Racial/Ethnic Disparities Impact the Real-World Effectiveness of a Multicomponent Maternal Smoking Cessation Program: Findings from the CTTP Cohort

INTRODUCTION

Smoking during pregnancy adversely affects perinatal outcomes for both women and infants. We conducted a retrospective cohort study of the state-funded Comprehensive Tobacco Treatment Program (CTTP) - the largest maternal tobacco cessation program in San Bernardino County, California - to determine the real-world program effectiveness and to identify variables that can potentially improve effectiveness.

METHODS

During 2012-2019, women who smoked during pregnancy were enrolled in CTTP's multicomponent behavioral smoking cessation program that implemented components of known efficacy (i.e., incentives, biomarker testing, feedback, and motivational interviewing).

RESULTS

We found that 40.1% achieved prolonged abstinence by achieving weekly, cotinine-verified, 7-day abstinence during 6 to 8 weeks of enrollment. Using intention-to-treat analyses, we computed that the self-reported point prevalence abstinence rate (PPA) at the six-month telephone follow-up was 36.7%. Cohort members achieving prolonged abstinence during the CTTP were five times more likely to achieve PPA six months after CTTP. Several non-Hispanic ethnicities (Black, Native American, White, or More than one ethnicity) in the cohort were two-fold less likely (relative to Hispanics) to achieve prolonged abstinence during CTTP or PPA at six months after CTTP. This disparity was further investigated in mediation analysis. Variables such as quitting during the first trimester and smoking fewer cigarettes at enrollment were also associated with achieving PPA at six months.

DISCUSSION

Racial/ethnic health disparities that have long been linked to a higher rate of maternal smoking persist even when the pregnant smoker enrolls in a smoking cessation program.

Fungal Planet description sheets: 1383-1435

Novel species of fungi described in this study include those from various countries as follows: Australia, Agaricus albofoetidus, Agaricus aureoelephanti and Agaricus parviumbrus on soil, Fusarium ramsdenii from stem cankers of Araucaria cunninghamii, Keissleriella sporoboli from stem of Sporobolus natalensis, Leptosphaerulina queenslandica and Pestalotiopsis chiaroscuro from leaves of Sporobolus natalensis, Serendipita petricolae as endophyte from roots of Eriochilus petricola, Stagonospora tauntonensis from stem of Sporobolus natalensis, Teratosphaeria carnegiei from leaves of Eucalyptus grandis × E. camaldulensis and Wongia ficherai from roots of Eragrostis curvula. Canada, Lulworthia fundyensis from intertidal wood and Newbrunswickomyces abietophilus (incl. Newbrunswickomyces gen. nov.) on buds of Abies balsamea. Czech Republic, Geosmithia funiculosa from a bark beetle gallery on Ulmus minor and Neoherpotrichiella juglandicola (incl. Neoherpotrichiella gen. nov.) from wood of Juglans regia. France, Aspergillus rouenensis and Neoacrodontium gallica (incl. Neoacrodontium gen. nov.) from bore dust of Xestobium rufovillosum feeding on Quercus wood, Endoradiciella communis (incl. Endoradiciella gen. nov.) endophytic in roots of Microthlaspi perfoliatum and Entoloma simulans on soil. India, Amanita konajensis on soil and Keithomyces indicus from soil. Israel, Microascus rothbergiorum from Stylophora pistillata. Italy, Calonarius ligusticus on soil. Netherlands, Appendopyricularia juncicola (incl. Appendopyricularia gen. nov.), Eriospora juncicola and Tetraploa juncicola on dead culms of Juncus effusus, Gonatophragmium physciae on Physcia caesia and Paracosmospora physciae (incl. Paracosmospora gen. nov.) on Physcia tenella, Myrmecridium phragmitigenum on dead culm of Phragmites australis, Neochalara lolae on stems of Pteridium aquilinum, Niesslia nieuwwulvenica on dead culm of undetermined Poaceae, Nothodevriesia narthecii (incl. Nothodevriesia gen. nov.) on dead leaves of Narthecium ossifragum and Parastenospora pini (incl. Parastenospora gen. nov.) on dead twigs of Pinus sylvestris. Norway, Verticillium bjoernoeyanum from sand grains attached to a piece of driftwood on a sandy beach. Portugal, Collybiopsis cimrmanii on the base of living Quercus ilex and amongst dead leaves of Laurus and herbs. South Africa, Paraproliferophorum hyphaenes (incl. Paraproliferophorum gen. nov.) on living leaves of Hyphaene sp. and Saccothecium widdringtoniae on twigs of Widdringtonia wallichii. Spain, Cortinarius dryosalor on soil, Cyphellophora endoradicis endophytic in roots of Microthlaspi perfoliatum, Geoglossum lauri-silvae on soil, Leptographium gemmatum from fluvial sediments, Physalacria auricularioides from a dead twig of Castanea sativa, Terfezia bertae and Tuber davidlopezii in soil. Sweden, Alpova larskersii, Inocybe alpestris and Inocybe boreogodeyi on soil. Thailand, Russula banwatchanensis, Russula purpureoviridis and Russula lilacina on soil. Ukraine, Nectriella adonidis on overwintered stems of Adonis vernalis. USA, Microcyclus jacquiniae from living leaves of Jacquinia keyensis and Penicillium neoherquei from a minute mushroom sporocarp. Morphological and culture characteristics are supported by DNA barcodes. Citation: Crous PW, Boers J, Holdom D, et al. 2022. Fungal Planet description sheets: 1383-1435. Persoonia 48: 261-371. https://doi.org/10.3767/persoonia.2022.48.08.

Cohort profile for the Loma Linda University Health BREATHE programme: a model to study continuously incentivised employee smoking cessation

PURPOSE

The purpose of the Loma Linda University Health (LLUH) BREATHE cohort is to test the efficacy of a novel method of continuously incentivising participation in workplace smoking cessation on participation, long-term abstinence, health outcomes, healthcare costs and healthcare utilisation.

PARTICIPANTS

In 2014, LLUH-a US academic medical centre and university-incentivised participation in a workplace smoking cessation programme (LLUH BREATHE) by lowering health plan costs. Specifically, LLUH introduced a Wholeness Health Plan (WHP) option that, for the smokers, continuously incentivises participation in nicotine screening and the LLUH BREATHE smoking cessation programme by offering an 'opt-in wellness discount' that consisted of 50%-53% lower out of pocket health plan costs (ie, monthly employee premiums, copayments). This novel 'continuously incentivised' model lowers annual health plan costs for smokers who, on an annual basis, attempt or maintain cessation from tobacco use. The annual WHP cost savings for smokers far exceed the value of short-term incentives that have been tested in workplace cessation trials to date. This ongoing health plan option offered to over 16 000 employees has created an open, dynamic LLUH BREATHE cohort of current and former smokers (n=1092).

FINDINGS TO DATE

Our profile of the LLUH BREATHE cohort indicates that after 5 years of follow-up in a prospective cohort study (2014-2019), continuously incentivised smoking cessation produced a 74% participation (95% CI (71% to 77%)) in employer-sponsored smoking cessation attempts that were occurring less than a year after the incentive was offered. The cohort can be purposed to examine the effect of continuously incentivised cessation on cessation outcomes, health plan utilisation/costs, use of electronic nicotine delivery systems, and COVID-19 outcomes.

Implementation and Outcomes of a Maternal Smoking Cessation Program for a Multi-ethnic Cohort in California, USA, 2012-2019

Smoking during pregnancy remains one of the most significant risk factors for poor birth outcomes. During 2012-2019, the Loma Linda University Health Comprehensive Tobacco Treatment Program (CTTP) used a multicomponent behavioral intervention for tobacco cessation for 1402 pregnant smokers with components of known efficacy (i.e., incentives, biomarker testing, feedback, and motivational interviewing). The CTTP cohort includes a multi-ethnic sample of pregnant women with a mean age of 27 years referred by collaborating community-based healthcare providers in San Bernardino county. Evaluation of program outcomes from 7 years of follow-up (2012-2019) creates a rich cohort dataset for implementation science research to examine the real-world effectiveness of the program. In this report, we provide a cohort profile, and 8-week prolonged abstinence (8-week PA) and relapse findings from the first year of follow-up (n = 233). We found: (1) 28.4% achieved 8-week PA, (2) At a median of 6.2 months of follow-up after achieving 8-week PA, 23.2% of enrolled subjects reported tobacco cessation, and (3) a high rate of loss to follow-up (44%). In addition, our modeling indicated that the odds of relapse/smoking after enrollment was significantly higher in young mothers, non-Hispanic mothers (White, Black/African-American), mothers in the first and third trimester, and rural mothers. Formative quantitative and qualitative research on the CTTP cohort will consider the effects of a range of implementation science (number of intervention sessions, addition of a mHealth component, distance to care) and individual (partner/household smoking, birth outcomes, NICU) outcome measures for the purpose of scaling up the CTTP model.

Cumulative summation analysis of learning curve for robotic-assisted hiatal hernia repairs

BACKGROUND

Robotic-assisted laparoscopic surgery (RALS) is evolving as an important surgical approach in the field of general surgery. We aimed to evaluate the learning curve for RALS procedures involving repair of hiatal hernias.

METHODS

A series of robotic-assisted hiatal hernia (HH) repairs were performed between 2013 and 2017 by a surgeon at a single institution. Data were entered into a retrospective database. Patient demographics and intraoperative parameters including console time (CT), surgery time (ST), and total operative time (OT) were examined and abstracted for learning curve analysis using the cumulative sum (CUSUM) method. Assessment of perioperative and post-operative outcomes were calculated using descriptive statistics.

RESULTS

The average age of the patients was 57.4 years, average BMI was 29.9 kg/m², median American Society of Anesthesiologists (ASA) classification was 2, and average Charlson Comorbidity Index (CCI) score was 2.8. The series had a mean CT of 132.6 min, mean ST of 145.1 min, and mean OT of 197.4 min. The CUSUM learning curve for CT was best approximated as a third-order polynomial consisting of three unique phases: the initial training phase (case 1-40), the improvement phase (case 41-85), and the mastery phase (case 86 onwards). There was no significant difference in perioperative complications between the phases. Short-term clinical outcomes were comparable with national standards and did not correlate significantly with operative experience.

CONCLUSIONS

The three phases identified with CUSUM analysis represented characteristic stages of the learning curve for robotic hiatal hernia procedures. Our data suggest the training phase is achieved after 40 cases and a high level of mastery is achieved after approximately 85 cases. Thus, the CUSUM method serves as a useful tool for objectively evaluating practical skills for surgeons and can ultimately help establish milestones that assess surgical competency during robotic surgery training.

Pilot Feasibility Study of Incorporating Whole Person Care Health Coaching Into an Employee Wellness Program

Prior research supports positive health coaching outcomes, but there is limited literature on the integration of employer-sponsored health coaching into employee wellness strategy. The aim of our mixed methods study was to assess feasibility, acceptability, and preliminary efficacy of incorporating a whole-person care model of health coaching into an employee wellness program (i.e., weight loss, smoking cessation) that is made available by an employer-sponsored health plan. For the quantitative study, eligible employees and covered spouses (n = 39) from Loma Linda University Health were recruited into a novel, 12-week, whole person care intervention that combined health coaching and health education and examined outcomes from surveys detailing the participants' experience and biometric data from the intervention and maintenance periods. For the qualitative study, data were collected through key informant interviews from three health coaches and six intervention participants who were recruited via random sampling. Health coaching was well-received by the participants, and led to a slight albeit positive behavioral change for obesity. A significant decrease in body mass index occurred over 12 weeks of intervention (−0.36 kg/m², p = 0.016), that did not continue during the maintenance phase (−0.17 kg/m², p = 0.218). Qualitative findings indicated improved personal health awareness, accountability, motivation, and self-efficacy along with goal setting and barrier overcoming skills among the key themes. Our pilot study findings identify positive behavior change effects of an employee health intervention based on a whole person care model of health coaching with integrated health education, and also identify the need for methods to maintain behavior change (i.e., mHealth, peer-support) post-intervention. Further investigation in randomized controlled trials is the next step in this research.

Incorporating an Increase in Plant-Based Food Choices into a Model of Culturally Responsive Care for Hispanic/Latino Children and Adults Who Are Overweight/Obese

Introduction: The national rate of obesity in US Hispanic/Latinos exceeds all other major ethnic subgroups and represents an important health disparity. Plant-based diet interventions that emphasize whole plant foods with minimal processing and less refined grains and sugar have shown great promise in control of obesity, but there is a paucity of data translating this treatment effect to disparate populations. The objective of our study was to evaluate the efficacy of the Healthy Eating Lifestyle Program (HELP) for accomplishing weight management in a hospital-based, family centered, culturally tailored, plant-based diet intervention for Hispanic/Latino children who were overweight or obese. Methods: Our mixed methods evaluation included: (1) A one arm study to measure changes in body mass index (BMI) from pre- to post-intervention, and (2) A stakeholder analysis of the program staff. Results: For children ages 5–12 years who were overweight/obese, we found no evidence of excess weight gain evidenced by BMI Z scores (Z_post-pre = −0.02, p = 0.11). Among the parent/guardians who were overweight or obese, we found a decrease in BMI that was stronger in men (BMI _post-pre = −0.75 kg/m², p = 0.01) than in women (BMI _post-pre = −0.12 kg/m², p = 0.30). A program strength was the cultural tailoring of the plant-based diet choices. Conclusions: The evaluation raises the possibility that incorporating intervention components of HELP (plant-based food choices, family-based, cultural tailoring) into pediatric weight management can improve the standard of care.

Participation in a workplace smoking cessation program incentivized by lowering the cost of health care coverage: Findings from the LLUH BREATHE cohort

INTRODUCTION

Systematic analyses of workplace smoking cessation programs indicate that efficacy can be enhanced by using incentives. There is variation in the type of incentives used and their effect on participation and efficacy. The aim of our study was to examine whether lowering employee health plan costs (employee contributions, co-pays) encourage employee smokers to participate in workplace smoking cessation.

METHODS

We conducted a 2014-2015 prospective cohort study of 415 employee smokers of Loma Linda University Health (LLUH). The employees were offered participation in a workplace smoking cessation program (LLUH BREATHE Initiative) with the incentive of enrollment in an employer-provided health plan that had a 50% lower employee monthly contribution and co-payment relative to the employer-provided health plan for non-participants. Participation rates and variables associated with participation were analyzed.

RESULTS

In the LLUH BREATHE cohort, we found a very high rate of participation (72.7%; 95% CI: 69-77%) in workplace smoking cessation that was encouraged by a lower out-of-pocket health plan cost for the participating employee and/or spouse. Participation did, however, vary by gender and spouse, whereby female employee households with a qualifying smoker were more than two times more likely (employee: OR=2.89, 95% CI: 1.59-5.24; or spouse: OR=2.71, 95% CI: 1.47-5.00) to participate in smoking cessation than male employee households. The point prevalence, at four months, of abstinence from smoking among the participants was 48% (95% CI: 42-54%).

CONCLUSIONS

Our findings indicate that a workplace smoking cessation program that uses a novel reward-based incentive of lower out-of-pocket health plan costs results in a participation rate that is much higher than US norms.

Air Pollution in a Nationally Representative Sample: Findings from the National Adult Tobacco Survey of Lao PDR

In Southeast Asia, household air pollution (HAP) from solid fuel use is the leading cause of disability-adjusted life years (DALYs), a risk which is compounded by exposure to other sources of indoor and outdoor air pollution including secondhand tobacco smoke (SHS). The purpose of this study was to measure the individual and combined prevalence of exposure to household and community sources of air pollution in a national sample of adults in Lao PDR. We analyzed data from the 2012 National Adult Tobacco Survey (NATSL) of Lao PDR-a multi-stage stratified cluster sample of 9706 subjects from 2822 households located in all 17 provinces. Our findings indicate a high prevalence of exposure to household air pollution from cooking fires (78%) and SHS exposure in the home (74.5%). More than a third (32.8%) reported exposure to both inside the home. Exposure to outdoor sources of smoke from cooking, trash, and crop fires was substantial (30.1% to 56.0%). The aggregation of exposures from multiple sources of household air pollution raises the need for initiatives that establish programmatic linkages in the health, environmental, and agricultural sectors to provide a comprehensive strategy to reduce risk factors for respiratory disease in Lao PDR and the region.

Smoked Tobacco, Air Pollution, and Tuberculosis in Lao PDR: Findings from a National Sample

In 2017, more than half of the global burden of incident tuberculosis (TB) came from the Western Pacific region. In Lao People's Democratic Republic (PDR), the high rates of tobacco use and use of polluting biomass fuels for cooking (e.g., wood, charcoal, crop waste, dung) represent significant risk factors for TB. The purpose of this study was to determine the association between self-reported (1) smoking and TB; and (2) exposure to air pollution (from both cooking fires and environmental tobacco smoke) and TB among adults in Lao PDR. We analyzed data from the 2012 National Adult Tobacco Survey (NATSL) of Lao PDR-a multi-stage stratified cluster sample of 9706 subjects from 2822 households located in all 17 provinces. Utilizing a nationally representative sample and inferential, multivariable methods, we observed a significant increase in odds of self-reported TB among those who smoked tobacco (OR = 1.73, 95% CI = (1.00 to 2.98)). Larger multivariable models identified independent contributions from exposure to tobacco pipes (OR = 21.51, 95% CI = (6.34 to 72.89)) and communal outdoor fires (OR = 2.27, 95% CI = (1.15 to 4.49)). An index measuring combined exposure to smoked tobacco, environmental tobacco smoke in enclosed workspace, indoor cooking fire, trash fires, and other outdoor communal fires also showed a positive association (OR per added exposure = 1.47, 95% CI = (1.14 to 1.89)). The findings of this study underscore the need for multi-sectoral collaboration between tobacco control, environmental health, TB prevention and treatment programs, national authorities, policy makers, civil groups, and the private sector to address the convergence of potential risk factors impacting respiratory health in Lao PDR.

Plant-Based Diets Are Associated With Lower Adiposity Levels Among Hispanic/Latino Adults in the Adventist Multi-Ethnic Nutrition (AMEN) Study

Background: The Hispanic/Latino population in the US is experiencing high rates of obesity and cardio-metabolic disease that may be attributable to a nutrition transition away from traditional diets emphasizing whole plant foods. In the US, plant-based diets have been shown to be effective in preventing and controlling obesity and cardio-metabolic disease in large samples of primarily non-Hispanic subjects. Studying this association in US Hispanic/Latinos could inform culturally tailored interventions.

Objective: To examine whether the plant-based diet pattern that is frequently followed by Hispanic/Latino Seventh-day Adventists is associated with lower levels of adiposity and adiposity-related biomarkers.

Methods: The Adventist Multiethnic Nutrition Study (AMEN) enrolled 74 Seventh-day Adventists from five Hispanic/Latino churches within a 20 mile radius of Loma Linda, CA into a cross-sectional study of diet (24 h recalls, surveys) and health (anthropometrics and biomarkers).

Results: Vegetarian diet patterns (Vegan, Lacto-ovo vegetarian, Pesco-vegetarian) were associated with significantly lower BMI (24.5 kg/m² vs. 27.9 kg/m², p = 0.006), waist circumference (34.8 in vs. 37.5 in, p = 0.01), and fat mass (18.3 kg vs. 23.9 kg, p = 0.007), as compared to non-vegetarians. Adiposity was positively associated with pro-inflammatory cytokines (Interleukin-6) in this sample, but adjusting for this effect did not alter the associations with vegetarian diet.

Conclusions: Plant-based eating as practiced by US-based Hispanic/Latino Seventh-day Adventists is associated with BMI in the recommended range. Further work is needed to characterize this type of diet for use in obesity-related interventions among Hispanic/Latinos in the US.

Plant-Based Diets in Hispanic/Latino Adult Adventists in the United States and Their Association With Body Mass Index

PURPOSE

To characterize plant-based dietary practices and examine their relationship with body mass index (BMI) in Hispanic/Latino Seventh-day Adventists (SDA).

DESIGN

Cross-sectional analyses of data among Hispanics/Latinos in the Adventist Health Study-2 (AHS-2).

SETTING

The AHS-2 is a cohort of SDA adults (n = 96 592) in North America.

PARTICIPANTS

A total of 3475 Hispanics/Latinos who provided demographic, dietary, anthropometric, and lifestyle data at enrollment.

MEASURES

Plant-based dietary practices were determined from food frequency questionnaire; BMI, demographic, and lifestyle data were assessed by questionnaire.

ANALYSIS

In linear regression analysis, plant-based diets were modeled as dummy variables with nonvegetarian as the referent group and log(BMI) as the outcome adjusted for age, sex, education, exercise, nativity, alcohol use, smoking, and energy intake.

RESULTS

We identified 202 vegans, 664 vegetarians, 409 pesco-vegetarians, 227 semi-vegetarians, and 1973 nonvegetarians. Compared to the nonvegetarian referent (BMI = 27.50), estimated BMI were lower among vegans (23.58, P < .0001), vegetarians (25.24, P < .0001), pesco-vegetarians (26.36, P = .0002), and semi-vegetarians (26.69, P = .130). Other factors associated with lower BMI were being female (P = .001), nativity (Mexico, P = .002; South America, P < .0001; Caribbean, P = .004), having a college degree or higher (P = .01), exercise (P < .0001), and never smoked (P = .0006).

CONCLUSION

Hispanic/Latino SDAs who consumed plant-based diets had lower BMI than nonvegetarians. The application of a plant-based diet as practiced by the Hispanic/Latino Adventists in this population may have public health impact on US Hispanic/Latinos.

Constraints on Sub-GeV Dark-Matter-Electron Scattering from the DarkSide-50 Experiment

We present new constraints on sub-GeV dark-matter particles scattering off electrons based on 6780.0 kg d of data collected with the DarkSide-50 dual-phase argon time projection chamber. This analysis uses electroluminescence signals due to ionized electrons extracted from the liquid argon target. The detector has a very high trigger probability for these signals, allowing for an analysis threshold of three extracted electrons, or approximately 0.05 keVee. We calculate the expected recoil spectra for dark matter-electron scattering in argon and, under the assumption of momentum-independent scattering, improve upon existing limits from XENON10 for dark-matter particles with masses between 30 and 100  MeV/c^{2}.

Low-Mass Dark Matter Search with the DarkSide-50 Experiment

We present the results of a search for dark matter weakly interacting massive particles (WIMPs) in the mass range below 20  GeV/c^{2} using a target of low-radioactivity argon with a 6786.0 kg d exposure. The data were obtained using the DarkSide-50 apparatus at Laboratori Nazionali del Gran Sasso. The analysis is based on the ionization signal, for which the DarkSide-50 time projection chamber is fully efficient at 0.1  keVee. The observed rate in the detector at 0.5  keVee is about 1.5  event/keVee/kg/d and is almost entirely accounted for by known background sources. We obtain a 90% C.L. exclusion limit above 1.8  GeV/c^{2} for the spin-independent cross section of dark matter WIMPs on nucleons, extending the exclusion region for dark matter below previous limits in the range 1.8-6  GeV/c^{2}.

Anthropometric Factors and Thyroid Cancer Risk by Histological Subtype: Pooled Analysis of 22 Prospective Studies

BACKGROUND

Greater height and body mass index (BMI) have been associated with an increased risk of thyroid cancer, particularly papillary carcinoma, the most common and least aggressive subtype. Few studies have evaluated these associations in relation to other, more aggressive histologic types or thyroid cancer-specific mortality.

METHODS

This large pooled analysis of 22 prospective studies (833,176 men and 1,260,871 women) investigated thyroid cancer incidence associated with greater height, BMI at baseline and young adulthood, and adulthood BMI gain (difference between young-adult and baseline BMI), overall and separately by sex and histological subtype using multivariable Cox proportional hazards regression models. Associations with thyroid cancer mortality were investigated in a subset of cohorts (578,922 men and 774,373 women) that contributed cause of death information.

RESULTS

During follow-up, 2996 incident thyroid cancers and 104 thyroid cancer deaths were identified. All anthropometric factors were positively associated with thyroid cancer incidence: hazard ratios (HR) [confidence intervals (CIs)] for height (per 5 cm) = 1.07 [1.04-1.10], BMI (per 5 kg/m2) = 1.06 [1.02-1.10], waist circumference (per 5 cm) = 1.03 [1.01-1.05], young-adult BMI (per 5 kg/m2) = 1.13 [1.02-1.25], and adulthood BMI gain (per 5 kg/m2) = 1.07 [1.00-1.15]. Associations for baseline BMI and waist circumference were attenuated after mutual adjustment. Baseline BMI was more strongly associated with risk in men compared with women (p = 0.04). Positive associations were observed for papillary, follicular, and anaplastic, but not medullary, thyroid carcinomas. Similar, but stronger, associations were observed for thyroid cancer mortality.

CONCLUSION

The results suggest that greater height and excess adiposity throughout adulthood are associated with higher incidence of most major types of thyroid cancer, including the least common but most aggressive form, anaplastic carcinoma, and higher thyroid cancer mortality. Potential underlying biological mechanisms should be explored in future studies.

Central adiposity, obesity during early adulthood, and pancreatic cancer mortality in a pooled analysis of cohort studies

BACKGROUND

Body mass index (BMI), a measure of obesity typically assessed in middle age or later, is known to be positively associated with pancreatic cancer. However, little evidence exists regarding the influence of central adiposity, a high BMI during early adulthood, and weight gain after early adulthood on pancreatic cancer risk.

DESIGN

We conducted a pooled analysis of individual-level data from 20 prospective cohort studies in the National Cancer Institute BMI and Mortality Cohort Consortium to examine the association of pancreatic cancer mortality with measures of central adiposity (e.g. waist circumference; n = 647 478; 1947 pancreatic cancer deaths), BMI during early adulthood (ages 18-21 years) and BMI change between early adulthood and cohort enrollment, mostly in middle age or later (n = 1 096 492; 3223 pancreatic cancer deaths). Multivariable hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression models.

RESULTS

Higher waist-to-hip ratio (HR = 1.09, 95% CI 1.02-1.17 per 0.1 increment) and waist circumference (HR = 1.07, 95% CI 1.00-1.14 per 10 cm) were associated with increased risk of pancreatic cancer mortality, even when adjusted for BMI at baseline. BMI during early adulthood was associated with increased pancreatic cancer mortality (HR = 1.18, 95% CI 1.11-1.25 per 5 kg/m(2)), with increased risk observed in both overweight and obese individuals (compared with BMI of 21.0 to <23 kg/m(2), HR = 1.36, 95% CI 1.20-1.55 for BMI 25.0 < 27.5 kg/m(2), HR = 1.48, 95% CI 1.20-1.84 for BMI 27.5 to <30 kg/m(2), HR = 1.43, 95% CI 1.11-1.85 for BMI ≥30 kg/m(2)). BMI gain after early adulthood, adjusted for early adult BMI, was less strongly associated with pancreatic cancer mortality (HR = 1.05, 95% CI 1.01-1.10 per 5 kg/m(2)).

CONCLUSIONS

Our results support an association between pancreatic cancer mortality and central obesity, independent of BMI, and also suggest that being overweight or obese during early adulthood may be important in influencing pancreatic cancer mortality risk later in life.

Vegetarian dietary patterns and the risk of colorectal cancers

IMPORTANCE

Colorectal cancers are a leading cause of cancer mortality, and their primary prevention by diet is highly desirable. The relationship of vegetarian dietary patterns to colorectal cancer risk is not well established.

OBJECTIVE

To evaluate the association between vegetarian dietary patterns and incident colorectal cancers.

DESIGN, SETTING, AND PARTICIPANTS

The Adventist Health Study 2 (AHS-2) is a large, prospective, North American cohort trial including 96,354 Seventh-Day Adventist men and women recruited between January 1, 2002, and December 31, 2007. Follow-up varied by state and was indicated by the cancer registry linkage dates. Of these participants, an analytic sample of 77,659 remained after exclusions. Analysis was conducted using Cox proportional hazards regression, controlling for important demographic and lifestyle confounders. The analysis was conducted between June 1, 2014, and October 20, 2014.

EXPOSURES

Diet was assessed at baseline by a validated quantitative food frequency questionnaire and categorized into 4 vegetarian dietary patterns (vegan, lacto-ovo vegetarian, pescovegetarian, and semivegetarian) and a nonvegetarian dietary pattern.

MAIN OUTCOMES AND MEASURES

The relationship between dietary patterns and incident cancers of the colon and rectum; colorectal cancer cases were identified primarily by state cancer registry linkages.

RESULTS

During a mean follow-up of 7.3 years, 380 cases of colon cancer and 110 cases of rectal cancer were documented. The adjusted hazard ratios (HRs) in all vegetarians combined vs nonvegetarians were 0.78 (95% CI, 0.64-0.95) for all colorectal cancers, 0.81 (95% CI, 0.65-1.00) for colon cancer, and 0.71 (95% CI, 0.47-1.06) for rectal cancer. The adjusted HR for colorectal cancer in vegans was 0.84 (95% CI, 0.59-1.19); in lacto-ovo vegetarians, 0.82 (95% CI, 0.65-1.02); in pescovegetarians, 0.57 (95% CI, 0.40-0.82); and in semivegetarians, 0.92 (95% CI, 0.62-1.37) compared with nonvegetarians. Effect estimates were similar for men and women and for black and nonblack individuals.

CONCLUSIONS AND RELEVANCE

Vegetarian diets are associated with an overall lower incidence of colorectal cancers. Pescovegetarians in particular have a much lower risk compared with nonvegetarians. If such associations are causal, they may be important for primary prevention of colorectal cancers.

Patterns of food consumption among vegetarians and non-vegetarians

Vegetarian dietary patterns have been reported to be associated with a number of favourable health outcomes in epidemiological studies, including the Adventist Health Study 2 (AHS-2). Such dietary patterns may vary and need further characterisation regarding foods consumed. The aims of the present study were to characterise and compare the food consumption patterns of several vegetarian and non-vegetarian diets. Dietary intake was measured using an FFQ among more than 89 000 members of the AHS-2 cohort. Vegetarian dietary patterns were defined a priori, based on the absence of certain animal foods in the diet. Foods were categorised into fifty-eight minor food groups comprising seventeen major food groups. The adjusted mean consumption of each food group for the vegetarian dietary patterns was compared with that for the non-vegetarian dietary pattern. Mean consumption was found to differ significantly across the dietary patterns for all food groups. Increased consumption of many plant foods including fruits, vegetables, avocados, non-fried potatoes, whole grains, legumes, soya foods, nuts and seeds was observed among vegetarians. Conversely, reduced consumption of meats, dairy products, eggs, refined grains, added fats, sweets, snack foods and non-water beverages was observed among vegetarians. Thus, although vegetarian dietary patterns in the AHS-2 have been defined based on the absence of animal foods in the diet, they differ greatly with respect to the consumption of many other food groups. These differences in food consumption patterns may be important in helping to explain the association of vegetarian diets with several important health outcomes.

Reliability of meat, fish, dairy, and egg intake over a 33-year interval in Adventist Health Study 2

We studied Adventist Health Study 2 (AHS-2) cohort members to determine the reliability of long-term recall of adult dietary intake that occurred 33 years ago. Establishing the reliability of these measures supports studies of how dietary exposure across the life course affects risk of cancer and other noncommunicable disease outcomes. Among 1816 AHS-2 cohort members, we conducted a statistical comparison of long-term recall of meat, fish, dairy, and eggs at AHS-2 baseline with their report of current diet 33 years before AHS-2 baseline at an age of 30-60 years. Major findings are as follows: 1) a high correlation for frequency of red meat (R = 0.71), poultry (R = 0.67), and fish (R = 0.60); lower correlations for dairy (R = 0.19) and eggs (R = 0.28); 2) good concordance for dichotomous measures of red meat [sensitivity: 0.70; specificity: 0.92; positive predictive value (PPV): 0.91], poultry (sensitivity: 0.76; specificity: 0.87; PPV: 0.83), fish (sensitivity: 0.61; specificity: 0.93; PPV: 0.89), dairy (sensitivity: 0.95; specificity: 0.57; PPV: 0.99), and eggs (sensitivity: 0.95; specificity: 0.41; PPV: 0.96); negative predictive value for dairy and eggs was poor. Among older AHS-2 cohort members, we found good reliability of recall of red meat, poultry, and fish intake that occurred 33 years earlier.

Reaction time in Stroop test in Nepalese Medical Students

BACKGROUND

Stroop test is one of the widely used tests in cognitive psychology. It is used both in healthy population and also in patients to assess the selective attention. The selective attention as assessed by it is also found to be altered in bilinguals. In Nepal, most of the students are bilingual since most of the courses are in English language. Thus, they learn English language along with their native languages. This study is aimed to assess the selective attention in healthy Nepalese medical students.

OBJECTIVE

To study the reaction time in stroop test in medical students of Nepal.

MATERIALS AND METHODS

This study was conducted on 30 healthy male students aged 23.1±2.8 yrs. They were asked to read congruent (red printed in red ink) and incongruent (red printed in blue ink) tests in classical stroop cards. The reaction times for both the tests were calculated. Median with inter-quartile range was obtained for reaction time. Wilcoxon's Sign Rank Test was used to compare reaction time and errors between congruent and incongruent cards.

RESULTS

The subjects took 82.10 (63.75-107.76) sec longer to read incongruent stroop test (p<0.001). The error made was 0 in congruent stroop test and 1.5 (0-3) in incongruent stroop test (p<0.001). No students made error in the congruent test but 60% (18) of students made error in incongruent test (p<.001) and interference percentage in incongruent was 157 (115.32-213.50)%.

CONCLUSION

The reaction time and interferences were more in incongruent stroop test than congruent test. The interference was very high than that of previous literature's value. This indicates that Nepalese students have delayed attention while performing classical English version of stroop test.

Association between class III obesity (BMI of 40-59 kg/m2) and mortality: a pooled analysis of 20 prospective studies

BACKGROUND

The prevalence of class III obesity (body mass index [BMI]≥40 kg/m2) has increased dramatically in several countries and currently affects 6% of adults in the US, with uncertain impact on the risks of illness and death. Using data from a large pooled study, we evaluated the risk of death, overall and due to a wide range of causes, and years of life expectancy lost associated with class III obesity.

METHODS AND FINDINGS

In a pooled analysis of 20 prospective studies from the United States, Sweden, and Australia, we estimated sex- and age-adjusted total and cause-specific mortality rates (deaths per 100,000 persons per year) and multivariable-adjusted hazard ratios for adults, aged 19-83 y at baseline, classified as obese class III (BMI 40.0-59.9 kg/m2) compared with those classified as normal weight (BMI 18.5-24.9 kg/m2). Participants reporting ever smoking cigarettes or a history of chronic disease (heart disease, cancer, stroke, or emphysema) on baseline questionnaires were excluded. Among 9,564 class III obesity participants, mortality rates were 856.0 in men and 663.0 in women during the study period (1976-2009). Among 304,011 normal-weight participants, rates were 346.7 and 280.5 in men and women, respectively. Deaths from heart disease contributed largely to the excess rates in the class III obesity group (rate differences = 238.9 and 132.8 in men and women, respectively), followed by deaths from cancer (rate differences = 36.7 and 62.3 in men and women, respectively) and diabetes (rate differences = 51.2 and 29.2 in men and women, respectively). Within the class III obesity range, multivariable-adjusted hazard ratios for total deaths and deaths due to heart disease, cancer, diabetes, nephritis/nephrotic syndrome/nephrosis, chronic lower respiratory disease, and influenza/pneumonia increased with increasing BMI. Compared with normal-weight BMI, a BMI of 40-44.9, 45-49.9, 50-54.9, and 55-59.9 kg/m2 was associated with an estimated 6.5 (95% CI: 5.7-7.3), 8.9 (95% CI: 7.4-10.4), 9.8 (95% CI: 7.4-12.2), and 13.7 (95% CI: 10.5-16.9) y of life lost. A limitation was that BMI was mainly ascertained by self-report.

CONCLUSIONS

Class III obesity is associated with substantially elevated rates of total mortality, with most of the excess deaths due to heart disease, cancer, and diabetes, and major reductions in life expectancy compared with normal weight. Please see later in the article for the Editors' Summary.

Global epidemiology of obesity, vegetarian dietary patterns, and noncommunicable disease in Asian Indians

An increase in noncommunicable disease (NCD) in India has been attributed to an epidemiologic transition whereby, due to urbanization, there is an increase in traditional cardiovascular disease risk factors such as obesity. Accumulated biomarker data on the "Asian Indian phenotype" identify central obesity, which occurs at a lower body mass index (BMI), as a particularly potent risk factor in Asian Indians. A revised WHO case definition for obesity in India [BMI (in kg/m(2)) >25] has identified an obesity epidemic that exceeds 30% in some cities and rivals that in Western nations. This review summarizes 2 key lines of evidence: 1) the emergence of an obesity epidemic in urban and rural India and its contribution to the NCD burden and 2) the role of a "nutrition transition" in decreasing the whole plant food content of diets in India and increasing risk of obesity and NCDs. We then present new epidemiologic evidence from Asian Indians enrolled in the Adventist Health Study 2 that raises the possibility of how specific whole plant foods (eg, nuts) in a vegetarian dietary pattern could potentially prevent obesity and NCDs in a target population of >1 billion persons.

Body size and multiple myeloma mortality: a pooled analysis of 20 prospective studies

Multiple myeloma (MM) is a rare but highly fatal malignancy. High body weight is associated with this cancer, but several questions remain regarding the aetiological relevance of timing and location of body weight. To address these questions, we conducted a pooled analysis of MM mortality using 1·5 million participants (including 1388 MM deaths) from 20 prospective cohorts in the National Cancer Institute Cohort Consortium. Proportional hazards regression was used to calculate pooled multivariate hazard ratios (HRs) and 95% confidence intervals (CIs). Associations with elevated MM mortality were observed for higher early-adult body mass index (BMI; HR = 1·22, 95% CI: 1·09-1·35 per 5 kg/m(2) ) and for higher cohort-entry BMI (HR 1·09, 95% CI: 1·03-1·16 per 5 kg/m(2) ) and waist circumference (HR = 1·06, 95% CI: 1·02-1·10 per 5 cm). Women who were the heaviest, both in early adulthood (BMI 25+) and at cohort entry (BMI 30+) were at greater risk compared to those with BMI 18·5 ≤ 25 at both time points (HR = 1·95, 95% CI: 1·33-2·86). Waist-to-hip ratio and height were not associated with MM mortality. These observations suggest that overall, and possibly also central, obesity influence myeloma mortality, and women have the highest risk of death from this cancer if they remain heavy throughout adulthood.

Estimating the impact of smoking cessation during pregnancy: the San Bernardino County experience

We examined the relation between maternal smoking and adverse infant outcomes [low birth weight (LBW), and preterm birth (PTB)] during 2007-2008 in San Bernardino County, California-the largest county in the contiguous United States which has one of the highest rates of infant mortality in California. Using birth certificate data, we identified 1,430 mothers in 2007 and 1,355 in 2008 who smoked during pregnancy. We assessed the effect of never smoking and smoking cessation during pregnancy relative to smoking during pregnancy for the 1,843/1,798 LBW, and 3,480/3,238 PTB's recorded for 2007/2008, respectively. To describe the effect of quitting smoking during pregnancy, we calculated the exposure impact number for smoking during pregnancy. Major findings are: (1) relative to smoking during pregnancy, significantly lower risk of LBW among never smoking mothers [OR, year: 0.56, 2007; 0.54, 2008] and for smoking cessation during pregnancy [0.57, 2007; 0.72, 2008]; (2) relative to smoking during pregnancy, significantly lower risk of PTB was found for never smoking mothers [0.68, 2007; 0.68, 2008] and for smoking cessation during pregnancy [0.69, 2007; 0.69, 2008]; (3) an exposure impact assessment indicating each LBW or PTB outcome in the county could have been prevented either by at least 35 mothers quitting smoking during pregnancy or by 25 mothers being never smokers during pre-pregnancy. Our findings identify an important burden of adverse infant outcomes due to maternal smoking in San Bernardino County that can be effectively decreased by maternal smoking cessation.

Cotinine levels among betel quid users and cigarette smokers in Cambodia

Smokeless tobacco use in the form of the betel quid is common in the Western Pacific Region, and yet few studies have determined the nicotine delivery of this habit. During a validation substudy, we randomly sampled 201 adults from a rural province of Cambodia and determined nonparametric (bootstrapped) confidence intervals (CIs) for salivary cotinine levels in tobacco users. We found that cotinine levels for daily betel quid use among women (95% CI = 218.6-350.0 ng/mL) were (1) similar to the levels for daily cigarette smoking in men (95% CI = 240.2-317.1 ng/mL) and (2) significantly higher than the levels for daily cigarette smoking in women (95% CI = 71.8-202.7 ng/mL). The 95% confidence range for these habits exceeded the threshold for addiction. Our findings from rural Cambodia indicate that the typical betel quid habit among women supports the same level of nicotine addiction as the typical cigarette habit in men.

Environmental exposures, lung function, and respiratory health in rural Lao PDR

Although the individual contributions of smoked tobacco and indoor air pollution have been identified, there are very few studies that have characterized and measured the effects of inhaled particles from a wide range of personal, household, and community practices common in rural Asia. The objective of our study was to examine the association between environmental inhaled exposures and lung function among rural males of Lao PDR. In a sample of 92 males from rural Lao PDR, study subjects completed a survey on household exposures, a physical exam, and the following measures of lung function: FEV1, FVC, and the ratio of FEV1/FVC. Our findings were as follows: a) > 80% of the subjects were exposed to indoor cooking fires (wood fuel), animal handling, dust and dirt; b) 57.6% of subjects were in the impaired range (FEV1/FVC < 0.7); and c) animal handling was negatively associated (p < 0.03) with FEV1 and FVC. Among males in rural Lao PDR, we found a high prevalence of chronic exposure to inhaled particles (animal handling, dust/dirt, smoke) and a high prevalence of impaired lung function. Findings from this pilot study indicate that associations between exposure to multiple sources of particulate matter common in rural areas and lung function need further investigation.

Maternal use of cigarettes, pipes, and smokeless tobacco associated with higher infant mortality rates in Cambodia

In the Western Pacific Region, rural women use loose tobacco in betel quid chewing and pipe smoking. We examined the relation between maternal use of tobacco and infant mortality (IM) in a national sample of 24 296 birth outcomes in adult women (n = 6013) in Cambodia. We found that (1) age-adjusted odds of IM were higher for maternal use of any tobacco (odds ratio [OR] = 1.69; 95% confidence interval [CI] = 1.27-2.26); (2) age-adjusted odds of IM were higher for cigarette use (OR = 2.54; 95% CI = 1.54- 4.1), use of pipes (OR = 3.09; [95% CI = 1.86-5.11]), and betel quid chewing (OR = 1.55; 95% CI = 1.10-2.17); and (3) these associations remained after multivariable adjustment for environmental tobacco smoke, malnutrition, ethnicity, religion, marital status, education, income, occupation, and urban/rural dwelling. In addition to finding the established association with cigarettes, we also found that maternal use of smokeless tobacco and pipes was associated with higher rates of infant death in Cambodia.

Beliefs about tobacco, health, and addiction among adults in Cambodia: findings from a national survey

There remains a very high rate of smoked and smokeless tobacco use in the Western Pacific Region. The most recent findings from national adult tobacco surveys indicate that very few daily users of tobacco intend to quit tobacco use. In Cambodia, a nation that is predominantly Buddhist, faith-based tobacco control programs have been implemented where, under the fifth precept of Buddhism that proscribes addictive behaviors, monks were encouraged to quit tobacco and temples have been declared smoke-free. In the present study, we included items on a large national tobacco survey to examine the relation between beliefs (faith-based, other) about tobacco, health, and addiction among adults (18 years and older). In a stratified, multistage cluster sample (n=13,988) of all provinces of Cambodia, we found that (1) 88-93% believe that Buddhist monks should not use tobacco, buy tobacco, or be offered tobacco during a religious ceremony; (2) 86-93% believe that the Wat (temple) should be a smoke-free area; (3) 93-95% believe that tobacco is addictive in the same way as habits (opium, gambling, alcohol) listed under the fifth precept of Buddhism; and (4) those who do not use tobacco are significantly more likely to cite a Buddhist principle as part of their anti-tobacco beliefs. These data indicate that anti-tobacco sentiments are highly prevalent in the Buddhist belief system of Cambodian adults and are especially evident among non-users of tobacco. Our findings indicate that faith-based initiatives could be an effective part of anti-tobacco campaigns in Cambodia.

Vegetarian dietary patterns and mortality in Adventist Health Study 2

IMPORTANCE

Some evidence suggests vegetarian dietary patterns may be associated with reduced mortality, but the relationship is not well established.

OBJECTIVE

To evaluate the association between vegetarian dietary patterns and mortality.

DESIGN

Prospective cohort study; mortality analysis by Cox proportional hazards regression, controlling for important demographic and lifestyle confounders.

SETTING

Adventist Health Study 2 (AHS-2), a large North American cohort.

PARTICIPANTS

A total of 96,469 Seventh-day Adventist men and women recruited between 2002 and 2007, from which an analytic sample of 73,308 participants remained after exclusions.

EXPOSURES

Diet was assessed at baseline by a quantitative food frequency questionnaire and categorized into 5 dietary patterns: nonvegetarian, semi-vegetarian, pesco-vegetarian, lacto-ovo-vegetarian, and vegan.

MAIN OUTCOME AND MEASURE

The relationship between vegetarian dietary patterns and all-cause and cause-specific mortality; deaths through 2009 were identified from the National Death Index.

RESULTS

There were 2570 deaths among 73,308 participants during a mean follow-up time of 5.79 years. The mortality rate was 6.05 (95% CI, 5.82-6.29) deaths per 1000 person-years. The adjusted hazard ratio (HR) for all-cause mortality in all vegetarians combined vs nonvegetarians was 0.88 (95% CI, 0.80-0.97). The adjusted HR for all-cause mortality in vegans was 0.85 (95% CI, 0.73-1.01); in lacto-ovo-vegetarians, 0.91 (95% CI, 0.82-1.00); in pesco-vegetarians, 0.81 (95% CI, 0.69-0.94); and in semi-vegetarians, 0.92 (95% CI, 0.75-1.13) compared with nonvegetarians. Significant associations with vegetarian diets were detected for cardiovascular mortality, noncardiovascular noncancer mortality, renal mortality, and endocrine mortality. Associations in men were larger and more often significant than were those in women.

CONCLUSIONS AND RELEVANCE

Vegetarian diets are associated with lower all-cause mortality and with some reductions in cause-specific mortality. Results appeared to be more robust in males. These favorable associations should be considered carefully by those offering dietary guidance.

Validity and reliability of survey items and pictograms for use in a national household survey of tobacco use in Cambodia

The validity of survey measures of smoked and smokeless tobacco use in the Western Pacific Region is often unknown. We conducted a validation study (n = 201) in a random sample of rural adults in Cambodia. A comparison with salivary cotinine indicated (1) that survey items and pictograms of current tobacco use had an 87% (95% confidence interval [CI] = 78%-93%) sensitivity, 94% specificity (95% CI = 87%-98%), and 93% (95% CI = 85%-97%) positive predictive value in detecting cotinine levels >10 ng/mL; (2) a positive correlation with number of cigarettes smoked (R = 0.34; P = .01); and (3) a positive correlation with the amount of tobacco chewed (R = 0.44; P = .02). The validity of the index for the amount of smokeless tobacco used was enhanced by adding to the index the data from pictograms that were utilized to help participants estimate the amount of loose tobacco used per session. These tobacco items and pictograms were found to have excellent reliability (κ = 0.80-1) over 2 to 3 weeks. Interviewer-administered survey items and pictograms can provide an accurate, quantitative measure of smoked and smokeless tobacco use in rural Cambodia.

Obesity and life expectancy among long-lived Black adults

BACKGROUND

In samples of African Americans and the elderly adults, obesity is often not found to be a risk factor for mortality. These data contradict the evidence linking obesity to chronic disease in these groups. Our objective was to determine whether obesity remains a risk factor for mortality among long-lived black adults.

METHODS

The Adventist Health Study 2 is a large prospective cohort study of Seventh-day Adventist church members who are encouraged by faith-based principles to avoid tobacco, alcohol, and meat consumption. We conducted an attained age survival analysis of 22,884 U.S. blacks of the cohort-half of whom attained an age of 58-108 years during the follow-up (adult life expectancy of 84 years in men, 89 years in women).

RESULTS

Women in the highest body mass index quintile (>33.8) experienced a significant 61% increase (hazard ratio [95% CI] = 1.62 [1.23, 2.11] relative to the middle quintile) in mortality risk and a 6.2-year (95% CI = 2.8-10.2 years) decrease in life expectancy. Men in the highest body mass index quintile (>30.8) experienced a significant 87% increase (hazard ratio [95% CI] = 1.87 [1.28, 2.73] relative to the middle quintile) in mortality risk and 5.9-year (95% CI = 2.1- 9.5 years) decrease in life expectancy. Obesity (>30) was a significant risk factor relative to normal weight (18.5-24.9) in never-smokers. Instantaneous hazards indicated excess risk from obesity was evident through at least age 85 years. The nonobese tended to follow plant-based diets and exercise vigorously.

CONCLUSIONS

Avoiding obesity promotes gains in life expectancy through at least the eighth decade of life in black adults. Evidence for weight control through plant-based diets and active living was found in long-lived nonobese blacks.

Poverty does not limit tobacco consumption in Cambodia: quantitative estimate of tobacco use under conditions of no income and adult malnutrition

Current data indicate that under conditions of poverty, tobacco is consumed at the expense of basic needs. In a large national sample from Cambodia, we sought to determine whether tobacco consumption declines under extreme conditions of no income and malnutrition. Our major findings are as follows: (1) Among men, there was no significant difference in the number of cigarettes smoked for no income (425, 95% confidence interval [CI] = 395-456) versus >US$2 per day (442, 95% CI = 407-477); (2) among women, there was no significant difference in the amount of loose tobacco (ie, betel quid) consumed for no income (539 g, 95% CI = 441-637) versus >US$2 per day (558 g, 95% CI = 143-973); (3) for the contrast of no income + malnutrition versus >US$2 per day + no malnutrition in a linear model, there was no significant difference for men who smoked (462 vs 517 cigarettes/month, P = .82) or women who chewed (316 vs 404 g tobacco/month, P = .34), adjusting for confounders. Among the poorest and malnourished Cambodian adults, lack of resources did not appear to prevent them from obtaining smoked or smokeless tobacco.

Patterns of Maternal Tobacco Use Among Cambodian Women

Although current trends indicate that the rate of cigarette smoking tends to be low among women in the Western Pacific Region (<10%), recent epidemiologic data from South Asia (India, Bangladesh) and Southeast Asia (Cambodia, Vietnam, Indonesia, Malaysia) identify that a large proportion of women of reproductive age and older chew tobacco—often as part of a betel quid mixture that includes other potentially harmful ingredients (eg, areca nut). Our findings from currently pregnant women identified during a nationwide survey of adult tobacco use in Cambodia indicate that 13.0% (95% confidence interval [CI] = 8% to 17%) were current users of smoked or smokeless (in the form of a betel quid) tobacco. Most pregnant women who used tobacco indicated that their habit was either initiated (29.1%; 95% CI = 16.3-46.3) or increased (33.7%; 95% CI = 18.3-53.5) during pregnancy. Pregnancy-related symptoms such as morning sickness were reported as the reason for more than half (54.9%; 95% CI = 34.8-73.4) of the currently pregnant users to have started a tobacco habit during their lifetime. Among those pregnant women who did not use tobacco, we found strong associations (odds ratios from 2 to 14) with beliefs about the harmful effects of tobacco on adult health, faith-based beliefs in addictive substances, and beliefs that influential members of the community, health professionals, and children should not use tobacco. Our findings indicate that tobacco cessation and prevention programs in Cambodia should specifically target pregnant and reproductive-age women.

Cigarette smoking and tuberculosis in Cambodia: findings from a national sample

BACKGROUND

Cambodia has very high rates of tuberculosis and smoked tobacco use among adults. Efforts to control both tobacco use and tuberculosis in Cambodia need to be informed by nationally representative data. Our objective is to examine the relation between daily cigarette smoking and lifetime tuberculosis (TB) history in a national sample of adults in Cambodia.

METHODS

In 2011, a multi-stage, cluster sample of 15,615 adults (ages 15 years and older) from all regions of Cambodia were administered the Global Adult Tobacco Survey by interviewers from the National Institute of Statistics of Cambodia.

RESULTS

Our findings include: 1) among daily smokers, a significant positive relation between TB and number of cigarettes smoked per day (OR = 1.70 [95% CI 1.01, 2.87]) and pack-years of smoking (OR = 1.53 [95% CI 1.05, 2.25]) 2) a non-significant 58% increase in odds of ever having being diagnosed with TB among men who smoked manufactured cigarettes (OR = 1.58 [95% CI 0.97, 2.58]).

CONCLUSION

In Cambodia, manufactured cigarette smoking was associated with lifetime TB infection and the association was most evident among the heaviest smokers (> 1 pack per day, > 30 pack years).

Differences in health and religious beliefs about tobacco use among waterpipe users in the rural male population of Egypt

Waterpipe use is a highly prevalent form of tobacco use in the Eastern Mediterranean Region that is rooted in long-held cultural traditions that predate the use of cigarettes and present a particular challenge for tobacco control efforts. We did a stratified sampling of 4,994 Egyptian men from rural households of Egypt in order to conduct an interviewer-administered prevalence survey to identify differences in attitudes and beliefs toward smoking and smoking cessation between waterpipe users, cigarette smokers, mixed users (cigarette + waterpipe), and non-smokers. We found that cigarette smokers, mixed users, and/or non-smokers were (1) two- to ninefold more likely to believe that smoking decreased adult life expectancy and harmed a fetus than waterpipe users, (2) significantly more likely to believe that smoking is a sin ("haram") than were waterpipe users. Among tobacco users, we found that cigarette smokers and/or mixed users were significantly more likely to indicate pre-contemplation, contemplation, or intention to quit tobacco than waterpipe users. Our findings from rural Egyptian men indicate that waterpipe users are distinct from cigarette smokers in their perception that their form of tobacco use is less harmful and/or less subject to religious proscription. These beliefs may explain why waterpipe users seem less inclined to quit their tobacco habit and need to be considered in the design of tobacco cessation and prevention methods in Egypt and the region.

Patterns of alcohol and tobacco use in Cambodia

Few studies have considered whether the habitual use of tobacco in Southeast Asia is part of an established pattern of addiction that includes regular alcohol use. As part of a national survey of adult tobacco use in Cambodia (n = 13 988), we found that men who smoked were 2 times more likely to have drank alcohol in the past week (odds ratio = 2.53, 95% confidence interval = 2.10-3.03). By age 18 to 25 years, 47% of male smokers drank alcohol, and this pattern of alcohol and tobacco use increased to >55% through the fifth decade. Women using smokeless tobacco with betel quid were more likely to be alcohol drinkers (odds ratio = 1.49, 95% confidence interval = 1.12-1.98). Past week's drinking declined by late middle age and was associated with lower education and being currently married; the behavior was lower in some ethnic groups (ie, Cham). Our findings indicate an important association between alcohol and tobacco use, and raise the possibility that reducing alcohol consumption can be an important component of tobacco control.

Validation of recall of body weight over a 26-year period in cohort members of the Adventist Health Study 2

PURPOSE

The validity of recall of past body weight has been measured and tends to be high; however, the paucity of validation data for recall in older age is noteworthy given the need for accounting for age and disease-related weight change in prospective studies.

METHODS

The Adventist Health Study-2 (AHS-2) is a prospective, questionnaire-based study (n = 96,710) that enrolled a cohort from 2002 through 2007 to investigate the role of lifestyle exposures (diet, physical activity, anthropometrics) and health on outcomes such as cancer and mortality.

RESULTS

The mean difference between current weight reported 26 years earlier in AHS-1 and recall of past body weight in AHS-2 was only 0.67 kg, indicating underestimation in the recall of past body weight from ages 30 to 70 years.

CONCLUSIONS

Misclassification is differential across both age and adiposity, and this tendency needs to be incorporated into the interpretation of weight history and health outcome literature.

Adult tobacco cessation in Cambodia: II. Determinants of intent to quit

Identifying determinants of intent to quit may aid the design of antitobacco programs and promote effective tobacco control policies. In a nationwide survey in Cambodia, two thirds of tobacco smokers and 45% of female smokeless tobacco users planned to stop in the future. Multivariate determinants of intent in 2279 male smokers were age <37 years, age at initiation ≥ 18 years, Cham versus Khmer ethnicity (odds ratio [OR] = 6.93; 95% confidence interval[CI] = 1.38-34.89), longer education, and professional occupation. In 1188 female smokeless tobacco users, age <25 years, age at initiation ≥ 18 years, and tuberculosis (OR = 3.26; 95% CI = 1.61-6.61) were associated with intent. In female smokers (n = 321), age 18 to 25 years at initiation was associated with intent. In male smokers and female smokeless tobacco users, perceived physical advantages of tobacco were inversely associated with intent. These findings underscore the importance of policies and interventions to delay initiation and promote cessation in young people and counteract perceived physical benefits.

Adult tobacco cessation in Cambodia: I. Determinants of quitting tobacco use

This study determined factors associated with quitting tobacco in Cambodia, a country with a high prevalence of men who smoke and women who use smokeless tobacco. As part of a nationwide survey, face-to-face interviews were conducted with 5145 current and 447 former tobacco users who had quit for ≥ 2 years. Determinants of quitting in multivariate analyses were age >48 years, age at initiation >25 years, ≥ 7 years of education, income ≥ 1 US dollar per day, professional (odds ratio [OR] = 2.52; 95% confidence interval [CI] = 1.27-5.01) or labor (OR = 1.98, 95% CI = 1.10-3.56) occupations, and heart disease (OR = 1.94; 95% CI = 1.10, 3.42). Smokeless tobacco users were 10-fold less likely to quit (OR = 0.10; 95% = CI 0.05-0.20) than smokers. In conclusion, tobacco cessation among Cambodians was lower than in nations with decades of comprehensive tobacco control policies. Tobacco cessation programs and policies should include all forms of tobacco and target young to middle-aged users before onset of disease and premature death.

Betel quid use in relation to infectious disease outcomes in Cambodia

OBJECTIVES

The habitual chewing of betel quid (areca nut, betel leaf, tobacco) is estimated to occur among 600 million persons in Asia and the Asia-Pacific Region. Emerging data from rural Asia indicate that the betel quid is part of traditional medicine practices that promote its use for a wide range of ailments, including infectious disease. In the present study, we examined the association between betel quid, traditional medicine, and infectious disease outcomes.

METHODS

For the purpose of a nationwide, interviewer-administered, cross-sectional survey of tobacco use (including betel quid), we conducted a stratified three-stage cluster sampling of 13 988 adults aged 18 years and older from all provinces of Cambodia.

RESULTS

We found an association between the intensity of betel quid use and HIV/AIDS (odds ratio (OR) 2.06, 95% CI 1.09-3.89), dengue fever (OR 2.40, 95% CI 1.55-2.72), tuberculosis (OR 1.50, 95% CI 0.96-2.36), and typhoid (OR 1.48, 95% CI 0.95-2.30). These associations were even stronger in women - the primary users of betel quid in Cambodia. Multivariable analyses that controlled for age, gender, income, education, urban versus rural dwelling, receiving care from traditional medicine practitioners, and cigarette smoking did not alter the betel quid-infectious disease association.

CONCLUSIONS

Our findings raise the possibility of a role of betel quid use in the transmission of infectious disease through pathways such as immunosuppression, oral route of entry for a pathogen (i.e., through injury to the oral mucosa), and contamination (i.e., fecal-oral) of the betel quid ingredients.

Effect of weight loss in adults on estimation of risk due to adiposity in a cohort study

The effect of overweight and obesity on the risk of fatal disease tends to attenuate with age. To evaluate whether this effect is partly attributable to disease-related weight loss, we examined the prebaseline history of weight loss and diseases associated with weight loss among adults enrolled in a cohort study. We conducted an analysis of 7,855 adult cohort members of the Adventist Health Study (AHS) I who had provided anthropometric data on surveys at baseline and 17 years prior to baseline. Among adults in the recommended range of BMI (19-25 kg/m(2)) at baseline we found that: (i) the prevalence of prebaseline weight loss of 5 kg/m(2) from an overweight or obese state was 20.4% and increased with age (12.6% for <65 years; 27.7% for 65-84 years; 36.7% for >85 years) and (ii) prebaseline weight loss of 5 kg/m(2) from an overweight or obese state was associated with diabetes (odds ratio (OR) = 2.91 95% confidence interval (CI) = (2.16, 3.93)), coronary heart disease (OR = 1.84 95% CI = (1.42, 2.40)), and high blood pressure (OR = 1.51 95% CI = (1.26, s1.82)). During 12 years of follow-up, we found evidence that hazard ratios for adiposity can be confounded by disease-related weight loss. Our findings raise the possibility that prebaseline weight loss can confound the estimation of risk due to adiposity at baseline in a cohort study.