Socioeconomic disparities in smoking are partially explained by chronic financial stress: marginal structural model of older US adults

Social determinants of health and clinical outcomes among patients with atrial fibrillation: evidence from a global federated health research network

BACKGROUND

Few studies have investigated the role of social determinants of health (SDoH) in patients with atrial fibrillation (AF).

AIM

To investigate the relationship between SDoH and adverse events in a large multinational AF cohort.

DESIGN

Retrospective study utilizing a global federated health research network (TriNetX).

METHODS

Patients with AF were categorized as socially deprived defined according to ICD codes based on three SDoHs: (i) extreme poverty; (ii) unemployment; and/or (iii) problems related with living alone. The outcomes were the 5-year risk of a composite outcomes of all-cause death, hospitalization, ischemic heart disease (IHD), stroke, heart failure (HF) or severe ventricular arrhythmias. Cox regression was used to compute hazard rate ratios (HRs) and 95% confidence intervals (CIs) following 1:1 propensity score matching (PSM).

RESULTS

The study included 24 631 socially deprived (68.8 ± 16.0 years; females 51.8%) and 2 462 092 non-deprived AF patients (75.5 ± 13.1 years; females 43.8%). Before PSM, socially deprived patients had a higher risk of the composite outcome (HR 1.9, 95% CI 1.87-1.93), all-cause death (HR 1.34, 95% CI 1.28-1.39), hospitalization (HR 2.01, 95% CI 1.98-2.04), IHD (HR 1.67, 95% CI 1.64-1.70), stroke (HR 2.60, 95% CI 2.51-2.64), HF (HR 1.91, 95% CI 1.86-1.96) and severe ventricular arrhythmias (HR 1.83, 95% CI 1.76-1.90) compared to non-deprived AF patients. The PSM-based hazard ratios for the primary composite outcome were 1.54 (95% CI 1.49-1.60) for the unemployed AF patients; 1.39 (95% CI 1.31-1.47) for patients with extreme poverty or with low income; and 1.42 (95% CI 1.37-1.47) for those with problems related with living alone.

CONCLUSIONS

In patients with AF, social deprivation is associated with an increased risk of death and adverse cardiac events. The presence of possible unmeasured bias associated with the retrospective design requires confirmation in future prospective studies.

Helping low-income smokers quit: findings from a randomized controlled trial comparing specialized quitline services with and without social needs navigation

Background

Quitting smoking is especially challenging for low-income smokers due to high stress, high smoking prevalence around them, and limited support for quitting. This study aimed to determine whether any of three interventions designed specifically for low-income smokers would be more effective than standard tobacco quitline services: a specialized quitline, the specialized quitline with social needs navigation, or the standard quitline with social needs navigation.

Methods

Using a randomized 2 × 2 factorial design, low-income daily cigarette smokers (n = 1944) in Missouri, USA who called a helpline seeking assistance with food, rent or other social needs were assigned to receive Standard Quitline alone (n = 485), Standard Quitline + Social Needs Navigation (n = 484), Specialized Quitline alone (n = 485), or Specialized Quitline + Social Needs Navigation (n = 490). The target sample size was 2000, 500 per group. The main outcome was 7-day self-reported point prevalence abstinence at 6-month follow-up. Multiple imputation was used to impute outcomes for those missing data at 6-month follow-up. Binary logistic regression analyses were used to assess differences between study groups.

Findings

Participants were recruited from June 2017 to November 2020; most were African American (1111 [58%]) or White (666 [35%]), female (1396 [72%]), and reported <$10,000 (957 [51%]) or <$20,000 (1529 [82%]) annual pre-tax household income. At 6-month follow-up (58% retention), 101 participants in the Standard Quitline group reported 7-day point prevalence abstinence (20.8% of those assigned at baseline, 38.1% after imputation). Quit rates in the Specialized Quitline (90 quitters, 18.6%, 38.1%) and Specialized Quitline + Social Needs Navigation (103 quitters, 21.0%, 39.8%) were not different from the Standard Quitline. Quit rates for Standard Quitline + Social Needs Navigation (74 quitters, 15.3%, 30.1%) were significantly lower than Standard Quitline (OR = 0.70, 95% CI = 0.50-0.98).

Interpretation

A specialized version of a state tobacco quitline was no more effective than standard quitline services in helping low-income smokers quit. Adding social needs navigation to a standard quitline decreased its effectiveness.

Trial registration

ClinicalTrials.gov Identifier: NCT03194958.

Funding

National Cancer Institute: R01CA201429.

Trends in Socio-economic Inequality in Smoking Among Middle-aged and Older Adults in China: Evidence From the 2011 and 2018 China Health and Retirement Longitudinal Study

INTRODUCTION

Socio-economic inequalities in smoking and related health problems are a public health concern worldwide. To support the development of effective tobacco control policies, this study examines trends in smoking rates according to socio-economic status (SES) in China.

AIMS AND METHODS

We analyzed data from repeated cross-sectional China Health and Retirement Longitudinal Study (CHARLS) on adults aged ≥45 years for the years 2011 and 2018, which involved 16 471 participants in 2011 and 19 367 in 2018. We then estimated the SES of individuals based on four types of wealth-related variables, namely, education, occupation, household characteristics, and durable consumer goods. Principal-component analysis was conducted to measure SES, and the Erreygers normalised concentration index (ECI) was used to calculate socio-economic inequality in current smoking by gender, age, and region.

RESULTS

The overall ECI (95% confidence interval) for women was -0.042 (-0.054 to -0.031) and -0.038 (-0.047 to -0.029) for 2011 and 2018, respectively. The ECI (95% confidence interval) for men was -0.077 (-0.101 to -0.050) and -0.019 (-0.042 to 0.005) for 2011 and 2018, respectively. The inequality in smoking by SES for adults aged < 60 years in the Northeast region increased during 2011-2018, from -0.069 (-0.144 to 0.006) to -0.119 (-0.199 to -0.038) for women and from 0.009 (-0.115 to 0.132) to -0.164 (-0.296 to -0.032) for men.

CONCLUSIONS

smoking inequality by socio-economic among adults aged ≥45 years declined in recent years in China. However, smoking inequality by SES increased in other population groups.

IMPLICATIONS

Our research indicated that socio-economic inequality of current smoking among residents aged 45 years and older declined in 2018 when compared with 2011 numbers, particularly for men aged ≥ 60 years. Women in the Northeast region displayed more significant smoking inequality by SES than women in other regions did. During the study period, there was an increase in inequality in smoking by SES for adults aged < 60 years in the Northeast region. Thus, tobacco control policies and interventions should be targeted at high-risk subpopulations with lower SES, particularly in Northeast China.

Socioeconomic status across the life course and smoking cessation among older adult smokers in the U.S

INTRODUCTION

Socioeconomic status (SES) at different stages of the life course impacts late-life health. However, whether SES across the life course impacts smoking cessation in late-life is not known.

PURPOSE

Assess how life course SES impacts smoking cessation among older smokers.

METHODS

We identified 5,124 smokers, 50 years and older, from the 1998 to 2018 waves of the Health and Retirement Study. The outcome was self-reported smoking cessation. The main exposure was life course SES, defined as: low child and low adult SES (persistent low); low child, high adult SES (upward mobility); high child, low adult SES (downward mobility); and high child, high adult SES (persistent high). A multilevel mixed-effect logistic model was used to examine how life course SES predicts smoking cessation at age 65 and over time, adjusted for covariates.

RESULTS

Compared to those with persistent high SES, those with persistent low SES, upward and downward SES were more likely to be Hispanic or non-Hispanic Black. The adjusted results showed that at age 65, compared to those with persistent high SES, those with persistent low SES (OR= 0.69, 95 % CI = [0.51-0.92]), upward SES (OR= 0.49, [0.32-0.75]), and downward SES (OR= 0.55, [0.40-0.76]) were less likely to quit. However, as age increased, only those with downward or persistent low SES were significantly less likely to quit compared to those with persistent high SES.

DISCUSSION

Social mobility of SES from childhood to adulthood significantly impacts smoking cessation. Both stages of the life course should be considered to understand smoking behaviors.

Structural interventions that affect racial inequities and their impact on population health outcomes: a systematic review

Structural racism is the historical and ongoing reinforcement of racism within society due to discriminatory systems and inequitable distribution of key resources. Racism, embedded within institutional structures, processes and values, perpetuates historical injustices and restricts access to structural factors that directly impact health, such as housing, education and employment. Due to the complex and pervasive nature of structural racism, interventions that act at the structural level, rather than the individual level, are necessary to improve racial health equity. This systematic review was conducted to evaluate the effects of structural-level interventions on determinants of health and health outcomes for racialized populations. A total of 29 articles are included in this review, analyzing interventions such as supplemental income programs, minimum wage policies, nutrition safeguard programs, immigration-related policies, and reproductive and family-based policies. Most studies were quasi-experimental or natural experiments. Findings of studies were largely mixed, although there were clear benefits to policies that improve socioeconomic status and opportunities, and demonstrable harms from policies that restrict access to abortion or immigration. Overall, research on the effects of structural-level interventions to address health inequities is lacking, and the evidence base would benefit from well-designed studies on upstream policy interventions that affect the structural determinants of health and health inequities and improve daily living conditions.

Efficacy and utilization of smartphone applications for smoking cessation among low-income adults: Secondary analysis of the iCanQuit randomized trial

INTRODUCTION

Evidence of digital interventions that are efficacious among low-income populations is scarce. In a secondary analysis, we determined the efficacy and utilization of an Acceptance and Commitment Therapy (ACT)-based smartphone application (iCanQuit) versus a U.S. Clinical Practice Guidelines (USCPG)-based smartphone application (QuitGuide) for smoking cessation in low-income adults enrolled in the iCanQuit randomized trial.

METHODS

Participants were randomized to receive iCanQuit (n = 437) or QuitGuide (n = 460) for 12-months. Consistent with the main trial, the primary outcome was self-reported complete-case 30-day point prevalence abstinence (PPA) at 12-months. Secondary outcomes were 7-day PPA, missing-as-smoking and multiple imputation, prolonged abstinence, and cessation of all tobacco products at 12-months. Outcome data retention, utilization, and change in ACT-based processes were compared across arms.

RESULTS

Participants were recruited from 48 U.S. states. Retention rate was 88% at 12-months and did not differ by arm. At 12-months, iCanQuit was 1.46 times more efficacious than QuitGuide for smoking cessation (27% vs. 20%; OR=1.46 95% CI: 1.04, 2.06). Findings were similar for missing-as-smoking imputation (23% vs. 18%; OR=1.41 95% CI: 1.01, 1.97) and multiple imputation at 12-months (27% vs. 20%; OR=1.51 95% CI: 1.07, 2.14). Treatment utilization was significantly higher among iCanQuit than QuitGuide participants. Increased acceptance of cues to smoke mediated the effect of treatment on cessation.

CONCLUSIONS

The iCanQuit smartphone application was more efficacious and engaging for smoking cessation among low-income adults than a USCPG-based smartphone application. A nationwide dissemination trial of iCanQuit is warranted to determine whether iCanQuit may alleviate cessation-related disparities among low-income adults.

Associations of Quantity Smoked and Socioeconomic Status With Smoke-Free Homes and Cars Among Daily Smokers

INTRODUCTION

An association between socioeconomic status (SES) and smoke-free private spaces among smokers could be due to heavier smoking among low SES smokers. We assessed whether quantity smoked or SES are independently associated with smoke-free homes or cars in daily smokers.

METHOD

Data were drawn from a cross-sectional telephone survey (2011-2012) of 750 daily smokers age ≥18 years in Quebec, Canada (45% response). Multivariable logistic regression was used to model the independent association between (a) number of cigarettes smoked per day, and (b) each of educational attainment, annual household income, or active employment status and smoke-free homes or cars.

RESULTS

Participants were 41.0 years old on average, 57% were female. Median (IQR) number of cigarettes smoked per day was 14 (10, 20). Forty-eight percent of participants reported smoke-free homes; 34% reported smoke-free cars. Quantity smoked was strongly associated with both smoke-free homes and cars. Income and education (but not actively employed) were associated with smoke-free homes. None of the SES indicators were associated with smoke-free cars.

CONCLUSIONS

Interventions targeting smokers to promote smoke-free homes and cars should incorporate components to help smokers reduce quantity smoked or preferably, to quit. Interventions targeting smoke-free homes will also need to address SES inequalities by education and income. Our data suggest that reduction in quantity smoked may help smokers reduce SHS exposure in cars, but that an inequality lens may not be relevant.

Smoking and stress in the general population in Denmark

INTRODUCTION

The social pressure placed on smokers today might potentially lead to an increasing level of stress. We investigated if the proportion of persons with high stress level had increased over time more in smokers than in non-smokers.

METHODS

Data were obtained from repeated cross-sectional surveys of The Capital Region Health Survey conducted in 2010, 2013 and 2017. Survey data were weighted for survey design and non-response, and linked to national register data. Cohens Perceived Stress Scale (PSS-10) score was used. Logistic regression analyses, based on 136608 citizens’ self-reports, were adjusted for sex, age, education level, employment, and alcohol intake (and loneliness, in analysis investigating the associations between tobacco consumption and high stress level).

RESULTS

A significantly higher proportion of citizens reported a high stress level in 2017 compared with 2010 and 2013 but there was not a greater increase in smokers than in non-smokers. Daily smoking men had 69% higher odds of reporting perceived high stress level and daily smoking women had 36% higher odds, than never smokers of the same sex. There was a significant trend between higher daily tobacco consumption and a higher proportion of smokers with high stress level.

CONCLUSIONS

The increase in high stress level over time occurred independently of smoking status. Daily smokers had the highest odds of perceived high stress level, and a higher daily tobacco consumption was associated with a higher proportion of smokers with high stress level. Smoking cessation programs should, to a higher degree, consider implementing stress-coping elements to prevent relapse.

Neighborhood disadvantage is associated with stable deficits in neurocognitive functioning in traumatically-injured adults

BACKGROUND

In trauma-exposed adults, the relationship between an individual's socioeconomic position (SEP) and post-traumatic stress disorder (PTSD) has been well demonstrated. One potential mechanism by which the stress associated with lower SEPs may impact trauma outcomes is through changes in neurocognition. In both healthy and clinical samples, area-level factors also appear to be independently related to neurocognition. Far less is known about how neighborhood socioeconomic disadvantage, may impact cognition in traumatically-injured adults. The current study employed hierarchical linear modeling to longitudinally investigate whether neighborhood disadvantage was associated with neurocognitive functioning in five domains: processing speed, sustained attention, controlled attention, cognitive flexibility, and response inhibition.

METHODS

One-hundred and ninety-five socioeconomically diverse traumatically-injured subjects (mean age = 32.8, 52.8% female) were recruited from an Emergency Department. Two-weeks, three-months, and six-months post-trauma, participants completed self-report measures and a computerized test battery to evaluate neurocognition. An Area Deprivation Index (ADI) score, a measure of a neighborhood's socioeconomic disadvantage, was derived from each participants' home address.

RESULTS

Greater neighborhood disadvantage was significantly related to lower scores in all domains. Results of hierarchical linear models revealed neighborhood disadvantage was significantly associated with processing speed, controlled attention, cognitive flexibility, and response inhibition across time, even after adjusting for individual annual household income, baseline PTSD symptoms, and previous adverse life experiences. This relationship was stable for all domains except sustained attention, which varied across time.

CONCLUSION

These findings indicate neighborhood disadvantage contributes uniquely to neurocognitive functioning and, for the majority of domains, these contributions are stable across time. The relationship between area-level variables and cognitive function may underlie individual vulnerability to developing psychiatric disorders. Future work should continue to examine the interaction between socioenvironmental stressors and PTSD symptoms longitudinally.