Vicki Myers

Meta-analysis of Parental Protection of Children From Tobacco Smoke Exposure

BACKGROUND AND OBJECTIVE: Worldwide, roughly 40% of children are exposed to the damaging and sometimes deadly effects of tobacco smoke. Interventions aimed at reducing child tobacco smoke exposure (TSE) have shown mixed results. The objective of this study was to perform a systematic review and meta-analysis to quantify effects of interventions aimed at decreasing child TSE. METHODS: Data sources included Medline, PubMed, Web of Science, PsycNet, and Embase. Controlled trials that included parents of young children were selected. Two reviewers extracted TSE data, as assessed by parentally-reported exposure or protection (PREP) and biomarkers. Risk ratios and differences were calculated by using the DerSimonian and Laird random-effects model. Exploratory subgroup analyses were performed. RESULTS: Thirty studies were included. Improvements were observed from baseline to follow-up for parentally-reported and biomarker data in most intervention and control groups. Interventions demonstrated evidence of small benefit to intervention participants at follow-up (PREP: 17 studies, n = 6820, relative risk 1.12, confidence interval [CI] 1.07 to 1.18], P < .0001). Seven percent more children were protected in intervention groups relative to control groups. Intervention parents smoked fewer cigarettes around children at follow-up than did control parents (P = .03). Biomarkers (13 studies, n = 2601) at follow-up suggested lower child exposure among intervention participants (RD −0.05, CI −0.13 to 0.03, P = .20). CONCLUSIONS: Interventions to prevent child TSE are moderately beneficial at the individual level. Widespread child TSE suggests potential for significant population impact. More research is needed to improve intervention effectiveness and child TSE measurement.

Smoking Reduction at Midlife and Lifetime Mortality Risk in Men: A Prospective Cohort Study

Previous studies have not shown a survival advantage for smoking reduction. The authors assessed survival and life expectancy according to changes in smoking intensity in a cohort of Israeli working men. Baseline smokers recruited in 1963 were reassessed in 1965 (n = 4,633; mean age, 51 years) and followed up prospectively for mortality through 2005. Smoking intensity at both time points was self-reported and categorized as none, 1-10, 11-20, and ≥21 cigarettes per day. Change between smoking categories was noted, and participants were classified as increased (8%), maintained (65%), reduced (17%), or quit (10%) smoking. During a median follow-up of 26 (quartiles 1-3: 16-35) years, 87% of participants died. Changes in intensity were associated with survival. In multivariable-adjusted models, the hazard ratios for mortality were 1.14 (95% confidence interval (CI): 0.99, 1.32) among increasers, 0.85 (95% CI: 0.77, 0.95) among reducers, and 0.78 (95% CI: 0.69, 0.89) among quitters, compared with maintainers. Inversely, the adjusted odds ratios of surviving to age 80 years were 0.77 (95% CI: 0.60, 0.98), 1.22 (95% CI: 1.01, 1.47), and 1.33 (95% CI: 1.07, 1.66), respectively. The survival benefit associated with smoking reduction was mostly evident among heavy smokers and for cardiovascular disease mortality. These results suggest that decreasing smoking intensity should be considered as a risk-reduction strategy for heavy smokers who cannot quit abruptly.

Long-term predictors of smoking cessation in a cohort of myocardial infarction survivors: a longitudinal study

Background: Smoking has been causally linked to cardiovascular disease, and smoking cessation after myocardial infarction (MI) has been associated with a 50% reduction in mortality. Post-MI smokers are a vulnerable population for which efforts to encourage cessation should be maximized. We examined the determinants of smoking cessation after MI. Methods: A population-based cohort of 768 Israeli smokers was followed-up longitudinally after first MI. Data were collected at study entry on demographic, socioeconomic, smoking behaviour, and clinical variables. Psychosocial measures were obtained in a subsample (n = 330). Self-reported smoking status was assessed at 3–6 months, 1–2 years, 5 years, and 10–13 years after MI. Generalized estimating equation analyses determined which factors were significant predictors of smoking status. Results: Point abstinence rates throughout follow-up ranged from 55% to 70%, while continuous abstinence rates were 59% after 1–2 years, 44% after 5 years, and 35% after 10–13 years, among survivors. Variables most strongly associated with persistent smoking were young age, long duration and high intensity of pre-MI smoking, low education, poor family income, lack of a steady partner, non-diabetic status, and short hospital stay at the index MI. Significant psychosocial predictors were low sense of coherence and high depression. Conclusions: Determinants of smoking cessation after MI are multifactorial and include demographic, socioeconomic, smoking behaviour, clinical and psychosocial measures. Post-MI hospitalization is a window of opportunity for smoking cessation interventions. Patients should be assessed for psychosocial characteristics and those with low sense of coherence and high depression should be provided with targeted help to quit.

Effectiveness of Interventions to Reduce Tobacco Smoke Pollution in Homes: A Systematic Review and Meta-Analysis

Introduction: Smoke-free homes can help protect children from tobacco smoke exposure (TSE). The objective of this study was to conduct a meta-analysis to quantify effects of interventions on changes in tobacco smoke pollution in the home, as measured by air nicotine and particulate matter (PM). Methods: We searched MEDLINE, PubMed, Web of Science, PsycINFO, and Embase. We included controlled trials of interventions which aimed to help parents protect children from tobacco smoke exposure. Two reviewers identified relevant studies, and three reviewers extracted data. Results: Seven studies were identified. Interventions improved tobacco smoke air pollution in homes as assessed by nicotine or PM. (6 studies, N = 681, p = 0.02). Analyses of air nicotine and PM separately also showed some benefit (Air nicotine: 4 studies, N = 421, p = 0.08; PM: 3 studies, N = 340, p = 0.02). Despite improvements, tobacco smoke pollution was present in homes in all studies at follow-up. Conclusions: Interventions designed to protect children from tobacco smoke are effective in reducing tobacco smoke pollution (as assessed by air nicotine or PM) in homes, but contamination remains. The persistence of significant pollution levels in homes after individual level intervention may signal the need for other population and regulatory measures to help reduce and eliminate childhood tobacco smoke exposure.

Cumulative exposure to particulate matter air pollution and long-term post-myocardial infarction outcomes

INTRODUCTION Chronic environmental exposure to particulate matter <2.5μm in diameter (PM2.5) has been associated with cardiovascular disease; however, the effect of air pollution on myocardial infarction (MI) survivors is not clear. We studied the association of chronic exposure to PM2.5 with death and recurrent cardiovascular events in MI survivors. METHODS Consecutive patients aged ≤65years admitted to all medical centers in central Israel after first-MI in 1992-1993 were followed through 2005 for cardiovascular events and 2011 for survival. Data on sociodemographic and prognostic factors were collected at baseline and during follow-up. Residential exposure to PM2.5 was estimated for each patient based on data recorded at air quality monitoring stations. Cox and Andersen-Gill proportional hazards models were used to study the pollution-outcome association. RESULTS Among the 1120 patients, 469 (41.9%) died and 541 (48.3%) experienced one or more recurrent cardiovascular event. The adjusted hazard ratios associated with a 10μg/m(3) increase in PM2.5 exposure were 1.3 (95% CI 0.8-2.1) for death and 1.5 (95% CI 1.1-1.9) for multiple recurrences of cardiovascular events (MI, heart failure and stroke). CONCLUSION When adjustment for socio-demographic factors is performed, cumulative chronic exposure to PM2.5 is positively associated with recurrence of cardiovascular events in patients after a first MI.

Clinical relevance of frailty trajectory post myocardial infarction

Background Frailty describes the heterogeneity of vulnerability in older people and has been shown to predict mortality, disability, and institutionalization. Little is known about the clinical relevance of frailty post myocardial infarction (MI). Design The Rockwood frailty index, based on accumulation of deficits, was adapted in a cohort of MI survivors followed up for 20 years, in order to assess trajectory and predictive value for clinical outcomes. Methods Participants were 1521 patients aged ≤65 years admitted to one of eight Israeli hospitals with first acute MI between 1992 and 1993. A frailty index (on a 0–1 continuous scale) was developed comprising 32 variables, including self-rated health, functional limitations, comorbidity, weight loss, and physical activity. Frailty was assessed at baseline and 10–13 years after MI. Results Median frailty score increased from 0.08 to 0.19 during follow up. Participants in the frailest group (≥0.25) at baseline had twice the multivariable-adjusted mortality risk of those in the least frail group (<0.10) (hazard ratio, HR, 2.02, 95% CI 1.46–2.79). Frailty index modelled as a time-dependent variable showed a substantially stronger association (HR 3.61, 95% CI 2.82–4.63) and provided incremental value in risk discrimination beyond clinical and socio-demographic variables (p < 0.001 for improvement in c-statistic). The frailest patients were more than twice as likely to be hospitalized during follow up compared to the least frail (adjusted rate ratio 2.14, 95% CI 1.63–2.81). Conclusions Frailty, calculated via an index of deficits, was associated with mortality and hospitalizations following MI. Beyond predictive value, accurate identification of frailty may indicate which individuals will benefit most from preventive interventions.

Poor neighborhood socioeconomic status and risk of ischemic stroke after myocardial infarction

Background: Data linking neighborhood socioeconomic status (SES) to stroke risk are scarce. We examined long-term stroke incidence according to neighborhood SES in a population-based cohort of patients hospitalized with first myocardial infarction (MI). Methods: Consecutive patients aged 65 years or less, discharged from 8 hospitals in central Israel after incident MI in 1992–1993, were followed for stroke through 2005. Individual demographic, socioeconomic, and clinical data were obtained at study entry. We estimated neighborhood SES through a composite census-derived index developed by the Israel Central Bureau of Statistics. Results: During a median follow-up of 13 years, 196 incident ischemic strokes occurred in 1410 patients. Accounting for death as a competing risk, patients residing in disadvantaged neighborhoods had higher rates of ischemic stroke (cumulative survival estimates: 81%, 88%, and 89% in increasing tertiles of neighborhood SES). Upon multivariable adjustment for individual SES measures (including income, education, and employment), cardiovascular risk factors, MI characteristics and severity indices, and acute management, the overall hazard ratio for stroke in the lower versus upper tertile of neighborhood SES was 1.5 (95% confidence interval [CI] = 1.0–2.3); after 13 years, the adjusted absolute risk difference was 7.9 incident stroke cases per 100 participants with MI (95% CI = 1.7–14.1). Conclusions: Poor neighborhood SES is associated with increased risk of ischemic stroke post-MI. The association is only partly attributable to individual SES and other baseline characteristics. The potential mechanisms for this association require further study.

Sense of coherence predicts post-myocardial infarction trajectory of leisure time physical activity: a prospective cohort study

BackgroundPhysical activity confers a survival advantage after myocardial infarction (MI), yet the majority of post-MI patients are not regularly active. Since sense of coherence (SOC) has been associated with health outcomes and some health behaviours, we investigated whether it plays a role in post-MI physical activity.We examined the predictive role of SOC in the long-term trajectory of leisure time physical activity (LTPA) after MI using a prospective cohort design.MethodsA cohort of 643 patients aged ≤ 65 years admitted to hospital in central Israel with incident MI between February 1992 and February 1993 were followed up for 13 years. Socioeconomic, clinical and psychological factors, including SOC, were assessed at baseline, and LTPA was self-reported on 5 separate occasions during follow-up. The predictive role of SOC in long-term trajectory of LTPA was assessed using generalized estimating equations.ResultsSOC was consistently associated with engagement in LTPA throughout follow-up. Patients in the lowest SOC tertile had almost twice the odds (odds ratio,1.99; 95% confidence interval,1.52-2.60) of decreasing their engagement in LTPA as those in the highest tertile. A strong association remained after controlling for disease severity, depression, sociodemographic and clinical factors.ConclusionOur evidence suggests that SOC predicts LTPA trajectory post-MI. Assessment of SOC can help identify high-risk MI survivors, who may require additional help in following secondary prevention recommendations which can dramatically improve prognosis.

Perceived social support following myocardial infarction and long-term development of frailty

Aim Frailty is a multidimensional geriatric syndrome that indicates increasing vulnerability and decreasing resistance to stressors. Social support (SS) is linked both to cardiovascular disease and to frailty. However, few cohort studies evaluated SS as a potential predictor of frailty, and none involved coronary disease populations. The aim of this study was to evaluate the role of perceived SS (PSS) – a specific component of SS – in the prediction of frailty development in myocardial infarction (MI) survivors, controlling for other psychosocial risk factors. Method A cohort of 558 patients aged ≤65 years, admitted for first-ever MI to hospitals in central Israel, was studied. PSS and other clinical and sociodemographic variables were assessed at baseline. Frailty was assessed via a frailty index of deficit accumulation 10–13 years later. Logistic regression models were constructed to assess the odds ratios (OR) for frailty associated with PSS as well as other covariates. Results At last follow-up, 154 (28%) met the criteria for frailty. In the logistic regression models, higher PSS level was associated with lower frailty risk (unadjusted OR = 0.63, 95%CI 0.53–0.76; multivariable-adjusted OR = 0.80, 95%CI 0.64–0.98). Below average family income, poor self-rated health and higher depression scores were all associated with the development of frailty, in both the unadjusted and adjusted models. Conclusions PSS predicts frailty development post-MI, which has important implications for prognosis and healthcare use.

Neighborhood Socioeconomic Status and Leisure-Time Physical Activity After Myocardial Infarction: A Longitudinal Study

BACKGROUND Area-level SES is independently associated with myocardial infarction (MI) prognosis, yet the mechanisms for this association remain speculative. PURPOSE Using a population-based cohort of MI patients, this study examined whether neighborhood SES predicts long-term trajectory of leisure-time physical activity (LTPA), an established prognostic factor. METHODS Patients aged ≤65 years (n=1410) admitted to hospital in central Israel with first MI in 1992-1993, were followed up through 2005. LTPA was reported on five successive occasions: at baseline, 3-6 months, 1-2 years, 5 years, and 10-13 years post-MI. Generalized estimating equations (GEEs) with ordinal outcome variable (LTPA classified as regular, irregular, or none) were used to determine the independent predictive role of neighborhood SES in LTPA trajectory post-MI. Analyses were conducted in 2010-2011. RESULTS Engagement in LTPA was poor, with point prevalence rates ranging from 33% to 37% for inactivity and from 19% to 27% for irregular activity throughout follow-up. The GEE-derived ORs (95% CIs) for decreased LTPA level in the lower and middle vs upper neighborhood SES tertiles were 2.49 (2.05, 3.02) and 1.60 (1.33, 1.92) after age and gender adjustment, and 1.55 (1.26, 1.90) and 1.23 (1.02, 1.49) after multivariable adjustment for individual SES measures, cardiovascular risk factors, MI characteristics, and disease-severity indices, respectively (p for trend <0.001). CONCLUSIONS Low neighborhood SES is a powerful predictor of poor LTPA uptake in MI survivors, even after extensive adjustment for individual SES and baseline clinical profile. LTPA may thus represent an intermediate mechanism between neighborhood SES and post-MI outcome, which provides prevention opportunities.