Joanna E. Cohen

A systematic review of longitudinal studies on the association between depression and smoking in adolescents

BackgroundIt is well-established that smoking and depression are associated in adolescents, but the temporal ordering of the association is subject to debate.MethodsLongitudinal studies in English language which reported the onset of smoking on depression in non clinical populations (age 13-19) published between January 1990 and July 2008 were selected from PubMed, OVID, and PsychInfo databases. Study characteristics were extracted. Meta-analytic pooling procedures with random effects were used.ResultsFifteen studies were retained for analysis. The pooled estimate for smoking predicting depression in 6 studies was 1.73 (95% CI: 1.32, 2.40; p < 0.001). The pooled estimate for depression predicting smoking in 12 studies was 1.41 (95% CI: 1.21, 1.63; p < 0.001). Studies that used clinical measures of depression were more likely to report a bidirectional effect, with a stronger effect of depression predicting smoking.ConclusionEvidence from longitudinal studies suggests that the association between smoking and depression is bidirectional. To better estimate these effects, future research should consider the potential utility of: (a) shorter intervals between surveys with longer follow-up time, (b) more accurate measurement of depression, and (c) adequate control of confounding.

Smoking in the home: changing attitudes and current practices.

OBJECTIVES Trends in attitudes and current practices concerning smoking in the home were examined. METHODS Data from population-based surveys of adults in Ontario, Canada, were analyzed. RESULTS Between 1992 and 1996, the percentage of respondents who agreed that parents spending time at home with small children should not smoke increased from 51% to 70%. In 1996, 34% of the homes surveyed were smoke-free. Smoke-free homes were associated with nonsmoking respondents and with the presence of children and no daily smokers in the home. Only 20% of homes with children and any daily smokers were smoke-free. CONCLUSIONS Efforts are needed to assist parents in reducing childrens exposure to environmental tobacco smoke in the home.

Dispelling myths about gender differences in smoking cessation: population data from the USA, Canada and Britain

Objectives Based mainly on findings from clinical settings, it has been claimed that women are less likely than men to quit smoking successfully. If true, this would have important implications for tobacco control interventions. The authors aimed to test this possibility using data from general population surveys. Methods The authors used data from major national surveys conducted in 2006–2007 in the USA (Tobacco Use Supplement to the Current Population Survey), Canada (Canadian Tobacco Use Monitoring Survey) and the UK (General Household Survey) to estimate rates of smoking cessation by age in men and women. Results The authors found a pattern of gender differences in smoking cessation which was consistent across countries. Below age 50, women were more likely to have given up smoking completely than men, while among older age groups, men were more likely to have quit than women. Across all age groups, there was relatively little difference in cessation between the sexes. Conclusions Conclusions about gender differences in smoking cessation should be based on evidence from the general population rather than from atypical clinical samples. This study has found convincing evidence that men in general are not more likely to quit smoking successfully than women.

Political ideology and tobacco control

“More powerful than vested interests, more subtle than science, political ideology has, in the end, the greatest influence on disease prevention policy.” Sylvia Noble Tesh1 It is widely acknowledged that strong tobacco control policies are a crucial part of a comprehensive approach to reduce the health and economic impacts of tobacco use.2 Legislators, commissioners, and city councillors ultimately determine what policies are enacted and maintained. Yet, we know relatively little about the factors that influence elected officials to support or oppose these policies. Political scientists who traditionally study legislator voting behaviour often include measures of ideology in their analyses. However, health researchers have generally neglected political ideology in their studies of legislative outcomes related to tobacco control. Political ideology includes assumptions about whether the ultimate responsibility for health lies with the individual or with society, and whether the government has a right, or even a responsibility, to regulate individual behaviour and commercial activity to protect and promote the public good. The ideological arguments that most often come into play in discussions of public health policies tend to pit the duty of government to intervene to protect the health of its citizens against the right of individuals to make their own choices.3 Ideological arguments abound in debates about health issues, many of which are not new. Twenty years ago, Beauchamp wrote about the “growing tensions between the goals of protecting the public health and individual liberty”.4 About the same time, Baker described how ideological arguments regarding personal liberty were put forth to oppose mandating the use of motorcycle helmets and had been used for decades to delay milk pasteurisation.5 Arguments against fluoridation of public water supplies span five decades, with a prominent objection being the violation of individual rights.6-8 Of course, arguments in favour of …

Outlet density: a new frontier for tobacco control

The current model of selling cigarettes in Canada and elsewhere was instituted before the health effects of smoking were well known. An anachronism much in need of reform, this model makes cigarettes readily available in the retail environment so that they can be bought with minimal expenditure of time or effort. Such a state of affairs is inadvisable for an addictive and lethal substance. This editorial argues for a fundamental reconfiguration of the tobacco retail environment, particularly regarding outlet density. In the USA, the Institute of Medicine has recently made bold recommendations, calling for the development, implementation and evaluation of legal mechanisms for restructuring tobacco retail sales and restricting the number of tobacco outlets [1]. The connection between outlet density and public health can be garnered from alcohol policy [1,2]. Literature demonstrates that increased availability leads to increased consumption which leads in turn to increased problem rates [3]. For this reason, public health has advocated for the suppression of availability for disproportionately harmful things such as firearms [4–7] and enhancement of availability for disproportionately beneficial things such as fresh vegetables [8,9]. In some jurisdictions, alcohol availability theory has given rise to a population-level approach whereby taxes are high, outlet density is restricted and minimum age is enforced. Tobacco control already uses taxes and minimum age. The neglect of outlet density is not justified. There is inconsistency in public health messaging that combines warnings about the danger of smoking with tolerance of a retail environment that practically spews cigarettes out of every crevice. Public support exists for restricting the sale of tobacco. A 2006 representative survey (n = 976) showed that 30% of adults in Ontario, Canada did not want tobacco to be sold at all and 28% thought it should be sold in government-run stores in the way that alcohol is sold in Ontario [10]. In a national survey (n = 4048), one-third of Canadian smokers—especially young smokers—said if they had to travel further to buy cigarettes they would smoke less [11]. Studies on tobacco outlet density are not conclusive, but some show an association between greater density and higher smoking prevalence, economically disadvantaged neighborhoods [12–14] and increased youth smoking [15]. One study found that a greater number of tobacco outlets near schools was associated with an increased likelihood that underage smokers would buy their own cigarettes [16]. More research is needed to determine whether these associations are causal and, if so, in what direction. The relationship between outlet density and tobacco-related disease and death also requires further examination. Given the inconsistency in public health messages that discourage smoking but tolerate high outlet density, how can the number of outlets be reduced? One option is to require businesses to buy a license to sell tobacco and curtail the categories of store permitted to apply for the license. (In Canada and elsewhere, some jurisdictions currently require licenses for tobacco outlets; however, the licensing systems do not typically entail controls on availability.) Pharmacies are already not allowed to sell tobacco products in many Canadian provinces [10]. Licensing conditions could include a limit on hours and days of sale. Ideally licenses would be expensive, causing some retailers to abandon tobacco sales. Retailers failing to comply with regulations would lose their license. The impact would be stronger if there was a moratorium on new licenses until a target had been reached, e.g. 10 licenses per 20 square miles. Thus the stage would be set for reduced density by attrition. The upside of this gradual approach would be minor disruption and time to adjust for untoward effects. The downside would be delayed health benefits. Governments could also use zoning laws to ban tobacco outlets within a given distance of places where children congregate. Tobacco outlets might be deemed inappropriate near a place of worship, residential area or government office. Zoning laws could dictate a required distance between outlets to avoid clustering. New outlets would be allowed only in designated locations such as industrial use areas. The upside of zoning laws would be faster achievement of desired outcomes. The downside would be potential backlash from vested interests. The French model giving exclusive rights to sell tobacco in a specified area to licensed retailers, and requiring a licensee to be a real person as opposed to a corporation and not to operate more than one outlet [17], could be upgraded to include a public health component. For example, tobacco retailers might have to provide cessation information with every cigarette purchase. In addition to the ‘stick’ approach, ‘carrots’ could be used to encourage retailers not to sell tobacco. What about a rewards program for choosing not to sell cigarettes? Interestingly, a US grocery chain announced recently that it will stop selling tobacco because of the harmful effects of smoking [18]. Reducing the number of tobacco retail outlets is a challenge for tobacco control in the 21st century [19]. Unintended consequences are one possible hurdle. The EDITORIAL doi:10.1111/j.1360-0443.2008.02389.x

A Novel Evaluation of World No Tobacco Day in Latin America

Background World No Tobacco Day (WNTD), commemorated annually on May 31, aims to inform the public about tobacco harms. Because tobacco control surveillance is usually annualized, the effectiveness of WNTD remains unexplored into its 25th year. Objective To explore the potential of digital surveillance (infoveillance) to evaluate the impacts of WNTD on population awareness of and interest in cessation. Methods Health-related news stories and Internet search queries were aggregated to form a continuous and real-time data stream. We monitored daily news coverage of and Internet search queries for cessation in seven Latin American nations from 2006 to 2011. Results Cessation news coverage peaked around WNTD, typically increasing 71% (95% confidence interval [CI] 61–81), ranging from 61% in Mexico to 83% in Venezuela. Queries indicative of cessation interest peaked on WNTD, increasing 40% (95% CI 32–48), ranging from 24% in Colombia to 84% in Venezuela. A doubling in cessation news coverage was associated with approximately a 50% increase in cessation queries. To gain a practical perspective, we compared WNTD-related activity with New Year’s Day and several cigarette excise tax increases in Mexico. Cessation queries around WNTD were typically greater than New Year’s Day and approximated a 2.8% (95% CI –0.8 to 6.3) increase in cigarette excise taxes. Conclusions This novel evaluation suggests WNTD had a significant impact on popular awareness (media trends) and individual interest (query trends) in smoking cessation. Because WNTD is constantly evolving, our work is also a model for real-time surveillance and potential improvement in WNTD and similar initiatives.

Tobacco commerce on the internet: a threat to comprehensive tobacco control

Although internet use continues to increase and e-commerce sales are expected to exceed US

Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers.

1 trillion by the end of 2001, there have been few assessments in the literature regarding the implications of this medium for tobacco control efforts. This commentary explores the challenges that the internet may pose to the key components of a comprehensive tobacco control strategy, and pinpoints potential approaches for addressing these challenges. Four key challenges that the internet presents for tobacco control are identified: unrestricted sales to minors; cheaper cigarettes through tax avoidance and smuggling; unfettered advertising, marketing and promotion; and continued normalisation of the tobacco industry and its products. Potential strategies for addressing these challenges include international tobacco control agreements, national and state regulation, and legal remedies.

Alcohol and breast cancer mortality in a cohort study

Objectives The number of quit attempts it takes a smoker to quit successfully is a commonly reported figure among smoking cessation programmes, but previous estimates have been based on lifetime recall in cross-sectional samples of successful quitters only. The purpose of this study is to improve the estimate of number of quit attempts prior to quitting successfully. Design We used data from 1277 participants who had made an attempt to quit smoking in the Ontario Tobacco Survey, a longitudinal survey of smokers followed every 6 months for up to 3 years beginning in 2005. We calculated the number of quit attempts prior to quitting successfully under four different sets of assumptions. Our expected best set of assumptions incorporated a life table approach accounting for the declining success rates for subsequent observed quit attempts in the cohort. Results The estimated average number of quit attempts expected before quitting successfully ranged from 6.1 under the assumptions consistent with prior research, 19.6 using a constant rate approach, 29.6 using the method with the expected lowest bias, to 142 using an approach including previous recall history. Conclusions Previous estimates of number of quit attempts required to quit may be underestimating the average number of attempts as these estimates excluded smokers who have greater difficulty quitting and relied on lifetime recall of number of attempts. Understanding that for many smokers it may take 30 or more quit attempts before being successful may assist with clinical expectations.

Population Health and the Hardcore Smoker: Geoffrey Rose Revisited

Available epidemiological evidence indicates that alcohol intake is associated with a higher risk of developing breast cancer. Plausible biological pathways include its effect on levels of estrogens, cell membrane integrity and cell-to-cell communication, inhibition of DNA repair, and congener effect. The present study evaluated the impact of alcohol on mortality from breast cancer, an area with relatively few studies in the literature. The subjects were participants in a Canadian prospective cohort study, the National Breast Screening Study (NBSS). Women were enrolled in the cohort from 1980 to 1985 to evaluate the efficacy of mammographic screening. Information on usual diet and alcohol intake at enrolment and other epidemiological variables was collected by means of a mailed, self-administered questionnaire. Mortality from breast cancer during follow- up to 31 December, 1993 was ascertained by record linkage to the Canadian Mortality Data Base maintained by Statistics Canada. During the follow-up period of 1980–1993 (average 10.3 years), 223 deaths from breast cancer were identified for this analysis. The hazard ratios for the risk of death from breast cancer increased with intakes of total alcohol of 10–20 g/day (1.039, 1.009–1.071) and > 20 g/day (1.063, 1.029–1.098). This increase was contributed largely by the intake of wine, a 15% increase in risk at intakes higher than 10 g/day of alcohol from wine. Alcohol from spirits was associated with a small decrease in risk of death (hazard ratio at 10 g/day, 0.945, 0.915–0.976). The effect of alcohol from beer was not significant in the two categories studied. Although our results were statistically significant, the magnitude of the change in risk was small.