Nasir Mushtaq

Concurrent Use of Cigarettes and Smokeless Tobacco among US Males and Females

Background. The current study describes concurrent use of cigarettes and smokeless tobacco (CiST) among males and females and evaluates factors associated with CiST use. Methods. Cross-sectional data were drawn from the 2010 Behavioral Risk Factor Surveillance System (BRFSS). Weighted stratified analyses were performed to find associations between CiST use and sociodemographic factors by gender. CiST users were compared to three different tobacco use groups: nonusers, exclusive smokers, and exclusive ST users. Results. Younger age and heavy alcohol consumption were consistently associated with increased odds of CiST use among both males and females, and regardless of comparison group. Among males, education was inversely related to CiST use, and these findings were consistent in all three comparisons. Among women, those unable to work or out of work were more likely to be CiST users, which was consistent across comparisons. American Indian females had higher odds of CiST use than White females when nontobacco users or smokers were the comparison group. Conclusion. This study identified sociodemographic characteristics associated with CiST use, and differences in these associations among women and men. Additionally, this study highlights the need to carefully consider what comparison groups should be used to examine factors associated with CiST use.

Economics of tobacco control in Pakistan: estimating elasticities of cigarette demand

Background Despite ongoing global efforts for tobacco control, low-income countries with struggling economies have challenges to effectively implement tobacco policies and programs. Due to the complexity of the tobacco control issue and lack of comprehensive policies, tobacco use is increasing in Pakistan. Objective The aim of this study was to assess the effect of taxes on tobacco demand in Pakistan. Methods Various surveillance indicators of tobacco use were assessed from 2001 to 2009. Price elasticities of cigarette demand in Pakistan were investigated. Results During 2003–2009, annual per capita cigarette consumption increased by 30%. Analysis of economic data indicated that a 10% increase in cigarette prices would lead to 4.8% decrease in cigarette consumption while controlling for per capita income in the short term. The long-term price elasticities of cigarette demand were estimated at −1.17. The estimations provided support for myopic addiction model for cigarette consumption in Pakistan. Conclusions Increasing tobacco taxes would have a significant impact on tobacco consumption in Pakistan. Cigarette consumption could decrease by 11.7% in the long term if there was a 10% increase in its price. The results of this study should benefit policymakers as it provides information on the characteristics of the cigarette consumption and cigarette demand function that may help in planning tobacco control strategies in low-income and middle-income countries.

A review of the validity and reliability of smokeless tobacco dependence measures

INTRODUCTION With the growing marketing of alternate tobacco products, advocacy of harm reduction, and smoke free air policies, an overall increase in Smokeless Tobacco (ST) use has been observed since the 1970s. Numerous studies have been published addressing nicotine dependence measures for smokers; however, research in the field of ST dependence measures is scarce. PURPOSE The aim of this study is to summarize the psychometric properties of ST dependence measures by evaluating the reliability and validity of these scales through peer review research. METHODS A systematic literature search was conducted within the databases of PubMed and OVID Medline. Four publications reporting on the psychometric properties of ST dependence measures were identified; two regarding FTQ based scales, one regarding an FTND based scale, and one comparing two of these modified scales. A predefined set of criteria was used to assess the psychometric properties of these measures. RESULTS ST dependence measures depend heavily on two underlying factors, heaviness of tobacco use and withdrawal. The internal consistency of the measures was low to moderate, Cronbachs α ranging from 0.30 to 0.52 Cotinine was used as criterion variable to validate the results of the dependence measures. Concurrent validity against DIS-IV-ND based diagnosis was not established for modified FTQ scale. Predictive validity of these ST dependence scales was measured as abstinence of ST use at three and six months. FTQ-ST was predictive of abstinence at three months however failed to predict six months abstinence. CONCLUSION FTQ and FTND based measures have inherited shortcomings and have limited psychometric properties. With ease of use and wide application in tobacco research, these measures provide preliminary foundation for studying ST dependence. However, the complexity of tobacco dependence requires a multidimensional measure with high validity and reliability for effective prevention care and for research purposes.

Proximal radial artery arteriovenous fistula for hemodialysis vascular access

Objective This study reviewed our experience with proximal radial artery‐based arteriovenous fistulas (PRA‐AVFs) for hemodialysis vascular access, evaluating characteristics of the patients, functional patency, risk of steal syndrome, survival of the patient, and technical considerations. Methods We retrospectively analyzed our database of consecutive patients, identifying those individuals with a PRA‐AVF created during a 12‐year period. In addition to physical examination, all patients underwent ultrasound vessel mapping by the operating surgeon, identifying the PRA‐AVF configuration and outflow target most likely to succeed. Results PRA‐AVFs were created in 1396 individuals during the 12‐year study period. The mean age was 59 years (standard deviation, ±15.9 years); 717 (51%) patients were women, 819 (59%) were diabetic, and 394 (28%) were obese. A transposition procedure was required in 400 patients, and 189 (47%) of these were completed in two‐staged operations. Preoperative characteristics with a negative impact on PRA‐AVF cumulative patency included female gender (hazard ratio, 1.90; 95% confidence interval, 1.37‐2.65), obesity (hazard ratio, 1.92; 95% confidence interval, 1.40‐2.65), and younger age. Dialysis‐associated steal syndrome (DASS) requiring an intervention occurred in 39 (2.8%) patients, and 85% of these were diabetic. The most common procedures required to restore hand perfusion while preserving the AVF were banding and outflow branch ligation or coil occlusion to decrease access flow. DASS emerged spontaneously in 15 (1.1%) of the patients, and 24 (1.7%) individuals developed hand ischemia requiring intervention after fistulography with balloon angioplasty of the PRA‐AVF anastomosis during the first years of the study period. Limiting angioplasty balloon size for such patients avoided these uncommon angioplasty‐induced DASS events in later years. Primary, primary assisted, and cumulative (secondary) patency rates were 60%, 90%, and 93% at 12 months and 47%, 86%, and 91% at 24 months, respectively. Follow‐up was 0.7 to 127 months (median, 25 months). Conclusions PRA‐AVFs offer excellent functional patency with low risk of dialysis access‐related steal syndrome. The antecubital site has a wide range of venous outflow options for both direct PRA‐AVFs and transposition procedures.

Predictors of Smokeless Tobacco Cessation Among Telephone Quitline Participants

BACKGROUND The prevalence of smokeless tobacco use in the U.S. is increasing and its use is a risk factor for a number of adverse health outcomes. Currently, there is limited evidence on the effectiveness of quitlines for tobacco cessation among smokeless tobacco users. PURPOSE To examine factors related to tobacco abstinence among exclusive smokeless tobacco users registering for services with the Oklahoma Tobacco Helpline. METHODS Participants included 959 male exclusive smokeless tobacco users registering with the Helpline between 2004 and 2012; a total of 374 completed a follow-up survey 7 months post-registration. Data were collected between 2004 and 2013 and included baseline data at Helpline registration, services received, and 7-month follow-up for 30-day point-prevalence for tobacco abstinence. Univariate and multiple logistic regression examined associations between abstinence and participant characteristics, intensity of Helpline intervention, and behavioral factors. ORs and 95% CIs were reported. Analyses were completed in 2013. RESULTS At the 7-month follow-up, 43% of the participants reported 30-day abstinence from tobacco. Each additional completed Helpline call increased the likelihood of tobacco cessation by 20% (OR=1.20, 95% CI=1.05, 1.38). Smokeless tobacco users with higher levels of motivation to quit at baseline were twice as likely to be abstinent than those with low or moderate levels of motivation (OR=2.05, 95% CI=1.25, 3.35). Use of nicotine replacement therapy was not associated with abstinence when adjusted for Helpline calls, income, and level of motivation. CONCLUSIONS Tobacco quitlines offer an effective intervention to increase smokeless tobacco abstinence.

Determinants of Salivary Cotinine among Smokeless Tobacco Users: A Cross-Sectional Survey in Bangladesh.

Introduction More than 80% of all smokeless tobacco (ST) products in the world are consumed in South Asia; yet little is known about their consumption behaviour, addictiveness, and toxic properties. This paper, for the first time, describes associations between salivary cotinine concentrations among ST users in Bangladesh and their socio-demographic characteristics and tobacco use behaviours. Methods In a survey of ST users in Dhaka, Bangladesh, we purposively recruited 200 adults who were non-smokers but consumed ST on a regular basis. In-person interviews were conducted to obtain information about socio-demographic and ST use behaviours, and saliva samples were collected to measure cotinine concentration. Simple and multiple linear regression analyses were conducted to test associations between the log transformed salivary cotinine concentration and other study variables. Results The geometric mean of cotinine concentration among ST users was 380ng/ml (GSD:2). Total duration of daily ST use in months had a statistically significant association with cotinine concentration. Other ST use characteristics including type and quantity of ST use, swallowing of tobacco juice, urges and strength of urges and attempts to cut down on tobacco use were not found to be associated with cotinine concentration in a multivariable model. Conclusion This is the first report from Bangladesh studying cotinine concentration among ST users and it points towards high levels of addiction. This warrants effective tobacco control policies to help ST cessation and prevention.

Assessment of the Tobacco Dependence Screener Among Smokeless Tobacco Users

INTRODUCTION Variants of the Fagerström Tolerance Questionnaire and Fagerström Test for Nicotine Dependence (FTND) are widely used to study dependence among smokeless tobacco (ST) users. However, there is a need for a dependence measure which is based on the clinical definition of dependence and is easy to administer. The Tobacco Dependence Screener (TDS), a self-administered 10-item scale, is based on the Diagnostic and Statistical Manual, fourth edition (DSM-IV) and ICD-10 definitions of dependence. It is commonly used as a tobacco dependence screening tool in cigarette smoking studies but it has not been evaluated for dependence in ST users. The purpose of this study is to evaluate the TDS as a measure of tobacco dependence among ST users. METHODS Data collected from a community-based sample of exclusive ST users living in Oklahoma (n = 95) was used for this study. TDS was adapted to be used for ST dependence as the references for smoking were changed to ST use. Concurrent validity and reliability of TDS were evaluated. Salivary cotinine concentration was used as a criterion variable. Overall accuracy of the TDS was assessed by receivers operating characteristic (ROC) curve and optimal cutoff scores for dependence diagnosis were evaluated. RESULTS There was no floor or ceiling effect in TDS score (mean = 5.42, SD = 2.61). Concurrent validity of TDS as evaluated by comparing it with FTND-ST was affirmative. Study findings showed significant association between TDS and salivary cotinine concentration. The internal consistency assessed by Cronbachs alpha indicated that TDS had acceptable reliability (α = 0.765). TDS was negatively correlated with time to first chew/dip and positively correlated with frequency (number of chews per day) and years of ST use. Results of logistic regression analysis showed that at an optimal cutoff score of TDS 5+, ST users classified as dependent had significantly higher cotinine concentration and FTND-ST scores. CONCLUSIONS TDS demonstrated acceptable reliability and concurrent validity among ST users. These findings are consistent with the results of previous cigarette smoking studies evaluating TDS. A self-administered tobacco dependence measure for ST users based on a clinical definition of dependence is an effective tool in research setting. IMPLICATIONS ST dependence research is still evolving. This is the first study of the TDS among ST users providing preliminary evidence about some of the psychometric properties of the scale. Similar to cigarette smokers, TDS is an effective measure of ST dependence. Study showed moderate reliability and affirmative concurrent validity of the TDS among ST users.

A multiple motive/multi-dimensional approach to measure smokeless tobacco dependence

BACKGROUND Unlike various research studies conducted to address dependence among smokers, only a few studies have examined smokeless tobacco (ST) dependence. The Fagerström Tolerance Questionnaire (FTQ) and Fagerström Test for Nicotine Dependence (FTND) based scales are the most widely used measures of nicotine dependence for both ST users and smokers. These scales were initially developed to measure physical dependence and tolerance and not to assess other salient dimensions of dependence such as craving, compulsion, or withdrawal, as defined by DSM-IV and ICD-10. The aim of this study is to develop and validate a multidimensional scale that has better content coverage, factor structure, and psychometric properties to measure dependence among ST users. METHODS 100 adult male smokeless tobacco users were recruited through email distribution lists and community referral. Participants completed three different nicotine dependence questionnaires and provided information related to their tobacco use and demographic characteristics. They also provided a saliva sample for cotinine measurement. In order to develop the new ST scale, subscales and items were selected based on correlation and factor analysis of the modified WISDM-68. Reliability and validity of the new scale, Oklahoma Scale for Smokeless Tobacco Dependence (OSSTD) were also assessed. RESULTS The new ST scale identified seven latent constructs including 23 items to measure ST dependence. Internal consistency as measured by Cronbachs coefficient (α=0.925) indicated better reliability of OSSTD than FTND-ST. Concurrent validity of OSSTD as evaluated by comparing it with dependence diagnosis and FTND-ST was affirmative. There was a significant correlation between the OSSTD total score and the cotinine levels and tobacco use characteristics among study participants. CONCLUSION OSSTD possesses better psychometric properties and provides an effective and efficient tool to measure ST dependence as a multidimensional construct.

Ten-year trends in traumatic injury mechanisms and outcomes: A trauma registry analysis

BACKGROUND The Oklahoma Trauma Registry (OTR) collects data from all state-licensed acute care hospitals. This study investigates trends and outcomes of trauma in Oklahoma using OTR. METHODS 107,549 patients (2005-2014) with major severity and one of the following criteria were included: length of hospital stay ≥48 h, dead on arrival or death in the hospital, hospital transfer, ICU admission, or surgery on the head, chest, abdomen, or vascular system. Patient characteristics, mechanisms of injury, and outcomes of trauma were analyzed. RESULTS Hospital admissions due to falls increased with an annual percent change of 4.0% (95%CI: 3.1%-4.9%) while hospital admissions due to motor vehicle crashes decreased. The number of overall deaths per year remained stable except for the fall-related deaths, which increased proportionate to the increase in the incidence of fall. Fall-related mortality was 4.2% and intracranial bleeding was present in 60% in these patients. CONCLUSION Falls are significantly increasing as a mechanism of trauma admissions and trauma-related deaths in Oklahoma. Analysis of state-based trauma registries can identify trends in etiologies of injuries and may indicate a reference point to prioritize preventive plans.

Psychometric Properties of Fagerström Test for Nicotine Dependence for Smokeless Tobacco Users (FTND-ST).

Introduction Fagerström Test for Nicotine Dependence (FTND) is the most commonly used measure of dependence among tobacco users. Psychometric properties of FTND have been validated among cigarette smokers, but the reliability and validity of its variant for smokeless tobacco (ST) users (FTND-ST) is not well documented. The objective of the present study is to evaluate reliability, construct validity, and structure model of FTND-ST. Methods Data from 95 exclusive ST users living in Oklahoma were used for this study. Participants completed a self-administered mail survey including FTND-ST and other questionnaires. Measures of internal consistency, Cronbachs coefficient α and item-total correlation were estimated to evaluate reliability of the FTND-ST. To ascertain the factor structure of the scale, confirmatory factor analysis was performed. We examined concurrent and construct validity with correlation and regression analysis. Salivary cotinine concentration was used as a criterion variable. Results The FTND-ST demonstrated good reliability with acceptable Cronbachs coefficient (α = 0.72) and significant item-total correlations. Study findings showed that FTND-ST had positive significant association with salivary cotinine concentration (r = 0.61, p <.0001) and Tobacco Dependence Screener (r = 0.44, p < .0001). Results of factor analysis support a unidimensional factor structure of FTND-ST. Conclusions The FTND-ST demonstrated good psychometric properties. The unidimensional structure of the scale indicates that it measures single clearly defined aspect of dependence, physical dependence. Given its good reliability and demonstrated construct validity, FTND-ST is a useful measure of dependence among ST users. Implications Because of the paucity of ST dependence research, there are limited studies evaluating ST dependence measures. Although the FTND was exclusively developed for cigarette smoking, it has been adapted for ST users in the form of FTND-ST. This is the first study to examine reliability, concurrent and construct validity, and structure model of FTND-ST among regular ST users. Findings suggest that the FTND-ST measures physical aspect of dependence. Good psychometric properties of FTND-ST and its orientation as a continuous scale indicate that FTND-ST is a useful measure of dependence among ST users.