Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

Contribution of smoking towards the association between socioeconomic position and dementia: 32-year follow-up of the Whitehall II prospective cohort study

Background

There is consistent evidence of social inequalities in dementia but the mechanisms underlying this association remain unclear. We examined the role of smoking in midlife in socioeconomic differences in dementia at older ages.

Methods

Analyses were based on 9951 (67% men) participants, median age 44.3 [IQR=39.6, 50.3] years at baseline in 1985-1988, from the Whitehall II cohort study. Socioeconomic position (SEP) and smoking (smoking status (current, ex-, never-smoker), pack years of smoking, and smoking history score (combining status and pack-years)) were measured at baseline. Counterfactual mediation analysis was used to examine the contribution of smoking to the association between SEP and dementia.

Findings

During a median follow-up of 31.6 (IQR 31.1, 32.6) years, 628 participants were diagnosed with dementia and 2110 died. Analyses adjusted for age, sex, ethnicity, education, and SEP showed smokers (hazard ratio [HR] 1.36 [95% CI 1.10-1.68]) but not ex-smokers (HR 0.95 [95% CI 0.79-1.14]) to have a higher risk of dementia compared to never-smokers; similar results for smoking were obtained for pack-years of smoking and smoking history score. Mediation analysis showed low SEP to be associated with higher risk of dementia (HRs between 1.97 and 2.02, depending on the measure of smoking in the model); estimate for the mediation effect was 16% for smoking status (Indirect Effect HR 1.09 [95% CI 1.03-1.15]), 7% for pack-years of smoking (Indirect Effect HR 1.03 [95% CI 1.01-1.06]) and 11% for smoking history score (Indirect Effect HR 1.06 [95% CI 1.02-1.10]).

Interpretation

Our findings suggest that part of the social inequalities in dementia is mediated by smoking.

Funding

NIH.

Integrating human brain proteomic data with genome-wide association study findings identifies novel brain proteins in substance use traits

Despite the identification of a growing number of genetic risk loci for substance use traits (SUTs), the impact of these loci on protein abundance and the potential utility of relevant proteins as therapeutic targets are unknown. We conducted a proteome-wide association study (PWAS) in which we integrated human brain proteomes from discovery (Banner; N = 152) and validation (ROSMAP; N = 376) datasets with genome-wide association study (GWAS) summary statistics for 4 SUTs. The 4 samples comprised GWAS of European-ancestry individuals for smoking initiation [Smk] (N = 1,232,091), alcohol use disorder [AUD] (N = 313,959), cannabis use disorder [CUD] (N = 384,032), and opioid use disorder [OUD] (N = 302,585). We conducted transcriptome-wide association studies (TWAS) with human brain transcriptomic data to examine the overlap of genetic effects at the proteomic and transcriptomic levels and characterize significant genes through conditional, colocalization, and fine-mapping analyses. We identified 27 genes (Smk = 21, AUD = 3, CUD = 2, OUD = 1) that were significantly associated with cis-regulated brain protein abundance. Of these, 7 showed evidence for causality (Smk: NT5C2, GMPPB, NQO1, RHOT2, SRR and ACTR1B; and AUD: CTNND1). Cis-regulated transcript levels for 8 genes (Smk = 6, CUD = 1, OUD = 1) were associated with SUTs, indicating that genetic loci could confer risk for these SUTs by modulating both gene expression and proteomic abundance. Functional studies of the high-confidence risk proteins identified here are needed to determine whether they are modifiable targets and useful in developing medications and biomarkers for these SUTs.

Combined biological effects and lung proteomics analysis in mice reveal different toxic impacts of electronic cigarette aerosol and combustible cigarette smoke on the respiratory system

Combustible cigarettes produce many toxic substances that have been linked to diseases, such as lung cancer and chronic obstructive pulmonary disease. For those smokers unable or unwilling to quit, electronic cigarettes (e-cigarettes) could be used as an alternative to cigarettes. However, the effects and mechanisms of e-cigarette aerosol (ECA) on respiratory function have not been fully elucidated, and in vivo studies of its safety are limited compared to cigarette smoke (CS). In this article, we chose nicotine levels as dosing references and C57BL/6 mice for a 10-week subchronic inhalation toxicity study. A comprehensive set of toxicological endpoints was used to study the effect of exposure. Both CS (6 mg/kg) and ECA (6 or 12 mg/kg) inhalation had decreased the animal's lung function and increased levels of inflammation markers, along with pathological changes in the airways and lungs, with ECA displaying a relatively small effect at the same dose. Proteomic analysis of lung tissue showed greater overall protein changes by CS than that of ECA, with more severe inflammatory network perturbations. Compared with ECA, KEGG analysis of CS revealed upregulation of more inflammatory and virus-related pathways. Protein-protein interactions (PPI) showed that both ECA and CS significantly changed ribosome and complement system-related proteins in mouse lung tissue. The results support that e-cigarette aerosol is less harmful to the respiratory system than cigarette smoke at the same dose using this animal model, thus providing additional evidence for the relative safety of e-cigarettes.

Brief opportunistic interventions by general practitioners to promote smoking cessation: A conversation analytic study

Very brief opportunistic interventions for smoking cessation are effective, cost-saving for health systems, and universally recommended in guidelines. However, evidence suggests that clinicians are reluctant to intervene, citing interactional difficulties. Only one UK study has specifically examined smoking discussions, within naturally occurring primary care consultations. However smoking cessation treatment was not available at the time. We examined existing datasets amounting to 519 video-recordings of GP consultations in England for instances of talk about smoking. We used conversation analytic methods to assess patients' responses to doctors asking about smoking, giving advice on smoking, and offering cessation treatment. In 31 recordings it was apparent that the patient smoked, and, in 25/31 consultations, doctors initiated the topic of smoking. They did so by asking about smoking status, commonly during the history-taking phase of the consultation. In many instances, these questions led to active resistance from patients against being placed in a discreditable category, for example by minimising their smoking. This was more pronounced when GPs pursued efforts to quantify the amount smoked. Thereafter, where doctors returned to the topic of smoking, they did so typically by linking smoking to the patient's medical condition, which likewise led to resistance. Guidance recommends that GPs advise on how best to quit smoking where patients are interested in doing so, but this was only evident in a minority of consultations. Where GPs offered support for cessation, they did so using interactional practices that minimised the need for the patient to respond and thereby accept. Interactional difficulties were found to be common in consultations between GPs and people who smoke when GPs actions aligned with some VBA guidelines. Future research should examine when and how advice on how best to quit, and offers of support, should be delivered within primary care consultations.

Tobacco smoking and risks of more than 470 diseases in China: a prospective cohort study

BACKGROUND

Tobacco smoking is estimated to account for more than 1 million annual deaths in China, and the epidemic continues to increase in men. Large nationwide prospective studies linked to different health records can help to periodically assess disease burden attributed to smoking. We aimed to examine associations of smoking with incidence of and mortality from an extensive range of diseases in China.

METHODS

We analysed data from the prospective China Kadoorie Biobank, which recruited 512 726 adults aged 30-79 years, of whom 210 201 were men and 302 525 were women. Participants who had no major disabilities were identified through local residential records in 100-150 administrative units, which were randomly selected by use of multistage cluster sampling, from each of the ten diverse study areas of China. They were invited and recruited between June 25, 2004, and July 15, 2008. Upon study entry, trained health workers administered a questionnaire assessing detailed smoking behaviours and other key characteristics (eg, sociodemographics, lifestyle, and medical history). Participants were followed up via electronic record linkages to death and disease registries and health insurance databases, from baseline to Jan 1, 2018. During a median 11-year follow-up (IQR 10-12), 285 542 (55·7%) participants were ever hospitalised, 48 869 (9·5%) died, and 5252 (1·0%) were lost to follow-up during the age-at-risk of 35-84 years. Cox regression yielded hazard ratios (HRs) associating smoking with disease incidence and mortality, adjusting for multiple testing.

FINDINGS

At baseline, 74·3% of men and 3·2% of women (overall 32·4%) ever smoked regularly. During follow-up, 1 137 603 International Classification of Diseases, 10th revision (ICD-10)-coded incident events occurred, involving 476 distinct conditions and 85 causes of death, each with at least 100 cases. Compared with never-regular smokers, ever-regular smokers had significantly higher risks for nine of 18 ICD-10 chapters examined at age-at-risk of 35-84 years. For individual conditions, smokers had significantly higher risks of 56 diseases (50 for men and 24 for women) and 22 causes of death (17 for men and nine for women). Among men, ever-regular smokers had an HR of 1·09 (95% CI 1·08-1·11) for any disease incidence when compared with never-regular smokers, and significantly more episodes and longer duration of hospitalisation, particularly those due to cancer and respiratory diseases. For overall mortality, the HRs were greater in men from urban areas than in men from rural areas (1·50 [1·42-1·58] vs 1·25 [1·20-1·30]). Among men from urban areas who began smoking at younger than 18 years, the HRs were 2·06 (1·89-2·24) for overall mortality and 1·32 (1·27-1·37) for any disease incidence. In this population, 19·6% of male (24·3% of men residing in urban settings and 16·2% of men residing in rural settings) and 2·8% of female deaths were attributed to ever-regular smoking.

INTERPRETATION

Among Chinese adults, smoking was associated with higher risks of morbidity and mortality from a wide range of diseases. Among men, the future smoking-attributed disease burden will increase further, highlighting a pressing need for reducing consumption through widespread cessation and uptake prevention.

FUNDING

British Heart Foundation, Cancer Research UK, Chinese Ministry of Science and Technology, Kadoorie Charitable Foundation, UK Medical Research Council, National Natural Science Foundation of China, Wellcome Trust.

Quality of service and commitment to tobacco dependence treatment for individuals living with mental disorders in France: A pilot study

BACKGROUND

There are remarkably high smoking rates in patients living with mental disorders (PLWMD), and the absence of a specific treatment policy for smoking cessation for these patients worldwide. The present study aimed to (i) investigate the quality of service and commitment to tobacco dependence treatment, and (ii) produce high-quality French versions of the Index of Tobacco Treatment Quality (ITTQ) and Tobacco Treatment Commitment Scale (TTCS).

METHODS

ITTQ and TTCS were used to assess French mental health professionals (n = 80). Both scales were translated from their original language following standard procedures (i.e. forward translation). Descriptive analysis for total score, each factor and item were calculated for the entire sample, followed by subgroup analysis by gender, and role of the practitioner.

RESULTS

Nurses presented higher levels of both treatment commitment and treatment quality in their mental health care units, compared to psychiatrists, and residents. Overall, counseling offering was low and there was a perception that it is unfair to take tobacco away from PLWMD. In the other hand, there were high levels of smoking assessment and perceptions that nicotine dependence should be included in drug treatment programs.

CONCLUSIONS

There is a gap in tobacco treatment implementation for French PLWMD. The present pilot study alerts about the problem, and should stimulate larger studies validating such measures for wide use with French-speaking mental health professionals. French nurses presented higher levels of both treatment commitment and quality, and could be in a leadership position for such implementation. Encouraging the implementation of tobacco counseling within conventional mental health treatment is critical to improve cessation rates among this population. There is a potential for the sustainability of tobacco treatment interventions since the levels of commitment observed here were higher than in previous studies conducted abroad.

Burden of female breast cancer in the Middle East and North Africa region, 1990–2019

Background

There is no region-specific publication investigating the attributable burden of breast cancer, particularly among females. This article reported the burden of female breast cancer in the Middle East and North Africa (MENA) region, and its attributable risk factors between 1990 and 2019, by age, sex, and socio-demographic index (SDI).

Methods

Publicly available data on the incidence, death and disability-adjusted life years (DALY) were retrieved from the Global Burden of Disease (GBD) 2019 study for the 21 countries and territories in MENA, between 1990 and 2019, along with 95% uncertainty intervals (UIs). The relationship between the burden of female breast cancer, in terms of DALYs, and the SDI were also assessed using Smoothing Spline models.

Results

In 2019, the regional age-standardised incidence and death rates of female breast cancer were 37.5 and 15.2 per 100,000, which represent a 90.9 and 24.0% increase since 1990, respectively. In addition, in 2019 the regional age-standardised DALY rate was 472.7 per 100,000, which was 19.5% higher than in 1990. In 2019, the death rate increased steadily with advancing age, while the DALY rate increased steeply with age and reached its peak in the 70–74 age group. There was a positive association between SDI and the burden of breast cancer over the period 1990 to 2019. Moreover, in 2019 high fasting plasma glucose (6.9%) contributed to the largest proportion of attributable DALYs for female breast cancer in the MENA region.

Conclusions

There was a significant increase in the incidence rate of female breast cancer in MENA over the past three decades, although the death and DALY rates were both largely unchanged. Preventive programs targeting the major risk factors should be implemented in the region.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00918-y.

Trends of ischemic heart disease mortality attributable to household air pollution during 1990-2019 in China and India: an age-period-cohort analysis

Cardiovascular diseases (CVD) caused by household air pollution (HAP) have sparked widespread concern globally in the recent decade. Meanwhile, increased ischemic heart disease (IHD) mortality has been the leading cause of worldwide CVD deaths. Both China and India experienced a high IHD burden and high exposure to HAP. The present study aimed to estimate and compare the long-term trends of HAP-attributable IHD mortality in the two countries. The data of this study were extracted from the Global Burden of Diseases (GBD) Study 2019. The age-period-cohort (APC) analysis was utilized to estimate the independent trends of the age, period, and cohort effects from 1990 to 2019. The age-standardized mortality rates (ASMRs) of HAP-attributable IHD have fallen faster in China than in India for both sexes. The local drift and net drift values were < 0 for all age groups in both countries. The age effects in both countries and sexes increased with time, suggesting age is a risk factor for IHD; conversely, period and cohort effects in China demonstrated a faster decline in both genders than in India. It indicated that China has been more successful than India in decreasing HAP-attributable IHD mortality.

SMOKING MIGHT INCREASE THE FAILURE RATE AND MARGINAL BONE LOSS AROUND DENTAL IMPLANTS

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Mustapha AD, Salame Z, Chrcanovic BR. Smoking and Dental Implants: A Systematic Review and Meta-Analysis. Medicina. 2021 Dec 27;58(1):39.

SOURCE OF FUNDING

No external sources of funding were available for conducting this study.

TYPE OF STUDY/DESIGN

Systematic review (SR) with meta-analysis (MA) of data.

Tobacco use among Kola Sámi, the indigenous people of the Murmansk region, Russia: A cross-sectional study

Russia is among the top ten nations in terms of smoking prevalence. Little is known about smoking rates among Indigenous Peoples in Russia. Our aim was to assess the prevalence of tobacco and nicotine product use among Kola peninsula Sámi. An exploratory cross-sectional survey was conducted to determine tobacco or nicotine product use among 505 Sámi people (about 30% of the whole Sámi population of Russia). Over 60% of participants had tried tobacco or nicotine products. Median age of first use was 15 years, with cigarettes being the most frequent first product tried and the most common type of product used currently. About a third of participants used a tobacco or nicotine product at least occasionally; 25% (predominantly males) smoked at least occasionally with 23.8% smoking daily. Of participants who smoked, 52.5% scored medium and 44.2% scored high on the Heaviness of Smoking Index. Seventeen percent of participants smoked formerly but not currently. Like some other Indigenous Peoples, Kola Sámi in Russia have a higher smoking prevalence than the average among the Russian population. Interest in a smoking cessation mobile app designed for the Sámi population suggests that such an intervention could help to reduce this inequity.

Trends in hospitalization and death rates among patients with head and neck cancer in Spain, 2009 to 2019

BACKGROUND

Head and neck squamous cell carcinoma (HNSCC) is the seventh most common cancer worldwide, and prevalence is still substantially higher in men than in women. Causative factors include smoking and alcohol use, while human papillomavirus (HPV) infection is causally related to a subset of oropharyngeal cancers. In this retrospective study, we aimed to provide estimates on the clinical and economic burden of HNSCC in Spain.

METHODS

We used the discharge reports from the Spanish Minimum Basic Data Set (MBDS), to retrospectively analyze hospital discharge data in individuals with a diagnosis of HNSCC in any diagnostic position, based on the ICD coding system (ICD-9-CM and ICD10 CM), from 2009 to 2019.

RESULTS

A total of 175,340 admissions and 14,498 deaths due to laryngeal, pharyngeal and oral cavity cancer were recorded in Spain, of which 85% occurred in men. The most prevalent diagnoses were laryngeal cancer in men (50.9%) and oral cavity cancer in women (49.1%). In general, the hospitalization and death rates for all major head and neck cancer sites decreased in men and increased or remained stable in women during the study period. However, the corresponding rates for tonsil cancer, strongly associated with HPV infection, increased significantly in men. Overall, the economic burden of HNSCC during the study period was estimated at 100 million euros per year on average.

CONCLUSION

HNSCC still places an important clinical and economic burden on the health system in Spain. Prevention strategies should be prioritized, and vaccination programs against HPV in both sexes should be reinforced.

Trends in smoking-attributable mortality in Spain: 1990-2018

BACKGROUND

This study sought to analyse the trend in smoking-attributable mortality (SAM) in Spain among the population aged ≥35 years across the period 1990-2018.

METHODS

SAM was estimated by applying a prevalence-independent method, which uses lung cancer (LC) mortality as a proxy of tobacco consumption. We sourced observed mortality from the National Institute of Statistics (Spain), LC mortality rates in smokers and never smokers from the Cancer Prevention Study I-II, and relative risks from 5 US cohorts. Estimates of annual SAM by cause of death, sex and age are shown, along with crude and annual standardised SAM rates. The trend in standardised all-cause and LC rates was analysed using a joinpoint regression model.

RESULTS

Tobacco caused 1 717 150 deaths in Spain in the period 1990-2018. Among men, cancers replaced cardiovascular diseases-diabetes mellitus (CVD-DM) as the leading group of tobacco-related cause of death in 1994. Among women, CVD-DM remained the leading cause of death throughout the period. Trend analysis of standardised SAM rates due to all causes and LC showed a decrease in men and an increase in women.

CONCLUSIONS

The tobacco epidemic in Spain across the period 1990-2018 has had an important impact on mortality and has evolved differently in both genders. SAM is expected to increase dramatically in women in the coming years. SAM data highlight the importance of including a gender perspective in SAM analyses, in designing more effective and comprehensive public health interventions and in developing gender-specific tobacco control policies to curb tobacco consumption.

Global trend and risk factors of the disease burden for pharynx and larynx cancers between 1990 and 2019: a systematic analysis of the global burden of disease study 2019

BACKGROUND

Pharynx and larynx cancers (PLCs) are the top killer cancers in head and neck and significantly affect the quality of life of patients. A detailed study examining the disease burden and risk factors of PLCs is lacking.

METHODS

Data on mortality and disability-adjusted life-years (DALYs) were extracted from the Global Burden of Disease Study 2019. The estimated annual percentage change (EAPC) of the age-standardized mortality rate was calculated using a generalized linear model with a Gaussian distribution. Mortality and DALYs were stratified according to the sociodemographic index (SDI), age, gender, and risk factors. The association between the SDI and mortality rate was measured using Spearman's correlation.

RESULTS

Between 1990 and 2019, the total number of deaths due to PLCs increased by 60.7% (95% confidence intervals: 39.32 to 66.8), from 192.38 thousand in 1990 to 309.16 thousand in 2019, and the total DALYs due to PLCs increased by 49.41% (95% confidence intervals: 30.15 to 53.27), from 5.91 million in 1990 to 8.83 million in 2019. The age-standardized mortality rate declined for larynx cancer (from 2.19 in 1990 to 1.49 in 2019) and nasopharynx cancer (1.26 to 0.86) but increased slightly for other pharynx cancer (1.25 to 1.37). The death number of PLCs was significantly higher in men aged 50 to 70 years, which accounts for 46.05% and 43.83% of the total deaths in 1990 and 2019, respectively. Low and low-middle countries had the greatest age-standardized mortality rate for larynx and other pharynx cancer, while low-middle and middle countries dominated for nasopharynx cancer. The leading risk factors for PLCs were smoking and alcohol use, which account for 37.92% and 58.84% in total DALYs rate of PLCs, and the influence of risk factors was significant in men.

CONCLUSION

The total number of deaths and DALYs due to PLCs increased from 1990 to 2019. Countries with relatively low SDI and middle-aged and older men had the greatest burden of PLCs. Building better health care systems in relatively low SDI countries and improving strategies of smoking and alcohol control should be a priority in health policy.

Potential Disruption of Systemic Hormone Transport by Tobacco Alkaloids Using Computational Approaches

Tobacco/nicotine is one of the most toxic and addictive substances and continues to pose a significant threat to global public health. The harmful effects of smoking/nicotine affect every system in the human body. Nicotine has been associated with effects on endocrine homeostasis in humans such as the imbalance of gonadal steroid hormones, adrenal corticosteroid hormones, and thyroid hormones. The present study was conducted to characterize the structural binding interactions of nicotine and its three important metabolites, cotinine, trans-3'-hydroxycotinine, and 5'-hydroxycotinine, against circulatory hormone carrier proteins, i.e., sex-hormone-binding globulin (SHBG), corticosteroid-binding globulin (CBG), and thyroxine-binding globulin (TBG). Nicotine and its metabolites formed nonbonded contacts and/or hydrogen bonds with amino acid residues of the carrier proteins. For SHBG, Phe-67 and Met-139 were the most important amino acid residues for nicotine ligand binding showing the maximum number of interactions and maximum loss in ASA. For CBG, Trp-371 and Asn-264 were the most important amino acid residues, and for TBG, Ser-23, Leu-269, Lys-270, Asn-273, and Arg-381 were the most important amino acid residues. Most of the amino acid residues of carrier proteins interacting with nicotine ligands showed a commonality with the interacting residues for the native ligands of the proteins. Taken together, the results suggested that nicotine and its three metabolites competed with native ligands for binding to their carrier proteins. Thus, nicotine and its three metabolites may potentially interfere with the binding of testosterone, estradiol, cortisol, progesterone, thyroxine, and triiodothyronine to their carrier proteins and result in the disbalance of their transport and homeostasis in the blood circulation.

Outcomes of a Comprehensive Mobile Smoking Cessation Program With Nicotine Replacement Therapy in Adult Smokers: Pilot Randomized Controlled Trial

BACKGROUND

Cigarette smoking remains the leading cause of preventable illness and death, underscoring ongoing need for evidence-based solutions. Pivot, a US Clinical Practice Guideline-based mobile smoking cessation program, comprises a personal carbon monoxide breath sensor; a smartphone app; in-app, text-based human-provided coaching; nicotine replacement therapy; and a moderated web-based community. Promising Pivot cohort studies have established the foundation for comparative assessment.

OBJECTIVE

This study aimed to compare engagement, retention, attitudes toward quitting smoking, smoking behavior, and participant feedback between Pivot and QuitGuide, a US Clinical Practice Guideline-based smoking cessation smartphone app from the National Cancer Institute.

METHODS

In this remote pilot randomized controlled trial, cigarette smokers in the United States were recruited on the web and randomized to Pivot or QuitGuide. Participants were offered 12 weeks of free nicotine replacement therapy. Data were self-reported via weekly web-based questionnaires for 12 weeks and at 26 weeks. Outcomes included engagement and retention, attitudes toward quitting smoking, smoking behavior, and participant feedback. The primary outcome was self-reported app openings at 12 weeks. Cessation outcomes included self-reported 7- and 30-day point prevalence abstinence (PPA), abstinence from all tobacco products, and continuous abstinence at 12 and 26 weeks. PPA and continuous abstinence were biovalidated via breath carbon monoxide samples.

RESULTS

Participants comprised 188 smokers (94 Pivot and 94 QuitGuide): mean age 46.4 (SD 9.2) years, 104 (55.3%) women, 128 (68.1%) White individuals, and mean cigarettes per day 17.6 (SD 9.0). Engagement via mean "total app openings through 12 weeks" (primary outcome) was Pivot, 157.9 (SD 210.6) versus QuitGuide, 86.5 (SD 66.3; P<.001). Self-reported 7-day PPA at 12 and 26 weeks was Pivot, 35% (33/94) versus QuitGuide, 28% (26/94; intention to treat [ITT]: P=.28) and Pivot, 36% (34/94) versus QuitGuide, 27% (25/94; ITT: P=.12), respectively. Self-reported 30-day PPA at 12 and 26 weeks was Pivot, 29% (27/94) versus QuitGuide, 22% (21/94; ITT: P=.32) and Pivot, 32% (30/94) versus QuitGuide, 22% (21/94; ITT: P=.12), respectively. The biovalidated abstinence rate at 12 weeks was Pivot, 29% (27/94) versus QuitGuide, 13% (12/94; ITT: P=.008). Biovalidated continuous abstinence at 26 weeks was Pivot, 21% (20/94) versus QuitGuide, 10% (9/94; ITT: P=.03). Participant feedback, including ease of setup, impact on smoking, and likelihood of program recommendation were favorable for Pivot.

CONCLUSIONS

In this randomized controlled trial comparing the app-based smoking cessation programs Pivot and QuitGuide, Pivot participants had higher engagement and biovalidated cessation rates and more favorable user feedback at 12 and 26 weeks. These findings support Pivot as an effective, durable mobile smoking cessation program.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04955639; https://clinicaltrials.gov/ct2/show/NCT04955639.

Religious fasting and its impacts on individual, public, and planetary health: Fasting as a "religious health asset" for a healthier, more equitable, and sustainable society

Religious fasting is practiced by people of all faiths, including Christianity, Islam, Buddhism, Jainism, as well as Hinduism, Judaism, and Taoism. Individual/clinical, public, global, and planetary health has traditionally been studied as separate entities. Nevertheless, religious fasting, in conjunction with other religious health assets, can provide several opportunities, ranging from the individual to the population, environmental, and planetary levels, by facilitating and supporting societal transformations and changes, such as the adoption of healthier, more equitable, and sustainable lifestyles, therein preserving the Earth's systems and addressing major interconnected, cascading, and compound challenges. In this review, we will summarize the most recent evidence on the effects of religious fasting, particularly Orthodox and Ramadan Islamic fasting, on human and public health. Further, we will explore the potential effects of religious fasting on tackling current environmental issues, with a special focus on nutrition/food restriction and planetary health. Finally, specific recommendations, particularly around dietary intake during the fasting rituals, will be provided to ensure a sustainable healthy planet.

Insight into genetic, biological, and environmental determinants of sexual-dimorphism in type 2 diabetes and glucose-related traits

There is growing evidence that sex and gender differences play an important role in risk and pathophysiology of type 2 diabetes (T2D). Men develop T2D earlier than women, even though there is more obesity in young women than men. This difference in T2D prevalence is attenuated after the menopause. However, not all women are equally protected against T2D before the menopause, and gestational diabetes represents an important risk factor for future T2D. Biological mechanisms underlying sex and gender differences on T2D physiopathology are not yet fully understood. Sex hormones affect behavior and biological changes, and can have implications on lifestyle; thus, both sex-specific environmental and biological risk factors interact within a complex network to explain the differences in T2D risk and physiopathology in men and women. In addition, lifetime hormone fluctuations and body changes due to reproductive factors are generally more dramatic in women than men (ovarian cycle, pregnancy, and menopause). Progress in genetic studies and rodent models have significantly advanced our understanding of the biological pathways involved in the physiopathology of T2D. However, evidence of the sex-specific effects on genetic factors involved in T2D is still limited, and this gap of knowledge is even more important when investigating sex-specific differences during the life course. In this narrative review, we will focus on the current state of knowledge on the sex-specific effects of genetic factors associated with T2D over a lifetime, as well as the biological effects of these different hormonal stages on T2D risk. We will also discuss how biological insights from rodent models complement the genetic insights into the sex-dimorphism effects on T2D. Finally, we will suggest future directions to cover the knowledge gaps.

Environmental Factors in the Rehabilitation Framework: Role of the One Health Approach to Improve the Complex Management of Disability

Environment factors play a crucial implication in human health, with strong evidence suggesting that several biological, chemical, physical and social factors could be possible targets to implement effective strategies for human health promotion. On the other hand, a large gap of knowledge still exists about the implications of environmental factors in terms of functional impairment and disability, while the integration of an environmental-based approach in the therapeutic care of patients affected by disabilities remains still challenging. In this scenario, the One Health approach has been recently introduced in clinical care and aims to optimize health outcomes by recognizing the interconnection between people and the environment. Concurrently, the "Rehabilitation 2030 Initiative" proposed in 2017 by the WHO emphasized the need to integrate environmental-based strategies to promote rehabilitation across different health systems and different nations. However, no previous study underlined the potential implications of the One Health approach in the rehabilitation setting, nor the role of a comprehensive rehabilitation approach focused on environmental factors. Therefore, the aim of this narrative review was to present a comprehensive overview of the data currently available assessing the close relationship between rehabilitation and the environment to provide a different perspective on the comprehensive care of patients affected by disability.

The burden of rheumatoid arthritis in the Middle East and North Africa region, 1990-2019

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease. The present study reported the burden of RA in the Middle East and North Africa (MENA) region from 1990 to 2019 by age, sex, and socio-demographic index (SDI). Publicly available data from the Global Burden of Disease (GBD) 2019 study was used to report the modelled point prevalence, annual incidence, and disability-adjusted life-years (DALYs) of RA, as counts and age-standardised rates with their corresponding 95% uncertainty intervals (UIs). In 2019, RA had an age-standardised point prevalence of 120.6 per 100,000 population (107.0-135.7) and an annual incidence rate of 5.9 (5.2-6.6) in MENA, which have increased 28.3% and 25.2%, respectively, since 1990. In 2019, the number of DALYs due to RA in the region was 103.6 thousand (74.2-136.7), with an age-standardised rate of 19.0 (13.9-24.9) DALYs per 100,000 population, which has increased by 18.6% since 1990 (6.7-28.2). The highest point prevalence was found in females aged 50-54, and in males aged 45-49. The highest number of DALYs was observed in the 50-54 age group. The MENA DALY rate was lower than the global rate (19.0 vs. 39.6 per 100,000), but the rate was higher in all age groups in 2019, when compared with 1990. In addition, from 1990 to 2019 an increased burden from RA was associated with an increase in SDI. In line with global trends, the burden of RA in the MENA region showed a steady increase from 1990 to 2019. This highlights the increasing need for updating the available health data to design more accurate guidelines to enable the early detection and treatment of RA in the MENA countries.

Changes in Tobacco and Alcohol Consumption in France during the Spring 2020 Lockdown: Results of the Coviprev and Viquop Surveys

This study aims to describe changes in tobacco and alcohol consumption in France during the first COVID-19 lockdown in March 2020 and its gradual lifting in May. The associated factors and the reasons reported explaining those changes are also studied. Data came from five waves of the CoviPrev online cross-sectional survey (approximately n = 2000 per wave) and the ViQuoP qualitative survey (n = 60), which took place between April and June. Most people self-reported stable consumption compared to before the lockdown, but 27% to 32% of smokers and 10% to 16% of drinkers had increased their consumption, depending on the wave of the survey. Boredom, stress and the search for pleasure were the main reasons reported. While the sociodemographic factors associated with an increase in tobacco and alcohol use differed according to the product and month, poor mental health was associated with an increase in both products in April and May. Between 10% and 19% of smokers and 22% to 25% of drinkers reported having reduced their consumption for their health or through constraints. The measures taken to manage the spring 2020 epidemic appear to have had contrasting impacts on tobacco and alcohol consumption in France. People whose lifestyles and mental health was most affected appear to have modified their consumption more frequently.

A call to ban the sale of tobacco products

Tobacco is both toxic and addictive. Mounting evidence shows that tobacco use has a detrimental impact on almost every aspect of human health, causing or worsening deadly public health crises from the cancer epidemic to the COVID-19 pandemic. However, while tobacco use is a threat to both personal and public health, it continues to surge across the world, especially in China and other low- and middle-income countries. To this end, this article argues in favor of using a ban on the sale of all tobacco products as a practical solution to the global tobacco use epidemic. It is our hope that insights provided by our work will inspire swift policy actions in countries such as China and beyond to curb the tide of rising tobacco consumption, so that populations around the world could be better shielded from the pervasive and long-lasting damage that tobacco products cause or compound.

Assessing changes in nicotine consumption over two years in a population of Hanoi by wastewater analysis with benchmarking biomarkers

Monitoring the actual change in consumption of nicotine (a proxy for smoking) in the population is essential for formulating tobacco control policies. In recent years, wastewater-based epidemiology (WBE) has been applied as an alternative method to estimate changes in consumption of tobacco and other substances in different communities around the world, with high potential to be used in resource-scarce settings. This study aimed to conduct a WBE analysis in Hanoi, Vietnam, a lower-middle-income-country setting known for high smoking prevalence. Wastewater samples were collected at two sites along a sewage canal in Hanoi during three periods: Period 1 (September 2018), Period 2 (December 2018-January 2019), and Period 3 (December 2019-January 2020). Concentrations of cotinine, 3-hydroxycotinine, and nicotine ranged from 0.73 μg/L to 3.83 μg/L, from 1.09 μg/L to 5.07 μg/L, and from 0.97 μg/L to 9.90 μg/L, respectively. The average mass load of cotinine estimated for our samples was 0.45 ± 0.09 mg/day/person, which corresponds to an estimated daily nicotine consumption of 1.28 ± 0.25 mg/day/person. No weekly trend was detected over the three monitoring periods. We found the amount of nicotine consumption in Period 1 to be significantly lower than in Period 2 and Period 3. Our WBE estimates of smoking prevalence were slightly lower than the survey data. The analysis of benchmarking biomarkers confirmed that cotinine was stable in the samples similar to acesulfame, while paracetamol degraded along the sewer canal. Further refinement of the WBE approach may be required to improve the accuracy of analyzing tobacco consumption in the poor sewage infrastructure setting of Vietnam.

The Association of Smoking Status and Clustering of Obesity and Depression on the Risk of Early-Onset Cardiovascular Disease in Young Adults: A Nationwide Cohort Study

BACKGROUND AND OBJECTIVES

To evaluate the impact of smoking in young adults on the risk of cardiovascular disease (CVD) and the clustering effect of behavioral risk factors such as smoking, obesity, and depression.

METHODS

A Korean nationwide population-based cohort of a total of 3,280,826 participants aged 20-39 years old who underwent 2 consecutive health examinations were included. They were followed up until the date of CVD (myocardial infarction [MI] or stroke), or December 2018 (median, 6 years).

RESULTS

Current smoking, early age of smoking initiation, and smoking intensity were associated with an increased risk of CVD incidence. Even after quitting smoking, the risk of MI was still high in quitters compared with non-smokers. Cigarette smoking, obesity, and depression were independently associated with a 1.3-1.7 times increased risk of CVD, and clustering of 2 or more of these behavioral risk factors was associated with a 2-3 times increased risk of CVD in young adults.

CONCLUSIONS

In young adults, cigarette smoking was associated with the risk of CVD, and the clustering of 2 or more behavioral risk factors showed an additive risk of CVD.

The Current Burden of Oropharyngeal Cancer: A Global Assessment Based on GLOBOCAN 2020

BACKGROUND

Oropharyngeal cancer (OPC) is a complex disease whose etiologies, either related to risk factors such as smoking or alcohol, or linked to HPV infection, are believed to be responsible for wide gender and geographical variability. This study depicts the current burden of OPC worldwide.

METHODS

Estimated OPC new cases, deaths, age-standardized rates (ASR) for both incidence and mortality in 2020 were obtained from the GLOBOCAN database for each country and across 20 UN-defined world regions by sex. The incidence-to-mortality ratio (IMR) was also estimated from ASR.

RESULTS

Worldwide, 98,400 new cases and 48,100 OPC deaths were estimated in 2020, with ASR of 1.1 and 0.51 per 100,000 for incidence and mortality, respectively. ASR for both incidence and mortality were approximately four times higher in men and varied greatly across geographical regions and countries within the same region. Higher incidence was estimated in Europe, North-America, Australia, and New Zealand. Mortality was the highest in Central-East Europe, Western Europe, Melanesia, South-Central Asia, and the Caribbean. South-Central Asia, most African areas, and Central America exhibited the lowest IMR values, whereas North-America, Australia, New Zealand, and North-Europe had the highest.

CONCLUSIONS

The marked geographical and gender variability in OPC incidence and mortality is likely to reflect the distribution of risk factors and the diverse prevalence of HPV-negative and HPV-positive cases.

IMPACT

Findings are likely to drive future research, support the development of targeted strategies to counteract disease burden, establish priorities for prevention and treatment programs, and address inequality in access to services.

Impact of the '10,000 lives' program on Quitline referrals, use and outcomes by demography and Indigenous status

INTRODUCTION

In November 2017, Central Queensland Public Health Unit launched the '10,000 Lives' initiative to reduce smoking prevalence in Central Queensland. The program partnered with local champions and other programs (e.g. 'Deadly Choices') to promote the use of smoking cessation services (e.g. Quitline) in Central Queensland. This study assesses the program's impact on Quitline use by participant demographics and Indigenous status.

METHODS

We compared the number of referred individuals who participated in and completed the Quitline program, and quit smoking during 26-months before (July 2015 to August 2017) and after (November 2017 to December 2019) the '10,000 Lives' launch. We conducted an interrupted time series analysis of monthly referrals to and use of Quitline for Aboriginal and Torres Strait Islander peoples.

RESULTS

Overall, 3207 individuals were referred to Quitline during the 26-months-post-launch compared to 1594 during 26-months-pre-launch period of '10,000 Lives'. The number of referred individuals who completed Quitline program increased by 330.7% and quit smoking by 308.3% in post-launch period. The increase was substantially higher among aged 45+ years, females and Aboriginal and Torres Strait Islander peoples. The result for referrals and use of Quitline was validated by interrupted time series analysis for Aboriginal and Torres Strait Islander peoples.

DISCUSSION AND CONCLUSIONS

The '10,000 Lives' collaborative approach to partner with local champions and targeted smoking cessation programs was effective in increasing the use of Quitline and smoking cessation among all demographic groups, including Aboriginal and Torres Strait Islander peoples. This approach can be used in other regions to address higher smoking prevalence.

Health impact of e-cigarettes and heated tobacco products in chronic obstructive pulmonary disease: current and emerging evidence

INTRODUCTION

Quitting is the only proven method to attenuate the progression of chronic obstructive pulmonary disease (COPD). However, most COPD smokers do not seem to respond to smoking cessation interventions and may benefit by lessening the negative health effects of long-term cigarette smoke exposure by switching to non-combustible nicotine delivery alternatives, such as heated tobacco products (HTPs) and e-cigarettes (ECs).

AREAS COVERED

Compared with conventional cigarettes, HTPs and ECs offer substantial reduction in exposure to toxic chemicals and have the potential to reduce harm from cigarette smoke when used as tobacco cigarette substitutes. In this review, we examine the available clinical studies and population surveys on the respiratory health effects of ECs and HTPs in COPD patients.

EXPERT OPINION

The current research on the impact of ECs and HTPs on COPD patients' health is limited, and more high-quality studies are needed to draw definitive conclusions. However, this review provides a comprehensive overview of the available literature for health professionals looking to advise COPD patients on the use of these products. While ECs and HTPs may offer some benefits in reducing harm from cigarette smoke, their long-term effects on COPD patients' health are still unclear.

Firearm injury-a preventable public health issue

Firearm-related injury is a leading cause of death disproportionately affecting adolescents and young adults across the world, especially in the Americas. Little progress has been made over the past four decades, as inaction and the adoption of ineffective or unevidenced interventions have become commonplace. The COVID-19 pandemic reconfigured health systems towards prevention and harm reduction, sharpened public attention to the burden of preventable deaths, and inspired a fresh ambition of eliminating avertable deaths. In this Viewpoint, we argue that preventing firearm injury should garner bolder action in post-pandemic public health and we present a case for reducing the global burden of firearm injury supported by evidence and international examples. Crucially, we aim to guide policy making in directions that end the cycle of grief, anger, activism, deflection, and inaction and create more peaceful and fairer societies.

Age-sex differences in the global burden of lower respiratory infections and risk factors, 1990-2019: results from the Global Burden of Disease Study 2019

BACKGROUND

The global burden of lower respiratory infections (LRIs) and corresponding risk factors in children older than 5 years and adults has not been studied as comprehensively as it has been in children younger than 5 years. We assessed the burden and trends of LRIs and risk factors across all age groups by sex, for 204 countries and territories.

METHODS

In this analysis of data for the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we used clinician-diagnosed pneumonia or bronchiolitis as our case definition for LRIs. We included International Classification of Diseases 9th edition codes 079.6, 466-469, 470.0, 480-482.8, 483.0-483.9, 484.1-484.2, 484.6-484.7, and 487-489 and International Classification of Diseases 10th edition codes A48.1, A70, B97.4-B97.6, J09-J15.8, J16-J16.9, J20-J21.9, J91.0, P23.0-P23.4, and U04-U04.9. We used the Cause of Death Ensemble modelling strategy to analyse 23 109 site-years of vital registration data, 825 site-years of sample vital registration data, 1766 site-years of verbal autopsy data, and 681 site-years of mortality surveillance data. We used DisMod-MR 2.1, a Bayesian meta-regression tool, to analyse age-sex-specific incidence and prevalence data identified via systematic reviews of the literature, population-based survey data, and claims and inpatient data. Additionally, we estimated age-sex-specific LRI mortality that is attributable to the independent effects of 14 risk factors.

FINDINGS

Globally, in 2019, we estimated that there were 257 million (95% uncertainty interval [UI] 240-275) LRI incident episodes in males and 232 million (217-248) in females. In the same year, LRIs accounted for 1·30 million (95% UI 1·18-1·42) male deaths and 1·20 million (1·07-1·33) female deaths. Age-standardised incidence and mortality rates were 1·17 times (95% UI 1·16-1·18) and 1·31 times (95% UI 1·23-1·41) greater in males than in females in 2019. Between 1990 and 2019, LRI incidence and mortality rates declined at different rates across age groups and an increase in LRI episodes and deaths was estimated among all adult age groups, with males aged 70 years and older having the highest increase in LRI episodes (126·0% [95% UI 121·4-131·1]) and deaths (100·0% [83·4-115·9]). During the same period, LRI episodes and deaths in children younger than 15 years were estimated to have decreased, and the greatest decline was observed for LRI deaths in males younger than 5 years (-70·7% [-77·2 to -61·8]). The leading risk factors for LRI mortality varied across age groups and sex. More than half of global LRI deaths in children younger than 5 years were attributable to child wasting (population attributable fraction [PAF] 53·0% [95% UI 37·7-61·8] in males and 56·4% [40·7-65·1] in females), and more than a quarter of LRI deaths among those aged 5-14 years were attributable to household air pollution (PAF 26·0% [95% UI 16·6-35·5] for males and PAF 25·8% [16·3-35·4] for females). PAFs of male LRI deaths attributed to smoking were 20·4% (95% UI 15·4-25·2) in those aged 15-49 years, 30·5% (24·1-36·9) in those aged 50-69 years, and 21·9% (16·8-27·3) in those aged 70 years and older. PAFs of female LRI deaths attributed to household air pollution were 21·1% (95% UI 14·5-27·9) in those aged 15-49 years and 18·2% (12·5-24·5) in those aged 50-69 years. For females aged 70 years and older, the leading risk factor, ambient particulate matter, was responsible for 11·7% (95% UI 8·2-15·8) of LRI deaths.

INTERPRETATION

The patterns and progress in reducing the burden of LRIs and key risk factors for mortality varied across age groups and sexes. The progress seen in children younger than 5 years was clearly a result of targeted interventions, such as vaccination and reduction of exposure to risk factors. Similar interventions for other age groups could contribute to the achievement of multiple Sustainable Development Goals targets, including promoting wellbeing at all ages and reducing health inequalities. Interventions, including addressing risk factors such as child wasting, smoking, ambient particulate matter pollution, and household air pollution, would prevent deaths and reduce health disparities.

FUNDING

Bill & Melinda Gates Foundation.

Change in smoking status and its relation to the risk of gastroduodenal ulcer in Korean men

BACKGROUND AND AIM

Smoking is associated with the increased risk of gastroduodenal ulcer. However, although smoking status can vary over time, most of studies have analyzed this association with smoking status at a single point of time. We analyzed the risk of gastroduodenal ulcer according to change in smoking status for more than 5 years.

METHODS

Study participants were 43 380 Korean adults free of gastroduodenal ulcer who received health check-up between 2002 and 2013. Through evaluating their smoking status (never, quitter, and current) at 2003-2004 and 2009, they were categorized them into seven groups (never-never, never-quitter, never-current, quitter-quitter, quitter-current, current-quitter, and current-current) and monitored until 2013 to identify incident gastroduodenal ulcer. Cox-proportional hazard model was used to calculate the adjusted hazard ratios (HRs) and 95% confidence interval (CI) for incident gastroduodenal ulcer according to changes in smoking status and smoking amount.

RESULTS

Compared with never-never group (reference), other groups had the significantly increased adjusted HRs and 95% CI for gastroduodenal ulcer. In particular, participants with current smoking (never-current, quitter-current, and current-current) had the relatively higher HRs than other groups (never-quitter: 1.200 [1.070-1.346], never-current: 1.375 [1.156-1.636], quitter-quitter: 1.149 [1.010-1.306], quitter-current: 1.325 [1.058-1.660], current-quitter: 1.344 [1.188-1.519], and current-current: 1.379 [1.256-1.513]). Heavy smoker had the highest risk for gastroduodenal ulcer, followed by moderate and light smoker.

CONCLUSION

People who ever experienced smoking had increased risk of gastroduodenal ulcer. Out of smoking status, current smoking is more associated with the increased risk of gastroduodenal ulcer than past smoking.

Effects of fun-seeking and external locus of control on smoking behaviour: a cross-sectional analysis on a cohort of working men in Singapore

OBJECTIVES

We examined the combined effects of behavioural inhibition and behavioural activation, on one hand, and locus of control, on the other hand, on different categories of smoking behaviour (non-smoking, ex-smoking, occasional smoking, daily smoking).

DESIGN

This study adopted a cross-sectional design. Participants completed questionnaires regarding demographics, smoking patterns, behavioural inhibition/behavioural activation systems and locus of control.

SETTING

The study was conducted across four companies from the transportation, cooling plant and education sectors in Singapore.

PARTICIPANTS

Three hundred sixty-nine male working adults were included in the final sample.

RESULTS

Corroborating previous research, a logistic regression model examining behavioural inhibition/behavioural activation systems revealed that the fun-seeking aspect of behavioural activation was a unique predictor in distinguishing non-smokers from daily smokers (OR=1.24, p=0.012). By contrast, in a separate model examining locus of control, external locus of control was found to be a unique predictor in distinguishing non-smokers from daily smokers (OR=1.13, p<0.001). In addition, a third model combining both behavioural inhibition/behavioural activation systems and locus of control found that only external locus of control remained a significant predictor (OR=1.12, p<0.001). Further analyses revealed a mediating effect of external locus of control on the relationship between fun-seeking and smoking behaviour. That is, the increase in the odds of daily smoking due to fun-seeking was explained by external locus of control (direct pathway OR=1.20, p=0.058; indirect pathway OR=1.04, p<0.050).

CONCLUSIONS

Overall, fun-seeking through its influence on external locus of control indirectly affects daily smoking behaviour, suggesting a more complex relationship than shown in previous research.

The Differential Impact of the 2000 Canadian Graphic Warning Label Policy on Smoking Prevalence by Sex and Education: A Difference-in-Difference-in-Difference Model

INTRODUCTION

Using a quasiexperimental design, we compared the impact of the 2000 Canadian introduction of graphic warning labels (GWLs) on differences in smoking prevalence by sex and education, to the United States, where no GWLs were introduced.

METHODS

We pooled 1999-2004 data from the Canadian Tobacco Use Monitoring Survey and the U.S. Behavioral Risk Factor Surveillance System. We used a difference-in-difference (DD) model to assess the impact of Canadian policy introduction on smoking prevalence, and a difference-in-difference-in-difference (DDD) model to examine differences in the policy impact by sex and education, comparing Canada (the treatment group) with the United States (the control group).

RESULTS

From 1999 to 2004, smoking prevalence decreased from 23.7% to 18.6% in Canada, and from 21.7% to 20.0% in the United States. Results from the DD regression models showed that Canadian respondents reported lower odds of being a current smoker compared to the U.S. respondents following the 2000 introduction of GWLs (OR = 0.84, 95% CI = 0.74-0.94). The DDD model showed that the impact of the Canadian GWLs versus the United States did not differ by sex or education.

CONCLUSIONS

The 2000 Canadian GWL policy reduced smoking prevalence overall, with similar reductions for males and females and across education levels. The impact of the Canadian GWLs in reducing smoking prevalence did not reduce differences by sex or education. Although beneficial for all smokers, GWLs may not serve to decrease existing disparities, especially those by socioeconomic status.

IMPLICATIONS

Existing evidence shows that GWL implementation is associated with reductions in smoking prevalence. But there is limited evidence from past evaluation studies on whether the impact of GWLs on smoking prevalence differs by sociodemographic subgroup. Our findings confirm existing studies that the 2000 implementation of GWLs in Canada was significantly associated with an overall reduction in smoking prevalence in Canada compared to the United States. However, our study improves existing evidence by showing that the impact of the Canadian GWLs on smoking prevalence did not differ by sex or education, and thus did not reduce existing smoking disparities by educational levels.

Facilitating conditions for staff's confidence to enforce school tobacco policies: qualitative analysis from seven European cities

Background

School staff members’ consistent enforcement of school tobacco policies (STPs) is needed to decrease adolescent smoking and exposure to tobacco smoke. Staff’s confidence, indicating their perceived ability to cope with students’ negative responses, explains variations in staff’s STPs enforcement, yet understanding of the determinants for confidence is lacking. We analyzed the conditions in which the staff feel confident in addressing students who violate STPs to support staff’s enforcement. 

Methods

Data consists of 81 semi-structured interviews with the staff members from 26 secondary schools in seven European cities in Belgium, Finland, Germany, Ireland, Italy, The Netherlands, and Portugal. In every city, 3–4 staff members (senior management, teachers, supportive staff) in 3–4 schools (academic–vocational, high–low SES area) were interviewed. Transcripts were analyzed with thematic analysis.

Results

When staff felt confident in their ability to prevent, diminish, or handle students’ negative responses, they were more likely to address students on STP violations. The staff was more confident (1) when consistent policy enforcement within school and regarding the wider society ensured staff legitimacy for STPs enforcement, (2) when dialog and mutual familiarity with students allowed the staff to facilitate constructive interaction with STP violators, and (3) when organizational backup structures provided staff collegial support to overcome challenges in the enforcement. These conditions would support consistent enforcement, especially with persistent misbehavers and among the more uncertain staff members.

Conclusions

Our study stresses the need to implement strategies at multiple levels to strengthen staff’s confidence for STP enforcement. To support staff’s legitimacy for enforcement, we suggest reinforcing structures and practices that facilitate consistency in STP enforcement; to support staff’s ability for constructive interaction with STP violators, we suggest strengthening staff’s social and emotional learning; and to support staff’s experience of collegial support, we suggest reinforcing staff’s collective ability to cope with students’ negative responses.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00362-7.

Trends of cancer incidence among Chinese older adults from 2005 to 2016: A log-linear regression and age-period-cohort analysis

Background

To study the corresponding strategies for controlling cancer in older adults aged 60 and above in China, a comprehensive assessment of disease burden is required. Therefore, we will introduce the cancer epidemiological characteristics of older adults in China over a recent 12 year period.

Methods

The age-period-cohort model was constructed using the cancer incidence data from the Chinese Cancer Registry Annual Report published in 2008-2019. The annual change percentage (APC) was estimated by log-linear regression to reflect the time trend. The data from the GLOBOCAN 2020 database was selected for worldwide comparative analysis.

Results

The cancer incidence in older adults aged 60 and above in China showed a decreasing trend (APC = -0.73%, P = 0.009). The urban/rural ratio of cancer incidence increased from 0.94 to 1.07 (t = 3.52, P < 0.05), while the sex ratio (male/female) showed a significant decreasing trend only in rural areas (t = -6.77, P < 0.05), and the ratio decreased from 2.02 to 1.72. The results of the age-period-cohort model showed that the cancer incidence increased with age in both males and females, urban and rural areas. The RR of period effect increased from 2005 to 2010, then decreased from 2010 to 2015, and the downward trend was more obvious. The RR of the later-born cohort was lower than that of the earlier-born cohort in rural areas. Lung, gastric, colorectal, esophageal, liver, and breast cancers were common cancers in Chinese older adults. Lung cancer incidence ranked first in males, and it decreased with time in the 75-79 and 80-84 age groups (APC_{75 - 79} = -1.10%, APC_{80 - 84} = -0.88%, all P < 0.05). Breast cancer incidence ranked first among female in the 60-64 age group and showed an increasing trend (APC_{60 - 64} = 1.52%, P < 0.05).

Conclusions

The cancer incidence in Chinese older adults aged 60 and above showed a decreasing trend, but it was still at a relatively high level. The key targets of prevention and treatment should be males, urban areas, younger people, older adults aged 60-69, lung, gastrointestinal, and breast cancers in the future.

Tobacco industry messaging around harm: Narrative framing in PMI and BAT press releases and annual reports 2011 to 2021

Influencing public perception is a key way in which all transnational corporations (TNCs) maintain market dominance and political power. Transnational tobacco companies (TTCs) have a long history of leveraging narratives to serve commercial ambitions. The global reach of these companies' narratives has been highlighted as a challenge in combatting public health problems caused by tobacco. The corporate power of TTCs is carefully curated, and their narratives play an important role in the setting of governance dynamics at local, national and transnational levels. This qualitative work explores and compares the language used by British American Tobacco (BAT) and Philip Morris International (PMI) around harm, harm reduction and terms used to refer to newer nicotine and tobacco products, including electronic cigarettes and heated tobacco products. We systematically examine framings used by these two TTCs through company reports published between 2011 and 2021. Qualitative coding was carried out by four coders, according to a protocol developed specifically for this work. We firstly identified the presence of pre-selected keywords and then assigned chunks of text containing those key words to one or more associated frames drawn from Boydstun's policy frames codebook (2013). Qualitative coding identified the most common frames from Boydstun's codebook and thematic analysis highlighted three overarching themes. The most common frames assigned were "capacity and resources", "health and safety" and "economic" frames. The overarching themes were individualization, normalization, and regulation. These themes capture how both BAT and PMI use particular framings to downplay the role of TTCs in the perpetuation of population- and individual-level harms related to tobacco use. They seek to normalize their role in public discussions of health policy, to cast themselves as instrumental in the redress of tobacco-related inequalities and shift responsibility for the continuation of tobacco-product use onto individual consumers. These tactics are problematic for the effective and impartial development and implementation of local, national and international tobacco control agendas.

Evidence-based core information for health communication of tobacco control: The effect of smoking on risks of female disease

Objective

Cigarettes have become the the biggest killer of contemporary female's health and beauty. What kind of health information is suitable for the general public is an important issue to be discussed globally. The purpose of this study is to generate systematic, rigorous, public-demand-oriented and appropriate core information relevant to tobacco control based on the best available evidence, combined with audience preferences and pre-dissemination content review from multidisciplinary expertise in order to improve the effectiveness of health communication of tobacco control.

Methods

Relevant systematic reviews meta-analysis that reported smoking on risks of female disease were identified by searching PubMed, Embase, the Cochrane Library, Web of Science, Clinical Trials.gov, and the International Clinical Trial Registry Platform. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was applied to assess the evidence in order to make rigorous core information. The audience prevalence survey was conducted to ensure that core information was targeted and tailored. Finally, the expert assessment was used for a pre-dissemination content review and to evaluate whether the core information was appropriate or not.

Results

The final core information consisted of eight parts concerning the effects of smoking and female cardiovascular disease, diabetes, rheumatoid arthritis, respiratory disease, digestive system disease, mental disease, non-pregnant female reproductive system disease, as well as pregnant women and their fetuses. A total of 35 items of core information suitable for dissemination was included and the quality of evidence, the degree of public demand and the outcome of pre-dissemination content review were reported.

Conclusion

The core information related to female cardiovascular system diseases, as well as liver cancer and upper gastrointestinal cancer is the preferred content for health communication of tobacco control. The quality of evidence for core information related to pregnant women and their infants, as well as diseases of reproductive system, respiratory system, and diabetes needs to be improved to meet high public demand. The core information related to mental disease is more suitable for dissemination to patients with mental illness than to the general public. Besides, dissemination of core information should be individualized. Evidence-based Core Information for Health Communication of Tobacco Control would be helpful to provide evidence support for health communication related to tobacco control and enhance public health literacy for international communities that have high smoking prevalence and related disease burden.

Analysis of nicotine dependence among daily smokers in China: evidence from a cross-sectional study in Zhejiang Province

OBJECTIVE

The current study aimed to assess the level of nicotine dependence and its influencing factors among daily smokers in Zhejiang, China.

SETTING

The 2020 Global Adult Tobacco Survey was conducted in Zhejiang, China.

PARTICIPANTS

1244 daily smokers aged ≥15 years.

MEASURES

Respondents were asked questions regarding their age, sex, residence, education level, occupation, household income, age of starting daily smoking and nicotine dependence.

RESULTS

The findings revealed that 17.4% of daily smokers were highly dependent on nicotine, and the mean Fagerström Test for Nicotine Dependence score of daily smokers was (3.1±2.4). Age, educational level, occupation and age of starting daily smoking had significant effects on high nicotine dependence, whereas residence, sex and yearly household income were not significant factors. Compared with the age group ≥60 years, the proportion of respondents with a higher nicotine dependence level was lower in the age group of 15-39 years (OR=0.45). Daily smokers with a higher education level had a lower nicotine dependence level than those with a lower education level: primary or less (OR=3.07) and secondary (OR=2.62). Government institution staff (OR=4.02), unemployed persons (OR=3.08) and industrial workers (OR=2.46) had significantly higher nicotine dependence levels than did workers in the other occupation categories. People who started daily smoking at ≤18 years of age had a higher nicotine dependence level (OR=2.25) than those who started later.

CONCLUSIONS

This study elucidated that nearly one-fifth of daily smokers in Zhejiang, China, have high nicotine dependence levels. Improved health information on tobacco smoking is needed to encourage daily smokers to quit smoking, particularly among young males, unemployed persons and those with lower education levels.

Advances in Population-Based Healthcare Research: From Measures to Evidence

Whether "population health" encompasses a concept of health or a field of study of health determinants is not yet defined, though the term is widely used in healthcare and research worldwide [...].

Barriers Against and Motivations for Quitting Smoking during the COVID-19 Health Crisis: Results of a Qualitative Study in France

The COVID-19 epidemic and its psychological, economic and social consequences could have an impact on the evolution of tobacco-smoking prevalence and attitudes towards quitting. The aim of this study is to analyse the specific characteristics of the motivations for and barriers against smoking cessation in this period. The study is based on qualitative data collected from late 2020 to early 2021 in France from 89 smokers with a low or intermediate socio-economic level. Among the motivations for quitting smoking, health concerns and the financial cost of cigarettes carried increased importance among the smokers in this period. Inversely, perceived stress, isolation, and a lack of social or healthcare support prevented some smokers from attempting to quit. These results are useful for explaining the evolution of smoking prevalence and preparing future interventions in the context of the health crisis and its aftermath. They highlight the relevance of educational messages, of the promotion of validated smoking-cessation aids and, in particular, remote support, as well as the implementation of community-based actions.

Substance Use and Mental Health during the First COVID-19 Lockdown in Germany: Results of a Cross-Sectional Survey

BACKGROUND

The measures taken to contain the COVID-19 pandemic have led to significant changes in people's daily lives. This paper examines changes in substance use during the first lockdown (March-July 2020) and investigates mental health burdens in substance users with increased consumption of alcohol, nicotine or tetrahydrocannabinol (THC) in Germany compared to users with unchanged or reduced consumption.

METHOD

In a cross-sectional online survey, 2369 people were asked about their mental health and their substance use during the first lockdown in Germany.

RESULTS

Of the participants, 28.5% increased their alcohol use, 28.8% their use of tobacco products, and 20.6% their use of THC-containing products during the pandemic. The groups with increased alcohol, nicotine, and THC use during the first lockdown reported more depressive symptoms and anxiety. Individuals who reported increased consumption of alcohol or nicotine were also more likely to experience loneliness and have suicidal thoughts and were more often stressed due to social distancing.

CONCLUSION

Alcohol, nicotine and THC increased in a subgroup of consumers who reported to have more mental health problems compared to individuals who did not increase their consumption. This increased substance use could, therefore, be understood as a dysfunctional strategy to cope with negative emotions during the lockdown.

The case for investment in tobacco control: lessons from four countries in the Americas

Objective

To synthesize learnings from four national tobacco control investment cases conducted in the Americas (Colombia, Costa Rica, El Salvador, Suriname) under the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) 2030 project, to describe results and how national health authorities have used the cases, and to discuss implications for the role of investment cases in advancing tobacco control.

Methods

We draw on findings from four national investment cases that included 1) a cost-of-illness analysis calculating the health and economic burden of tobacco use, 2) a return-on-investment analysis of implementing key tobacco control demand reduction measures, and 3) a subsidiary analysis of one tobacco control topic of national interest (e.g., equity implications of cigarette taxation). Co-authors reported how cases have been used to advance tobacco control.

Results

In Colombia, Costa Rica, El Salvador, and Suriname, tobacco use causes social and economic losses equivalent to between 1.0 to 1.8 percent of GDP. Across these countries, implementing WHO FCTC demand reduction measures would save an average of 11 400 lives per year over the next 15 years. Benefits of the measures would far outweigh the costs of implementation and enforcement. Governments are using the cases to advance tobacco control, including to improve tobacco control laws and their enforcement, strengthen tobacco taxation, prioritize tobacco control planning, coordinate a multisectoral response, and engage political leaders.

Conclusions

National investment cases can help to strengthen tobacco control in countries, including by increasing public and political support for implementation of the WHO FCTC and by informing effective planning, legislation, coordination and financing.

Association Between Smoking, Smoking Cessation, and Mortality by Race, Ethnicity, and Sex Among US Adults

Importance

Patterns of cigarette smoking and smoking cessation vary considerably across demographic groups in the US, but there is limited evidence on whether the hazards of smoking and benefits of quitting vary across these groups. Population-specific evidence on the benefits of quitting smoking may motivate cessation among groups historically underrepresented in medical research.

Objective

To quantify the association between smoking, smoking cessation, and mortality by race, ethnicity, and sex.

Design, Setting, and Participants

This nationally representative, prospective cohort study used data from the US National Health Interview Survey collected via questionnaire between January 1997 and December 2018 among adults aged 25 to 84 years at recruitment. Participants were followed up for cause-specific mortality through December 31, 2019.

Exposures

Self-reported smoking status at recruitment, age at quitting smoking, and years since quitting smoking.

Main Outcomes and Measures

The main outcomes were all-cause mortality and mortality from cancer, cardiovascular disease, and lower respiratory disease. Adjusted mortality rate ratios comparing never, former, and current smokers were calculated using Cox proportional hazards regression. Weighted analyses were conducted by race, ethnicity, and sex as reported by participants.

Results

Among the 551 388 participants in the main analyses, the mean (SD) age at recruitment was 48.9 (15.3) years; 307 601 (55.8%) were women, 87 207 (15.8%) were Hispanic, 75 545 (13.7%) were non-Hispanic Black, 355 782 (64.5%) were non-Hispanic White, and 32 854 (6.0%) identified as other non-Hispanic race and ethnicity. There were 74 870 deaths among participants aged 25 to 89 years during follow-up (36 792 [49.1%] among men; 38 078 [50.9%] among women). The all-cause mortality rate ratio (RR) for current vs never smoking was 2.80 (95% CI, 2.73-2.88) overall. The RRs were similar by sex but varied by race and ethnicity: Hispanic, 2.01 (95% CI, 1.84-2.18); non-Hispanic Black, 2.19 (95% CI, 2.06-2.33); non-Hispanic White, 3.00 (95% CI, 2.91-3.10); and other non-Hispanic race and ethnicity, 2.16 (95% CI, 1.88-2.47). When comparing those who quit smoking before age 45 years with never smokers, all-cause mortality RRs were 1.15 (95% CI, 1.03-1.28) among Hispanic individuals, 1.16 (95% CI, 1.07-1.25) among non-Hispanic Black individuals, 1.11 (95% CI, 1.08-1.15) among non-Hispanic White individuals, and 1.17 (95% CI, 0.99-1.39) among other non-Hispanic individuals.

Conclusions and Relevance

In this prospective cohort study, among men and women from diverse racial and ethnic groups, current smoking was associated with at least twice the all-cause mortality rate of never smoking. Quitting smoking, particularly at younger ages, was associated with substantial reductions in the relative excess mortality associated with continued smoking.

Economic loss attributable to cigarette smoking in the USA: an economic modelling study

BACKGROUND

Despite large geographical disparities in the prevalence of cigarette smoking across the USA, there is a paucity of state-level estimates of economic loss attributable to smoking to inform tobacco control policies at the national and state levels. We aimed to estimate the state-level economic loss attributable to cigarette smoking in the USA.

METHODS

In this economic modelling study, we used a dynamic macroeconomic model of personal income per capita at the state level. Based on publicly available data on state-level income, its determinants, and smoking status for 2011-20, we first estimated the elasticity of personal income per capita with respect to the prevalence of non-smoking adults (aged ≥18 years) in the USA using a mixed-effects, generalised linear, dynamic panel data model. We used the estimated elasticity to measure the state-specific, annual, avoidable economic loss attributable to cigarette smoking in 2020 under the counterfactual 5% prevalence of cigarette smoking. We then estimated the state-specific cumulative economic loss attributable to cigarette smoking in 2020 using the coefficient of lagged income in the dynamic model. National estimates on economic loss attributable to cigarette smoking were obtained by summing state-specific estimates.

FINDINGS

In the mixed-effects model, the elasticity of personal income per capita with respect to the prevalence of non-smoking adults was 0·143 (p=0·063). The estimated annual income loss per capita in 2020 ranged from US$331 in Utah to $1674 in Kentucky. The state mean population-weighted loss per capita was $1100. The annual combined loss of income and unpaid household production at the national level was $436·7 billion (equivalent to 2·1% of US gross domestic product [GDP] in 2020). The cumulative loss of income and unpaid household production was $864·5 billion (equivalent to 4·3% of US GDP in 2020).

INTERPRETATION

Smoking causes substantial economic loss in the USA. Tobacco control efforts that lower the prevalence of smoking equitably can contribute considerably to improved macroeconomic performance in the short and long term by reducing health expenditures and avoiding productivity losses.

FUNDING

American Cancer Society.

Is early-onset cancer an emerging global epidemic? Current evidence and future implications

Over the past several decades, the incidence of early-onset cancers, often defined as cancers diagnosed in adults <50 years of age, in the breast, colorectum, endometrium, oesophagus, extrahepatic bile duct, gallbladder, head and neck, kidney, liver, bone marrow, pancreas, prostate, stomach and thyroid has increased in multiple countries. Increased use of screening programmes has contributed to this phenomenon to a certain extent, although a genuine increase in the incidence of early-onset forms of several cancer types also seems to have emerged. Evidence suggests an aetiological role of risk factor exposures in early life and young adulthood. Since the mid-20th century, substantial multigenerational changes in the exposome have occurred (including changes in diet, lifestyle, obesity, environment and the microbiome, all of which might interact with genomic and/or genetic susceptibilities). However, the effects of individual exposures remain largely unknown. To study early-life exposures and their implications for multiple cancer types will require prospective cohort studies with dedicated biobanking and data collection technologies. Raising awareness among both the public and health-care professionals will also be critical. In this Review, we describe changes in the incidence of early-onset cancers globally and suggest measures that are likely to reduce the burden of cancers and other chronic non-communicable diseases.

Roles, experiences and perspectives of the stakeholders of "10,000 Lives" smoking cessation initiative in Central Queensland: Findings from an online survey during COVID-19 situation

ISSUE ADDRESSED

The "10,000 Lives" initiative was launched in Central Queensland in November 2017 to reduce daily smoking prevalence to 9.5% by 2030 by promoting available smoking cessation interventions. One of the main strategies was to identify and engage possible stakeholders (local champions for the program) from hospitals and community organisations to increase conversations about smoking cessation and referrals to Quitline. We aimed to understand the roles, experiences and perceptions of stakeholders (possible champions for delivering smoking cessation support) of the "10,000 Lives" initiative in Central Queensland, Australia.

METHODS

We conducted a mixed-method online survey during the COVID-19 situation (23 June 2020 to 22 August 2020) with a cross-section of possible stakeholders who were targeted for involvement in "10, 000 Lives" using a structured questionnaire with mostly closed-ended questions. Questions were asked regarding their roles, experiences and perceptions about smoking cessation and "10,000 Lives".

RESULTS

Among the 110 respondents, 52 (47.3%) reported having provided smoking cessation support, including referral to Quitline, brief intervention and promoting existing interventions. Among them (n = 52), 31 (59.6%) were from hospitals and health services, 14 (26.9%) were from community services and three (5.8%) were from private medical practices while four of them did not report their setting. Twenty-five respondents (22.7%) self-identified as being directly involved with the "10, 000 Lives" initiative, which significantly predicted provision of smoking cessation support (OR 6.0, 95% CI: 2.1-19.8). However, a substantial proportion (63.5%) of those (n = 52) who reported delivering cessation support did not identify as contributing to "10,000 Lives".

CONCLUSIONS

Stakeholders from hospitals, health services and community services are the main providers of smoking cessation support in Central Queensland. More could be done to support other stakeholders to feel confident about providing cessation support and to feel included in the initiative. SO WHAT?: Engaging with a range of stakeholders is critical for health promotion program success, to further develop the program and to ensure its sustainability. As such, funding needs to be allocated to the activities that enable this process to occur.

Tobacco Cessation Intervention for Young People

Most adolescent tobacco control programs focus on preventing consumption, but teen smoking persists. It is uncertain whether adult-specific therapies can assist adolescents in quitting smoking. The rising incidence of smoking in low and middle-socioeconomic countries and the challenges of conducting tobacco cessation programs in these settings (due to increasing population, poor lifestyle, lack of awareness and education, professional stress, and non-compliance) need an emphasis on the scope of trials to conduct tobacco cessation in these settings. In the 11th Five Year Plan, the Indian government introduced a new National Tobacco Control Program, which currently spans 108 districts in 31 states across the country. The objective is to review the randomized control trials of selected individuals held in India and assess and evaluate the effectiveness of the steps taken by the government to help people quit tobacco consumption. These programs are important because of the hazards and impact they have on the public health indices of the nation. The government has taken steps like prohibiting smoking in public areas and banning sources. Several programs, particularly those that employed group counselling, included a range of approaches that proved beneficial in helping young people quit smoking. The RCTs mentioned are psychosocially followed by behavioral and pharmacological therapies. The challenges faced are not having participatory health care, motivating tobacco users to quit even in the short-term, adequate coverage; barriers at a different level of implementation (at a regional, state, or national level); and interference by the tobacco industry should be eliminated. The currently functioning programs in India are the National Tobacco Control Program, the National and three Regional Quitlines and mCessation.

A global burden assessment of lung cancer attributed to residential radon exposure during 1990-2019

This study aimed to explore the spatial and temporal trends of lung cancer burden attributable to residential radon exposure at the global, regional, and national levels. Based on the Global Burden of Disease Study (GBD) 2019, we collected the age-standardized mortality rate (ASMR) and age-standardized disability-adjusted life rate (ASDR) of lung cancer attributable to residential radon exposure from 1990 to 2019. The Joinpoint model was used to calculate the annual average percentage change (AAPC) to evaluate the trend of ASMR and ASDR from 1990 to 2019. The locally weighted regression (LOESS) was used to estimate the relationship of the socio-demographic index (SDI) with ASMR and ASDR. In 2019, the global ASMR and ASDR for lung cancer attributable to residential radon exposure were 1.03 (95% CI: 0.20, 2.00) and 22.66 (95% CI: 4.49, 43.94) per 100 000 population, which were 15.6% and 23.0% lower than in 1990, respectively. According to the estimation, we found the lung cancer burden attributable to residential radon exposure declined significantly in high and high-middle SDI regions, but substantially increased in middle and low-middle SDI regions from 1990 to 2019. Across age and sex, the highest burden of lung cancer attributable to residential radon exposure was found in males and elderly groups. In conclusion, the global burden of lung cancer attributable to residential radon exposure showed a declining trend from 1990 to 2019, but a relatively large increase was found in the middle SDI regions. In 2019, the burden of lung cancer attributable to residential radon exposure remained high, particularly in males, the elderly, and high-middle SDI regions compared with other groups.