Smoking and Risk of All-cause Deaths in Younger and Older Adults: A Population-based Prospective Cohort Study Among Beijing Adults in China

A comparison of different methods to adjust survival curves for confounders

Treatment specific survival curves are an important tool to illustrate the treatment effect in studies with time-to-event outcomes. In non-randomized studies, unadjusted estimates can lead to biased depictions due to confounding. Multiple methods to adjust survival curves for confounders exist. However, it is currently unclear which method is the most appropriate in which situation. Our goal is to compare forms of inverse probability of treatment weighting, the G-Formula, propensity score matching, empirical likelihood estimation and augmented estimators as well as their pseudo-values based counterparts in different scenarios with a focus on their bias and goodness-of-fit. We provide a short review of all methods and illustrate their usage by contrasting the survival of smokers and non-smokers, using data from the German Epidemiological Trial on Ankle-Brachial-Index. Subsequently, we compare the methods using a Monte-Carlo simulation. We consider scenarios in which correctly or incorrectly specified models for describing the treatment assignment and the time-to-event outcome are used with varying sample sizes. The bias and goodness-of-fit is determined by taking the entire survival curve into account. When used properly, all methods showed no systematic bias in medium to large samples. Cox regression based methods, however, showed systematic bias in small samples. The goodness-of-fit varied greatly between different methods and scenarios. Methods utilizing an outcome model were more efficient than other techniques, while augmented estimators using an additional treatment assignment model were unbiased when either model was correct with a goodness-of-fit comparable to other methods. These "doubly-robust" methods have important advantages in every considered scenario.

Epidemiology of comorbidities and their association with asthma control

Background

The prevalence of comorbidities and their relation to asthma control and treatment is a topic of increasing interest, however comprehensive studies are scarce. We aimed to determine the prevalence of the most common comorbidities in asthma in relation to patient characteristics (age, gender and body mass index [BMI]) and their association with asthma control in a large, specialist-managed representative patient population.

Methods

A secondary, exploratory analysis of the Asthma Reality (ARL), across-sectional, non-interventional real-life study was conducted. Basic patient characteristics, the prevalence of comorbidities and data on asthma control and risk factors had been collected and their interactions examined. Descriptive statistics and binomial regression were used to assess the distribution of the prevalence of comorbidities and propensity matching was applied to assess their effect on asthma control.

Results

Overall, 12,743 patients were enrolled in our study in 187 treatment centres covering all regions of Hungary. Most comorbidities showed significantly different distribution for all basic patient characteristics. Gender, age group, smoking status, BMI and the duration of asthma had a significant impact on asthma control. The frequency of uncontrolled asthma was higher in females (37.1%), in the age group of 46–65 years (39.6%), in severely obese patients (43.2%), in patients who had been diagnosed with asthma for more than 20 years (40.4%), and in active heavy smokers (55%), compared with respective groups in the same category. Based on the binomial regression with propensity score matching, concomitant chronic obstructive pulmonary disease (COPD) (odds ratio [OR] = 2.06, 95% confidence interval [CI] 1.80–2.36), ischaemic heart disease (OR = 1.86, 95% CI 1.64–2.10) and cerebrovascular events (OR = 1.85, 95% CI 1.47–2.32) had the strongest negative effect on asthma control, with the presence of all of these conditions increasing the risk of uncontrolled asthma.

Conclusions

This evaluation of comorbidity data of more than 12,000, adult asthmatic patients has provided a clearer picture of diseases that can frequently co-exist with asthma, and their influence on asthma control, assessed by the prevalence of symptoms. Our study suggests that most asthmatic patients have at least one comorbidity, and the presence of comorbidities may have a high impact on asthma control measures.

Childhood neurodevelopmental markers and risk of premature mortality: Follow-up to age 60-65 years in the Aberdeen Children of the 1950s study

Background

Individual neurodevelopmental disorders are associated with premature mortality. Little is known about the association between multiple neurodevelopmental markers and premature mortality at a population level. The ESSENCE (Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations) approach considers multiple neurodevelopmental parameters, assessing several markers in parallel that cluster, rather than considering individual diagnostic categories in isolation.

Objectives

To determine whether childhood neurodevelopmental markers, including reduced intellectual functioning, are associated with all-cause premature mortality.

Methods and procedures

In a general population cohort study (n = 12,150) with longitudinal follow up from childhood to middle age, Cox proportional hazard models were used to study the associations between childhood neurodevelopmental markers (Rutter B scale and IQ) and premature all-cause mortality.

Outcomes and results

The cognitive measures and 21 of the 26 Rutter B items were significantly associated with premature mortality in bivariate analyses with hazard ratios from 1.24 (95% CI 1.05–1.47) to 2.25 (95% CI 1.78–2.90). In the final adjusted model, neurodevelopmental markers suggestive of several domains including hyperactivity, conduct problems and intellectual impairment were positively associated with premature mortality and improved prediction of premature mortality.

Conclusions

A wide range of neurodevelopmental markers, including childhood IQ, were found to predict premature mortality in a large general population cohort with longitudinal follow up to 60–65 years of age.

Implications

These findings highlight the importance of a holistic assessment of children with neurodevelopmental markers that addresses a range of neurodevelopmental conditions. Our findings could open the door to a shift in child public mental health focus, where multiple and/or cumulative markers of neurodevelopmental conditions alert clinicians to the need for early intervention. This could lead to a reduction in the risk of broad health outcomes at a population level.

Comparison between Smoking and Nonsmoking Palestinian Medical Students in the Health-Promoting Behaviors and Lifestyle Characteristics

Objectives

This study was aimed at comparing the predictors of health-promoting lifestyle behaviors between smoking and nonsmoking medical students at An-Najah National University located in Palestine.

Methods

A descriptive cross-sectional study was performed during the academic year 2017/2018. Medical students were asked to complete a self-reported questionnaire that involved the predictors of Health-Promoting Lifestyle Profile-II. With the use of a suitable available sample composed of a total of 430 medical students, 400 had successfully completed the questionnaire and were included in the study. The data was analyzed by using SPSS version 24 software.

Results

The sample included 400 medical students with a mean age of 18.7 years, 311 (77.7%) were females, and 89 (22.3%) were males. The prevalence of smokers in the sample was 110 (27.5%). For the health status of over half the students, 211 (52.8%) were excellent. The total HPLP-II score for smoking students resulted to be significantly lower in comparison to nonsmoking students (131.2 versus 135.7). This significant difference was clear in the interpersonal relation subscale (25.6 versus 26.8) for smoking and nonsmoking students, respectively. The score differences in other subscales were generally lower in smoking students. However, these differences were not consistent with statistical significance.

Conclusion

The significant lower total Health-Promoting Lifestyle Profile-II score in smoking students necessitates the urgent need for awareness programs, not only towards smoking but also on how to enhance student health-promoting lifestyle behaviors.

Association of smoking status and health-related quality of life: difference among young, middle-aged, and older adults in Shandong, China

PURPOSE

Few studies explored the relationship between smoking status and health-related quality of life (HRQOL) among adults in China. This study aims to explore the relationship between smoking status and HRQOL among adults (18 +) and examine whether there is a difference in this relationship among young, middle-aged, and older adults in China.

METHODS

A total of 23,021 respondents were included in this study. The HRQOL is measured by EQ-5D-3L. The smoking status is divided into never smokers, current smokers, and former smokers. Tobit regression and Logistic regression are employed to explore the association between smoking status and HRQOL. The interaction term is included to explore the difference among young, middle-aged, and older adults.

RESULTS

This study finds smoking status is significantly associated with HRQOL. An interaction analysis shows that the association between smoking status and HRQOL is significantly different among young, middle-aged, and older adults (P < 0.05). The smoking status is only significantly associated with HRQOL in middle-aged and older adults, but not for young adults. Compared with never smokers, former smokers report significantly lower EQ-5D-3L utility value in middle-aged adults (coefficient =  - 0.089; 95%CI - 0.128 to - 0.050), current smokers report significantly higher EQ-5D-3L utility value in older adults (coefficient = 0.041; 95%CI 0.005 to 0.076).

CONCLUSIONS

This study demonstrates a significant association between smoking status and HRQOL among adults in China, and there is a difference in this relationship among young, middle-aged, and older adults. The government should take efforts to formulate a variety of measures to control tobacco use among adults.

To text or not to text? Acceptability of WeChat and text messaging intervention to promote tobacco control assistance among parents who smoke in rural China

INTRODUCTION

Although the use of mobile health (mHealth) to promote tobacco control and smoking cessation interventions has been available in developed countries, their use in low- and middle-income countries (i.e. in China) is lacking. This study examined the acceptance of text messaging and/or WeChat based tobacco control intervention among parents who smoke, in rural China.

METHODS

Using a structured questionnaire, we surveyed smoker households (n=668) of children aged ≤5 years in two rural regions of southern China. Descriptive analyses were used to characterize respondents; multivariate regression analysis was used to test the associations between participants’ sociodemographic and other characteristics, and their acceptability of text messaging and/or WeChat intervention for tobacco control.

RESULTS

After adjusting for other variables (i.e. region, ethnicity, age, education level, occupation, attitudes towards smoking, perception of cigarettes addictiveness, and quitting smoking), the overall knowledge about smoking and secondhand smoke (SHS) exposure significantly predicted a higher acceptance to text messaging/WeChat intervention (OR=0.567; 95% CI: 0.457–0.704). Participants who thought smoking made people feel relaxed were less likely to accept text messaging/WeChat intervention than those who did not think so (OR=1.403; 95% CI: 1.080–1.822).

CONCLUSIONS

Our findings suggest that households in rural China that were more knowledgeable about the hazards of smoking and SHS exposure, and had negative feelings about the benefits of smoking, were more likely to accept text messaging/WeChat for tobacco control intervention. Understanding rural smokers’ preferences to receive intervention and related characteristics can help with the design of targeted tobacco control intervention programs in rural China.

Active Smoking is Associated with Lower Dialysis Adequacy in Prevalent Dialysis Patients

BACKGROUND:

Dialysis adequacy measured by single pool Kt/V (spKt/V) lower than 1.2 or urea reduction rate (URR) lower than 65% is associated with a significant increase in patient mortality rate. Patients’ adherence to the medical treatment is crucial to achieve recommended targets for spKt/V. Smoking is a recognized factor of non-adherence.

AIM:

In this study we sought to assess the association of active smoking and dialysis adequacy.

METHODS:

A total of 134 prevalent dialysis patients from one dialysis center were included in an observational cross-sectional study. Clinical, laboratory and dialysis data were obtained from medical charts in previous 6 months. The number of missed, on purpose interrupted or prematurely terminated dialysis sessions was obtained. Dialysis adequacy was calculated as spKt/V and URR. Patients were questioned about current active smoking status. T-test and Chi-Square test were used for comparative analysis of dialysis adequacy with regard to smoking status.

RESULTS:

The majority of patients declared a non-smoking status (100 (75%)) and 34 (25%) were active smokers. Male gender, younger age and shorter dialysis vintage were significantly more often present in the active smokers ((9 (26%) vs 25 (73%), p = 0.028; 57.26 ± 12.59 vs 50.15 ± 14.10, p = 0.012; 118.59 ± 76.25 vs 88.82 ± 57.63, p = 0.030)), respectively. spKt/V and URR were significantly lower and Kt/V target was less frequently achieved in smokers ((1.46 ± 0.19 vs. 1.30 ± 0.021, p = 0.019; 67.14 ± 5.86 vs. 63.64 ± 8.30, p = 0.002; 14 (14%) vs. 11 (32%), p = 0.023), respectively. Shorter dialysis sessions, larger ultra filtrations and higher percentage of missed/interrupted dialysis session on patients’ demand were observed in smokers (4.15 ± 0.30 vs. 4.05 ± 0.17, p = 0.019; 3.10 ± 0.78 vs. 3.54 ± 0.92, p = 0.017; 25 (0.3%) vs. 48 (1.8%), p = 0.031), respectively.

CONCLUSION:

Active smokers, especially younger men, achieve lower than the recommended levels for dialysis adequacy. Non-adherence to treatment prescription in smokers is a problem to be solved. Novel studies are recommended in patients on dialysis, to further elucidate the association of dialysis adequacy with the active smoking status.

The Impact of Generativity Awareness on Mid- to Old-Age Smokers in China

Smoking remains a serious health threat to many mid- to old-age Chinese people. Many smoking interventions have been implemented in public areas, but smoking occurring in a private setting, such as at home, has largely been neglected. Generativity is based on evaluating the worth of one's life experience that can be passed on to others. This study evaluated whether generativity awareness can have an impact on smoking reduction. Five hundred and eight Chinese smokers were recruited and demonstrated their strong awareness of generativity, specifically general generativity (e.g., moral ethics), health-related generativity (e.g., living a healthy life), and smoke-free family generativity. The study showed support for a three-dimensional model for generativity, namely general, health, and smoke-free generativity. The three types of generativity varied in their effects on behavioral intention to reduce smoking and to encourage younger family members not to smoke. Family communication patterns also influenced behavioral intention to reduce smoking and to encourage younger family members not to smoke. Theoretical and practical implications are discussed.

A retrospective study of smoking cessation intervention among university students

This retrospective study investigated the effect of smoking cessation intervention (SCI) among university students in China.Around 192 eligible smokers among university students were included, and were assigned to an intervention group (n = 100), and a control group (n = 92). All included subjects in both groups were recommended to increase fruits and vegetables consumptions. Additionally, participants in the intervention group also underwent SCI therapy for a total of 4 weeks. The outcome measurements consisted of a number of students quit smoking, daily cigarettes, quit attempts, mean days of smoking in the past 30 days, and also stage of change.After 4-week treatment, SCI neither can decrease the number of students quit smoking (P = .21), daily cigarettes (P = .21), quit attempts (P = .07), and mean days of smoking in past 30 days (P = .77), nor can enhance the stage of change (precontemplation, P = .18; contemplation, P = .59; preparation, P = .46).The results of this study showed that after 4-week therapy, SCI may be ineffective for smokers among university students in Chinese.

Association Between ABCB1 Gene Polymorphism and Renal Function in Patients with Hypertension: A Case-Control Study

Background

A previous study found that target organ damage in patients with hypertension was related to genetic factors. The aim of our study aim was to explore the association between the ABCB1 gene and renal function injury induced by hypertension.

Material/Methods

We used a case-control study design. Patients with hypertension were enrolled from our hospital between July 2015 and December 2015. Questionnaire data included personal information, life habits and behavior. Clinical data included blood routine examination and liver and renal function. We used restriction fragment length polymorphism methods for ABCB1 gene polymorphism detection.

Results

There were 306 patients with hypertension included in the final analyses: 170 cases of hypertension and 136 controls. Compared to controls, the cases group had higher: drinking ratio (65.3% versus 52.9%, p=0.029), body mass index (p=0.032), systolic blood pressure (p<0.001), total cholesterol (p=0.004), blood urea nitrogen (p=0.029), creatinine (p=0.024), uric acid (p=0.011), estimated glomerular filtration rate level (p<0.001), and platelet level (p=0.003). There were no significant differences for others parameters. Genotype frequency distributions of rs1045642 were statistically significant between the two groups (χ²=24.966, p<0.001). No differences were observed for the frequency distribution of rs10808072 and rs1922242 (χ²=1.293, p=0.524; χ²=0.065, p=0.968). The multivariable logistics results found that patients with TT genotype had a higher risk for renal function injury for hypertensive patients compared to those with CC genotype (OR=3.47, 95% CI: 1.19–10.07).

Conclusions

Our results suggested that the rs1045642-T allele of the ABCB1 gene may be associated with increased risk for renal function injury in hypertensive patients.

Association between CYP3A5 genotypes with hypertension in Chinese Han population: A case-control study

BACKGROUND

The association of CYP3A5 gene polymorphisms with hypertension in the Chinese population is unknown. We explored the association between the CYP3A5 (rs776746) gene and hypertension in the Chinese Han population.

METHODS

Using a case-control design, 340 cases and 254 controls were enrolled from the Third Affiliated Hospital of South Medical University between July and December of 2015. We used a standardized questionnaire to collect data regarding age, sex, smoking, drinking, family history of hypertension, and physical exercise. Height and weight were measured, and the body mass index (BMI) was calculated by weight/height². Blood pressure was measured three times after 5 min of rest with at least 15 s between measurements, and the mean was considered the final BP. A Clinical examination was conducted.

RESULTS

A total of 594 participants, including 340 cases and 254 controls, were entered into the analyses. The genotype frequencies of the CYP3A5 G>A polymorphism did not deviate from the Hardy-Weinberg equilibrium. The genotype frequencies among the cases were 38.8% (GA, 132 individuals), 42.9% (GG, 146 individuals), and 18.2% (AA, 62 individuals). The differences in genotype between the cases and the controls were statistically significant. The AA genotype was associated with an elevated risk of hypertension after adjusting for potential confounders in Model 2. There was no interaction between smoking and the CYP3A5 genotype, while the interaction between drinking and the CYP3A5 genotype was significant.

CONCLUSION

The CYP3A5 gene may be associated with the risk of hypertension in the Chinese Han population, and this effect may be exacerbated by drinking.

Effect of Resting Heart Rate on All-Cause Mortality and Cardiovascular Events According to Age

OBJECTIVES

To examine whether the association between resting heart rate (RHR) and all-cause mortality and cardiovascular events differs according to age.

DESIGN

Prospective cohort.

SETTING

Community in Beijing, China.

PARTICIPANTS

Individuals aged 40 and older without cardiovascular disease at baseline (N = 6,209).

MEASUREMENTS

Trained investigators interviewed participants using a standard questionnaire to obtain information on demographic characteristics, medical history and lifestyle risk factors in 1991. RHR was evaluated according to quartiles (<72, 72-76, 76-84, ≥84 beats/min). Cox regression models were used to assess the associations between RHR and all-cause mortality and cardiovascular events.

RESULTS

During a mean follow-up of 8.3 years, 840 subjects died, and 676 experienced a cardiovascular event. Higher RHR was significantly associated with all-cause mortality (P trend < .001) and cardiovascular events (P trend = .002) in older (≥60) but not younger (<60) participants (both P trend > .05). There were significant modifying effects of age on the association between RHR and all-cause mortality (P interaction < .001) and cardiovascular events (P interaction =.002). Similar results were observed after exclusion of individuals who died (n = 100) or had a cardiovascular event (n = 45) during the first 2 years of follow-up.

CONCLUSION

High RHR appears to be an independent determinant of all-cause mortality and cardiovascular events in older but not younger individuals.

The efficacy of mobile phone-based text message interventions ('Happy Quit') for smoking cessation in China

Background

Considering the extreme shortage of smoking cessation services in China, and the acceptability, feasibility and efficacy of mobile phone-based text message interventions for quitting smoking in other countries, here we propose a study of “the efficacy of mobile phone-based text message interventions (‘Happy Quit’) for smoking cessation in China”. The primary objective of this proposed project is to assess whether a program of widely accessed mobile phone-based text message interventions (‘Happy Quit’) will be effective at helping people in China who smoke, to quit. Based on the efficacy of previous studies in smoking cessation, we hypothesize that ‘Happy Quit’ will be an effective, feasible and affordable smoking cessation program in China.

Methods/Design

In this single-blind, randomized trial, undertaken in China, about 2000 smokers willing to make a quit attempt will be randomly allocated, using an independent telephone randomization system that includes a minimization algorithm balancing for sex (male, female), age (19–34 or >34 years), educational level (≤ or >12 years), and Fagerstrom score for nicotine addiction (≤5, >5), to ‘Happy Quit’, comprising motivational messages and behavioral-change support, or to a control group that receives text messages unrelated to quitting. Messages will be developed to be suitable for Chinese. A pilot study will be conducted before the intervention to modify the library of messages and interventions. The primary outcome will be self-reported continuous smoking abstinence. A secondary outcome will be point prevalence of abstinence. Abstinence will be assessed at six time points (4, 8, 12, 16, 20 and 24 weeks post-intervention). A third outcome will be reductions in number of cigarettes smoked per day.

Discussion/Implications

The results will provide valuable insights into bridging the gap between need and services received for smoking cessation interventions and tobacco use prevention in China. It will also serve as mHealth model for extending the public health significance of other interventions, such as mental health interventions.

Trial registration

NCT02693626 (Registration data April 11, 2016).