Estimating the equity impacts of the smoking ban in England on cotinine levels: a regression discontinuity design

ObjectiveTo estimate the equity impacts of the 2007 smoking ban in England, for both smokers and non-smokers.DesignDoubly robust regression discontinuity analysis of salivary cotinine levels. Conditional average treatment effects were used to estimate differential impacts of the ban by socioeconomic deprivation (based on the Index of Multiple Deprivation). Distributional impacts were further assessed using conditional quantile treatment effects and inequality treatment effects.SettingIn 2007, England introduced a ban on smoking in public places. This had little impact on tobacco consumption by smokers but was associated with decreases in environmental tobacco smoke exposure for non-smokers. However, the impact of the ban on socioeconomic inequalities in exposure is unclear.Participants766 smokers and 2952 non-smokers responding to the Health Survey for England in 2007.Outcome measureLevels of salivary cotinine.ResultsBefore the ban, socioeconomic deprivation was associated with higher cotinine levels for non-smokers but not for smokers. The ban caused a significant reduction in average cotinine levels for non-smokers (p=0.043) but had no effect for smokers (p=0.817). Reductions for non-smokers were greater for more deprived groups with higher levels of exposure, and there was a significant reduction in socioeconomic-related inequality in cotinine. Across the whole population (both smokers and non-smokers), there was no significant increase in the concentration of cotinine levels among the socioeconomically deprived.ConclusionThe 2007 ban on smoking in public places had little impact on smokers, but was, as intended, associated with reductions in both (1) average levels of environmental tobacco smoke exposure and (2) deprivation-related inequality in exposure among non-smokers.

Smoke-Free Home Rules and Association with Child Secondhand Smoke Exposure among Mother–Child Dyad Relationships

Smoke-free home rules restrict smoking in the home, but biomarkers of secondhand smoke exposure are needed to help understand the association between smoke-free homes and child secondhand smoke exposure. Participants (n = 346) were majority Black/African American mother–child dyads from a longitudinal study in North Carolina. Mothers completed questionnaires on household smoking behaviors and rules, and child saliva samples were assayed for secondhand smoke exposure. Regression models used smoke-free home rules to predict child risk for secondhand smoke exposure. Children in households with smoke-free home rules had less salivary cotinine and risk for secondhand smoke exposure. After controlling for smokers in the household, home smoking rules were not a significant predictor of secondhand smoke exposure. Compared to children in households with no smokers, children in households with at least one smoker but a non-smoking mother (OR 5.35, 95% CI: 2.22, 13.17) and households with at least one smoker including a smoking mother (OR 13.73, 95% CI: 6.06, 33.28) had greater risk for secondhand smoke exposure. Results suggest smoke-free home rules are not sufficient to fully protect children from secondhand smoke exposure, especially in homes with smokers. Future research should focus on how household members who smoke can facilitate the prevention of child secondhand smoke exposure.

Determining Optimal Cutoffs for Exhaled Carbon Monoxide and Salivary Cotinine to Identify Smokers among Korean Americans in a Smoking Cessation Clinical Trial

Introduction. It is critical to accurately identify individuals who continue to smoke even after treatment, as this may prompt the use of more intensive and effective treatment strategies to help them attain complete abstinence. Aims. This study examined optimal cutoffs for exhaled carbon monoxide (CO) and salivary cotinine to identify smokers among Korean Americans in a smoking cessation clinical trial. Methods. CO and cotinine were measured three to four times over 12 months from the quit day. Statistical analysis was conducted using Receiver Operating Characteristic (ROC) curves. Results. A CO cutoff of 5 parts per million provided robust sensitivity (80.8-98.3%) and perfect specificity (100%), and a salivary cotinine cutoff of level 2 (30-100 ng/ml) provided the best sensitivity (91.2-95.6%) and perfect specificity (100%). Using these cutoffs, the agreement between self-reports and the two biomarkers ranged from 88.6% to 97.7%. The areas under ROC curves (AUCs) of exhaled CO ranged from 0.90 to 0.99, all of which were significant (all p values < 0.001), and the AUCs of salivary cotinine ranged from 0.96 to 0.98 (all p values < 0.001). Conclusion. Exhaled CO and salivary cotinine are complementary, and they should be used together to verify smoking abstinence for smokers in a clinical trial.

Nicotine Dependence among Adolescents Single and Dual Cigarette Users

The prevalence of concurrent use of combustible and electronic cigarettes (dual-use) is on the rise among Malaysian adolescents. This study compares nicotine dependence among exclusive cigarette users, e-cigarette users, and dual adolescent users. A total of 227 adolescent smokers completed a self-administrated questionnaire with items based on Hooked on Nicotine Checklist (HONC) incorporated. Endorsement of at least one HONC item indicates nicotine dependence. Exhaled carbon monoxide readings and salivary cotinine data were also collected. Over half (52.9%) of the participants were exclusive e-cigarette users (EC). The prevalence of exclusive conventional cigarette smokers (CC) and dual users was 11.9% and 35.2%, respectively. Adolescents who have mothers with secondary school education were more likely to become addicted to nicotine (Adjusted Odd Ratio (aOR) = 2.72; 95% CI = 1.17–6.32). Adolescents’ “mother’s education” level predicted nicotine dependence. This highlighted the need to target families within the identified demography with a more supportive anti-tobacco program.

Biomarker-assessed passive smoking in relation to cause-specific mortality: pooled data from 12 prospective cohort studies comprising 36 584 individuals

AimsWhile investigators have typically quantified the health risk of passive (secondhand) smoking by using self-reported data, these are liable to measurement error. By pooling data across studies, we examined the prospective relation of a biochemical assessment of passive smoking, salivary cotinine, with mortality from a range of causes.MethodsWe combined data from 12 cohort studies from England and Scotland initiated between 1998 and 2008. A total of 36 584 men and women aged 16–85 years of age reported that they were non-smoking at baseline, provided baseline salivary cotinine and consented to mortality record linkage.ResultsA mean of 8.1 years of mortality follow-up of 36 584 non-smokers (16 792 men and 19 792 women) gave rise to 2367 deaths (775 from cardiovascular disease, 779 from all cancers and 289 from smoking-related cancers). After controlling for a range of covariates, a 10 ng/mL increase in salivary cotinine was related to an elevated risk of total (HRs; 95% CI) (1.46; 1.16 to 1.83), cardiovascular disease (1.41; 0.96 to 2.09), cancer (1.49; 1.00 to 2.22) and smoking-related cancer mortality (2.92; 1.77 to 4.83).ConclusionsAssessed biomedically, passive smoking was a risk factor for a range of health outcomes known to be causally linked to active smoking.

Comparative Effects of E-cigarette Aerosol on Periodontium

IntroductionTobacco use is one of the main causes of periodontitis. E-cigarettes are gaining in popularity, and studies are needed to better understand the impact of e-cigarettes on oral health. Objective: To perform a longitudinal study to evaluate the adverse effects of e-cigarettes on periodontal health.MethodsNaïve e-cigarette users, cigarette smokers, and non-smokers were recruited using newspaper and social media. Demographics, age, gender, and ethnicity, were recorded. Participants were scheduled for two visits 6 months apart. At each visit, we collected data on the daily frequency puffs of an e-cigarette, the number of cigarettes smokes, and other parameters, such as alcohol consumption. Carbon monoxide levels, cotinine levels, salivary flow rate, probing depth, and bleeding on probing were determined at both baseline and follow-up visits. P-values less than 0.05 were considered statistically significant.ResultsWe screened 159 subjects and recruited 140 subjects. One-hundred-one subjects (31 cigarette smokers, 32 e-cigarette smokers, and 38 non-smokers) completed every assessment in both visits. The retention and compliance rate of subjects was 84.1%. The use of social media and craigslist was significant in recruiting e-cigarette subjects. Ethnicity and race differed between cohorts, as did average age in the male subjects. Carbon monoxide and salivary cotinine levels were highest among cigarette smokers. Bleeding on probing and average probing depths similarly increased over time in all three cohorts. Increase in the rates of severe periodontal disease were significantly higher in cigarette smokers and e-cigarette users than non-smokers. Confounding factors were subjects’ age as most of the e-cigarette group were much younger than cigarette smokers.ConclusionAmong the recruited participants, periodontal severity status after 6 month was significantly worse in cigarette smokers and e-cigarette smokers than non-smokers. This study design and protocol will assist in future larger studies on e-cigarette and oral health.

Evaluating the Psychometric Properties of the Severson 7-item Smokeless Tobacco Dependence Scale (SSTDS)

Introduction The objective of the study was to assess the psychometric properties of the Severson 7-item Smokeless Tobacco Dependence Scale (SSTDS). Methods Data from 95 male exclusive smokeless tobacco users were obtained through a self-administered mail survey to evaluate the reliability and validity of the SSTDS. Reliability of the scale was assessed by measures of internal consistency including, Cronbach’s coefficient alpha and item-total correlation. Other ST dependence scales and salivary cotinine concentration were used to evaluate concurrent validity. Structure model of the scale was ascertained by exploratory factor analysis. Overall accuracy and optimal cutoff score were obtained to evaluate SSTDS as a screening tool for ST dependence Results The SSTDS had high reliability as assessed by the internal consistency coefficient (ordinal α=0.83). SSTDS total score was significantly correlated with Fagerström Test for Nicotine Dependence for ST users - FTND-ST (r=0.42) and modified Tobacco Dependence Screener - TDS (r=0.58). Exploratory factor analysis of the SSTDS identified two underlying factors measuring distinct dimensions of dependence. With reference to TDS based dependence diagnosis, SSTDS demonstrated good diagnostic accuracy (AUC=0.82, 95%CI: 0.74–0.90). Salivary cotinine concentration was not associated with the total score of the SSTDS; however, at an optimal cutoff score of SSTDS &gt;9, everyday ST users classified as dependent had significantly higher cotinine concentration. Conclusions SSTDS is a reliable measure of dependence that has higher concurrent validity and reliability as compared to other commonly used smokeless tobacco (ST) dependence scales. Further research is needed using a larger and more diverse sample of ST users to unequivocally establish the validity of the scale. Implications Smokeless tobacco dependence has multiple aspects that can be best studied by multidimensional dependence scales. The study findings validate that the SSTDS measures not only the physical dependence but also the behavioral and psychological dimensions of dependence. Good psychometric properties, diagnostic accuracy, and multidimensional structure of SSTDS indicate that it may serve as an effective tool in assessing ST dependence in clinical and research settings.