Smoking-related Mortality Research Articles

Randomized Clinical Trials Investigating Innovative Interventions for Smoking Cessation in the Last Decade.

Every year, billions of dollars are spent treating smoking and related conditions, yet smoking-related morbidity and mortality continue to rise. There are currently only three FDA-approved medications for smoking cessation: nicotine replacement therapy, bupropion, and varenicline. Although these medications increase abstinence rates, most individuals relapse following treatment. This chapter reviews clinical trials published within the past 10years investigating novel smoking cessation pharmacotherapies. Among these pharmacotherapies, some showed promising results, such as cytisine and endocannabinoid modulators, whereas others failed to produce significant effects. More research is needed to develop drugs that produce higher rates of long-term abstinence and to determine which subgroups of patients benefit from a given treatment.

Patient-Physician Discussions on Lung Cancer Screening: A Missed Teachable Moment to Promote Smoking Cessation.

Little is known about whether patients and physicians perceive lung cancer screening (LCS) as a teachable moment to promote smoking cessation or the degree to which physicians in "real world" settings link LCS discussions with smoking cessation counseling. We sought to characterize patient and physician perspectives of discussions about smoking cessation during LCS. We conducted a qualitative study (interviews and focus groups) with 21 physicians and 28 smokers screened in four diverse hospitals. Transcripts were analyzed for characteristics of communication about smoking cessation and LCS, the perceived effect on motivation to quit smoking, the degree to which physicians leverage LCS as a teachable moment to promote smoking cessation, and suggestions to improve patient-physician communication about smoking cessation in the context of LCS. Patients reported that LCS made them more cognizant of the health consequences of smoking, priming them for a teachable moment. While physicians and patients both acknowledged that smoking cessation counseling was frequent, they described little connection between their discussions regarding LCS and smoking cessation counseling. Physicians identified several barriers to integrating discussions on smoking cessation and LCS. They volunteered communication strategies by which LCS could be leveraged to promote smoking cessation. LCS highlights the harms of smoking to patients who are chronic, heavy smokers and thus may serve as a teachable moment for promoting smoking cessation. However, this opportunity is typically missed in clinical practice. LCS highlights the harms of smoking to heavily addicted smokers. Yet both physicians and patients reported little connection between LCS and tobacco treatment discussions due to multiple barriers. On-site tobacco treatment programs and post-screening messaging tailored to the LCS results are needed to maximize the health outcomes of LCS, including smoking quit rates and longer-term smoking-related morbidity and mortality.

Hard-Core Smoking Among Daily Smokers in Male and Female Adults in 27 Countries: A Secondary Data Analysis of Global Adult Tobacco Surveys (2008-2014)

Background: Hard-core smokers (HCS) who do not want to quit make it more difficult for tobacco control efforts to further reduce smoking prevalence. Information about burden of hard-core smokers helps plan cessation services. Aim: Estimate sex-specific, country-wise proportion of HCS among the current daily smokers, and the population prevalence of HCS and estimated total number of hard-core smokers in 27 GATS countries. Methods: We used the Global Adult Tobacco Survey (GATS) data to estimate the prevalence of HCS (i.e., daily smokers who smoke within 30 minutes after waking up, smoke ≥ 10 cigarettes per day, not made any quit attempts during previous 12 months or have no intention to quit at all or quit during coming 12 months). For each GATS country, we estimated sex-wise, weighted and age-adjusted prevalence of daily smoking and HCS. Results: Overall weighted population prevalence (%) of HCS was highest in Greece (21.0), followed by Russia (13), Poland (9.4), Romania (9.0), and Ukraine (8.9) and lowest in Nigeria (0.4%). Estimated number of HCS (in millions) was highest in China (35.8) followed by India (28.2), Russia (18.5), Indonesia (16.1) and lowest in Panama (0.03). The proportion (%) of daily smokers classified as HCS was highest in Greece (56.2%) followed by Russia (42.2%), Ukraine (37.2) and Poland (36.2) and lowest in Mexico (8.29). Overall, proportion of HCS was higher among males in all countries. However, in Greece, Russia, Romania, Ukraine and Poland, both population prevalence of HCS among women and proportion of HCS among daily smoking women was higher than in other countries. Conclusion: At the country-level, a higher daily smoking rates also suggest a higher proportion of HCS. Countries with greater burden of HCS pose greater challenges in tobacco control efforts specifically toward tobacco cessation interventions. Interventions to reduce tobacco use and smoking-related mortality may need to be altered in populations with high proportions of HCS.

Potential gains in life expectancy by reducing inequality of lifespans in Denmark: an international comparison and cause-of-death analysis

BackgroundReducing lifespan inequality is increasingly recognized as a health policy objective. Whereas lifespan inequality declined with rising longevity in most developed countries, Danish life expectancy stagnated between 1975 and 1995 for females and progressed slowly for males. It is unknown how Danish lifespan inequality changed, which causes of death drove these developments, and where the opportunities for further improvements lie now.MethodsWe present an analytical strategy based on cause-by-age decompositions to simultaneously analyze changes in Danish life expectancy and lifespan inequality from 1960 to 2014, as well as current Swedish-Danish differences.ResultsStagnation in Danish life expectancy coincided with a shorter period of stagnation in lifespan inequality (1975–1990). The stagnation in life expectancy was mainly driven by increases in cancer and non-infectious respiratory mortality at higher ages (−.63 years) offsetting a reduction in cardiovascular and infant mortality (+ 1.52 years). Lifespan inequality stagnated because most causes of death did not show compression over the time period. Both these observations were consistent with higher smoking-related mortality in Danes born in 1919–1939. After 1995, life expectancy and lifespan equality increased in lockstep, but still lag behind Sweden, mainly due to infant mortality and cancer.ConclusionsSince 1960, Danish improvements in life expectancy and lifespan equality were halted by smoking-related mortality in those born 1919–1939, while also reductions in old-age cardiovascular mortality held back lifespan equality. The comparison with Sweden suggests that Denmark can reduce inequality in lifespans and increase life expectancy through a consistent policy target: reducing cancer and infant mortality.

Treatment of tobacco dependence: current state of the art.

The Centers for Medicare and Medicaid Services' requirement to integrate tobacco treatment with lung cancer screening (LCS) has served as a catalyst for motivating pulmonary medicine clinicians to improve upon their ability to effectively treat tobacco dependence. To do so, clinicians need to be well versed in the behavioral and pharmacologic tools that promote smoking cessation. The current review outlines current strategies for treating tobacco dependence, focusing on the important interplay between counseling and pharmacotherapy. Studies that have been found to be particularly effective in patients with smoking-related lung disease and in the LCS setting are reviewed. New therapies that are in the pipeline, as well as novel strategies aimed at improving both adoption and effectiveness of existing therapies, are discussed. Treating tobacco dependence improves mortality and quality of life far more than the limited therapies available to treat smoking-related lung disease. Novel strategies to making tobacco treatment services more widely available, particularly to vulnerable patient populations, are needed to further decrease smoking-related morbidity and mortality. The Affordable Care Act's greater focus on prevention represents a moment of opportunity for healthcare providers and systems to engage in these efforts.

The impact of the Danish smoking ban from 2007 on smoking-related morbidity. A register-based natural experiment

Introduction The number of countries introducing national tobacco control policies has increased. In terms of both countries and population covered, smoking bans in public settings that protect nonsmokers from second hand tobacco smoke, create supportive environments that encourage smoking cessation, and prevent smoking initiation, represents the one tobacco control policy with the greatest progress since 2007. Extensive research has documented the impact of smoke-free policies on preventing adverse health outcomes, especially cardiovascular diseases, reducing exposure to second hand tobacco smoke and decreasing smoking-related mortality. In 2007, Denmark introduced a national smoking ban, prohibiting all indoor smoking in workplaces and public places. However, little is known about the impact of this smoking ban over time on smoking-related morbidity in the Danish population. This study investigates the effect of the Danish smoking ban on hospital admissions for acute myocardial infarction (AMI), chronic obstructive pulmonary disorder (COPD) and cancer in oral cavity and pharynx. We hypothesized that admission rates decreased after the introduction of the Danish smoking ban in 2007 compared to pre-legislation. Methods This study was designed as a natural experiment in which the whole Danish population form the study population (> 30 years). Interrupted time series analysis was performed to quantify changes in-hospital admission rates for AMI, COPD and cancer in oral cavity and pharynx, pre- and post the introduction of the national smoking ban. Monthly age-standardised admission rates per 100,000 inhabitants were estimated for each diagnosis and two subperiods defined: pre-legislation (January 2000 to August 2007) and post-legislation (September 2007 to December 2015). As an immediate change in admission rates after the introduction of the smoking ban was not expected, increases or decreases in the slope of the trend after the introduction of the ban were compared with pre-legislative trends. Diagnostic information was obtained from the Danish National Patient Register and information on demographics was obtained from the Danish Civil Registration System. The exposure was defined as the introduction of the smoking ban in August 2007 and the outcome as hospital admissions during the study period 2000–2015 due to a primary diagnosis of AMI (I21), COPD (J44) and cancer in oral cavity and pharynx (C06-C06.9, C14). Results We found no significant changes in trends for hospital admissions for any of the included smoking-related diseases after the introduction of the smoking ban compared to post-legislation trends. To exemplify, a steady decrease in-hospital admissions for AMI was observed during the study period suggesting that the decrease in AMI admissions at the time the smoking ban was introduced represented a continuation of a pre-existing trend. Conclusion The findings may be explained by the fact that the smoking ban included several exceptions resulting in a less comprehensive ban compared to other countries.

Socioeconomic Disparities in Electronic Cigarette Use and Transitions from Smoking.

Socioeconomic disparities have been established for conventional cigarette use, but not for electronic cigarettes. This study estimates socioeconomic gradients in exclusive use of conventional cigarettes, electronic cigarettes, and dual use (ie, use of both products) among adults in the United States. Analyses consider nationally representative data on 25- to 54-year-old respondents to the 2014-2016 National Health Interview Surveys (N = 50306). Demographically adjusted seemingly unrelated regression models estimate how two socioeconomic status measures-respondent education and household income-relate to current exclusive use of conventional cigarettes, electronic cigarettes, and dual use. Conventional cigarette use exhibits negative education and income gradients, consistent with existing research: -12.9 percentage points (confidence interval [CI]: -14.0, -11.8) if college educated, and -9.5 percentage points (CI: -10.9, -8.1) if household income exceeds 400% of the federal poverty level. These gradients are flatter for dual use (-1.4 [CI: -1.8, -0.9] and -1.9 [CI: -2.5, -1.2]), and statistically insignificant for electronic cigarette use (-0.03 [CI: -0.5, 0.4] and -0.3 [CI: -0.8, -0.2]). Limiting the sample to ever-smokers, higher education is associated with a 0.9 percentage point increase in likelihood of exclusive electronic cigarette use at interview (CI: 0.0, 1.9). Education and income gradients in exclusive electronic cigarette use are small and statistically insignificant, contrasting with strong negative gradients in exclusive conventional cigarette use. Furthermore, more educated smokers are more likely to switch to exclusive e-cigarette use than less educated smokers. Such differential switching may exacerbate socioeconomic disparities in smoking-related morbidity and mortality, but lower the burden of tobacco-related disease. Research has not yet established whether socioeconomic disparities in electronic cigarette (e-cigarette) use resemble those observed for conventional cigarettes. This article uses nationally representative data on US adults aged 25-54 to estimate income and education gradients in exclusive use of conventional cigarettes, e-cigarettes, and dual use. Both gradients are steep and negative for conventional cigarette use, but flat and statistically insignificant for e-cigarette use. Repeating the analysis among ever-smokers indicates that more educated smokers are more likely to transition toward exclusive e-cigarette use than less educated smokers. Such differential substitution may exacerbate disparities in smoking-related morbidity and mortality.

Impact of declining exposure to secondhand tobacco smoke in public places to decreasing smoking-related cancer mortality in the US population

BackgroundThe major decrease in exposure to secondhand smoke (SHS) in public places in recent decades could have contributed to the decline in smoking-related cancer mortality observed in the US population. MethodsProspective study among 11,856 non-smoking adults aged ≥40 years who participated in NHANES 1988–1994 or 1999–2004 and were followed for mortality through 2006. We estimated the amount of change in cancer mortality over time attributed to the intermediate pathway of changes in SHS exposure in public places, after adjustment for risk factors and SHS exposure at home. ResultsThe adjusted smoking-related cancer mortality rate ratios (95% CI) for a two-fold increase in serum cotinine and a 1-hour increase in occupational SHS exposure time were 1.10 (1.03, 1.17) and 1.14 (1.06, 1.24) for all-cancer, and 1.13 (1.03, 1.24) and 1.14 (1.02, 1.26) for smoking-related cancer, respectively. The absolute reduction in mortality comparing 1999–2004 to 1988–1994 was 75.8 (−25.5, 177.0) and 77.0 (2.6, 151.4) deaths/100,000 person-years, for all-cancer and smoking-related cancer, respectively. Among these avoided all-cancer deaths, 45.8 (2.8, 89.5) and 18.1 (−1.2, 39.6)/100,000 person-year were attributable to changes in serum cotinine concentrations and occupational SHS exposure time, respectively. The corresponding numbers of smoking-related cancer avoided deaths were 36.4 (0.7, 72.8) and 9.9 (−3.8, 24.9)/100,000 person-year. ConclusionsDeclines in SHS exposure were associated with reductions in all-cancer and smoking-related cancer mortality, supporting that smoking bans in public places may have reduced cancer mortality among non-smoking adults.

Prison smoking bans in the United States: current policy, impact and obstacle

Smoking is the leading preventable risk factor of mortality in the United States. The threat of smoking is severer in prisons. Compared with the general US population, prisoners have a higher prevalence of smoking, as well as a higher smoking-related mortality. Nowadays, smoking bans have been enacted in 49 states’ federal correctional facilities, including 100% smoke-free and tobacco-free indoors and outdoors on all grounds (20 states), 100% smoke-free indoors and outdoors on all grounds (1 state), 100% smoke-free and tobacco-free indoors (16 states), and 100% smoke-free indoors (12 states). After implementation, a mortality reduction has been achieved, especially for cancers and respiratory diseases. In addition, a more comprehensive restriction (e.g., smoking and tobacco bans indoors and outdoors) and a longer implementation contribute to a higher reduction of mortality. However, some obstacles should not be ignored, such as the high relapse rate of smoking after release, existence of smoking in smoking-free prisons, nicotine dependence and nicotine withdrawal symptoms led by the bans, potentially high prevalence of mental illnesses among prisoners who also smoke, etc. Given the impact and obstacle of the current smoking bans, the author recommends that: (I) smoking bans should be kept enacting according to the mortality reduction after implementation; (II) more restrictive bans should be considered across the U.S. States, such as smoking-free insides and outsides on the ground; (III) further efforts should be made for reducing the high relapse rate of smoking after release; (IV) other implementations combining with smoking bans should be considered for smoking inmates with mental illnesses.

Perceived risk of developing smoking-related disease among persons living with HIV

ABSTRACTPerceived risk of smoking is associated with smoking status, interest in quitting, cessation attempts, and quit success. Research is needed to explore risk perceptions of developing smoking-related disease among persons living with HIV (PLWH). Data came from 267 HIV-positive smokers who completed an online survey assessing perceived health risks associated with (a) generic smoking status; (b) generic non-smoking status; (c) their own personal current smoking; and (d) a hypothetical situation in which they were a non-smoker. PLWH perceived greater risk associated with their current smoking versus hypothetical personal non-smoking (p’s < 0.001), and greater risks associated with generic smoking status compared with their current smoking (p’s < 0.001). Being on HIV medication (β = 0.65, 95% CI = 0.17, 1.12), interest in quitting smoking (β = 0.89, 95% CI = 0.45, 1.32), and having an HIV healthcare provider who has recommended cessation (β = 1.04, 95% CI = 0.42, 1.67) were positively associated with perceived risk of developing smoking-related diseases. Findings have implications for developing targeted interventions to correct misperceptions regarding the health risks of smoking among PLWH, a population at particular risk for smoking and smoking-related morbidity and mortality.

Mental health service user and staff perspectives on tobacco addiction and smoking cessation: A meta-synthesis of published qualitative studies.

Introduction People with mental illness are up to three times more likely to smoke and experience greater challenges and less success when trying to quit and therefore have higher risk of smoking-related morbidity and mortality. There is a lack of evidence on successful interventions to reduce the smoking rates in people living with serve mental illness. A meta-synthesis was undertaken to summarize the data from multiple studies to inform the development of future smoking cessation intervention studies. Methods MEDLINE, PsycINFO, Embase and CINAHL were searched in March 2017. A total of 965 titles and abstracts were screened for inclusion with 29 papers reviewed in full and 15 studies that met inclusion criteria. Included studies were assessed for quality using the Critical Appraisal Skills Programme tool. Key data across studies were examined and compared, and a thematic analysis was conducted. Results Analysis and synthesis developed five analytical themes: environmental and social context, living with a mental health illness, health awareness, financial awareness and provision of smoking cessation support. Themes generated the interpretive construct: "Whose role is it anyway?" which highlights tensions between staff perspectives on their role and responsibilities to providing smoking cessation support and support service users would like to receive. Relevance to mental health nursing Routine smoking cessation training for mental health professionals and research on innovative smoking cessation interventions to support people living with mental illness are needed. The Cochrane tobacco group has not found sufficient direct evidence of existing evidence-based interventions that have beneficial effect on smoking in people living with mental illness. With this in mind, mental health professionals should be encouraged to engage in future research into the development of new interventions and consider innovative harm reduction strategies for smoking into their practice, to reduce the morbidity and mortality many people living with mental illness experience from tobacco smoking.

Smoke-free legislation and socioeconomic inequalities in smoking-related morbidity and mortality among adults: a systematic review

Smoke-free legislation and socioeconomic inequalities in smoking-related morbidity and mortality among adults: a systematic review

Carbonyl Emissions in E-cigarette Aerosol: A Systematic Review and Methodological Considerations.

Carbonyl emissions from tobacco cigarettes represent a substantial health risk contributing to smoking-related morbidity and mortality. As expected, this is an important research topic for tobacco harm reduction products, in an attempt to compare the relative risk of these products compared to tobacco cigarettes. In this study, a systematic review of the literature available on PubMed was performed analyzing the studies evaluating carbonyl emissions from e-cigarettes. A total of 32 studies were identified and presented. We identified a large diversity of methodologies, with substantial discrepancies in puffing patterns, aerosol collection and analytical methods as well as reported units of measurements. Such discrepancies make comparisons difficult, and in some cases the accuracy of the findings cannot be determined. Importantly, control for the generation of dry puffs was not performed in the vast majority of studies, particularly in studies using variable power devices, which could result in testing conditions and reported carbonyl levels that have no clinical relevance or context. Some studies have been replicated, verifying the presence of dry puff conditions. Whenever realistic use conditions were ensured, carbonyl emissions from e-cigarettes were substantially lower than tobacco cigarette smoke, while newer generation (bottom-coil, cotton wick) atomizers appeared to emit minimal levels of carbonyls with questionable clinical significance in terms of health risk. However, extremely high levels of carbonyl emissions were reported in some studies, and all these studies need to be replicated because of potentially important health implications.

A cost-effectiveness analysis of varenicline for smoking cessation using data from the EAGLES trial.

BackgroundThe cost-effectiveness of varenicline has been demonstrated in the US health care setting using the Benefits of Smoking Cessation on Outcomes (BENESCO) model to simulate the lifetime direct costs and consequences of a hypothetical cohort of US adult smokers who make a single attempt to quit. The aim of this study was to undertake an updated cost-effectiveness analysis, using current epidemiology inputs and recently published smoking cessation data from the Evaluating Adverse Events in a Global Smoking Cessation Study (EAGLES), the largest clinical trial of smoking cessation pharmacotherapies conducted to date.MethodsBENESCO is a Markov model simulating the effect of a single attempt to quit smoking on four smoking-related diseases: coronary heart disease, stroke, chronic obstructive lung disease, and lung cancer. Inputs were updated to include efficacy from EAGLES and newer data for the epidemiology of smoking in the US, the epidemiology and direct treatment costs of the four morbidities, and the costs of the interventions. Analyses compared varenicline, bupropion, nicotine replacement therapy (NRT) patch, and placebo with regard to the incidence of smoking-related morbidity, the incidence of smoking-related mortality, and cost-effectiveness at a time horizon from 2 years to lifetime.ResultsThe study cohort comprised of 18,394,068 US adult smokers who made a single quit attempt during the first year of the model. For varenicline, there were an estimated 319,730 fewer smoking-related morbidities at the lifetime compared with placebo. Similarly, smoking-related mortality decreased by 198,240 subjects when varenicline was compared with placebo. For the same time horizon, varenicline was more effective and less costly, ie, dominant, compared with all comparators in the cost-effectiveness analysis.ConclusionBased on the BENESCO model, smoking cessation with varenicline results in reduced incidence of smoking-related morbidity and mortality compared with other smoking cessation interventions and remains a cost-effective strategy in the US population.

Content analysis of homeless smokers’ perspectives on established and alternative smoking interventions

BackgroundCigarette smoking is 5 times more prevalent among homeless individuals than in the general population, and homeless individuals are disproportionately affected by smoking-related morbidity and mortality. Homeless smokers report interest in changing their smoking behavior; however, established smoking cessation interventions are neither desirable to nor highly effective for most members of this population. The aim of this study was to document homeless smokers’ perceptions of established smoking interventions as well as self-generated, alternative smoking interventions to elucidate points for intervention enhancement. MethodsParticipants (N=25) were homeless smokers who responded to semistructured interviews regarding smoking and nicotine use as well as experiences with established and alternative smoking interventions. Conventional content analysis was used to organize data and identify themes. ResultsParticipants appreciated providers’ initiation of conversations about smoking. They did not, however, feel simple advice to quit was a helpful approach. Instead, they suggested providers use a nonjudgmental, compassionate style, offer more support, and discuss a broader menu of options, including nonabstinence-based ways to reduce smoking-related harm and improve health-related quality of life. Most participants preferred engaging in their own self-defined, alternative smoking interventions, including obtaining nicotine more safely (e.g., vaping, using smokeless tobacco) and using behavioral (e.g., engaging in creative activities and hobbies) and cognitive strategies (e.g., reminding themselves about the positive aspects of not smoking and the negative consequences of smoking). Abrupt, unaided quit attempts were largely unsuccessful. ConclusionsThe vast majority of participants with the lived experience of homelessness and smoking were uninterested in established smoking cessation approaches. They did, however, have creative ideas about alternative smoking interventions that providers may support to reduce smoking-related harm and enhance quality of life. These ideas included providing information about the relative risks of smoking and the relative benefits of alternative strategies to obtaining nicotine and avoiding smoking.

3B.02 Trends and Patterns of Disparities in Tracheal, Bronchus, and Lung Cancer Mortality Among US Counties, 1980-2014: Topic: Pulmonology

Lung cancer is the leading cause of cancer death among men and the second leading cause of cancer death among women worldwide. Rates are highest in countries where smoking uptake began earliest, such as those in North America and Europe. Although rates are now decreasing in most of these countries, especially in men, they are increasing in countries where smoking uptake occurred later. Variation between countries may reflect different prevalence of risk factors, use of screening, and diagnostic methods. Lung cancer is the leading cause of cancer death among both men and women in the United States. Smoking is the leading cause of lung cancer incidence and mortality. In the United States, smoking rates among women peaked after those among men. The peak in smoking-related cancer mortality also occurred earlier for men than for women. The main objective is to estimate age-standardized mortality rates by US county from tracheal, bronchus, and lung cancer. Using the finding of the Global Burden of Disease (GBD) 2015 methodology which death records from the National Center for Health Statistics (NCHS) and population counts from the Census Bureau, the NCHS, and the Human Mortality Database from 1980 to 2014 were used. Lung cancer cases were classified using the International Classification of Diseases for Oncology ICDO, third edition. Rates are per 100,000 population and age-adjusted by the direct method to the 2000 U.S. standard population. A total of 19 511 910 cancer deaths were recorded in the United States between 1980 and 2014, cancer mortality decreased by 20.1% [18.2%-21.4%) ], between 1980 and 2014, from 240.2 (95% UI, 235.8-244.1) to 192.0 (95% UI, 188.6-197.7) deaths per 100 000 population. A total of 5 656 423 deaths from tracheal, bronchus, and lung (TBL) cancer were recorded. There were large differences in the mortality rate among counties throughout this period. TBL cancer mortality declined by 21.0% (95% UI, 17.9%-24.0%) between 1980 and 2014, from 68.6 (95% UI, 66.8-70.3) deaths per 100 000 population to 54.2 (95% UI, 52.7-55.6). The West and Northeast experienced declines in the mortality rate, as did Florida, while increases were observed in the South, Appalachian region, and the Midwest. The largest increase from 1980 to 2014 was observed in Owsley County, Kentucky (99.7%; 95% UI, 73.7%-130.8%), while the greatest decline was observed in Aleutians East Borough and Aleutians West Census Area, Alaska (63.6%; 95% UI, 50.3%-73.5%). High mortality rates in 2014 were clustered in Kentucky and West Virginia. Because national rates peaked in 1988, women in 2215 counties experienced a statistically significant increase in the mortality rate, while this was true for men in only 11 counties. The highest national mortality rate for men was present in 1980, while the peak in mortality rate for women was in 2001. The largest percentage increase (168.3%; 95% UI, 136.4%207.8) from 1980 to the peak in 2001 for women was observed in Marlboro County, South Carolina (mortality rate of 67.1 [95% UI, 61.4-73.5] deaths per 100 000 population in 2001). Mortality rates varied from 10.6 (95% UI, 8.6-12.8) in Summit County, Colorado, to 334.9 (95% UI, 300.5-375.2) in Union County, Florida, for males and 10.9 (95% UI, 8.3-13.8) in Summit County, Colorado, to 121 (95% UI, 101.6-142.0) in Owsley County, Kentucky, for females. Low rates were observed along the US border with Mexico and in Utah, Colorado, and parts of Arizona, New Mexico, and Idaho. From 1980 to 2014 there has been a steady decline in the cancer death rate as a result of fewer Americans smoking and advances in cancer prevention, early detection, and treatment. Local efforts to reduce smoking in poor and rural areas are needed to reduce the burden of smoking-related cancer and other diseases.

Delivering tobacco dependence treatment in lung cancer screening programs serving socioeconomically disadvantaged populations

Smokers with low socioeconomic status (SES) are at a higher risk for developing and dying from lung cancer due to limited access to health care services and higher smoking prevalence. In 2011, the National Lung Screening Trial (NLST) found that in patients at high risk for developing lung cancer, lung cancer screening with low-dose helical computed tomography (LDCT) resulted in a 20% reduction in mortality from lung cancer. Current smokers who undergo annual LDCT screening and quit smoking derive the greatest reduction in lung cancer mortality. Thus, providing both LDCT screening and tobacco dependence treatment to current smokers can dramatically reduce smoking-related morbidity and mortality. In this report, we summarize the Society for Research on Nicotine and Tobacco (SRNT) and the Association for the Treatment of Tobacco Use and Dependence (ATTUD) guidelines on integrating smoking cessation interventions into lung cancer screening programs. We discuss barriers, potential solutions, and ongoing research efforts on how to implement tobacco treatment within LDCT screening, particularly as it pertains to low SES populations.

The contribution of alcohol consumption and smoking to educational inequalities in life expectancy among Swedish men and women during 1991\u20132008

ObjectivesTo assess the level and changes in contribution of smoking and alcohol-related mortality to educational differences in life expectancy in Sweden.MethodsWe used register data on the Swedish population at ages 30–74 during 1991–2008. Cause of death was used to identify alcohol-related deaths, while smoking-related mortality was estimated using lung cancer mortality to indirectly assess the impact of smoking on all-cause mortality.ResultsAlcohol consumption and smoking contributed to educational differences in life expectancy. Alcohol-related mortality was higher among men and contributed substantially to inequalities among men and made a small (but increasing) contribution to inequalities among women. Smoking-related mortality decreased among men but increased among women, primarily among the low educated. At the end of the follow-up, smoking-related mortality were at similar levels among men and women. The widening gap in life expectancy among women could largely be attributed to smoking.ConclusionsSmoking and alcohol consumption contribute to educational differences in life expectancy among men and women. The majority of the widening in the educational gap in mortality among women can be attributed to alcohol and smoking-related mortality.

Smoking-related general and cause-specific mortality in Estonia

BackgroundTobacco smoking is known to be the single largest cause of premature death worldwide. The aim of present study was to analyse the effect of smoking on general and cause-specific mortality in the Estonian population.MethodsThe data from 51,756 adults in the Estonian Genome Center of the University of Tartu was used. Information on dates and causes of death was retrieved from the National Causes of Death Registry. Smoking status, general survival, general mortality and cause-specific mortality were analysed using Kaplan-Meier estimator and Cox proportional hazards models.ResultsThe study found that smoking reduces median survival in men by 11.4 years and in women by 5.8 years. Tobacco smoking produces a very specific pattern in the cause of deaths, significantly increasing the risks for different cancers and cardiovascular diseases as causes of death for men and women. This study also identified that external causes, such as alcohol intoxication and intentional self-harm, are more prevalent causes of death among smokers than non-smokers. Additionally, smoking cessation was found to reverse the increased risks for premature mortality.ConclusionsTobacco smoking remains the major cause for losses of life inducing cancers and cardiovascular diseases. In addition to the common diseases, external causes also reduce substantially the years of life. External causes of death indicate that smoking has a long-term influence on the behaviour of smokers, provoking self-destructive behaviour. Our study supports the idea, that tobacco smoking generates complex harm to our health increasing mortality from both somatic and mental disorders.

Improved Depressive Symptoms in Adults with Schizophrenia During a Smoking Cessation Attempt with Varenicline and Behavioral Therapy

ABSTRACTObjective: Smoking prevalence rates are elevated in individuals with schizophrenia spectrum disorders (SSD) compared with the general population, with attendant disproportionate smoking-related morbidity and mortality. Pharmacotherapies that improve abstinence rates in this population are underutilized, partly due to concerns about neuropsychiatric safety, particularly for those with comorbid depression or prior suicide attempt. Prospective assessment of the psychiatric safety profile of varenicline in those with SSD is needed. Methods: Adult smokers with SSD entered a 12-week trial of varenicline and behavioral therapy for smoking cessation. Depressive symptoms were assessed with the Calgary Depression Scale for Schizophrenia (CDSS) at baseline and weekly thereafter. Participants with baseline and one or more postbaseline CDSS assessments, n = 179, were included in a secondary analysis of change in depressive symptoms with varenicline treatment, adjusting for abstinence status and baseline depressive symptoms. Results: Twenty-seven percent of participants had a CDSS score at baseline consistent with current major depressive disorder, and more than half had a prior suicide attempt. Forty-one percent (74/179) achieved two or more weeks of continuous abstinence at the end of treatment. CDSS scores declined 31% during the 12-week treatment period. Controlling for baseline CDSS scores, depressive symptoms declined over time in those who completed the trial, independent of abstinence status, and either declined or remained unchanged in those with major depressive disorder or prior suicide attempt or who were taking antidepressant medication. Those who did not complete the trial had no change in depressive symptoms. Discussion: Depressive symptoms declined in adults with schizophrenia during 12 weeks of varenicline treatment and cognitive behavioral therapy, independent of tobacco abstinence. Smokers with SSD who have significant depressive symptoms may be successful in smoking cessation attempts with pharmacotherapeutic aids such as varenicline while maintaining stable psychiatric symptoms. This is a secondary analysis of data collected as part of a clinical trial registered as NCT00621777, at www.clinicaltrials.gov.