Assessing smoking status in disadvantaged populations: is computer administered self report an accurate and acceptable measure?

Smoking Status and Survival in Patients With Early-Stage Primary Cutaneous Melanoma

Importance

While smoking is associated with a decreased incidence of cutaneous melanoma, the association of smoking with melanoma progression and death is not well defined.

Objective

To determine the association of smoking with survival in patients with early-stage primary cutaneous melanoma.

Design, Setting, and Participants

This cohort study performed a post hoc analysis of data derived from the randomized, multinational first and second Multicenter Selective Lymphadenectomy Trials (MSLT-I and MSLT-II). Participants were accrued for MSLT-I from January 20, 1994, to March 29, 2002; MSLT-II, from December 21, 2004, to March 31, 2014. Median follow-up was 110.0 (IQR, 53.4-120.0) months for MSLT-I and 67.6 (IQR, 25.8-110.2) months for MSLT-II. Patients aged 18 to 75 years with clinical stages I or II melanoma with a Breslow thickness of 1.00 mm or greater or Clark level IV to V and available standard prognostic and smoking data were included. Analyses were performed from October 4, 2022, to March 31, 2023.

Exposure

Current, former, and never smoking.

Main Outcomes and Measures

Melanoma-specific survival of patients with current, former, and never smoking status was assessed for the entire cohort and for nodal observation and among subgroups with sentinel lymph node biopsy (SLNB)-negative and SLNB-positive findings.

Results

Of 6279 included patients, 3635 (57.9%) were men, and mean (SD) age was 52.7 (13.4) years. The most common tumor location was an extremity (2743 [43.7%]), and mean (SD) Breslow thickness was 2.44 (2.06) mm. Smoking status included 1077 (17.2%) current, 1694 (27.0%) former, and 3508 (55.9%) never. Median follow-up was 78.4 (IQR, 30.5-119.6) months. Current smoking was associated with male sex, younger age, trunk site, thicker tumors, tumor ulceration, and SLNB positivity. Current smoking was associated with a greater risk of melanoma-associated death by multivariable analysis for the entire study (hazard ratio [HR], 1.48 [95% CI, 1.26-1.75]; P < .001). Former smoking was not. The increased risk of melanoma-specific mortality associated with current smoking was greatest for patients with SLNB-negative melanoma (HR, 1.85 [95% CI, 1.35-2.52]; P < .001), but also present for patients with SLNB-positive melanoma (HR, 1.29 [95% CI, 1.04-1.59]; P = .02) and nodal observation (HR, 1.68 [95% CI, 1.09-2.61]; P = .02). Smoking at least 20 cigarettes/d doubled the risk of death due to melanoma for patients with SLNB-negative disease (HR, 2.06 [95% CI, 1.36-3.13]; P < .001).

Conclusions and Relevance

The findings of this cohort study suggest that patients with clinical stage I and II melanoma who smoked had a significantly increased risk of death due to melanoma. Smoking status should be assessed at time of melanoma diagnosis and may be considered a risk factor for disease progression.

Multidimensional pain profiling in people living with obesity and attending weight management services: a protocol for a longitudinal cohort study

INTRODUCTION

Pain is prevalent in people living with overweight and obesity. Obesity is associated with increased self-reported pain intensity and pain-related disability, reductions in physical functioning and poorer psychological well-being. People living with obesity tend to respond less well to pain treatments or management compared with people living without obesity. Mechanisms linking obesity and pain are complex and may include contributions from and interactions between physiological, behavioural, psychological, sociocultural, biomechanical and genetic factors. Our aim is to study the multidimensional pain profiles of people living with obesity, over time, in an attempt to better understand the relationship between obesity and pain.

METHODS AND ANALYSIS

This longitudinal observational cohort study will recruit (n=216) people living with obesity and who are newly attending three weight management services in Ireland. Participants will complete questionnaires that assess their multidimensional biopsychosocial pain experience at baseline and at 3, 6, 12 and 18 months post-recruitment. Quantitative analyses will characterise the multidimensional pain experiences and trajectories of the cohort as a whole and in defined subgroups.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Ethics and Medical Research Committee of St Vincent's Healthcare Group, Dublin, Ireland (reference no: RS21-059) and the University College Dublin Human Research Ethics Committee (reference no: LS-E-22-41-Hinwood-Smart). Findings will be disseminated through peer-reviewed journals, conference presentations, public and patient advocacy groups, and social media.

STUDY REGISTRATION

Open Science Framework Registration DOI: https://doi.org/10.17605/OSF.IO/QCWUE.

A comparison of self-reported to cotinine-detected smoking status among adults in Georgia

BACKGROUND

Self-reported measures of tobacco use may have limited validity, particularly among some populations. This study aims to validate self-reported smoking measures among Georgian adults participating in the 2016 STEPS survey using cotinine biomarker measurements, and to explore potential differences according to sociodemographic characteristics. Additionally, this paper examines how the estimated prevalence of smoking in the population varies according to measurement type.

METHODS

Using the WHO standardized STEPS methodology, adults self-reported their smoking status. In a later stage of the survey, a subset of participants provided a urine sample, which was tested for cotinine. Using each participant's objective cotinine measurement and their self-reported smoking status, we calculated the sensitivity, specificity and positive predictive value of self-reported smoking. Next, we calculated the estimated prevalence of smokers according to the type of measurement.

RESULTS

Results indicated high sensitivity (83.37%, 95% CI: 76.79-88.37%) among males and relatively low sensitivity (38.60% CI: 29.23-48.90%) among females. According to self-report, the prevalence of smokers was 26.44% (23.61-29.48%), while according to cotinine detection, the prevalence of smokers was 32.27% (29.16-35.55%). Among all subgroups, the self-reported prevalence of smoking was significantly lower than the cotinine-detected prevalence.

CONCLUSIONS

To the best of our knowledge, this is the first time that the validity of the STEPS self-reported tobacco indicator has been tested. Self-reported measures of smoking status may lead to an under-estimation of smoking prevalence among Georgian adults, especially women. These findings suggest that integration of biochemical measures of smoking into tobacco use studies may be an important investment.

Racial disparities and factors associated with prescription for smoking cessation medications among smokers receiving routine clinical care for HIV

Factors associated with prescription of smoking cessation medication (SCM), including the impact of race, have not been well described among a large population of people living with HIV (PLWH) engaged in routine clinical care. Our study investigated whether there are racial differences between African-American and White PLWH regarding SCM prescription and sought to identify other factors associated with these prescriptions at a large HIV clinic in the Southeastern United States. Among 1899 smokers, 38.8% of those prescribed SCMs were African-American and 61.2% were White. Factors associated with lower odds of SCM prescription included African-American race (AOR, 0.63 [95% CI: 0.47, 0.84]) or transferring care from another HIV provider during the study period (AOR, 0.63 [95% CI: 0.43, 0.91]). Whereas major depression (AOR, 1.54 [95% CI: 1.10, 2.15]), anxiety symptoms (AOR, 1.43 [95% CI: 1.05, 1.94]), and heavy smoking (>20 cigarettes/day) (OR, 3.50 [95% CI: 2.11, 5.98]) were associated with increased likelihood of SCM prescription. There were racial disparities in the prescription of SCM in African Americans with HIV. These findings underscore the need to increase pharmacotherapy use among African Americans to improve smoking cessation outcomes across racial groups among PLWH.

Effect of increasing the delivery of smoking cessation care in alcohol and other drug treatment centres: a cluster-randomized controlled trial

AIM

Aims were to test the effectiveness of an organizational change intervention integrating smoking cessation treatment into usual alcohol and other drug (AOD) treatment, compared with usual care, on (1) 7-day point prevalence abstinence (PPA) at 8 weeks follow-up; (2) prolonged abstinence; (3) cigarettes smoked per day; (4) number of quit attempts; and (5) offer and use of nicotine replacement therapy (NRT). All outcomes were assessed at 8 weeks and 6.5 months follow-up.

DESIGN

Cluster-randomized controlled trial, with AOD service as unit of randomization, conducted January 2015-March 2016.

SETTING

Thirty-two eligible services (provided face-to-face client sessions to ≥ 50 clients/year) in Australia were randomized to control (usual care; n = 15) or intervention (n = 17) groups by an independent blinded biostatistician.

PARTICIPANTS

Eligible participants (≥ 16 years, current smoker) completed surveys at the service at baseline (n = 896) and telephone follow-up surveys (conducted by blinded assessors) at 8 weeks (n = 471; 53%) and 6.5 months (n = 427; 48%).

INTERVENTION

Intervention services received an intervention to establish routine screening, assessment and delivery of smoking cessation care.

MEASUREMENTS

Primary outcome was biochemically verified 7-day PPA at 8-week follow-up. Secondary outcomes included verified and self-reported prolonged abstinence, self-reported 7-day PPA, cigarettes/day, quit attempts and offer and use of NRT. Intention-to-treat analyses were performed, assuming missing participants were not abstinent.

FINDINGS

At 8 weeks, the findings in verified 7-day PPA between groups [2.6 versus 1.8%, odds ratio (OR) = 1.72, 95% confidence interval (CI) = 0.5-5.7, P = 0.373] were inconclusive as to whether a difference was present. Significantly lower mean cigarettes/day were reported in the intervention group compared to the usual care group at 8 weeks [incidence rate ratio (IRR) = 0.88, 95% CI = 0.8-0.95, P = 0.001] but were similar at 6.5 months (IRR = 0.96, 95% CI = 0.9-1.02, P = 0.240) follow-up. At both follow-ups the intervention group reported higher rates of NRT use.

CONCLUSIONS

Integrating smoking cessation treatment into addiction services did not significantly improve short-term abstinence from smoking.

Correlation between radiographic knee osteoarthritis and lifetime cigarette smoking amount in a Korean population: A cross-sectional study

Although the inverse correlation between smoking and degenerative arthritis is controversial, quantitative analysis of the correlation between lifetime cigarette smoking amount and degenerative arthritis has not been performed. We investigated the correlation between knee radiographic osteoarthritis (ROA) and lifetime cigarette smoking amount in the general population.This cross-sectional study used the Fifth and Sixth Korean National Health and Nutrition Examination Survey (2010-2013) data. Subjects included 11,638 community-dwelling adults aged ≥50 years. Knee ROA was defined as a Kellgren/Lawrence grade ≥2 on plain radiography. Lifetime cigarette smoking amount was calculated in terms of pack-year and further divided into quartile groups. Independent correlation between smoking and knee ROA was determined using odds ratios (OR) adjusted for age, sex, obesity, physical activity, and household income on multivariate logistic regression analysis.Knee ROA prevalence was 37.3%; prevalence of lifetime cigarette smokers was 26.0%. Subjects with knee ROA had higher mean age, female sex ratio, and body mass index but lower physical activity level. The adjusted logistic regression model revealed that female sex (OR, 2.110; 95% confidence interval [CI], 1.895-2.349) was significantly associated with knee ROA. Older age, obesity, and lower household income were positively correlated with knee ROA. Second-and fourth-quartile groups of smokers had the lower ROA prevalence than never-smokers (OR, 0.800; 95% CI, 0.643-0.99; OR, 0.812; 95% CI, 0.684-0.965, respectively).An inverse correlation with knee ROA was confirmed in mid-light to heavy smokers. Prospective studies are needed to reveal whether knee ROA involves smoking.

A Web-Based Communication Platform to Improve Home Care Services in Norway (DigiHelse): Pilot Study

Background

Home care service in Norway is struggling to meet the increasing demand for health care under restricted budget constraints, although one-fourth of municipal budgets are dedicated to health services. The integration of Web-based technology in at-home care is expected to enhance communication and patient involvement, increase efficiency and reduce cost. DigiHelse is a Web-based platform designed to reinforce home care service in Norway and is currently undergoing a development process to meet the predefined needs of the country’s municipalities. Some of the main features of the platform are digital messages between residents and the home care service, highlighting information on planned and completed visits, the opportunity to cancel visits, and notifications for completed visits.

Objective

This study aimed to test the usability and economic feasibility of adopting DigiHelse in four districts in Oslo by applying registry and behavioral data collected throughout a one-year pilot study. Early health technology assessment was used to estimate the potential future value of DigiHelse, including the predictive value of behavior data.

Methods

Outcome measures identified by stakeholder insights and scenario drafting in the project’s concept phase were used to assess potential socioeconomic benefits. Aggregated data were collected to assess changes in health consumption at baseline, and then 15 and 52 weeks after DigiHelse was implemented. The present value calculation was updated with data from four intervention groups and one control group. A quasi-experimental difference-in-difference design was applied to estimate the causal effect. Descriptive behavioral data from the digital platform was applied to assess the usability of the platform.

Results

Over the total study period (52 weeks), rates increased for all outcome estimates: the number of visits (rate ratio=1.04; P=.10), unnecessary trips (rate ratio=1.37; P=.26), and phone calls (rate ratio=1.24; P=.08). A significant gap was found between the estimated value of DigiHelse in the concept phase and after the one-year pilot. In the present pilot assessment, costs are expected to exceed potential savings by €67 million (US $75 million) over ten years, as compared to the corresponding concept estimates of a potential gain of €172.6 million (US $193.6 million). Interestingly, behavioral data from the digital platform revealed that only 3.55% (121/3405) of recipients actively used the platform after one year.

Conclusions

Behavioral data provides a valuable source for assessing usability. In this pilot study, the low adoption rate may, at least in part, explain the inability of DigiHelse to perform as expected. This study points to an early assessment of behavioral data as an opportunity to identify inefficiencies and direct digital development. For DigiHelse, insight into why the recipients in Oslo have not made greater use of the Web-based platform seems to be the next step in ensuring the right improvement measures for the home care service.

Patterns of cigarette, e-cigarette, and cannabis use among adult smokers in primary care 2014-2015

BACKGROUND

Poly-use of tobacco, cannabis, and electronic cigarettes (e-cigarettes) is an emerging problem in the general population. The current study investigated poly-use of these products and receipt of smoking cessation counseling in a primary care setting.

METHODS

We conducted a cross-sectional secondary data analysis from a trial of a tablet intervention to increase provider delivery of the 5As (Ask, Advise, Assess, Assist, Arrange follow-up), a brief counseling intervention for smoking cessation, in 3 diverse primary care clinics in San Francisco, CA from 2014 to 2015. Participants were currently smoking cigarettes (N = 601; mean age = 50.8; 38.1% female) and reported information on past 30-day cigarette and e-cigarette use and past 3-month cannabis use. We classified participants into 4 groups: (1) cigarette-only, (2) dual-use of cigarettes and e-cigarettes, (3) dual-use of cigarettes and cannabis, (4) poly-use of cigarettes, e-cigarettes, and cannabis, and examined correlates of use.

RESULTS

Only cigarette smoking was reported by 48.6% of participants, 30.4% reported use of cigarettes and cannabis, 10.5% reported use of cigarettes and e-cigarettes, and 10.5% reported use of cigarettes, e-cigarettes, and cannabis. Cigarette-only smokers did not differ from other groups by cigarette smoking behavior and motivation to quit. Patients reporting dual-use of cigarettes and e-cigarettes had a higher likelihood of receiving the Arrange step and all 5As compared to cigarette-only smokers.

CONCLUSIONS

Providers should screen for co-use of cigarettes and other nicotine/cannabis products and consider co-use when delivering smoking cessation treatment and evaluating treatment outcomes. Development of guidelines to help facilitate provider training is needed.

Cancer Screening Patterns Among Current, Former, and Never Smokers in the United States, 2010-2015

IMPORTANCE

National guidelines recommend screening for several cancer types, yet screening rates remain below target. To date, cancer screening patterns by smoking status, a major cancer risk factor, are unknown.

OBJECTIVE

To assess cancer screening patterns among individuals who never smoked (never smokers), formerly smoked (former smokers), and currently smoke (current smokers) in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study assessed data from the National Health Interview Survey years 2010, 2013, and 2015. Adult participants (aged ≥18 years) who had never reported a cancer diagnosis were included in the analysis. Data were analyzed from August 1, 2018, through February 1, 2019.

EXPOSURES

Receipt of cancer screening, including colonoscopy, mammography, prostate-specific antigen testing, and Papanicolaou test per the US Preventive Services Task Force guidelines.

MAIN OUTCOMES AND MEASURES

Multivariable logistic regression defined adjusted odds ratios (AORs) and 95% CIs for undergoing cancer screening by smoking status. Among participants who received a specific screening test, AORs and 95% CIs of receiving the test within guideline-recommended intervals were also assessed.

RESULTS

Among 83 176 participants (45 851 [55.1%] women; mean [SD] age, 47 [18] years), 51 014 (61.3%) were never smokers; 17 235 (20.7%), former smokers; and 14 927 (17.9%), current smokers. Compared with never smokers, current smokers were less likely to ever have received a colonoscopy (43.8% vs 57.7%; AOR, 0.74; 95% CI, 0.68-0.82; P < .001), mammogram (88.8% vs 93.3%; AOR, 0.70; 95% CI, 0.57-0.87; P = .001), or prostate-specific antigen test (46.1% vs 60.8%; AOR, 0.76; 95% CI, 0.64-0.90; P = .001). Among those who had ever received a specific screening test, current smokers were less likely to have undergone colonoscopy (92.1% vs 95.1%; AOR, 0.75; 95% CI, 0.59-0.96; P = .02), mammography (62.4% vs 79.4%; AOR, 0.52; 95% CI, 0.45-0.60; P < .001), or Papanicolaou test (80.9% vs 90.8%; AOR, 0.61; 95% CI, 0.56-0.67; P < .001) within the recommended time frame compared with never smokers. Former smokers were more likely than never smokers to undergo any of the screening studies evaluated, with the exception of prostate-specific antigen screening (colonoscopy, 65.2% vs 57.7%; AOR, 1.20; 95% CI, 1.12-1.30; P < .001; mammography, 95.7% vs 93.3%; AOR, 1.35; 95% CI, 1.07-1.70; P = .01; Papanicolaou test, 97.6% vs 91.4%; AOR, 2.51; 95% CI, 1.93-3.26; P < .001).

CONCLUSIONS AND RELEVANCE

This study found that current smokers appeared to be less likely to receive guideline-concordant screening studies for breast, prostate, and colorectal cancer compared with never smokers. Further research is needed to identify barriers to screening among current smokers with the goal of increasing acceptance and uptake of cancer screening among this population at high risk of cancer.

Smoking and Accelerated Lung Function Decline in HIV-Positive Individuals: A Secondary Analysis of the START Pulmonary Substudy

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a leading cause of death and disability globally. Both cigarette smoking and HIV have been identified as independent risk factors for COPD. We used data from the strategic timing of antiretroviral treatment (START) Pulmonary Substudy to quantify the impact of smoking on rate of lung function decline in HIV.

METHODS

We included START Pulmonary Substudy participants who contributed at least 2 good quality spirometry measures during the study. Slope of forced expiratory volume in 1 second (FEV1) was estimated using a repeated-measures model adjusted for the treatment group (immediate vs deferred treatment arm of START), age, sex, race, baseline COPD, and region.

RESULTS

Of 1026 START Pulmonary Substudy participants, 915 (89%) were included in this analysis. Median follow-up time was 3.9 years. Smokers and nonsmokers were similar in baseline age (median 36 years), but smokers were more likely to be white, male, and from Europe/Israel/Australia. Smokers had faster average FEV1 decline compared with nonsmokers [-38.3 mL/yr vs -25.1 mL/yr; difference of -13.2 mL/yr (95% confidence interval: -23.6 to -2.7); P = 0.013], were more likely to meet criteria for rapid FEV1 decline [7.2%-11.7% more likely (P = 0.09-P = 0.002), depending on the definition of rapid decline], and had borderline, but not statistically significant, higher incident COPD during follow-up (9.7% vs 5.8%, P = 0.06).

CONCLUSIONS

Compared to nonsmokers, HIV-positive smokers experience faster decline in lung function. These results underscore the need for a better understanding of how to best support smoking cessation among HIV-positive populations.

The BeHealthyR Study: a randomized trial of a multicomponent intervention to reduce stress, smoking and improve financial health of low-income residents in Rotterdam

BACKGROUND

Compared to higher socioeconomic status (SES) groups, those in lower SES groups are financially strained, experience higher rates of smoking-related morbidity, are in poorer health and have reduced life expectancy. This is especially true for the city of Rotterdam, where a large inequality in health is observed between low and high SES groups. The BeHealthyR study (Dutch: Grip en Gezondheid) is a randomized controlled trial (RCT) which will evaluate the impact of a theory-based multicomponent behavior intervention aiming to reduce stress, smoking, and improve financial health by means of a group-based stress management program combining cognitive and behavioral techniques, and nudges in low-SES residents living in Rotterdam.

METHODS

The BeHealthyR study is a three-arm RCT. Between February 2018 and July 2019, low-SES participants who perceive stress, smoke, are financially strained and reside in Rotterdam (one of the four largest cities in The Netherlands) are recruited. Subsequently, participants are randomly assigned to either a stress management condition (SM), stress management with a buddy condition (SM-B) or a control condition (CC). Participants in the SM and SM-B conditions will attend four weekly group sessions (1.5 h/session) and a follow-up session eight weeks later. The SM condition includes psychoeducation and exercises, and cognitive and behavioral intervention techniques. Demographic data and objective measures will be collected at baseline (T0), four weeks post-baseline (T1), and twelve weeks post-baseline (T2). Primary outcome measures are to reduce stress, smoking and improve financial health. We hypothesize that low-SES participants in the intervention conditions, compared with those in the control condition, will experience less stress, smoke less and have improved financial health.

DISCUSSION

This study is a group-based intervention which aims to investigate the effects of a theory-based behavioral change intervention employing several components on reducing stress, smoking, and improving financial health in low-SES residents living in Rotterdam. If effective, the findings from the present study will serve to inform future directions of research and clinical practice with regard to behavioral change interventions for low-SES groups.

TRIAL REGISTRATION

ClinicalTrials.gov (ID: NCT03553979 ). Registered on January 1 2018.

Using SmartQuit®, an Acceptance and Commitment Therapy Smartphone application, to reduce smoking intake

Objective

SmartQuit® is a smartphone application (app) for smoking cessation based on Acceptance and Commitment Therapy, a behavioural therapy that encourages individuals to accept internal experiences, such as cravings to smoke, without acting on those experiences or urges. We used a single-subject (A-B-A) design with 10 participants to examine whether SmartQuit® use would reduce cigarette intake in a New Zealand sample.

Methods

10 smokers tallied their own cravings experienced and cigarettes smoked then sent those tallies to the first author every day until we observed stable patterns (Phase A1). We then gave the participants individual access to the SmartQuit® app (Phase B). When they advised that they had ceased using the app, they again recorded daily cravings and cigarettes smoked for a minimum of three days (Phase A2). We also collected follow-up smoking and craving data at 1, 2 and up to 13 months after completion of Phase A2.

Results

Using SmartQuit® reduced our participants' daily cigarette intake significantly in the short-term and three individuals remained smoke-free up to 13 months later. Cravings to smoke did not differ significantly across Phases A1, B and A2, but graphical analysis showed a trend for decreasing cravings.

Conclusion

Our results suggest that SmartQuit® provides another readily accessible intervention to help people stop smoking and is suited for use with a New Zealand population.

Financial Stress and Smoking within a Large Sample of Socially Disadvantaged Australians

Financial stress is associated with fewer quit attempts and higher relapse rates. This study aimed to compare financial stress among smokers, ex-smokers and never smokers in a highly socioeconomically disadvantaged sample. The study also aimed to determine whether specific indicators of financial stress differ according to smoking status. Adult clients seeking welfare assistance from two Social and Community Service Organisation sites in New South Wales, Australia, were invited to complete a cross-sectional survey between March 2012 and December 2013. Responses to a financial stress scale, smoking status and demographics were collected. Linear and logistic regression modelling was used to examine associations between smoking status and financial stress. A total of 1463 participants completed the survey. Current smokers had significantly higher total financial stress scores than ex-smokers and non-smokers respectively. Current smokers also had higher odds of severe financial stress indicators, such as going without meals (Odds Ratio = 2.2 and 2.0), than both non-smokers and ex-smokers. Even among a highly socioeconomically disadvantaged sample with high levels of financial stress, smoking status further exacerbates experiences of deprivation. Given the relationship between financial stress, socioeconomic disadvantage and difficulty quitting, it is important to provide enhanced cessation support to smokers experiencing financial stress.

Disparities in receipt of 5As for smoking cessation in diverse primary care and HIV clinics

Clinical practice guidelines recommend that clinicians implement the 5As (Ask, Advise, Assess, Assist, and Arrange) for smoking cessation at every clinical encounter. We sought to examine the prevalence of patient- and clinician-reported 5As in two primary care and one HIV care clinics in San Francisco, California between August 2013 and March 2014 (n = 462 patients and n = 61 clinicians). We used multivariable logistic regression analysis to identify factors associated with receipt of the 5As, adjusting for patient demographics, patient insurance, clinic site, patient tobacco use, and patient comorbidities. The patient-reported prevalence of 5As receipt was as follows: Ask, 49.9%; Advise, 47.2%; Assess, 40.6%; any Assist, 44.9%; and Arrange, 22.4%. In multivariable analysis, receipt of Advise, Assess, and Assist were associated with older patient age. Whereas patients with HIV had a lower odds of reporting being advised (AOR 0.5, 95% CI 0.3–0.8) or assessed for readiness to quit (AOR 0.6, 95% CI 0.4–0.9), patients with pulmonary diseases had higher odds of reporting being assisted (AOR 1.6, 95% 1.0–2.6) than patients without these diagnoses. Although the majority of clinicians reported asking (91.8%), advising (91.8%), and assessing (93.4%) tobacco use ‘most of the time’ or ‘always’ during a clinical encounter, fewer reported assisting (65.7%) or arranging (19.7%) follow-up. Only half of patients reported being screened for tobacco use and fewer reported receipt of the other 5As, with significant disparities in receipt of the 5As among patients with HIV. Our findings confirm the need for interventions to increase clinician-delivered cessation treatment in primary and HIV care.

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Clinical practice guidelines recommend the use of 5As for smoking cessation.

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Patient reports of Assist and Arrange were low in primary care and HIV care.

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There were significant disparities in the receipt of 5As among patients with HIV.

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Digital interventions could facilitate clinician-delivered 5As for patients.

An organisational change intervention for increasing the delivery of smoking cessation support in addiction treatment centres: study protocol for a randomized controlled trial

Background

The provision of smoking cessation support in Australian drug and alcohol treatment services is sub-optimal. This study examines the cost-effectiveness of an organisational change intervention to reduce smoking amongst clients attending drug and alcohol treatment services.

Methods/design

A cluster-randomised controlled trial will be conducted with drug and alcohol treatment centres as the unit of randomisation. Biochemically verified (carbon monoxide by breath analysis) client 7-day-point prevalence of smoking cessation at 6 weeks will be the primary outcome measure. The study will be conducted in 33 drug and alcohol treatment services in four mainland states and territories of Australia: New South Wales, Australian Capital Territory, Queensland, and South Australia. Eligible services are those with ongoing client contact and that include pharmacotherapy services, withdrawal management services, residential rehabilitation, counselling services, and case management services. Eligible clients are those aged over 16 years who are attending their first of a number of expected visits, are self-reported current smokers, proficient in the English language, and do not have severe untreated mental illness as identified by the service staff. Control services will continue to provide usual care to the clients. Intervention group services will receive an organisational change intervention, including assistance in developing smoke-free policies, nomination of champions, staff training and educational client and service resources, and free nicotine replacement therapy in order to integrate smoking cessation support as part of usual client care.

Discussion

If effective, the organisational change intervention has clear potential for implementation as part of the standard care in drug and alcohol treatment centres.

Trial registration

Australian and New Zealand Clinical Trials Registry, ACTRN12615000204549. Registered on 3 March 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1401-6) contains supplementary material, which is available to authorized users.

Self-Exempting Beliefs and Intention to Quit Smoking within a Socially Disadvantaged Australian Sample of Smokers

An investigation of beliefs used to rationalise smoking will have important implications for the content of anti-smoking programs targeted at socioeconomically disadvantaged groups, who show the lowest rates of cessation in the population. This study aimed to assess the types of self-exempting beliefs reported by a sample of socioeconomically disadvantaged smokers, and identify associations between these beliefs and other smoking-related factors with quit intentions. A cross-sectional survey was conducted from March-December 2012 with smokers seeking welfare assistance in New South Wales (NSW), Australia (n = 354; response rate 79%). Responses to a 16-item self-exempting beliefs scale and intention to quit, smoker identity, and enjoyment of smoking were assessed. Most participants earned <AUD$400/week (70%), and had not completed secondary schooling (64%). All "jungle" beliefs (normalising the dangers of smoking due to ubiquity of risk) and selected "skeptic" beliefs were endorsed by 25%-47% of the sample, indicating these smokers may not fully understand the extensive risks associated with smoking. Smokers with limited quit intentions held significantly stronger self-exempting beliefs than those contemplating or preparing to quit (all p < 0.01). After adjusting for smoking-related variables only "skeptic" beliefs were significantly associated with intention to quit (p = 0.02). Some of these beliefs are incorrect and could be addressed in anti-smoking campaigns.

The Role of eHealth in Optimizing Preventive Care in the Primary Care Setting

Modifiable health risk behaviors such as smoking, overweight and obesity, risky alcohol consumption, physical inactivity, and poor nutrition contribute to a substantial proportion of the world’s morbidity and mortality burden. General practitioners (GPs) play a key role in identifying and managing modifiable health risk behaviors. However, these are often underdetected and undermanaged in the primary care setting. We describe the potential of eHealth to help patients and GPs to overcome some of the barriers to managing health risk behaviors. In particular, we discuss (1) the role of eHealth in facilitating routine collection of patient-reported data on lifestyle risk factors, and (2) the role of eHealth in improving clinical management of identified risk factors through provision of tailored feedback, point-of-care reminders, tailored educational materials, and referral to online self-management programs. Strategies to harness the capacity of the eHealth medium, including the use of dynamic features and tailoring to help end users engage with, understand, and apply information need to be considered and maximized. Finally, the potential challenges in implementing eHealth solutions in the primary care setting are discussed. In conclusion, there is significant potential for innovative eHealth solutions to make a contribution to improving preventive care in the primary care setting. However, attention to issues such as data security and designing eHealth interfaces that maximize engagement from end users will be important to moving this field forward.

Smoking Status Confirmation by Proxy: Validation in a Smoking Cessation Trial

INTRODUCTION

Biochemical confirmation (BC) of self-report is the gold standard of evidence for abstinence in smoking cessation research, but difficulty in obtaining samples may bias estimates of quit rates. Proxy confirmation (PC) has not been validated in cessation trials. We assessed the feasibility and validity of PC in a cessation trial for hospitalized smokers.

METHODS

We enrolled 402 daily cigarette smokers during a hospital admission. At enrollment, participants provided demographics, smoking history, and named proxies to confirm their smoking status at follow-up. Participants provided self-reported (SR) 7-day tobacco abstinence by telephone at 6 months post-discharge. SR quitters were asked to mail a saliva sample for BC. Incentives were offered for survey completion ($20) and returned samples ($50). We called proxies for all those with SR to obtain PC. Quit rates were calculated with missing data indicating smoking. We assessed associations of nonresponse with baseline characteristics using chi-squared tests and logistic regression. We calculated the sensitivity and specificity of PC in detecting smokers as determined by BC.

RESULTS

All patients named at least one proxy. Response rates were 82% for SR, 84% for PC, and 69% for BC. Observed participant characteristics were unrelated to provision of sample for BC. Estimated quit rates were 35% for SR, 27% for SR + PC, 21% for SR + BC and 27% for SR + BC or PC. Sensitivity of PC was not higher than SR (73% vs. 77%); specificity was lower (84% vs. 100%).

CONCLUSION

PC was feasible but not superior to self-report in a cessation trial.

Global trends and projections for tobacco use, 1990-2025: an analysis of smoking indicators from the WHO Comprehensive Information Systems for Tobacco Control

BACKGROUND

Countries have agreed on reduction targets for tobacco smoking stipulated in the WHO global monitoring framework, for achievement by 2025. In an analysis of data for tobacco smoking prevalence from nationally representative survey data, we aimed to provide comprehensive estimates of recent trends in tobacco smoking, projections for future tobacco smoking, and country-level estimates of probabilities of achieving tobacco smoking targets.

METHODS

We used a Bayesian hierarchical meta-regression modelling approach using data from the WHO Comprehensive Information Systems for Tobacco Control to assess trends from 1990 to 2010 and made projections up to 2025 for current tobacco smoking, daily tobacco smoking, current cigarette smoking, and daily cigarette smoking for 173 countries for men and 178 countries for women. Modelling was implemented in Python with DisMod-MR and PyMC. We estimated trends in country-specific prevalence of tobacco use, projections for future tobacco use, and probabilities for decreased tobacco use, increased tobacco use, and achievement of targets for tobacco control from posterior distributions.

FINDINGS

During the most recent decade (2000-10), the prevalence of tobacco smoking in men fell in 125 (72%) countries, and in women fell in 156 (88%) countries. If these trends continue, only 37 (21%) countries are on track to achieve their targets for men and 88 (49%) are on track for women, and there would be an estimated 1·1 billion current tobacco smokers (95% credible interval 700 million to 1·6 billion) in 2025. Rapid increases are predicted in Africa for men and in the eastern Mediterranean for both men and women, suggesting the need for enhanced measures for tobacco control in these regions.

INTERPRETATION

Our findings show that striking between-country disparities in tobacco use would persist in 2025, with many countries not on track to achieve tobacco control targets and several low-income and middle-income countries at risk of worsening tobacco epidemics if these trends remain unchanged. Immediate, effective, and sustained action is necessary to attain and maintain desirable trajectories for tobacco control and achieve global convergence towards elimination of tobacco use.

FUNDING

Ministry of Health, Labour and Welfare, Japan; Ministry of Education, Culture, Sports and Technology, Japan; Department of Health, Australia; Bloomberg Philanthropies.

Reaching the hard-to-reach: a systematic review of strategies for improving health and medical research with socially disadvantaged groups

Background

This study aims to review the literature regarding the barriers to sampling, recruitment, participation, and retention of members of socioeconomically disadvantaged groups in health research and strategies for increasing the amount of health research conducted with socially disadvantaged groups.

Methods

A systematic review with narrative synthesis was conducted. Searches of electronic databases Medline, PsychInfo, EMBASE, Social Science Index via Web of Knowledge and CINHAL were conducted for English language articles published up to May 2013. Qualitative and quantitative studies as well as literature reviews were included. Articles were included if they reported attempts to increase disadvantaged group participation in research, or the barriers to research with disadvantaged groups. Groups of interest were those described as socially, culturally or financially disadvantaged compared to the majority of society. Eligible articles were categorised according to five phases of research: 1) sampling, 2) recruitment and gaining consent, 3) data collection and measurement, 4) intervention delivery and uptake, and 5) retention and attrition.

Results

In total, 116 papers from 115 studies met inclusion criteria and 31 previous literature reviews were included. A comprehensive summation of the major barriers to working with various disadvantaged groups is provided, along with proposed strategies for addressing each of the identified types of barriers. Most studies of strategies to address the barriers were of a descriptive nature and only nine studies reported the results of randomised trials.

Conclusions

To tackle the challenges of research with socially disadvantaged groups, and increase their representation in health and medical research, researchers and research institutions need to acknowledge extended timeframes, plan for higher resourcing costs and operate via community partnerships.

Associations between alcohol, smoking, socioeconomic status and comorbidities: evidence from the 45 and Up Study

INTRODUCTION AND AIMS

Understanding how tobacco, alcohol and mental health are related is important for developing population-level policies and individual-level treatments that target comorbidities. The current study aimed to examine sociodemographic characteristics and mental health comorbidities associated with the odds of using tobacco and harmful levels of alcohol concurrently.

DESIGN AND METHODS

Data were drawn from the 45 and Up Study, a large cohort study with 267 153 adults aged 45 years and over in New South Wales, Australia. Participants completed a survey assessing alcohol, smoking, psychological distress, treatment for depression and anxiety, and a range of socioeconomic status indicators. Univariate analyses and three multiple-logistic regression models were used to determine associations with (i) tobacco but not alcohol use; (ii) alcohol but not tobacco use; and (iii) concurrent tobacco and risky levels of alcohol use.

RESULTS

Being female, younger, lower individual and area-level socioeconomic status (SES) and depression and psychological distress were associated with tobacco use alone. Factors associated with alcohol use alone were older age, male gender, higher SES, and lower psychological distress and no recent depression treatment. Factors associated with concurrent risky alcohol consumption and tobacco use included being 45-64, being male, less education, earning <$30 000, being employed, and living in lower-SES areas, treatment for depression, and high distress on the Kessler-10.

DISCUSSION AND CONCLUSIONS

Results suggest strong links between SES, treatment for depression, psychological distress, and concurrent tobacco and alcohol use. This has implications for public health policies and clinical treatment for tobacco and alcohol use, suggesting greater emphasis on addressing multiple health and social concerns. [Bonevski B, Regan T, Paul C, Baker AL, Bisquera A. Associations between alcohol, smoking, socioeconomic status and comorbidities: Evidence from the 45 and Up Study. Drug Alcohol Rev 2014;33:169-176].

An RCT protocol of varying financial incentive amounts for smoking cessation among pregnant women

Background

Smoking during pregnancy is harmful to the unborn child. Few smoking cessation interventions have been successfully incorporated into standard antenatal care. The main aim of this study is to determine the feasibility of a personal financial incentive scheme for encouraging smoking cessation among pregnant women.

Design

A pilot randomised control trial will be conducted to assess the feasibility and potential effectiveness of two varying financial incentives that increase incrementally in magnitude ($20 vs. $40AUD), compared to no incentive in reducing smoking in pregnant women attending an Australian public hospital antenatal clinic.

Method

Ninety (90) pregnant women who self-report smoking in the last 7 days and whose smoking status is biochemically verified, will be block randomised into one of three groups: a. No incentive control group (n=30), b. $20 incremental incentive group (n=30), and c. $40 incremental incentive group (n=30). Smoking status will be assessed via a self-report computer based survey in nine study sessions with saliva cotinine analysis used as biochemical validation. Women in the two incentive groups will be eligible to receive a cash reward at each of eight measurement points during pregnancy if 7-day smoking cessation is achieved. Cash rewards will increase incrementally for each period of smoking abstinence.

Discussion

Identifying strategies that are effective in reducing the number of women smoking during pregnancy and are easily adopted into standard antenatal practice is of utmost importance. A personal financial incentive scheme is a potential antenatal smoking cessation strategy that warrants further investigation.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) number: ACTRN12612000399897

Demethylation of the aryl hydrocarbon receptor repressor as a biomarker for nascent smokers

Epigenetic modifications to peripheral white blood cell DNA occur in response to a wide variety of exposures. In prior work, we and others have shown that broad changes in DNA methylation, particularly at the aryl hydrocarbon receptor repressor (AHRR) locus, occur in samples from subjects with long histories of smoking. However, given the large number of epigenetic changes that occur in response to prolonged smoking, the primacy of the response at AHRR and the sensitivity of these changes to low levels of smoking are not known. Therefore, we examined the association of smoking to genome lymphocyte DNA methylation status in a representative sample of 399 African American youths living in the rural South that includes 72 subjects with less than one half-pack year of exposure. Consistent with our prior findings, we found a stepwise effect of smoking on DNA methylation among youth with relatively brief exposure histories at a CpG residue in AHRR (cg05575921) (FDR corrected p values; 3 × 10 (-7) and 0.09 in the male and female samples, respectively) that was identified in previous studies and at which the effects of smoking were significant, even in those subjects with less than one half pack year exposure. We conclude that AHRR demethylation at cg05575921 in peripheral cells may serve as an early, sensitive biomarker for even low levels of exposure to tobacco smoke, providing a non-self-report alternative for nascent exposure to tobacco smoke. We also suggest that the AHRR/AHR pathway may be functional in the response of peripheral white blood cells to tobacco smoke exposure.