Prevalence and correlates of smoking and nicotine dependence: results of a nationwide cross-sectional survey among Singapore residents

Global burden of bladder cancer attributable to smoking in 204 countries and territories, 1990-2019

Bladder cancer (BCa) poses a significant medical burden worldwide. However, the epidemiological pattern of the global smoking-induced BCa burden is unclear. Our analysis of the 2019 Global Burden of Disease (GBD) database showed a significant increase in the number of BCa cases worldwide from 1990 to 2019, with a clear upward trend in both age-standardized prevalence and incidence. In contrast, age-standardized rates of mortality (ASMR) and disability-adjusted life-years (ASDR) showed a downward trend, despite an increase in the absolute number of death and disability-adjusted life years. The burden of BCa caused by smoking is greater in males, middle-aged and older adults, and people in countries with high-middle socio-demographic indices (SDI). The study highlights the continuing global health challenge posed by smoking-related BCa. Targeted health policies and interventions are critical, especially in areas with high smoking rates and low socioeconomic status.

Prevalence of nicotine dependence among smokers aged 40 years and older in China

Background

Nicotine dependence, also known as tobacco dependence, is a common chronic disease and a major risk factor for chronic respiratory diseases. The present study was designed to determine the prevalence of nicotine dependence and its changes among smokers aged 40 years and older in China, to analyze the characteristics of nicotine dependence among smokers, and to provide a reference for smoking cessation interventions.

Methods

The data were sourced from nationally representative large-sample surveys conducted during 2014-2015 and 2019-2020 in the Chinese population, covering 125 counties (districts) in 31 provinces, autonomous regions and municipalities. Variables related to smoking and nicotine dependence among residents ≥40 years old were collected in face-to-face interviews. A total of 20,062 and 18,975 daily smokers were included in the 2014-2015 and 2019-2020 surveys, respectively. The severity of nicotine dependence was evaluated according to the Fagerström Test for Nicotine Dependence and Heaviness of Smoking Index. The level and change in nicotine dependence among daily smokers aged ≥40 years were estimated using a complex weighted sampling design, and their influencing factors were analyzed.

Results

Levels of nicotine dependence among daily smokers aged ≥40 years in China could be divided into very low, low, medium, high, and very high, accounting for 31.1%, 27.9%, 13.4%, 20.5%, and 7.1% of the total, respectively. The average Fagerström Test for Nicotine Dependence score was 3.9 (95% confidence interval [CI]: 3.8-4.0), with the prevalence of medium-high nicotine dependence being 41.0% (95% CI: 39.0-42.9%) and that of high and very high nicotine dependence being 27.6% (95% CI: 26.0-29.3%), both of which were significantly higher in men than in women (both P < 0.001). Among daily smokers, those with a low education level, age at smoking initiation <18 years, and with smoking duration of ≥20 years had a higher degree of nicotine dependence. In terms of geographic region, the level of medium-high nicotine dependence in South China was higher than in other areas, and the decline in the prevalence of high nicotine dependence was the greatest in Northwest China (P < 0.001). The prevalence of medium-high and high and very high nicotine dependence was significantly higher in men with chronic respiratory symptoms, chronic obstructive pulmonary disease (COPD), and/or chronic respiratory diseases than in men without these conditions (all P < 0.05). The prevalence of high and very high nicotine dependence in women with chronic respiratory symptoms and chronic respiratory diseases was significantly higher than that in women without these conditions (both P < 0.05). Compared with that during 2014-2015, the prevalence of high nicotine dependence among daily smokers decreased during 2019-2020 by 4.5 percentage points in the total population (P < 0.001) and by 4.8 percentage points in men (P < 0.001), with no significant change seen in women (P > 0.05). Additionally, the prevalence of high nicotine dependence in men with chronic respiratory symptoms and COPD decreased by 6.7 and 4.7 percentage points, respectively (P < 0.05), but showed no significant change in women with these conditions (P > 0.05). Multivariate logistic regression analysis showed that the risk of medium-high nicotine dependence was higher among daily smokers who were male; 50-59 years old; unmarried/divorced/widowed/separated; engaged in agriculture, forestry, husbandry, fishery and water conservancy; had a low education level; started smoking before the age of 18 years; and smoked for more than 20 years.

Conclusions

The past few years have seen a slight decline in the prevalence of high (severe) nicotine dependence among smokers aged ≥40 years in China. However, 41.0% of daily smokers had medium-high nicotine dependence, and 27.6% had high or very high nicotine dependence, with notable differences in population and geographic distributions. Development of tailored interventions, optimization of smoking cessation service systems, and integration of smoking cessation into the management of chronic diseases will effectively reduce the burden of nicotine dependence in China.

Unhealthy behaviors associated with mental health disorders: a systematic comparative review of diet quality, sedentary behavior, and cannabis and tobacco use

Background

There are well-established literatures documenting the associations between mental disorders and unhealthy behaviors such as poor diet quality, sedentary behavior, and cannabis and tobacco use. Few studies have attempted to understand the respective findings in light of each other, however.

Objective

The purpose of this review was to assemble comparable data for each behavior-disorder association and assess the associations in terms of their overall strength. The review aimed to include a representative, but not exhaustive, range of studies that would allow for explorative comparisons.

Methods

Eligible studies were identified via Pubmed searches and citation searching, restricted to publications no older than 2015 written in English. To obtain comparable data, only studies that reported findings as odds ratios were included, and risk of bias related to study samples, behavioral measurement disparities, and control variables was assessed via sensitivity analyses. Findings for each disorder were compared on the basis of different measures of central tendency.

Results

From 3,682 records, 294 studies were included. The review found evidence of associations between each of the four unhealthy behaviors and psychosis, depression, anxiety, bipolar disorder, attention-deficit/hyperactivity disorder (ADHD), and post-traumatic stress disorder (PTSD), while personality disorder was only investigated in relation to cannabis and tobacco use. In overall comparison, the associations were generally of similar strength, and only the association between cannabis use and personality disorder was exceptional in terms of being significantly stronger than its counterparts across disorders and across behaviors. Analyses of bias risk identified some influence from behavioral measurement disparities and lack of adequate statistical control, but findings were generally robust across a range of sensitivity analyses.

Conclusion

This explorative and comparative review found that poor diet quality, sedentary behavior, and cannabis and tobacco use are about equally strongly associated with a range of different mental disorders. Given the general nature of these associations, we should probably understand them to reflect a general and shared etiology. However, the findings in this review should be regarded as tentative until confirmed by more comprehensive investigations.

Determinants of Hardcore Smoking in a MULTI-ETHNIC Study of Cigarette Smokers in Singapore

Smokers who are resistant to quitting are not well studied in Asia, particularly in multi-ethnic populations. We compared the characteristics of hardcore smokers in Singapore, a multi-ethnic Asian population, with other daily smokers, and investigated the role of ethnicity as an effect modifier on identified determinants, including cigarette flavor preferences, using cross-sectional data from Singapore Smokers' Survey (n = 1,501). Multivariable logistic regression was used to assess the association. 22.8% of adult daily smokers were hardcore smokers. Novel findings on hardcore smokers' preference for regular flavored cigarettes (AOR = 1.54; 95%CI: 1.14, 2.07) suggest there is room for interventions among hardcore smokers through regulation of cigarette flavors and nicotine content. Although ethnicity was not a significant factor, it was an effect modifier with peers' disapproval of smoking (p-value for interaction = 0.024), significantly lowering odds of Malays being hardcore smokers (stratified odds ratio, AOR stratified, Malay = 0.35; CI: 0.17, 0.71), but not Chinese (AOR stratified, Chinese = 1.27; CI: 0.70, 2.42) and Indian smokers (AOR stratified, Indian = 0.62; CI: 0.18, 2.28), suggesting that smoking cessation policies utilizing social norm change strategies may be more effective when tailored to the differing roles of peer norms among different ethnic groups, in Singapore and other multi-ethnic Asian populations.

Adverse physiological effects of smoking cessation on the gastrointestinal tract: A review

Smoking cessation is known to have numerous health benefits, but it can also induce adverse physiological effects, including those affecting the gastrointestinal tract (GIT). Understanding the adverse physiological effects of smoking cessation on the GIT is critical for healthcare professionals and smokers attempting to quit, as it enables them to anticipate and manage potential challenges during the smoking cessation process. Although the detrimental effects of smoking on the GIT have been well established, there is a gap in the literature regarding the specific physiological reactions that may occur upon smoking cessation. This mini-review summarizes the current literature on the predisposing factors, pathophysiology, clinical presentation, and treatment options for adverse physiological effects of smoking cessation on the GIT. We aimed to raise awareness among busy clinical professionals about these adverse effects, empowering them to effectively support individuals striving to quit smoking and maintain their cessation. By consolidating the existing knowledge in this field, this review offers practical implications for smokers, healthcare providers, and policymakers to optimize smoking cessation interventions and support strategies to improve health outcomes.

Global prevalence of smoking among individuals with obsessive-compulsive disorder and symptoms: a systematic review and meta-analysis

Disease from nicotine dependency continues to be a leading cause of preventable death worldwide, and therefore research that elucidates potential correlates of tobacco use may facilitate the advancement of research, clinical practice, and policy in this area to target this public health challenge. One potential tobacco use correlate is obsessive-compulsive disorder (OCD) phenomena. The growing research evidence on the association between tobacco use and OCD phenomena is mixed, making it difficult to synthesize extant findings into meaningful conclusions. Indeed, there has never been a systematic review or meta-analysis of this area of research. To this end, a systematic review was carried out with studies between 1988 and 2021, and from this review, 71 independent estimations (n = 10,475; Females = 51.95%; mean age = 37.29, SD = 13.78) were extracted for meta-analysis. We found that about three in ten participants with OCD are likely to use tobacco, which is higher than the general population. The prevalence was the same among OCD participants at all levels (those with symptomology but no confirmed diagnosis, those surpassing a clinical cutoff for OCD but no confirmed diagnosis, and those with a confirmed OCD diagnosis). The results also indicated considerable variability across study results and a wide confidence interval associated with the tobacco use prevalence rate among those with OCD phenomena. The findings provide support for continued study of this comorbidity, perhaps with longitudinal and experimental designs to test for reciprocal associations between tobacco use and OCD phenomena in the service of targeting nicotine dependence as a substantial global public health concern.

Maternal preconception circulating blood biomarker mixtures, child behavioural symptom scores and the potential mediating role of neonatal brain microstructure: the S-PRESTO cohort

Human brain development starts in the embryonic period. Maternal preconception nutrition and nutrient availability to the embryo may influence brain development at this critical period following conception and early cellular differentiation, thereby affecting offspring neurodevelopmental and behavioural disorder risk. However, studying this is challenging due to difficulties in characterizing preconception nutritional status and few studies have objective neurodevelopmental imaging measures in children. We investigated the associations of maternal preconception circulating blood nutrient-related biomarker mixtures (~15 weeks before conception) with child behavioural symptoms (Child Behaviour Checklist (CBCL), aged 3 years) within the Singapore Preconception Study of Long-Term Maternal and Child Outcomes (S-PRESTO) study. The CBCL preschool form evaluates child behaviours based on syndrome scales and Diagnostic and Statistical Manual of Mental Disorders (DSM) oriented scales. These scales consist of internalizing problems, externalizing problems, anxiety problems, pervasive developmental problems, oppositional defiant, etc. We applied data-driven clustering and a method for modelling mixtures (Bayesian kernel machine regression, BKMR) to account for complex, non-linear dependencies between 67 biomarkers. We used effect decomposition analyses to explore the potential mediating role of neonatal (week 1) brain microstructure, specifically orientation dispersion indices (ODI) of 49 cortical and subcortical grey matter regions. We found that higher levels of a nutrient cluster including thiamine, thiamine monophosphate (TMP), pyridoxal phosphate, pyridoxic acid, and pyridoxal were associated with a higher CBCL score for internalizing problems (posterior inclusion probability (PIP) = 0.768). Specifically, thiamine independently influenced CBCL (Conditional PIP = 0.775). Higher maternal preconception thiamine level was also associated with a lower right subthalamic nucleus ODI (P-value = 0.01) while a lower right subthalamic nucleus ODI was associated with higher CBCL scores for multiple domains (P-value < 0.05). One potential mechanism is the suboptimal metabolism of free thiamine to active vitamin B1, but additional follow-up and replication studies in other cohorts are needed.

Academic Performance and Peer or Parental Tobacco Use among Non-Smoking Adolescents: Influence of Smoking Interactions on Intention to Smoke

BACKGROUND

Intention to smoke is an important predictor of future smoking among adolescents. The purpose of our study was to examine the interaction between academic performance and parents/peer tobacco use on adolescents' intention to smoke.

METHODS

A multi-stage stratified sampling was used to select participants, involving 9394 students aged between 9-16 years in Changchun city, northeastern China. Multiple logistic regression analyses were conducted to examine the individual effect of academic performance and peer/parental smoking behavior. Stratified logistic regressions were conducted to examine the protective effect of academic performance based on peer or parental smoking. Interaction effects of academic performance × peer/parental smoking on adolescents' intention to smoke were tested.

RESULTS

Of all the non-smoking students sampled, 11.9% intended to smoke within the next five years. The individual effect of academic performance and peer/parental smoking was significant. The protective effect of academic performance on the intention to smoke was significant regardless of whether peers smoked or not. However, the protective effect was not significant among adolescents with only maternal smoking and both parental smoking. The current study found the significant interaction effects of academic performance × peer smoking and the academic performance × both parents' smoking. Students with poor academic performance were more likely to intend to smoke if their peers or both parents smoked.

CONCLUSION

These preliminary results suggest that peer smoking or smoking by both parents reinforces the association between low academic performance and the intention to smoke among adolescents. Enhancing school engagement, focusing on social interaction among adolescents with low academic performance, and building smoke-free families may reduce adolescents' intention to smoke.

Differences in the Prevalence and Profile of DSM-IV and DSM-5 Alcohol Use Disorders-Results from the Singapore Mental Health Study 2016

INTRODUCTION

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria for alcohol use disorders (AUD) was a significant shift from the historical DSM-IV Text Revised version. Following this shift in diagnostic criteria, a difference in the prevalence of AUD was expected. The current study aimed to evaluate the consequences of the modification of the diagnostic criteria from DSM-IV to DSM-5 AUD using lifetime diagnosis in Singapore's multi-ethnic population using data from a nationwide epidemiological study.

METHODS

Respondents were assessed for lifetime mental disorders using the Composite International Diagnostic Interview (CIDI) administered through face-to-face interviews. Lifetime DSM-IV AUD diagnoses were compared with DSM-5 AUD diagnoses generated by modifying the criteria and the addition of the craving criterion. Sociodemographic correlates of lifetime DSM-IV/DSM-5 AUD were examined using multiple logistic regression analysis. Associations between DSM-IV/DSM-5 AUD, chronic conditions, and the HRQOL summary scores were examined using logistic and linear regression after controlling for significant sociodemographic factors.

RESULTS

The lifetime prevalence of DSM-IV AUD was 4.6% (0.5% for dependence and 4.1% for abuse) in the adult population, while the lifetime prevalence of DSM-5 AUD was 2.2%. Younger age, male gender, and lower education were associated with higher odds of both DSM-IV and DSM-5 AUD. However, those who were economically inactive (versus employed) (AOR, 0.4; 95% CI 0.2-0.9) and had a higher monthly household income (SGD 4000-5999 versus below SGD 2000) had lower odds of DSM-IV AUD (AOR, 0.4; 95% CI 0.2-0.7), but this was not observed among those with DSM-5 AUD. Both DSM-IV and DSM-5 AUD were associated with significant comorbidities in terms of other mental disorders; however, those diagnosed with lifetime GAD had significantly higher odds of having DSM-5 AUD (AOR, 5; 95% CI 1.9-13.2) but not DSM-IV AUD.

CONCLUSIONS

While using the DSM-5 criteria would result in a lower prevalence of AUD in Singapore, it remains a highly comorbid condition associated with a poor health-related quality of life that is largely untreated, which makes it a significant public health concern.

Prevalence of tobacco dependence and associated factors in China: Findings from nationwide China Health Literacy Survey during 2018–19

Background

Tobacco dependence is the key barrier to successful smoking cessation. However, little is known about its prevalence, sociodemographic characteristics and determinants. We aimed to estimate the prevalence, associated factors and burden of tobacco dependence in China.

Methods

During 2018–2019, the nationally representative 2018 China Health Literacy Survey (2018 CHLS) invited 87,708 participants to participate using a multistage stratified sampling method from 31 provinces (or equivalent) in mainland China, and 84,839 participants aged 20–69 with valid data were included in the analysis. We diagnosed tobacco dependence based on international criteria (ICD-10, DSM-4) and tailored to Chinese population according to China Clinical Guideline for Tobacco Cessation (2015 version). The prevalence of tobacco dependence was estimated overall and by sociodemographic factors. The Logistic regression was conducted to estimate odds ratios (OR) and 95% confidence intervals (CIs) for tobacco dependence and success of smoking cessation (being ex-smokers), with different levels of adjustment. These were used to estimate the total number of adults who were tobacco dependent in China.

Findings

In China, the estimated prevalence of current smoking was 25.1%, significantly higher in men than in women (47.6% vs 1.9%). The prevalence of current smoking varied approximately 3-fold (12.9% to 37.9%) across 31 provinces of China. Among general population aged 20–69 years, the prevalence of tobacco dependence was 13.1% (95% CI:12.2–14.1). Among current smokers, the prevalence of tobacco dependence was 49.7% (46.5–52.9%), with no difference between men and women (49.7% vs 50.8%). The prevalence of tobacco dependence was associated significantly with smoking intensity, defined by pack-years (1.62 [1.54–1.70] per 10 pack-years), cigarettes smoked per day (2.01 [1.78, 2.27] per 10 cigarettes), and smoking starting age (0.93 [0.90, 0.97] per 5 years). Given smoking intensity, the prevalence of tobacco dependence also varied by age, gender, certain socioeconomic status and regions. Compared with those without tobacco dependence, ever smokers with tobacco dependence were less likely to be ex-smokers (2.88, 2.59–3.21). In China, 183.5 (170.4–197.4) million adults (177.5 million were men) were tobacco dependent in 2018.

Interpretation

In China, tobacco dependence is highly prevalent, with approximately half of current smokers being addictive, highlighting the need for coordinated effort to improve awareness, diagnosis and treatment of tobacco dependence.

Funding

Chinese Academy of Medical Sciences (CAMS) Initiative for Innovative Medicine (CAMS 2021-I2M-1-010), National Key R&D Program of China (grant no 2017YFC1309400), and National Natural Science Foundation of China (grant no 81720108001).

Note

Chinese translation of abstract is available in appendix section.

Associations between education levels and prevalence of depressive symptoms: NHANES (2005-2018)

PURPOSE

Our study investigated the relationships between the prevalence of depressive symptoms and education levels in those aged ≥20 years.

METHODS

A total of 34,102 participants from the National Health and Nutrition Examination Surveys 2005-2018 were involved in our cross-sectional study. The relations of depressive symptoms (as outcome variable) and education levels (as an independent variable) were analyzed using multivariable logistic regression models in the main analyzes. Sensitivity analyzes, including a multiple sensitivity analysis, were also performed.

RESULT

The education levels were negatively associated with depressive symptoms after adjusting related covariates. Compared with the reference group of individuals with less than 9th grade, people with college graduate or above had an adjusted odds ratio (OR) of 0.464 (95% CI 0.361, 0.595, P < 0.0001). On the other hand, the statistically significant negative association disappeared among Mexican Americans, other races, separated, and high family poverty income ratio group. These results remained stable under a wide range of sensitivity analyzes.

CONCLUSION

Our study indicated the elevated education levels correlated with the decreased prevalence of depressive symptoms, and race, marital status, and family economic factors played a critical role in the relationship. This report reminds us to pay close attention to the further study of factors that affected the association between depressive symptoms and education levels.

LIMITATIONS

The cross-sectional study leaves problems about the direction of causality unclear.

Smoking Is Associated With Lower Satisfaction in Nondiabetic Patients Undergoing Minimally Invasive Single-level Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

This was a retrospective review of prospectively collected registry data.

OBJECTIVE

The objective of this study was to investigate the effect of smoking on 2 years postoperative functional outcomes, satisfaction, and radiologic fusion in nondiabetic patients undergoing minimally invasive transforaminal lumbar interbody fusion (TLIF) for degenerative spine conditions.

SUMMARY OF BACKGROUND DATA

There is conflicting data on the effect of smoking on long-term functional outcomes following lumbar fusion. Moreover, there remains a paucity of literature on the influence of smoking within the field of minimally invasive spine surgery.

METHODS

Prospectively collected registry data of nondiabetic patients who underwent primary single-level minimally invasive TLIF in a single institution was reviewed. Patients were stratified based on smoking history. All patients were assessed preoperatively and postoperatively using the Numerical Pain Rating Scale for back pain and leg pain, Oswestry Disability Index, Short-Form 36 Physical and Mental Component Scores. Satisfaction was assessed using the North American Spine Society questionnaire. Radiographic fusion rates were compared.

RESULTS

In total, 187 patients were included, of which 162 were nonsmokers, and 25 had a positive smoking history. In our multivariate analysis, smoking history was insignificant in predicting for minimal clinically important difference attainment rates in Physical Component Score and fusion grading outcomes. However, in terms of satisfaction score, positive smoking history remained a significant predictor (odds ratio=4.7, 95% confidence interval: 1.10-20.09, P=0.036).

CONCLUSIONS

Nondiabetic patients with a positive smoking history had lower satisfaction scores but comparable functional outcomes and radiologic fusion 2 years after single-level TLIF. Thorough preoperative counseling and smoking cessation advice may help to improve patient satisfaction following minimally invasive spine surgery.

LEVEL OF EVIDENCE

Level III-nonrandomized cohort study.

Prevalence and Correlates of Physical Comorbidities in Alcohol Use Disorder (AUD): a Pilot Study in Treatment-Seeking Population

This study aimed to understand the prevalence of physical comorbidities, undiagnosed and inadequately controlled chronic physical conditions and correlates of high cholesterol, hypertension and liver enzyme abnormalities in those with alcohol use disorder (AUD). Participants (n = 101) with AUD were recruited from a tertiary care centre through convenient sampling. The prevalence of physical and psychiatric comorbidities in the sample was 83.17% and 51.49%, respectively. Around 53.47% had two or more chronic physical conditions (multimorbidity). Hypertension (44.55%), asthma (23.76%), high cholesterol (22.77%) and liver enzyme abnormalities (21.78%) were the top four physical comorbidities. The prevalence of undiagnosed and inadequately controlled chronic physical conditions was 61.4% and 32.7%, respectively. Gender, education and body mass index (BMI) were associated with hyperlipidaemia while age and education were associated with hypertension. Higher waist-hip ratio was associated with liver enzyme abnormalities. Routine clinical care must include regular screening and follow-up of the risk groups to monitor their physical and mental health.

Nicotine Dependence in Patients with Major Depressive Disorder and Psychotic Disorders and Its Relationship with Quality of Life

The aim of the current study was to examine the associations between nicotine dependence and quality of life (QOL) among individuals diagnosed with major depressive disorder (MDD) or psychotic disorders. Methods: A total of 378 participants diagnosed with either MDD or psychotic disorders were recruited. The Fagerstorm Test for Nicotine Dependence was used to measure the level of nicotine dependence. The SF-12 health survey questionnaire was used to measure the QOL. Results: The prevalence of nicotine dependence was 23.3% in this sample population. For those diagnosed with MDD, moderate level of nicotine dependence was negatively associated with Vitality and Mental Component Score. For those diagnosed with a psychotic disorder high nicotine dependence was negatively associated with Role Emotional, Mental Health and Mental Component Score. Discussion: Compared to the general population, the prevalence of smoking in this psychiatric population was 2.4 times higher, while that of nicotine dependence was seven times higher. Individuals with psychotic disorder generally reported better QOL as compared to individuals with MDD. QOL differed across diagnostic groups with regards to socio-demographics, such as age, ethnicity, marital status, education, employment status and monthly income. Among individuals with MDD and psychotic disorders, different levels of nicotine dependence resulted in different levels of association with QOL. More research is needed to better understand the differences in QOL among the varying levels of nicotine dependence.

A Cross-Sectional Evaluation of Cigarette Smoking in the Brazilian Youth Population

Introduction: The transition from adolescence to adulthood involves a variety of physical, behavioral, and social transformations, often including tobacco use. Because understanding smoking at this stage is important for tobacco control, we aimed to analyze the prevalence of cigarette smoking in the Brazilian youth population. Methods: This study included participants aged 16-25 years from all Brazilian capitals. A standardized questionnaire was administered by trained healthcare professionals to collect information about sociodemographic status, sexual behavior, and tobacco use. The samples from each capital were weighted by age range and sex. Results: Of the 8,581 participants, 15.1% were current smokers, and 20.0% were former smokers; the average age at first tobacco use was 15.5 years. The prevalence of smoking in men was higher than that in women (20.1 vs. 10.3%, p < 0.01). Education level was associated with current smoking and former smoking. Participants with an elementary education level had a higher smoking prevalence (PR: 5.84, 95%, CI: 4.29-7.95) than those with a secondary education (PR: 2.19, 95% CI: 1.63-2.93) and those with higher education. Those without current partners (PR: 1.27, 95% CI: 1.03-1.56) also had a higher prevalence of smoking than those with partners, and participants who had a previous same-sex sexual experience smoked more (PR: 2.29, 95% CI: 1.78-2.96) than those who did not. In addition, regular use of alcohol was associated with higher prevalence of cigarette smoking (PR: 5.65, 95% CI: 4.03-7.90) than a lack of alcohol consumption. Skin color and socioeconomic class did not exhibit significant relationships with tobacco use patterns. Conclusions: Smoking was associated with education level regardless of social class, and some specific behaviors associated with a same-sex sexual experience were associated with a higher prevalence of smoking. These findings are important for formulating policies and directing actions to combat and prevent smoking among young populations.

Adolescent depression symptoms and e-cigarette progression

BACKGROUND

Depression symptoms are associated with the initiation of cigarette smoking and progression to regular use. Whether similar relationships exist between depression symptoms and adolescent e-cigarette progression has not been firmly established.

METHODS

This prospective longitudinal survey study measured the relationship between depression symptoms and e-cigarette use among 1822 adolescents from four public high schools outside of Philadelphia, PA. Adolescents completed in-classroom surveys at wave 1 (fall 2016, 9th grade) and 6-month intervals for the following 36 months (fall 2019, 12th grade). E-cigarette use, depression symptoms, and potential covariates were measured at each wave. A latent growth curve model was used to assess the longitudinal relationship between e-cigarette use and depression symptoms.

RESULTS

Baseline depressive symptoms had a significant effect on e-cigarette use trend (b = 0.01, z = 4.29, p < 0.0001) while holding other variables constant. A standard deviation increase in depressive symptoms at baseline was associated with a 0.25 standard deviation increase in the rate of e-cigarette progression across the following 36 months. By contrast, the path from baseline e-cigarette use to depressive symptoms trend was not significant (p = 0.74).

CONCLUSIONS

The present study provides new evidence for the effects of depression symptoms on adolescent e-cigarette progression. Greater depressive symptoms at age 14 years old were associated with a faster rate of e-cigarette escalation. However, e-cigarette use was not related to the development of depression symptoms over time. It will be important to examine whether adolescents with elevated depression symptoms respond similarly to e-cigarette prevention campaigns as adolescents in general.

Associations of clinical, psychological, and socioeconomic characteristics with nicotine dependence in smokers

Cigarette smoking is a risk factor of mortality and morbidity from various cancerous, respiratory, and myocardial diseases. Nicotine dependence is assessed based on the degree of physical dependence. We aimed to determine the clinical, socioeconomic and psychological factors associated with the smoking status and degree of nicotine dependence of smokers. From April 2009 to September 2010, we retrospectively collected data from 17,577 subjects aged ≥ 18 years who had undergone a general health examination at a health promotion center. The instruments used included the Fagerström Tolerance Questionnaire (FTQ), Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), Stress Response Inventory (SRI), and Alcohol Use Disorder Identification Test (AUDIT). Of the current smokers (N = 3946), 2345 (59%), 1154 (29%), and 447 (12%) had low, moderate, and high nicotine dependence, respectively. In multiple logistic analysis, predictors of high nicotine dependence were male sex (odds ratio [OR] 3.705, 95% confidence interval [CI] 1.997–6.945), older age (≥ 65 years) (OR 1.016, 95% CI 1.004–1.029), higher body mass index (BMI) (OR 1.048, 95% CI 1.018–1.078), diabetes (OR 1.870, 95% CI 1.251–2.794), single marital status (OR 1.575, 95% CI 1.186–2.092), lower education level (OR 1.887, 95% CI 1.463–2.433), and a higher stress level (OR 1.018, 95% CI 1.997–6.945). Thus, clinical, psychological, socioeconomic status including male, older age, higher BMI, diabetes, single marital status, lower education, and higher stress should be taken into consideration by promoting smoking cessation.

Occupational groups and its physical and mental health correlates: results from the Singapore Mental Health Study 2016

Purpose

The physical and mental wellbeing of an individual is impacted by the type occupation one does. This study aims to establish the prevalence of mental and physical disorders, the association of occupational groups and health-related quality of life, and the extent of work-loss and work-cut back in past 30 days among the employed in the Singapore resident population.

Methods

Data from a population-based, epidemiological survey of a representative sample of Singapore citizens and permanent residents aged 18 years and above were used. Lifetime diagnosis of select mental disorders was established using the World Health Organization’s Composite International Diagnostic Interview version 3.0 (WHO-CIDI 3.0). Data on nicotine dependence, work productivity, quality of life and socio-demographics were obtained via self-report. Ten major occupational groups based on the Singapore Standard Occupational Classification were included in the analysis.

Results

The sample comprised 4021 employed individuals who were predominantly males (54.7%) and aged 35–49 years (35.4%). ‘Service and sales workers’ (22.6%), ‘Professionals’ (17.3%) and ‘Legislators, senior officials and managers’ (16.4%) were the three largest occupational groups. Socio-demographic characteristics differed significantly (p < 0.001) across all occupational groups. Lifetime prevalence of mood disorders among the employed was 8.4% and the most prevalent physical disorder was chronic pain (18.9%). No significant differences were observed in work productivity loss across the occupational groups.

Conclusions

The disparities in the socio-demographic characteristics and prevalence of mental and physical disorders across occupational categories provide policymakers with vital information to pilot effective interventions that can improve the psychosocial and physical conditions at work.

Whole-Exome Sequencing to Identify Potential Genetic Risk in Substance Use Disorders: A Pilot Feasibility Study

Genetics intersects with environmental, cultural, and social factors in the development of addictive disorders. This study reports the feasibility of whole-exome sequencing of trios (subject and two family members) to discover potential genetic variants in the development of substance use disorders (SUD). Family trios were recruited from the National Addictions Management Service in Singapore during the 2016–2018 period. Recruited subjects had severe alcohol use disorder (AUD) or opioid use disorder (OUD), with nicotine dependence (ND) and a family history of addictive disorders. Demographic characteristics and severity of addiction were captured. Whole-exome sequencing (WES) and analysis were performed on salivary samples collected from the trios. WES revealed variants in several genes in each individual and disruptive protein mutations in most. Variants were identified in genes previously associated with SUDs, such as Pleckstrin homology domain-containing family M member 3 (PLEKHM3), coiled-coil serine-rich protein 1 (CCSER1), LIM and calponin homology domains-containing protein 1 (LIMCH1), dynein axonemal heavy chain 8 (DNAH8), and the taste receptor type 2 member 38 (TAS2R38) involved in the perception of bitterness. The feasibility study suggests that subjects with a severe addiction profile, polysubstance use, and family history of addiction may often harbor gene variants that may predispose them to SUDs. This study could serve as a model for future precision medicine-based personalized interventional strategies for behavioral addictions and SUDs and for the discovery of potentially pathogenic genetic variants.

Hypertension in a multi-ethnic Asian population of Singapore

The prevalence of hypertension varies by country and region, but it remains a leading yet modifiable risk factor of cardiovascular disease. There are many factors that contribute to the burden of hypertension in Asia, a region with diverse ethnicity. It has been shown that sociodemographic variability is related to ethnic differences, thereby emphasizing the importance of hypertension screening and educating at-risk or vulnerable groups. In this review, we describe the ethnic differences in genetic variants, dietary choice, and lifestyle habits, as well as its association with sociodemographic differences, hypertension awareness, and treatment control.

Nicotine dependence and its association with health utility ratings among a sample of Indian dental patients

OBJECTIVES

To measure utility ratings and quality-adjusted life-years(QALYs) for nicotine dependence-related health states using the standard gamble approach among a sample of dental patients; investigate the possible associations of nicotine dependence, and study the influences on tobacco-related health state utilities estimates among patients.

METHODS

A sample of 200 adult outpatients who were current or former consumers of tobacco were included in the cross-sectional study. Demographic, oral health self-rating and tobacco-related data (Fagerstrom scale for nicotine dependence, type of tobacco consumed, frequency and duration of the habit) were collected. A standard gamble method of utility valuation was also carried out.

RESULTS

Older age, lower educational attainment, higher frequency of consumption, increased duration of the habit, consumption of chewing tobacco, as opposed to smoking tobacco, and poor oral health were associated with higher nicotine dependence. Lower nicotine dependence, better oral health and quitting the habit were associated with better health utility estimates. QALYs lost due to the habit among the 'low to moderate' and 'significant' nicotine dependence groups were 2.7 (sd, 3.7) and 6.7 (sd, 8.0) years, respectively.

CONCLUSIONS

Higher health utility ratings were seen among patients with 'low to moderate' nicotine dependence, better oral health status and quitters of the tobacco habit. Quality of life weights generated through this method could be used for cost-utility analyses of tobacco cessation/prevention interventions in different settings and cultures.

Smoking-Related Health Beliefs in a Sample of Psychiatric Patients: Factors Associated with the Health Beliefs and Validation of the Health Belief Questionnaire

This study examined the (a) health beliefs and emotions (perception of risk, benefits, severity, and worry) about smoking among current and former smokers, (b) their awareness of health warnings, (c) factors associated with smoking-related health beliefs, and (d) the factor structure of the health belief questionnaire. Participants (n = 184) were recruited from a tertiary psychiatric care hospital. Current smokers showed a significantly higher risk perception and lower perceived benefits compared to former smokers. Younger age (<40 years), nicotine dependence (ND), a history of smoking-related diseases (SRD), and intention to quit were significantly associated with a higher risk perception in current smokers. Younger age, a history of SRDs, and motivation to quit were positively associated with health beliefs, while the latter two were associated with worry. Motivation and younger age were associated with a better perception of benefits and severity. Information on the cigarette packets was the major source of awareness for the sample, and 69% reported that existing campaigns were not effective in discouraging their smoking. Personalized risk communication and educational initiatives must focus on improving the knowledge of risk, benefits, and increase motivation to promote health cognition and thus smoking cessation.

Problematic Drug Use Among Outpatients With Schizophrenia and Related Psychoses

Background: Problematic drug use is common among psychiatric patients and is linked with poorer course and outcomes of illness. The aim of this study is to assess the prevalence of problematic drug use, and to explore its sociodemographic correlates and associations with health behaviors and outcomes among outpatients with schizophrenia and related psychoses in Singapore. Methods: Data from 397 individuals who were aged 21-65 years and were seeking treatment for schizophrenia and related psychoses in the outpatient clinics of a tertiary psychiatric hospital were analyzed. The Drug Abuse Screening Test (DAST-10) was used to assess problematic drug use. Information on sociodemographics, smoking status, alcohol use, symptoms severity and quality of life were collected. Multivariable logistic regressions were conducted to explore correlates and associations of problematic drug use. Results: The prevalence of problematic drug use was 5.8% (n = 23) in the sample, and 10.6% (n = 42) of the participants reported having problematic drug use and/or problematic alcohol use. More males than females reported having problematic drug use (p = 0.021), and also problematic drug and/or alcohol use (p = 0.004). Significant associations were observed between problematic drug use and smokers with nicotine dependence, and with physical health domain of quality of life. Individuals with greater symptom severity were approximately twice as likely to have problematic drug use and/or alcohol use. Conclusion: While the prevalence of problematic drug use in this sample population is relatively lower compared to other countries, there is a considerable number who might be at risk. Routine screening and close monitoring of drug use is recommended as part of psychiatric assessment, particularly among males and patients with nicotine dependence.

Age at the onset of tobacco smoking in South Africa: a discrete-time survival analysis of the prognostic factors

Background

While knowledge of onset of smoking tobacco, and associated risk factors can aid the formulation of evidence-based policy and interventions, such information is scarce in South Africa. We assessed age at onset of tobacco smoking in South Africa and identified its risk factors.

Methods

We analysed data of 15,316 respondents aged 15–98 years from the 2012 South African National Health and Nutrition Examination Survey. Descriptive statistics and survival analysis techniques were used alongside weighted percentages.

Results

Overall lifetime prevalence of smoking was 20.5%. Among the 3360 ever-smoked respondents, the overall median age at smoking onset was 18 years (Inter-quartile range (IQR) =5) with 2% starting before age 10 while 60% had smoked before age 20. Likelihood of tobacco smoking was higher among adolescents (<=20 years) and those aged 20–29 years than those aged > = 60 years, thrice higher among males, 29% higher among urban dwellers and thrice higher in Western Cape and Free State than in North West Province. The onset of tobacco smoking was earlier among males, wealthier and “coloured” people from Northern and Eastern Capes.

Conclusion

The onset of tobacco smoking peaked at 15–22 years and varied by province, sex, location, race and other characteristics. The age restrictions on smoking in South Africa has changed over time, coupled with the recent open and electronic advertisement of tobacco, and social media could have influenced the earlier onset of tobacco smoking in South Africa. Stricter regulations on tobacco-related advertisement and sales should be implemented.

Smoking and Mental Illness: Prevalence, Patterns and Correlates of Smoking and Smoking Cessation among Psychiatric Patients

This study aims to understand (a) the prevalence and correlates of smoking in a psychiatric population, (b) factors that encourage smoking cessation, and (c) awareness towards cessation programmes. This study captured data (n = 380) through a modified version of the Global Adult Tobacco Survey (GATS). A descriptive analysis of the data was performed. The prevalence of smoking was 39.5% (n = 150) and 52.3% of the smokers were dependent on nicotine. More than half of the smokers had made at least one attempt to quit in the past 12 months and 56% reported no immediate plans to quit smoking. The awareness towards institutional smoking cessation programmes was fair (44%), with 49.7% of smokers having indicated that they were willing to use the service upon referral. Smokers endorsed that increasing the cost of cigarettes, restricting availability, and increasing knowledge of health harms could encourage smoking cessation. Past smokers reported that self-determination/willpower followed by substitution of smoking with other types of foods and drinks were factors that helped them achieve successful cessation. Given that the readiness to quit and awareness towards cessation programmes are low among the smokers, concerted efforts through educational programmes and policy changes are crucial to achieve successful cessation.

Tobacco smoking in three “left behind” subgroups: indigenous, the rainbow community and people with mental health conditions

Purpose

This paper aims to investigate the extent to which three subgroups – people with mental health conditions, people belonging to sexual minority and gender groups and Indigenous peoples – have been “left behind” by countries implementing the World Health Organization’s Framework Convention on Tobacco Control.

Design/methodology/approach

A general review of electronic bibliographical databases to provide an overview of smoking prevalence among the three groups and interventions designed specifically to reduce their smoking rates.

Findings

Although explanations and specific rates differ, two trends are consistent across all three groups. First, information reported in the past two decades suggests that smoking prevalence is disproportionately high among people with mental health conditions, and in the rainbow and indigenous communities. Second, most cessation programmes are targeted at majority politically dominant groups, missing opportunities to reduce smoking rates in these minority communities.

Research limitations/implications

There is a general dearth of data preventing detailed analysis. Better data collection efforts are required. Trials to identify effective smoking reduction interventions for marginalised groups are needed.

Social implications

It is socially unjust that these groups are being systematically ignored by tobacco control initiatives. A failure to equitably reduce tobacco harms among all groups across society has contributed to the perceived concentration of smoking in some subgroups. The increasing stigmatisation of people who smoke then adds a marginality, compounding the negative effects associated with belonging to a marginalised group. Ongoing marginalisation of these groups is an important determinant of smoking.

Originality/value

Cross-case analysis of neglected subgroups with disproportionately high smoking rates suggests social marginalisation is a shared and important determinant of smoking prevalence.