Mortality among "never smokers" living with smokers: two cohort studies, 1981-4 and 1996-9

Staying Quit After Release (SQuARe) trial protocol: a randomised controlled trial of a multicomponent intervention to maintain smoking abstinence after release from smoke-free prisons in Victoria, Australia

INTRODUCTION

Smoke-free policies have been introduced in prisons internationally. However, high rates of relapse to smoking after release from prison indicate that these policies typically result in short-term smoking cessation only. These high rates of relapse, combined with a lack of investment in relapse prevention, highlight a missed opportunity to improve the health of a population who smoke tobacco at two to six times the rate of the general population. This paper describes the rationale and design of a randomised controlled trial, testing the effectiveness of a caseworker-delivered intervention promoting smoking cessation among former smokers released from smoke-free prisons in Victoria, Australia.

METHODS AND ANALYSIS

The multicomponent, brief intervention consists of behavioural counselling, provision of nicotine spray and referral to Quitline and primary care to promote use of government-subsidised smoking cessation pharmacotherapy. The intervention is embedded in routine service delivery and is administered at three time points: one prerelease and two postrelease from prison. Control group participants will receive usual care. Smoking abstinence will be assessed at 1 and 3 months postrelease, and confirmed with carbon monoxide breath testing. Linkage of participant records to survey and routinely collected administrative data will provide further information on postrelease use of health services and prescribed medication.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Corrections Victoria Research Committee, the Victorian Department of Justice Human Research Ethics Committee, the Department of Human Services External Request Evaluation Committee and the University of Melbourne Human Research Ethics Committee. Results will be submitted to major international health-focused journals. In case of success, findings will assist policymakers to implement urgently needed interventions promoting the maintenance of prison-initiated smoking abstinence after release, to reduce the health disparities experienced by this marginalised population.

TRIAL REGISTRATION NUMBER

ACTRN12618000072213; Pre-results.

Changing smoking-mortality association over time and across social groups: National census-mortality cohort studies from 1981 to 2011

The difference in mortality between current and never-smokers varies over time, affecting future projections of health gains from tobacco control. We examine this heterogeneity by sex, ethnicity and cause of death on absolute and relative scales using New Zealand census data. These data included smoking status, and were linked to subsequent mortality records in 1981-84, 1996-99 and 2006-11 for 25-74 year olds (16.1 million person-years of follow-up). Age-standardised mortality rates and rate differences (SRDs) were calculated comparing current to never-smokers, and Poisson regression was used to adjust for multiple socioeconomic factors and household smoking. We found that mortality declined over time in never-smokers; however, mortality trends in current-smokers varied by sex, ethnicity and cause of death. SRDs were stable over time in European/Other men, moderately widened in European/Other women and markedly increased in Māori men and women (Indigenous population). Poisson smoking-mortality rate ratios (RRs) increased from 1981-84 to 1996-99 with a moderate increase from 1996-99 to 2006-11 (RRs 1.48, 1.77, 1.79 in men and 1.51, 1.80, 1.90 in women). Socioeconomic confounding increased over time. In summary, this marked heterogeneity in smoking-mortality RRs over time has implications for estimating the future health and inequality impacts of tobacco control interventions.

A prospective study of tobacco smoking and mortality in Bangladesh

Background

Limited data are available on smoking-related mortality in low-income countries, where both chronic disease burden and prevalence of smoking are increasing.

Methods

Using data on 20, 033 individuals in the Health Effects of Arsenic Longitudinal Study (HEALS) in Bangladesh, we prospectively evaluated the association between tobacco smoking and all-cause, cancer, and cardiovascular disease mortality during ∼7.6 years of follow-up.

Cox proportional hazards models were used to estimate hazard ratios (HRs) and their 95% confidence intervals (CIs) for deaths from all-cause, cancer, CVD, ischemic heart disease (IHD), and stroke, in relation to status, duration, and intensity of cigarette/bidi and hookah smoking.

Results

Among men, cigarette/bidi smoking was positively associated with all-cause (HR 1.40, 95% CI 1.06 1.86) and cancer mortality (HR 2.91, 1.24 6.80), and there was a dose-response relationship between increasing intensity of cigarette/bidi consumption and increasing mortality. An elevated risk of death from ischemic heart disease (HR 1.87, 1.08 3.24) was associated with current cigarette/bidi smoking. Among women, the corresponding HRs were 1.65 (95% CI 1.16 2.36) for all-cause mortality and 2.69 (95% CI 1.20 6.01) for ischemic heart disease mortality. Similar associations were observed for hookah smoking. There was a trend towards reduced risk for the mortality outcomes with older age at onset of cigarette/bidi smoking and increasing years since quitting cigarette/bibi smoking among men. We estimated that cigarette/bidi smoking accounted for about 25.0% of deaths in men and 7.6% in women.

Conclusions

Tobacco smoking was responsible for substantial proportion of premature deaths in the Bangladeshi population, especially among men. Stringent measures of tobacco control and cessation are needed to reduce tobacco-related deaths in Bangladesh.

Burden of household environmental tobacco smoke on medical expenditure for Japanese women: a population-based cohort study

BACKGROUND

The economic consequences of environmental tobacco smoke (ETS) have been simulated using models. We examined the individual-level association between ETS exposure and medical costs among Japanese nonsmoking women.

METHODS

This population-based cohort study enrolled women aged 40 to 79 years living in a rural community. ETS exposure in homes at baseline was assessed with a self-administered questionnaire. We then collected health insurance claims data on direct medical expenditures from 1995 through 2007. Using generalized linear models with interaction between ETS exposure level and age stratum, average total monthly expenditure (inpatient plus outpatient care) per capita for nonsmoking women highly exposed and moderately exposed to ETS were compared with expenditures for unexposed women. We performed separate analyses for survivors and nonsurvivors.

RESULTS

We analyzed data from 4870 women. After adjustment for potential confounding factors, survivors aged 70 to 79 who were highly exposed to ETS incurred higher expenditures than those who were not exposed. We found no significant difference in expenditures between moderately exposed and unexposed women. Total expenditures were not significantly associated with ETS exposure among survivors aged 40 to 69 or nonsurvivors of any age stratum.

CONCLUSIONS

We calculated individual-level excess medical expenditures attributable to household exposure to ETS among surviving older women. The findings provide direct evidence of the economic burden of ETS, which is helpful for policymakers who seek to achieve the economically attractive goal of eliminating ETS.

Are there health benefits associated with comprehensive smoke-free laws

INTRODUCTION

In the past few years, comprehensive smoke-free laws that prohibit smoking in all workplaces have been introduced in many jurisdictions in the US, Canada, and Europe. In this paper, we review published studies to ascertain if there is any evidence of health benefits resulting from the implementation of these laws.

METHODS

All papers relating to smoke-free legislation published in or after 2004 were considered for inclusion in this review. We used Pubmed, Google scholar, and Web of Science as the main search tools. The primary focus of the paper is on health outcomes, and thus many papers that only report exposure data are not included.

RESULTS

Studies using subjective measures of respiratory health based on questionnaire data alone consistently reported that workers experience fewer respiratory and irritant symptoms following the introduction of smoke-free laws. Some studies also found measured improvements in the lung function of workers. However, the most dramatic health outcome associated with smoke-free laws has been the reduction in myocardial infarction in the general population. This outcome has been observed in the US, Canada, and Europe, with studies reporting reductions of between 6 and 40%, post-legislation, the larger reductions being mostly from studies with smaller population groups. The evidence as to whether these smoke-free laws have helped smokers to stop smoking or to reduce tobacco consumption is less clear.

CONCLUSIONS

There is now significant body of published literature that demonstrates that smoke-free laws can lead to improvements in the health of both workers who are occupationally exposed and of the general population. There is no longer any reason why non-smokers should be exposed to SHS in any workplace. We recommend that all countries adopt national smoke-free laws that are in line with article 8 of the WHO Framework Convention on Tobacco Control that sets out recommendations for the development, implementation, and enforcement of national, comprehensive smoke-free laws.

Population level policy options for increasing the prevalence of smokefree homes

OBJECTIVE

To identify and evaluate the options for population level government policies to increase the prevalence of homes free of secondhand smoke.

METHODS

The literature was searched for population level policy options and evidence on them. Three criteria were used to evaluate the policy options: effectiveness, the reductions on inequalities in secondhand smoke exposure, and cost effectiveness. The setting was four developed, English speaking jurisdictions: Britain, USA, Australia, and New Zealand.

RESULTS

Evidence from all four countries shows some association between relatively comprehensive tobacco control programmes and lower prevalence levels of smoking in homes. The evidence of the effect of such programmes on inequalities in smokefree home prevalence is limited. No published evidence was found of the cost effectiveness of the programmes in achieving changes in smokefree homes. Within comprehensive programmes, there is some indirect evidence that some mass media campaigns could increase the prevalence of smokefree homes. Structural options that have potential to support smokefree homes include smokefree places legislation, and laws for the protection of children.

CONCLUSION

The available evidence to date suggests that comprehensive tobacco control programmes (to reduce the prevalence of smoking in the total population) are likely to be the most effective and sustainable option for increasing the prevalence of smokefree homes.

Environmental tobacco smoke and mortality in Chinese women who have never smoked: prospective cohort study

OBJECTIVE

To evaluate the association of environmental exposure to tobacco smoke from husbands and from work, as well as from family members in early life, with all cause mortality and mortality due to cancer or cardiovascular disease in Chinese women.

DESIGN

Ongoing prospective cohort study in Shanghai, China.

PARTICIPANTS

Of 72,829 women who had never smoked, 65,180 women provided information on smoking by their husbands, and 66,520 women provided information on exposure to tobacco smoke at work and in early life from family members.

MAIN OUTCOME MEASURES

All cause mortality and cause specific mortality with the main focus on cancer and cardiovascular disease. Cumulative mortality according to exposure status, and hazard ratios.

RESULTS

Exposure to tobacco smoke from husbands (mainly current exposure) was significantly associated with increased all cause mortality (hazard ratio 1.15, 95% confidence interval 1.01 to 1.31) and with increased mortality due to cardiovascular disease (1.37, 1.06 to 1.78). Exposure to tobacco smoke at work was associated with increased mortality due to cancer (1.19, 0.94 to 1.50), especially lung cancer (1.79, 1.09 to 2.93). Exposure in early life was associated with increased mortality due to cardiovascular disease (1.26, 0.94 to 1.69).

CONCLUSIONS

In Chinese women, exposure to environmental tobacco smoke is related to moderately increased risk of all cause mortality and mortality due to lung cancer and cardiovascular disease.

The dirty dozen: 12 myths that undermine tobacco control

Cigarette smoking is the leading cause of preventable death in the United States. The health risks of smoking are well documented, as is the effectiveness of clinical and public health interventions to prevent and reduce smoking. However, many myths about smoking either encourage people to begin or continue smoking or deter them from quitting. Some myths stem from a misapplied understanding of what might seem to be common sense; others are deliberately promulgated by the tobacco industry to induce people--especially children--to start smoking and to keep them smoking as adults. These myths undermine tobacco control. However, comprehensive tobacco control programs that include anti-smoking public education campaigns can effectively counter these myths and prevent illness and premature death.

Tobacco taxation and public health: ethical problems, policy responses

This article aims to describe the major ethical issues surrounding tobacco taxation, and to identify policy responses to minimise any ethical dilemmas. It uses the standard ethical framework for biomedicine (covering beneficence, non-maleficence, respect for autonomy and justice), in conjunction with relevant data on tobacco taxation from various developed countries. Tobacco taxation contributes substantial benefits at the population level by protecting health (i.e., by deterring the uptake of smoking by youth, by promoting quitting, and by reducing harm from exposure to second-hand smoke (SHS)). However, tobacco taxes can contribute to financial hardship among low-socioeconomic status populations where smoking persists. Such taxes can contribute to autonomy, by reducing SHS exposure to non-smokers, and by allowing freedom from nicotine-dependency for those who quit smoking or do not start regular smoking as a result of high tobacco prices. Furthermore, increases in tobacco taxation may reduce health inequalities and so contribute to justice. Nevertheless, the additional tax burden imposed on smokers who wish to continue to smoke, or are unable to quit, can be considered unjust. The autonomy of such smokers may be partly impaired. Although tobacco tax can be regarded as ethically justifiable because of its substantial overall benefit to society, there is substantial scope for policy changes to further reduce any harms and injustices for those populations who continue to smoke.

Clear the air: adolescents' perceptions of the risks associated with secondhand smoke

BACKGROUND

Despite numerous studies on adolescents' recognition of the medical risks of primary smoke, there have been surprisingly few investigations of how adolescents perceive the risks associated with exposure to secondhand smoke. This study examined whether adolescents' risk estimates when exposed to secondhand smoke differed by: (1) actual smoking experience and (2) adolescents' intentions to smoke in the near future. We also explored whether adolescents perceive different risk depending on who is producing the secondhand smoke.

METHODS

Three hundred and ninety-five 9th graders (mean age = 14.0) completed a survey concerning their perceptions of secondhand smoke, smoking experiences, and intentions.

RESULTS

On average, adolescents were aware of the serious risks posed by exposure to secondhand smoke. However, adolescents who smoke or intend to smoke were more likely to perceive the risks from exposure to secondhand smoke as lower than did adolescents who had never smoked or had no intentions to smoke.

CONCLUSIONS

The findings from this study suggest that education regarding the risks of secondhand smoke might serve as an additional deterrent against smoking and smoking intentions. Further study using longitudinal data is still needed to fully understand the relationship between such perceptions and smoking behavior.

[Passive smoking]

INTRODUCTION

Environmental tobacco smoke is a recognized factor of morbidity and mortality. The first victims are children, sometimes starting from conception, but adults are not spared. In practice, evaluation of exposure to tobacco smoke can be achieved with more or less specific markers of tobacco smoke.

CURRENT KNOWLEDGE

Exposure of the fetus to maternal smoking and of the infant to environmental smoke can have a serious sometimes life-threatening impact. Such exposure increases the risk of spontaneous abortion, ectopic pregnancy, intrauterine growth retardation, premature membrane rupture, preterm birth, retroplacental hematoma, placenta praevia, and sudden infant death. Adult respiratory and cardiovascular disease are also influenced by environmental smoke. In France passive smoking causes premature death of 3000 persons per year.

PERSPECTIVES

Better knowledge of the risks of exposure to passive smoking can facilitate application of legislation with the objective of protecting non-smokers.

CONCLUSIONS

Rigorous application of current legislation is important to achieve the stated goals of prevention of smoking as well as assistance to cease smoking.