Tobacco Control in Denmark - How the Ugly Duckling Turned into a Swan

INTRODUCTION

The implementation of tobacco control policies has been a neglected topic in tobacco research. A comprehensive Tobacco Action Plan including plain packaging, point-of-sale display ban, a ban on characterizing flavours (in products other than cigarettes), a strengthening of the promotion and marketing ban, a ban on the sale of novel nicotine products to minors, smoke-and nicotine-free-school hours in all schools with minors, and a significant increase in tobacco tax, was adopted in Denmark in 2019.

METHODS

Eleven people involved or very close to the advocacy process were invited, two did not respond and nine attended our research centre. We used the Nominal Group Technique, a consensus method, to identify the most important driving factors for passing the Tobacco Action Plan.

RESULTS

The round-robin identified 39 driving factors merged into 13 in the clarification phase. In the ranking phase, participants agreed on seven factors that they perceived have strongly influenced the political will to strengthen national tobacco control comprehensively. The most important factors were national data and evidence, a nationwide alliance with broad partnerships, a strict focus on young people, continuous media coverage, intensive lobbying by many different advocates, making it a community agenda - not a political one, and effective professional campaigns.

CONCLUSION

Our findings agree with experiences from other countries that significantly improved tobacco control. The Danish strategy, including a nationwide alliance with broad partnerships, had a high influence on the political agenda.

IMPLICATIONS

In this study, there was a consensus that seven factors strongly influenced the political will to comprehensively strengthen the national tobacco control in Denmark in a short time: national data and evidence; a nationwide alliance with broad partnerships; a strict focus on children and young people; continuous media coverage; intensive lobbying by many different advocates; making it a community agenda - not a political one, and effective professional campaigns. This is consistent with findings from other countries.

Opportunistic screening for COPD among socially marginalized patients

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a common disease associated with premature death. Tobacco exposure is the main risk factor, but lower socioeconomic status, early life insults, and occupational exposures are also important risk factors. Socially marginalized people, facing homelessness, substance use disorder, and mental illness, are likely to have a higher risk of developing COPD, and, furthermore, experience barriers to healthcare access and consequently poorer outcomes.

OBJECTIVE

This study aims to assess COPD prevalence and the impact of opportunistic screening among hospitalized patients who are in contact with hospital social nurses. These patients constitute a group of patients with a high prevalence of psychiatric and somatic diseases, substance use, low life expectancy, and are socially marginalized.

METHODS

The present prospective longitudinal study includes a clinical examination at baseline. Participants will have spirometry done and be interviewed regarding risk factors, socioeconomic conditions, and respiratory symptoms. The 5-year follow-up assessment incorporates data from baseline and register data over the 5 years, including information on morbidity, use of COPD medication, hospital contacts, mortality, and socioeconomic factors.

ANTICIPATED RESULTS

Referral for further diagnostic work-up and management after the screening, including COPD treatment and smoking cessation support, is expected to improve survival rates. The study is still enrolling patients.

TRIAL REGISTRATION

The study is registered at ClinicalTrials.gov , NCT04754308 with study status: "enrolling".

Barriers to implementation of smoking cessation support among healthcare professionals in the secondary healthcare sector: A qualitative and quantitative evaluation

INTRODUCTION

Smoking cessation support (SCS) in the hospital is essential; patients often struggle to maintain quit attempts, which necessitates assistance from healthcare professionals (HCPs). However, unknown barriers can obstruct the implementation of SCS in hospitals. This study aims to uncover barriers to the implementation of SCS in psychiatric, somatic, inpatient, and outpatient hospital settings.

METHODS

In the period from June to September 2021, HCPs in a large secondary care hospital in the Region of Southern Denmark completed an online, cross-sectional study, providing sociodemographic details and listing potential barriers to SCS. They also shared additional barriers in the form of free-text responses. Descriptive statistics and thematic analysis of free-text responses were performed.

RESULTS

Of 1645 HCPs surveyed, 409 elaborated their response in the free-text field assessing unlisted barriers. Top listed barriers, reported by more than one-third of participants, included: 'lack of time' (45.1%), 'lack of patient motivation' (34.3%), and 'insufficient knowledge on how to support' (32.2%). Free-text responses revealed three barrier-related, which we grouped under the themes of: 'Concerned about the patient', 'Not part of my job', and 'Inappropriate setting'.

CONCLUSIONS

This quantitative and qualitative study identifies barriers to SCS on multiple levels in the hospital setting, i.e. on the patient, provider, and organizational levels. These results can inform healthcare organizations and professionals in the implementation of SCS in routine hospital care.

Do school-based smoking preventive interventions have unintended effects? Post hoc analysis of the Focus cluster randomised controlled trial

OBJECTIVES

Public health interventions are designed to improve specific health-related outcomes; however, they may also produce negative side effects, such as substitution use, psychological or social harms. Knowledge about the unintended effects of school-based smoking preventive interventions is sparse. Hence, this study examined these potential unintended effects of the smoking-reducing intervention, Focus, among students in the vocational education and training setting.

DESIGN

Cluster randomised controlled trial stratified by school type with 5 months follow-up.

SETTING AND PARTICIPANTS

Across Denmark, eight schools were randomised to the intervention group (n=844 students, response proportion 76%) and six schools to the control group (n=815 students, response proportion 75%). This study focused solely on students who smoked at baseline (N=491).

INTERVENTIONS

The intervention was developed systematically based on theory and a thoroughly mixed-methods needs assessment. Intervention components included a comprehensive school tobacco policy (smoke-free school hours) supported by a 3-day course for school staff and launched by an edutainment session for students; class-based lessons and a quit-and-win competition; and individual telephone smoking cessation support.

OUTCOMES

Alternative tobacco and nicotine products (regular use of smokeless tobacco, hookah and e-cigarettes), regular cannabis use, boredom and loneliness at school, stress and perceived stigmatisation among smokers.

RESULTS

We found no statistically significant unintended effects of the intervention. Nonetheless, insignificant findings indicated that students in the intervention group were less likely to be bored during school hours (OR 0.59, 95% CI 0.32 to 1.10) and experience stress (OR 0.62, 95% CI 0.35 to 1.10), but more likely to report feeling stigmatised compared with the control group (OR 1.55, 95% CI 0.71 to 3.40).

CONCLUSIONS

Overall, findings suggested no unintended effects of the Focus trial with respect to substitution use, psychological, nor group or social harms. Future research is encouraged to report potential harmful outcomes of smoking preventive interventions, and interventions should be aware of the possible stigmatisation of smokers.

TRIAL REGISTRATION NUMBER

ISRCTN16455577.

Towards Tobacco-Free Generation: implementation of preventive tobacco policies in the Nordic countries

AIMS

Europe's Beating Cancer Plan set a goal of creating a Tobacco-Free Generation in Europe by 2040. Prevention is important for achieving this goal. We compare the Nordic countries' preventive tobacco policies, discuss the possible determinants for similarities and differences in policy implementation, and provide strategies for strengthening tobacco prevention.

METHODS

We used the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) to identify the key policies for this narrative review. We focused on Articles 6, 8, 9, 11, 13 and 16 of the WHO FCTC, and assessed the status of the required (core) and recommended (advanced) policies and their application to novel tobacco and nicotine products. Information on the implementation of strategies, acts and regulations were searched from global and national tobacco control databases, websites and scientific articles via PubMed and MEDLINE.

RESULTS

The WHO FCTC and European regulations have ensured that the core policies are mostly in place, but also contributed to the shared deficiencies that are seen especially in the regulations on smokeless tobacco and novel products. Strong national tobacco control actors have facilitated countries to implement some advanced policies - even as the first countries in the world: point-of-sale display bans (Iceland), outdoor smoking bans (Sweden), flavour bans on electronic cigarettes (Finland), plain packaging (Norway), and plain packaging on electronic cigarettes (Denmark).

CONCLUSIONS

Collaboration and participation in reinforcing the European regulations, resources for national networking between tobacco control actors, and national regulations to provide protection from the tobacco industry's interference are needed to strengthen comprehensive implementation of tobacco policies in the Nordic countries.

Corrigendum: Implementation fidelity of a smoke-free workplace intervention in a private medical company: A mixed-methods process evaluation

[This corrects the article DOI: 10.18332/tpc/162878.].

Trends in smoking-related diseases by socioeconomic position following a national smoking ban in 2007: a nationwide study in the Danish population

BACKGROUND

National comprehensive smoke-free legislation has been found to decrease the incidence of several smoking-related diseases. In 2007, Denmark introduced a national smoking ban, which banned smoking indoor in workplaces and public places, although only partial restrictions were applied in certain settings. We examined the impact of the smoking ban on smoking-related diseases and whether this differed across socioeconomic groups.

METHODS

Interrupted time series analyses of nationwide register data were performed using Poisson regression models to examine the differential impact of the smoking ban on monthly incidence rates of acute myocardial infarction, chronic obstructive pulmonary disease, and smoking-related cancers from 2002 to 2015. Immediate changes in incidence rates after the smoking ban and long-term changes in disease trends were estimated by comparing data from the pre- and post-ban period. Models were stratified by socioeconomic position.

RESULTS

Overall, we found neither immediate changes in rates of acute myocardial infarction, chronic obstructive pulmonary disease, and smoking-related cancers following the smoking ban nor long-term post-ban changes in disease trends as compared to before the ban. Results did not differ across socioeconomic groups. A pronounced socioeconomic gradient in incidence rates was observed for all outcomes both before and after the smoking ban.

CONCLUSION

The national smoking ban was not associated with a lower incidence of smoking-related diseases in the post-ban period compared to pre-ban levels and no differences between socioeconomic groups were observed. Future tobacco control in Denmark should consider which measures most effectively target the low socioeconomic groups to decrease the current strong socioeconomic inequality in health.

Nationwide experiences with youth-targeted smoking and nicotine product cessation

INTRODUCTION

Most adolescent and young adult (youth) smokers and users of novel nicotine products wish to quit. Little is known, at a population level, about youth cessation activities, and the counselor's experiences in working with youth smoking and nicotine product cessation.

METHODS

A questionnaire was mailed to all 98 municipalities in Denmark on 31 October 2022. Youths were defined as those aged 16-25 years. The participation rate was 96% (n=94). Simple descriptive statistics were performed.

RESULTS

This survey explored youth-targeted smoking and nicotine product cessation activities and ex-periences from municipality counselors across the whole nation. Overall, 60% of the Danish municipal counselors had low/very low/no personal experience with youth cessation interventions, 89% found it dif-ficult to work with youth counseling, 90% found it difficult to recruit youth to nicotine cessation services, and only 25% of the active municipalities were described as highly experienced. A higher percentage of the highly experienced municipalities reported that they share the responsibility of recruitment to cessation services with schools, counsel youths in separate groups from adults, and have good experiences with online counseling.

CONCLUSIONS

This Danish nationwide survey showed that even in a country with very well-organized and free-of-charge cessation counseling programs, very few municipalities give assistance to youth, and most find it difficult to work with youth. Cessation services have been designed for adult smokers and seem to have failed to meet the needs of young smokers and users of novel nicotine products, at least in Denmark. There is an urgent need for research on how to effectively recruit youth to cessation services, and what works to help youth quit.

A survey exploring the practices of smoking cessation support among hospital-based healthcare providers

BACKGROUND

Hospital visits constitute a 'window of opportunity' for initiating smoking cessation attempts, and healthcare providers (HCPs) play an important role in supporting patients to stop smoking. Yet, the current practices of supporting smoking cessation in the hospital setting are largely unexplored. The aim of this study was to explore practices of smoking cessation support among hospital-based HCPs.

METHODS

HCPs working in a large hospital in the secondary care sector completed an online, cross-sectional survey, including sociodemographic and work-related factors as well as 21 questions assessing practices of smoking cessation support based on the "five As" framework. Descriptive statistics were computed, and predictors of HCPs giving patients advice to stop smoking were explored using logistic regression analysis.

RESULTS

All employees (N = 3998) in the hospital received a survey link; 1645 (41.1%) HCPs with daily patient contact completed the survey. Smoking cessation support in the hospital setting was limited with regard to assessment of smoking; providing information and advice; planning and referral for further support; and follow-up on smoking cessation attempts. Almost half (44.8%) of participating HCPs with daily patient contact never or rarely advise their patients to stop smoking. Physicians were more likely than nurses to advice patients to stop smoking, and HCPs in outpatient clinics were more likely to give advice than inpatient clinic HCPs.

CONCLUSION

Smoking cessation support is very limited in the hospital-based healthcare setting. This is problematic, as hospital visits can be windows of opportunity to help patients change their health behaviour. An intensified focus on the implementation of hospital-based smoking cessation support is needed.

Smoking as a prognostic factor for survival in patients with disseminated germ cell cancer

We investigated the impact of smoking on overall survival (OS) in testicular germ cell cancer (TC) patients receiving first-line combination chemotherapy (bleomycin-etoposide-cisplatin [BEP]). Patients who received BEP for metastatic TC were identified in the Danish Testicular Cancer database. Information on smoking status at the time of diagnosis was obtained by medical record review. OS and cause of death were compared between current smokers and never-smokers. Of 1883 eligible patients, information on smoking status was available in 1156 patients, of whom 602 were current smokers. The 10-year OS was 92% in never-smokers compared with 83% in current smokers (P < .001) (hazard ratio for death = 1.85, 95% confidence interval = 1.29 to 2.66, P = .001). A higher proportion of current smokers died of TC compared with nonsmokers (P < .01). Smoking negatively affects survival after BEP in patients with disseminated TC. Vigorous smoking cessation programs are advocated in TC patients.

Implementation fidelity of a smoke-free workplace intervention in a private medical company: A mixed-methods process evaluation

INTRODUCTION

Smoke-free workplaces are considered an important part of tobacco control strategies. The purpose of this study was to evaluate implementation fidelity and explore the significance of social and contextual factors for the implementation of a strict smoke-free workplace intervention in a large Danish medical company.

METHODS

The UK Medical Research Council's guidance for process evaluation was used as a framework. Data were collected from approximately six months before the implementation until ten months after (2019-2020). A mixed method study design was used (a survey of 398 employees, a focus group of four employees and field visits on two days). Data were analyzed separately and later integrated through triangulation. We used the Fisher's exact test in the analysis of the questionnaire.

RESULTS

We assessed the implementation fidelity through four key factors: reach, dose and delivery, mechanisms of change, and context for the intervention components. Despite compliance issues, the policy component had high implementation fidelity. However, the implementation fidelity of the smoking cessation support component was low. We identified three social mechanisms influencing the employees' responsiveness towards the policy: expectation, the social aspect of the smoking facilities, and management leadership. COVID-19 was identified as the main contextual factor affecting the implementation.

CONCLUSIONS

Although not all elements of the intervention components were implemented as planned, the strict smoke-free workplace intervention is considered implemented. Further strategies can be initiated to raise implementation fidelity through better communication concerning the cessation support component, compliance, and enforcement of the policy.

Effectiveness of the multi-component intervention 'Focus' on reducing smoking among students in the vocational education setting: a cluster randomized controlled trial

BACKGROUND

Social inequality in smoking remains an important public health issue. Upper secondary schools offering vocational education and training (VET) comprise more students from lower socioeconomic backgrounds and have higher smoking prevalence than general high schools. This study examined the effects of a school-based multi-component intervention on students' smoking.

METHODS

A cluster randomized controlled trial. Eligible participants were schools offering VET basic courses or preparatory basic education in Denmark, and their students. Schools were stratified by subject area and eight schools were randomly allocated to intervention (1,160 invited students; 844 analyzed) and six schools to control (1,093 invited students; 815 analyzed). The intervention program comprised smoke-free school hours, class-based activities, and access to smoking cessation support. The control group was encouraged to continue with normal practice. Primary outcomes were daily cigarette consumption and daily smoking status at student level. Secondary outcomes were determinants expected to impact smoking behavior. Outcomes were assessed in students at five-month follow-up. Analyses were by intention-to-treat and per protocol (i.e., whether the intervention was delivered as intended), adjusted for covariates measured at baseline. Moreover, subgroup analyses defined by school type, gender, age, and smoking status at baseline were performed. Multilevel regression models were used to account for the cluster design. Missing data were imputed using multiple imputations. Participants and the research team were not blinded to allocation.

RESULTS

Intention-to-treat analyses showed no intervention effect on daily cigarette consumption and daily smoking. Pre-planned subgroup analyses showed statistically significant reduction in daily smoking among girls compared with their counterparts in the control group (OR = 0.39, 95% CI: 0.16, 0.98). Per-protocol analysis suggested that schools with full intervention had higher benefits compared with the control group (daily smoking: OR = 0.44, 95% CI: 0.19, 1.02), while no marked differences were seen among schools with partial intervention.

CONCLUSION

This study was among the first to test whether a complex, multicomponent intervention could reduce smoking in schools with high smoking risk. Results showed no overall effects. There is a great need to develop programs for this target group and it is important that they are fully implemented if an effect is to be achieved.

TRIAL REGISTRATION

https://www.isrctn.com/ISRCTN16455577 , date of registration 14/06/2018.

Our Healthy Community Conceptual Framework and Intervention Model for Health Promotion and Disease Prevention in Municipalities

This paper introduces the conceptual framework and intervention model of Our Healthy Community (OHC), a new, coordinated, and integrated approach towards health promotion and disease prevention in municipalities. The model is inspired by systems-based approaches and employs a supersetting approach for engaging stakeholders across sectors in the development and implementation of interventions to increase health and well-being among citizens. The conceptual model includes a combination of a bottom-up approach emphasizing involvement of citizens and other community-based stakeholders combined with a top-down approach emphasizing political, legal, administrative, and technical support from a variety of councils and departments in local municipality government. The model operates bidirectionally: (1) by pushing political and administrative processes to promote the establishment of conducive structural environments for making healthy choices, and (2) by involving citizens and professional stakeholders at all levels in co-creating processes of shaping their own community and municipality. An operational intervention model was further developed by the OHC project while working with the OHC in two Danish municipalities. The operational intervention model of OHC comprises three main phases and key actions to be implemented at the levels of local government and community: (1) Local government: Situational analysis, dialogue, and political priorities; (2) Community: Thematic co-creation among professional stakeholders; and (3) Target area: Intervention development and implementation. The OHC model will provide municipalities with new tools to improve the citizens' health and well-being with available resources. Health promotion and disease prevention interventions are developed, implemented, and anchored in the local community by citizens and local stakeholders at municipal and local community levels using collaboration and partnerships as leverage points.

Making smoking history: temporal changes in support for a future smoking ban and increasing taxes in the general population of Denmark

BACKGROUND

An end date for smoking has been adopted in several countries and is now being discussed by governments all over the world. However, little is known about temporal changes in citizens' support for a future smoking ban.

AIM

To examine temporal changes in support for a future smoking ban and for increasing taxes on tobacco in Denmark, and to explore whether these changes differ across sex, age, educational attainment, smoking status and between smokers with/without intention to quit.

METHOD

The study was based on two waves of 'The Danish Capital Region Health Survey' conducted in 2013 and 2017. The pooled study sample included 96 521 citizens aged ≥16 years old.

RESULTS

Public support for a future smoking ban increased from 30.6% in 2013 to 50.3% in 2017, whereas support for increasing tobacco taxes remained unchanged at 59%. Support for a future smoking ban increased significantly in almost all subgroups from 2013 to 2017: Support among daily smokers increased by 27% between 2013 and 2017. Support among never smokers was almost 2.63 times higher than among smokers in 2013 and increased further in 2017 (OR: 2013=2.63; 2017=5.13).

CONCLUSION

This study indicates a readiness to support a future smoking ban and increasing tobacco taxes. Support for a future smoking ban has increased from 2013 to 2017 among both young people and adults. By 2017, about half of the population supported a future smoking ban and increasing tobacco taxes. Findings may help inform policy-making related to endgame strategies.

E-cigarette use in global digital youth culture. A qualitative study of the social practices and meaning of vaping among 15-20-year-olds in Denmark, Finland, and Norway

BACKGROUND

The introduction of e-cigarettes on the tobacco market has brought new regulatory challenges, and particular concerns relate to e-cigarette uptake among young people. The aim of this study was to explore the use and social meaning of e-cigarettes among Nordic young people and to discuss this in the context of current legislation.

METHODS

Thirteen focus groups were conducted with 46 Danish, Finnish, and Norwegian young people (24 boys) with vaping experience aged 15-20 years (mean age 17 years).

RESULTS

Young people's vaping stood out as an inherently social practice that was commonly interlinked with experimental use patterns. Relative to smoking, vaping was seen as socially acceptable and less harmful to health. Product innovations like flavour additives and nicotine-free liquid options added to perceptions of low harm, and innovative device design features facilitated new and playful user practices. Finally, digital markets eased the young people's access to e-cigarettes, and the digital world also represented an arena for e-cigarette exposure and self-presentation. They commonly viewed vaping-related content in their social media feeds and also produced such content themselves.

CONCLUSION

Young people's vaping is a social practice interwoven in contemporary digital and global youth culture. Transnational regulations are needed to support individual countries in preventing e-cigarette use and exposure among young people.

The Health Effects of Real-World Dual Use of Electronic and Conventional Cigarettes versus the Health Effects of Exclusive Smoking of Conventional Cigarettes: A Systematic Review

BACKGROUND

A high prevalence of dual use of e-cigarettes and conventional cigarettes has been reported across the world.

METHODS

A systematic search was carried out. We included original articles on any topic relevant to health, excluding mental health, in all languages. The PRISMA guidelines were followed. Both reviewers independently screened and read all publications. We compared dual use with exclusive smoking of conventional cigarettes (ESCC).

RESULTS

Fifty-two publications (49 studies) were included. Thirteen papers/10 studies were prospective. There was great heterogeneity across studies. Many methodological weaknesses, such as inaccurate exposure measurement, lack of adjustment for former tobacco consumption, and lack of significance testing were identified. Most prospective studies found dual use to be at least as harmful as ESCC. The longest follow-up was six years. Most of the best available cross-sectional studies found dual use associated with the same and, in several studies, significantly higher risk of self-reported symptoms/disease than in ESCC. The intensity of cigarette smoking seems associated with worse health.

CONCLUSION

Existing studies indicate that dual use is at least as, or probably even more, harmful than ESCC. Due to the predominance of cross-sectional studies and the methodological weaknesses we judged the overall certainty of the evidence as "low certainty".

Intervention Activities Associated with the Implementation of a Comprehensive School Tobacco Policy at Danish Vocational Schools: A Repeated Cross-Sectional Study

School tobacco policies are often poorly implemented, which may explain their limited effectiveness. Further, constructs to measure implementation outcomes of school tobacco policies are missing. The Smoke-Free Vocational Schools intervention was designed to stimulate the implementation of a comprehensive school tobacco policy into routine practice. This study (1) developed implementation fidelity outcomes measures for the school tobacco policy and (2) examined associations between intervention activities and implementation fidelity at two time points. We applied a repeated cross-sectional survey study design across seven schools: the first time point was >5 months after the policy was established and the second time point > 14 months after policy establishment. The dependent/outcome variables were four binary fidelity domains as well as a total score across domains. A total of six intervention activities were measured among either students (e.g., new school-break facilities) or staff/managers (e.g., a joint workshop before policy implementation). Associations were analyzed separately for students and staff/managers using generalized linear mixed models, adjusted for confounders. A total of n = 2674 students and n = 871 staff/managers participated. The total implementation fidelity scores increased over time among both students and staff/managers. Three intervention activities were consistently associated with the total implementation fidelity score, including: new school-break facilities (B_T1 = 0.08, 95% CI = 0.03; 0.12; B_T2 = 0.07, 95% CI = 0.04-0.50), the joint workshop before policy implementation (B_T1 = 0.13, 95% CI = 0.02; 0.25; B_T2 = 0.13, 95% CI = 0.004; 0.24), and internalization of fixed procedures for enforcement (B_T1 = 0.19, 95% CI = 0.13-0.26; B_T2 = 0.16, 95% CI = 0.13-0.26). These findings can be applied by schools and other actors in practice. The developed implementation fidelity outcomes measures can be applied in future research on school tobacco policies.

Smoking Cessation Programs Are Less Effective in Smokers with Low Socioeconomic Status Even When Financial Incentives for Quitting Smoking Are Offered-A Community-Randomized Smoking Cessation Trial in Denmark

Financial incentives offered to those who quit smoking have been found effective, also in persons with low socioeconomic status (SES), but no previous study has investigated who benefits most: smokers with low or high SES. In this community-randomized trial ("Richer without smoking"), three Danish municipalities were randomized to reward persons who were abstinent when attending the municipal smoking cessation program (FIMs) and three municipalities were randomized to spend the same amount on smoking cessation campaigns recruiting smokers to the smoking cessation program (CAMs). The municipalities each received approximately USD 16,000. An intention-to-treat approach was used in analyses. In regression analyses adjusted for individual- and municipal-level differences, we found that smokers with high SES living in FIMs had significantly higher proportion of validated long-term successful quitters (OR (95% CI): 2.59 (1.6-4.2)) than high-SES smokers living in CAM. Smokers with low SES, however, did not experience the same benefit of financial incentives as smokers with high SES. Neither the FIMs nor the CAMs succeeded in attracting more smokers with low SES during the intervention year 2018 than the year before. Our study showed that smokers with low SES did not experience the same benefit of financial incentives as smokers with high SES.

Single, Dual, and Triple Use of Cigarettes, e-Cigarettes, and Snus among Adolescents in the Nordic Countries

New tobacco and nicotine products have emerged on the market in recent years. Most research has concerned only one product at a time, usually e-cigarettes, while little is known about the multiple use of tobacco and nicotine products among adolescents. We examined single, dual, and triple use of cigarettes, e-cigarettes, and snus among Nordic adolescents, using data of 15-16-year-olds (n = 16,125) from the European School Survey Project on Alcohol and other Drugs (ESPAD) collected in 2015 and 2019 from Denmark, Finland, Iceland, Norway, Sweden, and the Faroe Islands. Country-specific lifetime use of any of these products ranged between 40% and 50%, and current use between 17% and 31%. Cigarettes were the most common product in all countries except for Iceland, where e-cigarettes were remarkably more common. The proportion of dual and triple users was unexpectedly high among both experimental (24%-49%) and current users (31-42%). Triple use was less common than dual use. The users' patterns varied somewhat between the countries, and Iceland differed substantially from the other countries, with a high proportion of single e-cigarette users. More knowledge on the patterns of multiple use of tobacco and nicotine products and on the potential risk and protective factors is needed for targeted intervention and prevention efforts.

Are financial incentives more effective than health campaigns to quit smoking? A community-randomised smoking cessation trial in Denmark

The aim of this community-randomised smoking cessation (SC) trial was to investigate both recruitment and SC-rates in three municipalities offering financial incentives (FIM) to smokers who stop smoking when attending a municipal SC-program and compare these with three municipalities investing in a campaign (CAM) that should encourage smokers to use the SC-program. Furthermore, in a non-randomised matched control design we investigated whether there was a difference in recruitment and SC-rates in the three FIM and the three CAM, comparing each with three matched control municipalities (MCM). Each municipality received approx. $16,000. The FIM rewarded persons who were abstinent when attending the municipal SC-program. The CAM spent the money on a campaign recruiting smokers to the SC-program. Two of three FIM were only partly active in recruiting smokers in the intervention year 2018. An intention-to-treat (ITT) approach was used in analyses. Complete case analyses and multiple imputation were used to address loss to follow-up. No difference in recruitment was found between the CAM and the FIM (p = 0.954), in adjusted analyses. In ITT analyses, FIM achieved significantly higher odds of validated abstinence from smoking at one-year follow-up (OR (95%CI): 1.63(1.1-2.4)), but not of self-reported continuous abstinence after six months than CAM. Compared with no intervention, campaigns increased the recruitment of smokers to the SC-program while financial incentives increased six months abstinence rates. In a randomised trial, no difference was demonstrated in the effect of financial incentives and campaigns to recruit smokers to a SC-program and financial incentives seemed superior to help smokers staying smoke-free for a year. TRIAL REGISTRATION: ClinicalTrials.Gov ID: NCT03849092.

Electronic cigarettes and health with special focus on cardiovascular effects: position paper of the European Association of Preventive Cardiology (EAPC)

BACKGROUND

Tobacco use is the single largest preventable risk factor for premature death of non-communicable diseases and the second leading cause of cardiovascular disease. In response to the harmful effects of tobacco smoking, the use of electronic cigarettes (e-cigarettes) has emerged and gained significant popularity over the past 15 years. E-cigarettes are promoted as safe alternatives for traditional tobacco smoking and are often suggested as a way to reduce or quit smoking. However, evidence suggests they are not harmless.

DISCUSSION

The rapid evolution of the e-cigarette market has outpaced the legislator's regulatory capacity, leading to mixed regulations. The increasing use of e-cigarettes in adolescents and young individuals is of concern. While the long-term direct cardiovascular effects of e-cigarettes remain largely unknown, the existing evidence suggests that the e-cigarette should not be regarded as a cardiovascular safe product. The contribution of e-cigarette use to reducing conventional cigarette use and smoking cessation is complex, and the impact of e-cigarette use on long-term cessation lacks sufficient evidence.

CONCLUSION

This position paper describes the evidence regarding the prevalence of e-cigarette smoking, uptake of e-cigarettes in the young, related legislations, cardiovascular effects of e-cigarettes and the impact of e-cigarettes on smoking cessation. Knowledge gaps in the field are also highlighted. The recommendations from the population science and public health section of the European Association of Preventive Cardiology are presented.

Reducing smoking in youth by a smoke-free school environment: A stratified cluster randomized controlled trial of Focus, a multicomponent program for alternative high schools

Youth smoking remains a major challenge for public health. Socioeconomic position influences the initiation and maintenance of smoking, and alternative high school students are at particularly high risk. The school environment is an important setting to promote health, however there is a lack of evidence-based school intervention programs. This article presents the Focus study, which aims to test the implementation and effectiveness of a school-based intervention integrating¹ a comprehensive school smoking policy [i.e. smoke-free school hours (SFSH)]², a course for school staff in short motivational conversations³, school class-based teaching material⁴, an edutainment session5, a class-based competition, and6 access to smoking cessation support. Together these intervention components address students' acceptability of smoking, social influences, attitudes, motivation, and opportunities for smoking. The setting is alternative high schools across Denmark, and the evaluation design is based on a stratified cluster randomized controlled trial comparing the intervention group to a control group. Outcome data is collected at baseline, midway, and at the end of the intervention period. Moreover, a detailed process evaluation, using qualitative and quantitative methods, is conducted among students, teachers, and school principals. The results from this trial will provide important knowledge on the effectiveness of a smoke-free school environment. The findings will lead to a better understanding of which policies, environments, and cognitions, contribute to preventing and reducing cigarette use among young people in a diverse and high-risk school setting, and illuminate which complementary factors are significant to achieve success when implementing SFSH.

Readiness for implementation of smoke-free work hours in private companies: A qualitative study of perceptions among middle managers

INTRODUCTION

Workplaces are important settings for implementation of smoke-free environments. In this study, we follow a medical production company with 677 employees that implemented one of the most stringent tobacco policies legally possible in Denmark – smoke-free work hours – which means that employees are not allowed to smoke during work time. This study explores tobacco use restrictions during work hours regarding readiness of implementation, focusing specifically on middle managers’ perceptions and considerations, as well as their perceived responsibility in enforcing these.

METHODS

A case study is presented. Two focus groups of 10 middle managers were conducted, seven months before smoke-free work hours were implemented. The facilitators used open-ended questions, which consisted of a structured section with specific themes related to the implementation of smoke-free work hours. Focus groups were recorded, transcribed, and analyzed thematically.

RESULTS

We identified five main themes: 1) Benefits of the new policy due to better health, lower sickness-related absences, increased productivity, and improved branding value; 2) Social interactions across smoking status; 3) Smoking is a private matter with ethical dimensions; 4) The role of middle managers and concerns about enforcement; and 5) Limited experience with resistance from the smoking employees.

CONCLUSIONS

The findings suggest that workplaces in the preparation phase should ensure that: 1) The middle managers gain training on how to talk with employees about smoking cessation; 2) The middle managers are equipped to handle the new policy and have a joint vision and understanding of why and how they should enforce it; and 3) Room is made for discussions on resistance and enforcement-related challenges as well as ethical issues.

Smoking and stress in the general population in Denmark

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Programme theory and realist evaluation of the 'Smoke-Free Vocational Schools' research and intervention project: a study protocol

INTRODUCTION

Smoke-free school hours (SFSHs) entails a smoking ban during school hours and might be an effective intervention to reduce the high smoking prevalence in vocational schools. For SFSH to be effective, the policy must be adequately implemented and enforced; this challenge for schools constitutes a research gap. The 'Smoke-Free Vocational Schools' research and intervention project has been developed to facilitate schools' implementation of SFSH. It is scheduled to run from 2018 to 2022, with SFSH being implemented in 11 Danish vocational schools. This study protocol describes the intervention project and evaluation design of the research and intervention project.

METHODS AND ANALYSIS

The intervention project aims to develop an evidence-based model for implementing SFSH in vocational schools and similar settings. The project is developed in a collaboration between research and practice. Two public health NGOs are responsible for delivering the intervention activities in schools, while the research partner evaluates what works, for whom, and under what circumstances. The intervention lasts one year per school, targeting different socioecological levels. During the first 6 months, activities are delivered to stimulate organisational readiness to implement SFSH. Then, SFSH is established, and during the next 6 months, activities are delivered to stimulate implementation of SFSH into routine practice. The epistemological foundation is realistic evaluation. The evaluation focuses on both implementation and outcomes. Process evaluation will determine the level of implementation and explore what hinders or enables SFSH becoming part of routine practice using qualitative and quantitative methods. Outcomes evaluation will quantitively assess the intervention's effectiveness, with the primary outcome measure being changes in smoking during school hours.

ETHICS AND DISSEMINATION

Informed consent will be obtained from study participants according to the General Data Protection Regulation (GDPR) and Danish data protection law. The study adheres to Danish ethics procedures. Study findings will be disseminated at conferences and further published in open-access peer-reviewed journals.

TOB-STOP-COP (TOBacco STOP in COPd trial): study protocol-a randomized open-label, superiority, multicenter, two-arm intervention study of the effect of "high-intensity" vs. "low-intensity" smoking cessation intervention in active smokers with chronic obstructive pulmonary disease

BACKGROUND

Cigarette smoking is the leading cause of chronic obstructive pulmonary disease (COPD), and it contributes to the development of many other serious diseases. Smoking cessation in COPD patients is known to improve survival and reduce the number of hospitalization-requiring acute exacerbations of COPD. However, smoking cessation interventions in these patients have only been successful for approximately 15-20% for consistent smoking abstinence in 12 months. Thus, more effective interventions are needed for this patient group. The aim of this study is to determine whether a high-intensity intervention compared to a low-intensity intervention can increase the proportion of persistent (> 12 months) anamnestic and biochemical smoking cessation in active smokers with COPD.

METHODS

This study is a randomized controlled trial. A total of 600 active smokers with COPD will be randomly assigned 1:1 to either a standard treatment (guideline-based municipal smoking cessation program, "low intensity" group) or an intervention ("high-intensity" group) group, which consists of group sessions, telephone consultations, behavior design, hotline, and "buddy-matching" (smoker matched with COPD patient who has ceased smoking). Both groups will receive pharmacological smoking cessation. The primary endpoint is anamnestic and biochemical (cotinine analysis in urine) validated smoking cessation after 12 months.

DISCUSSION

The potential benefit of this project is to improve smoking cessation rates and thereby reduce smoking-related exacerbations of COPD. In addition, the project can potentially benefit from increasing the quality of life and longevity of COPD patients and reducing the risk of other smoking-related diseases.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04088942 . Registered on 13 September 2019.

Lifestyle Interventions for Weight Management in People with Serious Mental Illness: A Systematic Review with Meta-Analysis, Trial Sequential Analysis, and Meta-Regression Analysis Exploring the Mediators and Moderators of Treatment Effects

BACKGROUND

Serious mental illness (SMI) reduces life expectancy, primarily due to somatic comorbidity linked to obesity. Meta-analyses have found beneficial effects of lifestyle interventions in people with SMI and recommended their implementation to manage obesity.

OBJECTIVE

The objective of this systematic review was to assess the benefits and harms of individualized lifestyle interventions for weight in people diagnosed with SMI and to explore potential mediators and moderators of the effect.

METHODS

The protocol was registered at PROSPERO (CRD42016049093). Randomized clinical trials (RCTs) assessing the effect of individualized lifestyle interventions on weight management in people with SMI were included. Primary outcomes were differences in endpoint body mass index (BMI) and the proportion achieving clinically relevant weight loss (≥5%). Secondary outcomes included quality of life, cardiometabolic risk factors, and adverse effects.

RESULTS

We included 41 RCTs (n = 4,267). All trials were at high risk of bias according to the Cochrane Handbook for Systematic Reviews of Interventions. The experimental interventions reduced the mean difference in BMI by -0.63 kg/m2 (95% confidence interval [CI] = -1.02 to -0.23; p = 0.002; I2 = 70.7%) compared to the control groups. At postintervention follow-up (17 RCTs), the effect size remained similar but was no longer significant (BMI = -0.63 kg/m2; 95% CI = -1.30 to 0.04; p = 0.07; I2 = 48.8%). The risk ratio for losing ≥5% of baseline weight was 1.51 (95% CI = 1.07-2.13; p = 0.02) compared to the control groups. GRADE showed very low or low quality of evidence.

CONCLUSION

There is a statistically significant, but clinically insignificant, mean effect of individualized lifestyle interventions for weight reduction in people with SMI.

Reminders of a Stigmatized Status Might Help Smokers Quit

As members of a devalued group, it is not surprising that smokers experience stigmatization and discrimination. But it is not clear if smokers react to these experiences by moving toward or away from their group membership and identity as smokers. Guided by the identity threat model of stigma (Major and O'Brien, 2005) we examined the process of stigmatization and its emotional, cognitive, attitudinal, and behavioral consequences. We experimentally examined how reading a stigmatizing newspaper article or a control article (Experiment 1) and recalling one's experience with smoking discrimination or a control prompt (Experiment 2) affected smokers' responses. We also examined the role of cultural contexts (U.S. vs. Denmark; only in Experiment 1) and smoking identity. In Experiment 1, we used a community sample of smokers from the U.S. (N = 111) and Denmark (N = 111). We found that reading the stigmatizing article (compared to the control) caused more rejection sensitivity (U.S. participants only) and more intentions to quit smoking (both U.S. and Danish participants) for smokers low in smoking identity. In Experiment 2, we used an online sample of 194 U.S. smokers and found that recalling instances of mistreatment made smokers more stressed, rejection sensitive, and interested in smoking cessation, when smokers appraised the stigma cue as threatening. Thus, we generally found that identity threat moved smokers toward leaving their stigmatized group (e.g., quitting smoking) rather than away from it. Our studies highlight the importance of understanding psychological process by which smokers distance themselves from their spoiled identity.

Example 1: Danish regulations to phase out smoking

In recent years, progress in Danish tobacco control has come to a halt and there has been an increase in smoking prevalence. A capacity assessment report on the implementation of effective tobacco control measures concluded that there is no overall strategy or plan to protect children, adolescents and adults from the harms of tobacco, despite the national vision of no children and adolescents smoking by 2030. Another finding was that the tobacco industry is influential in Danish policy-making and not properly regulated. Key recommendations were: 1) Develop an overall, comprehensive strategy and implement a well-designed plan. 2) Increase tobacco taxes. 3) Adopt plain packaging and a point-of-sale display ban. 4) Ensure protection from exposure to second-hand smoke and 5) Protect public health policy from the influence of the tobacco industry. The Danish Government, however, is very reluctant and there is no sign of implementation of the recommendations, despite strong public support. On the other hand, there is progress at local level as many municipalities and private workplaces have implemented smokefree working hours (no smoking at all during working hours, even if you work at home), schools have implemented smokefree school hours (no smoking from 8 to 16, even if pupils go home for lunch or break) and large supermarket chains have implemented point-of-sale display bans.

The cardiovascular effects of electronic cigarettes: A systematic review of experimental studies

BACKGROUND

Smoking is responsible for substantial cardiovascular morbidity and mortality. Electronic cigarettes have been advocated as a means to reduce this disease burden; by reducing exposure to harmful substances in smokers who are unable to quit. Concerns have been raised however, about cardiovascular effects of their use, with inhalants containing carbonyls and fine particulate matter. We systematically reviewed experimental studies of in vitro, animal, and human cardiovascular effects associated with electronic cigarette use.

METHODS

A literature search was conducted using Ovid MEDLINE & Embase databases, identifying experimental studies investigating cardiovascular effects of electronic cigarette use. Subsequently, Cochrane Risk of Bias tools were used to assess study quality. Any differences in outcomes by conflict of interest and risk of bias status were sought.

RESULTS

38 studies were included, investigating animals (n=6), humans (n=24) and human cardiovascular cells in vitro (n=8). 74.3% of studies found potentially harmful effects. Increased sympathetic nerve activity was observed in human studies, whilst platelet haemostatic processes, reactive oxygen species production and endothelial dysfunction were reported across all study types. Studies with conflicts of interest or median-high risk of bias were less likely to identify potentially harmful effects (p=0.0007, p=0.04 respectively).

DISCUSSION

Most studies suggest potential for cardiovascular harm from electronic cigarette use, through mechanisms that increase risk of thrombosis and atherosclerosis. Notably, studies with conflicts of interest are significantly less likely to identify concerning cardiovascular effects. Included studies examine healthy, adult participants, limiting generalisation to potential high-risk groups including individuals with established cardiovascular disease or young, non-smokers.

DOES IT HELP SMOKERS IF WE STIGMATIZE THEM? A TEST OF THE STIGMA-INDUCED IDENTITY THREAT MODEL AMONG U.S. AND DANISH SMOKERS

Research shows that smokers feel stigmatized, but does stigmatizing smokers do more harm than good? The model of stigma-induced identity threat was used to experimentally examine how U.S. and Danish smokers respond to stigma-relevant cues. Heavy smokers (112 Americans, 112 Danes) smoked a cigarette while giving a speech that was either video (stigma-visible condition) or audio recorded (stigma-concealed condition). Smokers high in self-concept reacted to the stigma-visible (as opposed to the stigma-concealed) condition with greater physiological reactivity (b = -2.80, p = .05), cognitive depletion (U.S. smokers, b = -0.06, p = .11), self-exempting beliefs (b = 0.32, p < .001), and less interest in stopping smoking (b = 0.28, p = .02). Thus, stigmatization led smokers toward emotional, cognitive, and attitudinal reactions that might make them less likely to quit. Future research should examine when smokers respond to stigmatization by quitting rather than with resistance or indifference.

Maternal and fetal genetic effects on birth weight and their relevance to cardio-metabolic risk factors

Birth weight variation is influenced by fetal and maternal genetic and non-genetic factors, and has been reproducibly associated with future cardio-metabolic health outcomes. In expanded genome-wide association analyses of own birth weight (n = 321,223) and offspring birth weight (n = 230,069 mothers), we identified 190 independent association signals (129 of which are novel). We used structural equation modeling to decompose the contributions of direct fetal and indirect maternal genetic effects, then applied Mendelian randomization to illuminate causal pathways. For example, both indirect maternal and direct fetal genetic effects drive the observational relationship between lower birth weight and higher later blood pressure: maternal blood pressure-raising alleles reduce offspring birth weight, but only direct fetal effects of these alleles, once inherited, increase later offspring blood pressure. Using maternal birth weight-lowering genotypes to proxy for an adverse intrauterine environment provided no evidence that it causally raises offspring blood pressure, indicating that the inverse birth weight-blood pressure association is attributable to genetic effects, and not to intrauterine programming.

Healthy lifestyles reduce suPAR and mortality in a Danish general population study

Background

The plasma level of the inflammatory biomarker soluble urokinase plasminogen activator receptor (suPAR) is a strong predictor of disease development and premature mortality in the general population. Unhealthy lifestyle habits such as smoking or unhealthy eating is known to elevate the suPAR level. We aimed to investigate whether change in lifestyle habits impact on the suPAR level, and whether the resultant levels are associated with mortality.

Results

Paired suPAR measurements from baseline- and the 5-year visit of the population-based Inter99 study were compared with the habits of diet, smoking, alcohol consumption, and physical activity. Paired suPAR measurements for 3225 individuals were analyzed by linear regression, adjusted for demographics and lifestyle habits. Compared to individuals with a healthy lifestyle, an unhealthy diet, low physical activity, and daily smoking were associated with a 5.9, 12.8, and 17.6% higher 5-year suPAR, respectively. During 6.1 years of follow-up after the 5-year visit, 1.6% of those with a low suPAR (mean 2.93 ng/ml) died compared with 3.8% of individuals with a high suPAR (mean 4.73 ng/ml), P <  0.001. In Cox regression analysis, adjusted for demographics and lifestyle, the hazard ratio for mortality per 5-year suPAR doubling was 2.03 (95% CI: 1.22-3.37).

Conclusion

Lifestyle has a considerable impact on suPAR levels; the combination of unhealthy habits was associated with 44% higher 5-year suPAR values and the 5-year suPAR was a strong predictor of mortality. We propose suPAR as a candidate biomarker for lifestyle changes as well as the subsequent risk of mortality.

Meta-analysis of exome array data identifies six novel genetic loci for lung function

Background: Over 90 regions of the genome have been associated with lung function to date, many of which have also been implicated in chronic obstructive pulmonary disease. Methods: We carried out meta-analyses of exome array data and three lung function measures: forced expiratory volume in one second (FEV ₁), forced vital capacity (FVC) and the ratio of FEV ₁ to FVC (FEV ₁/FVC). These analyses by the SpiroMeta and CHARGE consortia included 60,749 individuals of European ancestry from 23 studies, and 7,721 individuals of African Ancestry from 5 studies in the discovery stage, with follow-up in up to 111,556 independent individuals. Results: We identified significant (P<2·8x10 ^-7) associations with six SNPs: a nonsynonymous variant in RPAP1, which is predicted to be damaging, three intronic SNPs ( SEC24C, CASC17 and UQCC1) and two intergenic SNPs near to LY86 and FGF10. Expression quantitative trait loci analyses found evidence for regulation of gene expression at three signals and implicated several genes, including TYRO3 and PLAU. Conclusions: Further interrogation of these loci could provide greater understanding of the determinants of lung function and pulmonary disease.

Ups and downs of a peer-based smoking cessation intervention help tailored to hospital-employees with low socioeconomic status: The RESPEKT Study

INTRODUCTION

Smoking is one of the most important determinants of socioeconomic inequality in mortality. Few studies have tested which interventions are effective in smokers with low socioeconomic status (SES).

METHODS

All hospitals in the Capital Region of Denmark were included and randomized to intervention or control groups. The target-group was smokers with low SES. Intervention hospitals: smokers in the target-group assisted researchers to tailor a group-based smoking cessation intervention. Further they helped recruiting smoking colleagues and motivating them to stay abstinent. Control hospitals: ‘as usual’. Unforeseen organizational challenges led to a change of study design; the hospital-level assessment was reduced to two cross-sectional surveys.

RESULTS

Response rates in hospitals’ smoking status survey were very low. Smoking status was reported by 1876 out of 7003 employees at baseline and 2280 out of 7496 employees at 1-year follow-up. Two cross-sectional surveys showed no significant difference in self-reported smoking at 1-year follow-up between intervention and control hospitals (p=0.262). We recruited 100 smokers in the group-based smoking cessation intervention tailored to smokers with low SES (corresponding to approx. 10% of smokers in target-group); 32.4% of these were validated as continuously abstinent at 6 months follow-up.

CONCLUSIONS

Involving smokers with low SES as partners at an early stage of study design facilitated both recruitment and development of the intervention. Despite high validated long-term abstinence rates in smoking cessation groups in the intervention hospitals we found no apparent effect of the intervention at hospital-level after one year. However, larger involvement of the target-group seems feasible and is recommended.

Electronic cigarette use in youths: a position statement of the Forum of International Respiratory Societies

Children and adolescents are highly susceptible to nicotine addiction, which affects their brain development, even in those who smoke infrequently. Young people who become addicted to nicotine are at greater risk of becoming lifelong tobacco consumers. The use of nicotine-delivering electronic cigarettes has risen dramatically among youths worldwide. In addition to physical dependence, adolescents are susceptible to social and environmental influences to use electronic cigarettes. The product design, flavours, marketing, and perception of safety and acceptability have increased the appeal of electronic cigarettes to young people, thus leading to new generations addicted to nicotine. Moreover, there is growing evidence that electronic cigarettes in children and adolescents serve as a gateway to cigarette smoking. There can be no argument for harm reduction in children. To protect this vulnerable population from electronic cigarettes and other nicotine delivery devices, we recommend that electronic cigarettes be regulated as tobacco products and included in smoke-free policies. Sale of electronic cigarettes should be barred to youths worldwide. Flavouring should be prohibited in electronic cigarettes, and advertising accessible by youths and young adults be banned. Finally, we recommend greater research on the health effects of electronic cigarettes and surveillance of use across different countries.

A multifactorial approach to explaining the stagnation in national smoking rates

The aim of this paper was to investigate if a multifactorial approach may be used to explain why national smoking rates have levelled off in Denmark after 60 years of decline. 
Methods: Seven hypothetical explanations for stagnation in smoking rate were explored. A period of five years with a declining smoking prevalence (2007-2011) was compared with four years of stalled smoking prevalence (2012-2015). We used individual and national level information sources, mostly cross-sectional data that were collected repeatedly, including large nationally representative surveys, sales stat-istics, nation-wide news and smoking cessation databases and legal information, among others. 
Results: Most theories were rejected, leaving some that might have contributed to the stagnation: substantially 
fewer smokers had tried to quit in the stagnation period. Furthermore, the price of tobacco had remained almost unchanged, tobacco control legislation and anti-smoking campaigns had not been very intensive, assistance to quit and the Health Authority's manpower allocated to tobacco control had decreased temporarily while the use of e-cigarettes had increased in the stagnation period.
 Conclusions: Important components to focus on in future tobacco control in Denmark were identified. The study suggests that, in future, we need to focus on exploring why Danish smokers have an increasing wish to quit while fewer and fewer, nevertheless, actually attempt to quit. Neither the authors nor the Danish Health Authority were aware of this paradox. 
Funding: We would like to express our gratitude to the Danish Health Foundation for financial support. The researchers are independent of the founders.
 Trial registration: not relevant.

Meta-analysis of exome array data identifies six novel genetic loci for lung function

Background: Over 90 regions of the genome have been associated with lung function to date, many of which have also been implicated in chronic obstructive pulmonary disease. Methods: We carried out meta-analyses of exome array data and three lung function measures: forced expiratory volume in one second (FEV ₁), forced vital capacity (FVC) and the ratio of FEV ₁ to FVC (FEV ₁/FVC). These analyses by the SpiroMeta and CHARGE consortia included 60,749 individuals of European ancestry from 23 studies, and 7,721 individuals of African Ancestry from 5 studies in the discovery stage, with follow-up in up to 111,556 independent individuals. Results: We identified significant (P<2·8x10 ^-7) associations with six SNPs: a nonsynonymous variant in RPAP1, which is predicted to be damaging, three intronic SNPs ( SEC24C, CASC17 and UQCC1) and two intergenic SNPs near to LY86 and FGF10. Expression quantitative trait loci analyses found evidence for regulation of gene expression at three signals and implicated several genes, including TYRO3 and PLAU. Conclusions: Further interrogation of these loci could provide greater understanding of the determinants of lung function and pulmonary disease.

Meta-analysis of exome array data identifies six novel genetic loci for lung function

Background: Over 90 regions of the genome have been associated with lung function to date, many of which have also been implicated in chronic obstructive pulmonary disease. Methods: We carried out meta-analyses of exome array data and three lung function measures: forced expiratory volume in one second (FEV 1), forced vital capacity (FVC) and the ratio of FEV 1 to FVC (FEV 1/FVC). These analyses by the SpiroMeta and CHARGE consortia included 60,749 individuals of European ancestry from 23 studies, and 7,721 individuals of African Ancestry from 5 studies in the discovery stage, with follow-up in up to 111,556 independent individuals. Results: We identified significant (P<2·8x10 -7) associations with six SNPs: a nonsynonymous variant in RPAP1, which is predicted to be damaging, three intronic SNPs ( SEC24C, CASC17 and UQCC1) and two intergenic SNPs near to LY86 and FGF10. Expression quantitative trait loci analyses found evidence for regulation of gene expression at three signals and implicated several genes, including TYRO3 and PLAU. Conclusions: Further interrogation of these loci could provide greater understanding of the determinants of lung function and pulmonary disease.