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Luykx JJ, Correll CU, Manu P, Tanskanen A, Hasan A, Tiihonen J, Taipale H. Pneumonia Risk, Antipsychotic Dosing, and Anticholinergic Burden in Schizophrenia. JAMA Psychiatry 2024:2820399. [PMID: 38922592 PMCID: PMC11209197 DOI: 10.1001/jamapsychiatry.2024.1441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/15/2024] [Indexed: 06/27/2024]
Abstract
Importance Antipsychotic drugs (particularly clozapine) have been associated with pneumonia in observational studies. Despite studies of the associations between antipsychotic use and incident pneumonia, it remains unclear to what degree antipsychotic use is associated with increased risk of pneumonia, whether dose-response associations exist, and what agents are specifically associated with incident pneumonia. Objective To estimate pneumonia risk associated with specific antipsychotics and examine whether polytherapy, dosing, and receptor binding properties are associated with pneumonia in patients with schizophrenia. Design, Setting, and Participants This cohort study identified patients with schizophrenia or schizoaffective disorder (hereafter, schizophrenia) aged 16 years or older from nationwide Finnish registers from 1972 to 2014. Data on diagnoses, inpatient care, and specialized outpatient care were obtained from the Hospital Discharge Register. Information on outpatient medication dispensing was obtained from the Prescription Register. Study follow-up was from 1996 to 2017. Data were analyzed from November 4, 2022, to December 5, 2023. Exposures Use of specific antipsychotic monotherapies; antipsychotics modeled by dosage as low (<0.6 of the World Health Organization defined daily dose [DDD] per day), medium (0.6 to <1.1 DDDs per day), or high dose (≥1.1 DDDs per day); antipsychotic polypharmacy; and antipsychotics categorized according to their anticholinergic burden as low, medium, and high. Main Outcomes and Measures The primary outcome was hospitalization for incident pneumonia. Pneumonia risk was analyzed using adjusted, within-individual Cox proportional hazards regression models, with no antipsychotic use as the reference. Results The study included 61 889 persons with schizophrenia (mean [SD] age, 46.2 [16.0] years; 31 104 men [50.3%]). During 22 years of follow-up, 8917 patients (14.4%) had 1 or more hospitalizations for pneumonia and 1137 (12.8%) died within 30 days of admission. Compared with no antipsychotic use, any antipsychotic use overall was not associated with pneumonia (adjusted hazard ratio [AHR], 1.12; 95% CI, 0.99-1.26). Monotherapy use was associated with increased pneumonia risk compared with no antipsychotic use (AHR, 1.15 [95% CI, 1.02-1.30]; P = .03) in a dose-dependent manner, but polytherapy use was not. When categorized by anticholinergic burden, only the use of antipsychotics with a high anticholinergic burden was associated with pneumonia (AHR, 1.26 [95% CI, 1.10-1.45]; P < .001). Of specific drugs, high-dose quetiapine (AHR, 1.78 [95% CI, 1.22-2.60]; P = .003), high- and medium-dose clozapine (AHR, 1.44 [95% CI, 1.22-1.71]; P < .001 and AHR, 1.43 [95% CI, 1.18-1.74]; P < .001, respectively), and high-dose olanzapine (AHR, 1.29 [95% CI, 1.05-1.58]; P = .02) were associated with increased pneumonia risk. Conclusions and Relevance Results of this cohort study suggest that in patients with schizophrenia, antipsychotic agents associated with pneumonia include not only clozapine (at dosages ≥180 mg/d) but also quetiapine (≥440 mg/d) and olanzapine (≥11 mg/d). Moreover, monotherapy antipsychotics and antipsychotics with high anticholinergic burden are associated with increased pneumonia risk in a dose-dependent manner. These findings call for prevention strategies aimed at patients with schizophrenia requiring high-risk antipsychotics.
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Affiliation(s)
- Jurjen J. Luykx
- Department of Psychiatry, Amsterdam University Medical Center, Amsterdam, the Netherlands
- GGZ inGeest Mental Health Care, Amsterdam, the Netherlands
- Neuroscience Mood, Anxiety, Psychosis, Stress & Sleep Research Program, Amsterdam University Medical Center, Amsterdam, the Netherlands
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, the Netherlands
- Public Health Mental Health Research Program, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Christoph U. Correll
- Department of Psychiatry, the Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York
- Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Manu
- Department of Psychiatry, Hofstra/Northwell School of Medicine, Hempstead, New York
- Department of Medicine, Hofstra/Northwell School of Medicine, Hempstead, New York
- South Oaks Hospital, Northwell Health System, Amityville, New York
| | - Antti Tanskanen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
- Public Health Solutions, National Institute for Health and Welfare, Helsinki, Finland
| | - Alkomiet Hasan
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- German Center for Mental Health, München, Germany
| | - Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
- Center for Psychiatric Research, Stockholm City Council, Stockholm, Sweden
| | - Heidi Taipale
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
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Brinch Hyttel C, Ghazanfar MN, Zhang DG, Thomsen SF, Ali Z. The association between psoriasis and chronic obstructive pulmonary disease: a systematic review and meta-analysis. Ital J Dermatol Venerol 2024; 159:329-335. [PMID: 38502534 DOI: 10.23736/s2784-8671.24.07641-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
INTRODUCTION Psoriasis is a chronic T-cell-mediated inflammatory and proliferative skin disease. Chronic obstructive pulmonary disease (COPD) is an inflammatory disease of the airways. COPD has been studied as a comorbidity of psoriasis, but the association needs further study, hence the objective of this study. EVIDENCE ACQUISITION A systematic review was performed using the database PubMed and 155 records were found including the ones found through references. Seven records were found eligible for this study including six observational studies and one experimental study with a total of 229,075 participants. The odds ratio of COPD in patients with psoriasis and healthy subjects was analysed using a random effects model. EVIDENCE SYNTHESIS The pooled data showed a significant association (OR=1.77, 95% CI [1.32; 2.39]) between psoriasis and COPD with high inter-study heterogeneity (I2=96%). Sub-analyses of the different types of studies (cohort study: OR=2.53 [2.43; 2.63], case-control study: OR=1.6 [0.03; 100.96] and cross-sectional study: OR=1.57 [0.58; 4.22]) and smoking status (OR=1.7 [0.69; 4.14]) were also performed to further examine the association. CONCLUSIONS There is a significant association between psoriasis and COPD, but the underlying mechanism and how smoking status affects the results remain unclear and need further study. Physicians should be aware of the risk and its seriousness to provide better and more targeted treatment.
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Affiliation(s)
- Camilla Brinch Hyttel
- Department of Dermato-Venereology and Wound Healing Center, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Misbah N Ghazanfar
- Department of Dermato-Venereology and Wound Healing Center, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark -
| | - Ditte G Zhang
- Department of Dermato-Venereology and Wound Healing Center, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Simon F Thomsen
- Department of Dermato-Venereology and Wound Healing Center, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Zarqa Ali
- Department of Dermato-Venereology and Wound Healing Center, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
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Wang Q, He Z, Zhu J, Hu M, Yang L, Yang H. Polyphyllin B inhibited STAT3/NCOA4 pathway and restored gut microbiota to ameliorate lung tissue injury in cigarette smoke-induced mice. BMC Biotechnol 2024; 24:13. [PMID: 38459479 PMCID: PMC10921762 DOI: 10.1186/s12896-024-00837-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 02/15/2024] [Indexed: 03/10/2024] Open
Abstract
OBJECTIVE Smoking was a major risk factor for chronic obstructive pulmonary disease (COPD). This study plan to explore the mechanism of Polyphyllin B in lung injury induced by cigarette smoke (CSE) in COPD. METHODS Network pharmacology and molecular docking were applied to analyze the potential binding targets for Polyphyllin B and COPD. Commercial unfiltered CSE and LPS were used to construct BEAS-2B cell injury in vitro and COPD mouse models in vivo, respectively, which were treated with Polyphyllin B or fecal microbiota transplantation (FMT). CCK8, LDH and calcein-AM were used to detect the cell proliferation, LDH level and labile iron pool. Lung histopathology, Fe3+ deposition and mitochondrial morphology were observed by hematoxylin-eosin, Prussian blue staining and transmission electron microscope, respectively. ELISA was used to measure inflammation and oxidative stress levels in cells and lung tissues. Immunohistochemistry and immunofluorescence were applied to analyze the 4-HNE, LC3 and Ferritin expression. RT-qPCR was used to detect the expression of FcRn, pIgR, STAT3 and NCOA4. Western blot was used to detect the expression of Ferritin, p-STAT3/STAT3, NCOA4, GPX4, TLR2, TLR4 and P65 proteins. 16S rRNA gene sequencing was applied to detect the gut microbiota. RESULTS Polyphyllin B had a good binding affinity with STAT3 protein, which as a target gene in COPD. Polyphyllin B inhibited CS-induced oxidative stress, inflammation, mitochondrial damage, and ferritinophagy in COPD mice. 16S rRNA sequencing and FMT confirmed that Akkermansia and Escherichia_Shigella might be the potential microbiota for Polyphyllin B and FMT to improve CSE and LPS-induced COPD, which were exhausted by the antibiotics in C + L and C + L + P mice. CSE and LPS induced the decrease of cell viability and the ferritin and LC3 expression, and the increase of NCOA4 and p-STAT3 expression in BEAS-2B cells, which were inhibited by Polyphyllin B. Polyphyllin B promoted ferritin and LC3II/I expression, and inhibited p-STAT3 and NCOA4 expression in CSE + LPS-induced BEAS-2B cells. CONCLUSION Polyphyllin B improved gut microbiota disorder and inhibited STAT3/NCOA4 pathway to ameliorate lung tissue injury in CSE and LPS-induced mice.
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Affiliation(s)
- Qing Wang
- The Affiliated Changsha Central Hospital, Department of Respiratory and Critical Care Medicine, Hengyang Medical School, University of South China, Changsha, Hunan, 410004, China
| | - Zhiyi He
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Jinqi Zhu
- The Affiliated Changsha Central Hospital, Department of Respiratory and Critical Care Medicine, Hengyang Medical School, University of South China, Changsha, Hunan, 410004, China
| | - Mengyun Hu
- The Affiliated Changsha Central Hospital, Department of Respiratory and Critical Care Medicine, Hengyang Medical School, University of South China, Changsha, Hunan, 410004, China
| | - Liu Yang
- The Affiliated Changsha Central Hospital, Department of Respiratory and Critical Care Medicine, Hengyang Medical School, University of South China, Changsha, Hunan, 410004, China
| | - Hongzhong Yang
- The Affiliated Changsha Central Hospital, Department of Respiratory and Critical Care Medicine, Hengyang Medical School, University of South China, Changsha, Hunan, 410004, China.
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Haque MA, Gedara MLB, Nickel N, Turgeon M, Lix LM. The validity of electronic health data for measuring smoking status: a systematic review and meta-analysis. BMC Med Inform Decis Mak 2024; 24:33. [PMID: 38308231 PMCID: PMC10836023 DOI: 10.1186/s12911-024-02416-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 01/03/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Smoking is a risk factor for many chronic diseases. Multiple smoking status ascertainment algorithms have been developed for population-based electronic health databases such as administrative databases and electronic medical records (EMRs). Evidence syntheses of algorithm validation studies have often focused on chronic diseases rather than risk factors. We conducted a systematic review and meta-analysis of smoking status ascertainment algorithms to describe the characteristics and validity of these algorithms. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. We searched articles published from 1990 to 2022 in EMBASE, MEDLINE, Scopus, and Web of Science with key terms such as validity, administrative data, electronic health records, smoking, and tobacco use. The extracted information, including article characteristics, algorithm characteristics, and validity measures, was descriptively analyzed. Sources of heterogeneity in validity measures were estimated using a meta-regression model. Risk of bias (ROB) in the reviewed articles was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. RESULTS The initial search yielded 2086 articles; 57 were selected for review and 116 algorithms were identified. Almost three-quarters (71.6%) of algorithms were based on EMR data. The algorithms were primarily constructed using diagnosis codes for smoking-related conditions, although prescription medication codes for smoking treatments were also adopted. About half of the algorithms were developed using machine-learning models. The pooled estimates of positive predictive value, sensitivity, and specificity were 0.843, 0.672, and 0.918 respectively. Algorithm sensitivity and specificity were highly variable and ranged from 3 to 100% and 36 to 100%, respectively. Model-based algorithms had significantly greater sensitivity (p = 0.006) than rule-based algorithms. Algorithms for EMR data had higher sensitivity than algorithms for administrative data (p = 0.001). The ROB was low in most of the articles (76.3%) that underwent the assessment. CONCLUSIONS Multiple algorithms using different data sources and methods have been proposed to ascertain smoking status in electronic health data. Many algorithms had low sensitivity and positive predictive value, but the data source influenced their validity. Algorithms based on machine-learning models for multiple linked data sources have improved validity.
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Affiliation(s)
- Md Ashiqul Haque
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | | | - Nathan Nickel
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Maxime Turgeon
- Department of Statistics, University of Manitoba, Winnipeg, MB, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
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Cook S, Buszkiewicz JH, Levy DT, Meza R, Fleischer NL. Association between cigar use, with and without cigarettes, and incident diagnosed COPD: a longitudinal cohort study. Respir Res 2024; 25:13. [PMID: 38178199 PMCID: PMC10765880 DOI: 10.1186/s12931-023-02649-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/21/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND While regular cigar smoking is believed to carry similar health risks as regular cigarette smoking, the impact of cigar use, alone or in combination with cigarettes, on obstructive pulmonary disease (COPD) has not been well characterized. The purpose of this study was to examine the prospective association between exclusive and dual cigar and cigarette use and incident self-reported diagnosed COPD. METHODS This study used data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative survey of U.S. adults. Longitudinal data from adults aged 40 to 79 at Wave 1, without a pre-existing COPD diagnosis who participated at follow-up interview were analyzed. A time-varying current tobacco exposure, lagged by one wave and categorized as: (a) never/non-current use; (b) exclusive cigar use; (c) exclusive cigarette use; and (d) dual cigar/cigarette use. Multivariable models adjusted for demographics (age, sex, race or ethnicity, education), clinical risk factors (asthma, obesity), and smoking-related confounders (second-hand smoke exposure, other combustible tobacco product use, e-cigarette use, time since quitting, cigarette pack-years). The incidence of self-reported diagnosed COPD was estimated using discrete-time survival models, using a general linear modeling (GLM) approach with a binomial distribution and a complementary log-log link function. RESULTS The analytic sample consisted of 9,556 adults with a mean (SD) age of 56 (10.4), who were predominately female (52.8%) and Non-Hispanic White (70.8%). A total of 906 respondents reported a diagnosis of COPD at follow-up. In the fully adjusted model, exclusive cigar use (adjusted hazard ratio (aHR) = 1.57, 95% CI: 0.77, 3.21) was not associated with increased COPD risk compared to non-use, while exclusive cigarette use (aHR = 1.48, 95% CI: 1.13, 1.93) and dual cigar/cigarette use (aHR = 1.88, 95% CI: 1.24, 2.85) were. CONCLUSIONS Exclusive cigarette use and dual cigar/cigarette use were associated with diagnosed incident COPD. These results suggest that cigars, when used in combination with cigarettes, may be associated with poorer COPD health outcomes. Dual use may promote a higher likelihood of inhaling cigar smoke, and future research would benefit from examining whether inhalation of cigar smoke increases COPD risk.
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Affiliation(s)
- Steven Cook
- Department of Epidemiology, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA.
| | - James H Buszkiewicz
- Department of Epidemiology, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - David T Levy
- Department of Oncology, Georgetown University, Washington, DC, USA
| | - Rafael Meza
- Department of Epidemiology, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
- Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, BC, USA
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Nancy L Fleischer
- Department of Epidemiology, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
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Papadopoulou E, Haidich AB, Mathioudakis A, Tsavlis D, Papadopoulou K, Oikonomidou R, Bogiatzidis P, Tryfon S. The Fagerström Test for Nicotine Dependence, as a prognostic factor, in current smokers with and without COPD: A cross-sectional study in northern Greece. Chron Respir Dis 2024; 21:14799731241235213. [PMID: 38476003 DOI: 10.1177/14799731241235213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Smoking poses the most common risk factor for chronic obstructive pulmonary disease (COPD) and aggravates disease progression. Tobacco dependence inhibits smoking cessation and may affect smoking patterns that increase tobacco exposure and predispose to lung function decline. AIMS AND OBJECTIVES We aimed to assess tobacco dependence in current smokers with and without COPD and evaluate its role in disease development. METHOD This cross-sectional study was conducted in Greek rural areas. Current smokers completed the Fagerström Test for Nicotine Dependence and were classified into COPD and non-COPD groups based on spirometry parameters. RESULTS Among current smokers, 288 participants comprised the non-COPD and 71 the COPD group. Both presented moderate tobacco dependence, but smokers with COPD started to smoke earlier in the morning. Multiple logistic regression analysis revealed higher COPD prevalence in smokers with higher scores in the Fagerström test (odds ratio OR = 1.12, 95% confidence interval [1.01 - 1.24]) and older age (OR = 1.06 [1.03 - 1.09]), independently of pack-years smoking index. Multiple linear regression analysis in smokers with COPD showed that the forced expiratory volume in the 1st second decreased by 2.3% of the predicted value for each point increase in the Fagerström Test and 0.59% for each year of age, independently of participants' sex and pack-years smoking index. CONCLUSION The Fagerström score appears to indicate a higher probability for COPD and lung function deterioration when assessed along with age in current smokers. Smoking cessation support programs are fundamental to COPD prevention and management.
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Affiliation(s)
- Efthymia Papadopoulou
- Pulmonology Department, General Hospital of Thessaloniki "G. Papanikolaou", Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexander Mathioudakis
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester; North West Lung Centre, Wythenshawe Hospital, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Drosos Tsavlis
- Laboratory of Experimental Physiology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantina Papadopoulou
- Internal Medicine Department, General Hospital of Thessaloniki "G. Papanikolaou", Thessaloniki, Greece
| | | | | | - Stavros Tryfon
- Pulmonology Department, General Hospital of Thessaloniki "G. Papanikolaou", Thessaloniki, Greece
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Padrón‐Monedero A. A pathological convergence theory for non-communicable diseases. Aging Med (Milton) 2023; 6:328-337. [PMID: 38239708 PMCID: PMC10792334 DOI: 10.1002/agm2.12273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/11/2023] [Accepted: 10/16/2023] [Indexed: 01/22/2024] Open
Abstract
The current paradigm considers the study of non-communicable diseases (NCDs), which are the main causes of mortality, as individual disorders. Nevertheless, this conception is being solidly challenged by numerous remarkable studies. The clear fact that the mortality, by virtually all NCDs, tends to cluster at old ages (with the exception of congenital malformations and certain types of cancer, among a few others); makes us intuitive to assume that the common convergence mechanism that exponentially increases mortality by almost all NCDs in older ages is cell aging. Moreover, when we study NCDs, we are not analyzing which disorders cause the mortality of the populations, rather that which disorders kill us before others do, because the aging of the individuals causes inevitably their death by one cause or another. This is not a defeatist perspective, but a challenging and efficient one. These intuitive assumptions have been supported by studies from the pathophysiologic, epidemiologic, and genetic fields, leading to the affirmation that, as NCDs share genetic and pathophysiological mechanisms (derived from mostly the same risk factors), they should no longer be considered independently. Those studies should make us reconsider our current conceptions of studying NCDs as individual disorders, and to hypothesize about a paradigm that would consider most NCDs (cancer, neurological pathologies, cardiovascular diseases, type II diabetes mellitus, chronic respiratory diseases, osteoarthritis, and osteoporosis, among others) different manifestations of the same process: the cell aging.
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van Nijnatten J, Faiz A, Timens W, Guryev V, Slebos DJ, Klooster K, Hartman JE, Kole T, Choy DF, Chakrabarti A, Grimbaldeston M, Rosenberger CM, Kerstjens H, Brandsma CA, van den Berge M. A bronchial gene signature specific for severe COPD that is retained in the nose. ERJ Open Res 2023; 9:00354-2023. [PMID: 38020574 PMCID: PMC10680034 DOI: 10.1183/23120541.00354-2023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/09/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction A subset of COPD patients develops advanced disease with severe airflow obstruction, hyperinflation and extensive emphysema. We propose that the pathogenesis in these patients differs from mild-moderate COPD and is reflected by bronchial gene expression. The aim of the present study was to identify a unique bronchial epithelial gene signature for severe COPD patients. Methods We obtained RNA sequencing data from bronchial brushes from 123 ex-smokers with severe COPD, 23 with mild-moderate COPD and 23 non-COPD controls. We identified genes specific to severe COPD by comparing severe COPD to non-COPD controls, followed by removing genes that were also differentially expressed between mild-moderate COPD and non-COPD controls. Next, we performed a pathway analysis on these genes and evaluated whether this signature is retained in matched nasal brushings. Results We identified 219 genes uniquely differentially expressed in severe COPD. Interaction network analysis identified VEGFA and FN1 as the key genes with the most interactions. Genes were involved in extracellular matrix regulation, collagen binding and the immune response. Of interest were 10 genes (VEGFA, DCN, SPARC, COL6A2, MGP, CYR61, ANXA6, LGALS1, C1QA and C1QB) directly connected to fibronectin 1 (FN1). Most of these genes were lower expressed in severe COPD and showed the same effect in nasal brushings. Conclusions We found a unique severe COPD bronchial gene signature with key roles for VEGFA and FN1, which was retained in the upper airways. This supports the hypothesis that severe COPD, at least partly, comprises a different pathology and supports the potential for biomarker development based on nasal brushes in COPD.
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Affiliation(s)
- Jos van Nijnatten
- University of Groningen, University Medical Center Groningen, Department of Pathology and Medical Biology, Groningen, the Netherlands
- University of Groningen University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands
- University of Technology Sydney, Respiratory Bioinformatics and Molecular Biology, Sydney, NSW, Australia
| | - Alen Faiz
- University of Groningen University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands
- University of Technology Sydney, Respiratory Bioinformatics and Molecular Biology, Sydney, NSW, Australia
- University of Groningen University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands
| | - Wim Timens
- University of Groningen, University Medical Center Groningen, Department of Pathology and Medical Biology, Groningen, the Netherlands
- University of Groningen University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands
| | - Victor Guryev
- University of Groningen University Medical Center Groningen, European Research Institute for the Biology of Ageing, Groningen, the Netherlands
| | - Dirk-Jan Slebos
- University of Groningen University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands
- University of Groningen University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands
| | - Karin Klooster
- University of Groningen University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands
- University of Groningen University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands
| | - Jorine E. Hartman
- University of Groningen University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands
- University of Groningen University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands
| | - Tessa Kole
- University of Groningen University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands
- University of Groningen University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands
| | | | | | | | | | - Huib Kerstjens
- University of Groningen University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands
| | - Corry-Anke Brandsma
- University of Groningen, University Medical Center Groningen, Department of Pathology and Medical Biology, Groningen, the Netherlands
- University of Groningen University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands
- These authors contributed equally
| | - Maarten van den Berge
- University of Groningen University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, the Netherlands
- University of Groningen University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands
- These authors contributed equally
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Nam JH, Yeo CD, Park CK, Kim SK, Kim JS, Kim YH, Kim JW, Kim SJ, Lee SH, Kang HS. Identification of predictive factors for early relapse in patients with unresectable stage III non-small cell lung cancer receiving consolidation durvalumab after concurrent chemoradiation therapy. Thorac Cancer 2023; 14:2657-2664. [PMID: 37519059 PMCID: PMC10493476 DOI: 10.1111/1759-7714.15050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND Patients with locally advanced, unresectable, non-small cell lung cancer (NSCLC) receiving definitive concurrent chemoradiation therapy (CCRT) benefit from durvalumab consolidation therapy. However, predictive factors for early relapse during durvalumab maintenance have not yet been identified. METHODS The present study included the lung cancer cohort of the Catholic Medical Centers at the Catholic University of Korea from January 2018 to December 2021. A total of 51 NSCLC patients treated with durvalumab consolidation therapy after definitive CCRT were included in the analysis. Early relapse was defined as patients experiencing relapse within 6 months of starting initial durvalumab therapy. RESULTS Among the 51 patients, 15 (29.4%) relapsed during the study period. Median time from initial therapy of durvalumab to progression was 451.00 ± 220.87 days (95% confidence interval [CI]: 18.10-883.90) in overall patients. In multivariate analysis, younger age (adjusted odds ratio [aOR], 0.792; 95% CI: 0.642-0.977; p = 0.030), higher pack-years (aOR, 1.315; 95% CI: 1.058-1.635; p = 0.014), non-COPD (aOR, 0.004; 95% CI: 0.000-0.828; p = 0.004) and anemia (aOR, 234.30; 95% CI: 1.212-45280.24; p = 0.042), were independent predictive factors for early relapse during durvalumab consolidation therapy. CONCLUSION Younger age, higher number of pack-years, non-COPD, and anemia were independent predictive factors for early relapse during durvalumab consolidation therapy in patients with unresectable stage III NSCLC after definitive CCRT. Careful patient selection and clinical attention are needed for high-risk individuals.
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Affiliation(s)
- Jung Hyun Nam
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of MedicineThe Catholic University of KoreaSeoulRepublic of Korea
| | - Chang Dong Yeo
- Division of Pulmonary, Sleep and Critical Care Medicine, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of MedicineThe Catholic University of KoreaSeoulRepublic of Korea
| | - Chan Kwon Park
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of MedicineThe Catholic University of KoreaSeoulRepublic of Korea
| | - Sung Kyoung Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, St. Vincent's Hospital, College of MedicineThe Catholic University of KoreaSeoulRepublic of Korea
| | - Ju Sang Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary's Hospital, College of MedicineThe Catholic University of KoreaSeoulRepublic of Korea
| | - Yong Hyun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of MedicineThe Catholic University of KoreaSeoulRepublic of Korea
| | - Jin Woo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of MedicineThe Catholic University of KoreaSeoulRepublic of Korea
| | - Seung Joon Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of MedicineThe Catholic University of KoreaSeoulRepublic of Korea
| | - Sang Haak Lee
- Division of Pulmonary, Sleep and Critical Care Medicine, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of MedicineThe Catholic University of KoreaSeoulRepublic of Korea
| | - Hye Seon Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of MedicineThe Catholic University of KoreaSeoulRepublic of Korea
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10
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Cook SF, Hirschtick JL, Fleischer NL, Arenberg DA, Barnes GD, Levy DT, Sanchez-Romero LM, Jeon J, Meza R. Cigarettes, ENDS Use, and Chronic Obstructive Pulmonary Disease Incidence: A Prospective Longitudinal Study. Am J Prev Med 2023; 65:173-181. [PMID: 36890083 PMCID: PMC10363225 DOI: 10.1016/j.amepre.2023.01.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/18/2023] [Accepted: 01/18/2023] [Indexed: 03/09/2023]
Abstract
INTRODUCTION Understanding the relationship between ENDS use and chronic obstructive pulmonary disease (COPD) and other respiratory conditions is critical. However, most previous studies have not fully adjusted for cigarette smoking history. METHODS Using Waves 1-5 of the U.S. Population Assessment of Tobacco and Health study, the association between ENDS use and self-reported incident COPD was examined among adults aged 40+ years using discrete-time survival models. Current ENDS use was measured as a time-varying covariate, lagged by 1 wave, defined as established daily or some days of use. Multivariable models were adjusted for baseline demographics (age, sex, race/ethnicity, education), health characteristics (asthma, obesity, exposure to second-hand smoke), and smoking history (smoking status and cigarette pack years). Data were collected between 2013 and 2019, and the analysis was conducted in 2021-2022. RESULTS Incident COPD was self-reported by 925 respondents during the 5-year follow-up. Before adjusting for other covariates, time-varying ENDS use appeared to double COPD incidence risk (hazard ratio=1.98, 95% CI=1.44, 2.74). However, ENDS use was no longer associated with COPD (adjusted hazard ratio=1.10, 95% CI=0.78, 1.57) after adjusting for current cigarette smoking and cigarette pack years. CONCLUSIONS ENDS use did not significantly increase the risk of self-reported incident COPD over a 5-year period once current smoking status and cigarette pack years were included. Cigarette pack years, by contrast, remained associated with a net increase in COPD incidence risk. These findings highlight the importance of using prospective longitudinal data and adequately controlling for cigarette smoking history to assess the independent health effects of ENDS.
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Affiliation(s)
- Steven F Cook
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Jana L Hirschtick
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Nancy L Fleischer
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Douglas A Arenberg
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Geoffrey D Barnes
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan Health System, Ann Arbor, Michigan; Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan
| | - David T Levy
- Department of Oncology, School of Medicine, Georgetown University, Washington, District of Columbia
| | - Luz Maria Sanchez-Romero
- Department of Oncology, School of Medicine, Georgetown University, Washington, District of Columbia
| | - Jihyoun Jeon
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Rafael Meza
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan; Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, British Columbia, Canada.
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11
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Boo HJ, Min HY, Park CS, Park JS, Jeong JY, Lee SY, Kim WY, Lee JW, Oh SR, Park RW, Lee HY. Dual Impact of IGF2 on Alveolar Stem Cell Function during Tobacco-Induced Injury Repair and Development of Pulmonary Emphysema and Cancer. Cancer Res 2023; 83:1782-1799. [PMID: 36971490 DOI: 10.1158/0008-5472.can-22-3543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 02/23/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
Pulmonary emphysema is a destructive inflammatory disease primarily caused by cigarette smoking (CS). Recovery from CS-induced injury requires proper stem cell (SC) activities with a tightly controlled balance of proliferation and differentiation. Here we show that acute alveolar injury induced by two representative tobacco carcinogens, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone and benzo[a]pyrene (N/B), increased IGF2 expression in alveolar type 2 (AT2) cells to promote their SC function and facilitate alveolar regeneration. Autocrine IGF2 signaling upregulated Wnt genes, particularly Wnt3, to stimulate AT2 proliferation and alveolar barrier regeneration after N/B-induced acute injury. In contrast, repetitive N/B exposure provoked sustained IGF2-Wnt signaling through DNMT3A-mediated epigenetic control of IGF2 expression, causing a proliferation/differentiation imbalance in AT2s and development of emphysema and cancer. Hypermethylation of the IGF2 promoter and overexpression of DNMT3A, IGF2, and the Wnt target gene AXIN2 were seen in the lungs of patients with CS-associated emphysema and cancer. Pharmacologic or genetic approaches targeting IGF2-Wnt signaling or DNMT prevented the development of N/B-induced pulmonary diseases. These findings support dual roles of AT2 cells, which can either stimulate alveolar repair or promote emphysema and cancer depending on IGF2 expression levels. SIGNIFICANCE IGF2-Wnt signaling plays a key role in AT2-mediated alveolar repair after cigarette smoking-induced injury but also drives pathogenesis of pulmonary emphysema and cancer when hyperactivated.
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Affiliation(s)
- Hye-Jin Boo
- Creative Research Initiative Center for Concurrent Control of Emphysema and Lung Cancer, College of Pharmacy, Seoul National University, Seoul, Republic of Korea
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Hye-Young Min
- Creative Research Initiative Center for Concurrent Control of Emphysema and Lung Cancer, College of Pharmacy, Seoul National University, Seoul, Republic of Korea
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Choon-Sik Park
- Soonchunhyang University Bucheon Hospital, Bucheon-si, Gyeonggi-do, Republic of Korea
| | - Jong-Sook Park
- Soonchunhyang University Bucheon Hospital, Bucheon-si, Gyeonggi-do, Republic of Korea
| | - Ji Yun Jeong
- Department of Pathology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | - Shin Yup Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Lung Cancer Center, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | - Woo-Young Kim
- College of Pharmacy, Sookmyung Women's University, Seoul, Republic of Korea
| | - Jae-Won Lee
- Natural Medicine Research Center, Korea Research Institute of Bioscience and Biotechnology, Cheongju-si, Chungcheongbuk-do, Republic of Korea
| | - Sei-Ryang Oh
- Natural Medicine Research Center, Korea Research Institute of Bioscience and Biotechnology, Cheongju-si, Chungcheongbuk-do, Republic of Korea
| | - Rang-Woon Park
- Department of Biochemistry and Cell Biology, School of Medicine, and Cell and Matrix Research Institute, Kyungpook National University, Daegu, Republic of Korea
| | - Ho-Young Lee
- Creative Research Initiative Center for Concurrent Control of Emphysema and Lung Cancer, College of Pharmacy, Seoul National University, Seoul, Republic of Korea
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
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12
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Tam J, Jaffri MA, Mok Y, Jeon J, Szklo AS, Souza MC, Holford TR, Levy DT, Cao P, Sánchez-Romero LM, Meza R. Patterns of Birth Cohort‒Specific Smoking Histories in Brazil. Am J Prev Med 2023; 64:S63-S71. [PMID: 36775755 PMCID: PMC10240503 DOI: 10.1016/j.amepre.2022.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/07/2022] [Accepted: 12/07/2022] [Indexed: 02/12/2023]
Abstract
INTRODUCTION Smoking prevalence has decreased considerably in Brazil from 34.8% in 1989 to 12.6% in 2019 owing to the implementation of strong tobacco control policies. However, recent data show that the downward trend may be stagnating. Detailed analyses of historical smoking patterns by birth cohort could guide tobacco control decision making in Brazil. METHODS Using the 2008 Global Adult Tobacco Survey and the 2013 and 2019 National Health Surveys, historical smoking patterns in Brazil were estimated, supplemented with data from the 2006‒2019 Surveillance System of Risk Factors for Chronic Diseases by Telephone Interviews. Age‒period‒cohort models with constrained natural splines were applied to estimate the annual probabilities of smoking initiation and cessation, current smoker prevalence, and mean cigarettes smoked per day by age, gender, and birth cohort. Analysis was conducted in 2021‒2022. RESULTS Current smoker prevalence has declined considerably since the 1950 and 1955 birth cohorts for males and females, respectively, reflecting decreased smoking initiation and increased smoking-cessation probabilities over time. Among female cohorts born on or after 2000, smoking initiation may be increasing even as their smoking cessation has increased considerably. Mean cigarettes smoked per day has remained relatively constant across period and cohorts, showing only a minor decrease among males. CONCLUSIONS These detailed cohort-specific smoking parameters can be used to inform models that evaluate the impact of tobacco use and policies on long-term health outcomes and guide public health decision making in Brazil. Stagnant mean cigarettes smoked per day, increasing female smoking initiation, and limited improvement in male cessation among recent cohorts present challenges to tobacco control.
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Affiliation(s)
- Jamie Tam
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut.
| | - Mohammed A Jaffri
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Yoonseo Mok
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan; Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, British Columbia, Canada
| | - Jihyoun Jeon
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - André S Szklo
- Division of Population Research, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
| | - Mirian C Souza
- Division of Population Research, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
| | - Theodore R Holford
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - David T Levy
- Department of Oncology, Georgetown University, Washington, District of Columbia
| | - Pianpian Cao
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | | | - Rafael Meza
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan; Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, British Columbia, Canada
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13
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Meza R, Cao P, Jeon J, Fleischer NL, Holford TR, Levy DT, Tam J. Patterns of Birth Cohort‒Specific Smoking Histories by Race and Ethnicity in the U.S. Am J Prev Med 2023; 64:S11-S21. [PMID: 36653232 PMCID: PMC10362802 DOI: 10.1016/j.amepre.2022.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/08/2022] [Accepted: 06/29/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION U.S. smoking prevalence varies greatly by race/ethnicity. However, little is known about how smoking initiation, cessation, and intensity vary by birth cohort and race/ethnicity. METHODS Adult smoking data were obtained from the 1978-2018 National Health Interview Surveys. Age‒period‒cohort models with constrained natural splines were developed to estimate historical smoking patterns among non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian and Pacific Islander, and non-Hispanic American Indian and Alaskan Native individuals. Annual smoking prevalence and probabilities of smoking initiation, cessation, and intensity by age, year, gender, and race/ethnicity were estimated for the 1900 to 2000 birth cohorts. Analysis was conducted in 2020-2021. RESULTS Smoking initiation probabilities were highest for the American Indian and Alaskan Native population, second highest among the non-Hispanic White population, and lowest among Asian and Pacific Islander and Hispanic populations across birth cohorts. Historically, initiation probabilities among non-Hispanic Black populations were comparable with those among non-Hispanic White populations but have decreased since the 1970 birth cohort. Cessation probabilities were lowest among American Indian and Alaskan Native and non-Hispanic Black populations and highest among non-Hispanic White and Asian and Pacific Islander populations across cohorts and ages. Initiation and cessation probabilities produce observed patterns of smoking where prevalence among American Indian and Alaskan Native populations is highest across all ages and cohorts. Across cohorts, smoking prevalence among non-Hispanic Black populations, particularly males, is lower than among non-Hispanic White populations at younger ages but higher at older ages. CONCLUSIONS There are important and persistent racial/ethnic differences in smoking prevalence, initiation, cessation, and intensity across U.S. birth cohorts. Targeted interventions should address widening smoking disparities by race/ethnicity, particularly for American Indian and Alaskan Native and non-Hispanic Black populations.
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Affiliation(s)
- Rafael Meza
- From the Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, British Columbia, Canada; Department of Epidemiology, University of Michigan, Ann Arbor, Michigan.
| | - Pianpian Cao
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | - Jihyoun Jeon
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | - Nancy L Fleischer
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | - Theodore R Holford
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - David T Levy
- Department of Oncology, Georgetown University, Washington, District of Columbia
| | - Jamie Tam
- and the Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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14
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NUCERA F, BIANCO A, DAVID T, SALVATO I, ADCOCK IM, CARAMORI G. Treatable traits in COPD patients. Minerva Med 2022; 113:449-459. [DOI: 10.23736/s0026-4806.22.08001-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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