Social Determinants of Health and Smoking Cessation: A Challenge
Kathleen T. Brady, M.D., Ph.D.
Published Online:1 Nov 2020
In 1965, 42% of adults were current smokers, and smoking rates had fallen to 15% in 2014
Individuals with current nicotine dependence and at least one comorbid psychiatric disorder made up 7.1% of the U.S. adult population, yet they consumed 34.2% of all cigarettes smoked. People with mental illness have a shorter lifespan than the general population (11), and smoking contributes to their additional risk of mortality and morbidity (12), yet relatively few studies have focused on smoking cessation for individuals with co-occurring psychiatric illness.
One unspoken element of the hardening hypothesis is that as a behavior becomes less mainstream, those who engage in it become marginalized. The hard-hitting anti-tobacco public health campaign, focused on awareness of health consequences of smoking and denormalizing smoking behavior, may have the unintended consequences of stigmatizing smoking and smoking-related illnesses
Commonly Applied Selection Criteria for Lung Cancer Screening May Have Strongly Varying Diagnostic Performance in Different Countries
Hermann Brenner and Agne Krilaviciute
Received: 15 September 2020; Accepted: 12 October 2020; Published: 16 October 2020
The effectiveness of low-dose CT screening was recently reconfirmed by the largest European randomized trial (NELSON study) after 10 years of follow-up (reduction in LC mortality of 24% and 33% as compared to no screening among men and women, respectively)
The U.S. Preventive Services Task Force and Centers for Medicare and Medicaid Services recommend low-dose CT screening of heavy smokers with at least a 30 pack-year smoking history [5,6]. Organized LC screening is not yet established in Europe and selection criteria that were used in
European CT screening trials differ with respect to the potential target population eligible for screening. Except from the UK Lung Cancer Screening Trial (UKLS) that identified the target group based on an individual LC risk model [7], other screening trials focused on smoking habits alone, by screening heavy smokers with a certain pack-year exposure [8–11] or heavy smokers with a defined smoking intensity over a period of time
Countries with higher sensitivities tended to exhibit lower specificities, and vice versa. The lowest sensitivities (≤42%) and highest specificities (≥86%) were seen in Sweden for all LC screening criteria. Differences in sensitivity estimates within each country are seen due to different populations being eligible for screening for each trial criteria, where differences in sensitivities larger or equal to 20 percent units were observed for Latvia, Lithuania and Estonia.
In the interpretation of our study, a number of strengths and limitations need to be kept in mind. Strengths include the large sample sizes from a pooled analysis of case-control studies and from national surveys using comparable data collection methods from 27 European countries which enabled
estimating relative risks by pack-year categories and smoking prevalences at high levels of precision across diverse populations.
However, our study also has limitations. First, relative risk estimates for pack-year categories used to derive sensitivity estimates of various screening criteria were available for current smokers as compared to never smokers only, and it was assumed that these relative risks also apply to former smokers who quit within 10 or 15 years. Second, the study populations included in the case-control studies from which the relative risk estimates were drawn were recruited in earlier decades (in the periods 1985–1996 in six studies, 1996–2002 in six studies and 1998–2005 in three studies) when the prevalence of daily smoking was higher as compared to now in most European countries.
Third, in the absence of available estimates of relative risks for preclinical, prevalent LC, our analysis was based on estimates of relative risk of incident, clinically manifest LC. This approximation could have had a major impact on the estimates of sensitivity and specificity in case of strong variation of sojourn time between pack-year categories which, though, seems to be unlikely. Fourth, we only addressed sensitivity and specificity as indicators of diagnostic performance of a pre-screening test. For the practice of screening, further parameters, such as the positive predictive value, which additionally depends on the prevalence of (undetected) LC among the target population, have to be considered.
Like sensitivity of smoking as a pre-screening test for LC, the prevalence of (undetected) LC is also expected to be higher in populations with higher smoking prevalence which further underlines the fact that performance of heavy smoking criteria as pre-screening tests for LC will strongly vary between populations. Fifth, specificities were approximated by the proportion of individuals not meeting the pre-selection-criteria for LC screening among the target age groups of screening. This approximation neglects the proportion of people with prevalent LC among the target population of screening, which is expected to be very low and should therefore not have led to relevant distortions of specificity estimates.
Sixth, our estimates are statistically derived from various data sources in the literature and should be validated in large-scale prospective studies.
Socioeconomic inequalities in secondhand smoke exposure before, during and after implementation of Quebec’s 2015 ‘An Act to Bolster Tobacco Control’
We detected inequalities in SHS exposure outcomes at each time point, most markedly at home among youth (OR of SHS exposure among youth living in the 20% poorest households vs the 20% richest=4.9, 95% CI 2.7 to 6.2). There were decreases in SHS exposure in homes and cars in each education/income group over time. The magnitude of inequalities in SHS exposure in homes and cars, however, did not change during this period.
Pediatric Resident Training in Tobacco Control and the Electronic Health Record
Available online 29 October 2020
In a 2012 survey of U.S. pediatric program directors, 65% of programs reported covering tobacco control in their curricula, but most training programs focused on tobacco's health effects and not intervention strategies for clinical practice. Since that survey, electronic health records have been implemented broadly nationwide and utilized to address tobacco smoke exposure. Investigators surveyed U.S. program directors in 2018 and residents in 2019 to explore the ways in which the residents learn about tobacco use and tobacco smoke exposure, components and use of the electronic record specific to tobacco use and tobacco smoke exposure, and perceived resident effectiveness in this area. All the program directors and 85% of the residents valued training, but 21% of the residents reported receiving none. Moreover, a minority of the residents assessed themselves as effective at counseling parents (19%) or adolescents (23%), and their perceived effectiveness was related to small group learning and active learning workshops, modalities that were infrequently implemented in training
Assessment of the change in burden of respiratory diseases in children and household smoking habits in Turkey after adoption of National Tobacco Control Program
European Respiratory Journal 2020 56: 3039
Percentages for both upper and lower respiratory illnesses decreased between 2006 and 2012 but increased between 2012 and 2016 (Figure 1 and 2). Household smoking habit frequencies slightly decreased between 2010 and 2016 (54,5% and 54,1% respectively).
Electronic cigarette use strongly associated with respiratory diseases: Results from Russian Tobacco Control Policy evaluation survey
European Respiratory Journal 2020 56: 1875
Cross-sectional data of adult representative sample from Russian Tobacco Control Policy Evaluation Survey are analysed, based on multistage sampling in 10 Russian regions in 2017-2018, stratified by smoking status: n=11625: 6569smokers, 2377former smokers, 2679never smokers.
Chronic bronchitis(CB) was reported by 14% respondents, COPD–by 4.3%, asthma–by 3.1%, emphysema–1.5%, lung cancer–1.1%, tuberculosis (TB)–1.3%. Ever EC use was prevalent in 9.3%, HTP use–in 3.3%, and current EC use–in 2.5% of population. Ever HTP users had 2.5 times higher chances of CB: OR2.52(95%CI 1.9-3.3), and 4 times higher chances of COPD: OR3.97(95%CI 2.8-5.7). The risk is even greater in case of dual EC and tobacco use in current smokers: OR 3.0 (95%CI 2.2-4.1) and 4.2(95%CI 2.8-6.3) respectively. Current EC use was significantly associated with asthma: OR 2.9 (95%CI 1.5-5.8) and OR 5.0(95%CI 2.6-11.3) in current smokers, lung cancer: OR 4.9(95%CI 1.6-14.8) and 7.2(95%CI 1.9-27.4); and TB:OR 4.1(95%CI 1.7-11.6) and 5.4(95%CI 1.6-17.9) respectively.
