Sleep disordered breathing and daytime sleepiness are associated with poor academic performance in teenagers. A study using the Pediatric Daytime Sleepiness Scale (PDSS)

STUDY OBJECTIVES

Inadequate sleep and sleep disordered breathing (SDB) can impair learning skills. Questionnaires used to evaluate sleepiness in adults are usually inadequate for adolescents. We conducted a study to evaluate the performance of a Spanish version of the Pediatric Daytime Sleepiness Scale (PDSS) and to assess the impact of sleepiness and SDB on academic performance.

DESIGN

A cross-sectional survey of students from 7 schools in 4 cities of Argentina.

MEASUREMENTS

A questionnaire with a Spanish version of the PDSS was used. Questions on the occurrence of snoring and witnessed apneas were answered by the parents. Mathematics and language grades were used as indicators of academic performance.

PARTICIPANTS

The sample included 2,884 students (50% males; age: 13.3 +/- 1.5 years)

RESULTS

Response rate was 85%; 678 cases were excluded due to missing data. Half the students slept <9 h per night on weekdays. The mean PDSS value was 15.74 +/- 5.93. Parental reporting of snoring occurred in 511 subjects (23%); snoring was occasional in 14% and frequent in 9%. Apneas were witnessed in 237 cases (11%), being frequent in 4% and occasional in 7%. Frequent snorers had higher mean PDSS scores than occasional or nonsnorers (18 +/- 5, 15.7 +/- 6 and 15.5 +/- 6, respectively; P < 0.001). Reported snoring or apneas and the PDSS were significant univariate predictors of failure and remained significant in multivariate logistic regression analysis after adjusting for age, sex, body mass index, specific school attended, and sleep habits.

CONCLUSIONS

Insufficient hours of sleep were prevalent in this population. The Spanish version of the PDSS was a reliable tool in middle-school-aged children. Reports of snoring or witnessed apneas and daytime sleepiness as measured by PDSS were independent predictors of poor academic performance.

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.

RESPIRATORY IMPACT OF ELECTRONIC CIGARETTES AND "LOW-RISK" TOBACCO

Electronic cigarettes, handheld devices that generate an aerosol that may contain nicotine by heating a solution or e-liquid, have been increasingly used especially in the young population. The aerosol's composition is determined by temperature, and by the substances contained in the heated liquid: glycerin, propylene glycol, nicotine in variable concentrations, flavoring agents, and other non-nicotine compounds. >80 compounds (including known toxics, e.g., formaldehyde, acetaldehyde, metallic nanoparticles, and acrolein) have been found in e-liquid and aerosols. Airway irritation, mucus hypersecretion, and inflammatory response, including systemic changes, have been observed after the exposure to e-cigarettes, leading to an increase in respiratory symptoms and changes in respiratory function and the host defense mechanisms. E-cigarette has been linked with an increase of symptoms in individuals with asthma, cystic fibrosis, and chronic obstructive pulmonary disease. One of the major concerns in public health is the rise in e-cigarette experimentation among never-smokers, especially children and adolescents, which leads to nicotine addiction and increases the chances of becoming with time a conventional smoker. There is an urgent need to regulate e-cigarettes and electronic nicotine delivery systems, at least with the same restrictions to those applied to tobacco products, and not to consider them as harmless products.

Smoke, Biomass Exposure, and COPD Risk in the Primary Care Setting: The PUMA Study

BACKGROUND

The evidence indicates that risk factors other than smoking are important in the development of COPD. It has been postulated that less traditional risk factors (eg, exposure to coal and/or biomass smoke) may interact with smoking to further increase COPD risk. This analysis evaluated the effect of exposure to biomass and smoking on COPD risk in a primary care setting in Latin America.

METHODS

Subjects attending routine primary care visits, ≥40 y old, who were current or former smokers or were exposed to biomass smoke, completed a questionnaire and performed spirometry. COPD was defined as post-bronchodilator FEV₁/FVC < 0.70 and the lower limit of normal. Smoking was defined by pack-years (≤ 20, 20-30, or > 30), and biomass exposure was defined as an exposure to coal or wood (for heating, cooking, or both) for ≥ 10 y.

RESULTS

One thousand seven hundred forty-three individuals completed the questionnaire, and 1,540 performed spirometry. Irrespective of COPD definition, approximately 40% of COPD subjects reported exposure to biomass versus 30% of those without COPD. A higher proportion of COPD subjects (post-bronchodilator FEV₁/FVC < 0.70) than those without COPD smoked > 30 pack-years (66% vs 39%); similar results were found with the lower limit of normal definition. Analysis of exposure to biomass > 10 y plus smoking > 20 pack-years (reference was no exposure) found that tobacco smoking (crude odds ratio [OR] 4.50, 95% CI 2.73-7.41; adjusted OR 3.30, 95% CI 1.93-5.63) and biomass exposure (crude OR 3.66, 95% CI 2.00-6.73; adjusted OR 2.28, 95% CI 1.18-4.41) were risk factors for COPD, with smoking a possible confounder for the association between biomass and COPD (post-bronchodilator FEV₁/FVC < 0.70); similar results were found with the lower limit of normal definition.

CONCLUSIONS

Subjects with COPD from primary care had a higher exposure to biomass and smoking compared with non-COPD subjects. Smoking and biomass are both risk factors for COPD, but they do not appear to have an additive effect.

Implementing evidence-based smoking cessation treatment in psychosocial care units (CAPS) in Brazil

BACKGROUND

The prevalence of smoking among mental health and addiction (MHA) patients is 3 times higher than it is in the general population, yet this patient population has received little help to combat smoking. Considering this, psychosocial care centers (CAPS - Centros de Atenção Psicossocial) are strategic locations for integrating tobacco dependence treatment (TDT) into existing treatment activities.

METHODS

Our team provided an 8-hour training package to the staff of CAPS that have not been providing specialized TDT for smokers. Our curriculum included the following topics focused on the implementation of treatment for MHA smokers: management, epidemiology, medications, psychotherapy, and smoking/mental health assessment instruments.

RESULTS

Our team trained the staff of 17 CAPS units within 10 cities - which included more than 186 health professionals. There were many barriers encountered as we provided this training. A summary of problems we faced were as follows: resistance to incorporating TDT in addiction/mental health-care units, resistance to the implementation of cognitive-behavioral therapy (CBT) (psychodynamic therapy and harm reduction were preferred) and treatment for smoking is already implemented in primary care network; resistance to the use of medication in addiction treatment (a preference for psychotherapy and psychosocial approach).

CONCLUSION

We learned a number of important lessons as we worked to improve the delivery of TDT to MHA patients in Brazil: provide clinicians an opportunity to explore how they feel/think about providing TDT to their clients at the very outset of the training, rather than focusing on a specific type of behavioral therapy for TDT (such as CBT), which some may find objectionable; use more generic descriptions of behavioral therapy such as 'supportive counseling'; include training professionals who are open to other forms of behavioral therapy in addition to psychoanalysis and discuss the important impact that MHA units can have in improving the quality of life for their patients who smoke.

Development of a simple binary response questionnaire to identify airflow obstruction in a smoking population in Argentina

The CODE questionnaire (COPD detection questionnaire), a simple, binary response scale (yes/no), screening questionnaire, was developed for the identification of patients with chronic obstructive pulmonary disease (COPD). We conducted a survey of 468 subjects with a smoking history in 10 public hospitals in Argentina. Patients with a previous diagnosis of COPD, asthma and other respiratory illness were excluded. Items that measured conceptual domains in terms of characteristics of symptoms, smoking history and demographics data were considered. 96 (20.5%) subjects had a diagnosis of COPD according to the 2010 Global Initiative for Chronic Obstructive Lung Disease strategy document. The variables selected for the final questionnaire were based on univariate and multivariate analyses and clinical criteria. Finally, we selected the presence or absence of six variables (age ≥50 years, smoking history ≥30 pack-years, male sex, chronic cough, chronic phlegm and dyspnoea). Of patients without any of these six variables (0 points), none had COPD. The ability of the CODE questionnaire to discriminate between subjects with and without COPD was good (the area under the receiver operating characteristic curve was 0.75). Higher scores were associated with a greater probability of COPD. The CODE questionnaire is a brief, accurate questionnaire that can identify smoking individuals likely to have COPD.

Respiratory medication use in primary care among COPD subjects in four Latin American countries

OBJECTIVES

To assess respiratory medications used, factors predicting treatment and patterns of corticosteroid (CS) use in primary care in Latin America among chronic obstructive pulmonary disease (COPD) patients.

METHODS

COPD was defined as post-bronchodilator forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) < 0.70 or previous medical diagnosis. To determine factors associated with respiratory medication use, crude and adjusted Poisson regression models were performed.

RESULTS

Of 1743 patients interviewed, 1540 completed spirometry, 309 had COPD (FEV1/FVC<0.70) and 102 had a prior diagnosis of COPD. Among spirometry-defined COPD patients, 36.6% used respiratory medications: bronchodilators (BD) 24.9%, CS 13.3%, BD+CS 15.2%. In those with a previous diagnosis, 79.4% used respiratory medications: BD 64.7%, CS 37.6%, BD+CS 25.6%. A total of 81/102 (79%) patients with prior diagnosis were using CS despite not having airway obstruction or exacerbation. In spirometry-defined COPD, dyspnoea (OR 2.09, 95%CI 1.13-3.87), severe airway obstruction (OR 3.36, 95%CI 1.40-8.03) and exacerbation in the past year (OR 5.52, 95%CI 2.19-13.89) were associated with increased respiratory medication use. Among those with a previous diagnosis, use of respiratory medications was associated with cough (OR 5.31, 95%CI 1.28-22.12), severe airway obstruction (OR 29.50, 95%CI 3.18-273.30) and fewer years of schooling (OR 0.12, 95%CI 0.03-0.52).

CONCLUSIONS

In the primary care setting, undertreatment is frequent in spirometry-defined COPD patients, and there is increased use of CS (overtreatment) in patients with a previous diagnosis of COPD.

Consensus Document on Medical Faculty Education on the Treatment of Smoking

We report the results of a consensus reached by an expert group of representatives from different medical societies in Latin America on the objectives, competencies (knowledge, and skills), content, and duration of smoking cessation education in Latin American medical schools. The document discusses the following aspects: epidemiology, nicotine dependence, factors for initiation and maintenance of tobacco use, smoking-related disorders, diagnosis, minimal intervention, non-pharmacological and pharmacological interventions for smoking cessation, and prevention of smoking.

SEPAR-ALAT Consensus Document on Antipneumoccal Vaccination in Smokers

Streptococcus pneumoniae is responsible for several clinical syndromes, such as community-acquired pneumonia, sinusitis, otitis media, and others. The most severe clinical entity caused by this bacteria is undoubtedly invasive pneumococcal disease. Certain factors are known to increase the risk of presenting invasive pneumococcal disease, the most important being smoking habit and underlying concomitant diseases. This article comprises a consensus document on antipneumococcal vaccination in smokers, drawn up by a Smoking Expert Group from the Spanish Society of Pulmonology and Thoracic Surgery and the Latin American Chest Association.

[Reflections on smoking intervention opportunities in Latin America]

The tobacco epidemic is a huge public health problem affecting all Latin American countries. These countries have the characteristic of a wide base of the pyramidal population structure, with many young people who have been natural targets for the tobacco industry. Therefore in this region there is an urgent need to establish prevention and treatment strategies capable to reduce incidence and prevalence of tobacco smoking in the population and as a consequence modify the health effects of tobacco consumption. Treating nicotine addiction requires intervention strategies really effective to reduce the number of current smokers as well as giving them tools to avoid relapse and maintain abstinence. Currently poor and vulnerable groups, which represent 44% of the total population in Latin America, are the most susceptible to suffer the health consequences of smoking since they show the highest prevalence rates and have little or no access to health services. The Framework Convention on Tobacco Control (FCTC) and MPOWER, both strategies proposed by the World Health Organization against tobacco, define clear goals to achieve their purposes, nevertheless they are limited by the economic and human resources assigned by each country. The scientific community involved in the fight against tobacco must think about new ways to place this issue in the political agenda so there will be more opportunities to increase the resources and therefore to reduce tobacco consumption in all the groups of the population. In the fight against tobacco, this is the right time to consider primarily issues related to equity and social justice.

[Tobacco use among secondary school students in Argentina]

OBJECTIVES

To evaluate the prevalence of smoking among Argentine adolescents and describe its usage, factors related to taking up the habit, and exposure to second-hand smoke in the home.

METHODS

A cross-sectional study conducted through an anonymous survey of students 12-18 years of age in either the 8th grade of basic education or in the second course of high school or polytechnic school. The study took place in 2002 at 239 school within five urban centers of Argentina (Ciudad Autónoma de Buenos Aires, Partidos del Gran Buenos Aires, Gran Córdoba, Gran Mendoza, and Santa Fe). The random sample was stratified by socioeconomic level and rates were calculated according to an expanded sample composed of samplings from each stage.

RESULTS

The survey was completed by 11 734 students (50.5% males; 44.1% were 12-14 years of age and 56.7% were 15-18 years). In all, 30.0% of the males and 35.0% of the females were smokers at the time of the survey (22.5% in the 12-14 year age group and 40.1% in the 15-18 group). The main reason given for taking up smoking was "to see what it was like" (43.7%); 44.3% of the students who smoked did so when they felt anxious. In all, 64.5% claimed they wanted to stop and 72.5% had attempted to quit, although fewer than 8% of the smokers had gotten any professional help to do so. The overwhelming majority considered it unhealthy to smoke tobacco (93.5%) and be around second-hand smoke (89.6%). Only 30.4% felt they had not received enough information on detrimental effects of smoking. More than 70% of the adolescents were living with a smoker.

CONCLUSIONS

There is a high rate of smoking among Argentine students, especially females. Policies must be established that will prevent smoking initiation in secondary school. Recommendations are to prohibit tobacco-product advertising and to require stronger health warnings labels.

Access to Treatment for Chronic Obstructive Pulmonary Disease in the Americas: A Call for Action. A Joint Perspective from the Brazilian Thoracic Society, Canadian Thoracic Society, Latin American Thoracic Society, and the American Thoracic Society

Chronic obstructive pulmonary disease (COPD) is a major public health problem in the Americas (a region of the world comprising North, Central, and South America), although there is substantial variation in disease prevalence, morbidity, and mortality between and within nations. Across the Americas, COPD disproportionately affects vulnerable populations, including minoritized populations and impoverished persons, who are more likely to be exposed to risk factors such as tobacco use, air pollution, infections such as tuberculosis, and biomass smoke, but less likely to have adequate healthcare access. Management of COPD can be challenging across the Americas, with some barriers being specific to certain countries and others shared across the United States, Canada, and Latin America. Because most cases of COPD are undiagnosed because of suboptimal access to health care and pulmonary function testing and, thus, cannot be treated, increased access to spirometry would have a substantial impact on disease management across the Americas. For individuals who are diagnosed, access to medications and other interventions is quite variable across and within nations, even in those with universal healthcare systems, such as Canada and Brazil. This emphasizes the importance of collaborative treatment guidelines, which should be adapted for the healthcare systems and policies of each nation or region, as appropriate. To have a positive impact on COPD management in the Americas, we propose actionable items, including the need for all our respiratory societies to engage key stakeholders (e.g., patient-led organizations, professional societies, and governmental and nongovernmental agencies) while advocating for campaigns and policies to ensure clean air for all; eliminate tobacco use and enhance coverage for treatment of nicotine dependence; and improve access to early case finding, diagnosis, and treatment for all patients, including underserved and vulnerable populations.