS

Our results support the importance of adhering to recommendations for a healthy lifestyle with regard to all-cause and cancer mortality. To reduce the burden of cancer in the population, preventive measures should stress the potential of low-risk health behavior patterns rather than of specific risk factors only.

Supporting smoking cessation in older patients: a continuing challenge for community nurses

Tobacco smoking continues to pose negative health consequences for smokers and their families, and is the single greatest cause of health inequalities in the UK. Older people are particularly vulnerable to the negative health impacts of smoking and therefore, supporting older smokers to quit remains an important public health goal. Community nurses are required to help patients to lead healthier lifestyles and have ideal opportunities to encourage smoking cessation in older people who are affected by smoking-related health conditions, or whose existing conditions may be exacerbated by continued smoking. This paper discusses how community nurses can support their older patients to quit smoking by fostering a patient-centred partnership through good communication and empathy. The newly developed 'Very Brief Advice on Smoking' (VBA) interventions can provide a useful tool for community nurses who experience time constraints to advise older people that psychosocial support with treatment is the most effective method of smoking cessation, while respecting the health decisions of patients.

Quantification of the smoking-associated cancer risk with rate advancement periods: meta-analysis of individual participant data from cohorts of the CHANCES consortium

BACKGROUND

Smoking is the most important individual risk factor for many cancer sites but its association with breast and prostate cancer is not entirely clear. Rate advancement periods (RAPs) may enhance communication of smoking related risk to the general population. Thus, we estimated RAPs for the association of smoking exposure (smoking status, time since smoking cessation, smoking intensity, and duration) with total and site-specific (lung, breast, colorectal, prostate, gastric, head and neck, and pancreatic) cancer incidence and mortality.

METHODS

This is a meta-analysis of 19 population-based prospective cohort studies with individual participant data for 897,021 European and American adults. For each cohort we calculated hazard ratios (HRs) for the association of smoking exposure with cancer outcomes using Cox regression adjusted for a common set of the most important potential confounding variables. RAPs (in years) were calculated as the ratio of the logarithms of the HRs for a given smoking exposure variable and age. Meta-analyses were employed to summarize cohort-specific HRs and RAPs.

RESULTS

Overall, 140,205 subjects had a first incident cancer, and 53,164 died from cancer, during an average follow-up of 12 years. Current smoking advanced the overall risk of developing and dying from cancer by eight and ten years, respectively, compared with never smokers. The greatest advancements in cancer risk and mortality were seen for lung cancer and the least for breast cancer. Smoking cessation was statistically significantly associated with delays in the risk of cancer development and mortality compared with continued smoking.

CONCLUSIONS

This investigation shows that smoking, even among older adults, considerably advances, and cessation delays, the risk of developing and dying from cancer. These findings may be helpful in more effectively communicating the harmful effects of smoking and the beneficial effect of smoking cessation.

The Impact of Chronic Tobacco Smoking on Retinal and Choroidal Thickness in Greek Population

Aim. To investigate the effect of more than 25-year cigarette smoking on choroidal and retinal thickness, using spectral domain optical coherence tomography (SD-OCT). Methods. Thirty-one smokers and 25 age- and sex-matched nonsmokers, serving as control group, were submitted to slit-lamp biomicroscopy and dilated fundoscopy, SD-OCT, measurements of intraocular pressure (IOP), central corneal thickness (CCT), and axial length (AL). Heidelberg Spectralis was used to calculate choroidal thickness (CT), ganglion cell complex (GCC), outer retina layers (ORL), and macular thicknesses (MT). Results. The smokers' group consisted of 17 males and 14 females with mean age of 57.8 ± 4.5 years, while the controls' group consisted of 14 males and 11 females with mean age of 68.0 ± 4.1 years. CT and GCC thicknesses were significantly reduced in smokers compared to control group. The differences in thicknesses of ORL were marginally significant between two groups. The measurements of MT, IOP, CCT, and AL had the same distributions between smokers and nonsmokers. Conclusions. Tobacco smoking seems to result in thinner choroid and retina compared to nonsmokers. This is the first study in literature that investigates the anatomical effect of smoking for more than 25 years on the choroid and retina.

Associations Between Excessive Sodium Intake and Smoking and Alcohol Intake Among Korean Men: KNHANES V

In this study, we evaluated the associations of smoking and alcohol intake, both independently and collectively, with sodium intake in Korean men. Subjects (6340 men) were from the fifth Korean National Health Examination Survey (2010–2012). Smoking-related factors included smoking status, urinary cotinine level, and pack-years of smoking. Food intake was assessed using a 24-h recall. The odds of excessive sodium intake were estimated using survey logistic regression analysis. The smoking rate was 44.1%. The geometric mean of the urinary cotinine level was 0.05 µg/mL, and the median (min–max) pack-years of smoking was 13.2 (0–180). When adjusted for related factors, the odds (95% confidence interval) of excessive sodium intake were 1.54 (1.00, 2.37), 1.55 (1.23, 1.94), 1.44 (1.07, 1.95), and 1.37 (1.11, 1.68) times higher in the group exposed to smoking and drinking than in the group that never smoked nor drank, the group that never smoked and drank <5 times per month, the group that did not currently smoke and never drank, and the group that did not currently smoke or drink <5 times per month, respectively. There was an interaction effect between smoking and alcohol intake (p-interaction = 0.02). The results suggest that simultaneous exposure to smoking and alcohol intake is associated with increased odds of excessive sodium intake.

Smoking habits and leukocyte telomere length dynamics among older adults: Results from the ESTHER cohort

BACKGROUND & AIMS

Leukocyte telomere length (LTL) shortens with age and short LTL has been associated with increased mortality and increased risk for some age-related outcomes. This study aims to analyse the associations of smoking habits with LTL and rate of LTL change per year in older adults.

METHODS

LTL was measured by quantitative PCR at baseline in 3600 older adults, who were enrolled in a population-based cohort study in Germany. For longitudinal analyses, measurements were repeated in blood samples obtained at 8-year follow-up from 1000 participants. Terminal Restriction Fragment analysis was additionally performed in a sub-sample to obtain absolute LTL in base pairs. Multivariate linear regression models were used to estimate associations of smoking habits with baseline LTL and changes in LTL over time.

RESULTS

LTL was inversely associated with age (r=-0.090, p<0.0001). Women had longer LTL than men (p<0.0001). Smoking was inversely associated with LTL. On average, current smokers had 73 base pairs (BP) shorter LTL compared to never smokers. Smoking intensity and pack-years of smoking were also inversely associated with LTL, and a positive association was observed with years since smoking cessation. Slower LTL attrition rates were observed in ever smokers over 8years of follow-up.

CONCLUSIONS

Our cross-sectional analysis supports suggestions that smoking might contribute to shortening of LTL but this relationship could not be shown longitudinally. The overall rather small effect sizes observed for smoking-related variables suggest that LTL reflects smoking-related health hazards only to a very limited extent.