Association of Cantonese dietary patterns with mortality risk in older Chinese: a 16-year follow-up of a Guangzhou Biobank cohort study.

Background: Evidence about the associations between Cantonese dietary patterns and mortality is scarce. We examined the prospective association of the dietary pattern with all-cause, cancer and cardiovascular disease (CVD) mortality in older Chinese. Methods: We included 19 598 participants of a Guangzhou Biobank cohort study aged 50+ years, who were recruited from 2003 to 2006 and followed up until July, 2022. The diet was assessed by using a 300-item validated food frequency questionnaire. The food items were collapsed into 27 food groups. Factor analysis (FA) was used to identify dietary patterns. Multivariable Cox regression produced hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality. Results: During 305 410 person-years, 4966 deaths including 1971 CVD, 1565 cancer and 1436 other-causes occurred. Four dietary patterns were identified by FA. No association of the vegetable-based dietary pattern with all-cause, CVD and cancer mortality was found. Compared with the lowest quartile of the healthy Cantonese dietary pattern score, the highest quartile showed lower risks of all-cause (HR 0.86, 95% CI 0.80-0.94) and CVD mortality (HR 0.84, 95% CI 0.72-0.97). The highest quartile of the nut and fruit dietary pattern showed lower risks of all-cause (HR 0.92, 95% CI 0.85-0.99) and CVD mortality (HR 0.82, 95% CI 0.72-0.93), while the unhealthy western dietary pattern was associated with a higher risk of all-cause (HR 1.10, 95% CI 1.01-1.19) and cerebrovascular disease mortality (HR 1.28, 95% CI 1.03-1.58). Conclusion: We have first identified four dietary patterns based on the Cantonese cuisine and found that healthy Cantonese and nut and fruit dietary patterns were associated with lower risks of all-cause and CVD mortality, whereas the unhealthy western dietary pattern was associated with a higher risk of all-cause and cerebrovascular disease mortality.

Associations of soy product intake with all-cause, cardiovascular disease and cancer mortality: Guangzhou Biobank Cohort Study and updated meta-analyses.

PURPOSE: We examined the associations of soy product intake with all-cause, cardiovascular disease (CVD), and cancer mortality and mediations through CVD risk factors based on the Guangzhou Biobank Cohort Study (GBCS), and conducted updated meta-analyses. METHODS: A total of 29,825 participants aged 50 + years were included. Causes of death were identified through record linkage. Soy product intake was assessed by food frequency questionnaire. Cox proportional hazards regression was used to analyze the associations between soy product intake and mortality, yielding hazard ratios (HRs) and 95% confidence intervals (CIs). Mediation analyses with CVD risk factors as mediators, and updated meta-analyses were conducted. RESULTS: During 454,689 person-years of follow-up, 6899 deaths occurred, including 2694 CVD and 2236 cancer. Participants who consumed soy product of 1-6 portions/week, versus no consumption, had significantly lower risks of all-cause and CVD mortality (adjusted HR (95% CI) 0.91 (0.86, 0.97) and 0.87 (0.79, 0.96), respectively). In participants who consumed soy product of ≥ 7 portions/week, the association of higher intake with lower CVD mortality was modestly mediated by total cholesterol (4.2%, 95% CI 1.0-16.6%). Updated meta-analyses showed that the highest level of soy product intake, versus the lowest, was associated with lower risks of all-cause and CVD mortality (pooled HR (95% CI) 0.92 (0.88, 0.96) and 0.92 (0.87, 0.98), respectively). CONCLUSION: Moderate and high soy product intake were associated with lower risks of all-cause and CVD mortality. Our findings provide support for current dietary guidelines recommending moderate soy product intake, and contribute additional evidence regarding the potential protective effects of high soy product intake.

Association between tobacco industry denormalisation beliefs and support for tobacco endgame policies: a population-based study in Hong Kong.

OBJECTIVES: To examine the associations between tobacco industry denormalisation (TID) beliefs and support for tobacco endgame policies. METHODS: A total of 2810 randomly selected adult respondents of population-based tobacco policy-related surveys (2018-2019) were included. TID beliefs (agree vs disagree/unsure) were measured by seven items: tobacco manufacturers ignore health, induce addiction, hide harm, spread false information, lure smoking, interfere with tobacco control policies and should be responsible for health problems. Score of each item was summed up and dichotomised (median=5, >5 strong beliefs; ≤5 weak beliefs). Support for tobacco endgame policies on total bans of tobacco sales (yes/no) and use (yes/no) was reported. Associations between TID beliefs and tobacco endgame policies support across various smoking status were analysed, adjusting for sociodemographics. RESULTS: Fewer smokers (23.3%) had strong beliefs of TID than ex-smokers (48.4%) and never smokers (48.5%) (p<0.001). Support for total bans on tobacco sales (74.6%) and use (76.9%) was lower in smokers (33.3% and 35.3%) than ex-smokers (74.3% and 77.9%) and never smokers (76.0% and 78.3%) (all p values<0.001). An increase in the number of TID beliefs supported was positively associated with support for a total ban on sales (adjusted risk ratio 1.06, 95% CI 1.05 to 1.08, p<0.001) and use (1.06, 95% CI 1.05 to 1.07, p<0.001). The corresponding associations were stronger in smokers than non-smokers (sales: 1.87 vs 1.25, p value for interaction=0.03; use: 1.78 vs 1.21, p value for interaction=0.03). CONCLUSION: Stronger TID belief was associated with greater support for total bans on tobacco sales and use. TID intervention may increase support for tobacco endgame, especially in current smokers.

Corrigendum: Risk perceptions and changes in tobacco use in relation to Coronavirus Disease 2019 pandemic: A qualitative study on adolescent tobacco users in Hong Kong.

[This corrects the article DOI: 10.18332/tid/167479.].

Experiences of quitting smoking in prisons: A qualitative study of people in custody.

INTRODUCTION: Smoking prevalence among people in custody (PIC) is extremely high, and prison-based smoking cessation interventions are needed. The study explored the quitting experiences of PIC who participated in the 'Quit to Win' contest (QTW). METHODS: This qualitative study, conducted from 2019 to 2021 in two Hong Kong prisons, included semi-structured individual interviews with 26 PIC (13 men and 13 women) who were participants in QTW and two correctional staff who coordinated QTW. A semi-structured interview guide with open-ended questions was developed to examine multilevel factors that promote or impede smoking cessation in prisons. Maximum variation sampling was used to ensure a diverse range of social, demographic, and smoking profiles. Data were managed and analyzed using thematic analysis. RESULTS: Two themes were identified from the data: 1) quitting in prison: barriers and facilitators; and 2) QTW in prison: a trigger for behavior change. Barriers (i.e. stress, boredom, isolation, lack of self-autonomy, nicotine dependence and lack of cessation medication, barriers to moving to a different wing) and facilitators (i.e. concerns about health, money savings, and the smoke-free wing) that impeded or supported smoking cessation during incarceration were identified. QTW provided health education, quitting incentives, and social support that helped PIC overcome the barriers of quitting by serving as a trigger for behavior change. Notably, social visits with family were identified as key drivers of PIC's quitting success, whereas their suspension during the COVID-19 pandemic disincentivized their abstinence. CONCLUSIONS: This study introduced the QTW contest to prisons and provided qualitative evidence on the multilevel factors promoting or impeding smoking cessation in prison. QTW helped PIC overcome the barriers of quitting by serving as a trigger for behavior change. Future prison-based interventions should leverage social support, enhance stress-coping skills, facilitate access to pharmacotherapy, and collaborate with correctional services agencies.

Associations of meat, fish and seafood consumption with kidney function in middle-aged to older Chinese: a cross-sectional study based on the Guangzhou Biobank Cohort Study.

OBJECTIVE: To examine the associations of red meat, poultry, fish and seafood and processed meat consumption with kidney function in middle-aged to older Chinese. DESIGN: A cross-sectional study based on the Guangzhou Biobank Cohort Study. SETTING: Community-based sample. PARTICIPANTS: 9768 participants (2743 men and 7025 women) aged 50+ years. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was estimated glomerular filtration rate (eGFR) derived from the Chinese-specific equation based on the Modification of Diet in Renal Disease (MDRD) equation (c-aGFR). eGFR derived from the original isotope-dilution mass spectrometry-traceable MDRD study equation, and prevalent chronic kidney disease (CKD) defined as c-aGFR<60 mL/min/1.73 m2 were considered the secondary outcomes. RESULTS: After adjusting for sex, age, body mass index, education, occupation, family income, smoking status, alcohol use, physical activity, daily energy intake, self-rated health and chronic disease history (diabetes, hypertension and dyslipidaemia), compared with processed meat consumption of 0-1 portion/week, those who consumed ≥3 portions/week had lower c-aGFR (ß=-2.74 mL/min/1.73 m2, 95% CI=-4.28 to -1.20) and higher risk of prevalent CKD (OR=1.40, 95% CI=1.09 to 1.80, p<0.0125). Regarding fish and seafood consumption, the associations varied by diabetes (p for interaction=0.02). Fish and seafood consumption of ≥11 portions/week, versus 0-3 portions/week, was non-significantly associated with higher c-aGFR (ß=3.62 mL/min/1.73 m2, 95% CI=-0.06 to 7.30) in participants with diabetes, but was associated with lower c-aGFR in normoglycaemic participants (ß=-1.51 mL/min/1.73 m2, 95% CI=-2.81 to -0.20). No significant associations of red meat or poultry consumption with c-aGFR nor prevalent CKD were found. Similar results were found for meat, fish and seafood consumption with eGFR. CONCLUSIONS: Higher processed meat, fish and seafood consumption was associated with lower kidney function in normoglycaemic participants. However, the associations in participants with diabetes warrant further investigation.

Risk perceptions and changes in tobacco use in relation to Coronavirus Disease 2019 pandemic: A qualitative study on adolescent tobacco users in Hong Kong.

INTRODUCTION: Tobacco use is associated with an increased risk of Coronavirus Disease 2019 (COVID-19) infection, severe COVID-19 outcomes requiring intensive care, and mortality. We investigated the perceived risk of and changes in cigarette, e-cigarette (EC) and heated tobacco product (HTP) use in relation to COVID-19 in Hong Kong adolescent tobacco users. METHODS: We conducted semi-structured telephone interviews from January to April 2021 and in February 2022 on 40 adolescents (65% boys, Secondary school grades 2-6) who participated in our previous smoking surveys and were using cigarettes, ECs or HTPs before the first wave of the COVID-19 pandemic in January 2020. RESULTS: Adolescents generally perceived higher risks of contracting and having more severe COVID-19 from using cigarettes than ECs/HTPs, but they had limited knowledge of COVID-19 risks from EC/HTP use, particularly. Both increased and reduced consumption were found in tobacco, with EC use being the less affected product. Changes also included switching to ECs for convenience and lower cost and shifting from smoking cigarettes outside to mainly at home or in hidden areas. COVID-related policies, fear of infection, non-COVID-related health concerns, less social opportunities and pocket money, and limited access to tobacco products were barriers to tobacco use. In contrast, greater freedom at home versus school and negative emotions due to social distancing were facilitators. Family/peer influence had mixed impacts. CONCLUSIONS: Adolescent tobacco users perceived lower COVID risks associated with HTPs and ECs than cigarettes, and various changes in tobacco use were found amid the pandemic in Hong Kong. COVID-19 and related social changes may both facilitate or deter adolescent tobacco use.

Impact of mandatory masking amid the COVID-19 pandemic on outdoor smoking: an interrupted time-series analysis of a 33-month unobtrusive observational study.

Background: Mask-wearing in outdoor public places in Hong Kong was mandated on 29 July 2020, amid the COVID-19 pandemic. We aimed to evaluate the impact of mandatory masking with no exemption for smoking on outdoor smoking. Methods: We conducted 253 unobtrusive observations at 10 outdoor smoking hotspots in 33 months from July 2019 to March 2022 and counted smokers and non-smoking pedestrians in fixed boundaries. We conducted interrupted time-series analyses on the monthly mean volume of smokers (persons per hour) using generalized linear models. The independent variables were as follows: time since the first observation, implementation of the mask regulation, time since the regulation, seasonality, and waves 1-5 outbreaks. We checked the robustness of the association using the daily mean volume of smokers as the dependent variable. Two sensitivity analyses were conducted to include the hotspot location or the number of all pedestrians as an offset. Results: Monthly outdoor smoking decreased immediately after the regulation (incidence rate ratio [IRR]: 0.505, 95% confidence interval [CI]: 0.374 to 0.680, P < 0.001). Daily smoking analysis and the two sensitivity analyses supported the results. However, monthly outdoor smoking increased by 11% since the regulation (IRR: 1.110, 95% CI: 1.074 to 1.147, P < 0.001). An exception was observed at the most severe wave 5 outbreak when monthly outdoor smoking decreased (IRR: 0.415, 95% CI: 0.327 to 0.525, P < 0.001). Conclusion: Outdoor smoking fell immediately after mandatory masking, rebounded to pre-pandemic levels, and decreased again at the most severe wave 5.

Effect of smoking-related COVID-19 risk messaging on smoking cessation in community smokers: A pragmatic randomized controlled trial.

INTRODUCTION: Observational and experimental studies have suggested that messaging on smoking-related COVID-19 risk may promote smoking abstinence, but evidence from randomized clinical trials (RCTs) is lacking. METHODS: This was a pragmatic RCT in Hong Kong, China, to compare the effectiveness of communicating smoking-related COVID-19 risk with generic cessation support on abstinence. Both groups received brief cessation advice at baseline. The intervention group received messaging on smoking-related COVID-19 risk and cessation support via instant messaging for three months (16 messages in total), which highlighted the increased risk of severe COVID-19 and deaths, and potentially higher risk of viral exposure (e.g. due to mask removal) for smokers. The control group received generic text messaging support for three months (16 messages). The primary outcomes were biochemically validated 7-day point prevalence abstinence (PPA) at 3 and 6 months. Intention to treat analyses was used. RESULTS: Between 13 June and 30 October 2020, 1166 participants were randomly assigned to an intervention (n=583) or control (n=583) group. By intention-to-treat, validated 7-day PPA did not significantly differ between the intervention and control groups at three months (9.6% and 11.8%, relative risk, RR=0.81; 95% CI: 0.58-1.13, p=0.22) or six months (9.3% and 11.7%, RR=0.79; 95% CI: 0.57-1.11, p=0.18). A higher perceived severity of COVID-19 in smokers at baseline was associated with a greater validated 7-day PPA at six months, and a marginally significant intervention effect on changes in perceived severity from baseline through 6 months was found (p for group × time interaction = 0.08). CONCLUSIONS: Communicating smoking-related COVID-19 risk via instant messaging was not more effective in increasing smoking abstinence than generic cessation support. TRIAL REGISTRATION: The study is registered on ClinicalTrials.gov Identifier: NCT04399967.

High-throughput identification of regulatory elements and functional assays to uncover susceptibility genes for nasopharyngeal carcinoma.

Large-scale genetic association studies have identified multiple susceptibility loci for nasopharyngeal carcinoma (NPC), but the underlying biological mechanisms remain to be explored. To gain insights into the genetic etiology of NPC, we conducted a follow-up study encompassing 6,907 cases and 10,472 controls and identified two additional NPC susceptibility loci, 9q22.33 (rs1867277; OR = 0.74, 95% CI = 0.68-0.81, p = 3.08 × 10-11) and 17q12 (rs226241; OR = 1.42, 95% CI = 1.26-1.60, p = 1.62 × 10-8). The two additional loci, together with two previously reported genome-wide significant loci, 5p15.33 and 9p21.3, were investigated by high-throughput sequencing for chromatin accessibility, histone modification, and promoter capture Hi-C (PCHi-C) profiling. Using luciferase reporter assays and CRISPR interference (CRISPRi) to validate the functional profiling, we identified PHF2 at locus 9q22.33 as a susceptibility gene. PHF2 encodes a histone demethylase and acts as a tumor suppressor. The risk alleles of the functional SNPs reduced the expression of the target gene PHF2 by inhibiting the enhancer activity of its long-range (4.3 Mb) cis-regulatory element, which promoted proliferation of NPC cells. In addition, we identified CDKN2B-AS1 as a susceptibility gene at locus 9p21.3, and the NPC risk allele of the functional SNP rs2069418 promoted the expression of CDKN2B-AS1 by increasing its enhancer activity. The overexpression of CDKN2B-AS1 facilitated proliferation of NPC cells. In summary, we identified functional SNPs and NPC susceptibility genes, which provides additional explanations for the genetic association signals and helps to uncover the underlying genetic etiology of NPC development.

Perceived increased susceptibility to COVID-19 due to smoking was associated with reduced smoking at home but not on the streets amid the pandemic: A population-based cross-sectional study.

INTRODUCTION: Perceived risk of COVID-19 infection is associated with smoking behaviors, but the change in smoking across different settings are uncertain. We examined the associations of perceived increased susceptibility to COVID-19 due to smoking with change in smoking at home and on the streets. METHODS: We analyzed data of 1120 current cigarette smokers aged ≥15 years from a population-based telephone survey in Hong Kong. Perceived increased susceptibility to COVID-19 due to smoking, change in smoking, intention to quit, and tobacco dependence were measured. We used Poisson regression with robust variance to estimate adjusted risk ratio (ARR) for associations, adjusting for sociodemographic characteristics, intention to quit, and time to first cigarette after waking. RESULTS: More current smokers reduced smoking on the streets (46.1%; 95% CI: 42.8-50.0) than at home (8.7%; 95% CI: 7.0-10.8). Perceived increased susceptibility to COVID-19 due to smoking was associated with smoking reduction at home (ARR=3.29; 95% CI: 1.80-6.00, p<0.001) but not on the streets (ARR=1.13; 95% CI: 0.98-1.30, p=0.09). More smokers with stronger quit intention and lower tobacco dependence reduced smoking at home but not on the streets in those with high perceived increased susceptibility to COVID-19 due to smoking. CONCLUSIONS: This is the first report showing that more cigarette smokers reduced smoking on the streets than at home, and the perceived increased susceptibility to COVID-19 due to smoking was only associated with smoking reduction at home but not on the streets. Improving smokers' awareness of the susceptibility to COVID-19 may be an effective strategy to reduce tobacco consumption and secondhand smoke exposure at home within the context of future respiratory pandemics.

Effect of mobile interventions with nicotine replacement therapy sampling on long-term smoking cessation in community smokers: A pragmatic randomized clinical trial.

INTRODUCTION: Mobile interventions enable personalized behavioral support that could improve smoking cessation (SC) in smokers ready to quit. Scalable interventions, including unmotivated smokers, are needed. We evaluated the effect of personalized behavioral support through mobile interventions plus nicotine replacement therapy sampling (NRT-S) on SC in Hong Kong community smokers. METHODS: A total of 664 adult daily cigarette smokers (74.4% male, 51.7% not ready to quit in 30 days) were proactively recruited from smoking hotspots and individually randomized (1:1) to the intervention and control groups (each, n=332). Both groups received brief advice and active referral to SC services. The intervention group received 1-week NRT-S at baseline and 12-week personalized behavioral support through SC advisor-delivered Instant Messaging (IM) and a fully automated chatbot. The control group received regular text messages regarding general health at a similar frequency. Primary outcomes were carbon monoxide-validated smoking abstinence at 6 and 12 months post-treatment initiation. Secondary outcomes included self-reported 7-day point-prevalence and 24-week continuous abstinence, quit attempts, smoking reduction, and SC service use at 6 and 12 months. RESULTS: By intention-to-treat, the intervention group did not significantly increase validated abstinence at 6 months (3.9% vs 3.0%, OR=1.31; 95% CI: 0.57-3.04) and 12 months (5.4% vs 4.5%, OR=1.21; 95% CI: 0.60-2.45), as were self-reported 7-day point-prevalence abstinence, smoking reduction, and SC service use at 6 and 12 months. More participants in the intervention than control group made a quit attempt by 6 months (47.0% vs 38.0%, OR=1.45; 95% CI: 1.06-1.97). Intervention engagement rates were low, but engagement in IM alone or combined with chatbot showed higher abstinence at 6 months (adjusted odds ratios, AORs=4.71 and 8.95, both p<0.05). CONCLUSIONS: Personalized behavioral support through mobile interventions plus NRT-S did not significantly improve abstinence in community smokers compared to text only messaging. The suboptimal intervention engagement needs to be addressed in future studies. TRIAL REGISTRATION: ClinicalTrials.gov NCT04001972.

Quantity and Variety in Fruit and Vegetable Consumption and Mortality in Older Chinese: A 15-year Follow-Up of a Prospective Cohort Study.

BACKGROUND: Independent associations of quantity and variety of fruit and vegetables (FVs) with mortality in older people are still unclear. OBJECTIVES: This study aimed to explore the association between the quantity and variety in FV consumption and mortality in older Chinese. METHODS: A total of 19,597 participants of the Guangzhou Biobank Cohort Study aged >50 y were recruited from 2003 to 2006 and followed up until April 2021. The diet was assessed using a 300-item validated FFQ. Variety as a continuous variable was defined as the number of unique FV items (excluding potatoes, legumes, and fruit juices) intake per week over the past week. The associations of quantity and variety of FVs with mortality were analyzed, and analyses by the color of edible parts was performed. Multivariable Cox regression yielded HRs and 95% CIs. RESULTS: During 286,821 person-year of follow-up, 4385 deaths occurred, including 1678 cardiovascular diseases (CVD), 1450 cancer, and 1257 other causes. Compared with the lowest quintile of variety in FV, the highest quintile was associated with lower risks of all-cause (HR: 0.81; 95% CI: 0.73-0.89) and CVD mortality (HR: 0.79; 95% CI 0.67-0.92). A greater variety of green and white FV intake was associated with lower risks of all-cause and CVD morality, and a greater variety of red/purple FV intake was associated with lower risks of all-cause and cancer mortality. However, the quantity of FV intake showed no association with all-cause, CVD, and cancer mortality. CONCLUSION: Our findings have first showed that the variety, rather than quantity, in FV intake was associated with a lower risk of mortality in older Chinese. Dietary guidelines may recommend increasing the variety in FV intake, especially green, red/purple, and white FVs in older people.

Increase of unmotivated and hardened smokers in Hong Kong: a repeated cross-sectional trend analysis.

OBJECTIVES: To examine the trends in the prevalence of hardening indicators and hardened smokers in Hong Kong, where the low smoking prevalence has plateaued in the recent decade. METHODS: This is an analysis of repeated cross-sectional data from 9 territory-wide smoking cessation campaigns conducted annually from 2009 to 2018 (except 2011). Participants were 9837 biochemically verified daily cigarette smokers aged ≥18 years (18.5% female, mean age 43.2±14.2 years) recruited from the communities. Hardening indicators included heavy smoking (>15 CPD), high nicotine dependence (Heaviness of Smoking Index ≥5), no intention to quit within next 30 days and no past-year quit attempt. Perceived importance, confidence and difficulty of quitting were measured (each ranged 0-10). Multivariable regressions were used to model the changes in hardening indicators by calendar year, adjusting for sociodemographic characteristics. RESULTS: From 2009 to 2018, the prevalence of heavy smoking decreased from 57.6% to 39.4% (p<0.001), high nicotine dependence also decreased from 10.5% to 8.6% (p=0.06). However, the proportion of smokers with no intention to quit (12.7%-69.0%) and no past-year quit attempt (74.4%-80.4%) significantly increased (both p values <0.001). Hardened smokers (heavy smoking, no intention to quit, no past-year attempt quit attempt) significantly increased from 5.9% to 20.7% (p<0.001). Mean perceived importance (from 7.9±2.3 to 6.6±2.5) and confidence (from 6.2±2.6 to 5.3±2.4) of quitting also decreased significantly (all p values <0.001). CONCLUSIONS: Daily cigarette smokers in Hong Kong were motivational hardening, but not dependence hardening. Effective tobacco control policies and interventions are warranted to motivate quitting to further reduce smoking prevalence.

Effect of quitting immediately vs progressively on smoking cessation for smokers at emergency department in Hong Kong: A posteriori analysis of a randomized controlled trial.

BACKGROUND: A progressive approach to quitting smoking has been a popular strategy for motivating smokers who are reluctant to quit. However, whether this strategy can effectively achieve complete cessation or is as successful as quitting immediately remains unresolved. This study aimed to determine whether quitting immediately or progressively was more effective in achieving complete cessation among smokers in Hong Kong who presented at emergency departments. METHODS AND FINDINGS: A posteriori analysis of a single-blinded, multicenter, randomized controlled trial was performed. The original trials was conducted at emergency departments of four major acute hospitals in different districts of Hong Kong. In total, 1571 smokers 18 years or older who presented at 4 major emergency departments between July 4, 2015 and March 17, 2017 were randomized into an intervention group (n = 787) and a control group (n = 784). The intervention group received brief advice (about 1 minute) and could choose their own quit schedules (immediate or progressive, labeled QI and QP, respectively). The control group received a smoking cessation leaflet. Follow-ups were conducted at 1, 3, 6 and 12 months. The primary outcomes, by intention-to-treat, were biochemically validated abstinence between the QI subgroup and control group; between the QP subgroup and control group, and between the QI subgroup and QP subgroup at 6 months. After the propensity sore matching, the biochemically validated abstinence was statistically significantly higher in the QI subgroup than the control group at 6 months (12.1% vs 3.4%, P = 0.003; adjusted odds ratio [aOR] 4.34, 95% CI 1.63-11.52) and higher in the QP subgroup than the control group at 6 months (9.8% vs 3.4%, P = 0.02; aORs 2.95, 95% CI: 1.04-8.39). No statistically significant differences of biochemically validated abstinence at both 6 month (12.1% vs 9.8%, P = 0.49; aORs 1.50, 95% CI: 0.71-3.19) were found in the comparison between QI and QP subgroups. CONCLUSIONS: This study demonstrates that the strategy of quitting progressively is effective, especially for smokers who lack motivation or find it difficult to quit. If adopted routinely, such an approach can help achieve a greater level of smoking abstinence in the community. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02660957.

Cigarettes, heated tobacco products and dual use: exhaled carbon monoxide, saliva cotinine and total tobacco consumed by Hong Kong tobacco users.

BACKGROUND: Independent studies on exhaled carbon monoxide (CO) and saliva cotinine levels in regular heated tobacco product (HTP) users, and how they compare with conventional cigarette (CC) smokers, are lacking. METHODS: A total of 3294 current users of CCs, HTPs or electronic cigarettes (ECs) from a household survey and a smoking hotspot survey were classified into seven groups: exclusive users of CCs, HTPs, ECs; dual users of CCs and HTPs, CCs and ECs, HTPs and ECs; and triple users. We measured exhaled CO level using the piCo Smokerlyzer (n=780) and saliva cotinine using NicAlert cotinine test strips (n=620). Among the seven groups, the differences in (1) CO and cotinine levels were examined using Kruskal-Wallis test, and (2) the average daily tobacco consumption in the past 30 days was examined using multivariable linear regression. RESULTS: Both exclusive and dual users of CCs had a higher CO level than exclusive HTP or EC users (p<0.05). Exhaled CO levels were similar between HTP and EC users, as were saliva cotinine levels among the seven groups. Compared with exclusive CC users, those who also used HTPs or ECs smoked fewer CCs (CCs+HTPs: adjusted coefficient -2.79, 95% CI -3.90 to -1.69; CCs+ECs: -1.34, 95% CI -2.34 to -0.34), but consumed more tobacco sticks equivalent in total (2.79 (95% CI 1.61 to 3.96); 1.95 (95% CI 0.79 to 3.12)). CONCLUSIONS: HTP or EC use showed lower exhaled CO but similar saliva cotinine levels compared with CC use. Dual users of CCs and HTPs/ECs smoked fewer CCs than exclusive CC users, but consumed more tobacco in total.

Mobile Chat Messaging for Preventing Smoking Relapse Amid the COVID-19 Pandemic: A Pilot Randomized Controlled Trial.

INTRODUCTION: The ongoing COVID-19 pandemic had reduced access to traditional, in-person smoking cessation treatment. We examined the feasibility, acceptability, and potential effectiveness of mobile chat messaging in preventing smoking relapse in smokers who have recently quit smoking. METHODS: In this assessor-blinded, pilot randomized controlled trial in five cessation clinics, we recruited adult daily smokers who had been receiving cessation treatments and abstained for 3 to 30 days. The intervention group received real-time, personalized chat messaging on relapse prevention via WhatsApp for 3 months. The control group received generic text messaging on the harms of smoking and benefits of quitting for 3 months. The primary outcome was carbon monoxide-validated abstinence at 6 months post-treatment initiation. The trial was registered with ClinicalTrials.gov (NCT04409496). RESULTS: From June to July 2020, 108 of 130 (83%) eligible subjects were randomized to the intervention (N = 54) or control (N = 54) groups. The retention rate was 93% at 3 months (end of treatment) and 85% at 6 months. In the intervention group, 80% of participants responded to the chat messages at least once; 43% continuously engaged with the intervention over the 3-month intervention period. By intention-to-treat, validated abstinence at 6 months was higher in the intervention than control group (31% vs. 22%), with a relative risk of 1.72 (95% CI = 0.91% to 3.23%; p = .09) after adjusting for pre-quit nicotine dependence, duration of abstinence, and cessation treatment at baseline. CONCLUSIONS: This pilot trial showed the feasibility and acceptability of mobile chat messaging for relapse prevention with preliminary evidence on its effectiveness in increasing validated abstinence. IMPLICATIONS: Smoking relapse is the most likely outcome of smoking cessation attempts and an undertreated problem. This pilot trial showed the feasibility and acceptability of personalized chat messaging via WhatsApp for relapse prevention in recent abstainers amid the COVID-19 pandemic. The higher carbon monoxide-validated abstinence rate in participants who received chat messaging than controls showed preliminary evidence on the effectiveness of the intervention. Fully powered trials are warranted to test the intervention.

Changes in Tobacco Use in the Early Phase of Coronavirus Disease 2019 Pandemic in Hong Kong: A Qualitative Study.

INTRODUCTION: Changes in tobacco use and related personal and environmental factors amid the coronavirus disease 2019 (COVID-19) pandemic can be captured by qualitative studies, but they are few in non-Western populations. AIMS AND METHODS: We assessed the perceived links between tobacco use and COVID-19, and changes in the use of cigarettes, electronic cigarettes (ECs), and heated tobacco products (HTPs) in the early phase of the pandemic in Hong Kong, where lockdown was not implemented. Semi-structured telephone interviews were conducted from January to June 2021 in 95 participants (36 EC users, 28 HTP users, and 32 exclusive cigarette users). Transcriptions were coded using deductive and inductive approaches, and factors for changes were nested in the social-ecological model. RESULTS: Two-thirds of participants perceived their infection susceptibility was the same as never tobacco users, and 44.2% perceived more severe COVID-19 disease if infected. Amid the pandemic, tobacco use decreased overall but increased indoors for all three products. Increased tobacco use was mostly attributed to increased emotional distress, while decreases were attributed to various personal (health concerns) and environmental factors (e.g., COVID-19 regulations). Perceived convenience and lower costs were reasons for increased EC use. Limited access to HTPs was compensated by cigarette use. CONCLUSIONS: Many participants were unaware of the potential harm of tobacco use on COVID-19. Overall tobacco use decreased due to COVID-19 regulations, which may not be sustainable post-pandemic. Indoor consumption increased, supporting a comprehensive smoke-free policy that covers private indoor areas. Better cessation services targeting EC, HTP, and cigarette use are needed. IMPLICATIONS: Smokers need better awareness of the risk of tobacco use on COVID-19. Smoking cessation services can be improved by offering brief advice, strengthening advocacy against secondhand smoke, and covering EC and HTP use, highlighting their potential harms to users and others, and their risk of addiction and relapse to cigarette use.

Association of Multi-Dimensional Factors with Accelerating Age and Constructing a Healthy Lifestyle Index: Guangzhou Biobank Cohort Study.

INTRODUCTION: Ageing process is influenced by multi-dimensional factors collectively. Previous studies examined association of one separate factor with mortality without considering different manifestations of ageing process. We investigated associations of multi-dimensional factors with accelerating age (AA), a proxy to quantify ageing, in older Chinese. METHODS: 9,831 participants from Guangzhou Biobank Cohort Study were included. Four exposure domains of 15 variables including demographic and socio-economic factors, lifestyle factors, stress across the life course, and common diseases were assessed. AA was calculated based on chronological age and eight biomarkers. Traditional multivariable linear and Bayesian Network (BN) models were used. RESULTS: In both traditional and BN models, male sex, smoking, alcohol use, physical inactivity, greater waist circumference, and body mass index (BMI) were associated with higher AA, with the adjusted ß (95% confidence intervals) being 2.75 (2.40-3.09), 1.31 (0.87-1.76), 1.35 (0.55-2.15), 0.64 (0.40-0.88), 0.09 (0.06-0.11), and 0.13 (0.07-0.19) years, respectively. A Healthy Lifestyle Index (HLI) was constructed including the above lifestyle factors (non-smoking, non-alcohol use, physically active, non-central, and non-general obesity) with a point assigned for each. A higher index indicates healthier lifestyle. Compared with participants with an HLI of 5, those with an HLI of 0-2 had 2.90 (2.48-3.32) years older AA. CONCLUSIONS: Male sex, smoking, alcohol use, physical inactivity, greater waist circumference, and BMI were associated with higher AA by 0.09-2.75 years, suggesting that adopting a healthy lifestyle may alleviate process of phenotypic ageing.

Cereal intake and mortality in older Chinese: a 15-year follow-up of a prospective cohort study.

PURPOSE: We examined the association between whole grain and refined grain intake with all-cause, cancer and cardiovascular disease (CVD) mortality using the data from the Guangzhou Biobank Cohort Study. METHODS: 19,597 participants aged 50+ years were recruited from 2003 to 2006 and followed-up until April 2021. Multivariable Cox regression was used to calculate hazard radios (HRs) and 95% confidence intervals (CIs). Substitution analysis was used to replace a serving (50 g/day) of whole grain with a serving of refined grain. RESULTS: During 286,821 person-years of follow-up, 4385 deaths occurred, including 1450 from cancer, 1678 from CVD and 1257 from other causes. Compared with never whole grain intake, the highest intake category of whole grain (> 300 g/week) was associated with lower risk of all-cause (HR 0.90, 95% CI 0.82-0.98) and CVD mortality (HR 0.85, 0.74-0.98). Compared with the low-intake category of refined grain (< 500 g/day), the highest intake category (> 900 g/week) was associated with a lower risk of cancer mortality (HR 0.76, 0.62-0.95), but a higher risk of CVD mortality (HR 1.25, 1.03-1.51). No significant associations were found between whole grain intake and cancer mortality nor refined grain and all-cause mortality. The HRs of all-cause, cancer and CVD mortality substituting a serving of whole grain for refined grain were 0.96 (0.94-0.99), 1.01 (0.99-1.02) and 0.95 (0.90-0.99), respectively. CONCLUSION: We have first shown that in older Chinese, whole grain intake was associated with lower risk of all-cause and CVD mortality. Our results suggest that intake of whole grain of at least 300 g/week and refined grain of ≤ 900 g/day might be suitable for older Asian. Substituting 50 g/day of whole grain for refined grain was associated with a 4-5% lower risk of all-cause and CVD mortality.