Assessment of salivary cotinine concentration among general non-smokers population: Before and after Spanish smoking legislations

Effect of educational intervention in reducing exposure to second hand tobacco smoke among 12-year-old children as determined by their salivary cotinine levels and knowledge, attitude and behavior - a randomized controlled trial

Background

Tobacco use is one of the most important public health concerns, with approximately 8.7 million tobacco-related deaths each year, primarily in low- and middle-income countries. Even more concerning is the fact that 1.3 million of these deaths are seen in nonsmokers, including babies and children. This study was performed to determine whether a school-based "tobacco-free" educational intervention program among 12-year-old children would be effective in reducing their exposure to second-hand tobacco smoke (SHS) by improving their knowledge, attitude and behavior post intervention and estimating salivary cotinine levels as markers of SHS exposure.

Materials and method

A randomized controlled trial was performed by a cluster random sampling technique, with 30 participants each in the experimental and control arms. A knowledge, attitude, avoidance behavior and self-efficacy of avoidance questionnaire was administered, followed by estimation of salivary cotinine levels. The experimental arm received the "tobacco-free" intervention, which comprised a 40-min health education session, with the first follow-up at 15 days and the second at 30 days after the intervention. After the intervention, the questionnaire was readministered, followed by re-estimation of salivary cotinine levels.

Results

One month after the intervention, the number of participants who had a smoker who lived with them and the number of people who smoked inside the house were reduced in the experimental group compared to the control group. In the knowledge domain and the attitude domain, 80% and 60% of the items showed a statistically significant improvement in the experimental group compared to the control group. In the avoidance behavior domain and the Self-Efficacy of Avoidance Domain, all the items showed improvement in the experimental group compared to the control group. When the mean salivary cotinine levels were compared pre- and postintervention, it was found that although the mean postintervention salivary cotinine levels increased in both the experimental and control groups, the increase was less in the experimental group than in the control group.

Conclusion

The present study has been shown to be effective in improving the knowledge, attitude and avoidance behavior of adolescents toward exposure to secondhand smoke.

Variation in Nicotine Metabolization According to Biological Factors and Type of Nicotine Consumer

This study aims to describe the nicotine metabolite ratio among tobacco smokers and electronic cigarette (e-cigarette) users and nonusers. We analyzed pooled data from a longitudinal and a cross-sectional study of the adult population from the city of Barcelona. The final sample included information on 166 smokers, 164 e-cigarettes users with nicotine, 41 e-cigarette users without nicotine, 95 dual users (users of both products), and 508 nonusers. We used log-linear models to control for the potential confounding effect of the daily number of cigarettes smoked. Salivary nicotine metabolic rate assessment included the rate of nicotine metabolism (cotinine/nicotine) and the nicotine metabolite ratio (trans-3′-hydroxycotinine/cotinine). Exclusive users of e-cigarette without nicotine have the lowest rate of nicotine metabolism (Geometric mean: 0.08, p-values < 0.001) while cigarette smokers have the highest (Geometric mean: 2.08, p-values < 0.001). Nonusers have lower nicotine metabolic rate than cigarette smokers (Geometric means: 0.23 vs. 0.18, p-value < 0.05). Younger individuals (18−44 years) have a higher rate of nicotine metabolism than older individuals (45−64 years and 65−89) (Geometric means: 0.53 vs. 0.42 and 0.31, respectively, p-values < 0.01) and individuals with lower body mass index (21−25 kg/m2) have a higher rate of nicotine metabolism than the rest (26−30 kg/m2 and 31−60 kg/m2) (Geometric means: 0.52 vs. 0.35 and 0.36, respectively-values < 0.01). Nicotine metabolic rates are useful biomarkers when reporting smoking status and biological differences between individuals.

Changes in the salivary cotinine cut-offs to discriminate smokers and non-smokers before and after Spanish smoke-free legislation

INTRODUCTION

High levels of cotinine in non-smokers indicate passive exposure to tobacco smoke. This study aims to evaluate variations in salivary cotinine cut-offs to discriminate smokers and non-smokers before and after the implementation of smoke-free legislation (Law 28/2005 and Law 42/2010) in a sample of the adult population of Barcelona, Spain.

METHODS

This longitudinal study analyzes salivary cotinine samples and self-reported information from a representative sample (n = 676) of the adult population from Barcelona before and after the approval of smoke-free legislation. We calculated the receiver operating characteristic (ROC) curves, to obtain optimal cotinine cut-off points to discriminate between smokers and non-smokers overall, by sex and age, and their corresponding sensitivity, specificity, and area under the curve. We used linear mixed-effects models, with individuals as random effects, to model the percentage change of cotinine concentration before and after the implementation of both laws.

RESULTS

The mean salivary cotinine concentration was significantly lower post-2010 law (-85.8%, p < 0.001). The ROC curves determined that the optimal cotinine cut-off points for discriminating non-smokers and smokers were 10.8 ng/mL (pre-2005 law) and 5.6 ng/mL (post-2010 law), with a post-2010 law sensitivity of 92.6%, specificity of 98.4%, and an area under the curve of 97.0%. The post-2010 law cotinine cut-off points were 5.6 ng/mL for males and 1.9 ng/mL for females.

CONCLUSION

The implementation of Spanish smoke-free legislation was effective in reducing secondhand smoke exposure and, therefore, also in reducing the cut-off point for salivary cotinine concentration. This value should be used to better assess tobacco smoke exposure in this population.

Third-hand exposure at homes: Assessment using salivary cotinine

BACKGROUND/OBJECTIVES

While exposure to secondhand smoke (SHS) is a well-established problem, exposure to third-hand smoke (THS) is scanty known and needs to be studied. The objective of this work is to characterize salivary cotinine concentrations among people who self-reported exposure to SHS and THS at home.

METHODS

Cross-sectional study of a representative sample (n = 736) of the adult population (≥16 years) from the city of Barcelona carried out in 2013-2014. A questionnaire on tobacco use and passive exposure was administered, and a saliva sample was collected for cotinine determination. For this study, the information of the non-smoker participants who provided saliva sample (n = 519) was used. The geometric means (GM) and geometric standard deviations (GSD) of the cotinine concentration were compared according to the type of self-reported exposure at home: (1) Not exposed to SHS or THS; (2) Exposed to SHS and THS; and (3) Only exposed to THS. We used log-linear models to compare the cotinine concentration of each exposed group with respect to the unexposed group, adjusting for sex, age, educational level, and tobacco exposure in other settings.

RESULTS

The GM of the salivary cotinine concentration was 0.34 ng/ml (GSD = 0.16) among individuals reporting SHS and THS exposure, 0.22 ng/ml (GSD = 0.15) among those reporting only THS exposure and 0.11 ng/ml (GSD = 0.04) among those who declared not to be exposed to SHS nor THS (p-value for trend <0.001). The regression model showed a statistically significant increase in cotinine concentration among those exposed to SHS and THS (188% higher, 95% CI: 153%; 223%), and only exposed to THS (106% higher, IC95. %: 74.5%; 137.0%) when comparing with the unexposed group. No statistically significant differences in cotinine concentration were observed between those exposed to SHS and THS compared to the THS group (-25.8%, 95% CI: -69.5%; 17.9%).

CONCLUSIONS/RECOMMENDATIONS

People exposed to third-hand smoke at home had quantifiable cotinine levels in saliva. No differences in cotinine levels were found between those exposed to second-hand and third-hand smoke at home. The reduction of exposure to third-hand smoke at home should be put into the agenda of tobacco control.

Correlation between tobacco control policies and mortality of haematological cancers across Europe: An ecological study

INTRODUCTION

To determine the correlation between tobacco control policies and mortality of haematological malignancies: leukemia, lymphoma and multiple myeloma (MM).

METHODS

Ecological study with the countries as the unit of analysis. Tobacco Control Scale (TCS) scores from 2010, 2013 and 2016 were used as measures for the level of tobacco control policy implementation in 27 European countries. Mortality rates for leukemia, lymphoma, and MM, were obtained from the WHO Mortality Database and the European Cancer Information System for each country for 2010, 2013, 2015 and 2018. Correlation between yearly TCS scores and mortality rates from the same and prospective years were calculated using Spearman's rank correlation coefficients (r_sp) and 95% confidence intervals (95% CI) (2010 TCS scores vs 2010, 2013, 2015, 2018 mortality rates; 2013 TCS scores vs 2013, 2015, 2018 mortality rates; and 2016 TCS scores vs 2018 mortality rates).

RESULTS

The 2010 TCS scores were significantly negatively associated with leukemia mortality rates in 2013 (r_sp=-0.58; 95% CI: -0.79, -0.24; p=0.002), 2015 (r_sp=-0.65; 95% CI: -0.85, -0.30; p=0.001) and 2018 (r_sp=-0.44; 95% CI: -0.71, -0.06; p=0.021). TCS scores from 2013 and 2016 had significant negative associations with leukemia mortality in all prospective years. TCS scores did not demonstrate consistent correlations with lymphoma and MM mortality.

CONCLUSIONS

The level of tobacco control policies in European countries correlates negatively with leukemia mortality at ecological level, with no correlation seen for lymphoma and MM. This study advocates that increased tobacco control implementation may improve leukemia mortality.

Reducing Secondhand Smoke Exposure Among Nonsmoking Pregnant Women: A Systematic Review

Introduction

Exposure to secondhand smoke (SHS) in pregnancy leads to an increased risk of stillbirths, congenital malformations, and low birth weight. There is a lack of evidence about how best to achieve reductions in SHS exposure among nonsmoking pregnant women. This work systematically reviews individual or household interventions to reduce pregnant women’s exposure to SHS.

Methods

MEDLINE, EMBASE, and CINAHL databases were searched from their dates of inception to April 17, 2019. Studies were included if: participants were nonsmoking pregnant women; involved an intervention to reduce SHS exposure or encourage partner quitting; and measured SHS exposure of pregnant women and/or recorded quit rates among partners. The UK National Institute for Health & Care Excellence (NICE) Quality Appraisal checklist was used to determine internal and external validity.

Results

Nine studies met the inclusion criteria. Educational interventions were primarily targeted at the pregnant woman to change her or others’ behavior, with only two studies involving the partner who smoked. Intervention delivery was mixed, spanning brief discussions through to more involving sessions with role play. The effective interventions involved multiple follow-ups. There was no standardized method of assessing exposure to SHS. Many of the included studies had moderate to high risk of bias.

Conclusion

There is mixed evidence for interventions aimed at reducing pregnant women’s exposure to SHS, though multi-component interventions seem to be more effective. The effectiveness of family-centered approaches involving creating smoke-free homes alongside partner smoking cessation, perhaps involving pharmacological support and/or financial incentives, should be explored.

Implications

• Measures to protect nonsmoking pregnant women from SHS tend to place the responsibility for “avoidance” on the woman.

• There is little work that seeks to involve the smoking partner or other smokers in protecting pregnant women from SHS.

• Interventions to create smoke-free homes and/or smoking partner cessation need to be developed: pharmacological and financial support should be explored.

Glasgow Coma Scale Score Fluctuations are Inversely Associated With a NIRS-based Index of Cerebral Autoregulation in Acutely Comatose Patients

BACKGROUND

The Glasgow Coma Scale (GCS) is an essential coma scale in critical care for determining the neurological status of patients and for estimating their long-term prognosis. Similarly, cerebral autoregulation (CA) monitoring has shown to be an accurate technique for predicting clinical outcomes. However, little is known about the relationship between CA measurements and GCS scores among neurological critically ill patients. This study aimed to explore the association between noninvasive CA multimodal monitoring measurements and GCS scores.

METHODS

Acutely comatose patients with a variety of neurological injuries admitted to a neurocritical care unit were monitored using near-infrared spectroscopy-based multimodal monitoring for up to 72 hours. Regional cerebral oxygen saturation (rScO2), cerebral oximetry index (COx), GCS, and GCS motor data were measured hourly. COx was calculated as a Pearson correlation coefficient between low-frequency changes in rScO2 and mean arterial pressure. Mixed random effects models with random intercept was used to determine the relationship between hourly near-infrared spectroscopy-based measurements and GCS or GCS motor scores.

RESULTS

A total of 871 observations (h) were analyzed from 57 patients with a variety of neurological conditions. Mean age was 58.7±14.2 years and the male to female ratio was 1:1.3. After adjusting for hemoglobin and partial pressure of carbon dioxide in arterial blood, COx was inversely associated with GCS (β=-1.12, 95% confidence interval [CI], -1.94 to -0.31, P=0.007) and GCS motor score (β=-1.06, 95% CI, -2.10 to -0.04, P=0.04). In contrast rScO2 was not associated with GCS (β=-0.002, 95% CI, -0.01 to 0.01, P=0.76) or GCS motor score (β=-0.001, 95% CI, -0.01 to 0.01, P=0.84).

CONCLUSIONS

This study showed that fluctuations in GCS scores are inversely associated with fluctuations in COx; as COx increases (impaired autoregulation), more severe neurological impairment is observed. However, the difference in COx between high and low GCS is small and warrants further studies investigating this association. CA multimodal monitoring with COx may have the potential to be used as a surrogate of neurological status when the neurological examination is not reliable (ie, sedation and paralytic drug administration).