Ingvar Rosendahl

Validity of self reports in a cohort of Swedish adolescent smokers and smokeless tobacco (snus) users

Objective: To validate self reports of cigarette and smokeless tobacco (snus) use in a prospective cohort of adolescents. Design: A cross sectional analysis of a cohort sub-sample. Setting: County of Stockholm, Sweden. Subjects: 520 adolescents in the final grade of junior high school (mean age 15.0 years). Main outcome measure: Concordance between self reported tobacco use and saliva cotinine concentration. Results: Using a cut point of 5 ng/ml saliva cotinine to discriminate active tobacco use, there was a 98% concordance between self reported non-use in the past month and cotinine concentration. The sensitivity of the questionnaire compared to the saliva cotinine test, used as the gold standard, was 90% and the specificity 93%. One hundred and fifteen out of 520 subjects (22%) reported monthly tobacco use. Among these, 67% (46/69) of the exclusive cigarette smokers, 82% (23/28) of exclusive snus users, and 94% (15/16) of mixed users (cigarettes + snus) had cotinine concentrations above 5 ng/ml. Among subjects reporting daily use 96% (64/67) had saliva cotinine concentrations above the cut point. Exclusive current cigarette users were more likely to be classified discordantly by questionnaire and cotinine test compared to snus users (odds ratio 3.2, 95% confidence interval 1.2 to 8.6). Conclusion: This study confirms the reliability of adolescents’ self reported tobacco use. In a context of low exposure to environmental tobacco smoke a cut off for saliva cotinine of 5 ng/ml reliably discriminated tobacco users from non-users. Irregular use of tobacco in this age group probably explains the discrepancy between self reported use and cotinine concentrations.

Symptoms of nicotine dependence in a cohort of Swedish youths: a comparison between smokers, smokeless tobacco users and dual tobacco users

AIMS To determine whether symptoms of nicotine dependence, addiction and withdrawal symptoms differ between exclusive smokers, exclusive snus (moist snuff) users and dual users. DESIGN A cross-sectional survey of a cohort subsample. Setting County of Stockholm, Sweden. PARTICIPANTS Current exclusive smokers (n = 466), exclusive snus users (n = 209) and dual users (n = 144), mean age 17.6 years. MEASUREMENTS Self-reported life-time experience of nicotine dependence and withdrawal symptoms in periods of discontinued tobacco use. Selected items from the modified Fagerstöm Tolerance Questionnaire (mFTQ), the Hooked on Nicotine Checklist (HONC) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). FINDINGS The odds ratio of endorsing each of four mFTQ items as well as the HONC item investigating the risk of feeling addicted to tobacco was two to five-fold higher for exclusive snus users and for dual users compared to exclusive smokers. One DSM-IV item (difficult to refrain from use) was elevated among dual users compared to smokers. Dual users reported the highest prevalence of any withdrawal symptom in contrast to exclusive snus users, who reported a lower risk of withdrawal symptoms compared to exclusive smokers. CONCLUSIONS Smokeless tobacco users show symptoms of nicotine dependence at least as frequently as cigarette smokers. Symptoms of nicotine dependence and of withdrawal during quit attempts are particularly frequent in the subgroup of users who combine smokeless tobacco with smoking.

Increased Risk of Second Primary Malignancies in Patients with Gynecological Cancer: A Swedish record-linkage study

The Stockholm-Gotland Cancer Register was used to study the risk of developing second primary malignancies (SPM) in women diagnosed with cancer of the uterine cervix, uterine corpus and ovaries during the period 1958-1992. Among 5,325 patients with uterine cervix cancer, 619 developed SPM. Standardized incidence ratio (SIR) was 1.29 (95% confidence interval (CI) 1.19-1.39). Significantly increased risks were observed for cancer of the colon, rectum, lung, vulva, kidney and bladder. A total of 4,815 women with uterine corpus cancer were followed and 660 SPM were found. The overall SIR was 1.21 (95% CI 1.12-1.30) with significantly increased risk for cancer of the colon, ovary, vulva and bladder. The incidence of leukemia was also significantly elevated (SIR = 3.03; 95% CI 1.70-5.00). Among 5,060 patients with ovarian cancer, 379 SPM were found (SIR 1.49; 95% CI 1.34-1.64). Increased risks of cancer of the colon, rectum, breast, uterine corpus, bladder and leukemia were observed. All three primary sites showed elevated risks of cancer of the colon and bladder. For patients with a primary cancer of the corpus and ovary an elevated risk of leukemia was also noted. The conclusion from these findings is that SPM to some extent can be explained by previously known factors, i.e. treatment and common risk factors. However, further studies concerning the role of common etiology, for instance hereditary and hormonal factors, are needed to increase the knowledge on the etiology of second primary malignancies.

Motivational Interviewing in an ordinary clinical setting: A controlled clinical trial at the Swedish National Tobacco Quitline

INTRODUCTION The present study aimed to assess the effect of adding motivational interviewing (MI) to the first session of an effective smoking cessation treatment protocol in an ordinary clinical setting: the Swedish National Tobacco Quitline (SNTQ). METHOD The study was designed as a controlled clinical trial. Between September 2005 and October 2006, 772 clients accepted the invitation to participate in the study and were semi-randomised to either standard treatment (ST) or MI. The primary outcome measures were self-reported 7-day point prevalence abstinence and 6-month continuous abstinence. RESULTS At 12-month follow-up, the 772 clients were included in an intention to treat analysis. Of the clients allocated to MI, 57/296 (19%) reported 6-month continuous abstinence compared to 66/476 (14%) of the clients allocated to ST (OR 1.48, 95% CI 1.00-2.19; P=.047). CONCLUSIONS Integrating MI into a cognitive behavioural therapy-based smoking cessation counselling in an ordinary clinical setting at a tobacco quitline increased client 6-month continuous abstinence rates by 5%.

The Association Between Compulsory School Achievement and Problem Gambling Among Swedish Young People

PURPOSE We aimed to examine the association between school grades at the age of 16 years and problem gambling at the age of 17-25 years among Swedish females and males. METHODS In a cohort design, we followed the 16- to 24-year-old participants in the representative Swedish Longitudinal Gambling Study for 2 years, 2008/2009 and 2009/2010, generating 3,816 person-years of follow-up time. The outcome, incidence of mild and moderate/severe gambling problems, was measured by the Problem Gambling Severity Index in telephone interviews. The exposure was register-linked information about final grades in compulsory school. The association between school grades and problem gambling was estimated in multinomial logistic regressions. RESULTS Low and average school grades were associated with increased incidence of mild and moderate/severe problem gambling compared to high grades, adjusted for sociodemographic characteristics, psychological distress, and alcohol use. Low grades, compared to high grades, were associated with a higher risk of mild gambling problems for adolescent males, whereas the incidence proportion of moderate/severe problem gambling was high for males aged 20-25 years with low grades, among whom unemployment was also very high. Furthermore, we found a strong and graded association between school grades and moderate/severe problem gambling for women in both age groups, despite a low prevalence of gambling participation among females compared to males. CONCLUSIONS Our findings show that Swedish youth with low school achievement have an increased risk of gambling problems up to 8 years after school graduation, after control for confounding from sociodemographic characteristics, psychological distress, and alcohol use, and that this association is stronger for females than males.

Mental Health Services and Public Safety: Substance Abuse Outpatient Visits Were Associated with Reduced Crime Rates in a Swedish Cohort.

Substance abuse is related to offending and substance abuse treatment has been associated with reductions in criminal behavior. This cohort study aimed to explore the relationship between participation in substance abuse interventions and general criminal recidivism among offenders with a combination of mental health problems and substance use problems. In total, 150 Swedish offenders with self-reported mental health and substance use problems were followed for approximately three years with regard to participation in substance abuse interventions and criminal recidivism. Participants with at least three planned visits to specialized outpatient substance abuse clinics had a substantially reduced risk of reoffending as compared to those with fewer than three such visits (HR = 0.47, 95% CI 0.29–0.77). For those with at least three planned visits, general criminal recidivism was reduced by 75% during periods of participation in outpatient visits, as compared to periods of non-participation (HR = 0.25, 95% CI 0.11–0.60). For offenders with mental health problems and substance use problems, outpatient substance abuse interventions could be regarded as important from a clinical risk management perspective, and be encouraged.

The relationship between counselors' technical skills, clients' in-session verbal responses, and outcome in smoking cessation treatment

BACKGROUND The technical component of Motivational Interviewing (MI) posits that client language mediates the relationship between counselor techniques and subsequent client behavioral outcomes. The purpose of this study was to examine this hypothesized technical component of MI in smoking cessation treatment in more depth. METHOD Secondary analysis of 106 first treatment sessions, derived from the Swedish National Tobacco Quitline, and previously rated using the Motivational Interviewing Sequential Code for Observing Process Exchanges (MI-SCOPE) Coders Manual and the Motivational Interviewing Treatment Integrity code (MITI) Manual, version 3.1. The outcome measure was self-reported 6-month continuous abstinence at 12-month follow-up. RESULTS Sequential analyses indicated that clients were significantly more likely than expected by chance to argue for change (change talk) following MI-consistent behaviors and questions and reflections favoring change. Conversely, clients were more likely to argue against change (sustain talk) following questions and reflections favoring status-quo. Parallel mediation analysis revealed that a counselor technique (reflections of client sustain talk) had an indirect effect on smoking outcome at follow-up through client language mediators. CONCLUSIONS The study makes a significant contribution to our understanding of how MI works in smoking cessation treatment and adds further empirical support for the hypothesized technical component in MI. The results emphasize the importance of counselors avoiding unintentional reinforcement of sustain talk and underline the need for a greater emphasis on the direction of questions and reflections in MI trainings and fidelity measures.

The association between at-risk gambling and binge drinking in the general Swedish population

While the association between problem gambling and alcohol use disorders has been studied previously, little is known about the association between risk gambling and risk drinking. This study aimed at examining the association between at-risk gambling and binge drinking in the general Swedish population and to test whether this association remained after controlling for demographic factors. The data was part of a larger ongoing survey in the general Swedish population. Respondents (N = 19 530) were recruited through random digit dialing and interviewed about their alcohol habits (binge drinking), at-risk gambling (the Lie/Bet questionnaire) and demographics (gender, age, education, residence size, marital status, labor market status, country of origin and smoking). There was an association between lifetime at-risk gambling and current (12 months) weekly binge drinking for both men (OR = 1.73; CI 95%: 1.27–2.35) and women (OR = 2.27; CI 95%: 1.05–4.90). After controlling for demographics this association no longer remained significant (OR = 1.38; CI 95%; .99–1.90 for men and OR = 1.99; CI 95%: .94–4.66 for women). Age and smoking had the largest impact on this association. At-risk gambling and binge drinking are associated behaviors. However, it seems as if this association may be confounded by demographic variables. We hypothesize that similarities in personality profiles and health aspects could account for an additional part of the association.

People with gambling disorder and risky alcohol habits benefit more from motivational interviewing than from cognitive behavioral group therapy

Background. Effective psychological treatment, including cognitive behavioral therapy and motivational interviewing (MI), is available for people with problematic gambling behaviors. To advance the development of treatment for gambling disorder, it is critical to further investigate how comorbidity impacts different types of treatments. The purpose of this study was to investigate whether screening for risky alcohol habits can provide guidance on whether people with gambling disorder should be recommended cognitive behavioral group therapy (CBGT) or MI. Methods. The present study is a secondary analysis of a previous randomized controlled trial that compared the effects of CBGT, MI and a waitlist control group in the treatment of disordered gambling. Assessment and treatment was conducted at an outpatient dependency clinic in Stockholm, Sweden, where 53 trial participants with gambling disorder began treatment. A modified version of the National Opinion Research Centre DSM-IV Screen for gambling problems was used to assess gambling disorder. The Alcohol Use Disorders Identification Test (AUDIT) was used to screen for risky alcohol habits. Results. The interaction between treatment and alcohol habits was significant and suggests that patients with gambling disorder and risky alcohol habits were better helped by MI, while those without risky alcohol habits were better helped by CBGT. Conclusions. The results support a screening procedure including the AUDIT prior to starting treatment for gambling disorder because the result of the screening can provide guidance in the choice of treatment. Patients with gambling disorder and risky alcohol habits are likely to be best helped if they are referred to MI, while those without risky alcohol habits are likely to be best helped if they are referred to CBGT.