Evaluating a pre-surgical health optimisation programme: a feasibility study.

BACKGROUND: Health optimisation programmes are increasingly popular and aim to support patients to lose weight or stop smoking ahead of surgery, yet there is little published evidence about their impact. This study aimed to assess the feasibility of evaluating a programme introduced by a National Health Service (NHS) clinical commissioning group offering support to smokers/obese patients in an extra 3 months prior to the elective hip/knee surgery pathway. METHODS: Feasibility study mapping routinely collected data sources, availability and completeness for 502 patients referred to the hip/knee pathway in February-July 2018. RESULTS: Data collation across seven sources was complex. Data completeness for smoking and ethnicity was poor. While 37% (184) of patients were eligible for health optimisation, only 28% of this comparatively deprived patient group accepted referral to the support offered. Patients who accepted referral to support and completed the programme had a larger median reduction in BMI than those who did not accept referral (- 1.8 BMI points vs. - 0.5). Forty-nine per cent of patients who accepted support were subsequently referred to surgery, compared to 61% who did not accept referral to support. CONCLUSIONS: Use of routinely collected data to evaluate health optimisation programmes is feasible though demanding. Indications of the positive effects of health optimisation interventions from this study and existing literature suggest that the challenge of programme evaluation should be prioritised; longer-term evaluation of costs and outcomes is warranted to inform health optimisation policy development.

Standardised packs and larger health warnings: visual attention and perceptions among Colombian smokers and non-smokers.

AIMS: To measure how cigarette packaging (standardised packaging and branded packaging) and health warning size affect visual attention and pack preferences among Colombian smokers and non-smokers. DESIGN: To explore visual attention, we used an eye-tracking experiment where non-smokers, weekly smokers and daily smokers were shown cigarette packs varying in warning size (30%-pictorial on top of the text, 30%-pictorial and text side-by-side, 50%, 70%) and packaging (standardised packaging, branded packaging). We used a discrete choice experiment (DCE) to examine the impact of warning size, packaging and brand name on preferences to try, taste perceptions and perceptions of harm. SETTING: Eye-tracking laboratory, Universidad Nacional de Colombia, Bogotá, Colombia. PARTICIPANTS: Participants (n = 175) were 18 to 40 years old. MEASUREMENTS: For the eye-tracking experiment, our primary outcome measure was the number of fixations toward the health warning compared with the branding. For the DCE, outcome measures were preferences to try, taste perceptions and harm perceptions. FINDINGS: We observed greater visual attention to warning labels on standardised versus branded packages (F[3,167] = 22.87, P < 0.001) and when warnings were larger (F[9,161] = 147.17, P < 0.001); as warning size increased, the difference in visual attention to warnings between standardised and branded packaging decreased (F[9,161] = 4.44, P < 0.001). Non-smokers visually attended toward the warnings more than smokers, but as warning size increased these differences decreased (F[6,334] = 2.92, P = 0.009). For the DCE, conditional trials showed that increasing the warning size from 30% to 70% reduced preferences to try (odds ratio [OR] = 0.48, 95% CI = [0.42,0.54], P < 0.001), taste perceptions (OR = 0.61, 95% CI = [0.54,0.68], P < 0.001); and increased harm perceptions (OR = 0.78, 95% CI = [0.76,0.80], P < 0.001). Compared with branded packaging, standardised packaging reduced our DCE outcome measures with ORs ranging from OR = 0.25 (95% CI = [0.17,0.38], P < 0.001) to OR = 0.79 (95% CI = [0.67,0.93], P < 0.001) across two brands. These effects were more pronounced among non-smokers, males and younger participants. Unconditional trials showed similar results. CONCLUSIONS: Standardised cigarette packaging and larger health warnings appear to decrease positive pack perceptions and have the potential to reduce the demand for cigarette products in Colombia.

Investigating the DNA methylation profile of e-cigarette use.

BACKGROUND: Little evidence exists on the health effects of e-cigarette use. DNA methylation may serve as a biomarker for exposure and could be predictive of future health risk. We aimed to investigate the DNA methylation profile of e-cigarette use. RESULTS: Among 117 smokers, 117 non-smokers and 116 non-smoking vapers, we evaluated associations between e-cigarette use and epigenome-wide methylation from saliva. DNA methylation at 7 cytosine-phosphate-guanine sites (CpGs) was associated with e-cigarette use at p < 1 × 10-5 and none at p < 5.91 × 10-8. 13 CpGs were associated with smoking at p < 1 × 10-5 and one at p < 5.91 × 10-8. CpGs associated with e-cigarette use were largely distinct from those associated with smoking. There was strong enrichment of known smoking-related CpGs in the smokers but not the vapers. We also tested associations between e-cigarette use and methylation scores known to predict smoking and biological ageing. Methylation scores for smoking and biological ageing were similar between vapers and non-smokers. Higher levels of all smoking scores and a biological ageing score (GrimAge) were observed in smokers. A methylation score for e-cigarette use showed poor prediction internally (AUC 0.55, 0.41-0.69) and externally (AUC 0.57, 0.36-0.74) compared with a smoking score (AUCs 0.80) and was less able to discriminate lung squamous cell carcinoma from adjacent normal tissue (AUC 0.64, 0.52-0.76 versus AUC 0.73, 0.61-0.85). CONCLUSIONS: The DNA methylation profile for e-cigarette use is largely distinct from that of cigarette smoking, did not replicate in independent samples, and was unable to discriminate lung cancer from normal tissue. The extent to which methylation related to long-term e-cigarette use translates into chronic effects requires further investigation.

Avoidance of tobacco health warnings? An eye-tracking approach.

AIMS: Among three eye-tracking studies, we examined how cigarette pack features affected visual attention and self-reported avoidance of and reactance to warnings. DESIGN: Study 1: smoking status × warning immediacy (short-term versus long-term health consequences) × warning location (top versus bottom of pack). Study 2: smoking status × warning framing (gain-framed versus loss-framed) × warning format (text-only versus pictorial). Study 3: smoking status × warning severity (highly severe versus moderately severe consequences of smoking). SETTING: University of Bristol, UK, eye-tracking laboratory. PARTICIPANTS: Study 1: non-smokers (n = 25), weekly smokers (n = 25) and daily smokers (n = 25). Study 2: non-smokers (n = 37), smokers contemplating quitting (n = 37) and smokers not contemplating quitting (n = 43). Study 3: non-smokers (n = 27), weekly smokers (n = 26) and daily smokers (n = 26). MEASUREMENTS: For all studies: visual attention, measured as the ratio of the number of fixations to the warning versus the branding, self-reported predicted avoidance of and reactance to warnings and for study 3, effect of warning on quitting motivation. FINDINGS: Study 1: greater self-reported avoidance [mean difference (MD) = 1.14; 95% confidence interval (CI) = 0.94, 1.35, P < 0.001, ηp2  = 0.64] and visual attention (MD = 0.89, 95% CI = 0.09, 1.68, P = 0.03, ηp2  = 0.06) to long-term warnings, but not for reactance (MD = 0.14, 95% CI = -0.04, 0.32, P = 0.12, ηp2  = 0.03). Increased visual attention to warnings on the upper versus lower half of the pack (MD = 1.8; 95% CI = 0.33, 3.26, P = 0.02, ηp2  = 0.08). Study 2: higher self-reported avoidance of (MD = 0.70; 95% CI = 0.59,0.80, P < 0.001, ηp2  = 0.61) and reactance to (MD = 0.37; 95% CI = 0.27, 0.47, P < 0.001, ηp2  = 0.34) loss-framed warnings but little evidence of a difference for visual attention (MD = 0.52; 95% CI = -0.54, 1.58, P = 0.30, ηp2  = 0.01). Greater visual attention, avoidance and reactance to pictorial versus text-only warnings (all Ps < 0.001, ηp2  > 0.25). Study 3: greater self-reported avoidance of (MD = 0.37; 95% CI = 0.25, 0.48, P < 0.001, ηp2  = 0.33) and reactance to (MD = 0.14; 95% CI = 0.05, 0.23, P = 0.003, ηp2  = 0.11) highly severe warnings but findings were inconclusive as to whether there was a difference in visual attention (MD = -0.55; 95% CI = -1.5, 0.41, P = 0.24, ηp2  = 0.02). CONCLUSIONS: Subjective and objective (eye-tracking) measures of avoidance of health warnings on cigarette packs produce different results, suggesting these measure different constructs. Visual avoidance of warnings indicates low-level disengagement with warnings, while self-reported predicted avoidance reflects higher-level engagement with warnings.