Agreement between self-reported smoking and cotinine concentration in adolescents: a validation study in Brazil

Monitoring Cigarette Smoking and Relapse in Young Adults With and Without Remote Biochemical Verification: Randomized Brief Cessation Study

BACKGROUND

Technological advancements to study young adult smoking, relapse, and to deliver interventions remotely offer conceptual appeal, but the incorporation of technological enhancement must demonstrate benefit over traditional methods without adversely affecting outcomes. Further, integrating remote biochemical verification of smoking and abstinence may yield value in the confirmation of self-reported smoking, in addition to ecologically valid, real-time assessments.

OBJECTIVE

The goal of this study was to evaluate the impact of remote biochemical verification on 24-hour self-reported smoking and biochemical verification agreement, retention, compliance with remote sessions, and abstinence during a brief, 5-week cessation attempt and relapse monitoring phase.

METHODS

Participants (N=39; aged 18-25 years; mean age 21.6, SD 2.1 years; n=22, 56% male; n=29, 74% White) who smoked cigarettes daily engaged in a 5-week cessation and monitoring study (including a 48-hour quit attempt and provision of tobacco treatment in the form of nicotine replacement therapy, brief cessation counseling, and financial incentives for abstinence during the 2-day quit attempt only). Smoking (cigarettes per day) was self-reported through ecological momentary assessment (EMA) procedures, and participants were randomized to either (1) the inclusion of remote biochemical verification (EMA + remote carbon monoxide [rCO]) 2× per day or (2) in-person, weekly CO (wCO). Groups were compared on the following outcomes: (1) agreement in self-reported smoking and breath carbon monoxide (CO) at common study time points, (2) EMA session compliance, (3) retention in study procedures, and (4) abstinence from smoking during the 2-day quit attempt and at the end of the 5-week study.

RESULTS

No significant differences were demonstrated between the rCO group and the wCO (weekly in-person study visit) group on agreement between 24-hour self-reported smoking and breath CO (moderate to poor), compliance with remote sessions, or retention, though these outcomes numerically favored the wCO group. Abstinence was numerically higher in the wCO group after the 2-day quit attempt and significantly different at the end of treatment (day 35), favoring the wCO group.

CONCLUSIONS

Though study results should be interpreted with caution given the small sample size, findings suggest that the inclusion of rCO breath added to EMA compared to EMA with weekly, in-person CO collection in young adults did not yield benefit and may have even adversely affected outcomes. Our results suggest that technological advancements may improve data accuracy through objective measurement but may also introduce barriers and burdens and could result in higher rates of missing data. The inclusion of technology to inform smoking cessation research and intervention delivery among young adults should consider (1) the research question and necessity of biochemical verification and then (2) how to seamlessly incorporate monitoring into personalized and dynamic systems to avoid the added burden and detrimental effects to compliance and honesty in self-report.

School tobacco-related curriculum and behavioral factors associated with cigarette smoking among school-going adolescents in Zambia: Results from the 2011 GYTS study

INTRODUCTION

Tobacco smoking is a global public health concern. It has been projected that children and young people who are alive today in developing countries will bear the most burden of tobacco-related morbidity and mortality in the near future. This study investigated the school tobacco-related curriculum and behavioral factors associated with cigarette smoking among school-going adolescents.

METHODS

We accessed secondary data in a public domain collected using a cross-sectional study design. Altogether, 3377 seventh to ninth grade students were selected by stratified two-stage cluster sampling. Data were collected using a Global Youth Tobacco Survey (GYTS) Core Questionnaire. Multivariate logistic regression models were used to determine associations of school tobacco-related curriculum and behavioral factors with current cigarette smoking status. Adjusted odds ratios and their 95% confidence intervals are reported.

RESULTS

Of the 2611students included in the analysis, 6.8% (7.8% of males and 5.8% of females) reported smoking cigarettes. Slightly over half of the students were taught in schools about the effects of smoking (53.6%) and the dangers of smoking (64.1%). Adolescents who had friends who smoked were more likely to smoke compared to those who did not have friends who smoked. Adolescents whose parents smoked were more likely to smoke compared to those who did not have parents who smoked. Adolescents who were not taught at school about the dangers of smoking, or were not sure about it, were more likely to smoke compared to those who were taught (AOR=1.94; 95% CI: 1.28–2.94).

CONCLUSIONS

Schools play an important role in shaping smoking behavior among school-going adolescents. Based on our findings, school programs aimed at reducing cigarette smoking among school-going adolescents may achieve greater impact by implementing anti-smoking interventions that involve parents and peers in smoking prevention activities, and have a robust tobacco school curriculum.

Prevalence and determinants of current cigarette smoking and secondhand smoking among Greek adolescents: the Global Youth Tobacco Survey (GYTS) 2013 study

OBJECTIVES

Smoking prevalence in Greece is considered high within the European Union and the collection of evidence on tobacco use among adolescents is of vital importance in order to develop effective smoking prevention and cessation programmes.

DESIGN

Cross-sectional.

SETTING

Greece.

PRIMARY AND SECONDARY OUTCOME MEASURES

Global Youth Tobacco Survey (GYTS) is a national representative, paper-and-pencil, cross-sectional, school-based study of students at ages 13-15 years. The survey employed a multistage cluster sample design with schools selected proportional to enrolment size. Finally, 4618/5127 students aged 13-15 years participated in the survey. The school response rate was 98.1%, the student response rate was 90.1% and the overall response rate was 88.4%.

RESULTS

The prevalence of current cigarette smoking was estimated at 10.1% (10.4% in GYTS 2005) and of exposure to secondhand smoking in public places at 67.4% (94.1% in GYTS 2005). The vast majority of the adolescents (82.1%) supported the banning of smoking inside enclosed public places. Most of the current smokers (90.8%) were not prevented/refused purchase because of their age according to existing law. Multivariate analysis showed that peer influence (OR=48.32; 95% CI 36.2 to 64.48), pocket money (OR=2.63; 95% CI 1.28 to 3.41), increasing age (OR=2.35; 95% CI 1.63 to 3.39) and low educational level of father (OR=2.82; 95% CI 1.7 to 4.68) were risk factors independently associated with current cigarette smoking.

CONCLUSIONS

Despite the existence of strict laws related to tobacco control, exposure to secondhand smoking among Greek students remained high even when compared with GYTS in 2005. This is likely a result of weak enforcement, what is really missing is the enforcement of the related legislation.

Association Between Cotinine-verified Smoking Status and Risk of Colorectal Neoplasia

GOALS

We evaluated the association of urinary cotinine-verified smoking status with the risk of colorectal neoplasia (CRN).

BACKGROUND

Many studies have reported the association between the risk of CRN and smoking status, based on self-reported questionnaires. Although self-reported smoking status may be inaccurate, to our knowledge, no study has yet assessed the association between objective biomarkers of tobacco exposure and the risk of CRN.

STUDY

A cross-sectional study was conducted on 96,806 asymptomatic examinees who underwent colonoscopy and urinary cotinine measurements as part of a health check-up. Cotinine-verified current smokers were participants having a urinary cotinine level ≥50 ng/mL.

RESULTS

The mean participant age was 38.4 years, and the proportion of cotinine-verified current smokers was 23.0%. Cotinine-verified current smoking was an independent risk factor for CRN [adjusted odds ratio (AOR), 1.49; 95% confidence interval (CI), 1.42-1.56] and advanced CRN (ACRN) (AOR, 1.79; 95% CI, 1.57-2.05). Moreover, the risk of CRN and ACRN increased with increasing cotinine levels. Among self-reported never smokers, cotinine-verified current smokers had a higher risk of CRN (AOR, 1.77; 95% CI, 1.57-2.00) and ACRN (AOR, 1.94; 95% CI, 1.37-2.74) than cotinine-verified never smokers did, whereas among self-reported current smokers, cotinine-verified never smokers had a lower risk of CRN (AOR, 0.78; 95% CI, 0.70-0.87) and ACRN (AOR, 0.71; 95% CI, 0.52-0.98) than cotinine-verified current smokers did.

CONCLUSIONS

Cotinine-captured smoking status and metabolic variation exhibit associations with CRN more accurately and objectively than self-reporting does, providing clearer evidence for the role of tobacco in the development of CRN.

Acceptability and compliance with a remote monitoring system to track smoking and abstinence among young smokers

BACKGROUND

Similar to adult smokers, quit attempts among younger smokers almost inevitably result in relapse. Unlike adults, less is known about the process of relapse in this younger age group. A technology-based remote monitoring system may allow for detailed and accurate characterization of smoking and abstinence and would help to improve cessation strategies.

OBJECTIVES

This study describes a mobile system that captures smoking using breath carbon monoxide (CO) and real-time self-reports of smoking behavior. Compliance, feasibility, acceptability, and accuracy of the system were measured during a quit attempt and subsequent monitoring period.

METHODS

The mobile application (My Mobile Monitor, M3) combined breath CO with ecological momentary assessment, delivered via smartphone. Participants (N = 16; 75% female) were daily smokers between the ages of 19 and 25, who used the app for 11 days during which they agreed to make a quit attempt. Acceptability, compliance, and abstinence were measured.

RESULTS

Participants averaged 22.3 ± 2.0 years old and smoked an average of 13.0 ± 6.1 cigarettes per day. Overall session compliance was 69% and during the quit attempt, 56% of participants abstained from smoking for at least 24 hours. Agreement between self-reported smoking compared to breath CO was generally high, when available for comparison, though underreporting of cigarettes was likely.

CONCLUSION

This study demonstrates feasibility of a remote monitoring app with younger smokers, though improvements to promote compliance are needed. Remote monitoring to detect smoking and abstinence represents a step forward in the improvement of cessation strategies, but user experience and personalization are vital.

Underestimation of Self-Reported Smoking Prevalence in Korean Adolescents: Evidence from Gold Standard by Combined Method

The objective of this study was to evaluate the validity of self-reported smoking prevalence in Korean adolescents by using an improved gold standard by a combined method. Using a stratified sampling method, we selected 13 schools from among 397 high schools that participated in the 2015 Korean Youth Health Risk Behavior Web-Based Survey (KYRBS). A second survey (repeated self-reporting questionnaire and urinary cotinine test) was conducted on 1058 students who completed the KYRBS. The gold standard of current smoker was defined as those either self-reporting as a smoker in the second survey or having a urinary cotinine concentration ≥50 ng/mL. The current smoking prevalence in the first survey (KYRBS) was 7.9% (boys 16.5% and girls 1.8%), which was lower than the results based on gold standard (11.3% total, boys 21.9% and girls 3.7%). The sensitivity and specificity of self-reported smoking status was 62.5% and 99.0%, respectively. In particular, the sensitivity of girls (43.5%) was lower than that of boys (67.0%). The self-reported smoking prevalence in Korean adolescents was underestimated, particularly among girls. Careful attention should be paid to interpreting adolescents’ smoking prevalence, and supplementary surveys or periodic validity tests need to be considered in Asian countries.

Uso de outros produtos do tabaco entre escolares brasileiros (PeNSE 2012)

Resumo: Estimar a prevalência e identificar fatores associados ao uso de outros produtos do tabaco entre escolares. Foi realizado um estudo transversal, com amostra representativa de escolares que cursaram o 9º ano do Ensino Fundamental. Foram entrevistados 109.104 estudantes, sendo que 4,8% fizeram uso de outros produtos de tabaco nos últimos 30 dias. Os fatores que aumentaram a chance de uso de outros produtos do tabaco foram: sexo masculino, dependência administrativa da escola, trabalhar, morar com mãe e/ou pai, percepção de que os pais ou responsáveis se importariam pouco caso fumasse, ter dificuldade para dormir, não ter amigos próximos, sofrer violência familiar, faltar às aulas, ter feito uso de tabaco e álcool nos últimos 30 dias, ter experimentado drogas, possuir pais ou responsáveis fumantes e ter presenciado pessoas fumando. A prevalência de consumo de outros produtos do tabaco é elevada entre estudantes brasileiros e está associada com melhores condições socioeconômicas, presença de comportamentos de risco e viver em ambiente permissível ao consumo de tabaco.

Prenatal tobacco exposure, birthweight, and offspring psychopathology

Although prenatal tobacco exposure (PTE) is associated with several adverse offspring mental health outcomes, mechanisms remain unclear. We test whether associations between PTE and offspring psychopathology are explained by birthweight, one of the earliest-occurring outcomes of PTE. The analysis focuses on 238 offspring from a family study of depression with (1) collected prenatal histories and (2) at least one clinical interview in adulthood to assess psychiatric problems. Exposure was categorized by maternal smoking of ≥10 cigarettes daily/nearly daily; diagnostic outcomes were confirmed by clinicians using the best-estimate procedure, blind to exposure. After adjusting for potential confounders, PTE was associated with 0.7lb(9%) lower birthweight (p=0.0002), increased rates of disruptive behavior disorders [males: OR=2.66(1.15,6.16), and (trend) substance use disorders [females: OR=2.23(0.98,5.09)], and decreased rates of mood disorders (males: OR=0.42(0.17,0.98)]. Birthweight was not independently associated with diagnoses and did not mediate the association between exposure and psychopathology. Maternal smoking has long-term adverse consequences for offspring. Although birthweight cannot be manipulated, smoking is a modifiable risk factor. Thus, cessation efforts focused on pregnant women may not only improve maternal wellbeing, but also mitigate adverse proximal (e.g., birthweight) and long-term (psychopathology) outcomes in offspring.

Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: a systematic analysis from the Global Burden of Disease Study 2015

BACKGROUND

The scale-up of tobacco control, especially after the adoption of the Framework Convention for Tobacco Control, is a major public health success story. Nonetheless, smoking remains a leading risk for early death and disability worldwide, and therefore continues to require sustained political commitment. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) offers a robust platform through which global, regional, and national progress toward achieving smoking-related targets can be assessed.

METHODS

We synthesised 2818 data sources with spatiotemporal Gaussian process regression and produced estimates of daily smoking prevalence by sex, age group, and year for 195 countries and territories from 1990 to 2015. We analysed 38 risk-outcome pairs to generate estimates of smoking-attributable mortality and disease burden, as measured by disability-adjusted life-years (DALYs). We then performed a cohort analysis of smoking prevalence by birth-year cohort to better understand temporal age patterns in smoking. We also did a decomposition analysis, in which we parsed out changes in all-cause smoking-attributable DALYs due to changes in population growth, population ageing, smoking prevalence, and risk-deleted DALY rates. Finally, we explored results by level of development using the Socio-demographic Index (SDI).

FINDINGS

Worldwide, the age-standardised prevalence of daily smoking was 25·0% (95% uncertainty interval [UI] 24·2-25·7) for men and 5·4% (5·1-5·7) for women, representing 28·4% (25·8-31·1) and 34·4% (29·4-38·6) reductions, respectively, since 1990. A greater percentage of countries and territories achieved significant annualised rates of decline in smoking prevalence from 1990 to 2005 than in between 2005 and 2015; however, only four countries had significant annualised increases in smoking prevalence between 2005 and 2015 (Congo [Brazzaville] and Azerbaijan for men and Kuwait and Timor-Leste for women). In 2015, 11·5% of global deaths (6·4 million [95% UI 5·7-7·0 million]) were attributable to smoking worldwide, of which 52·2% took place in four countries (China, India, the USA, and Russia). Smoking was ranked among the five leading risk factors by DALYs in 109 countries and territories in 2015, rising from 88 geographies in 1990. In terms of birth cohorts, male smoking prevalence followed similar age patterns across levels of SDI, whereas much more heterogeneity was found in age patterns for female smokers by level of development. While smoking prevalence and risk-deleted DALY rates mostly decreased by sex and SDI quintile, population growth, population ageing, or a combination of both, drove rises in overall smoking-attributable DALYs in low-SDI to middle-SDI geographies between 2005 and 2015.

INTERPRETATION

The pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should not be taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobacco industry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces are poised to heighten smoking's global toll, unless progress in preventing initiation and promoting cessation can be substantially accelerated. Greater success in tobacco control is possible but requires effective, comprehensive, and adequately implemented and enforced policies, which might in turn require global and national levels of political commitment beyond what has been achieved during the past 25 years.

FUNDING

Bill & Melinda Gates Foundation and Bloomberg Philanthropies.

Evaluating the validity of self-reported smoking in Mexican adolescents

OBJECTIVES

We aimed to evaluate the validity of the self-reported smoking indicator used in the Global Youth Tobacco Survey (GYTS).

SETTING

43 middle and high-school classrooms from 26 schools were selected from Mexico City and Cuernavaca, Morelos.

PARTICIPANTS

A total of 1257 students provided both a questionnaire and a urine sample.

PRIMARY AND SECONDARY OUTCOME

Sensitivity and specificity of self-reported smoking compared to urinary cotinine. Validity indices were evaluated by subgroups of gender, social acceptability of smoking (ie, smoking parents or friends) and smoking frequency.

RESULTS

Sensitivity and specificity for current smoking were 93.2% and 81.7%, respectively. Validity indices remained stable across gender. Parental smoking status moderated the validity of self-report, which had lower sensitivity in adolescents with non-smoking parents (86.7%) than in adolescents with smoking parents (96.6%). Sensitivity and specificity increased with smoking frequency.

CONCLUSIONS

This first validation study of self-reported current smoking used in the GYTS among Mexican adolescents suggests that self-reported smoking in the past 30 days is a valid and stable indicator of current smoking behaviour. This measure appears suitable for public health research and surveillance.

The Correlation of Different Cotinine Levels With Questionnaire Results: A Comparative Study for Different Measurement Methods of the Adolescent Smoking Rate in Korea

This study compares the results of the Korea National Health and Nutrition Examination Survey (Self-Reported; KNHANEs [SR]) survey with urine-cotinine concentration (UCC) and the official index issued by the Korea Youth Risk Behavior Web-based Survey (KYRBS). We established standard cutoffs of 20 ng/mL, 30 ng/mL, 50 ng/mL, and 100 ng/mL to compare the results of UCC testing with those of self-reporting methods. The KYRBS demonstrated an overall current smoking rate of 12.25%, while the KNHANEs measured an overall rate of 9.63%. The UCC20 reported the highest current smoking rate at 25.6% overall. Methods that detected a lower prevalence of current smoking, in declining order, were the UCC30, UCC50, UCC100, online survey, and the KNHANEs (SR). The results of this study show that online surveys on smoking administered to adolescents have fewer false responses compared with the KNHANEs (SR). However, compared with UCC testing, online surveys still significantly underreport adolescent smoking rates.

Validation of self-reported smokeless tobacco use by measurement of serum cotinine concentration among US adults

Although investigators have assessed the relationship between self-reported cigarette smoking and biomarker levels, the validity of self-reported information on smokeless tobacco (SLT) use is uncertain. We used aggregated data from the 2003-2004, 2005-2006, 2007-2008, and 2009-2010 administrations of the National Health and Nutrition Examination Survey (NHANES) to compare self-reported SLT use with serum concentrations of cotinine, a metabolite of nicotine, among US adults aged ≥18 years. Receiver operating characteristic analysis was used to determine the optimal serum cotinine cutpoint for discriminating SLT users from nonusers of tobacco, and concordance analysis was used to compare self-reported SLT use with cotinine levels. Among the 30,298 adult respondents who completed the NHANES during 2003-2010, 418 reported having exclusively used SLT and no other type of tobacco (cigarettes, cigars, or pipes) during the past 5 days, while 23,457 reported not using any tobacco. The optimal cotinine cutpoint for discriminating SLT users from non-tobacco users was 3.0 ng/mL (sensitivity=97.0%, specificity=93.0%), which was comparable to a revised cutpoint recommended for identifying adult cigarette smokers. Concordance with cotinine was 96.4% and 93.7% for self-reported SLT use and tobacco nonuse, respectively. These findings indicate that self-reported SLT use among adults correlates highly with serum cotinine levels and that the optimal cutpoint for minimizing misclassification of self-reported use is a serum cotinine concentration of 3.0 ng/mL.

The Remote Monitoring of Smoking in Adolescents

BACKGROUND/OBJECTIVES

Cigarette smoking remains the leading cause of preventable death in the United States with the vast majority of adult smokers starting prior to the age of 18. Despite the public health relevance and implications of studying smoking in adolescents, little is known about the initiation of quit attempts, the process of relapse, and the most efficacious treatment interventions in this high-risk and underserved population. Issues such as retention in research studies and accuracy of self-reports have prompted investigators to explore innovative technology-based systems to integrate into treatment studies and services delivery.

METHODS

This paper will review the remote monitoring of smoking through means of ecological momentary assessment, biochemical verification of smoking verified through video capture, physiological monitoring, and mobile-delivered interventions using self-reported smoking outcomes in adolescents, when applicable.

RESULTS

Use of remote monitoring methods in adolescent smokers has been limited thus far, though monitoring technology in adults has shown promise for understanding relapse and delivering treatment interventions.

CONCLUSIONS

Comprehensive technology-based systems that do not rely primarily on self-report to monitor smoking would be a highly fruitful and innovative avenue to explore with adolescent smokers. Technology integration holds great promise to improve health-related research, treatment delivery, cost-effectiveness, and just-in-time interventions, but its novelty comes with unique problems and concerns to be carefully considered.

School-based programmes for preventing smoking

BACKGROUND

Helping young people to avoid starting smoking is a widely endorsed public health goal, and schools provide a route to communicate with nearly all young people. School-based interventions have been delivered for close to 40 years.

OBJECTIVES

The primary aim of this review was to determine whether school smoking interventions prevent youth from starting smoking. Our secondary objective was to determine which interventions were most effective. This included evaluating the effects of theoretical approaches; additional booster sessions; programme deliverers; gender effects; and multifocal interventions versus those focused solely on smoking.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Tobacco Addiction Group's Specialised Register, MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, Health Star, and Dissertation Abstracts for terms relating to school-based smoking cessation programmes. In addition, we screened the bibliographies of articles and ran individual MEDLINE searches for 133 authors who had undertaken randomised controlled trials in this area. The most recent searches were conducted in October 2012.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) where students, classes, schools, or school districts were randomised to intervention arm(s) versus a control group, and followed for at least six months. Participants had to be youth (aged 5 to 18). Interventions could be any curricula used in a school setting to deter tobacco use, and outcome measures could be never smoking, frequency of smoking, number of cigarettes smoked, or smoking indices.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for inclusion, extracted data and assessed risk of bias. Based on the type of outcome, we placed studies into three groups for analysis: Pure Prevention cohorts (Group 1), Change in Smoking Behaviour over time (Group 2) and Point Prevalence of Smoking (Group 3).

MAIN RESULTS

One hundred and thirty-four studies involving 428,293 participants met the inclusion criteria. Some studies provided data for more than one group.Pure Prevention cohorts (Group 1) included 49 studies (N = 142,447). Pooled results at follow-up at one year or less found no overall effect of intervention curricula versus control (odds ratio (OR) 0.94, 95% confidence interval (CI) 0.85 to 1.05). In a subgroup analysis, the combined social competence and social influences curricula (six RCTs) showed a statistically significant effect in preventing the onset of smoking (OR 0.49, 95% CI 0.28 to 0.87; seven arms); whereas significant effects were not detected in programmes involving information only (OR 0.12, 95% CI 0.00 to 14.87; one study), social influences only (OR 1.00, 95% CI 0.88 to 1.13; 25 studies), or multimodal interventions (OR 0.89, 95% CI 0.73 to 1.08; five studies). In contrast, pooled results at longest follow-up showed an overall significant effect favouring the intervention (OR 0.88, 95% CI 0.82 to 0.96). Subgroup analyses detected significant effects in programmes with social competence curricula (OR 0.52, 95% CI 0.30 to 0.88), and the combined social competence and social influences curricula (OR 0.50, 95% CI 0.28 to 0.87), but not in those programmes with information only, social influence only, and multimodal programmes.Change in Smoking Behaviour over time (Group 2) included 15 studies (N = 45,555). At one year or less there was a small but statistically significant effect favouring controls (standardised mean difference (SMD) 0.04, 95% CI 0.02 to 0.06). For follow-up longer than one year there was a statistically nonsignificant effect (SMD 0.02, 95% CI -0.00 to 0.02).Twenty-five studies reported data on the Point Prevalence of Smoking (Group 3), though heterogeneity in this group was too high for data to be pooled.We were unable to analyse data for 49 studies (N = 152,544).Subgroup analyses (Pure Prevention cohorts only) demonstrated that at longest follow-up for all curricula combined, there was a significant effect favouring adult presenters (OR 0.88, 95% CI 0.81 to 0.96). There were no differences between tobacco-only and multifocal interventions. For curricula with booster sessions there was a significant effect only for combined social competence and social influences interventions with follow-up of one year or less (OR 0.50, 95% CI 0.26 to 0.96) and at longest follow-up (OR 0.51, 95% CI 0.27 to 0.96). Limited data on gender differences suggested no overall effect, although one study found an effect of multimodal intervention at one year for male students. Sensitivity analyses for Pure Prevention cohorts and Change in Smoking Behaviour over time outcomes suggested that neither selection nor attrition bias affected the results.

AUTHORS' CONCLUSIONS

Pure Prevention cohorts showed a significant effect at longest follow-up, with an average 12% reduction in starting smoking compared to the control groups. However, no overall effect was detected at one year or less. The combined social competence and social influences interventions showed a significant effect at one year and at longest follow-up. Studies that deployed a social influences programme showed no overall effect at any time point; multimodal interventions and those with an information-only approach were similarly ineffective.Studies reporting Change in Smoking Behaviour over time did not show an overall effect, but at an intervention level there were positive findings for social competence and combined social competence and social influences interventions.

Prevalence of alcohol and tobacco use among Brazilian adolescents: a systematic review

OBJECTIVE: To analyze alcohol and tobacco use among Brazilian adolescents and identify higher-risk subgroups. METHODS: A systematic review of the literature was conducted. Searches were performed using four databases (LILACS, MEDLINE /PubMed, Web of Science, and Google Scholar), specialized websites and the references cited in retrieved articles. The search was done in English and Portuguese and there was no limit on the year of publication (up to June 2011). From the search, 59 studies met all the inclusion criteria: to involve Brazilian adolescents aged 10-19 years; to assess the prevalence of alcohol and/or tobacco use; to use questionnaires or structured interviews to measure the variables of interest; and to be a school or population-based study that used methodological procedures to ensure representativeness of the target population (i.e. random sampling). RESULTS: The prevalence of current alcohol use (at the time of the investigation or in the previous month) ranged from 23.0% to 67.7%. The mean prevalence was 34.9% (reflecting the central trend of the estimates found in the studies). The prevalence of current tobacco use ranged from 2.4% to 22.0%, and the mean prevalence was 9.3%. A large proportion of the studies estimated prevalences of frequent alcohol use (66.7%) and heavy alcohol use (36.8%) of more than 10%. However, most studies found prevalences of frequent and heavy tobacco use of less than 10%. The Brazilian literature has highlighted that environmental factors (religiosity, working conditions, and substance use among family and friends) and psychosocial factors (such as conflicts with parents and feelings of negativeness and loneliness) are associated with the tobacco and alcohol use among adolescents. CONCLUSIONS: The results suggest that consumption of alcohol and tobacco among adolescents has reached alarming prevalences in various localities in Brazil. Since unhealthy behavior tends to continue from adolescence into adulthood, public policies aimed towards reducing alcohol and tobacco use among Brazilians over the medium and long terms may direct young people and the subgroups at higher risk towards such behavior.

Clustering of risk factors for chronic diseases among adolescents from Southern Brazil

OBJECTIVE

To investigate the clustering of risk behaviors for chronic non-communicable diseases and their associated factors among adolescents from Southern Brazil.

METHODS

In 2008, a survey was conducted with 3990 adolescents aged 14-15 years (mean: 14.3; SD: 0.6) from the 1993 Pelotas Birth Cohort Study. Clustering was determined by comparing observed (O) and expected (E) prevalence of all possible combinations of the four risk factors investigated (smoking, alcohol intake, low fruit intake, and physical inactivity). We carried out Poisson regression to evaluate the effect of individual characteristics on the presence of at least three risk behaviors.

RESULTS

All risk factors tended to cluster together (O/E prevalence=3.0), especially smoking and alcohol intake (odds ratio to present on behavior in the presence of other >5.0). Approximately 15% of adolescents displayed three or more risk behaviors. Females (adjusted OR=1.55), people 15 years and older (OR=1.47), with black skin color (OR=1.23), and of low socioeconomic level (OR=1.29) were more likely to display three or more risk factors.

CONCLUSION

These findings suggest that lifestyle-related risk factors tend to cluster among adolescents. Identifying subgroups at greater risk of simultaneously engaging in multiple risk behaviors may aid in the planning of preventive strategies.

Racial/ethnic and sex differences in the relationship between uric acid and metabolic syndrome in adolescents: an analysis of National Health and Nutrition Survey 1999-2006

Among adolescents, uric acid is associated with insulin resistance, hypertension, and the metabolic syndrome (MetS); and in adults, high uric acid levels are an independent risk factor for cardiovascular disease and diabetes. The objective was to determine whether the relationship of uric acid with MetS varies in adolescents by race/ethnicity and sex. We used linear regression to evaluate associations between uric acid and other MetS-associated clinical and laboratory measures among 3296 non-Hispanic white, non-Hispanic black, and Hispanic adolescents aged 12 to 19 years participating in the National Health and Nutrition Evaluation Survey (1999-2006). Overall, non-Hispanic white males and females had the highest uric acid levels among the 3 racial/ethnic groups. In each racial/ethnic group, there were higher uric acid levels for those adolescents with vs without MetS. However, the extent of the MetS-related increase in uric acid level varied by race and sex. Among males, MetS was associated with the greatest increases in uric acid among non-Hispanic whites. However, among females the MetS-related increase in uric acid was greater among non-Hispanic blacks and Hispanics. Non-Hispanic white females exhibited the lowest degrees of correlation between levels of uric acid and MetS-associated variables. Uric acid levels did not correlate with insulin levels in non-Hispanic white females. These data suggest that the relationship between uric acid and MetS varies by race/ethnicity and sex. In particular, non-Hispanic white males exhibit a strong relationship and non-Hispanic white females exhibit a relatively poor correlation between uric acid and MetS-related factors. These data may have implications for the use of uric acid as a marker of future risk among adolescents.

Racial/ethnic and sex differences in the ability of metabolic syndrome criteria to predict elevations in fasting insulin levels in adolescents

OBJECTIVE

To evaluate racial/ethnic and sex differences in the relationship between metabolic syndrome (MetS) diagnosis and fasting insulin in adolescents.

STUDY DESIGN

We analyzed data from the National Health and Nutrition Evaluation Survey 1999-2008 for 3693 non-Hispanic-white, non-Hispanic-black, and Hispanic adolescents (12 to 19 years of age). We used linear regression to evaluate differences in fasting insulin levels between those with and without an adolescent adaptation of ATPIII-MetS in a sex- and race/ethnicity-specific basis.

RESULTS

Females had higher insulin levels than males, and non-Hispanic blacks and Hispanics had higher levels than non-Hispanic whites. Adolescents with MetS had higher insulin levels than those without MetS. The difference in insulin levels between those with and without MetS was greater in non-Hispanic blacks than in non-Hispanic whites (P < .05) but not Hispanics (P = .10). The sensitivity of MetS in detecting elevated insulin levels was lower in non-Hispanic blacks and females than in other ethnicities and males, respectively. Correlations between insulin and individual MetS components were similar among ethnicities.

CONCLUSION

MetS diagnosis performed more poorly in predicting elevated insulin levels in non-Hispanic blacks and in females. These data support the hypothesis that non-Hispanic blacks do not meet current criteria for MetS until they have reached a more advanced degree of insulin resistance.

Socioeconomic trajectory from birth to adolescence and lung function: prospective birth cohort study

Background

Socioeconomic status (SES) has been shown to be an important contributor to lung function. The aim of this study was to evaluate the association between lung function in adolescence and (a) SES at birth; (b) SES in adolescence; (c) SES trajectory from birth to adolescence ('never poor', 'non poor-poor', 'poor-non poor' and 'always poor'). Additionally, we investigate the role of adolescent and parental variables at mediating these associations.

Methods

Prospective birth cohort study in Pelotas, Brazil, including 4,005 adolescents (mean age: 14.7 years) followed up from birth. Lung function was measured by spirometry. Outcome variables were forced expiratory volume in one second in liters (FEV1) and forced vital capacity also in liters (FVC).

Results

Mean FEV1 was 3.46 L (95%CI 3.43-3.49) among boys and 2.93 L (95%CI 2.91-2.95) among girls. Mean FVC was 4.00 L (95%CI 3.97; 4.04) among boys and 3.30 L (95%CI 3.27; 3.32) among girls. SES at birth, in adolescence and its trajectory from birth to adolescence were inversely associated with lung function in both adolescent boys and girls. After adjustment for mediating variables, coefficients were largely reduced, particularly among boys, and the main predictor of change in coefficients was the inclusion of height in the models.

Conclusion

Low income adolescents from Brazil present impaired lung function as compared to the better off, and this is largely explained by height.

Contextual factors associated with smoking among Brazilian adolescents

BACKGROUND

Very few studies have examined the role of school, household and family contexts in youth smoking in middle-income countries.

METHODS

This work describes smoking exposure among 59,992 high school students who took part in the Brazilian Survey of School Health and investigates contextual factors associated with regular smoking, defined as smoking cigarettes at least once in the past 30 days. The explaining variables were grouped into: socio-demographic characteristics, school context, household context and family rapport. Variables independently associated with smoking in each context were identified by multiple logistic regression analysis.

RESULTS

53% of the total sample were girls, 89% were aged 13-15 years. 24% had already experimented with cigarettes, 50% before the age of 12 years. The prevalence of regular smoking was 6.3% (95% CI 5.87 to 6.74), with no sex variation. Smoking was not associated with either the mother's education or the index of household assets. In the multivariable analysis, studying at a private school, the possibility of purchasing cigarettes at school and skipping of classes without parents' consent increased the chances of smoking. In the household context, living with both parents was negatively associated with smoking, while having smoking parents and exposure to other people's smoking was positively related to smoking. In the family context, parental unawareness of what the adolescent was doing increased smoking, but having meals with the mother one or more days per week and parents' negative reactions to adolescent smoking reduced the chances of smoking.

CONCLUSION

The results reinforce the role of school, household and family contexts in youth smoking behaviours and will help improve public health policies aimed at preventing smoking and health promotion in adolescents.

Diagnosis of the metabolic syndrome is associated with disproportionately high levels of high-sensitivity C-reactive protein in non-Hispanic black adolescents: an analysis of NHANES 1999-2008

OBJECTIVE

Whereas it is known that the metabolic syndrome (MetS) has a paradoxically lower prevalence in non-Hispanic black adolescents than in non-Hispanic whites or Hispanics, the relative severity of MetS by race/ethnicity is unknown. Inflammation, indicated by high-sensitivity C-reactive protein (hsCRP), is a key factor linking MetS to cardiovascular disease and type 2 diabetes. Our goal was to determine whether elevations of hsCRP vary by race/ethnicity among adolescents with MetS.

RESEARCH DESIGN AND METHODS

We used the National Health and Nutrition Examination Survey (1999-2008) and evaluated adolescents (age 12-19 years) using a pediatric/adolescent adaptation of the ATP III definition of MetS. We used linear regression to evaluate the interaction between MetS status and ethnicity with respect to hsCRP concentration.

RESULTS

For male and female adolescents, MetS was associated with elevated hsCRP levels compared with adolescents without MetS. However, the elevation in hsCRP between adolescents with and without MetS was greater in non-Hispanic blacks compared with that in non-Hispanic whites (P = 0.04) but not that in Hispanics (P = 0.18). hsCRP concentrations correlated with individual MetS components similarly among all ethnicities. In an evaluation of adolescents diagnosed with MetS, non-Hispanic blacks had higher BMI and more hypertension than other ethnicities but there were no other racial/ethnic differences in the features of MetS.

CONCLUSIONS

Non-Hispanic black adolescents have a greater differential in hsCRP between those with and those without MetS than the differential in non-Hispanic whites but not that in Hispanics. Therefore, even though MetS has a low prevalence in non-Hispanic blacks, MetS is a particularly good indicator of inflammation in non-Hispanic black adolescents.

Efetividade de uma intervenção educacional em tabagismo entre adolescentes escolares

O objetivo do estudo foi avaliar a efetividade de um programa educacional sobre tabagismo desenvolvido pelo Instituto Nacional do Câncer em adolescentes escolares de Pelotas, RS. Das 46 escolas públicas da cidade, 32 foram sorteadas aleatoriamente e, posteriormente, randomizadas em grupo controle ou intervenção. Em ambas as fases do estudo (pré e pós-intervenção), os estudantes de 7ª e 8ª série responderam a um questionário, e uma amostra de urina foi coletada para análise de cotinina. A intervenção educativa teve duração de seis meses. Os desfechos estudados foram: "auto-relato de uso de cigarros nos últimos 30 dias" e "concentração de cotinina na urina (categorizada em > 10 ng/ml e > 30 ng/ml)". A intervenção não provocou mudança na prevalência de tabagismo, tanto mensurado por auto-relato como pela concentração de cotinina. No entanto, o conhecimento dos alunos acerca dos malefícios do cigarro aumentou no grupo intervenção. Em resumo, não houve efetividade da intervenção educacional para mudanças de comportamento, mas houve melhora no conhecimento dos prejuízos do fumo.

Assessment of nicotine dependence among adolescent and young adult smokers: a comparison of measures

INTRODUCTION

Tobacco use often starts in adolescence, yet assessment of dependence among adolescent smokers remains a challenge, particularly given the potential discord between self-reports of smoking behavior and actual use. We could find no prior study, among adolescents, that directly compares the association between objective biomarkers of tobacco exposure (e.g., cotinine) and multiple measures of dependence. This study examined the concurrent validity of two common dependence measures: the Fagerström Test for Nicotine Dependence (FTND) and the Hooked on Nicotine Checklist (HONC). We further examined the FTND by removing the one item on cigarettes smoked per day.

METHODS

Based within a parent clinical trial for adolescent smoking cessation, eligible participants were 12-21years old, smoking >/=5cigarettes per day on average, and with urine cotinine >100ng/ml at baseline. Results are based on participants who completed each measure and who provided a urine cotinine sample at baseline (N=73).

RESULTS

Results showed that the FTND was associated with cotinine (p<0.001; R(2)=0.25), and that this relationship held true for the revised FTND as well (p<0.001; R(2)=0.18). However, the HONC was only marginally associated with cotinine (p=0.06; R(2)=0.09).

DISCUSSION

Our results suggest that the FTND may be better associated with actual smoking behavior in adolescents as compared to the HONC. Pending replication, our data provide caution with regard to assessment of nicotine dependence at least among established adolescent smokers who have more entrenched smoking behavior.

Exposição ao tabagismo entre escolares no Brasil

O objetivo deste trabalho é descrever a exposição ao tabagismo de participantes da Pesquisa Nacional de Saúde do Escolar (PeNSE) e identificar fatores associados a ele. Para se apresentar o perfil de tabagismo regular, era preciso ter fumado cigarro pelo menos um dia nos 30 dias anteriores à pesquisa. As características estudadas foram idade, sexo, raça/cor, escolaridade da mãe, índice de bens do domicílio e dependência administrativa da escola. Os comportamentos de risco e proteção incluídos foram experimentar álcool ou drogas, ter relação sexual, consumo de > 1 copo de bebida alcoólica nos últimos 30 dias e realizar/ter interesse em realizar atividade física na maioria dos dias da semana. A prevalência de fumante regular foi 6,3% (IC95%:5,87-6,74), sendo estatisticamente maior nos mais velhos, de cor parda, cujas mães têm menor escolaridade, estudantes em escolas públicas e apresentando os comportamentos estudados. Na análise multivariável, o tabagismo permaneceu associado à idade e a comportamentos de risco. A chance de fumar também foi menor em quem não faz nem gostaria de fazer atividade física. CONCLUSÃO: comportamentos de risco para a saúde coexistem também na adolescência, sugerindo que políticas de promoção da saúde na adolescência provavelmente terão impacto amplo, incluindo o problema do tabagismo.

Enrollment in physical education is associated with health-related behavior among high school students

BACKGROUND

Physical education (PE) plays a critical role in the healthy development of youth; however, the influence of PE classes in helping to provide students with health-related behavior patterns is not clear. This study aims to analyze whether participation in PE classes is associated with health-related behavior among high school students.

METHODS

A total of 4210 students attending public high schools in Pernambuco (northeast of Brazil) were selected using random 2-stage cluster sampling. Data were collected by using the Global School-based Student Health Survey. The independent variable was the frequency of participation in PE classes, whereas physical activity, television viewing, smoking, and alcohol, fruit, vegetables and soda consumption were dependent variables. Logistic regressions were carried out to perform crude and adjusted analysis of the association between enrollment in PE classes and health-related behaviors.

RESULTS

Sixty-five percent of students do not take part in PE classes, with a significantly higher proportion among females (67.8%). It was observed that enrollment in PE classes was positively associated with physical activity, TV viewing, and fruit consumption, but was negatively associated with soda drinking. The likelihood of reporting being active and eating fruit on a daily basis was 27% and 45% higher, respectively, among those who participate in at least 2 classes per week in comparison with those who do not. Students who participate in PE classes had 28-30% higher likelihood of reporting lower TV viewing during week days.

CONCLUSIONS

Findings suggest that higher levels of enrollment in PE classes could play a role in the promotion of health-related behaviors among high school students.

Validity of self-reported smoking using urinary cotinine among vocational high school students

OBJECTIVES

This study was conducted to validate self-reported smoking among high school students using urinary cotinine.

METHODS

A self report of smoking behavior was collected together with urine sample for cotinine analysis from 130 male and female students in two vocational high school students in November, 2007. Validity and agreement between self-reported smoking and urinary cotinine was analyzed with STATA 9.0 for different definitions of current smokers, and frequent and daily smokers. Urinary cotinine concentration was measured by the DRI Cotinine Assay for urine (Microgenics Corp., Fremont, CA) on Toshiba 200FR. The cut-off point of urinary cotinine was 50 ng/dl.

RESULTS

The concentrations of urinary cotinine were significantly different according to the frequency and amount of smoking. Sensitivity and specificity was 90.9% and 91.8% respectively, and the Cohen's kappa value was 0.787 among the current smokers who smoked at least one day during one month preceding the survey. The comparable high sensitivity, specificity, and kappa value were shown also among the other definitions of current smokers, that is, subjective smokers, and weekly smokers.

CONCLUSIONS

The results showed the high validity of self-reported smoking among high school students. However, due to the small sample size and limitation of the participants, it is cautious to generalize the results to overall high school students.

Psychometric testing of the Chinese version of the Hooked on Nicotine Checklist in adolescents

PURPOSE

To examine the psychometric properties of the Hooked on Nicotine Checklist (HONC) on a Taiwanese sample. The HONC as a measure of nicotine dependence in adolescents is in worldwide use. Less is known regarding its psychometric properties for a Chinese population.

METHODS

A cross-sectional, descriptive study was conducted from January to May 2008 with 373 male adolescent smokers aged 15 to 20 years. The criterion validity of the Chinese HONC was determined using the Fagerstrom Test of Nicotine Dependence (FTND) and saliva cotinine. Because the responses to the items are dichotomous, the validity and factorial structures were examined using tetrachoric and biserial techniques by PRELIS 2 and LISREL 8.7.

RESULTS

Most of interitem correlations are between 0.3 and 0.7. Each item is highly associated with the full scale (r > .7). The HONC total score is significantly associated with the FTND (r=.58, p < .01) and with saliva cotinine levels (r=.27, p < .05). Confirmatory factor analyses were performed to compare the relative fit of three competing models. The three-correlated factor model has a better fit than other models, according to the cutoff criteria for relatively good fit. The coefficient alpha of the full scale is .83.

CONCLUSIONS

The Chinese version of the HONC is a reliable and valid measure of tobacco dependence in adolescent smokers. Studies involving female adolescent and younger smokers will be needed to evaluate the applicability of the scales to the different genders and age populations.