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Trigg J, Calabro R, Anastassiadis P, Bowden J, Bonevski B. Association of anxiety and depression symptoms with perceived health risk of nicotine vaping products for smoking cessation. Front Psychiatry 2024; 15:1277781. [PMID: 38487571 PMCID: PMC10937398 DOI: 10.3389/fpsyt.2024.1277781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 02/05/2024] [Indexed: 03/17/2024] Open
Abstract
As tobacco smoking prevalence is unacceptably high for the one in five Australians reporting a mental health condition in the past year, multiple cessation supports are needed to reduce tobacco-related disease. Nicotine vaping product (NVP)-facilitated smoking cessation is one option requiring a medical prescription in Australia. Yet, people easily obtain NVPs via non-prescription channels. As mental health impacts quitting intentions and health system engagement, this study examined how presence of anxiety and depression symptoms may be associated with perceived health risk of using NVPs from prescription or non-prescription sources for smoking cessation. We used cross-sectional South Australian (15 years +) 2022 survey data on vaping, smoking, anxiety, and depression. Robust linear regression was used to examine the association of anxiety and depression symptoms and nicotine addiction concern on perceived health risk of using NVPs from prescription or non-prescription sources. For prescription NVPs, vaping was associated with lower perceived health risk (b=-0.732). Higher perceived addiction risk was associated with higher perceived health risk from prescription NVPs (b=0.784). For non-prescription NVPs, vaping (b=-0.661) or smoking (b=-0.310) was associated with lower perceived health risk, and higher perceived addiction risk (b=0.733) was associated with a higher perceived health risk. Although anxiety and depression were not directly associated with NVP health risk perceptions, vaping while having depression symptoms was associated with higher perceived health risk ratings for prescription (b=0.700) but not non-prescription sources. People with depression who vape may see health risk barriers in NVP prescription access for smoking cessation, a smoking cessation support gap.
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Affiliation(s)
- Joshua Trigg
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Ryan Calabro
- Behavioural Research Unit, Cancer Council SA, Adelaide, SA, Australia
| | | | - Jacqueline Bowden
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- National Centre for Education and Training on Addiction, Flinders University, Bedford Park, SA, Australia
| | - Billie Bonevski
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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East K, Taylor E, Simonavičius E, Nottage M, Reid JL, Burkhalter R, Brose L, Wackowski OA, Liber AC, McNeill A, Hammond D. Noticing education campaigns or public health messages about vaping among youth in the United States, Canada and England from 2018 to 2022. HEALTH EDUCATION RESEARCH 2024; 39:12-28. [PMID: 38165724 PMCID: PMC10805379 DOI: 10.1093/her/cyad044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/29/2023] [Accepted: 12/08/2023] [Indexed: 01/04/2024]
Abstract
Public health campaigns have the potential to correct vaping misperceptions. However, campaigns highlighting vaping harms to youth may increase misperceptions that vaping is equally/more harmful than smoking. Vaping campaigns have been implemented in the United States and Canada since 2018 and in England since 2017 but with differing focus: youth vaping prevention (United States/Canada) and smoking cessation (England). We therefore examined country differences and trends in noticing vaping campaigns among youth and, using 2022 data only, perceived valence of campaigns and associations with harm perceptions. Seven repeated cross-sectional surveys of 16-19 year-olds in United States, Canada and England (2018-2022, n = 92 339). Over half of youth reported noticing vaping campaigns, and noticing increased from August 2018 to February 2020 (United States: 55.2% to 74.6%, AOR = 1.21, 95% CI = 1.18-1.24; Canada: 52.6% to 64.5%, AOR = 1.13, 1.11-1.16; England: 48.0% to 53.0%, AOR = 1.05, 1.02-1.08) before decreasing (Canada) or plateauing (England/United States) to August 2022. Increases were most pronounced in the United States, then Canada. Noticing was most common on websites/social media, school and television/radio. In 2022 only, most campaigns were perceived to negatively portray vaping and this was associated with accurately perceiving vaping as less harmful than smoking among youth who exclusively vaped (AOR = 1.46, 1.09-1.97). Consistent with implementation of youth vaping prevention campaigns in the United States and Canada, most youth reported noticing vaping campaigns/messages, and most were perceived to negatively portray vaping.
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Affiliation(s)
- Katherine East
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, Addictions Sciences Building, 4 Windsor Walk, London SE5 8BB, UK
- School of Public Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
| | - Eve Taylor
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, Addictions Sciences Building, 4 Windsor Walk, London SE5 8BB, UK
| | - Erikas Simonavičius
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, Addictions Sciences Building, 4 Windsor Walk, London SE5 8BB, UK
| | - Matilda Nottage
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, Addictions Sciences Building, 4 Windsor Walk, London SE5 8BB, UK
| | - Jessica L Reid
- School of Public Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
| | - Robin Burkhalter
- School of Public Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
| | - Leonie Brose
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, Addictions Sciences Building, 4 Windsor Walk, London SE5 8BB, UK
| | - Olivia A Wackowski
- School of Public Health, Rutgers, The State University of New Jersey, 683 Hoes Lane West, Piscataway, NJ 08854, USA
| | - Alex C Liber
- Cancer Prevention and Control, Lombardi Comprehensive Cancer Center, Georgetown University, 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Ann McNeill
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, Addictions Sciences Building, 4 Windsor Walk, London SE5 8BB, UK
| | - David Hammond
- School of Public Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
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Tehrani H, Rajabi A, Ghelichi- Ghojogh M, Nejatian M, Jafari A. The prevalence of electronic cigarettes vaping globally: a systematic review and meta-analysis. Arch Public Health 2022; 80:240. [PMID: 36415010 PMCID: PMC9682677 DOI: 10.1186/s13690-022-00998-w] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The purpose of this systematic review study was to determine the national, regional, and global prevalence of electronic cigarettes (e-cigarettes) vaping. METHOD The articles were searched in July 2020 without a time limit in Web of Science (ISI), Scopus, PubMed, and Ovid-MEDLINE. At first, the titles and abstracts of the articles were reviewed, and if they were appropriate, they entered the second stage of screening. In the second stage, the whole articles were reviewed and articles that met the inclusion criteria were selected. In this study, search, selection of studies, qualitative evaluation, and data extraction were performed by two authors independently, and any disagreement between the two authors was reviewed and corrected by a third author. RESULTS In this study, the lifetime and current prevalence of e-cigarettes vaping globally were 23% and 11%, respectively. Lifetime and current prevalence of e-cigarettes vaping in women were 16% and 8%, respectively. Also, lifetime and current prevalence of e-cigarettes vaping in men were 22% and 12%, respectively. In this study, the current prevalence of e-cigarettes vaping in who had lifetime smoked conventional cigarette was 39%, and in current smokers was 43%. The lifetime prevalence of e-cigarettes vaping in the Continents of America, Europe, Asia, and Oceania were 24%, 26%, 16%, and 25%, respectively. The current prevalence of e-cigarettes vaping in the Continents of America, Europe, Asia, and Oceania were 10%, 14%, 11%, and 6%, respectively. CONCLUSIONS Based on the results of this study, it can be concluded that the popularity of e-cigarettes is increasing globally. Therefore, it is necessary for countries to have more control over the consumption and distribution of e-cigarettes, as well as to formulate the laws prohibiting about the e-cigarettes vaping in public places. There is also a need to design and conduct information campaigns to increase community awareness about e-cigarettes vaping.
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Affiliation(s)
- Hadi Tehrani
- Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Health Education and Health Promotion, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Abdolhalim Rajabi
- Environmental Health Research Center, Department of Biostatistics and Epidemiology, Faculty of Health, Golestan University of Medical Sciences, Gorgan, Iran
| | | | - Mahbobeh Nejatian
- Social Determinants of Health Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Alireza Jafari
- Department of Health Education and Health Promotion, School of Health, Social Development and Health Promotion Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
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Wamamili B, Lawler S, Wallace-Bell M, Gartner C, Sellars D, Grace RC, Courtney R, Coope P. Cigarette smoking and e-cigarette use among university students in Queensland, Australia and New Zealand: results of two cross-sectional surveys. BMJ Open 2021; 11:e041705. [PMID: 33563621 PMCID: PMC7875298 DOI: 10.1136/bmjopen-2020-041705] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 12/07/2020] [Accepted: 12/22/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Examine the patterns of cigarette smoking and e-cigarette use (vaping), the perceived harm of e-cigarettes compared with tobacco cigarettes, and associations between smoking and vaping with student characteristics. DESIGN Cross-sectional studies. SETTING The University of Queensland (UQ), Australia and eight New Zealand (NZ) universities. PARTICIPANTS Students at UQ: 4957 (70.8% aged <25 years, 63.0% women) and NZ: 1854 (82.5% aged <25 years, 60.1% women). METHODS Χ2 tests compared smoking by age and gender, and vaping by age, gender and smoking status. Two-sided p<0.05 was considered significant and 95% CIs reported where appropriate. Multinomial logistic regression examined associations between smoking and vaping (exclusive smoking, exclusive vaping, dual use and non-use) with age, gender and student type (domestic vs international). RESULTS Smoking (UQ vs NZ, 95% CI): ever 45.2% (43.8% to 46.6%) vs 50.0% (47.7% to 52.3%), current 8.9% (8.1% to 9.7%) vs 10.4% (9.1% to 11.9%) and daily 5.2% (4.6% to 5.8%) vs 5.6% (4.6% to 6.7%), and not smoking in indoor 98.3% vs 87.7% or outdoor smoke-free spaces 83.8% vs 65.3%.Vaping (UQ vs NZ, 95% CI): ever 20.9% (19.8% to 22.1%) vs 37.6% (35.4% to 39.9%), current 1.8% (1.5% to 2.2%) vs 6.5% (5.4% to 7.7%) and daily 0.7% (0.5% to 1.0%) vs 2.5% (1.9% to 3.4%), and not vaping in indoor 91.4% vs 79.6% or outdoor smoke-free spaces 84.4% vs 71.3%. Of respondents, 71.7% (70.3% to 73.2%) vs 75.3% (72.9% to 77.6%) perceived e-cigarettes as less harmful than tobacco cigarettes.Men were more likely than women to smoke and vape, and to believe that e-cigarettes are less harmful. Regression models containing all predictors for smoking and vaping were significant and the effect of gender was significant for dual use, exclusive smoking and exclusive vaping (all p<0.01). Men had higher odds for smoking, vaping or dual use. CONCLUSIONS Results suggest significant differences in patterns of smoking and vaping of university students in Australia and NZ, and a strong influence of gender on smoking and vaping.
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Affiliation(s)
- Ben Wamamili
- School of Health Sciences, University of Canterbury, Christchurch, New Zealand
| | - Sheleigh Lawler
- School of Public Health, University of Queensland, Brisbane, Queensland, Australia
| | - Mark Wallace-Bell
- School of Health Sciences, University of Canterbury, Christchurch, New Zealand
| | - Coral Gartner
- School of Public Health, University of Queensland, Brisbane, Queensland, Australia
- Queensland Alliance for Environmental Health Sciences, Brisbane, Queensland, Australia
| | - David Sellars
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Randolph C Grace
- School of Psychology, Speech and Hearing, University of Canterbury, Christchurch, New Zealand
| | - Ryan Courtney
- National Drug and Alcohol Research Centre, University of New South Wales, Kensington, New South Wales, Australia
| | - Pat Coope
- College of Education, Health and Human Development, University of Canterbury, Christchurch, New Zealand
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Erku DA, Zhang R, Gartner CE, Morphett K, Steadman KJ. How are nicotine vaping products represented to pharmacists? A content analysis of Australian pharmacy news sources. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2020; 28:390-394. [PMID: 32311165 DOI: 10.1111/ijpp.12623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/16/2020] [Accepted: 03/16/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND With the growing popularity and use of nicotine vaping products (NVPs), it is important that pharmacists have evidence-based information in order to provide guidance to their customers. The news media can play an important role in shaping how pharmacists think, feel and act regarding NVPs. This paper examines how NVPs are portrayed and framed in Australian pharmacy news sources. METHODS Four leading Australian online pharmacy professional news sources were searched for articles published between 2007 and August 2019. A combination of qualitative and quantitative methods was employed to explore how the safety, efficacy and regulation of NVPs was communicated. RESULTS We identified and analysed 103 relevant articles. Academic research findings and/or expert opinions were either cited or referenced most often, appearing in a total of 59% of articles analysed, followed by government sources quoted in 41% of articles. Health effects and safety issues of NVPs were the most frequently mentioned topic appearing in a total of 79% of the stories, followed by NVP-related regulatory issues (47%). The majority of NVP-related articles were framed in a loss rather than gain contexts, with more emphasis given to the concern that NVPs have the potential to addict youth to nicotine and undermine Australia's progress in tobacco control. CONCLUSION Australian pharmacy news media have more often reported the potential risks than the potential benefits of NVPs. Such portrayal is likely to contribute to misperceptions about the relative harm of NVPs. Pharmacy staff need access to unbiased and evidence-based guidance on how to handle customer enquiries regarding NVPs.
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Affiliation(s)
- Daniel A Erku
- School of Pharmacy, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Rebecca Zhang
- School of Pharmacy, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Coral E Gartner
- School of Public Health, The University of Queensland, Herston, Queensland, Australia.,Queensland Alliance for Environmental Health Sciences, The University of Queensland, Woolloongabba, Queensland, Australia
| | - Kylie Morphett
- School of Public Health, The University of Queensland, Herston, Queensland, Australia
| | - Kathryn J Steadman
- School of Pharmacy, The University of Queensland, Woolloongabba, Queensland, Australia
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Soteriades S, Barbouni A, Rachiotis G, Grevenitou P, Mouchtouri V, Pinaka O, Dadouli K, Hadjichristodoulou C. Prevalence of Electronic Cigarette Use and its Determinants among 13-to-15-Year-Old Students in Greece: Results from the 2013 Global Youth Tobacco Survey (GYTS). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E1671. [PMID: 32143414 PMCID: PMC7084902 DOI: 10.3390/ijerph17051671] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 02/26/2020] [Accepted: 03/03/2020] [Indexed: 11/30/2022]
Abstract
Electronic cigarette use has increased over the past decade. Its potential role in smoking cessation, in addiction and as a 'gateway' to tobacco smoking is subject to intense research. This cross-sectional study, carried out in 2013, aims to present the habits of students aged 13-15 in Greece with regard to e-cigarettes and investigate potential risk factors and the relationship between e-cigarettes, tobacco smoking and other nicotine products. It is the first such study to be carried out in Greece. The survey was based on the standardized methodology of the Global Youth Tobacco Survey. All potential associations were investigated using multiple logistic regression. In total 2.8% of the 4096 participating students were current e-cigarette users and 12.3% of them were ever users. E-cigarette use was associated with male gender, being older, current use of combustible tobacco products and e-cigarette use in the family. Ever e-cigarette use, being older, female gender and higher pocket money were associated with an increased susceptibility to tobacco smoking. E-cigarette prevalence in Greece in 2013 was similar to that of other, developed countries. The smoking and vaping habits of adolescents must be monitored in order to assess trends over time and whether any policy alterations are necessary.
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Affiliation(s)
- Soteris Soteriades
- Laboratory of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Katsigra Building, 22 Papakyriazi St., 41222 Larissa, Greece (C.H.)
| | - Anastasia Barbouni
- Department of Public Health, University of West Attica, 196 Alexandras Ave., 11521 Athens, Greece
| | - George Rachiotis
- Laboratory of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Katsigra Building, 22 Papakyriazi St., 41222 Larissa, Greece (C.H.)
| | - Panoraia Grevenitou
- Laboratory of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Katsigra Building, 22 Papakyriazi St., 41222 Larissa, Greece (C.H.)
| | - Varvara Mouchtouri
- Laboratory of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Katsigra Building, 22 Papakyriazi St., 41222 Larissa, Greece (C.H.)
| | - Ourania Pinaka
- Laboratory of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Katsigra Building, 22 Papakyriazi St., 41222 Larissa, Greece (C.H.)
| | - Katerina Dadouli
- Laboratory of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Katsigra Building, 22 Papakyriazi St., 41222 Larissa, Greece (C.H.)
| | - Christos Hadjichristodoulou
- Laboratory of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Katsigra Building, 22 Papakyriazi St., 41222 Larissa, Greece (C.H.)
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Policy Debates Regarding Nicotine Vaping Products in Australia: A Qualitative Analysis of Submissions to a Government Inquiry from Health and Medical Organisations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16224555. [PMID: 31752132 PMCID: PMC6888569 DOI: 10.3390/ijerph16224555] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/03/2019] [Accepted: 11/14/2019] [Indexed: 11/16/2022]
Abstract
Australia has maintained a highly restrictive regulatory framework for nicotine vaping products (NVPs) and the regulatory approach differs from most other high income countries. This paper employed a thematic analysis to assess policy consultation submissions made to a government inquiry regarding use and marketing of NVPs. We included in the analysis submissions (n = 40) made by Australian institutions that influence or contribute to health policy-making including government agencies, health bodies and charities (n = 23), and public health academics and healthcare professionals (n = 18). Submissions from commercial entities and consumers were excluded. The majority of submissions from representatives of government agencies, health bodies and charities recommended maintaining current restrictions on NVPs. Arguments against widening access to NVPs included the demand for long-term evidence on safety and efficacy of an unusually high standard. There was widespread support for restrictions on sales, advertising and promotion, with most submissions supporting similar controls as for tobacco products. In contrast, the majority of individual submissions from healthcare professionals and public health academics advocated for widening access to NVPs for smokers and emphasized the potential benefits of smokers switching to vaping and the policy incoherence of regulating less harmful nicotine products more strictly than tobacco cigarettes. Progress in resolving the policy debate concerning NVP regulation in Australia will require policy makers, clinicians and the public health community to engage in a meaningful dialogue which gives due consideration to both intended and unintended consequences of proposed policies.
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Lewek P, Woźniak B, Maludzińska P, Smigielski J, Kardas P. E-cigarette use and its predictors: Results from an online cross-sectional survey in Poland. Tob Induc Dis 2019; 17:79. [PMID: 31772557 PMCID: PMC6856825 DOI: 10.18332/tid/113093] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 10/05/2019] [Accepted: 10/15/2019] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Since the invention of electronic cigarettes (ECs) in 2003, their use has spread worldwide; however, little is known about the profiles of EC users. Understanding the motivators for using ECs enables more accurate prediction of their use and more effective direction of pro-health activities. Our objective was to identify the factors that may influence the decision to use ECs and their possible adverse effects according to the experiences of EC users. METHODS A cross-sectional online survey was administered between 1 July 2016 and 1 January 2017 among 1288 Polish-speaking users of social networks and EC forums. To explore associations between current EC use and other factors, multivariate binary logistic regression analyses were performed. RESULTS The final analysis included 1142 survey participants: mean age 25.9 years (± 11.1), 85.6% were male, 50.3% had secondary education, 98.2% were Polish citizens, and 81.0% were current EC users. Male gender, lower education, aged ≤40 years, former cigarette smoking, previous attempts to quit smoking, perception of lack of harmful effects of ECs, perception of ECs as being tastier and cheaper than cigarettes, awareness of the advantages of ECs and their use as a smoking cessation aid were all statistically significant factors increasing the risk of EC use. The majority of study participants claimed that ECs are less addictive or not addictive compared to cigarettes (62.6%) and less harmful or not harmful (89.5%) compared to cigarettes. The most common reported side effects of ECs were dryness in the mouth (8.3%), itching in the throat (4.5%) and nausea (1.9%). CONCLUSIONS Males aged ≤40 years with a lower level education were more likely to use ECs in the studied Polish population. The perception that ECs are less harmful than regular cigarettes is a factor increasing the odds of EC use; however, although ECs have few adverse effects, they nevertheless exist.
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Affiliation(s)
- Pawel Lewek
- Department of Family Medicine, Medical University of Lodz, Lodz, Poland
| | | | | | - Janusz Smigielski
- Social and Technical Department, State Higher Vocational School, Konin, Poland
| | - Przemyslaw Kardas
- Department of Family Medicine, Medical University of Lodz, Lodz, Poland
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