Eight-year post-trial follow-up of health care and long-term care costs of tele-based health coaching.

OBJECTIVE: To evaluate the long-term effect of telephone health coaching on health care and long-term care (LTC) costs in type 2 diabetes (T2D) and coronary artery disease (CAD) patients. DATA SOURCES/STUDY SETTING: Randomized controlled trial (RCT) data were linked to Finnish national health and social care registries and electronic health records (EHR). Post-trial eight-year economic evaluation was conducted. STUDY DESIGN: A total of 1,535 patients (≥45 years) were randomized to the intervention (n = 1034) and control groups (n = 501). The intervention group received monthly telephone health coaching for 12 months. Usual health care and LTC were provided for both groups. PRINCIPAL FINDINGS: Intention-to-treat analysis showed no significant change in total health and long-term care costs (intervention effect €1248 [3 percent relative reduction], CI -6347 to 2217) in the intervention compared to the control group. There were also no significant changes among subgroups of patients with T2D or CAD. CONCLUSIONS: Health coaching had a nonsignificant effect on health care and long-term care costs in the 8-year follow-up among patients with T2D or CAD. More research is needed to study, which patient groups, at which state of the disease trajectory of T2D and cardiovascular disease, would best benefit from health coaching.

Smoking, nicotine dependence and nicotine intake by socio-economic status and marital status.

INTRODUCTION: Low socio-economic status (SES) is strongly related to smoking, but studies examining the association of SES with nicotine dependence (ND) are scarce. The aim of this study was to examine the associations of SES and marital status with smoking, multiple measures of ND, and cotinine as a nicotine intake biomarker. METHODS: The sample comprised 1746 ever smokers, sampled from the National FINRISK 2007 Study, who had completed a tobacco specific questionnaire in addition to the standard clinical examination. The Fagerström Test for Nicotine Dependence (FTND), the Heaviness of Smoking Index (HSI), the Nicotine Dependence Syndrome Scale (NDSS), and the Hooked On Nicotine Checklist (HONC) were assessed, while plasma cotinine was measured as a biomarker of nicotine exposure in daily smokers. Univariate and multivariate associations were assessed by linear regression and multinomial logistic regression. RESULTS: In multivariate models, lower education was associated with higher FTND and HSI, income with HSI, and occupation with HSI (men only), FTND, HONC and NDSS scores. Lower education was related to higher cotinine levels among daily smokers, although the association diminished slightly after adjusting for daily smoking amount. Living without a spouse was associated with daily smoking and higher ND. CONCLUSION: In this cross-sectional study low SES was linked with higher ND among current smokers, while low SES was associated with higher cotinine levels among daily smokers. Living alone was linked with higher ND. Longitudinal studies are warranted to further explore these associations. As lower SES smokers are more addicted they may need more targeted cessation services to succeed in quitting smoking.

Age, marital status and changes in dietary habits in later life: a 21-year follow-up among Finnish women.

OBJECTIVE: To examine 21-year longitudinal changes in dietary habits and their associations with age and marital status among women aged 50-60 years at baseline. DESIGN: Prospective, longitudinal study of a cohort in the FINMONICA population-based risk factor survey with clinical assessments in 1982, 1992 and 2003. Dietary habits were assessed via self-reported consumption of foods typically contributing to SFA, cholesterol and sugar intakes in the Finnish diet. A dietary risk score based upon five items was used. SETTING: Kuopio region, Finland. SUBJECTS: Complete data from all three assessments for 103 women of the original cohort of 299 were included for two age groups: 50-54 and 55-60 years at baseline. RESULTS: Dietary habits improved between 1982 and 1992 and showed continued but less pronounced improvement between 1992 and 2003: within the younger age group, 78 % of the women reduced the number of dietary risk points from the 1982 to 2003 scores, whereas 3 % increased them and 19 % reported no change. In the older age group these percentages were 61 %, 23 % and 16 %, respectively. Women who remained married showed a steadier decline in dietary risk points than single women or women who were widows at the beginning of the follow-up. CONCLUSIONS: Older women make positive changes to their dietary habits but the consistency of these changes may be affected by the ageing process, marital status and changes in the latter.

Adult smoking as a proxy for environmental tobacco smoke exposure among children - comparing the impact of the level of information in Estonia, Finland and Latvia.

OBJECTIVE: International comparability of environmental tobacco smoke (ETS) exposure levels is difficult. This study assesses whether estimating children's exposure from information on adult smoking and exposure to ETS makes international comparisons more reliable. METHODS: The exposure among children was estimated using three different combinations (models) based on different sets of information on adult smoking, household composition or adult exposure to ETS at home in three cross-sectional nationally representative samples drawn from data sets from Estonia (n=2650), Finland (n=2829) and Latvia (n=5440) in the years 2002 and 2004. The first two models were based on adult smoking and the third also included ETS exposure. RESULTS: The parental smoking rate was similar to the general smoking prevalence. ETS exposure in non-smoking parents ranged from 22% in Finland to 60% in Latvia. All models gave rather comparative ranges except in Latvia, where the proportion of children with exposure varied from 67% with the simplest model to 81% with the most complex one. CONCLUSIONS: Adult exposure at home or adult smoking prevalence, preferably among people with children, could be used as a proxy for children's exposure to ETS. It is recommended that population questionnaires include detailed information on exposure and household composition.

Trends of tobacco use in Sweden and Finland: do differences in tobacco policy relate to tobacco use?

BACKGROUND: Sweden and Finland, neighbouring countries in Scandinavia, share features in health and social policies but retain a few differences in tobacco policy, including oral tobacco product regulation. This paper analyses the differences between tobacco policy and tobacco use between these two countries. MATERIAL: Representative data sets from both countries, for age groups 18 to 64, were used to compare the status of tobacco use. The study covered the years 1988/89, 1996/97 and 2004/05. RESULTS: Among men, daily use of tobacco products is more common in Sweden than in Finland. The daily smoking rate for men in Sweden is 16% compared to 28% in Finland. In Sweden, 27% of men use snuff daily and 17% of never smoking men reported daily use of snuff. In Finland, 3% of all males report daily use of snuff. Concurrent snuff use was linked to occasional smoking in Sweden, where 23% of male daily snuff users smoke occasionally. Among women smoking prevalence has decreased significantly in Sweden during the study period, but no real change in daily smoking can be detected in Finland. CONCLUSIONS: Tobacco control measures did gain good results among women in Sweden whereas in Finland development was modest. In Sweden, tobacco use has increased mainly due to an increase in snuff use, and snuff seems to appeal not only to switchers, but to young males without a history of smoking.

Smoking and related factors of the social environment among adolescents in the Republic of Karelia, Russia in 1995 and 2004.

BACKGROUND: To investigate changes in smoking prevalence associated with social factors and existing health policies among adolescents in Russia from 1995 to 2004. METHODS: In 1995 and 2004 a confidential questionnaire was distributed to every 9th grade student of all 10 comprehensive schools of the Pitkäranta in Republic of Karelia, Russia. In 1995, 385 children participated in the survey (response rate 95%) and 395 children (response rate 85%) in 2004. RESULTS: Twenty-nine percent of boys smoked daily in 1995 and 31% in 2004. Daily smoking doubled from 7% to 15% for girls. Smoking in the schoolyard increased among girls. The proportion of girls who reported smoking at home with their parents' knowledge increased. Both genders cited the ease of purchasing tobacco as a minor. Knowledge about the fast development of tobacco addiction increased statistically significantly among boys. Fewer numbers of respondents of either gender thought that young smokers look 'cool' and more grown up. Having a best friend who smoked was the strongest predictor for smoking for both genders. CONCLUSION: Smoking has increased among girls. Social environment is a predisposing factor. Anti-smoking legislation was implemented weakly. Minors purchase tobacco relatively easily. Knowledge about tobacco's harmfulness has somewhat increased but is not sufficient to deter starting smoking, especially among non-smoking girls. Adequate education of adolescents on the hazards of tobacco consumption is needed, accompanied by a more determined enforcement of health policies. The potent influence of peers should be considered when planning preventive interventions.

The impact of smoking on health-related and overall quality of life: a general population survey in Finland.

The objective of the study was to examine the association between overall and health-related quality of life and smoking in men and women of discrete smoking groups in Finland. The design was a Health 2000 Survey, conducted in Finland 2000--2001. The setting and participants were a two-stage, stratified, nationally representative cluster sample that comprised 8,028 persons aged 30 or over living in mainland Finland. Health-related quality of life was measured by the 15D questionnaire; and overall quality of life was assessed by a single question measure capturing the respondent's own perception and estimation of his/her quality of life. The present study showed that daily smokers had both lower health-related and overall quality of life than never-smokers among the Finnish adult population. Health-related quality of life profiles showed that daily smokers did worse than never-smokers in a considerable number of the health dimensions. The effects of smoking were observed not only through health: the daily smokers registered significantly lower ratings of overall quality of life compared with never-smokers, too. Both the health-related and overall quality of life of ex-smokers approached those of never-smokers. The results of the present study suggest that improved health is not the only benefit of smoking cessation; better quality of life and more fulfilling everyday living can also be expected. As the major health consequences of smoking usually manifest themselves only after several years of smoking, both health-related and overall quality of life measurements could be used as an intervention tool for motivating people to quit.

Did the Tobacco Control Act Amendment in 1995 affect daily smoking in Finland? Effects of a restrictive workplace smoking policy.

BACKGROUND: This study examined changes in adult daily smoking in 1981-2005 in Finland, in order to evaluate the impact of the 1995 Tobacco Control Act Amendment (TCAA) and accompanying measures on the proportion of daily smokers. The main focus of the TCAA was to prohibit smoking at workplaces (designated rooms excluded) in order to protect workers from environmental tobacco smoke. METHODS: The study was based on data from annual postal surveys among 15- to 64-year-olds in 1981-2005 (average response rate 73%). The data set for this study comprised men and women aged 25-64 years (n = 73 471). Logistic models were used to test the effect of the 1995 TCAA across employment status while controlling for the effect of changes in the real price of tobacco and in gross domestic product per capita, and adjusting for age, education, secular trend and prevalence of ever-smokers in each birth cohort. RESULTS: Controlling for confounding factors, the odds ratio (OR) for daily smoking after 1995 among employed men was 0.83 (95% CI 0.73-0.94) compared with the OR (1.0) for the period ending 1994. The corresponding figure for employed women was 0.78 (95% CI 0.68-0.91). The results can be interpreted as a positive effect of the 1995 TCAA on employees' daily smoking. Moreover, a similar decrease in daily smoking was not seen among those not targeted by the TCAA (including farmers, students, housewives, pensioners and the unemployed). CONCLUSION: Smoking behaviour was and can be influenced by national tobacco policy measures.

Impact of the 1976 Tobacco Control Act in Finland on the proportion of ever daily smokers by socioeconomic status.

OBJECTIVE: To assess the impact of the 1976 Tobacco Control Act (TCA) on smoking initiation across socioeconomic groups. METHODS: Nationwide data from independent annual cross-sectional postal surveys in 1978-2002 in Finland. Subjects were 25-64-year-old men and women born 1926-1975 (n=68 071). Socioeconomic status was derived individually from population census data. Logistic regression was applied to assess the impact of the 1976 TCA on the prevalence of ever daily smoking in birth cohorts and socioeconomic groups. RESULTS: Clear socioeconomic differences in ever daily smoking among men and women were found. In all socioeconomic groups a declining cohort trend was observed among men whereas women showed an increasing trend in early cohorts and a declining one thereafter. A statistically significant decline in the proportion of ever daily smokers compatible with the impact of the TCA was found in all socioeconomic groups except farmers. Among women the decline was roughly similar in each socioeconomic group, while among men it varied and was most pronounced among white collar employees. CONCLUSIONS: The impact of the 1976 TCA was less pronounced among male lower socioeconomic groups. In spite of the even impact of the TCA on female smoking across socioeconomic groups, large socioeconomic disparities remain. Tobacco control policy measures specifically directed at lower socioeconomic groups are needed.

Rural-urban differences in health and health behaviour: a baseline description of a community health-promotion programme for the elderly.

STUDY OBJECTIVE: To (1) describe the setting and design of the Good Ageing in Lahti Region (GOAL) programme; (2) by using the baseline results of the GOAL cohort study, to examine whether living in urban, semi-urban, or rural communities is related to risk factors for chronic diseases and functional disability in ageing individuals. DESIGN: The baseline data of a cohort study of ageing individuals living in three community types (urban, semi-urban, rural). Data were collected by two questionnaires and laboratory assessments. SETTING: Fourteen municipalities in the Lahti region (Päijät-Häme County) in Finland. PARTICIPANTS: A regionally and locally stratified random sample of men and women born in 1946-50, 1936-40, and 1926-30. A total of 4,272 were invited and 2,815 (66%) participated. MAIN RESULTS: Elevated serum cholesterol, obesity, disability, sedentary lifestyle (<2 times/week walking), and high fat intake were more prevalent in rural vs. urban and semi-urban communities. After adjustment for sex, age, education, obesity, diet, physical activity, smoking, and alcohol use, rural communities remained the only community type with increased (p<0.05) probability for high BMI (OR 1.33) and high waist circumference (OR 1.43). CONCLUSIONS: The unfavourable health and lifestyle profile, together with an old population, makes health promotion for elderly citizens a special challenge for rural communities such as those in Päijät-Häme County, Finland. Most, if not all, of the differences in health between the three community types were explained by educational background, physical activity, and smoking.

Determinants of daily smoking in Estonia, Latvia, Lithuania, and Finland in 1994-2002.

AIMS: To investigate time trends in the smoking prevalence and the sociodemographic and psychosocial background of smoking in the Baltic countries in comparison with Finland during 1994-2002. METHODS: Differences in daily smoking according to age, education, urbanization, and psychological distress in the Baltic countries and Finland were studied using postal surveys in 1994, 1996, 1998, 2000, and 2002 among adults (20-64 years old) in Estonia (n = 6,271), Latvia (n = 6,106), Lithuania (n = 9,824), and Finland (n = 15,764). RESULTS: In 1994, 1996, 1998, 2000, and 2002 the prevalence of smoking in Estonia, Latvia, Lithuania, and Finland was 47%, 54%, 46%, and 29% among men, and 21%, 19%, 11%, and 19% among women, respectively. Smoking increased among Lithuanian women from 6% in 1994 to 13% in 2002, but decreased among Estonian men and women. Smoking was generally more common among younger individuals, the less educated, and people with distress in all four countries. The odds ratios for smoking for those with low education compared with those with high education were 2.18 (1.69-2.81), 3.32 (2.55-4.31), 2.20 (1.79-2.70) and 2.80 (2.40-3.27) in men, and 1.90 (1.42-2.52). 3.09 (2.28-4.18), 0.86 (0.59-1.26), and 3.00 (2.53-3.55) in women, in Estonia, Latvia, Lithuania, and Finland, respectively. There were indications of increasing educational differences in Latvian men. Smoking was less common among rural women in all countries except Estonia. CONCLUSIONS: Estonia, Latvia, and Finland show characteristics of the "mature" phase of a smoking epidemic, and smoking may not increase in these countries. In Lithuanian women smoking may increase. Smoking may be increasingly unequally distributed in the future in all the studied countries.

Influence of parental education, childhood adversities, and current living conditions on daily smoking in early adulthood.

AIMS: To assess the association of parental education, childhood living conditions and adversities with daily smoking in early adulthood and to analyse the effect of the respondent's own education, main economic activity, and current family structure on these associations. METHODS: The study is based on a representative two-stage cluster sample (N = 1894, participation rate 79%) of young adults aged 18-29, in 2000, in Finland. The outcome measure is daily smoking. RESULTS: Parental smoking and the respondent's own education had the strongest effects on daily smoking. If both parents of the respondent were smokers, then the respondent was most likely to be a smoker too (for men OR (odds ratio) = 3.01, for women OR = 2.41 after all adjustments). Young adults in the lowest educational category had a much higher risk of daily smoking than those in the highest category (OR = 5.88 for women, 4.48 for men). For women parental divorce (OR = 2.31) and current family structure also determined daily smoking. Parental education had a strong gradient in daily smoking and the effect appeared to be mediated largely by the respondent's own educational level. CONCLUSIONS: Childhood living conditions are strong determinants of daily smoking. Much of their influence seems to be mediated through current living conditions, which are also determined by childhood conditions. Determinants of smoking behaviour are developed throughout the life course. The findings stress the importance of the respondent's education and parental smoking as determinants of smoking behaviour. Our results support the notion that intervention on smoking initiation and cessation should be considered throughout the life course. Parental involvement in fostering non-smoking would be important.