Changes in smoking habits in adults: results from a prospective study in Spain

Gender, smoking, and tobacco cessation with pharmacological treatment in a cluster randomized clinical trial

INTRODUCTION

Whether men find it easier to quit smoking than women is still controversial. Different studies have reported that the efficacy of pharmacological treatments could be different between men and women. This study conducted a secondary analysis of 'Subsidized pharmacological treatment for smoking cessation by the Spanish public health system' (FTFT-AP study) to evaluate the effectiveness of a drug-funded intervention for smoking cessation by gender.

METHODS

A pragmatic randomized clinical trial by clusters was used. The population included smokers aged ≥18 years, smoking >10 cigarettes per day, randomly assigned to an intervention group receiving regular practice and financed pharmacological treatment, or to a control group receiving only regular practice. The main outcome was continued abstinence at 12 months, self-reported and validated with CO-oximetry. The percentage, with 95% confidence intervals, of continued abstinence was compared between both groups at 12 months post-intervention, by gender and the pharmacological treatment used. Multilevel logistic regression analysis was performed.

RESULTS

A total of 1154 patients from 29 healthcare centers were included. The average age was 46 years (SD=11.78) and 51.7% were men. Overall, the self-reported abstinence at 12 months was 11.1% (62) in women and 15.7% (93) in men (AOR=1.4; 95% CI: 1.0-2.0), and abstinence validated by CO-oximetry was 4.6% (26) and 5.9% (35) in women and men, respectively (OR=1.3; 95% CI: 0.7-2.2). In the group of smokers receiving nicotine replacement treatment, self-reported abstinence was higher in men compared to women (29.5% vs 13.5%, OR=2.7; 95% CI: 1.3-5.8).

CONCLUSIONS

The effectiveness of a drug-financed intervention for smoking cessation was greater in men, who also showed better results in self-reported abstinence with nicotine replacement treatment.

The effect of alcohol use on smoking cessation: A systematic review

Only a small minority of all attempts to stop smoking are successful, especially among smokers who are heavy drinkers and those with an alcohol use disorder. The current systematic review focuses on the negative effects of alcohol use, either before or during attempts to quit smoking, on the success rate of these attempt(s) in alcohol-drinking tobacco smokers. We conducted a systematic review of naturalistic and experimental studies, which included at least 40 tobacco smokers with a recorded drinking status (non-drinking, heavy drinking, alcohol use disorder) and a clearly documented change in alcohol consumption. We could not conduct a meta-analysis and, thus, used consistency across studies to draw conclusions. The evidence presented here shows that alcohol use is associated with lower rates of success in quitting smoking in 20 out of 27 studies. This includes both lapses and relapses. Similarly, in 19 out of 20 long-term follow-up studies, the duration of smoking abstinence was shorter among persons with higher alcohol consumption. Finally, 12 out of 13 experimental studies showed that exposure of smokers to alcohol cues or to drinking of alcohol induce a strong propensity to smoke. It is, therefore, recommended for smokers who drink alcohol and who intend to quit smoking to use an integrated approach, i.e., to stop or substantially reduce their alcohol consumption before and/or during their attempt to quit smoking.

Predictors of Persistence of Risky Drinking in Adults: An 11-Year Follow-Up Study

AIM

To examine the long-term predictors of persistence of risky drinking in a baseline group of risky drinkers in whom alcohol use disorder had not been diagnosed.

METHODS

The data was derived from a representative sample of the Finnish adult population aged 30 years or more, surveyed at 2 time points in the years 2000 (n = 5,726) and 2011 (n = 3,848, 67.2% of the baseline sample). Risky drinking was defined using BSQF-measurement (for men, 21 standard UK drinks or more per week; for women 14+ drinks) and not having alcohol abuse or alcohol dependence. The sample of risky drinkers in baseline comprised 642 persons, of whom 380 (59.2%) people provided follow-up data. Multivariable logistic regression models were estimated to identify determinants of persistence of risky drinking.

RESULTS

The rate for persistence of risky drinking was 48.7%. Persistence was predicted by daily smoking, low physical activity, and male gender, whereas higher age and later onset of drinking predicted cessation of risky drinking. Daily smoking remained an independent predictor after adjusting for other risk factors.

CONCLUSIONS

Health behaviour predicts the persistence of risky drinking in a study population of adults aged 30 and over. These factors should be taken into account when assessing the long-term prognosis on risky drinking.

Factors associated with smoking and smoking cessation among primary care patients with depression: a naturalistic cohort study

Purpose

– People with a history of depression are more likely to smoke and less likely to achieve abstinence from smoking long term. The purpose of this paper is to understand the factors associated with smoking and smoking cessation among patients with depression.

Design/methodology/approach

– This paper reports on smoking prevalence and cessation in a cohort of 789 primary care attendees with depressive symptoms (Centre for Epidemiologic Studies Depression Scale score of=16) recruited from 30 randomly selected Primary Care Practices in Victoria, Australia in 2005.

Findings

– At baseline, 32 per cent of participants smoked. Smokers were more likely to be male, unmarried, receive government benefits, have difficulty managing on available income, have emphysema, a chronic illness, poor self-rated health, to have more severe depressive and anxiety symptoms, to be taking anti-depressants, to be hazardous drinkers, to report suicidal ideation and to have experienced childhood physical or sexual abuse. At 12 months, 20 participants reported quitting. Females and people with good or better self-rated health were significantly more likely to have quit, while people with a chronic illness or suicidal ideation were less likely to quit. Smoking cessation was not associated with increases in depression or anxiety symptoms. Only six participants remained quit over four years.

Practical implications

– Rates of smoking were high, and long-term cessation was low among primary care patients with depressive symptoms. Primary care physicians should provide additional monitoring and support to assist smokers with depression quit and remain quit.

Originality/value

– This is the first naturalistic study of smoking patterns among primary care attendees with depressive symptoms.

Naltrexone improves quit rates, attenuates smoking urge, and reduces alcohol use in heavy drinking smokers attempting to quit smoking

BACKGROUND

Heavy drinking smokers (HDS) have more difficulty quitting smoking than lighter drinkers or abstainers. The opioid antagonist naltrexone may improve smoking quit rates and reduce alcohol use in drinker-smokers, but its relative efficacy in smokers with a range of drinking patterns is unknown. The current study tested the hypothesis that HDS would show differential benefit of naltrexone versus placebo relative to moderate-to-light or nondrinking smokers in terms of improving smoking outcomes and reducing alcohol consumption.

METHODS

Adult smokers (N = 315) enrolled in a 12-week, double-blinded, placebo-controlled trial of 50 mg naltrexone for smoking cessation were categorized into subgroups based upon past 6-month drinking patterns: HDS (n = 69; i.e., averaged ≥2 heavy drinking episodes per month), moderate-to-light drinking smokers (n = 204, i.e., consumed 1 drink up to a maximum of <2 heavy drinking episodes per month on average), or nondrinking smokers (n = 42, no alcohol consumed in the past 6 months). The groups were compared on the main study outcomes of biochemically verified prolonged abstinence quit rates (i.e., no smoking weeks 2 to 12), and smoking urge and alcohol use (drinks/wk) during treatment.

RESULTS

Naltrexone significantly increased 12-week smoking abstinence rates and decreased smoking urge and alcohol use among HDS, but not moderate-to-light or nondrinking smokers. Mediation analyses in HDS revealed that naltrexone's effect on smoking urge during the first 4 weeks of treatment mediated its effect on quit rates.

CONCLUSIONS

HDS appear to be particularly sensitive to naltrexone effects on smoking and drinking outcomes. This group may represent an important target for adjunctive treatment with naltrexone to optimize smoking cessation outcomes.

Reciprocal effects of alcohol and nicotine in smoking cessation treatment studies

OBJECTIVE

Smoking and alcohol use are highly related; as such the present study investigated whether alcohol use is associated with failure in tobacco cessation attempts. We first examined the self-reported drinking behavior and smoking over the course of a year at a basic level. Next, we addressed two hypotheses to characterize this relationship at a deeper level: (Hypothesis 1) Alcohol use would be lower for those who attempted to quit smoking (quit for one or more days) during the year compared to those who never quit, and (Hypothesis 2) for those who relapsed to smoking after a quit increases in alcohol consumption would be positively associated with increases in smoking.

METHOD

Subjects were participants in two smoking cessation programs. One group of participants (N=139) was part of a smoking cessation study in alcohol dependent smokers in early recovery and the other group of participants (N=163) was drawn from a smoking cessation study for HIV positive smokers. H1 was tested using t-tests. For H2, a time series analysis examined relationships between smoking and alcohol use within person over a one year period. For H1 and for H2, the analyses utilized bivariate time series procedures. Timeline follow-back data allowed for detailed daily reports of both tobacco and alcohol use.

RESULTS

In the overall sample, there was no difference in alcohol use between those who stopped smoking and those who never stopped. However, when broken up by study, a difference was found in the alcohol dependent sample such that mean drinks were higher for those who stopped compared to those who never stopped smoking (H1). The results indicated a high number of positive significant cross-correlations between tobacco and alcohol use such that one substance predicted current, as well as past and future use of the alternate substance. Same-day cross-correlations were the most common, and dissipated with time (H2).

CONCLUSIONS

This analysis provided insights into the proximal influence of one substance on the other. Alcohol is related to relapse in smoking cessation attempts. It is important that smoking cessation efforts in alcohol using populations consider alcohol use in treatment.

Tobacco quitlines need to assess and intervene with callers' hazardous drinking

BACKGROUND

Based on published data showing that daily smokers have high rates of hazardous drinking and higher rates of smoking relapse, we hypothesized that New York State Smokers' Quitline (NYSSQL) callers would exhibit elevated rates of risky drinking and risky drinking callers would report lower rates of smoking cessation.

METHODS

We assessed rates of hazardous drinking among 88,479 callers to the NYSSQL using modified NIAAA guidelines. Using 2 routine NYSSQL short-term follow-up interviews (n = 14,123 and n = 24,579) and a 3-month follow-up interview (n = 2,833), we also compared smoking cessation rates for callers who met criteria for hazardous drinking compared to moderate drinkers and nondrinkers.

RESULTS

At baseline, 56% of callers reported drinking, and 23% reported hazardous drinking using modified NIAAA guidelines. Hazardous drinkers did not differ on measures of smoking cessation outcomes compared to nondrinkers but did have lower smoking cessation rates compared to persons who reported moderate alcohol consumption for the enhanced services program 1-week follow-up (adjusted OR [95% CI] = 1.09 [1.01, 1.17], p = 0.04) and the standard 2-week follow-up (adjusted OR [95% CI] = 1.17 [1.07, 1.29], p = 0.001).

CONCLUSIONS

Nearly a quarter of smokers calling the NYSSQL reported a hazardous drinking pattern, which was associated with lower cessation outcomes compared to those who reported a moderate drinking profile. Given the large number of high-risk drinkers who can be identified through a quitline, tobacco quitlines may provide a venue for providing brief alcohol interventions to these high-risk drinkers. Future studies should evaluate whether a brief alcohol intervention would result in improved smoking cessation rates for hazardous drinking smokers.

Analysing the Spanish smoke-free legislation of 2006: a new method to quantify its impact using a dynamic model

BACKGROUND

There are many models that study aspects of smoking habits: the influence of price, tax, relapse time, and the effects of prohibition. There are also studies examining the effects of the Spanish smoke-free law. We wanted to build a model able to separate the effect of the law from the pre-law evolution of smoking habits.

METHODS

Using data from the Spanish Ministry of Health and Social Policy, we developed a dynamic model of tobacco use. The model projects the evolution over time of the number of non-smokers, smokers and ex-smokers before 2006. Then, we compared the predictions of the model with data for the years after the law came into force, 2006 and 2009.

RESULTS

We show that smoke-free law has had a significant impact on different sub-populations. The number of ex-smokers increased significantly in 2006 and this increase was maintained in 2009. The number of smokers also decreased significantly in 2006, but in 2009 this returned to its value before the law. Simultaneously, the number of non-smokers decreased in 2009.

CONCLUSIONS

When the law came into force (2006), its restriction on smoking in public and work places made many smokers decide to give up smoking, decreasing the number of smokers and increasing the number of ex-smokers. In 2009, the majority of those who succeeded in giving up smoking did not return to the habit. However, the smoke-free law had no effect on new smokers and the number of smokers returned to previous levels, whereas the number of non-smokers decreased. Therefore, we can conclude that the law had a very positive effect in the first few years but this has dissipated over time, with the exception of ex-smokers, whose number is still higher than before the law.

[Reasons for smoking cessation in Spain by gender and age]

OBJECTIVE

To analyze gender- and age-related motivations among smokers wishing to quit.

METHODS

We performed a multicenter cross-sectional study in 1,634 smokers attended by general practitioners and specialized physicians in Spain who, after being explicitly asked about their intention to quit smoking, expressed a desire to do so. Sociodemographic data, history of smoking and motivations for cessation were collected. A descriptive statistical analysis was performed.

RESULTS

The mean age was 45.6 years (SD+/-12.0 years). Fifty-six percent were men. A total of 35.2% had studied beyond high school. The main motivation expressed by 63.9% of men and 81.1% of smokers older than 60 years old was medical advice; 60.7% of women were motivated by disease prevention; 31.5% of smokers aged between 31 and 45 years old wanted to be a good role model for their children and 11.4% of those aged between 18 and 30 were motivated by esthetic reasons.

CONCLUSIONS

Men tend to be motivated by medical advice, while women are motivated by a desire to be a role model for their children, to prevent diseases or improve their appearance. The greater the age, the greater the percentage of patients motivated by medical advice. Middle-aged adults want to be good role models for their children while young patients are motivated by esthetic concerns.

Risk factors for treatment failure in smokers: relationship to alcohol use and to lifetime history of an alcohol use disorder

Little is known about the impact of alcohol involvement on smoking cessation relapse or possible mechanisms for these associations. We addressed these issues using data from a randomized clinical trial of two types of framed messages (gain vs. loss) in conjunction with open label sustained-release (SR) bupropion (Toll et al., 2007) (N = 249). Participants were categorized according to whether or not they were diagnosed with a lifetime alcohol use disorder (AUD; i.e., current or past alcohol abuse or past alcohol dependence) and according to three levels of alcohol use: abstinence, moderate, or hazardous use. Alcohol use categories were established for drinking at baseline, during the 6-week treatment period and through 12 weeks post-quit. There were few significant differences by baseline alcohol use level or AUD history for a series of predictors of smoking cessation failure (e.g., depressive symptoms). During treatment and follow-up, the probability of any smoking on heavy drinking days was significantly higher than the probability of smoking on moderate drinking or abstinent days. AUD history did not predict smoking cessation relapse in any analysis, nor were any alcohol usexAUD history interactions significant. Moderate alcohol users and, to a lesser extent, abstainers from alcohol at baseline were less likely than hazardous drinkers to have relapsed at 12 weeks post-quit. Based on these findings, it appears that risk of any smoking and of relapse was associated primarily with heavy drinking days and a hazardous pattern of use respectively, rather than with moderate drinking.

Trends in smoking in Sweden from 1968 to 2002: age, period, and cohort patterns

OBJECTIVE

Smoking is related to many later life health outcomes. We examined age, period, and cohort patterns in smoking between 1968 and 2002.

METHODS

A nationally representative panel study allowed repeated cross-sectional comparisons of ages 18-75 (5 waves n approximately 5000), and ages 77+ at later waves (2 waves n approximately 500). Cross-sectional 10-year age group differences in 5 waves, time-lag differences between waves for age groups, and within-cohort differences between waves for 10-year birth cohorts were evaluated using graphs and ordered logistic regressions.

RESULTS

Age-period-cohort models suggested that period and age effects dominated smoking patterns, showing decreases over time and age. The 1935-44 and 1945-54 cohorts, however, showed lesser period decline. Moreover, men showed a period reduction of smoking rates but no age related decrease, while women showed an age related decrease but no period effect. The genders' cohort patterns were similar, with higher smoking rates in the last waves for some cohorts, for men the 1945-54 cohort and women the 1935-44 cohort.

CONCLUSIONS

Cross-sectional studies of cohorts must be aware of age effects. Due to the coming of age of the 1940s' cohorts smoking may increase among women in the oldest age groups.

Validity of self reported diagnoses of cancer in a major Spanish prospective cohort study

INTRODUCTION

This study aims to assess the validity of self reported diagnoses of cancer by persons recruited for the Spanish EPIC (European prospective investigation into cancer and nutrition) cohort study and to identify variables associated with correctly reporting a diagnosis of cancer.

METHODS

41 440 members of EPIC were asked at the time of recruitment whether they had been diagnosed with cancer and the year of diagnosis and site. The process of validating self reported diagnoses of cancer included comparison of the cohort database with the data from the population based cancer registries. Cancer diagnostic validity tests were calculated. The association between a correct report and certain sociodemographic, tumour related, or health related variables were analysed by logistic regression.

RESULTS

The overall sensitivity of self reported diagnoses of cancer is low (57.5%; 95% CI: 51.9 to 63.0), the highest values being shown by persons with a higher level of education or with a family history of cancer and the lowest values by smokers. Breast and thyroid cancers are those with the highest diagnostic validity and uterus, bladder, and colon-rectum those with the lowest. In both sexes the variables showing a significant association with a correct report of cancer are: higher education level, number of previous pathologies, invasive tumour, and, in women, a history of gynaecological surgery.

CONCLUSIONS

The overall sensitivity of self reported diagnoses of cancer is comparatively low and it is not recommended in epidemiological studies for identifying tumours. However, self reported diagnoses might be highly valid for certain tumour sites, malignant behaviour, and average to high levels of education.

Intake and food sources of nitrites and N-nitrosodimethylamine in Spain

OBJECTIVE

To conduct a comprehensive assessment of dietary intakes of nitrites and N-nitrosodimethylamine (NDMA).

SUBJECTS AND SETTING

A study was conducted within the Spanish cohort of the European Prospective Investigation in Cancer and Nutrition (EPIC) to assess the intake and food sources of these compounds in Spanish adults. The study included 41,446 health volunteers, aged 29-69 years, from Northern and Southern regions. Usual food intake was estimated by in-person interviews using a computerised dietary questionnaire.

RESULTS

The estimated geometric mean was 0.994 mg day(-1) for nitrites and 0.114 microg day(-1) for NDMA. For both compounds a positive trend in consumption with increasing energy intake was observed. Dietary NDMA was related to age and sex after energy adjustment, while nitrite consumption increased with higher intakes of vitamin C (P < 0.001). The food groups that contributed most to intakes were meat products, cereals, vegetables and fruits for nitrites, and processed meat, beer, cheese and broiled fish for NDMA. Current and past smokers, who had high levels of NDMA from tobacco exposure, were also identified as the highest consumers of dietary NDMA. Furthermore, smokers had low intakes of vitamin C (an inhibitor of endogenous nitrosation).

CONCLUSIONS

Intake levels of NDMA and nitrites in a Mediterranean cohort are currently relatively lower than those previously reported, although processed meat, beer and cured cheese still are the most important contributors to NDMA intake.

Smoking Cessation in a Population-Based Cohort Study

OBJECTIVE

To study the incidence rates and the determinants of smoking cessation in a population-based cohort.

MATERIAL AND METHODS

We used data from the Cornellà Health Interview Survey Follow-up Study. Subjects who declared they were daily smokers at baseline (1994) and had complete follow-up, with information on smoking status in 2002, entered into analysis. We calculated incidence rates and the relative risks of cessation (with 95% confidence intervals) using the Cox model.

RESULTS

Out of 353 daily smokers, 100 quit smoking during the follow-up period (cumulative incidence of 28.3%). The incidence rate of cessation was higher among men (42.34 per 1000 person-years) than among women (24.97 per 1000 person-years), with a relative risk of cessation of 1.69 (95% confidence interval, 1.02-2.79) for men. Age and level of education were associated with a higher relative risk of quitting in men.

CONCLUSIONS

The main determinants for smoking cessation are sociodemographic (sex, age, and level of education).