Impact of smoking and smoking cessation on cardiovascular events and mortality among older adults: meta-analysis of individual participant data from prospective cohort studies of the CHANCES consortium

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cancer risk among young men with weight gain after smoking cessation: A population-based cohort study

BACKGROUND

Smoking cessation may help the current smokers to reduce cancer risk. However, weight gain following smoking cessation may attenuate the protective association of cessation with cancer.

PATIENTS AND METHODS

Our study included 1,278,794 men who were aged 20-39 years and underwent two consecutive health examinations by the National Health Insurance Service, without previous diagnosis of cancer. Participants were categorized into continual smokers, quitters with different degree of body weight change, and never smokers based on the biennial national health screening program (2002-2003 and 2004-2005) and were followed from January 1, 2006 to December 31, 2015. Cox proportional hazard models and restricted cubic spline model was used to evaluate the association of post-cessation weight change and cancer risk after adjustment for potential confounders.

RESULTS

During the 10 years of follow-up, the analyses included 1,278,794 men with 21,494 cancer incidences. Compared to continual smokers, quitters without weight gain of 2.0 kg had significantly lower risk of obesity-related cancer (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.79-0.97), smoking-related cancer (HR, 0.90; 95% CI, 0.83 to 0.98), and gastrointestinal cancer (HR, 89; 95% CI, 0.80 to 0.98). Weight gain among quitters attenuated the risk reduction of cancer compared to continual smoking. Among quitters, weight gain up to 5.0 kg with smoking cessation showed protective association with cancer risk among quitters without weight gain.

CONCLUSION

Excessive weight gain with smoking cessation among quitters was not associated with reduced risk of several cancer types. This association should be taken into account when recommending smoking cessation to prevent cancer.

Development and Validation of the Policies, Opportunities, Initiatives and Notable Topics (POINTS) Audit for Campuses and Worksites

Background: Workplace or campus wellness/obesity-prevention policies and initiatives can improve health. Research tools to assess worksite or campus policies/initiatives are scarce. Thus, the aim of this research is to develop and validate the policies, opportunities, initiatives, and notable topics (POINTS) audit. Methods: POINTS was developed and refined via expert review, pilot-testing, and field testing. Trained researchers completed a web-based review from a student-focus or employee-focus regarding 34 health-promoting topics for colleges. Each topic was evaluated on a 0⁻2 scale: 0 = no policy/initiative, 1 = initiatives, 2 = written policy. When a written policy was detected, additional policy support questions (administered, monitored, reviewed) were completed. Results: Cronbach's Alpha for the student-focused POINTS audit was α = 0.787 (34 items, possible points = 65), and for the employee-focused POINTS audit was α = 0.807 (26 items, possible points = 50). A total of 115 student-focused and 33 employee-focused audits were completed. Although there was little evidence of policy presence beyond stimulant standards (smoking and alcohol), there were extensive examples of health initiatives. The student-focused POINTS audit was validated using the Healthier Campus Initiative's survey. Conclusions: POINTS is a web-based audit tool that is valid and useful for pre-assessment, advocacy, benchmarking, and tracking policies for health and well-being for students (campus) and employees (worksite).

Temperature variability and hospitalization for cardiac arrhythmia in Brazil: A nationwide case-crossover study during 2000-2015

BACKGROUND

There is growing recognition of a potential role for environmental and climatic factors in influencing cardiovascular risk. It has been speculated that temperature variability (TV) is a risk factor for cardiac arrhythmia but evidence is limited.

OBJECTIVE

To quantify the geographic and demographic variations in the association between TV and hospitalization for cardiac arrhythmia in Brazil during 2000-2015.

METHODS

Data on hospitalization for arrhythmia and weather conditions were collected from 1,814 cities. TV was calculated as the standard deviation of daily maximum and minimum temperatures during exposure days. A time-stratified case-crossover approach was applied to examine the city-specific association between TV and hospitalization for arrhythmia. City-specific estimates were pooled at the national and regional levels using a random-effect meta-analysis. Stratified analyses were conducted by sex, three age-groups (0-64, 65-74 and ≥75 years), and three arrhythmia subtypes (paroxysmal tachycardia, atrial fibrillation and flutter, and other arrhythmias).

RESULTS

There were 447,667 arrhythmia-related hospitalizations during 2000-2015. The odds ratio of hospitalization per 1 °C increase in TV peaked on 0-1 days' exposure [1.012 (95% confidence interval: 1.010-1.015)]. There were no substantial differences in effect estimates of TV_0-1 by region, age or sex, except for the non-significant association observed in the north. However, women were more affected by prolonged TV exposure than men. For the three arrhythmias subtypes, only paroxysmal tachycardia and other arrhythmias were sensitive to TV. Assuming a causal relationship, 35,813 (95%CI: 18,302-51,665) cases were attributable to TV_0-1 in Brazil during 2000-2015, accounting for 8.0% (95%CI: 4.1-11.5%) of hospitalizations for cardiac arrhythmia.

CONCLUSIONS

At a population-level exposure to TV was associated with increased risk of arrhythmia-related hospitalization in Brazil, with the relationship equally distributed across most residents but varied by arrhythmia subtypes. Our findings add to the accumulating evidence-base that climatic factors can influence cardiovascular outcomes in populations.

Weight change after smoking cessation and incident metabolic syndrome in middle-aged Korean men: an observational study

We aimed to examine the effect of weight change attributable to cessation of cigarette smoking on newly diagnosed metabolic syndrome (MetS). We prospectively followed 5,809 men aged between 40 to 69 years without MetS at baseline in the Health Examinees-Gem (HEXA-G) study up to 4 years. The participants were grouped into continual smokers, quitters with weight gain, quitters without weight change, quitters with weight loss, and never smokers. We constructed multivariable logistic regression models adjusted for sociodemographic factors, health status, and health conditions to estimate the odds of newly diagnosed MetS. During the follow-up, there were 609 cases of newly diagnosed MetS in 5,809 men of the HEXA-G study. After adjustment for potential confounders, the odd ratios (OR) and 95% confidence intervals (95% CI) for MetS were 1.90 (95% CI: 1.43–2.52) in quitters with weight gain, 0.77 (95% CI: 0.60–1.00) in quitters without weight change, and 0.40 (95% CI: 0.28–0.57) in quitters with weight loss compared with continual smokers. Never smokers also had lower odds of MetS (OR = 0.54; 95% CI: 0.42–0.71) compared to continual smokers. Weight management program following smoking cessation may be necessary in clinical practice to reduce worsening of cardiometabolic risk factors related to post-cessation weight gain.

Tachycardia: The hidden cardiovascular risk factor in uncomplicated arterial hypertension

Early detection and management of elevated blood pressure is crucial in reducing the burden of cardiovascular disease (CVD). The importance of an absolute risk assessment and patient risk stratification has been highlighted in the European hypertension guidelines since 2003. Amongst numerous risk factors influencing patient prognosis, elevated heart rate (HR) has been indicated as important predictor of future risk of hypertension, coronary heart disease, sudden cardiac death, heart failure, CVD, stroke, total cancer and mortality. Given that resting HR can be easily determined in clinical practice and modified by lifestyle changes as well as beta-blocker therapy, it seems reasonable that lowering resting HR should be a potential target to reduce disease burden and premature mortality. However, there is a lack of outcome studies of HR lowering in tachycardia-related hypertension. This review outlines the underlying mechanisms of early course hypertension pathophysiology with the critical role of the sympathetic nervous system activation, the prognostic significance of fast HR and the mechanistic rationale for the use of non-pharmacological approaches and/or highly long-acting cardioselective beta-blockers with some consideration given to betaxolol properties.

Curing breast cancer and killing the heart: A novel model to explain elevated cardiovascular disease and mortality risk among women with early stage breast cancer

Due to advances in prevention, early detection and treatment, early breast cancer mortality has decreased by nearly 40% during the last four decades. Yet, the risk of cardiovascular disease (CVD) mortality is significantly elevated following a breast cancer diagnosis, and it is a leading cause of death in this population. This review will discuss the most recent evidence for risks, pathology, mechanisms, and prevention of CVD morbidity and mortality in women with breast cancer. This evidence will be synthesized into a new model 'the compounding risk and protection model.' This model proposes that the balance between risk factors (i.e., older age, pre-existing traditional CVD risk factors and shared biologic pathways for CVD and cancer such as inflammation, as well as treatment-related and lifestyle toxicity) and potential protection factors (i.e., lifelong non-smoking, regular physical activity, a healthy diet rich in fruits and vegetables, and management of body weight and stress, heart failure therapy) determine the individual risk of CVD morbidity and mortality after diagnosis of early breast cancer.

Skin autofluorescence predicts incident type 2 diabetes, cardiovascular disease and mortality in the general population

AIMS/HYPOTHESIS

Earlier studies have shown that skin autofluorescence measured with an AGE reader estimates the accumulation of AGEs in the skin, which increases with ageing and is associated with the metabolic syndrome and type 2 diabetes. In the present study, we examined whether the measurement of skin autofluorescence can predict 4 year risk of incident type 2 diabetes, cardiovascular disease (CVD) and mortality in the general population.

METHODS

For this prospective analysis, we included 72,880 participants of the Dutch Lifelines Cohort Study, who underwent baseline investigations between 2007 and 2013, had validated baseline skin autofluorescence values available and were not known to have diabetes or CVD. Individuals were diagnosed with incident type 2 diabetes by self-report or by a fasting blood glucose ≥7.0 mmol/l or HbA_1c ≥48 mmol/mol (≥6.5%) at follow-up. Participants were diagnosed as having incident CVD (myocardial infarction, coronary interventions, cerebrovascular accident, transient ischaemic attack, intermittent claudication or vascular surgery) by self-report. Mortality was ascertained using the Municipal Personal Records Database.

RESULTS

After a median follow-up of 4 years (range 0.5-10 years), 1056 participants (1.4%) had developed type 2 diabetes, 1258 individuals (1.7%) were diagnosed with CVD, while 928 (1.3%) had died. Baseline skin autofluorescence was elevated in participants with incident type 2 diabetes and/or CVD and in those who had died (all p < 0.001), compared with individuals who survived and remained free of the two diseases. Skin autofluorescence predicted the development of type 2 diabetes, CVD and mortality, independent of several traditional risk factors, such as the metabolic syndrome, glucose and HbA_1c.

CONCLUSIONS/INTERPRETATION

The non-invasive skin autofluorescence measurement is of clinical value for screening for future risk of type 2 diabetes, CVD and mortality, independent of glycaemic measures and the metabolic syndrome.

Active smoking among people with diabetes mellitus or hypertension in Africa: a systematic review and meta-analysis

The objective was to summarize existing data on the prevalence of active tobacco smoking among patients with hypertension or diabetes mellitus in Africa. We searched PubMed, EMBASE, and AJOL to include studies published from January 01, 2000 to August 23, 2017 reporting on the prevalence of active smoking in individuals aged ≥15 years with hypertension or diabetes mellitus residing inside Africa. We used a random-effects meta-analysis model to pool studies. The pooled prevalence of active smoking among patients with hypertension or diabetes was 12.9% (95%CI: 10.6–15.3; 50 studies; 16,980 patients) and 12.9% (95%CI: 9.6–16.6; 42 studies; 18,564 patients), respectively. For both conditions, the prevalence of active smoking was higher in males than in females (p < 0.001), and in Northern compared to sub-Saharan Africa (p < 0.001). There was no difference between urban and rural settings, and between community-based and hospital-based studies, except for patients with diabetes for whom the prevalence was higher in hospital-based studies (p = 0.032). The prevalence of active smoking is high among patients with hypertension or diabetes mellitus in Africa, with the heaviest burden in Northern Africa. Interventions for smoking prevention or cessation should be implemented in these high risk populations, targeting particularly the males.

Effectiveness of stop smoking interventions among adults: protocol for an overview of systematic reviews and an updated systematic review

BACKGROUND

Tobacco smoking is the leading cause of cancer, preventable death, and disability. Smoking cessation can increase life expectancy by nearly a decade if achieved in the third or fourth decades of life. Various stop smoking interventions are available including pharmacotherapies, electronic cigarettes, behavioural support, and alternative therapies. This protocol outlines an evidence review which will evaluate the benefits and harms of stop smoking interventions in adults.

METHODS

The evidence review will consist of two stages. First, an overview of systematic reviews evaluating the benefits and harms of various stop smoking interventions delivered in or referred from the primary care setting will be conducted. The second stage will involve updating a systematic review on electronic cigarettes identified in the overview; randomized controlled trials will be considered for outcomes relating to benefits while randomized controlled trials, non-randomized controlled trials, and comparative observational studies will be considered for evaluating harms. Search strategies will be developed and peer-reviewed by medical information specialists. The search strategy for the updated review on e-cigarettes will be developed using that of the candidate systematic review. The MEDLINE®, PsycINFO, Embase, and the Cochrane Library electronic databases will be searched as of 2008 for the overview of reviews and from the last search date of the selected review for the updated review. Organizational websites and trial registries will be searched for unpublished or ongoing reviews/studies. Two reviewers will independently screen the title and abstracts of citations using the liberal accelerated method. Full-text screening will be performed independently by two reviewers. Extracted data will be verified by a second reviewer. Disagreements regarding full-text screening and data extraction will be resolved by consensus or third-party adjudication. The methodological quality of systematic reviews, risk of bias of randomized and non-randomized trials, and methodological quality of cohort studies will be evaluated using AMSTAR 2, the Cochrane risk of bias tool, and a modified version of the Scottish Intercollegiate Guidelines Network critical appraisal tool, respectively. The GRADE framework will be used to assess the quality of the evidence for outcomes.

DISCUSSION

The evidence review will evaluate the benefits and harms of various stop smoking interventions for adults. Findings will be used to inform a national tobacco cessation guideline by the Canadian Task Force on Preventive Health Care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42018099691, CRD42018099692).

Differences in quality of life among older adults in Brazil according to smoking status and nicotine dependence

BACKGROUND

Research on quality of life QOL is limited in Brazil and few studies have examined the association between smoking status and quality of life. This study addresses this gap and also examines the association between smoking, nicotine dependence, and duration of smoking cessation on (QOL) among older adults in an urban area in Brazil.

METHODS

Data are from a household survey conducted in urban areas of Uberaba, Brazil, in 2012 (n = 980). Multivariable linear regressions were used to evaluate the association between smoking, nicotine dependence based on Fageström test, and smoking cessation on the World Health Organization Quality of Life WHOQOL-BREF and Quality of Life Assessment for Older Adults WHOQOL-OLD.

RESULTS

The mean age of older adults in the study was 74.0 (SD = 6.9 years) and 64% of participants were women. The majority, 55% had never smoked, 12.4% were current smokers, and 32.7% were past-smokers. Current smokers had lower scores for social participation (β = - 2.6) and intimacy (β = - 3.8) than never smokers. Smokers with high or very high dependence reported higher levels of fear and concern about death and pain before death than those with low or very low dependence (β = - 10.6). However, smokers with medium levels of nicotine dependence had higher scores on social relationship. Longer cessation time was positively associated with higher scores for psychological health.

CONCLUSIONS

Except for the positive association between medium levels of nicotine dependence and better social relationships, smoking and higher levels of nicotine dependence were associated with worse QOL among older adults in Brazil. Nonetheless, smoking cessation had positive effects in QOL. Campaigns targeting older adults should point to the negative impact of tobacco use on QOL and the benefits of smoking cessation.

Cigarette use and smoking beliefs among older Americans: findings from a nationally representative survey

Background: Between 2005 and 2015, the prevalence of smoking among US adults has decreased for all age subgroups, except those aged 65 and older. Aim: In order to identify potential correlates of smoking behaviors in older adults, this research examined associations between age, smoking beliefs, and quitline utilization. Methods: Self-reported, nationally representative data from the Health Information National Trends Survey 2015 cycle (HINTS-FDA) were used (n = 3738). Multivariable logistic regression analyses examined associations between sociodemographic characteristics and beliefs about smoking behaviors. All analyses were conducted with jackknife estimation using sampling weights. Results: Among all survey respondents, 10.5% of those aged 65+ were current smokers (smoked 100 lifetime cigarettes and currently smoked every day or some days). These older adults, compared to those aged 18-29 years, had significantly higher odds of agreeing that smoking behavior is something one can do little to change (AOR = 1.89, 95% CI =1.08, 3.28) and agreeing that nicotine is the substance that causes cancer (AOR = 3.93, 95% CI = 2.17, 7.12). Post hoc analyses compared midlife adults (ages 50-64) with older adults (ages 65+), and indicated older adults had lower odds of having used a quitline/smoking cessation website (AOR = 0.36, 95% CI = 0.14, 0.94, p = 0.04) compared to their midlife peers. Discussion: US adults aged 65 and older hold erroneous beliefs about cigarette smoking behaviors and are less likely to utilize quitline supports. This may be contributing to the stagnant smoking rates among older adults. Smoking cessation efforts targeting older adult Americans are critical in order to stem tobacco use among all Americans.

Associations of evolutionary-concordance diet, Mediterranean diet and evolutionary-concordance lifestyle pattern scores with all-cause and cause-specific mortality

Various individual diet and lifestyle factors are associated with mortality. Investigating these factors collectively may help clarify whether dietary and lifestyle patterns contribute to life expectancy. We investigated the association of previously described evolutionary-concordance and Mediterranean diet pattern scores and a novel evolutionary-concordance lifestyle pattern score with all-cause and cause-specific mortality in the prospective Iowa Women's Health Study (1986-2012). We created the diet pattern scores from Willett FFQ responses, and the lifestyle pattern score from self-reported physical activity, BMI and smoking status, and assessed their associations with mortality, using multivariable Cox proportional hazards regression. Of the 35 221 55- to 69-year-old cancer-free women at baseline, 18 687 died during follow-up. The adjusted hazard ratios (HR) and 95 % CI for all-cause, all CVD, and all-cancer mortality among participants in the highest relative to the lowest quintile of the evolutionary-concordance lifestyle score were, respectively, 0·52 (95 % CI 0·50, 0·55), 0·53 (95 % CI 0·49, 0·57) and 0·51 (95 % CI 0·46, 0·57). The corresponding findings for the Mediterranean diet score were HR 0·85 (95 % CI 0·82, 0·90), 0·83 (95 % CI 0·76, 0·90) and 0·93 (95 % CI 0·84, 1·03), and for the evolutionary-concordance diet score they were close to null and not statistically significant. The lowest estimated risk was among those in the highest joint quintile of the lifestyle score and either diet score (both Pinteraction <0·01). Our findings suggest that (1) a more Mediterranean-like diet pattern and (2) a more evolutionary-concordant lifestyle pattern, alone and in interaction with a more evolutionary-concordant or Mediterranean diet pattern, may be inversely associated with mortality.

Tobacco use in cardiac patients: Perceptions, use, and changes after a recent myocardial infarction among US adults in the PATH study (2013-2015)

Smoking status following cardiac events strongly predicts future morbidity and mortality. Using a nationally representative sample of United States adults, aims of this study were (1) to estimate use of, and attitudes towards, tobacco products as a function of level of cardiac risk, and (2) to explore changes in attitudes and tobacco use among adults experiencing a recent myocardial infarction (MI). Data were obtained from the first and second waves of the Population Assessment of Tobacco and Health (PATH) study. Use and attitudes towards tobacco products were examined at Wave 1 among adults with no chronic health condition (n = 18,026), those with risk factors for heart disease (n = 4593), and those who reported ever having had an MI (n = 643). Changes in perceived risk of tobacco and use between the two waves and having an MI in the last 12 months (n = 240) were also examined. Those who reported lifetime MI were more likely to believe that smoking/using tobacco was causing/worsening a health problem. Having had a recent MI event increased perceived tobacco-related risk and attempts at reduction/quitting, but did not significantly impact combusted tobacco cessation/reduction or uptake of non-combusted tobacco products. Sociodemographic characteristics and use of other tobacco products were associated with change in use of tobacco products. Those who have an MI are sensitized to the harm of continued smoking. Nonetheless, having an MI does not predict quitting combusted tobacco use or switching to potentially reduced harm products. Intense intervention is necessary to reduce combusted use in this high-risk population.

Additional value of a combined genetic risk score to standard cardiovascular stratification

The utility of genetic risk scores (GRS) as independent risk predictors remains inconclusive. Here, we evaluate the additive value of a multi-locus GRS to the Framingham risk score (FRS) in coronary artery disease (CAD) risk prediction. A total of 2888 individuals (1566 coronary patients and 1322 controls) were divided into three subgroups according to FRS. Multiplicative GRS was determined for 32 genetic variants associated to CAD. Logistic Regression and Area Under the Curve (AUC) were determined first, using the TRF for each FRS subgroup, and secondly, adding GRS. Different models (TRF, TRF+GRS) were used to classify the subjects into risk categories for the FRS 10-year predicted risk. The improvement offered by GRS was expressed as Net Reclassification Index and Integrated Discrimination Improvement. Multivariate analysis showed that GRS was an independent predictor for CAD (OR = 1.87; p<0.0001). Diabetes, arterial hypertension, dyslipidemia and smoking status were also independent CAD predictors (p<0.05). GRS added predictive value to TRF across all risk subgroups. NRI showed a significant improvement in all categories. In conclusion, GRS provided a better incremental value in intermediate subgroup. In this subgroup, inclusion of genotyping may be considered to better stratify cardiovascular risk.

Dose-dependent effect of smoking on risk of coronary heart disease, heart failure and stroke in individuals with type 1 diabetes

AIMS/HYPOTHESIS

The aim of this study was to assess the potential dose-dependent effects of smoking on the risk of CHD, heart failure and stroke in individuals with type 1 diabetes.

METHODS

The study included 4506 individuals with type 1 diabetes who were participating in the Finnish Diabetic Nephropathy (FinnDiane) study. Intensity of smoking was estimated by packs per day and cumulative smoking by pack-years. Cox regression analyses were used to estimate the risk of incident CHD, heart failure or stroke during follow-up.

RESULTS

One pack per day significantly increased the risk of incident CHD in current smokers compared with never smokers (HR 1.45 [95% CI 1.15, 1.84]), after adjustment for age, sex, HbA_1c, hypertension, duration of diabetes and BMI. The risk of CHD in former smokers was similar to the risk in never smokers. The risk of incident heart failure was 1.43 (95% CI 1.03, 1.97) in current smokers per one pack per day and 1.37 (95% CI 1.05, 1.77) in former smokers, while the risk of incident stroke was 1.70 (95% CI 1.26, 2.29) and 1.49 (95% CI 1.14, 1.93), respectively. After further adjustments for lipids, however, the difference in the risk of heart failure in current and former smokers was no longer significant. Cumulative smoking data were similar to smoking intensity data.

CONCLUSIONS/INTERPRETATION

There is a dose-dependent association between smoking and cardiovascular disease in individuals with type 1 diabetes. In men in particular, the risk of incident stroke remains high even after smoking cessation and is increased in current and former smokers independently of other risk factors.

Special Article: 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis

OBJECTIVE

To develop an evidence-based guideline for the pharmacologic and nonpharmacologic treatment of psoriatic arthritis (PsA), as a collaboration between the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF).

METHODS

We identified critical outcomes in PsA and clinically relevant PICO (population/intervention/comparator/outcomes) questions. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available pharmacologic and nonpharmacologic therapies for PsA. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of the evidence. A voting panel, including rheumatologists, dermatologists, other health professionals, and patients, achieved consensus on the direction and the strength of the recommendations.

RESULTS

The guideline covers the management of active PsA in patients who are treatment-naive and those who continue to have active PsA despite treatment, and addresses the use of oral small molecules, tumor necrosis factor inhibitors, interleukin-12/23 inhibitors (IL-12/23i), IL-17 inhibitors, CTLA4-Ig (abatacept), and a JAK inhibitor (tofacitinib). We also developed recommendations for psoriatic spondylitis, predominant enthesitis, and treatment in the presence of concomitant inflammatory bowel disease, diabetes, or serious infections. We formulated recommendations for a treat-to-target strategy, vaccinations, and nonpharmacologic therapies. Six percent of the recommendations were strong and 94% conditional, indicating the importance of active discussion between the health care provider and the patient to choose the optimal treatment.

CONCLUSION

The 2018 ACR/NPF PsA guideline serves as a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios. Best treatment decisions consider each individual patient situation. The guideline is not meant to be proscriptive and should not be used to limit treatment options for patients with PsA.

Special Article: 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis

OBJECTIVE

To develop an evidence-based guideline for the pharmacologic and nonpharmacologic treatment of psoriatic arthritis (PsA), as a collaboration between the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF).

METHODS

We identified critical outcomes in PsA and clinically relevant PICO (population/intervention/comparator/outcomes) questions. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available pharmacologic and nonpharmacologic therapies for PsA. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of the evidence. A voting panel, including rheumatologists, dermatologists, other health professionals, and patients, achieved consensus on the direction and the strength of the recommendations.

RESULTS

The guideline covers the management of active PsA in patients who are treatment-naive and those who continue to have active PsA despite treatment, and addresses the use of oral small molecules, tumor necrosis factor inhibitors, interleukin-12/23 inhibitors (IL-12/23i), IL-17 inhibitors, CTLA4-Ig (abatacept), and a JAK inhibitor (tofacitinib). We also developed recommendations for psoriatic spondylitis, predominant enthesitis, and treatment in the presence of concomitant inflammatory bowel disease, diabetes, or serious infections. We formulated recommendations for a treat-to-target strategy, vaccinations, and nonpharmacologic therapies. Six percent of the recommendations were strong and 94% conditional, indicating the importance of active discussion between the health care provider and the patient to choose the optimal treatment.

CONCLUSION

The 2018 ACR/NPF PsA guideline serves as a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios. Best treatment decisions consider each individual patient situation. The guideline is not meant to be proscriptive and should not be used to limit treatment options for patients with PsA.

Migration Status and Smoking Behaviors in Later-Life in China-Evidence From the China Health and Retirement Longitudinal Study (CHARLS)

Background: China is the biggest consumer of tobacco in the world, with a high prevalence of smoking especially among men. Along with the rapid demographic change in China, the burden of diseases attributable to health behaviors, particularly smoking is steadily increasing. So, smoking has become a major risk factor for mortality in China. Smoking behaviors may be related to migration processes, as a result of both who migrates and post-migration experiences related to socioeconomic position, stress and acculturation. Existing studies that have examined smoking and migration in China have, however, only focused on temporary rural-to-urban migrants and focused on relatively younger migrants. This paper examines the association between smoking behaviors and a comprehensive assessment of migration status in later-life in China.

Methods: Using the China Health and Retirement Longitudinal Study (CHARLS), a nationally representative dataset, this paper studies smoking behaviors of rural-to-urban migrants, urban-to-urban migrants, rural return migrants, and urban return migrants. We compare them with corresponding non-migrant groups in both rural and urban locations in China. Using a model that controls for demographic factors, early-life circumstances, socioeconomic factors, and factors related to migration, we examine both the decision to start smoking and the decision to quit smoking. In addition, we also address pre-migration selection in our analyses.

Results: The results show rural-to-urban migrants are no more likely to start smoking compared with rural non-migrants, but they are more likely to quit smoking. While urban-to-urban migrants are more likely to start smoking compared with urban non-migrants, this effect is explained by the factors we include in the full model. Urban-to-urban migrants are, however, less likely to quit smoking. Moreover, both rural return migrants and urban return migrants seem to be more likely to start smoking and less likely to quit smoking compared with non-migrant groups.

Conclusion: There are strong associations between migration status and later-life smoking behaviors in China; these associations vary greatly according to different migration status and point to populations and factors that public health activities should focus on.

[COPD and smoking cessation: Patients' expectations and responses of health professionals]

The importance of smoking cessation in the management of COPD is well-established: the benefit of quitting smoking as regards morbidity and mortality outcomes in patients, is unquestioned. The smoking cessation in COPD patients is difficult: high levels of consumption, the duration of smoking, high dependence level, psychological co-morbidities such as anxiety and depression, lower socio-economic and intellectual level, constitute barriers. Studies have shown that patients often minimize the risks of smoking, that others do not believe in the benefits of quitting or doubt their ability to quit smoking. The patients' experience, and expectations with regard to smoking cessation are incompletely satisfied: are considered, the smoking characteristics of these patients, the understanding of the tobacco dependence, the beliefs and ideas of smokers, the knowledge of smoking cessation methods, the role of validated aids and alternative treatments, failure management. The answers of the health professionals can be in several directions: establishment of a better communication patient-doctor (empathy), more centered on the needs of the smoker, the role of the motivation and the place of the motivational interview, the understanding of the mechanisms of addiction, a better individualisation of therapeutics, the necessity of a extended follow-up, the contribution of modern technologies, the electronic cigarette, the smoking cessation in respiratory rehabilitation, guidelines that address smoking cessation treatment.

Accelerometer-assessed Physical Activity in Epidemiology: Are Monitors Equivalent?

PURPOSE

Accelerometers are increasingly being used to assess physical activity in large-scale surveys. Establishing whether key physical activity outcomes can be considered equivalent between three widely used accelerometer brands would be a significant step toward capitalizing on the increasing availability of accelerometry data for epidemiological research.

METHODS

Twenty participants wore a GENEActiv, an Axivity AX3, and an ActiGraph GT9X on their nondominant wrist and were observed for 2 h in a simulated living space. Participants undertook a series of seated and upright light/active behaviors at their own pace. All accelerometer data were processed identically using open-source software (GGIR) to generate physical activity outcomes (including average dynamic acceleration (ACC) and time within intensity cut points). Data were analyzed using pairwise 95% equivalence tests (±10% equivalence zone), intraclass correlation coefficients (ICC) and limits of agreement.

RESULTS

The GENEActiv and Axivity could be considered equivalent for ACC (ICC = 0.95, 95% confidence interval (CI), 0.87-0.98), but ACC measured by the ActiGraph was approximately 10% lower (GENEActiv/ActiGraph: ICC = 0.86; 95% CI, 0.56-0.95; Axivity/ActiGraph: ICC = 0.82; 95% CI, 0.50-0.94). For time spent within intensity cut points, all three accelerometers could be considered equivalent to each other for more than 85% of outcomes (ICC ≥0.69, lower 95% CI ≥0.36), with the GENEActiv and Axivity equivalent for 100% of outcomes (ICC ≥0.95, lower 95% CI ≥0.86).

CONCLUSIONS

GENEActiv and Axivity data processed in GGIR are largely equivalent. If GENEActiv or Axivity is compared with the ActiGraph, time spent within intensity cut points has good agreement. These findings can be used to inform selection of appropriate outcomes if outputs from these accelerometer brands are compared.

Diverting dementia: Reducing the risk of cognitive loss

As the population ages, more adults in the United States are living with dementia. Younger family members often are concerned that they too may develop dementia, but the general public is largely unaware that strategies exist to slow or delay onset of dementia. In fact, by implementing a number of healthful strategies throughout their lifespans, patients may be able to reduce the likelihood of developing dementia or at least delay its onset. These strategies include eating a high-quality diet; keeping physically, socially, and intellectually active; preventing or treating hearing loss; avoiding obesity, hypertension, and diabetes; and avoiding or stopping tobacco smoking. This article reviews the recent scientific literature for dementia risk-reduction strategies and offers suggestions to healthcare professionals who wish to help their patients stave off cognitive loss.

The health effects of smoking bans: Evidence from German hospitalization data

This paper studies the short-term impact of public smoking bans on hospitalizations in Germany. It exploits the staggered implementation of smoking bans over time and across the 16 federal states along with the universe of hospitalizations from 2000 to 2008 and daily county-level weather and pollution data. Smoking bans in bars and restaurants have been effective in preventing 1.9 hospital admissions (-2.1%) due to cardiovascular diseases per day, per 1 million population. We also find a decrease by 0.5 admissions (-6.5%) due to asthma per day, per 1 million population. The health prevention effects are more pronounced on sunny days and days with higher ambient pollution levels.

[The global medical network Education Against Tobacco-voluntary tobacco prevention made in Germany]

Smoking is the leading preventable cause of premature death in Germany. The network "Education Against Tobacco" (EAT) is an initiative that was founded in Germany in 2012, in which more than 3500 medical students and physicians engage in volunteer work in about 80 medical faculties in 14 countries. In this article, the concept, activities, objectives and associated research studies oft he EAT initiative are introduced.On the school level, the initiative addresses 10- to 15-year-old secondary school students. In addition to a multimodal approach, school visits use modern media such as facemorphing apps, which are not only used by students (45,000 per year in 14 countries), but by a total of over 500,000 other people as well. The effectiveness of the school-based intervention is currently being investigated in randomised long-term studies with 20,000 adolescents in Germany. A first long-term study demonstrated evidence of a protective effect regarding the onset of smoking, especially among female students, students having a low level of education and students with a migratory background.The programme educates several hundred prospective physicians at 13 (of 28 participating) German medical faculties each year in science-based elective courses for the well-established smoking cessation counselling of patients and sensitises them to the tobacco epidemic. The approved members engage in dialogue with local members of the German house of representatives as "Ärzteverband Tabakprävention".EAT motivates the prospective generation of physicians, initially through prevention in school settings, to face the challenge of national tobacco control at the university and federal level.

Association of smoking with risk of stroke in middle-aged and older Chinese: Evidence from the China National Stroke Prevention Project

Although the impacts of smoking on health are well established, it is unclear on how they affect the Chinese population aged ≥40 years. This study aimed to investigate the association between smoking and risk of stroke in middle-aged and older Chinese adults, based on the data from the China National Stroke Prevention Project.A community-based cross-sectional study with 12,704 (5681 men, 7023 women) Chinese adults aged ≥40 years was conducted to examine the association of smoking with stroke. Multivariable logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs).Among the study population, a total of 524 stroke survivors were identified. The age-adjusted prevalence of stroke was 4.06% for both sexes, 2.95% for women, and 5.38% for men. The multivariate-adjusted ORs (95% CI) of stroke associated with current cigarette smoking and former cigarette smoking were 1.67 (1.24-2.25) and 1.93 (1.29-2.87), respectively. Compared with those who were never-smokers, the multivariate-adjusted OR of stroke (95% CI) were 1.48 (0.96 to -2.29), 1.75 (1.20-2.56), and 2.37 (1.20 to -4.68) for those who smoked 1 to 10, 11 to 20, and ≥21 cigarettes per day; and 0.51 (0.19 to -1.42), 1.90 (1.36 to -2.67), and 2.01 (1.17 to -3.46) for those who smoked 1 to 19, 20 to 39, and ≥40 years, respectively (both P < .001 for linear trends). Among former smokers, the multivariable-adjusted ORs of stroke by duration of smoking cessation (compared with never smokers) for <5, 5 to 19, and ≥20 years were 3.47 (1.42-8.49), 3.37 (1.95-5.80), and 0.95 (0.49-1.84), respectively (P = .009 for linear trend). The increased odds of stroke with smoking were more evident among participants who were men, >60 years old, or without family history of stroke than their counterparts.This study suggests the increased odds of stroke in current cigarette smokers with a graded increase in prevalent risk that depended on how many cigarettes and how many years were smoked. Moreover, quitting smoking appears to decrease this excess risk substantially.

Evaluating the Evidence on Sitting, Smoking, and Health: Is Sitting Really the New Smoking?

Sitting has frequently been equated with smoking, with some sources even suggesting that smoking is safer than sitting. This commentary highlights how sitting and smoking are not comparable. The most recent meta-analysis of sedentary behavior and health outcomes reported a hazard ratio of 1.22 (95% confidence interval [CI] = 1.09, 1.41) for all-cause mortality. The relative risk (RR) of death from all causes among current smokers, compared with those who have never smoked, is 2.80 (95% CI = 2.72, 2.88) for men and 2.76 for women (95% CI = 2.69, 2.84). The risk is substantially higher for heavy smokers (> 40 cigarettes per day: RR = 4.08 [95% CI = 3.68, 4.52] for men, and 4.41 [95% CI = 3.70, 5.25] for women). These estimates correspond to absolute risk differences of more than 2000 excess deaths from any cause per 100 000 persons per year among the heaviest smokers compared with never smokers, versus 190 excess deaths per 100 000 persons per year when comparing people with the highest volume of sitting with the lowest. Conflicting or distorted information about health risks related to behavioral choices and environmental exposures can lead to confusion and public doubt with respect to health recommendations.

Predictors of statin use among older adults: A nationwide cross-sectional study

BACKGROUND

Statins comprise a key strategy for the prevention and treatment of arteriosclerotic cardiovascular disease, but prescribing remains suboptimal.

OBJECTIVES

The objective of this study was to characterize the predictors of statin use among adults aged ≥65 years.

METHODS

A cross-sectional study using Pharmaceutical Benefits Scheme (PBS) data on reimbursed prescriptions for a 10% random sample of the Australian population in 2016 was performed. Predictors of statin use were identified via multivariable logistic regression. Analyses were performed separately for people who were concessional beneficiaries (with a low, capped copayment) and other ("general") people.

RESULTS

Among 351,471 (concessional = 295,875 and general = 55,596) older adults, 44.2% were dispensed statins (concessional = 46.4% and general = 32.2%). Among the concessional beneficiaries, people aged 75 to 84 years were more likely to use statins (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.06-1.10), whereas those aged ≥85 years were less likely to use statins (OR 0.71, 95% CI 0.69-0.72), compared with people aged 65 to 74 years. Men were more likely to use statins than women (OR 1.14, 95% CI 1.12-1.16). Diabetes was associated with over 2-fold (OR 2.48, 95% CI 2.43-2.53) increased likelihood of statin use. People with cardiovascular-related conditions including hypertension, angina, and congestive heart failure experienced increased likelihood of statin use as was being dispensed anticoagulant or antiplatelet medication. Having malignancy, psychotic illness, or pain were associated with lower likelihood of statin use. Similar predictors of statin use were noted for the general population.

CONCLUSION

More than 40% of older adults in Australia used statins in 2016 with uptake dependent on individual-level factors such as demographics and comorbidities. Future research should examine the extent to which provider and/or health system-level factors contribute to the variable uptake of statin therapy.

Gender Differences among Elderly Patients with Primary Percutaneous Coronary Intervention

Several epidemiological and clinical studies have shown that females with ST-segment elevation myocardial infarction (STEMI) have a higher mortality than males following primary percutaneous coronary intervention (PPCI). Many analyses of sex-based differences following STEMI have revealed conflicting results. Currently, more and more elderly patients with STEMI have undergone emergency interventional therapy. From January 2014 to December 2016, a total of 337 elderly patients with STEMI were enrolled in this study from two chest pain centers, and all patients underwent PPCI. Patients were divided into two groups: elderly females (n=117, mean age 73.4±9.6 years) and elderly males (n=220, mean age 71.7±8.6 years). The prevalence of diabetes was higher in females than in males (29.1% vs. 19.6%,P<0. 01). Typical ischemic chest pain was lower in females than in males (45.3% vs 57.3%, P<0.01). The number of nonsmokers was also significantly higher in females than in males (5.1% vs. 52.3%,P<0. 01). Serum creatinine (sCr) levels (87.6±17.4 umol/L vs 99.5±20.2 umol/L,P<0.01) and body mass index (23.8±2.7 vs 27.3±3.1, P<0.01) were lower in females than in males. The incidences of major adverse cardiac events (MACE) in-hospital showed no significantly difference (P>0.05) between the two groups. However, the cumulative MACE showed a significant difference between the two groups in the 12-month follow-up (16.8% in male vs 12.8% in female, P = 0.04). Our results suggest that the PPCI is safe and effective in elderly female STEMI patients. The cumulative MACE in females are not higher than in males. PPCI are helpful in elderly STEMI patients.

A prospective study of the hypertriglyceridemic waist phenotype and risk of incident ischemic stroke in a Chinese rural population

OBJECTIVES

The hypertriglyceridemic waist phenotype has been reported as a practical tool to screen people with an increased risk of coronary artery disease and type 2 diabetes. The aim of this study was to investigate the relationship between the phenotype and ischemic stroke in a rural population in south China.

MATERIALS AND METHODS

A total of 4081 participants aged over 35 years old without a stroke history were surveyed in 2009 and followed up from May 2014 to January 2016. The hypertriglyceridemic waist phenotype was defined as a waist circumference ≥90 cm and a triglyceride level ≥2.0 mmol/L in males, and a waist circumference ≥85 cm and a triglyceride level ≥1.5 mmol/L in females. A Cox regression model was used to estimate the association of the phenotype and ischemic stroke.

RESULTS

After a mean of 5.16 years of follow-up, 138 individuals developed ischemic stroke. The hypertriglyceridemic waist phenotype was significantly associated with an increased risk of ischemic stroke before and after adjustment for confounding factors; the hazard ratios and 95% confidence intervals were 1.94 (1.27-2.96) and 1.71 (1.05-2.78), respectively. Further stratified analysis confirmed the associations in females (2.37 [1.09-5.14]) and smokers (3.20 [1.30-7.92]). A significant association of the phenotype and ischemic stroke risk was observed in subjects with normal glucose levels (2.94 [1.58-5.47]) but not in subjects with impaired fasting glucose and diabetes.

CONCLUSIONS

The hypertriglyceridemic waist phenotype is associated with an increased risk of ischemic stroke and might be a simple tool to screen individuals with a high risk for ischemic stroke.

The effects of cigarette smoking and smoking cessation on high-density lipoprotein functions: implications for coronary artery disease

BACKGROUND

Smoking cessation was associated with improved prognosis of coronary artery disease. This study was designed to investigate the effect of smoking cessation on high-density lipoprotein functionality in coronary artery disease patients.

METHODS

In this prospective, randomized and parallel controlled study, coronary artery disease smokers ( n = 28) and healthy smokers ( n = 30) were divided into smoking cessation group and continuous smoking group, respectively. Blood samples were collected before and after three-month smoking cessation. Plasma high-density lipoprotein was isolated by density gradient centrifugation. The ability of high-density lipoprotein against copper-induced oxidation of lipoprotein was determined to evaluate the antioxidative property of high-density lipoprotein, and the macrophage migration inhibited by high-density lipoprotein was tested to identify the antichemotactic property of high-density lipoprotein. High-density lipoprotein-induced macrophage cholesterol efflux was measured by fluorescence spectrometry using NBD cholesterol analogue. Healthy non-smoking volunteers were enrolled as the baseline control.

RESULTS

The baseline antioxidative, antichemotactic ability of high-density lipoprotein and high-density lipoprotein-induced cellular cholesterol efflux in coronary artery disease smokers and healthy smokers were significantly attenuated when compared with those in healthy non-smokers. After three-month smoking cessation, both the antioxidative ability and antichemotactic ability of high-density lipoprotein were improved significantly in coronary artery disease smokers. However, high-density lipoprotein-induced cellular cholesterol efflux was not increased by smoking cessation. In in vitro experiments, carbon monoxide reduced the antioxidative ability and nicotine enhanced the antichemotactic ability of high-density lipoprotein.

CONCLUSIONS

Smoking cessation is an effective measure to improve high-density lipoprotein functions in coronary artery disease smokers. Our study re-emphasizes the importance of smoking cessation in the secondary prevention of coronary artery disease.

Prevalence and associated factors of ischemic heart disease (IHD) among patients with diabetes mellitus: a nation-wide, cross-sectional survey

BACKGROUND

Ischemic Heart Disease (IHD) is the first ranked among most common causes of death involving cardiovascular and other diseases. The information on the prevalence of IHD in Thailand is lacking especially among patients with diabetes mellitus. The objectives of this study were to determine the prevalence of IHD among patients with diabetes mellitus and to determine factors associated with IHD in a nation-wide survey.

METHODS

A cross-sectional study to assess national outcomes among patients with diabetes who visited 831 public hospitals in Thailand was conducted in 2013 to evaluate status of care among patients with diabetes aged at least 18 years who received medical treatment in the target hospital for the last 12 months.

RESULTS

A total of 25,902 patients with diabetes were included in this study. IHD was detected among 918 patients (3.54%; 95%CI 3.32-3.77). Multivariate analysis was conducted to determine which factors were most associated with IHD, and the results showed age (AORs 1.05; 95%CI 1.04-1.05), being male (AORs 1.78; 95%CI 1.53-2.07), hypertensive comorbidity (AORs 2.10; 95%CI 1.68-2.62), being in Health Region 4 (AORs 1.93; 95%CI 1.54-2.35), presenting hyperglycemic crisis (AORs 1.53; 95%CI 1.14-2.06) and insulin therapy (AORs 1.40; 95%CI 1.17-1.66) were the highest associated factors for IHD in this population.

CONCLUSION

Our data emphasized that IHD was a problem among patients with diabetes. Diabetic patients should be regularly assessed for IHD and their risk factors should be better controlled. Moreover, the Ministry of Public Health managers and clinicians should provide further preventative strategies to attenuate cardiovascular disease.

Impact of Healthy Lifestyle Factors on Life Expectancies in the US Population

BACKGROUND

Americans have a shorter life expectancy compared with residents of almost all other high-income countries. We aim to estimate the impact of lifestyle factors on premature mortality and life expectancy in the US population.

METHODS

Using data from the Nurses' Health Study (1980-2014; n=78 865) and the Health Professionals Follow-up Study (1986-2014, n=44 354), we defined 5 low-risk lifestyle factors as never smoking, body mass index of 18.5 to 24.9 kg/m2, ≥30 min/d of moderate to vigorous physical activity, moderate alcohol intake, and a high diet quality score (upper 40%), and estimated hazard ratios for the association of total lifestyle score (0-5 scale) with mortality. We used data from the NHANES (National Health and Nutrition Examination Surveys; 2013-2014) to estimate the distribution of the lifestyle score and the US Centers for Disease Control and Prevention WONDER database to derive the age-specific death rates of Americans. We applied the life table method to estimate life expectancy by levels of the lifestyle score.

RESULTS

During up to 34 years of follow-up, we documented 42 167 deaths. The multivariable-adjusted hazard ratios for mortality in adults with 5 compared with zero low-risk factors were 0.26 (95% confidence interval [CI], 0.22-0.31) for all-cause mortality, 0.35 (95% CI, 0.27-0.45) for cancer mortality, and 0.18 (95% CI, 0.12-0.26) for cardiovascular disease mortality. The population-attributable risk of nonadherence to 5 low-risk factors was 60.7% (95% CI, 53.6-66.7) for all-cause mortality, 51.7% (95% CI, 37.1-62.9) for cancer mortality, and 71.7% (95% CI, 58.1-81.0) for cardiovascular disease mortality. We estimated that the life expectancy at age 50 years was 29.0 years (95% CI, 28.3-29.8) for women and 25.5 years (95% CI, 24.7-26.2) for men who adopted zero low-risk lifestyle factors. In contrast, for those who adopted all 5 low-risk factors, we projected a life expectancy at age 50 years of 43.1 years (95% CI, 41.3-44.9) for women and 37.6 years (95% CI, 35.8-39.4) for men. The projected life expectancy at age 50 years was on average 14.0 years (95% CI, 11.8-16.2) longer among female Americans with 5 low-risk factors compared with those with zero low-risk factors; for men, the difference was 12.2 years (95% CI, 10.1-14.2).

CONCLUSIONS

Adopting a healthy lifestyle could substantially reduce premature mortality and prolong life expectancy in US adults.

Current Smoking and Prognosis After Acute ST-Segment Elevation Myocardial Infarction: New Pathophysiological Insights

Objectives

The aim of this study was to mechanistically investigate associations among cigarette smoking, microvascular pathology, and longer term health outcomes in patients with acute ST-segment elevation myocardial infarction (MI).

Background

The pathophysiology of myocardial reperfusion injury and prognosis in smokers with acute ST-segment elevation MI is incompletely understood.

Methods

Patients were prospectively enrolled during emergency percutaneous coronary intervention. Microvascular function in the culprit artery was measured invasively. Contrast-enhanced magnetic resonance imaging (1.5-T) was performed 2 days and 6 months post-MI. Infarct size and microvascular obstruction were assessed using late gadolinium enhancement imaging. Myocardial hemorrhage was assessed with T2* mapping. Pre-specified endpoints included: 1) all-cause death or first heart failure hospitalization; and 2) cardiac death, nonfatal MI, or urgent coronary revascularization (major adverse cardiovascular events). Binary logistic regression (odds ratio [OR] with 95% confidence interval [CI]) with smoking status was used.

Results

In total, 324 patients with ST-segment elevation MI were enrolled (mean age 59 years, 73% men, 60% current smokers). Current smokers were younger (age 55 ± 11 years vs. 65 ± 10 years, p < 0.001), with fewer patients with hypertension (52 ± 27% vs. 53 ± 41%, p = 0.007). Smokers had better TIMI (Thrombolysis In Myocardial Infarction) flow grade (≥2 vs. ≤1, p = 0.024) and ST-segment resolution (none vs. partial vs. complete, p = 0.010) post–percutaneous coronary intervention. On day 1, smokers had higher circulating C-reactive protein, neutrophil, and monocyte levels. Two days post-MI, smoking independently predicted infarct zone hemorrhage (OR: 2.76; 95% CI: 1.42 to 5.37; p = 0.003). After a median follow-up period of 4 years, smoking independently predicted all-cause death or heart failure events (OR: 2.20; 95% CI: 1.07 to 4.54) and major adverse cardiovascular events (OR: 2.79; 95% CI: 2.30 to 5.99).

Conclusions

Smoking is associated with enhanced inflammation acutely, infarct-zone hemorrhage subsequently, and longer term adverse cardiac outcomes. Inflammation and irreversible myocardial hemorrhage post-MI represent mechanistic drivers for adverse long-term prognosis in smokers. (Detection and Significance of Heart Injury in ST Elevation Myocardial Infarction. [BHF MR-MI]; NCT02072850)

A cost-benefit analysis of smoking cessation prescription coverage from a US payer perspective

Introduction

Smoking drives substantial direct health care spending, comprising 8.7% ($168 billion) of annual United States aggregated spending. Smoking cessation (SC) prescription use is an effective strategy to improve health outcomes, increase quit rates, and reduce economic burden. However, patient out-of-pocket costs may limit the use. Health care payers play a vital role in driving use through formulary decisions and copayment policies but must consider both the near-term financial investment as well as downstream effects of increased coverage on health care budgets. This study estimates the return on investment (ROI) of providing Affordable Care Act (ACA)-recommended prescription SC coverage.

Methods

A cost–benefit analysis (CBA) estimates the ROI of providing prescription SC coverage, based on pharmacy costs and savings from smoking-attributable medical expenditures among Medicare, Medicaid, and commercial plan enrollees over 10 years. The CBA incorporated national-level population demographics, smoking prevalence estimates, proportion of smokers attempting to quit, and the utilization of SC products. A five-state Markov chain model simulated patterns of quit attempts, relapse, and cessation assuming two quit attempts per year, no patient cost-sharing, and 25.4% utilization of prescription SC aids. Results include number of quitters, annual pharmacy and smoking-attributable medical costs, and ROI.

Results

After initial investment in SC treatment, smoking-attributable medical benefits accrue over time, generating a positive ROI by year 4 for commercial (11.3%) and Medicaid (78.4%) plans and by year 3 for Medicare (30.6%). Over 10 years, an average return of $1.18, $2.50, and $3.22 savings per dollar spent on SC prescriptions for commercial, Medicaid, and Medicare plans, respectively, may be realized.

Discussion

Given the proven efficacy of SC pharmacotherapy, near-term investments in supporting ACA-recommended SC coverage translate into a positive ROI. As smoking is a leading cause of morbidity and mortality, increased access to prescription SC medications may improve health outcomes and reduce smoking-attributable costs to payers over time.

Genetic Risk Analysis of Coronary Artery Disease in a Population-based Study in Portugal, Using a Genetic Risk Score of 31 Variants

BACKGROUND

Genetic risk score can quantify individual's predisposition to coronary artery disease; however, its usefulness as an independent risk predictor remains inconclusive.

OBJECTIVE

To evaluate the incremental predictive value of a genetic risk score to traditional risk factors associated with coronary disease.

METHODS

Thirty-three genetic variants previously associated with coronary disease were analyzed in a case-control population with 2,888 individuals. A multiplicative genetic risk score was calculated and then divided into quartiles, with the 1st quartile as the reference class. Coronary risk was determined by logistic regression analysis. Then, a second logistic regression was performed with traditional risk factors and the last quartile of the genetic risk score. Based on this model, two ROC curves were constructed with and without the genetic score and compared by the Delong test. Statistical significance was considered when p values were less than 0.05.

RESULTS

The last quartile of the multiplicative genetic risk score revealed a significant increase in coronary artery disease risk (OR = 2.588; 95% CI: 2.090-3.204; p < 0.0001). The ROC curve based on traditional risk factors estimated an AUC of 0.72, which increased to 0.74 when the genetic risk score was added, revealing a better fit of the model (p < 0.0001).

CONCLUSIONS

In conclusion, a multilocus genetic risk score was associated with an increased risk for coronary disease in our population. The usual model of traditional risk factors can be improved by incorporating genetic data.

Factors associated with continued smoking after the diagnosis of type 2 diabetes: a retrospective study in the Korean cohort

OBJECTIVE

To investigate the factors associated with continued smoking in patients newly diagnosed with type 2 diabetes.

DESIGN

Retrospective study using the Korean National Health Insurance Service-National Health Screening Cohort (2002-2013) database.

PARTICIPANTS

Male patients newly diagnosed with type 2 diabetes between 1 January 2004 and 31 December 2011.

MEASUREMENT

Change in smoking behaviour after the diabetes diagnosis was assessed using a self-reported questionnaire, which was administered before and after the diagnosis. To identify the factors associated with continued smoking after diabetes diagnosis, a multivariate-adjusted logistic regression was conducted using only the variables with statistical significance from the univariate analyses.

RESULTS

Younger age, lower economic status, heavier smoking habit, lower Charlson Comorbidity Index and comorbid hypertension were identified as factors associated with continued smoking after the diagnosis of type 2 diabetes. Older patients (adjusted OR (aOR) 0.71, 95% CI 0.63 to 0.79) and patients with longer diabetic duration (1-2 years OR 0.88, 95% CI 0.80 to 0.98, ≥3 years OR 0.63, 95% CI 0.55 to 0.73) were more likely to quit smoking. Contrastingly, smokers in the lower economic status (aOR 1.29, 95% CI 1.18 to 1.42) and heavier smoking habit (moderate: aOR 1.53, 95% CI 1.35 to 1.72; heavy: aOR 1.90, 95% CI 1.67 to 2.17) categories were more likely to continue smoking after the diagnosis.

CONCLUSIONS

It is important to identify the factors associated with smoking behaviour in patients with type 2 diabetes. Recognising the factors that contribute to the vulnerability of patients to continued smoking will be helpful in developing policies and intervention strategies in future. Vulnerable patients may require intensive education and encouragement to quit smoking. We recommend physicians to take a more proactive approach, such as encouraging frequent clinical sessions for behavioural counselling and even early pharmacological interventions, when they encounter patients with the factors outlined in this study.

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

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

Alcohol intake in relation to non-fatal and fatal coronary heart disease and stroke: EPIC-CVD case-cohort study

OBJECTIVE

To investigate the association between alcohol consumption (at baseline and over lifetime) and non-fatal and fatal coronary heart disease (CHD) and stroke.

DESIGN

Multicentre case-cohort study.

SETTING

A study of cardiovascular disease (CVD) determinants within the European Prospective Investigation into Cancer and nutrition cohort (EPIC-CVD) from eight European countries.

PARTICIPANTS

32 549 participants without baseline CVD, comprised of incident CVD cases and a subcohort for comparison.

MAIN OUTCOME MEASURES

Non-fatal and fatal CHD and stroke (including ischaemic and haemorrhagic stroke).

RESULTS

There were 9307 non-fatal CHD events, 1699 fatal CHD, 5855 non-fatal stroke, and 733 fatal stroke. Baseline alcohol intake was inversely associated with non-fatal CHD, with a hazard ratio of 0.94 (95% confidence interval 0.92 to 0.96) per 12 g/day higher intake. There was a J shaped association between baseline alcohol intake and risk of fatal CHD. The hazard ratios were 0.83 (0.70 to 0.98), 0.65 (0.53 to 0.81), and 0.82 (0.65 to 1.03) for categories 5.0-14.9 g/day, 15.0-29.9 g/day, and 30.0-59.9 g/day of total alcohol intake, respectively, compared with 0.1-4.9 g/day. In contrast, hazard ratios for non-fatal and fatal stroke risk were 1.04 (1.02 to 1.07), and 1.05 (0.98 to 1.13) per 12 g/day increase in baseline alcohol intake, respectively, including broadly similar findings for ischaemic and haemorrhagic stroke. Associations with cardiovascular outcomes were broadly similar with average lifetime alcohol consumption as for baseline alcohol intake, and across the eight countries studied. There was no strong evidence for interactions of alcohol consumption with smoking status on the risk of CVD events.

CONCLUSIONS

Alcohol intake was inversely associated with non-fatal CHD risk but positively associated with the risk of different stroke subtypes. This highlights the opposing associations of alcohol intake with different CVD types and strengthens the evidence for policies to reduce alcohol consumption.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Smoking and early retirement due to chronic disability

This paper considers the long-term effects of smoking on disability retirement in Sweden. Smoking is known to have damaging effects on health, but there is limited evidence on how the effects of smoking translate into worse labour market outcomes, such as the inability to work. In contrast to the few previous studies on smoking and disability retirement, we use a large population sample with registry information on smoking, which is recorded for all women who give birth in Sweden. Thanks to these comprehensive data, we are able to account for a much broader range of potential confounders. In particular, by the use of sibling and twin fixed effects, we account for unobserved heterogeneity in childhood environment and family characteristics. Given that smoking is often initiated in adolescence, one would suspect such factors to play important roles. Among individuals aged 50-64 in 2011, a simple model suggested smokers to have a 5 percentage point higher probability of receiving (full) disability pension, making them more than twice as likely as non-smokers to receive this. However, in a model with sibling fixed effects, the size of the effect was reduced by more than a third. The results point to the importance of confounders, such as childhood circumstances or behaviours, which were not accounted for by previous studies. We also consider effects on disability due to different health conditions. In relative terms, effects are the largest for circulatory conditions and tumours. Results are largely driven by health problems severe enough to merit hospitalization, and there is no evidence of a role played by financial incentives.

Effects of smoking habit change on all-cause mortality and cardiovascular diseases among patients with newly diagnosed diabetes in Korea

This study aimed to investigate the effects of smoking habit change on the risks of all-cause mortality and cardiovascular diseases (CVDs) among patients with newly diagnosed diabetes using the Korean National Sample Cohort data. Survival regression analyses for the risks of all-cause mortality and CVDs were performed. Quitters without body mass index (BMI) change (adjusted hazard ratio [aHR], 0.68; 95% confidence interval [CI], 0.46-1.00) and quitters with BMI loss (aHR, 1.76; 95% CI, 1.13-2.73) showed significantly reduced and substantially the increased risk of all-cause mortality, respectively, compared with sustained smokers. Smoking reduction after diabetes diagnosis may have potential positive effects. However, definite benefits on the health outcomes were not identified in this study. Participants who started smoking after diabetes diagnosis had higher risks of all-cause mortality and CVDs than those who were never smokers or ex-smokers, although not statistically significant. In conclusion, smoking cessation after diabetes diagnosis could reduce the risks of all-cause mortality and cardiovascular events among patients with newly diagnosed diabetes when accompanied by proper weight management. Therefore, physicians should advice patients with newly diagnosed type 2 diabetes on the importance of smoking cessation in combination with long-term weight management to maximize the benefits of smoking cessation.

Effect of Smoking and Folate Levels on the Efficacy of Folic Acid Therapy in Prevention of Stroke in Hypertensive Men

BACKGROUND AND PURPOSE

We aimed to examine whether the efficacy of folic acid therapy in the primary prevention of stroke is jointly affected by smoking status and baseline folate levels in a male population in a post hoc analysis of the CSPPT (China Stroke Primary Prevention Trial).

METHODS

Eligible participants of the CSPPT were randomly assigned to a double-blind daily treatment of a combined enalapril 10-mg and folic acid 0.8-mg tablet or an enalapril 10-mg tablet alone. In total, 8384 male participants of the CSPPT were included in the current analyses. The primary outcome was first stroke.

RESULTS

The median treatment duration was 4.5 years. In the enalapril-alone group, the first stroke risk varied by baseline folate levels and smoking status (never versus ever). Specifically, there was an inverse association between folate levels and first stroke in never smokers (P for linear trend=0.043). However, no such association was found in ever smokers. A test for interaction between baseline folate levels and smoking status on first stroke was significant (P=0.045). In the total sample, folic acid therapy significantly reduced the risk of first stroke in never smokers with folate deficiency (hazard risk, 0.36; 95% confidence interval, 0.16-0.83) and in ever smokers with normal folate levels (hazard risk, 0.69; 95% confidence interval, 0.48-0.99).

CONCLUSIONS

Baseline folate levels and smoking status can interactively affect the risk of first stroke. Our data suggest that compared with never smokers, ever smokers may require a higher dosage of folic acid to achieve a greater beneficial effect on stroke. Our findings need to be confirmed by future randomized trials.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00794885.

Is there a role for lifestyle changes in cardiovascular prevention? What, when and how?

BACKGROUND AND AIMS

Lifestyle has been found to play an important role in the prevention of cardiovascular disease (CVD). There is evidence to suggest that if lifestyle factors are modified successfully, the relative risk of CVD can be reduced. Risk factors for CVD such as high blood pressure, diabetes mellitus and dyslipidaemias can be modified by lifestyle changes. The main aim of this article is to provide best practice approaches and support for healthcare professionals on the role of lifestyle changes in the prevention of CVD.

METHODS

A working group of experts discussed existing guidelines, clinical practice and evidence, and provided their recommendations on ten topics concerning the role of lifestyle in CVD prevention. These topics covered important lifestyle factors as well as tools/approaches to assess or encourage lifestyle changes.

RESULTS

The group of clinical experts collaborated to provide their opinion on the following topics: one diet versus customised diets; the role of alcohol consumption in a healthy diet; a diet based on nutrient composition or on whole foods; a Mediterranean versus low-fat diet; the role of dietary supplements; physical activity; smoking cessation; the role of a nutritionist/dietitian in a CVD risk multidisciplinary team; tools to be implemented to assess diet, physical activity and smoking status; and the most effective approaches to encourage lifestyle changes.

CONCLUSIONS

The expert working group agreed that lifestyle changes were important in preventing CVD and provided recommendations which complemented current guidance and increased clarity on several topics.

Smoking increases risks of all-cause and breast cancer specific mortality in breast cancer individuals: a dose-response meta-analysis of prospective cohort studies involving 39725 breast cancer cases

Smoking is associated with the risks of mortality from breast cancer (BC) or all causes in BC survivors. Two-stage dose-response meta-analysis was conducted. A search of PubMed and Embase was performed, and a random-effect model was used to yield summary hazard ratios (HRs). Eleven prospective cohort studies were included. The summary HR per 10 cigarettes/day, 10 pack-years, 10 years increase were 1.10 (95% confidence interval (CI) = 1.04–1.16), 1.09 (95% CI = 1.06–1.12), 1.10 (95% CI = 1.06–1.14) for BC specific mortality, and 1.15 (95% CI = 1.10–1.19), 1.15 (95% CI = 1.10–1.20), 1.17 (95% CI = 1.11–1.23) for all-cause mortality, respectively. The linear or non-linear associations between smoking and risks of mortality from BC or all causes were revealed. Subgroup analyses suggested a positive association between ever or former smoking and the risk of all-cause mortality in BC patients, especially in high doses consumption. In conclusion, higher smoking intensity, more cumulative amount of cigarettes consumption and longer time for smoking is associated with elevated risk of mortality from BC and all causes in BC individuals. The results regarding smoking cessation and “ever or former” smokers should be treated with caution due to limited studies.