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

The Effect of Smoking on Humoral Response to COVID-19 Vaccines: A Systematic Review of Epidemiological Studies

While the role of active smoking on response to vaccines is yet to be fully understood, some real-world studies have outlined a possible link between smoking and humoral response to COVID-19 vaccines. Thus, the present rapid systematic review aimed at summarizing the current epidemiological evidence on this association. Following PRISMA and WHO guidelines on rapid systematic reviews, we systematically reviewed published literature on this topic and discussed the findings according to the aim of analysing smoking and its impact on humoral response to COVID-19 postvaccination antibody titres. The search strategy yielded a total of 23 articles. The sample size amongst the studies ranged between 74 and 3475 participants (median, 360), with the proportion of smokers being between 4.2% and 40.8% (median, 26.0%). The studies included in this review analysis investigated the dynamics of antibody response to different type of COVID-19 vaccines. In 17 out of 23 studies, current smokers showed much lower antibody titres or more rapid lowering of the vaccine-induced IgG compared with nonsmokers. This rapid systematic review indicates that active smoking negatively impacts humoral response to COVID-19 vaccines, although the pathophysiologic mechanisms for this association have not been entirely suggested. The results advocate targeted policies to promote tailored health promotion initiatives, which can increase risk perception and ensure appropriate protection measures to be taken to avoid the health consequences of COVID-19 in smokers.

Prevalencia de enfermedades no transmisibles y factores de riesgo en industria de Minas Gerais

Objetivo: estimar a prevalência de doenças e agravos não transmissíveis e seus fatores de risco em industriários de Minas Gerais, Brasil. Materiais e método: estudo transversal com dados secundários cedidos pelo Serviço Social da Indústria. As variáveis estudadas foram tabagismo, uso de álcool, inatividade física, alimentação inadequada, excesso de peso, doenças e agravos não transmissíveis referidos e autoavaliação da saúde. Calcularam-se as prevalências e as diferenças segundo sexo, faixa etária e escolaridade pelo teste x2 de Pearson. Na sequência, calcularam-se as razões de prevalência ajustadas pelas covariáveis por meio de regressão de Poisson. Resultados: foram estudados 34.072 trabalhadores. A prevalência de prática insuficiente de atividade física foi 75 %, consumo inadequado de frutas 66 % e consumo regular de refrigerante ou suco artificial 42 %. O tabagismo foi relatado por 10 %, fumo passivo no ambiente de trabalho por 14 % e uso abusivo de álcool por 30 %.  Dos trabalhadores, 55 % estavam acima do peso, 2 % referiram diabetes, 10 % hipertensão e 10 % colesterol elevado. Homens apresentaram maiores prevalências de alimentação inadequada e colesterol elevado. Conclusões: os resultados mostram baixa prevalência de atividade física, alto consumo de alimentos não saudáveis e de sobrepeso, além de elevada prevalência de consumo abusivo de álcool entre trabalhadores das indústrias de Minas Gerais.

Spatiotemporal Trends of Colorectal Cancer Mortality Due to Low Physical Activity and High Body Mass Index From 1990 to 2019: A Global, Regional and National Analysis

Background: Understanding the spatiotemporal trends of colorectal cancer (CRC) deaths caused by low physical activity (LPA) and high body mass index (BMI) is essential for the prevention and control of CRC. We assessed patterns of LPA and high BMI-induced CRC deaths from 1990 to 2019 at global, regional, and national levels.

Methods: Data on CRC deaths due to LPA and high BMI was downloaded from the Global Burden of Disease 2019 Study. We calculated estimated annual percentage change (EAPC) to quantify spatiotemporal trends in the CRC age-standardized mortality rate (ASMR) due to LPA and high BMI.

Results: In 2019, CRC deaths due to LPA and high BMI were estimated as 58.66 thousand and 85.88 thousand, and the corresponding ASMRs were 0.77/100,000 and 1.07/100,000, with EAPCs of−0.39 [95% confidence interval (CI):−0.49,−0.29] and 0.64[95% CI: 0.57, 0.71] from 1990 to 2019 respectively. Since 1990, the ASMR of CRC attributable to LPA and high BMI has been on the rise in many geographic regions, especially in low middle and middle sociodemographic index (SDI) regions. Thirteen countries had a significant downward trend in CRC ASMR attributed to LPA, with EAPCs < −1. And, only 4 countries had a significant downward trend in CRC ASMR attributable to high BMI, with EAPCs < −1. Countries with a higher baseline burden in 1990 and a higher SDI in 2019 had a faster decline in ASMR due to high BMI and LPA.

Conclusions: The burden of CRC caused by LPA and high BMI is on the rise in many countries. Countries should adopt a series of measures to control the local prevalence of obesity and LPA in order to reduce disease burden, including CRC.

Cigarette sharing and gifting in China: Patterns, associated factors, and behavioral outcomes

INTRODUCTION

The purpose of this study was to investigate the patterns and factors associated with cigarette sharing and gifting, and to explore whether smoking can be predicted by these social practices.

METHODS

A cross-sectional survey using a multi-stage sampling design was conducted online from 30 April to 30 July 2020 in China. A sample of 982 household heads from Guangdong Province and 530 household heads from Shaanxi province were involved in the data analysis. Demographic characteristics, social participation, beliefs and behaviors related to cigarette sharing and gifting were assessed. Chi-squared analysis and multiple logistic regression analysis were used to explore the key factors associated with cigarette sharing and gifting, and to identify their relationship with smoking.

RESULTS

The shared and gift cigarettes were both mainly offered to friends, and receiving gift cigarettes mostly occurred during the holidays. Gender and province were associated with cigarette sharing, and marital status and social participation were associated with cigarette gifting. Cigarette gifting beliefs and smoking status were prominent predictors for both sharing and gifting cigarettes. Cigarette gifting beliefs were significantly higher among smokers than non-smokers, and people with high cigarette gifting beliefs were 1.68 (adjusted odds ratio, AOR=19.17; 95% CI: 13.31-27.61) times more likely to be a smoker. Offering shared cigarettes has been found to significantly predict tobacco use (AOR=19.17; 95% CI: 13.31-27.61), while people who received shared and gift cigarettes were 1.50 (95% CI: 1.08-2.09) and 2.58 (95% CI: 1.66-4.00) times more likely to be a current smoker than those who did not receive cigarettes, respectively.

CONCLUSIONS

Cigarette sharing and gifting were especially pervasive among male smokers and married people in Shaanxi Province. Offering shared cigarettes and receiving shared/gift cigarettes might facilitate cigarette use. This study provides evidence-based data to support the design and implementation of tobacco control programs for the denormalization of gifting and sharing cigarettes.

Regional Differences in Precipitating Factors of Hospitalization for Acute Heart Failure: Insights from the REPORT‐HF Registry

AIMS

Few prior studies have investigated differences in precipitants leading to hospitalizations for acute heart failure (AHF) in a cohort with global representation.

METHODS AND RESULTS

We analysed the prevalence of precipitants and their association with outcomes in 18 553 patients hospitalized for AHF in REPORT-HF (prospective international REgistry to assess medical Practice with lOngitudinal obseRvation for Treatment of Heart Failure) according to left ventricular ejection fraction subtype (reduced [HFrEF] and preserved ejection fraction [HFpEF]) and presentation (new-onset vs. decompensated chronic heart failure [DCHF]). Patients were enrolled from 358 centres in 44 countries stratified according to Latin America, North America, Western Europe, Eastern Europe, Eastern Mediterranean and Africa, Southeast Asia, and Western Pacific. Precipitants were pre-with mutually exclusive categories and selected according to the local investigator's discretion. Outcomes included in-hospital and 1-year mortality. The median age was 67 (interquartile range 57-77) years, and 39% were women. Acute coronary syndrome (ACS) was the most common precipitant in patients with new-onset heart failure in all regions except for North America and Western Europe, where uncontrolled hypertension and arrhythmia, respectively, were the most common precipitants, independent of confounders. In patients with DCHF, non-adherence to diet/medication was the most common precipitant regardless of region. Uncontrolled hypertension was a more likely precipitant in HFpEF, non-adherence to diet/medication, and ACS were more likely precipitants in HFrEF. Patients admitted due to worsening renal function had the worst in-hospital (5%) and 1-year post-discharge (30%) mortality rates, regardless of region, heart failure subtype and admission type (p_interaction  >0.05 for all).

CONCLUSION

Data on global differences in precipitants for AHF highlight potential regional differences in targets for preventing hospitalization for AHF and identifying those at highest risk for early mortality.

Eye tracking applied to tobacco smoking: current directions and future perspectives

Over the years the general awareness of the health costs associated with tobacco smoking has motivated scientists to apply the measurement of eye movements to this form of addiction. On one hand they have investigated whether smokers attend and look preferentially at smoking related scenes and objects. In parallel, on the other hand eye tracking has been used to test how smokers and nonsmokers interact with the different types of health warning that policymakers have mandated in tobacco advertisements and packages. Here we provide an overview of the main findings from the different lines of research, such as the evidence related to the attentional bias for smoking cues in smokers and the evidence that graphic warning labels and plain packages measurably increase the salience of the warning labels. We point to some open questions, such as the conditions that determine whether heavy smokers exhibit a tendency to actively avoid looking at graphic warning labels. Finally we argue that the research applied to gaze exploration of warning labels would benefit from a more widespread use of the more naturalistic testing conditions (e.g. mobile eye tracking or virtual reality) that have been introduced to study the smokers' attentional bias for tobacco-related objects when freely exploring the surrounding environment.

Joint effect of particulate matter and cigarette smoke on women's sex hormones

BACKGROUND

Although relationships between exposure to air pollution and reproductive health are broadly studied, mechanisms behind these phenomena are still unknown. The aim of the study was to assess whether exposure to particulate matter (PM10) and tobacco smoking have an impact on menstrual profiles of 17β-estradiol (E2) and progesterone (P) and the E2/P ratio.

METHODS

Levels of sex hormones were measured daily in saliva during the entire menstrual cycle among 132 healthy, urban women. Exposure to smoking (active or passive) was assessed by questionnaire, whilst exposure to PM10 with municipal monitoring data.

RESULTS

During the early luteal phase, profiles of E2 were elevated among women with higher versus lower exposure to PM10 (p = 0.02, post-hoc tests). Among those who were exposed versus unexposed to tobacco smoking, the levels of mean E2 measured during the entire cycle were higher (p = 0.02). The difference in mean E2 levels between the group of joint exposure (i.e. to high PM10 and passive or active smoking) versus the reference group (low PM10, no smoking) was statistically significant at p = 0.03 (18.4 vs. 12.4 pmol/l, respectively). The E2/P ratios were higher among women with higher versus lower exposure to PM10 and this difference was seen only in the early luteal phase (p = 0.01, exploratory post-hoc tests).

CONCLUSIONS

We found that PM10 and tobacco smoking affect ovarian hormones independently and do not interact with each other. Both exposures appear to have estrogenic effects even though women's susceptibility to these effects differs across the menstrual cycle. We propose that the hormonal mechanisms are involved in observed relationships between air pollution and smoking with women's reproductive health.

Heated tobacco products for smoking cessation and reducing smoking prevalence

BACKGROUND

Heated tobacco products (HTPs) are designed to heat tobacco to a high enough temperature to release aerosol, without burning it or producing smoke. They differ from e-cigarettes because they heat tobacco leaf/sheet rather than a liquid. Companies who make HTPs claim they produce fewer harmful chemicals than conventional cigarettes. Some people report stopping smoking cigarettes entirely by switching to using HTPs, so clinicians need to know whether they are effective for this purpose and relatively safe. Also, to regulate HTPs appropriately, policymakers should understand their impact on health and on cigarette smoking prevalence.

OBJECTIVES

To evaluate the effectiveness and safety of HTPs for smoking cessation and the impact of HTPs on smoking prevalence.  SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group's Specialised Register, CENTRAL, MEDLINE, and six other databases for relevant records to January 2021, together with reference-checking and contact with study authors and relevant groups.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which people who smoked cigarettes were randomised to switch to exclusive HTP use or a control condition. Eligible outcomes were smoking cessation, adverse events, and selected biomarkers.  RCTs conducted in clinic or in an ambulatory setting were deemed eligible when assessing safety, including those randomising participants to exclusively use HTPs, smoke cigarettes, or attempt abstinence from all tobacco. Time-series studies were also eligible for inclusion if they examined the population-level impact of heated tobacco on smoking prevalence or cigarette sales as an indirect measure.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking at the longest follow-up point available, adverse events, serious adverse events, and changes in smoking prevalence or cigarette sales. Other outcomes included biomarkers of harm and exposure to toxicants/carcinogens (e.g. NNAL and carboxyhaemoglobin (COHb)). We used a random-effects Mantel-Haenszel model to calculate risk ratios (RR) with 95% confidence intervals (CIs) for dichotomous outcomes. For continuous outcomes, we calculated mean differences on the log-transformed scale (LMD) with 95% CIs. We pooled data across studies using meta-analysis where possible.

MAIN RESULTS

We included 13 completed studies, of which 11 were RCTs assessing safety (2666 participants) and two were time-series studies. We judged eight RCTs to be at unclear risk of bias and three at high risk. All RCTs were funded by tobacco companies. Median length of follow-up was 13 weeks. No studies reported smoking cessation outcomes.  There was insufficient evidence for a difference in risk of adverse events between smokers randomised to switch to heated tobacco or continue smoking cigarettes, limited by imprecision and risk of bias (RR 1.03, 95% CI 0.92 to 1.15; I2 = 0%; 6 studies, 1713 participants). There was insufficient evidence to determine whether risk of serious adverse events differed between groups due to very serious imprecision and risk of bias (RR 0.79, 95% CI 0.33 to 1.94; I2 = 0%; 4 studies, 1472 participants). There was moderate-certainty evidence for lower NNAL and COHb at follow-up in heated tobacco than cigarette smoking groups, limited by risk of bias (NNAL: LMD -0.81, 95% CI -1.07 to -0.55; I2 = 92%; 10 studies, 1959 participants; COHb: LMD -0.74, 95% CI -0.92 to -0.52; I2 = 96%; 9 studies, 1807 participants). Evidence for additional biomarkers of exposure are reported in the main body of the review. There was insufficient evidence for a difference in risk of adverse events in smokers randomised to switch to heated tobacco or attempt abstinence from all tobacco, limited by risk of bias and imprecision (RR 1.12, 95% CI 0.86 to 1.46; I2 = 0%; 2 studies, 237 participants). Five studies reported that no serious adverse events occurred in either group (533 participants). There was moderate-certainty evidence, limited by risk of bias, that urine concentrations of NNAL at follow-up were higher in the heated tobacco use compared with abstinence group (LMD 0.50, 95% CI 0.34 to 0.66; I2 = 0%; 5 studies, 382 participants). In addition, there was very low-certainty evidence, limited by risk of bias, inconsistency, and imprecision, for higher COHb in the heated tobacco use compared with abstinence group for intention-to-treat analyses (LMD 0.69, 95% CI 0.07 to 1.31; 3 studies, 212 participants), but lower COHb in per-protocol analyses (LMD -0.32, 95% CI -1.04 to 0.39; 2 studies, 170 participants). Evidence concerning additional biomarkers is reported in the main body of the review. Data from two time-series studies showed that the rate of decline in cigarette sales accelerated following the introduction of heated tobacco to market in Japan. This evidence was of very low-certainty as there was risk of bias, including possible confounding, and cigarette sales are an indirect measure of smoking prevalence.

AUTHORS' CONCLUSIONS

No studies reported on cigarette smoking cessation, so the effectiveness of heated tobacco for this purpose remains uncertain. There was insufficient evidence for differences in risk of adverse or serious adverse events between people randomised to switch to heated tobacco, smoke cigarettes, or attempt tobacco abstinence in the short-term. There was moderate-certainty evidence that heated tobacco users have lower exposure to toxicants/carcinogens than cigarette smokers and very low- to moderate-certainty evidence of higher exposure than those attempting abstinence from  all tobacco. Independently funded research on the effectiveness and safety of HTPs is needed.  The rate of decline in cigarette sales accelerated after the introduction of heated tobacco to market in Japan but, as data were observational, it is possible other factors caused these changes. Moreover, falls in cigarette sales may not translate to declining smoking prevalence, and changes in Japan may not generalise elsewhere. To clarify the impact of rising heated tobacco use on smoking prevalence, there is a need for time-series studies that examine this association.

What Are We Measuring When We Evaluate Digital Interventions for Improving Lifestyle? A Scoping Meta-Review

Background: Lifestyle Medicine (LM) aims to address six main behavioral domains: diet/nutrition, substance use (SU), physical activity (PA), social relationships, stress management, and sleep. Digital Health Interventions (DHIs) have been used to improve these domains. However, there is no consensus on how to measure lifestyle and its intermediate outcomes aside from measuring each behavior separately. We aimed to describe (1) the most frequent lifestyle domains addressed by DHIs, (2) the most frequent outcomes used to measure lifestyle changes, and (3) the most frequent DHI delivery methods. Methods: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR) Extension for Scoping Reviews. A literature search was conducted using MEDLINE, Cochrane Library, EMBASE, and Web of Science for publications since 2010. We included systematic reviews and meta-analyses of clinical trials using DHI to promote health, behavioral, or lifestyle change. Results: Overall, 954 records were identified, and 72 systematic reviews were included. Of those, 35 conducted meta-analyses, 58 addressed diet/nutrition, and 60 focused on PA. Only one systematic review evaluated all six lifestyle domains simultaneously; 1 systematic review evaluated five lifestyle domains; 5 systematic reviews evaluated 4 lifestyle domains; 14 systematic reviews evaluated 3 lifestyle domains; and the remaining 52 systematic reviews evaluated only one or two domains. The most frequently evaluated domains were diet/nutrition and PA. The most frequent DHI delivery methods were smartphone apps and websites. Discussion: The concept of lifestyle is still unclear and fragmented, making it hard to evaluate the complex interconnections of unhealthy behaviors, and their impact on health. Clarifying this concept, refining its operationalization, and defining the reporting guidelines should be considered as the current research priorities. DHIs have the potential to improve lifestyle at primary, secondary, and tertiary levels of prevention-but most of them are targeting clinical populations. Although important advances have been made to evaluate DHIs, some of their characteristics, such as the rate at which they become obsolete, will require innovative research designs to evaluate long-term outcomes in health.

THE ABCDE'S OF PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE

The growing burden of obesity, smoking, elevated cholesterol, diabetes, hypertension, sedentary lifestyle, and unhealthy dietary habits fuels cardiovascular disease. In 2015, the rates of cardiovascular disease in the United States rose for the first time after decades of steady decline. To combat this rising trend, there is a great need to emphasize primary cardiovascular prevention. In this review, we provide a summary of the current primary prevention recommendations using a simplified ABCDE approach. The aim is to help clinicians utilize an easy-to-use, structured approach to primary atherosclerotic cardiovascular disease prevention.

The burden of chronic obstructive pulmonary disease and its attributable risk factors in the Middle East and North Africa region, 1990–2019

Background

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease that is characterised by persistent respiratory symptoms and airflow limitation. The present study reported the burden of COPD, and its attributable risk factors, in the Middle East and North Africa (MENA) region between 1990 and 2019, by age, sex and socio-demographic index (SDI).

Methods

Data from the Global Burden of Disease (GBD) 2019 study were used to report the burden of COPD in the MENA countries. The prevalence, deaths, and disability-adjusted life-years (DALYs) were presented as counts and age-standardised rates per 100,000 population, with their associated 95% uncertainty intervals (UIs).

Results

In 2019, the regional age-standardised point prevalence and rates of death due to COPD were 2333.9 (2230.1, 2443.6) and 26.1 (22.2, 29.5) per 100,000, which represent a 30.6% (28.2%, 33.0%) increase and an 18.0% (2.8%, 30.9%) decrease, respectively, since 1990. The regional age-standardised DALY rate in 2019 was 649.1 (574.6, 717.7) per 100,000, which had decreased by 11.8% (0.9%, 21.1%) since 1990. Turkey had the highest age-standardised point prevalence in 2019 [3287.1 (3187.4, 3380.3)], while Afghanistan had the highest age-standardised death [40.4 (24.2, 52.6)] and DALY [964.5 (681.8, 1203.2)] rates. The regional age-standardised point prevalence, death and DALY rates in 2019 increased with advancing age and were higher in males in almost all age groups. There was a U-shaped association between SDI and the burden of COPD over the period 1990 to 2019. Moreover, in 2019 smoking (43.7%), ambient particulate matter pollution (22.8%) and occupational particulate matter (11.4%) had the largest proportion of attributable DALYs for both sexes.

Conclusions

COPD is one of the leading causes of death and disability in the MENA region, although the age-standardised burden has decreased over the last 30 years. Nevertheless, COPD accounted for a substantial number of deaths and DALYs, especially among the elderly. Programs targeting risk factors, like smoking, should be taken into consideration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02242-z.

Social support and quality of life among chronically homeless patients with schizophrenia

This study aimed to describe the sociodemographic characteristics, social support received, and quality of life of chronically homeless patients with schizophrenia in China. A self-prepared sociodemographic questionnaire, the Social Support Rating Scale (SSRS), European Five-dimensional Health Scale (EQ-5D), and Eysenck Personality were administrated to 3,967 chronically homeless and 3,724 non-homeless patients from the Department of Xiangtan Fifth People's Hospital, Hunan, China, between April 2011 and October 2016. Results indicated that the homeless patients were more likely to live outside the city and be ethnic minorities compared with non-homeless patients. Although the married proportion was higher among homeless patients, they had a higher rate of being divorced or widowed. Notably, the homeless patients had higher employment rates before illness, despite significantly lower education (P < 0.001). Chronically homeless patients with schizophrenia showed a lower score in the SSRS (30.29 ± 7.34 vs. 26.16 ± 10.04, p < 0.001); they had significantly lower objective support, subject support, social support, and EQ-Visual Analog Scale, Eysenck Personality Questionnaire-Psychoticism, and Eysenck Personality-Neuroticism scores (p < 0.001). Homeless patients may be worse off, and could be assisted by providing accommodation, family intervention, medical services (such as pain medication), and other comprehensive measures.

Prediction of Postoperative Respiratory Complications after Lobectomy in Lung Cancer Patients with COPD by Quantitative Image Analysis: A Historical Cohort Study

PURPOSE

We examined whether preoperative assessment of percentage of low attenuation area (LAA%) on the non-resected side can predict postoperative respiratory complications (PRC) after lobectomy.

MATERIALS AND METHODS

We conducted a historical cohort study of 217 smokers (175 males and 42 females) who underwent lobectomy for primary lung cancer at our hospital between January 2014 and March 2021. First, the relationship between LAA% and respiratory function parameters (RFPs) calculated for both the bilateral and non-resected sides was used to estimate the most effective patient group. Next, multivariate analyses of the relationship between LAA% of the non-resected side and PRC were performed using logistic regression analysis after adjusting for basic patient attributes and respiratory function.

RESULTS

A correlation was found between LAA% and RFP in smoking males. Multivariate analysis showed a strong relationship between model 3, adjusted for basic patient attributes and lung function factors, and PRC (odds ratio, 2.43; 95% confidence interval, 1.05-5.63).

CONCLUSION

LAA% of the non-resected side suggested that it may be able to predict the occurrence of PRC after lung cancer lobectomy.

Identifying misleading corporate narratives: The application of linguistic and qualitative methods to commercial determinants of health research

Narratives are key to the way corporations represent themselves to the outside world, are important to the development of shared understandings and ultimately determine whether and how corporations are able to influence societal norms and participate in policy debates. A leaked corporate affairs strategy document, from the world's largest transnational tobacco company, Philip Morris International (PMI), suggests a company concerned about credibility; it highlights "normalization" as a key strategic priority until at least 2024. This suggests that the PMI are seeking to rehabilitate their image and alter perceptions of their business. We designed a mixed-methods analysis of corporately authored content, combining quantitative querying of large bodies of text (Corpus Linguistics) with inductive coding of key themes to critically examine PMI's corporate language and how these themes might impact public health debates. We systematically analysed a sample of PMI's corporate communications (n = 170), comparing investor-facing (investor reports, slides and presentations as well as annual reports) and public-facing (YouTube content and Webpage content) communications covering a period of eight years (2012-2019). Our analysis identifies how PMI's misleading external communication contradicts its core business focus and may threaten public health. In public-facing communications, PMI stress their commitment to transformation and change, while in investor-facing communications, they focus on cigarettes and reiterate the strength of their existing cigarette brand portfolios. This suggests that webpage and YouTube content provide a means through which PMI attempt to neutralise negative public perception of tobacco-product related harms and to present themselves as advocates of "better" consumer choice and even public health. The recurrence of transformation, sustainability, and science, as well as the co-option of united-nations terminology in their external-facing communications may serve to legitimise their involvement in policy arenas from which they currently excluded. We present a novel method through which corporate narratives can be monitored and critically assessed.

The Effects of Immediate vs Gradual Reduction in Nicotine Content of Cigarettes on Smoking Behavior: An Ecological Momentary Assessment Study

BACKGROUND

In recent years, much research has examined the effects of various interventions and treatments for smoking cessation. The results suggest that interventions targeting changes of nicotine content can help smokers reduce tobacco use or quit smoking. A number of clinical studies show that smokers who received an immediate reduction in nicotine content to very low levels have significantly greater reductions in the number of cigarettes smoked and toxic substance exposure compared to those with gradual reductions. However, from the perspective of smoking craving, whether the immediate and gradual reduction in nicotine content reduce smoking by reducing cravings needs further investigation.

METHODS

74 eligible Participants were randomly allocated to one of the two experimental conditions: (1) immediate reduction to 0.1 mg of nicotine per cigarette (n = 40); (2) gradual reduction from 1.0 (0.8 g ~ 1.2 mg) to 0.1 mg of nicotine per cigarette (n = 34). All participants completed 1-week baseline period during which they smoked their usual cigarette, followed by 16-week of interventions. The primary outcomes included cigarette cravings and number of cigarettes smoked per day (CPD); secondary outcomes included the number of cigarette-free day and emotional states.

RESULTS

Among the 52 participants [51 (98.1%) men; mean (SD) age, 33.44 (6.71) years; mean (SD) CPD, 16.83 (9.94)] who completed the trial, significantly lower cravings for cigarettes were observed in the immediate (n = 25) vs. gradual nicotine reduction group (n = 27) in the morning (t = -2.072, p = 0.039) and after dinner (t = -2.056, p = 0.041). Compared with the baseline daily smoking, the number of cigarettes smoked per day was significantly reduced at the beginning of week 12 in the immediate nicotine reduction group (p = 0.001) and at week 16 in the gradual nicotine reduction group (p < 0.001). The number of participants with any cigarette-free day was not significantly different between the groups (p = 0.198). The number of cigarette-free days was significantly more in the immediate vs. gradual nicotine reduction group (p = 0.027).

CONCLUSIONS

The significantly lower cravings were observed in the immediate vs. gradual nicotine reduction group, and led to faster reduction in the number of CPD, and a significant increase in the number of cigarette-free days. These findings add to the evidence base for reduced nicotine content in cigarettes.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifier: ChiCTR2100048216.

Burden of esophageal cancer and its attributable risk factors in 204 countries and territories from 1990 to 2019

BACKGROUND

Esophageal cancer is a global health concern. Regularly updated data about the burden of esophageal cancer are essential for formulating specific public policies. We aimed to estimate the global, regional, and national burden and trends of esophageal cancer and its attributable risk factors from 1990 to 2019, by age, sex and socio-demographic index (SDI).

METHODS

Data about the incidence, death, disability-adjusted life-years (DALYs), and age-standardized rates were collected from Global Burden of Disease study 2019. Estimated annual percentage changes were used to quantify the temporal trends of age-standardized rates. Moreover, the risk factors attributable to esophageal cancer deaths were also presented.

RESULTS

There were 534,563 incident cases and 498,067 deaths in 2019, contributing to 11,666,017 DALYs. The absolute numbers of incidence, death, and DALYs had increased from 1990 to 2019, contrasting with declined changes in their corresponding age-standardized rates. The burden of esophageal cancer varied across different regions and countries, and the age-standardized rates were negative with SDI. Almost half of the esophageal cancer was concentrated in China. Males accounted for most of the burden of esophageal cancer, and the onset age tended to be older. The death of esophageal cancer was primarily attributable to smoking, followed by alcohol use, high body mass index, diet low in fruits and diet low in vegetables.

CONCLUSION

The burden of esophageal cancer was heterogeneous across regions and countries by sex, age, and SDI, providing information for governments that may help to formulate more targeted policies.

Precision Preventive Medicine of Relapse in Smoking Cessation: Can MRI Inform the Search of Intermediate Phenotypes?

Simple Summary

Addiction to tobacco is a serious health and economical problem because it is one of the most addictive and the most consumed substance in the world. Although well documented, and despite the desire of numerous smokers to quit, maintenance of abstinence is a daily challenge for most of them. The heterogeneity in achieving this maintenance raises the question of potential differences in brain reactivity. An emerging field of research has been interested in brain markers helping to identify individuals who are the most likely to relapse. Using brain imaging techniques such as Magnetic Resonance Imaging (MRI), one can hope it will be possible to offer tailored care for each patient.

Abstract

Chronic tobacco smoking remains a major health problem worldwide. Numerous smokers wish to quit but most fail, even if they are helped. The possibility of identifying neuro-biomarkers in smokers at high risk of relapse could be of incredible progress toward personalized prevention therapy. Our aim is to provide a scoping review of this research topic in the field of Magnetic Resonance Imaging (MRI) and to review the studies that investigated if MRI defined markers predicted smoking cessation treatment outcome (abstainers versus relapsers). Based on the available literature, a meta-analysis could not be conducted. We thus provide an overview of the results obtained and take stock of methodological issues that will need to be addressed to pave the way toward precision medicine. Based on the most consistent findings, we discuss the pivotal role of the insula in light of the most recent neurocognitive models of addiction.

Exposure to second-hand smoke during early life and subsequent sleep problems in children: a population-based cross-sectional study

BACKGROUND

Previous studies have revealed that current secondhand smoke exposure showed highly suggestive evidence for increased risk of simultaneous sleep problems in children. Data on the associations between early-life exposure to SHS with subsequent sleep problems in children were scarce. We aimed to evaluate the associations of early-life SHS exposure with sleep problems in children.

METHODS

In this cross-sectional study, children were recruited from elementary and middle schools in Liaoning Province, China between April 2012 and January 2013. We assessed early-life SHS exposure (pregnancy and the first 2 years of life) via questionnaires. Sleep problems and different types of sleep-related symptoms were measured based on the validated tool of the Sleep Disturbance Scale for Children (SDSC). Generalized linear mixed models were applied to estimate the associations of early-life SHS exposure with sleep problems.

RESULTS

We included a total of 45,562 children (22,657 [49.7%] males; mean [SD] age, 11.0 [2.6] years) and 6167 of them (13.5%) were exposed to early-life SHS during both pregnancy and the first 2 years of life. Compared with unexposed counterparts, children exposed to early-life SHS had higher total T-scores of SDSC (β = 4.32; 95%CI: 4.06, 4.58) and higher odds of increased sleep problems (OR = 2.14; 95%CI: 1.89, 2.42). When considering different sleep-related symptoms, the associations between early-life SHS exposure and symptom of sleep-wake transition disorders (i.e., bruxism) were the strongest in all analyses.

CONCLUSIONS

Early-life SHS exposure was associated with higher odds of global sleep problems and different sleep-related symptoms in children aged 6-18 years. Our findings highlight the importance to strengthen efforts to support the critical importance of maintaining a smoke-free environment especially in early life.

Agenda-setting of tobacco control policy in Iran: a retrospective policy analysis study

BACKGROUND

The prevalence of tobacco use, especially hookah, has increased in Iran In recent years, particularly among young people and women, and the age of onset of use has decreased. Tobacco use is the fourth leading risk factor for non-communicable diseases in Iran. These issues cause concerns in the country and led to the present study on tobacco control agenda-setting in Iran over a 30-year timeframe.

METHODS

We conducted this retrospective analytical study to investigate process analysis in Iran using Kingdon's multiple-streams framework (MSF). We collected the data using semi-structured interviews with key informants (n = 36) and reviewing policy documents (n > 100). Then, we analyzed the policy documents and in-depth interviews using the document and framework analysis method. We used MAXQDA 11 software to classify and analyze the data.

RESULTS

Iran's accession to the Framework Convention on Tobacco Control (FCTC) opened a window of opportunity for tobacco control. The policy window opens when all three streams have already been developed. The adoption of the comprehensive law on the national control and campaign against tobacco in the Islamic Consultative Assembly in 2006 is a turning point in tobacco control activities in Iran.

CONCLUSIONS

The tobacco control agenda-setting process in Iran was broadly consistent with MSF. The FCTC strengthened the comprehensive plan for national control of tobacco as a policy stream. However, there are several challenges in developing effective policies for tobacco control in the Iranian setting.

Education and training on addiction psychiatry in low and middle income countries: Observations from existing literature and recommendations going ahead

BACKGROUND

Addictive disorders are a significant contributor to the global burden of disease. The burden of addictive disorders in LMIC is expected to grow further over the coming years.

AIMS

In this article we present the observations from the existing literature on the current status of education and training on addiction psychiatry in LMIC and provide recommendation on way forward for this specialized field of psychiatry.

MATERIALS AND METHODS

We searched electronic databases of PubMed to access the literature on the current status of education and training on addiction psychiatry. Additional searches were also conducted in other database of Google Scholar for potential 'grey' literature.

RESULTS

We were able to identify a total of 11 relevant articles.

DISCUSSION

Currently there is limited published literature on education and training on addiction psychiatry from the LMICs.

CONCLUSIONS

Strengthening of the training on addictive disorders shall not only help bridge the gap of the unmet need for the evidence-based interventions of addictive disorders across these countries it shall also help enhance the research capacity on addictive disorders in these countries.

Trends in Prevalence of Tobacco Use by Sex and Socioeconomic Status in 22 Sub-Saharan African Countries, 2003-2019

IMPORTANCE

Tobacco companies have shifted their marketing and production to sub-Saharan African countries, which are in an early stage of the tobacco epidemic.

OBJECTIVE

To estimate changes in the prevalence of current tobacco use and socioeconomic inequalities among male and female participants from 22 sub-Saharan African countries from 2003 to 2019.

DESIGN, SETTING, AND PARTICIPANTS

Secondary data analyses were conducted of sequential Demographic and Health Surveys in 22 sub-Saharan African countries including male and female participants aged 15 to 49 years. The baseline surveys (2003-2011) and the most recent surveys (2011-2019) were pooled.

EXPOSURES

Household wealth index and highest educational level were the markers of inequality.

MAIN OUTCOMES AND MEASURES

Sex-specific absolute and relative changes in age-standardized prevalence of current tobacco use in each country and absolute and relative measures of inequality using pooled data.

RESULTS

The survey samples included 428 197 individuals (303 232 female participants [70.8%]; mean [SD] age, 28.6 [9.8] years) in the baseline surveys and 493 032 participants (348 490 female participants [70.7%]; mean [SD] age, 28.5 [9.4] years) in the most recent surveys. Both sexes were educated up to primary (35.7%) or secondary school (40.0%). The prevalence of current tobacco use among male participants ranged from 6.1% (95% CI, 5.2%-6.9%) in Ghana to 38.3% (95% CI, 35.8%-40.8%) in Lesotho in the baseline surveys and from 4.5% (95% CI, 3.7%-5.3%) in Ghana to 46.0% (95% CI, 43.2%-48.9%) in Lesotho during the most recent surveys. The decrease in prevalence ranged from 1.5% (Ghana) to 9.6% (Sierra Leone). The World Health Organization target of a 30% decrease in smoking was achieved among male participants in 8 countries: Rwanda, Nigeria, Ethiopia, Benin, Liberia, Tanzania, Burundi, and Cameroon. For female participants, the number of countries having a prevalence of smoking less than 1% increased from 9 in baseline surveys to 16 in the most recent surveys. The World Health Organization target of a 30% decrease in smoking was achieved among female participants in 15 countries: Cameroon, Namibia, Mozambique, Mali, Liberia, Nigeria, Burundi, Tanzania, Malawi, Kenya, Rwanda, Zimbabwe, Ethiopia, Burkina Faso, and Zambia. For both sexes, the prevalence of tobacco use and the decrease in prevalence of tobacco use were higher among less-educated individuals and individuals with low income. In both groups, the magnitude of inequalities consistently decreased, and its direction remained the same. Absolute inequalities were 3-fold higher among male participants, while relative inequalities were nearly 2-fold higher among female participants.

CONCLUSIONS AND RELEVANCE

Contrary to a projected increase, tobacco use decreased in most sub-Saharan African countries. Persisting socioeconomic inequalities warrant the stricter implementation of tobacco control measures to reach less-educated individuals and individuals with low income.

From Tobacco Cigarettes to Electronic Cigarettes: The Two Sides of a Nicotine Coin

Tobacco smoking-related diseases, including cardiovascular disease, pulmonary disease, stroke, and cancer in multiple organ sites, are the leading causes of preventable death, worldwide. Youth electronic cigarette use (vaping) is an evolving public health problem in the United States and around the world. Many of the same toxicants and carcinogens present in tobacco smoke are also found in electronic cigarette vapor, although mostly at substantially lower levels. The reduced concentrations of these chemicals in electronic cigarette vapor may imply lower health risk; however, they cannot equate to no risk. To date, the long-term health consequences of vaping are largely unknown. This "Perspective" provides a concise chronology of events leading up to an unprecedented global challenge, namely the convergence of global tobacco epidemic and youth vaping epidemic. Current state of knowledge, outstanding questions in the field, present challenges, and future directions in research are highlighted. The existing data show a continued and dynamic evolution of the converged epidemics. The goal should be to prevent youth vaping while improving smoking cessation strategies. In smokers who are unable or unwilling to quit smoking, the objective should be to provide "provably" safe or less-harmful alternatives, which should "completely" or "substantially" substitute tobacco cigarettes.

Predictors of Adherence to Smoking Cessation Medications among Current and Ex-Smokers in Australia: Findings from a National Cross-Sectional Survey

Background: Adherence to smoking cessation medications (SCMs) improve the rate of successful quitting. This study aimed to evaluate the level of adherence to SCMs and associated factors among smokers and ex-smokers in Australia. Method: A cross-sectional study using an online survey was conducted in Australia. Descriptive statistics were used to present the overall characteristics of participants. Cross-tabulation with Pearson’s chi-square test was performed to evaluate the possible associations between factors. To explore barriers and facilitators of adherence to SCMs, logistic regressions were conducted. Results: Among 201 participants, 57 (28.4%) were found to be adherent to SCMs. The odds of being adherent were found to be higher among participants with good social support (AOR = 3.28, 95% CI of 2.30–6.27). Participants who did not experience anxiety symptoms had higher odds of being adherent to SCMs as compared to smokers who had anxiety symptoms (AOR = 4.41, 95% CI of 3.64–14.68). Having previous experience of using SCMs improved adherence four-fold (AOR = 3.87, 95% CI of 1.11–13.44). Level of nicotine dependence showed a direct association with adherence (AOR = 3.53, 95% CI of 1.40–8.95). Not relapsing while on the medications improved adherence (AOR = 2.88, 95% CI of 1.21–6.88). Conclusion: In a study of smokers and ex-smokers in Australia, the self-reported level of adherence to SCMs was found to be low. Adherence was associated with social, psychological, and medication-related factors. Smoking cessation interventions are recommended to include strategies that can address medication adherence.

Global burden of COPD attributable to ambient PM2.5 in 204 countries and territories, 1990 to 2019: A systematic analysis for the Global Burden of Disease Study 2019

The global spatiotemporal pattern of the COPD burden attributable to ambient PM2.5 is unknown in the context of the continuing increase in exposure to ambient PM2.5. Data on COPD burden attributable to ambient PM2.5 from 1990 to 2019 were retrieved from the Global Burden of Disease Study 2019. Cases and age-standardized rates of COPD mortality (ASMR) and disability-adjusted life years (ASDR) were estimated by age, sex, region, and country. The estimated annual percentage change (EAPC) was calculated to quantify the secular trends of ASMR and ASDR from 1990 to 2019. Globally, the number of COPD deaths and DALYs attributable to ambient PM2.5 both increased by over 90% from 1990 to 2019, but ASMR and ASDR both slightly decreased, with EAPC of -0.58 (95% CI: -0.72, -0.44) and -0.40 (95% CI: -0.51, -0.29), respectively. Most COPD deaths and DALYs attributable to PM2.5 occurred in the middle sociodemographic index (SDI) region, but the fastest growth of ASMR and ASDR occurred in the low SDI region, with EAPCs of 2.41 (95% CI: 2.23, 2.59) and 2.34 (95% CI: 2.16, 2.52), respectively. East Asia and South Asia were the high-risk areas of COPD deaths and DALYs attributable to PM2.5, among which China and India were the countries with the heaviest burden. COPD deaths and DALYs attributable to PM2.5 mainly occurred in individuals 70-89 years old and 60-84 years old, respectively. The age-specific rates of mortality and DALYs had a rapid increase in low and low-middle SDI regions from 1990 to 2019. The ASMR or ASDR had a reverse V-shaped relationship with SDI. In summary, the ambient PM2.5-attributable COPD burden is socioeconomic- and age-dependent, and it mediates the heterogeneity of spatial and temporal distribution. Low- and middle-income countries endure the highest ambient PM2.5-attributable COPD burden due to the high exposure to PM2.5 and poor availability and affordability of medicines and diagnostic tests.

Recent updates on bioactive properties of linalool

Natural products, including essential oils and their components, have been used for their bioactivities. Linalool (2,6-dimethyl-2,7-octadien-6-ol) is an aromatic monoterpene alcohol that is widely found in essential oils and is broadly used in perfumes, cosmetics, household cleaners and food additives. This review covers the sources, physicochemical properties, application, synthesis and bioactivities of linalool. The present study focuses on the bioactive properties of linalool, including anticancer, antimicrobial, neuroprotective, anxiolytic, antidepressant, anti-stress, hepatoprotective, renal protective, and lung protective activity and the underlying mechanisms. Besides this, the therapeutic potential of linalool and the prospect of encapsulating linalool are also discussed. Linalool can induce apoptosis of cancer cells via oxidative stress, and at the same time protects normal cells. Linalool exerts antimicrobial effects through disruption of cell membranes. The protective effects of linalool to the liver, kidney and lung are owing to its anti-inflammatory activity. On account of its protective effects and low toxicity, linalool can be used as an adjuvant of anticancer drugs or antibiotics. Therefore, linalool has a great potential to be applied as a natural and safe alternative therapeutic.

Epidemiological Characteristics of Pancreatic Cancer in China From 1990 to 2019

Background

Pancreatic cancer is an aggressive cancer and is predicted to become the second leading cause of cancer-related deaths in China. To understand the epidemic trend of pancreatic cancer and formulate targeted preventive measures, it is important to analyze the incidence and mortality of pancreatic cancer.

Methods

The incidence and mortality data of pancreatic cancer in China were obtained from Global Burden of Disease (GBD) data. We used joinpoint regression analysis to calculate the magnitude and direction of trends, and the age-period-cohort method to analyze the effects of chronological age, time period, and birth cohort.

Results

The age-standardized rates (ASRs) for both incidence and mortality of pancreatic cancer increased from 1990 to 2019, and were higher in males than females. The incidence and mortality rates have increased year by year in the age group above 25 years. The most common age group was 55–79 years, accounting for approximately 50% of all incident cases. In terms of incidence and mortality rates, the overall net drifts were above 0. The local drifts in all age groups were above 0 in both sexes and males, while the local drifts in the 15–39 age groups were below 0 in females. The longitudinal age curves increased with age, with higher incidence and mortality rates, mainly in older age groups. The period rate ratios increased by year. The cohort rate ratios showed an upward trend before 1970 and fluctuated after 1975.

Conclusions

The burden of pancreatic cancer is still very high in China, and attention should be paid to the key population that is, males and older people. The results of our study can be used by policy makers to allocate resources efficiently to improve early diagnosis and treatment, improving the awareness of self-protection, and advocating a healthy lifestyle to prevent pancreatic cancer.

Obesity and the Bidirectional Risk of Cancer and Cardiovascular Diseases in African Americans: Disparity vs. Ancestry

Cardiovascular disease (CVD) and cancer often occur in the same individuals, in part due to the shared risk factors such as obesity. Obesity promotes adipose inflammation, which is pathogenically linked to both cardiovascular disease and cancer. Compared with Caucasians, the prevalence of obesity is significantly higher in African Americans (AA), who exhibit more pronounced inflammation and, in turn, suffer from a higher burden of CVD and cancer-related mortality. The mechanisms that underlie this association among obesity, inflammation, and the bidirectional risk of CVD and cancer, particularly in AA, remain to be determined. Socio-economic disparities such as lack of access to healthy and affordable food may promote obesity and exacerbate hypertension and other CVD risk factors in AA. In turn, the resulting pro-inflammatory milieu contributes to the higher burden of CVD and cancer in AA. Additionally, biological factors that regulate systemic inflammation may be contributory. Mutations in atypical chemokine receptor 1 (ACKR1), otherwise known as the Duffy antigen receptor for chemokines (DARC), confer protection against malaria. Many AAs carry a mutation in the gene encoding this receptor, resulting in loss of its expression. ACKR1 functions as a decoy chemokine receptor, thus dampening chemokine receptor activation and inflammation. Published and preliminary data in humans and mice genetically deficient in ACKR1 suggest that this common gene mutation may contribute to ethnic susceptibility to obesity-related disease, CVD, and cancer. In this narrative review, we present the evidence regarding obesity-related disparities in the bidirectional risk of CVD and cancer and also discuss the potential association of gene polymorphisms in AAs with emphasis on ACKR1.

Fighting the 'tobacco epidemic' - A call to action to identify Targeted Intervention Points (TIPs) for better counseling patients with urothelial cancer

The association between tobacco use and urothelial cancer of the bladder is well known. Given the worsening tobacco epidemic, here we make the case for systematic targeted points of intervention for urologists and other professionals to intervene against bladder cancer. Awareness of contemporary checkpoints where we can intervene for counseling patients may help medical education in a tobacco-pandemic difficult setting.

Prevalence and trends of coronary artery disease risk factors and their effect on age of diagnosis in patients with established coronary artery disease: Tehran Heart Center (2005-2015)

BACKGROUND

Coronary artery disease (CAD) is a universal public health challenge, more prominently so in the low- and middle-income countries. In this study, we aimed to determine prevalence and trends of CAD risk factors in patients with documented CAD and to determine their effects on the age of CAD diagnosis.

MATERIALS AND METHODS

We conducted a registry-based, serial cross-sectional study using the coronary angiography data bank of the Tehran Heart Center. Adult patients who had obstructive (> 50% stenosis) CAD were included in the study. The prevalence and 11-year trends of conventional CAD risk factors were analyzed by sex and age, and their adjusted effects on the age of CAD diagnosis were calculated.

RESULTS

From January 2005 to December 2015, data for 90,094 patients were included in this analysis. A total of 61,684 (68.5%) were men and 28,410 (31.5%) were women. Men were younger at diagnosis than women, with a mean age of 60.1 in men and 63.2 in women (p < 0.001), and had fewer risk factors at the time of diagnosis. Mean age at diagnosis had an overall increasing trend during the study period. Increasing trend was seen in body-mass index, hypertension prevalence, diabetes mellitus. All lipid profile components (total cholesterol, low-density lipoprotein cholesterol, triglycerides, and high-density lipoprotein cholesterol) decreased over time. Of particular interest, opium consumption was associated with 2.2 year earlier age of CAD diagnosis.

CONCLUSION

The major results of this study (lower age of CAD diagnosis in men, lower age of diagnosis associated with most risk factors, and lower prevalence of serum lipids over time) were expected. A prominent finding of this study is confirming opium use was associated with a much younger age of CAD onset, even after adjusting for all other risk factors. In addition to recommendations for control of the traditional risk factors, spreading information about the potential adverse effect of opium use, which has only recently been associated with higher risk of CAD, may be necessary.

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

BACKGROUND

Chewing tobacco and other types of smokeless tobacco use have had less attention from the global health community than smoked tobacco use. However, the practice is popular in many parts of the world and has been linked to several adverse health outcomes. Understanding trends in prevalence with age, over time, and by location and sex is important for policy setting and in relation to monitoring and assessing commitment to the WHO Framework Convention on Tobacco Control.

METHODS

We estimated prevalence of chewing tobacco use as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 using a modelling strategy that used information on multiple types of smokeless tobacco products. We generated a time series of prevalence of chewing tobacco use among individuals aged 15 years and older from 1990 to 2019 in 204 countries and territories, including age-sex specific estimates. We also compared these trends to those of smoked tobacco over the same time period.

FINDINGS

In 2019, 273·9 million (95% uncertainty interval 258·5 to 290·9) people aged 15 years and older used chewing tobacco, and the global age-standardised prevalence of chewing tobacco use was 4·72% (4·46 to 5·01). 228·2 million (213·6 to 244·7; 83·29% [82·15 to 84·42]) chewing tobacco users lived in the south Asia region. Prevalence among young people aged 15-19 years was over 10% in seven locations in 2019. Although global age-standardised prevalence of smoking tobacco use decreased significantly between 1990 and 2019 (annualised rate of change: -1·21% [-1·26 to -1·16]), similar progress was not observed for chewing tobacco (0·46% [0·13 to 0·79]). Among the 12 highest prevalence countries (Bangladesh, Bhutan, Cambodia, India, Madagascar, Marshall Islands, Myanmar, Nepal, Pakistan, Palau, Sri Lanka, and Yemen), only Yemen had a significant decrease in the prevalence of chewing tobacco use, which was among males between 1990 and 2019 (-0·94% [-1·72 to -0·14]), compared with nine of 12 countries that had significant decreases in the prevalence of smoking tobacco. Among females, none of these 12 countries had significant decreases in prevalence of chewing tobacco use, whereas seven of 12 countries had a significant decrease in the prevalence of tobacco smoking use for the period.

INTERPRETATION

Chewing tobacco remains a substantial public health problem in several regions of the world, and predominantly in south Asia. We found little change in the prevalence of chewing tobacco use between 1990 and 2019, and that control efforts have had much larger effects on the prevalence of smoking tobacco use than on chewing tobacco use in some countries. Mitigating the health effects of chewing tobacco requires stronger regulations and policies that specifically target use of chewing tobacco, especially in countries with high prevalence.

FUNDING

Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and initiation among young people in 204 countries and territories, 1990-2019

Background

Universally, smoking cessation rates among established smokers are poor. Preventing young people from starting use of and becoming addicted to tobacco products remains a key strategy to end the tobacco epidemic. Previous country-specific studies have found that initiation of smoking tobacco use occurs predominantly among young people and have found mixed progress in reducing the prevalence of smoking tobacco use among young people. Current and comparable estimates for all countries are needed to inform targeted interventions and policies.

Methods

We modelled two indicators: prevalence of current smoking tobacco use among young adults aged 15–24 years, and the age at which current smokers aged 20–54 years in 2019 began smoking regularly. We synthesised data from 3625 nationally representative surveys on prevalence of smoking and 254 on age at initiation. We used spatiotemporal Gaussian process regression to produce estimates of the prevalence of smoking and age of initiation by sex, for 204 countries and territories for each year between 1990 and 2019.

Findings

Globally in 2019, an estimated 155 million (95% uncertainty interval 150–160) individuals aged 15–24 years were tobacco smokers, with a prevalence of 20·1% (19·4–20·8) among males and 4·95% (4·64–5·29) among females. We estimated that 82·6% (82·1–83·1) of current smokers initiated between ages 14 and 25 years, and that 18·5% (17·7–19·3) of smokers began smoking regularly by age 15 years. Although some countries have made substantial progress in reducing the prevalence of smoking tobacco use among young people, prevalence in 2019 still exceeds 20% among males aged 15–24 years in 120 countries and among females aged 15–24 years in 43 countries.

Interpretation

The fact that most smokers start smoking regularly before age 20 years highlights the unique window of opportunity to target prevention efforts among young people and save millions of lives and avert health-care costs in the future. Countries can substantially improve the health of their populations by implementing and enforcing evidence-based tobacco control policies that prevent the next generation from initiating smoking.

Funding

Bloomberg Philanthropies.

Feasibility and Acceptability of a Cognitive Behavioral Therapy-Based Smartphone App for Smoking Cessation in China: A Single-Group Cohort Study

BACKGROUND

Previous research has suggested that mobile phone applications (apps) may potentially increase quit rates. The purpose of this single-group cohort study sought to examine the feasibility and acceptability of a novel smartphone-based smoking cessation app designed for smoking cessation in China: smoking quit rate.

METHODS

A total of 180 smokers from two cities of mainland China with willingness to make a quit attempt were invited to this smoking cessation app program, a cognitive behavioral theory (CBT)-based smoking cessation intervention via a smartphone app. Participants received 37- to 44-day intervention (including 7- to 14-day pre-quit preparation and 33-day intervention from quit date). Feasibility and acceptability of the program, and smoking status were assessed at baseline stage (initial installation), pre-quit stage, and post-quit stage (days 7, 15, and 33 after quit date).

RESULTS

A total of 163 (90.6%) participants completed the study. Among them, 76-89% of the participants logged into the app ≥1 time per day across stages (at baseline, during pre-quit stage, and on days 7, 15, and 33 of post-quit stage); approximately 90% of the participants were satisfied with the app across stages. A significant rise in self-reported overall satisfaction with the app is observed from baseline (93% at Time 1) to the end of the program (98% at Time 2, 33 days after quit date) (p = 0.021). Participants who believed/agreed this app can help them to quit smoking significantly increased from 69% at baseline to 97% at day 33 after quit date (p < 0.001). Participants were satisfied with most (80-90%) of the features, especially the information feature. Intention-to-treat analysis showed that the percentage of 33-day self-reported continuous prevalence abstinence was 63.9%, and 7-day point prevalence abstinence rate was 81.7, 87.2, and 77.8% on days 7, 15, and 33 after quit date, respectively.

CONCLUSIONS

This study demonstrated the feasibility and acceptability of the smartphone app intervention for smoking cessation and introduced a new digital treatment model, which is expected to overcome barriers facing accessing traditional in-person smoking cessation services and extend nationwide smoking cessation services in China.