Increasing prevalence of mental disorders in smokers seeking treatment of tobacco dependence: a retrospective observational study

BACKGROUND

There has been a noticeable relative increase in psychiatric comorbidities among smokers as opposed to the general population. This is likely due to comparatively slower decrease in smoking prevalence among individuals with mental health conditions. This study aims to assess the prevalence trend of past or current mental health disorders in individuals seeking specialized smoking cessation assistance.

METHODS

We conducted a retrospective single-centre observational study to assess the presence of mental disorders such as anxiety, depression, bipolar affective disorder, or schizophrenia in personal history of 6,546 smokers who sought treatment at the Centre for Treatment of Tobacco Dependence in Prague, Czech Republic between 2006 and 2019. The study examined the impact of gender, age, and the effect of successive years on the prevalence of the mental disorders using Poisson distribution regression.

RESULTS

In the studied cohort, 1,743 patients (26.6%) reported having one or more mental disorders. Compared to patients without a psychiatric disorder, they exhibited similar levels of carbon monoxide in expired air (mean 17 ppm, SD 11 ppm) and scored one point higher on the Fagerström Test of Cigarette Dependence. Among smokers with a mental disorder, women were more prevalent (62%) than men (38%). The prevalence of mental disorders increased on average by 4% every year, rising from 23% in 2006 to 35% in 2019.

CONCLUSIONS

Consistent with the observation that the prevalence of smoking among people with any mental disorder is higher and declining at a slower rate than in the general population, there is a steadily increasing percentage of these patients seeking specialized treatment over time. Professionals who offer tobacco dependence treatment should be aware of the upward trend in psychiatric disorders among smokers, as more intensive treatment may be needed. Similarly, psychiatric care should pay attention to smoking of their patients.

Relationship of Weight Concerns to Body Mass Index in a Tobacco Treatment Program

Objectives: Our aim was to examine the relationship between weight concerns (WC) and smoking cessation. Methods: WC was assessed before smoking cessation treatment in 671 adult patients who completed a 12-month follow-up visit at the Centre for Tobacco-Dependent, Prague, Czech Republic, from 2013 through 2019. We evaluated the abstinence rate at 12-month follow-up. Results: Among 669 patients with baseline WC (mean age, 43.4 years), 47% were women (145/306) and 21% were men (78/363). No association existed between WC and abstinence at 12 months. Smokers with obesity had increased fear of gaining weight (34% versus 24% of overweight and 23% of healthy-weight smokers) (p=.034) and were less confident in their ability to maintain their current weight (36% versus 55% of overweight smokers and 59% of healthy- weight smokers) (p<.001). Conclusions: Many smokers are concerned about gaining weight after stopping smoking, but in this cohort of patients, having WC was not associated with 12-month abstinence, but obesity or overweight was related to being afraid of postcessation weight-gain and low confidence for maintaining weight. Practitioners should be aware of the prevalence of WC in those stopping smoking and should address concerns, such as poor motivation and low confidence about managing their weight.

Cost-utility of cytisine for smoking cessation over and above behavioural support in people with newly diagnosed pulmonary tuberculosis: an economic evaluation of a multicentre randomised controlled trial

OBJECTIVES

To assess the cost-effectiveness of cytisine over and above brief behavioural support (BS) for smoking cessation among patients who are newly diagnosed with pulmonary tuberculosis (TB) in low-income and middle-income countries.

DESIGN

An incremental cost-utility analysis was undertaken alongside a 12-month, double-blind, two-arm, individually randomised controlled trial from a public/voluntary healthcare sector perspective with the primary endpoint at 6 months post randomisation.

SETTING

Seventeen subdistrict hospitals in Bangladesh and 15 secondary care hospitals in Pakistan.

PARTICIPANTS

Adults (aged ≥18 years in Bangladesh and ≥15 years in Pakistan) with pulmonary TB diagnosed within the last 4 weeks who smoked tobacco daily (n=2472).

INTERVENTIONS

Two brief BS sessions with a trained TB health worker were offered to all participants. Participants in the intervention arm (n=1239) were given cytisine (25-day course) while those in the control arm (n=1233) were given placebo. No significant difference was found between arms in 6-month abstinence.

PRIMARY AND SECONDARY OUTCOME MEASURES

Costs of cytisine and BS sessions were estimated based on research team records. TB treatment costs were estimated based on TB registry records. Additional smoking cessation and healthcare costs and EQ-5D-5L data were collected at baseline, 6-month and 12-month follow-ups. Costs were presented in purchasing power parity (PPP) adjusted US dollars (US$). Quality-adjusted life years (QALYs) were derived from the EQ-5D-5L. Incremental total costs and incremental QALYs were estimated using regressions adjusting for respective baseline values and other baseline covariates. Uncertainty was assessed using bootstrapping.

RESULTS

Mean total costs were PPP US$57.74 (95% CI 49.40 to 83.36) higher in the cytisine arm than in the placebo arm while the mean QALYs were -0.001 (95% CI -0.004 to 0.002) lower over 6 months. The cytisine arm was dominated by the placebo arm.

CONCLUSIONS

Cytisine plus BS for smoking cessation among patients with TB was not cost-effective compared with placebo plus BS.

TRIAL REGISTRATION NUMBER

ISRCTN43811467.

Comparison between success rates for smokers re-treated by a smokers' clinic and success rates for smokers treated for the first time

AIMS

To compare success rates and characteristics of smokers treated a second time by a smokers' clinic with success rates of their first treatment.

DESIGN

Retrospective cohort study.

SETTING

Tobacco Dependence Treatment clinic in Prague, Czech Republic, between 2005 and 2017.

PARTICIPANTS

A total of 5225 smokers treated either once (n = 5006, single treatment sample, SS) or also second time (n = 219, re-treated sample, RS), on average 4.47 years after the first visit.

INTERVENTION

Smokers received intensive treatment of tobacco dependence with pharmacotherapy options. Outcomes were evaluated after 1 year. In case of failure or relapse, participants could undergo re-treatment in the same setting at least 1 year after the start of the first treatment.

MEASUREMENTS

Twelve-month self-reported continuous abstinence; CO-validated (≤ 6 parts per million); number of visits; type of pharmacotherapy; mental health history; Fagerström Test for Cigarette Dependence; time between first and second treatment.

RESULTS

The abstinence rate in the SS was 34.8% [95% confidence interval (CI) = 33.4%, 36.1%] and in the RS was 37% (95% CI = 30.6%, 43.8%) and 39.7% (95% CI = 33.2%, 45.5%) for their first and second treatments, respectively. The samples were comparable on smoking and socio-demographic characteristics and pharmacotherapy used, but the RS in the second treatment had a higher prevalence of diagnosed mental health disorder at 39.3% (95% CI = 32.8%; 46.1%) compared with 23.7% (95% CI = 22.5%; 24.9%) in the SS. Participants who initiated their second quit attempt 1 to 2 years after the first one were less successful than those who initiated their second quit attempt later (25 versus 43%; P < 0.05). The results of the first treatment cycle were not found to be a reliable predictor for outcomes of the second cycle of treatment in univariate or multivariate logistic regression (odds ratio = 1.35, 95% CI = 0.70-2.63, P = 0.373).

CONCLUSION

In Prague, Czech Republic, smokers re-attending stop-smoking treatment more than 2 years after their previous quit attempt appear to achieve similar success rates to those being treated for the first time.

Building capacity in tobacco control by establishing the Eastern Europe Nurses' Center of Excellence for Tobacco Control

INTRODUCTION

Properly educated nurses delivering evidence-based tobacco dependence treatment could contribute to improving health and reducing regional disparities in tobacco-related disease and death in Central and Eastern Europe. The aims of this study are to describe development of the Eastern European Nurses’ Centre of Excellence for Tobacco Control (COE) and evaluate its online educational program on tobacco dependence treatment using the 5As framework.

METHODS

The online education evaluation followed a prospective, single group, pre- and post-assessment of changes in nurses’ self-reported tobacco cessation interventions. Leaders from five Eastern European countries (Hungary, Czech Republic, Romania, Slovakia, Slovenia) developed protocols for in-country tobacco control education. Nurses responded to a baseline survey, accessed an online nursing educational program, and completed a follow-up survey at 3 months, in the period December 2015 to June 2016. A total of 695 nurses from five countries answered questions on cessation interventions at baseline and of these 507 (73%) completed a follow-up survey at 3 months.

RESULTS

At the follow-up at 3 months, the 507 nurses self-reported a significant increase in providing all 5A components, i.e. nurses were significantly (p<0.0001) more likely to always /usually advise a patient to quit, assess interest in quitting (p=0.002), assist with a quit plan, review barriers to quitting and recommend a smoke-free home post-discharge (all p<0.0001). They were also significantly more likely (p=0.01) to agree or strongly agree that nurses have an obligation to advise patients on the risks of smoking. There was a significant increase (p<0.0001) in nurses’ estimate of the number of patients they provided a cessation intervention the previous week. Nurses who smoked were 60% more likely to assist and arrange compared to nurses who never smoked.

CONCLUSIONS

Coordinating multi-country activities through a COE was successful in engaging a network of nurses to use an online educational program and participate in other tobacco control activities.

A narrative review of facilitators and barriers to smoking cessation and tobacco-dependence treatment in patients with tuberculosis in low- and middle-income countries

INTRODUCTION

Smoking is a substantial cause of premature death in patients with tuberculosis (TB), particularly in low- and middle-income countries (LMICs) with high TB prevalence. The importance of incorporating smoking cessation and tobacco-dependence treatment (TDT) into TB care is highlighted in the most recent TB care guidelines. Our objective is to identify the likely key facilitators of and barriers to smoking cessation for patients with TB in LMICs.

METHODS

A systematic search of studies with English-language abstracts published between January 2000 and May 2019 was undertaken in the EMBASE, MEDLINE, EBSCO, ProQuest, Cochrane and Web of Science databases. Data extraction was followed by study-quality assessment and a descriptive and narrative synthesis of findings.

RESULTS

Out of 267 potentially eligible articles, 36 satisfied the inclusion criteria. Methodological quality of non-randomized studies was variable; low risk of bias was assessed in most randomized controlled studies. Identified facilitators included brief, repeated interventions, personalized behavioural counselling, offer of pharmacotherapy, smoke-free homes and a reasonable awareness of smoking-associated risks. Barriers included craving for a cigarette, low level of education, unemployment, easy access to tobacco in the hospital setting, lack of knowledge about quit strategies, and limited space and privacy at the clinics. Findings show that the risk of smoking relapse could be reduced through consistent follow-up upon completion of TB therapy and receiving a disease-specific smoking cessation message.

CONCLUSIONS

Raising awareness of smoking-related health risks in patients with TB and implementing guideline-recommended standardized TDT within national TB programmes could increase smoking cessation rates in this high-risk population.

SNPs within CHRNA5-A3-B4 and CYP2A6/B6, nicotine metabolite concentrations and nicotine dependence treatment success in smokers

AIM

Plasma values of nicotine and its metabolites are highly variable, and this variability has a strong genetic influence. In our study, we analysed the impact of common polymorphisms associated with smoking on the plasma values of nicotine, nicotine metabolites and their ratios and investigated the potential effect of these polymorphisms and nicotine metabolite ratios on the successful treatment of tobacco dependence.

METHODS

Five variants (rs16969968, rs6474412, rs578776, rs4105144 and rs3733829) were genotyped in a group of highly dependent adult smokers (n=103). All smokers underwent intensive treatment for tobacco dependence; 33 smokers were still abstinent at the 12-month follow-up.

RESULTS

The rs4105144 (CYP2A6, P<0.005) and rs3733829 (EGLN2, P<0.05) variants were significantly associated with plasma concentrations of 3OH-cotinine and with 3OH-cotinine: cotinine ratios. Similarly, the unweighted gene score was a significant (P<0.05) predictor of both cotinine:nicotine and 3OH-cotinine:cotinine ratios. No associations between the analysed polymorphisms or nicotine metabolite ratios and nicotine abstinence rate were observed.

CONCLUSION

Although CYP2A6 and EGLN2 polymorphisms were associated with nicotine metabolism ratios, neither these polymorphisms nor the ratios were associated with abstinence rates.

Lenalidomide and dexamethasone in treatment of patients with relapsed and refractory multiple myeloma - analysis of data from the Czech Myeloma Group Registry of Monoclonal Gammopathies

Lenalidomide (LEN) is an immunomodulator with clinical activity against myeloma cells. Based on the pivotal phase 3 trials MM-009 and MM010, the combination of lenalidomide and dexamethasone(DEX) was approved for patients with multiple myeloma who received at least one prior therapy. Here, we evaluated LEN/DEX therapy in unselected population and subsequently in selected sub-groups of patients with relapsed/refractory multiple myeloma followed in the Registry of Monoclonal Gammopathies of the Czech Myeloma Group. Altogether 858 patients were treated with LEN/DEX in the Czech Republic and Slovakia until end of 2017. The analyzed sub-groups were defined as patients with high risk cytogenetic aberrations and patients with relapsed and refractory MM. The overall response rate (ORR; partial remission or better response, PR) in the whole group of patients was 46.3% for all lines of therapy, 26.4% for high-risk group and 32.1% for relapsed and refractory group. Medians of overall survival (OS) in the same cohorts were as follows: 25.6, 15.7 and 18.5 months, progression free survival (PFS) was: 11.2, 6.4 and 9.0 months respectively. The most common adverse events were hematologic and infectious. In conclusion we found that our results correlated with those found in other studies in terms of response rates, survival measures, and also of treatment toxicity.

Is the impact of conventional risk factors the same in men and women? Plea for a more gender-specific approach

Cardiovascular disease (CVD) is the leading cause of death in women in developed countries. The traditional modifiable risk factors are able to explain the majority of CVD mortality. The aim of this review is to analyze gender-specific aspects of major conventional cardiovascular risk factors and to assess whether they have the same impact on CVD in women. Cigarette smoking remains the single largest preventable cause of cardiovascular morbidity and premature death worldwide. Women smoke less than men; however, smoking seems to be more harmful in women, particularly in oral contraceptive users. Obesity in the general population is more prevalent in women. Visceral adiposity is associated with insulin resistance and a higher risk of developing cardiovascular disease. Life expectancy in female diabetic patients is shorter than in men with diabetes; women with diabetes are also at higher risk of developing cardiovascular events. Changes of main lipid parameters in women are frequently associated with their hormonal status and/or hormonal treatment. Hypertension is highly prevalent in post-menopausal women and carries a higher risk of developing left ventricular hypertrophy, which, together with a greater increase in vascular and myocardial stiffness, results in a higher incidence of heart failure with preserved ejection fraction and a higher risk of developing stroke. The risk of abdominal aortic rupture is substantially higher in women. In conclusion, smoking, diabetes and hypertension seem to be more harmful in women. Therefore, the question is whether there should not be lower thresholds for initiating drug treatment in women with diabetes and hypertension.

Early weight gain after stopping smoking: a predictor of overall large weight gain? A single-site retrospective cohort study

OBJECTIVES

Most people gain weight on stopping smoking but the extent of weight gain varies greatly. Interventions aimed at all quitters to prevent weight gain on cessation have proven unpopular but targeting people who have gained excess weight immediately after quitting may improve uptake and cost-effectiveness. We examined whether early large postcessation weight gain predicts overall large weight gain.

DESIGN

Retrospective cohort study.

SETTING

Primary care setting-smoking cessation centre in Prague, Czech Republic.

PARTICIPANTS

Out of 3537 patients treated between 2005 and 2013, 1050 were continuous abstainers (verified by carbon monoxide measurement) at 1-year follow-up and formed the cohort of the current report. 48.7% were women (n=511) with the mean age of 46 (±14.4) years.

METHODS

In this retrospective cohort study, all patients underwent usual tobacco dependence treatment using evidence-based methods. Weight was measured prior to smoking cessation and at each visit after quitting.

RESULTS

The mean weight gain in the first month (n=763) was 0.79% (±2.03%), in the second month (n=646) was 1.49% (±2.58%), for the third month (n=566) 2.33% (±3.44%) and 4.1% (±5.31%) after 1-year follow-up (n=1050). The regression coefficient per 1% rise in the first 3 months was +0.13% (95% CI -0.04% to 0.30%). A receiver operating curve analysis showed that patients gaining more than 0.98% of their baseline weight during first 3 months had a sensitivity of 66% and specificity of 44% for gaining 7% or more weight by 12 months. In addition, lower body mass index and an increase in appetite at 3 months after quitting were associated with greater weight gain, while using nicotine replacement therapy was associated with less weight gain at 1-year follow-up.

CONCLUSIONS

People who stop smoking and gain a larger amount of weight early after quitting are not more likely to gain excessively at 1 year.

The safety, effectiveness and cost-effectiveness of cytisine in achieving six-month continuous smoking abstinence in tuberculosis patients-protocol for a double-blind, placebo-controlled randomized trial

BACKGROUND AND AIMS

Tuberculosis (TB) patients who quit smoking have much better disease outcomes than those who continue to smoke. In general populations, behavioural support combined with pharmacotherapy is the most effective strategy in helping people to quit. However, there is no evidence for the effectiveness of this strategy in TB patients who smoke. We will assess the safety, effectiveness and cost-effectiveness of cytisine-a low-cost plant-derived nicotine substitute-for smoking cessation in TB patients compared with placebo, over and above brief behavioural support.

DESIGN

Two-arm, parallel, double-blind, placebo-controlled, multi-centre (30 sites in Bangladesh and Pakistan), individually randomized trial.

SETTING

TB treatment centres integrated into public health care systems in Bangladesh and Pakistan.

PARTICIPANTS

Newly diagnosed (in the last 4 weeks) adult pulmonary TB patients who are daily smokers (with or without dual smokeless tobacco use) and are interested in quitting (n = 2388).

MEASUREMENTS

The primary outcome measure is biochemically verified continuous abstinence from smoking at 6 months post-randomization, assessed using Russell Standard criteria. The secondary outcome measures include continuous abstinence at 12 months, lapses and relapses; clinical TB outcomes; nicotine dependency and withdrawal; and adverse events.

COMMENTS

This is the first smoking cessation trial of cytisine in low- and middle-income countries evaluating both cessation and TB outcomes. If found effective, cytisine could become the most affordable cessation intervention to help TB patients who smoke.

Protocol for the mixed-methods process and context evaluation of the TB & Tobacco randomised controlled trial in Bangladesh and Pakistan: a hybrid effectiveness-implementation study

INTRODUCTION

Tuberculosis (TB) remains a significant public health problem in South Asia. Tobacco use increases the risks of TB infection and TB progression. The TB& Tobacco placebo-controlled randomised trial aims to (1) assess the effectiveness of the tobacco cessation medication cytisine versus placebo when combined with behavioural support and (2) implement tobacco cessation medication and behavioural support as part of general TB care in Bangladesh and Pakistan. This paper summarises the process and context evaluation protocol embedded in the effectiveness-implementation hybrid design.

METHODS AND ANALYSIS

We are conducting a mixed-methods process and context evaluation informed by an intervention logic model that draws on the UK Medical Research Council's Process Evaluation Guidance. Our approach includes quantitative and qualitative data collection on context, recruitment, reach, dose delivered, dose received and fidelity. Quantitative data include patient characteristics, reach of recruitment among eligible patients, routine trial data on dose delivered and dose received, and a COM-B ('capability', 'opportunity', 'motivation' and 'behaviour') questionnaire filled in by participating health workers. Qualitative data include semistructured interviews with TB health workers and patients, and with policy-makers at district and central levels in each country. Interviews will be analysed using the framework approach. The behavioural intervention delivery is audio recorded and assessed using a predefined fidelity coding index based on behavioural change technique taxonomy.

ETHICS AND DISSEMINATION

The study complies with the guidelines of the Declaration of Helsinki. Ethics approval for the study and process evaluation was granted by the University of Leeds (qualitative components), University of York (trial data and fidelity assessment), Bangladesh Medical Research Council and Bangladesh Drug Administration (trial data and qualitative components) and Pakistan Medical Research Council (trial data and qualitative components). Results of this research will be disseminated through reports to stakeholders and peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ISRCTN43811467; Pre-results.

Depression and Smoking Cessation: Evidence from a Smoking Cessation Clinic with 1-Year Follow-Up

BACKGROUND

Smoking is more prevalent among people with depression. Depression may make cessation more difficult and cessation may affect depression symptoms.

PURPOSE

The aims of this study were to assess the associations between (1) baseline depression and 1-year smoking abstinence and (2) abstinence and change in depression.

METHODS

Observational study using data collected routinely in a smoking cessation clinic in the Czech Republic from 2008 to 2014. Aim 1: N = 3775 patients; 14.3% reported mild and 15.4% moderate/severe baseline depression levels measured using Beck's Depression Inventory (BDI-II). Logistic regressions assessed if depression level predicted 1-year biochemically verified abstinence while adjusting for patient and treatment characteristics. Aim 2: N = 835 patients abstinent at 1 year; change in depression was analysed using Chi-square statistics, t test and mixed method analyses of variance.

RESULTS

Rate of abstinence was lower for patients with mild (32.5%, OR = 0.68; 95% CI: 0.54 to 0.87, p = 0.002) and moderate/severe depression (25.8%; OR = 0.57, 95% CI: 0.45 to 0.74, p < 0.001) compared with patients without depression (40.5%). Across abstinent patients, the majority with baseline depression reported lower depression levels at follow-up. Overall mean (SD) BDI-II scores improved from 9.2 (8.6) to 5.3 (6.1); t(834) = 14.6, p < 0.001. There were significant main effects of time (F(1832) = 880.8, p < 0.001, partial η2 = 0.51) and baseline depression level (F(2832) = 666.4, p < 0.001, partial η2 = 0.62) on follow-up depression and a significant depression * time interaction (F(2832) = 296.5, p < 0.001, partial η2 = 0.42).

CONCLUSIONS

In this effective smoking cessation clinic, depression at the start of treatment predicted reduced smoking abstinence 1 year later. Patients abstinent from smoking experienced considerable improvement in depression.

Impact of Online Education on Nurses' Delivery of Smoking Cessation Interventions With Implications for Evidence-Based Practice

BACKGROUND

Tobacco use is the leading cause of preventable disease and death in Europe and worldwide. Nurses, if properly educated, can contribute to decreasing the burden of tobacco use in the region by helping smokers quit smoking.

AIMS

To assess: (a) the feasibility of an online program to educate nurses in Czech Republic and Poland on evidence-based smoking cessation interventions for patients and (b) self-reported changes in practices related to consistently (usually or always) providing smoking cessation interventions to smokers, before and 3 months after participation in the program.

METHODS

A prospective single-group pre-post design.

RESULTS

A total of 280 nurses from Czech Republic and 156 from Poland completed baseline and follow-up surveys. At 3 months, nurses were significantly more likely to provide smoking cessation interventions to patients who smoke and refer patients for cessation services (p < .01). Nurses significantly improved their views about the importance of nursing involvement in tobacco control.

IMPLICATIONS FOR PRACTICE

Education about tobacco control can make a difference in clinical practice, but ongoing support is needed to maintain these changes. Health system changes can also facilitate the expectation that delivering evidence-based smoking cessation interventions should be routine nursing care.

LINKING EVIDENCE TO ACTION

Educating nurses on cessation interventions and tobacco control is pivotal to decrease tobacco-related disparities, disease, and death. Online methods provide an accessible way to reach a large number of nurses.

The steroid spectrum during and after quitting smoking

Addiction to tobacco results in an imbalance of endocrine homeostasis in both sexes. This can also have impacts on fertility problems. The male reproductive system is less susceptible than that of females, with a worsening spermiogram in smokers, the most cited effect in the literature. However, the literature is inconsistent as to the effects of smoking on steroid hormone levels in men, and there is very little data on the effects of quitting smoking in men. In this study we followed 76 men before quitting smoking, and then after 6, 12, and 24 weeks and 1 year of abstinence. We measured basic anthropomorphic data and steroid hormone levels along with steroid neuroactive metabolites using GC-MS. We demonstrate lower androgen levels in men who smoke, and these changes worsened after quitting smoking. There was a drop in SHBG already in the first week of non-smoking, and levels continued to remain low. Male smokers have lower androgen levels compared to non-smokers. The lower the initial level of androgen, the lower the likelihood of success in quitting smoking. Changes in steroid hormones proved to be a promising marker for the prediction of success in quitting smoking.

Current and past smoking patterns in a Central European urban population: a cross-sectional study in a high-burden country

BACKGROUND

Many studies have examined the socioeconomic variations in smoking and quitting rates across the European region; however, data from Central and East European countries, where the tobacco burden is especially high, are sparse. This study aimed to assess the patterns in current and past smoking prevalence based on cross-sectional data from a Central European urban population sample.

METHODS

Data from 2160 respondents aged 25-64 years in Brno, Czech Republic were collected in 2013-2014 using the Czech post-MONICA survey questionnaire to assess the prevalence of cardiovascular risk factors, including smoking status. The age- and sex-stratified randomized sample was drawn using health insurance registries. Descriptive statistics and quit ratios were calculated, and chi-square and multivariate logistic analyses conducted to examine relationships between current and past smoking and demographic (age, gender, marital status) and socioeconomic variables (education, income, occupation).

RESULTS

The prevalence of current and past smoking was 23.6 and 31.3 % among men and 20.5 and 23.2 % among women, respectively. Education reliably predicted smoking and quitting rates in both genders. Among men, being unemployed was associated with greater odds of smoking (OR 3.6; 1.6-8.1) and lower likelihood of quitting (OR 0.2: 0.1-0.6); the likelihood of quitting also increased with age (OR 1.8; 1.2-2.8). Among women, marital status (being married) decreased the odds of current smoking (OR 0.6; 0.4-0.9) and increased the odds of quitting (OR 2.2; 1.2-3.9). Quit ratios were the lowest in the youngest age group (25-34 years) where quitting was more strongly associated with middle income (OR 2.7; 95 % CI 1.2-5.9) than with higher education (OR 2.9; 95 % CI 0.9-8.2).

CONCLUSIONS

Interventions to increase cessation rates and reduce smoking prevalence need to be gender-specific and carefully tailored to the needs of the disadvantaged groups of the population, especially the less well-off young adults. Future studies should examine the equity impact of the tobacco control policies and be inclusive of the Central and East European countries.

European Code against Cancer, 4th Edition: Tobacco and cancer

Tobacco use, and in particular cigarette smoking, is the single largest preventable cause of cancer in the European Union (EU). All tobacco products contain a wide range of carcinogens. The main cancer-causing agents in tobacco smoke are polycyclic aromatic hydrocarbons, tobacco-specific N-nitrosamines, aromatic amines, aldehydes, and certain volatile organic compounds. Tobacco consumers are also exposed to nicotine, leading to tobacco addiction in many users. Cigarette smoking causes cancer in multiple organs and is the main cause of lung cancer, responsible for approximately 82% of cases. In 2012, about 313,000 new cases of lung cancer and 268,000 lung cancer deaths were reported in the EU; 28% of adults in the EU smoked tobacco, and the overall prevalence of current use of smokeless tobacco products was almost 2%. Smokeless tobacco products, a heterogeneous category, are also carcinogenic but cause a lower burden of cancer deaths than tobacco smoking. One low-nitrosamine product, snus, is associated with much lower cancer risk than other smokeless tobacco products. Smoking generates second-hand smoke (SHS), an established cause of lung cancer, and inhalation of SHS by non-smokers is still common in indoor workplaces as well as indoor public places, and more so in the homes of smokers. Several interventions have proved effective for stopping smoking; the most effective intervention is the use of a combination of pharmacotherapy and behavioural support. Scientific evidence leads to the following two recommendations for individual action on tobacco in the 4th edition of the European Code Against Cancer: (1) "Do not smoke. Do not use any form of tobacco"; (2) "Make your home smoke-free. Support smoke-free policies in your workplace".

No difference in hypertension prevalence in smokers, former smokers and non-smokers after adjusting for body mass index and age: a cross-sectional study from the Czech Republic, 2010

BACKGROUND

Several hypotheses suggest a temporary increase in blood pressure following smoking cessation. This may be the result of endocrine changes (e.g. alteration in adrenocorticotropic hormone and cortisol levels in post-cessation period) and/or post-cessation weight gain. Our aim was to identify factors that may be associated with the diagnosis of hypertension after quitting smoking.

METHODS

In 2010, we conducted a cross-sectional survey in a sample of 2065 Czech adults, chosen by quota selection and representative according to age, gender, education, region of residence and the size of settlement, aged 18 to 94 years. We examined the association between age, gender, body mass index, smoking status, and education with the hypertension diagnosis in their personal history. Data were compiled and weighed by age categories. Statistical significance was measured by Pearson Chi-square test at the level of significance 95 %.

RESULTS

Diagnosis of hypertension was reported in 461 (22 %) subjects, with no difference by gender. Based on univariate analysis, former smokers were more likely than non-smokers to be diagnosed for hypertension (OR 1.450 (1.110-1.900), p = 0.006). However, after adjusting for body mass index and age, the occurrence of hypertension diagnosis did not differ among non-smokers, smokers and former smokers (OR 0.760 for smokers, p = 0.082 and OR 1.020 for former smokers, p = 0.915).

CONCLUSION

We did not find any differences in hypertension diagnosis prevalence according to smoking status.

Do e-cigarettes have the potential to compete with conventional cigarettes?: a survey of conventional cigarette smokers' experiences with e-cigarettes

BACKGROUND

Electronic cigarettes (ECs) are becoming increasingly popular globally. If they were to replace conventional cigarettes, it could have a substantial impact on public health. To evaluate EC's potential for competing with conventional cigarettes as a consumer product, we report the first data, to our knowledge, on the proportion of smokers who try ECs and become regular users.

METHODS

A total of 2,012 people seen smoking or buying cigarettes in the Czech Republic were approached to answer questions about smoking, with no mention made of ECs to avoid the common bias in surveys of EC users. During the interview, the volunteers' experience with ECs was then discussed.

RESULTS

A total of 1,738 smokers (86%) participated. One-half reported trying ECs at least once. Among those who tried ECs, 18.3% (95% CI, 0.15.7%-20.9%) reported using them regularly, and 14% (95% CI, 11.6%-16.2%) used them daily. On average, regular users used ECs daily for 7.1 months. The most common reason for using ECs was to reduce consumption of conventional cigarettes; 60% of regular EC users reported that ECs helped them to achieve this. Being older and having a more favorable initial experience with ECs explained 19% of the variance in progressing to regular EC use.

CONCLUSIONS

Almost one-fifth of smokers who try ECs once go on to become regular users. ECs may develop into a genuine competitor to conventional cigarettes. Government agencies preparing to regulate ECs need to ensure that such moves do not create a market monopoly for conventional cigarettes.

Tobacco treatment outcomes in patients with and without a history of depression, Czech Republic, 2005-2010

Introduction

Higher prevalence of smoking among depressed patients, as well as the risk of depression in smokers, is well documented. The proportion of patients with a history of depression among those seeking intensive treatment of tobacco dependence is also high. In contrast, evidence of treatment success in this subgroup of patients is controversial. The aim of this study was to compare smoking abstinence rates after tobacco treatment in smokers with and without a history of depression.

Methods

We reviewed retrospective data from 1,730 smokers seeking treatment in Prague, Czech Republic. History of depression was defined as past diagnosis of depression or current treatment of depression. After a 1-year, self-reported smoking status was validated by expired-air carbon monoxide. We used logistic regression to analyze associations between abstinence rates, history of depression, and other factors (eg, age, sex, tobacco dependence).

Results

Of 1,730 smokers treated, 289 (16.7%) had a history of depression. The smoking abstinence rate at 1 year was 32.5% for smokers with a history of depression and 38.7% for those with no history (P = .048). Among women, abstinence did not differ between groups (35.0% vs 35.7%; P = .86). However, among men, those with a history of depression had lower rates of abstinence (27.4% vs 41.3%; P = .009). After adjustment for baseline covariates, history of depression was not significantly associated with smoking abstinence in men or women.

Conclusion

Intensive outpatient tobacco treatment programs can achieve abstinence rates among smokers with a history of depression similar to rates among the general population.

Fifty-two-week continuous abstinence rates of smokers being treated with varenicline versus nicotine replacement therapy

BACKGROUND AND AIMS

Cross-study comparisons of effect sizes suggest that varenicline is more effective than nicotine replacement therapy (NRT) in aiding smoking cessation, but evidence from direct comparisons is limited. This study compared biochemically verified 52-week sustained abstinence rates in smokers attending the same clinical service according to whether they used varenicline or NRT in their quit attempt.

METHODS

This was a prospective cohort study of 855 smokers attending a large smoking cessation clinic who used their choice of NRT product or varenicline in their quit attempt. All received the same behavioural support programme and chose their medication option (n = 519 varenicline; n = 336 NRT). The primary outcome measure was self-report of 52 weeks' abstinence following the target quit date confirmed by expired air carbon monoxide concentration. Baseline measures included socio-demographic variables, mental health diagnoses, measures of smoking, cigarette dependence and past use of NRT or varenicline.

RESULTS

The 52-week abstinence rates were 42.8% versus 31.0% in those using varenicline versus NRT, respectively (P < 0.001). After adjusting for all baseline variables, the odds of remaining abstinent for 52 weeks were 2.03 (95% CI 1.46-2.82), P < 0.001 times higher in those using varenicline than those using NRT.

CONCLUSIONS

Smokers in the same behavioural support programme who use varenicline appear to have a greater probability of achieving long-term abstinence than those using their choice of nicotine replacement therapy options, even after adjusting for potentially confounding smoker characteristics.

Attitudes of women from five European countries regarding tobacco control policies

AIMS

Tobacco-related cancers and, in particular, lung cancer still represents a substantial public health epidemic across Europe as a result of high rates of smoking prevalence. Countries in Europe have proposed and implemented tobacco control policies to reduce smoking prevalence, with some countries being more progressive than others. The aim of this study was to examine factors that influenced women's attitudes across five European countries relative to comprehensive smokefree laws in their countries.

METHODS

A cross-sectional landline telephone survey on attitudes towards tobacco control laws was conducted in five European countries: France, Ireland, Italy, the Czech Republic, and Sweden. Attitudinal scores were determined for each respondent relative to questions about smokefree laws. Logistic regression models were used to obtain odds ratios with 95% confidence intervals.

RESULTS

A total of 5000 women were interviewed (1000 women from each country). The majority of women, regardless of smoking history, objected to smoking in public buses, enclosed shopping centers, hospitals, and other indoor work places. More women who had quit smoking believed that new tobacco control laws would prompt cessation - as compared with women who still smoked.

CONCLUSIONS

In general, there is very high support for national smokefree laws that cover bars, restaurants, and public transport systems. As such laws are implemented, attitudes do change, as demonstrated by the differences between countries such as Ireland and the Czech Republic. Implementing comprehensive smokefree laws will gain high approval and will be associated with prompting people to quit.

Impact of tobacco control policy on quitting and nicotine dependence among women in five European countries

OBJECTIVE

To describe differences in and factors associated with former smoking and nicotine dependence among women in Ireland, Sweden, France, Italy and the Czech Republic.

METHODS

A cross-sectional, random digit dial telephone survey of 5000 women, aged 18 years and older, conducted in 2008. Analyses were conducted using logistic regression models.

RESULTS

Respondents from Ireland and Sweden had statistically significantly higher odds of having quit smoking within the 5 years before survey administration compared with respondents from the Czech Republic. Current smokers from Ireland, Sweden, France and Italy are more nicotine dependent than those from the Czech Republic.

CONCLUSIONS

Respondents from countries with stronger tobacco control policies were more likely to have quit smoking compared with those living in the Czech Republic. However, respondents in countries with some of the strongest policies (Ireland, Sweden, France and Italy) had higher odds of smoking within 30 min of waking, an established indicator of nicotine dependence. More research in this area is warranted, but this study suggests that now that the Czech Republic is beginning to implement strong tobacco control policy, they will probably achieve a rapid decline in population-level smoking. Ireland, Sweden, France, Italy and other countries with established, strong tobacco control policies would do well to consider what additional programmes they can put in place to help their highly nicotine-dependent population of smokers successfully quit.

A randomized placebo-controlled trial of varenicline for smoking cessation allowing flexible quit dates

INTRODUCTION

Current smoking cessation guidelines recommend setting a quit date prior to starting pharmacotherapy. However, providing flexibility in the date of quitting may be more acceptable to some smokers. The objective of this study was to compare varenicline 1 mg twice daily (b.i.d.) with placebo in subjects using a flexible quit date paradigm after starting medication.

METHODS

In this double-blind, randomized, placebo-controlled international study, smokers of ≥10 cigarettes/day, aged 18-75 years, and who were motivated to quit were randomized (3:1) to receive varenicline 1 mg b.i.d. or placebo for 12 weeks. Subjects were followed up through Week 24. Subjects were instructed to quit between Days 8 and 35 after starting medication. The primary endpoint was carbon monoxide-confirmed continuous abstinence during Weeks 9-12, and a key secondary endpoint was continuous abstinence during Weeks 9-24.

RESULTS

Overall, 493 subjects were randomized to varenicline and 166 to placebo. Continuous abstinence was higher for varenicline than for placebo subjects at the end of treatment (Weeks 9-12: 53.1% vs. 19.3%; odds ratio [OR] 5.9; 95% CI, 3.7-9.4; p < .0001) and through 24 weeks follow-up (Weeks 9-24: 34.7% vs. 12.7%; OR 4.4; 95% CI, 2.6-7.5; p < .0001). Serious adverse events occurred in 1.2% varenicline (none were psychiatric) and 0.6% placebo subjects. Fewer varenicline than placebo subjects reported depression-related adverse events (2.3% vs. 6.7%, respectively).

CONCLUSIONS

Varenicline 1 mg b.i.d. using a flexible quit date paradigm had similar efficacy and safety compared with previous fixed quit date studies.

Knowledge and beliefs about smoking and cancer among women in five European countries

BACKGROUND

Lung cancer mortality in women is increasing across Europe, reflecting the alarming increase in smoking prevalence. Understanding women's perception of smoking may help to identify ways to reduce its prevalence and prevent uptake of smoking. The aim of this study was to examine factors associated with knowledge and beliefs about smoking and cancer among European women.

METHODS

A cross-sectional landline telephone survey on health attitudes and knowledge was conducted in five European countries: France, Ireland, Italy, the Czech Republic, and Sweden. A general linear modeling was used to explore the factors related to knowledge and beliefs about smoking and cancer.

RESULTS

A total of 5,000 women were interviewed (1,000 women from each country). The mean knowledge and belief scores about smoking and cancer were lower in current smokers than those of never and former smokers (P < 0.05). Women with above-the-median income (P = 0.001) and women who held skilled occupations seemed to be more knowledgeable about tobacco health risks (P < 0.001). The number of friends and family who smoked was inversely associated with knowledge on the harmful effects of tobacco (P = 0.001). Swedish women were the most knowledgeable about tobacco-related cancer risk, whereas in France and Italy, current smokers were less knowledgeable.

CONCLUSIONS

Knowledge and beliefs about cancer and smoking varied significantly by smoking status.

IMPACT

Results emphasize the need to develop health education programs that enhance cancer knowledge among women who currently smoke and are in low socioeconomic groups.

Determinants of smoking initiation among women in five European countries: a cross-sectional survey

BACKGROUND

The rate of smoking and lung cancer among women is rising in Europe. The primary aim of this study was to determine why women begin smoking in five different European countries at different stages of the tobacco epidemic and to determine if smoking is associated with certain characteristics and/or beliefs about smoking.

METHODS

A cross-sectional telephone survey on knowledge and beliefs about tobacco was conducted as part of the Women in Europe Against Lung Cancer and Smoking (WELAS) Project. A total of 5,000 adult women from France, Ireland, Italy, Czech Republic, and Sweden were interviewed, with 1,000 from each participating country. All participants were asked questions about demographics, knowledge and beliefs about smoking, and their tobacco use background. Current and former smokers also were asked questions about smoking initiation. Basic statistics on the cross-sectional data was reported with chi-squared and ANOVA p-values. Logistic regression was used to analyze ever versus never smokers. Linear regression analyses were used to analyze age of smoking initiation.

RESULTS

Being older, being divorced, having friends/family who smoke, and having parents who smoke were all significantly associated with ever smoking, though the strength of the associations varied by country. The most frequently reported reason for initiation smoking was friend smoking, with 62.3% of ever smokers reporting friends as one of the reasons why they began smoking. Mean age of smoking initiation was 18.2 years and over 80% of participants started smoking by the age of 20. The highest levels of young initiators were in Sweden with 29.3% of women initiating smoking at age 14-15 and 12.0% initiating smoking younger than age 14. The lowest level of young initiators was in the Czech Republic with 13.7% of women initiating smoking at age 14-15 and 1.4% of women initiating smoking younger than age 14. Women who started smoking because their friends smoked or to look 'cool' were more likely to start smoking at a younger age. Women who started smoking to manage stress or to feel less depressed were more likely to start smoking at an older age.

CONCLUSIONS

In all five participating countries, friends were the primary factor influencing ever smoking, especially among younger women. The majority of participants began smoking in adolescence and the average reported age of smoking initiation was youngest in Sweden and oldest in the Czech Republic.

Smoking cessation or reduction with nicotine replacement therapy: a placebo-controlled double blind trial with nicotine gum and inhaler

Background

Even with effective smoking cessation medications, many smokers are unable to abruptly stop using tobacco. This finding has increased interest in smoking reduction as an interim step towards complete cessation.

Methods

This multi-center, double-blind placebo-controlled study evaluated the efficacy and safety of nicotine 4 mg gum or nicotine 10 mg inhaler in helping smokers (N = 314) to reduce or quit smoking. It included smokers willing to control their smoking, and participants could set individual goals, to reduce or quit. The study was placebo-controlled, randomized in a ratio of 2:1 (Active:Placebo), and subjects could choose inhaler or gum after randomization. Outcome was short-term (from Week 6 to Month 4) and long-term (from Month 6 to Month 12) abstinence or reduction. Abstinence was defined as not a single cigarette smoked and expired CO readings of <10 ppm. Smoking reduction was defined as a reduction in number of cigarettes per day by 50% or more versus baseline, verified by a lower-than-baseline CO reading at each visit during the same periods.

Results

Significantly more smokers managed to quit in the Active group than in the Placebo group. Sustained abstinence rates at 4 months were 42/209 (20.1%) subjects in the Active group and 9/105 (8.6%) subjects in the Placebo group (p = 0.009). Sustained abstinence rates at 12 months were 39/209 (18.7%) and 9/105 (8.6%), respectively (p = 0.019). Smoking reduction did not differ between the groups, either at short-term or long-term. Twelve-month reduction results were 17.2% vs. 18.1%, respectively. No serious adverse events were reported.

Conclusion

In conclusion, treatment with 10 mg nicotine inhaler or 4 mg nicotine chewing gum resulted in a significantly higher abstinence rate than placebo. In addition a large number of smokers managed to reduce their cigarette consumption by more than 50% compared to baseline.