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BACKGROUND: In 2021, the US Preventive Services Task Force expanded its lung screening recommendation to include persons aged 50-80 years who had ever smoked and had at least 20 pack-years of exposure and less than 15 years since quitting (YSQ). However, studies have suggested that screening persons who formerly smoked with longer YSQ could be beneficial. METHODS: The authors used two validated lung cancer models to assess the benefits and harms of screening using various YSQ thresholds (10, 15, 20, 25, 30, and no YSQ) and the age at which screening was stopped. The impact of enforcing the YSQ criterion only at entry, but not at exit, also was evaluated. Outcomes included the number of screens, the percentage ever screened, screening benefits (lung cancer deaths averted, life-years gained), and harms (false-positive tests, overdiagnosed cases, radiation-induced lung cancer deaths). Sensitivity analyses were conducted to evaluate the effect of restricting screening to those who had at least 5 years of life expectancy. RESULTS: As the YSQ criterion was relaxed, the number of screens and the benefits and harms of screening increased. Raising the age at which to stop screening age resulted in additional benefits but with more overdiagnosis, as expected, because screening among those older than 80 years increased. Limiting screening to those who had at least 5 years of life expectancy would maintain most of the benefits while considerably reducing the harms. CONCLUSIONS: Expanding screening to persons who formerly smoked and have greater than 15 YSQ would result in considerable increases in deaths averted and life-years gained. Although additional harms would occur, these could be moderated by ensuring that screening is restricted to only those with reasonable life expectancy.
Subject(s)
Lung Neoplasms , Mass Screening , Humans , Mass Screening/methods , Early Detection of Cancer/methods , Lung , Lung Neoplasms/etiology , ThoraxABSTRACT
BACKGROUND: While regular cigar smoking is believed to carry similar health risks as regular cigarette smoking, the impact of cigar use, alone or in combination with cigarettes, on obstructive pulmonary disease (COPD) has not been well characterized. The purpose of this study was to examine the prospective association between exclusive and dual cigar and cigarette use and incident self-reported diagnosed COPD. METHODS: This study used data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative survey of U.S. adults. Longitudinal data from adults aged 40 to 79 at Wave 1, without a pre-existing COPD diagnosis who participated at follow-up interview were analyzed. A time-varying current tobacco exposure, lagged by one wave and categorized as: (a) never/non-current use; (b) exclusive cigar use; (c) exclusive cigarette use; and (d) dual cigar/cigarette use. Multivariable models adjusted for demographics (age, sex, race or ethnicity, education), clinical risk factors (asthma, obesity), and smoking-related confounders (second-hand smoke exposure, other combustible tobacco product use, e-cigarette use, time since quitting, cigarette pack-years). The incidence of self-reported diagnosed COPD was estimated using discrete-time survival models, using a general linear modeling (GLM) approach with a binomial distribution and a complementary log-log link function. RESULTS: The analytic sample consisted of 9,556 adults with a mean (SD) age of 56 (10.4), who were predominately female (52.8%) and Non-Hispanic White (70.8%). A total of 906 respondents reported a diagnosis of COPD at follow-up. In the fully adjusted model, exclusive cigar use (adjusted hazard ratio (aHR) = 1.57, 95% CI: 0.77, 3.21) was not associated with increased COPD risk compared to non-use, while exclusive cigarette use (aHR = 1.48, 95% CI: 1.13, 1.93) and dual cigar/cigarette use (aHR = 1.88, 95% CI: 1.24, 2.85) were. CONCLUSIONS: Exclusive cigarette use and dual cigar/cigarette use were associated with diagnosed incident COPD. These results suggest that cigars, when used in combination with cigarettes, may be associated with poorer COPD health outcomes. Dual use may promote a higher likelihood of inhaling cigar smoke, and future research would benefit from examining whether inhalation of cigar smoke increases COPD risk.
Subject(s)
Electronic Nicotine Delivery Systems , Pulmonary Disease, Chronic Obstructive , Tobacco Products , Adult , Humans , Female , Longitudinal Studies , Tobacco Products/adverse effects , Cohort Studies , Pulmonary Disease, Chronic Obstructive/diagnosis , Pulmonary Disease, Chronic Obstructive/epidemiologyABSTRACT
BACKGROUND: We estimated the prevalence and mortality risks of preserved ratio impaired spirometry (PRISm) and chronic obstructive pulmonary disease (COPD) in the US adult population. METHODS: We linked three waves of pre-bronchodilator spirometry data from the US National Health and Nutritional Examination Survey (2007-2012) with the National Death Index. The analytic sample included adults ages 20 to 79 without missing data on age, sex, height, BMI, race/ethnicity, and smoking status. We defined COPD (GOLD 1, 2, and 3-4) and PRISm using FEV1/FVC cut points by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). We compared the prevalence of GOLD stages and PRISm by covariates across the three waves. We estimated adjusted all-cause and cause-specific mortality risks by COPD stage and PRISm using all three waves combined. RESULTS: Prevalence of COPD and PRISm from 2007-2012 ranged from 13.1%-14.3% and 9.6%-10.2%, respectively. We found significant differences in prevalence by sex, age, smoking status, and race/ethnicity. Males had higher rates of COPD regardless of stage, while females had higher rates of PRISm. COPD prevalence increased with age, but not PRISm, which was highest among middle-aged individuals. Compared to current and never smokers, former smokers showed lower rates of PRISm but higher rates of GOLD 1. COPD prevalence was highest among non-Hispanic White individuals, and PRISm was notably higher among non-Hispanic Black individuals (range 31.4%-37.4%). We found associations between PRISm and all-cause mortality (hazard ratio [HR]: 2.3 95% CI: 1.9-2.9) and various cause-specific deaths (HR ranges: 2.0-5.3). We also found associations between GOLD 2 (HR: 2.1, 95% CI: 1.7-2.6) or higher (HR: 4.2, 95% CI: 2.7-6.5) and all-cause mortality. Cause-specific mortality risk varied within COPD stages but typically increased with higher GOLD stage. CONCLUSIONS: The prevalence of COPD and PRISm remained stable from 2007-2012. Greater attention should be paid to the potential impacts of PRISm due to its higher prevalence in minority groups and its associations with mortality across various causes including cancer.
Subject(s)
Nutrition Surveys , Pulmonary Disease, Chronic Obstructive , Humans , Pulmonary Disease, Chronic Obstructive/mortality , Pulmonary Disease, Chronic Obstructive/epidemiology , Pulmonary Disease, Chronic Obstructive/diagnosis , Male , Female , Middle Aged , United States/epidemiology , Prevalence , Adult , Aged , Risk Factors , Young Adult , Spirometry , Forced Expiratory Volume/physiologyABSTRACT
INTRODUCTION: Over half of US adults who smoke cigars use flavored cigars, illustrating their broad appeal; however, their long-term impact on cigar and cigarette use is unknown. METHODS: Using restricted data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study, we investigated cross-sectional patterns and longitudinal transition rates of unflavored and flavored cigar use with and without cigarettes among a nationally representative sample of US adults. RESULTS: Proportionally, more adults who used flavored cigars without or with cigarettes were younger and female. More adults with exclusive cigar use were non-Hispanic Black. More adults with dual use had lower educational attainment. The median number of cigars smoked daily and tobacco dependence was highest among adults who used flavored cigars with cigarettes. Only 14.6% of adults with exclusive flavored cigar use at Wave 1 continued their use to Wave 5, with most transitioning to non-current (46.4%) or exclusive cigarette use (22.9%). Likewise, 13.8% of adults with dual flavored cigar and cigarette use at Wave 1 continued their use to Wave 5, with 57.6% transitioning to exclusive cigarette use and 19.7% transitioning to non-current use. Comparatively, 72.9% of adults with exclusive cigarette use continued their use to Wave 5, while 23.6% transitioned to non-current use. CONCLUSION: Adult cigar use was less stable than cigarette use, particularly among those who use flavored cigars. Future research should investigate whether these transition patterns between flavored and unflavored cigar and cigarette use vary across sociodemographic groups and their potential long-term health implications.
Subject(s)
Flavoring Agents , Tobacco Products , Humans , Female , Male , Cross-Sectional Studies , United States , Adult , Tobacco Products/statistics & numerical data , Middle Aged , Longitudinal Studies , Cigar Smoking/epidemiology , Adolescent , Young Adult , AgedABSTRACT
BACKGROUND: E-cigarette use has increased considerably among US adolescents. While many studies have described cross-sectional prevalence trends of youth e-cigarette use, less is known about cohort or generational initiation and use patterns. METHODS: We used data from the US National Youth Tobacco Survey (NYTS) from 2014 to 2022 and age-period-cohort models to analyze age-specific patterns of e-cigarette use initiation and prevalence by cohort and calendar. For comparison, we also examined initiation and prevalence for cigarettes, cigars, and smokeless tobacco, using NYTS data from 1999 to 2022. RESULTS: Age-specific e-cigarette initiation and prevalence varied considerably by calendar year and birth cohort. There was a rapid increase in e-cigarette initiation and prevalence starting with the 1995 birth cohort, peaking with the 2005 birth cohort, and showing signs of decline with more recent cohorts. In contrast, there were substantial continuous reductions in cigarette, cigar, and smokeless use initiation and prevalence by birth cohort. While the reductions in cigarette smoking started with the 1980s birth cohorts, cigar and smokeless initiation and prevalence did not decrease until the 1990-1995 cohorts. CONCLUSIONS: Despite their recent emergence, e-cigarette use has varied considerably across US adolescent cohorts. After early increases, e-cigarette use and initiation peaked with the 2005 birth cohort. These patterns are in contrast with the continuous decreases by cohort in cigarette, cigar, and smokeless use and initiation. As the tobacco product landscape continues to evolve, it will be essential to monitor patterns of use of adolescent and young adult cohorts as they age into adulthood.
Subject(s)
Electronic Nicotine Delivery Systems , Tobacco Use , Vaping , Humans , Adolescent , United States/epidemiology , Male , Female , Prevalence , Vaping/epidemiology , Vaping/trends , Electronic Nicotine Delivery Systems/statistics & numerical data , Cross-Sectional Studies , Tobacco Use/epidemiology , Tobacco Use/trends , Birth Cohort , Surveys and Questionnaires , Tobacco, Smokeless/statistics & numerical data , Adolescent BehaviorABSTRACT
INTRODUCTION: Menthol cigarette bans have been implemented in some US states and localities, and a federal ban is being proposed by the FDA. This study asks how young adults who use menthol cigarettes respond to changes in menthol cigarette availability. AIMS AND METHODS: An online survey of young adults ages 18-34 who reported smoking menthol cigarettes on ≥7 of 30 days around Thanksgiving 2019 (nâ =â 734), oversampling Massachusetts-the first state with a menthol ban. Participants reported their tobacco use behavior following real-world menthol cigarette bans or predicted their behavior under a hypothetical federal ban. RESULTS: Most respondents who exclusively smoked versus dual used with e-cigarettes continued smoking/using combustible tobacco following real-world bans (95.3% vs. 86.9%), accessing menthol cigarettes from other jurisdictions. Fewer who smoked exclusively responded by using e-cigarettes compared to those who dual used (3.9% vs. 43.7%). Quitting all tobacco use (ie, no smoking, vaping, or any tobacco use) was uncommon for both groups (3.6% vs. 9.0%). Under a hypothetical ban, majorities of those who exclusively smoke and who dual use predicted they would continue smoking (72.2% vs. 71.8%); fewer who smoke exclusively would use e-cigarettes compared to those who dual use (14.7% vs. 41.4%). Those who smoke exclusively were more likely to report quitting all tobacco compared to those who dual use (29.6% vs. 12.4%). CONCLUSIONS: Under real-world and hypothetical menthol cigarette bans, most respondents continued smoking. However, more young adults continued smoking following real-world bans, reflecting the limitations of local/state restrictions when menthol cigarettes are available in other jurisdictions. IMPLICATIONS: This survey asked young adults who use menthol cigarettes how they responded to real-world changes in the availability of menthol cigarettes; 89% reported continuing to smoke. Those who smoked exclusively were far less likely to respond by switching to e-cigarettes compared to people who dual used both products. Under a hypothetical federal menthol cigarette ban, 72% of young adults predicted that they would continue smoking. Quitting all tobacco was less common in the real-world scenario compared to the hypothetical ban. Access to menthol cigarettes in other jurisdictions and flavored cigars likely dampen the public health benefit of menthol cigarette bans.
Subject(s)
Flavoring Agents , Menthol , Tobacco Products , Humans , Young Adult , Adult , Male , Female , Adolescent , Tobacco Products/legislation & jurisprudence , United States , Electronic Nicotine Delivery Systems/statistics & numerical data , Surveys and Questionnaires , Smoking Cessation/methods , Vaping/epidemiology , Cigarette Smoking/epidemiology , Massachusetts/epidemiologyABSTRACT
INTRODUCTION: E-cigarette flavor bans could reduce or exacerbate population health harms. To determine how US e-cigarette flavor restrictions might influence tobacco use behavior, this study assesses responses to real-world and hypothetical flavor bans among young adults who use flavored e-cigarettes. AIMS AND METHODS: An online, national survey of young adults ages 18-34 who use flavored e-cigarettes was conducted in 2021 (nâ =â 1253), oversampling states affected by e-cigarette flavor restrictions. Participants were asked about their responses to real-world changes in the availability of flavored e-cigarettes. Unaffected participants were asked to predict their responses under a hypothetical federal e-cigarette flavor ban. RESULTS: The most common response to real-world changes in flavored e-cigarettes availability was to continue vaping (~80%). Among those who exclusively vaped, 12.5% switched to combustible tobacco. Quitting all forms of tobacco was selected by 5.3% of those exclusively vape versus 4.2% who dual use. Under a hypothetical federal ban, more than half of respondents stated they would continue vaping; 20.9% and 42.5% of those who exclusively vape versus dual use would use combustible tobacco. Quitting all tobacco products was endorsed by 34.5% and 17.2% of those who exclusively vape versus dual use. CONCLUSIONS: Young adults who vape flavored e-cigarettes have mixed responses to e-cigarette flavor bans. Under both real-world and hypothetical e-cigarette flavor bans, most who use flavored e-cigarettes continue vaping. Under a real-world ban, the second most common response among those who exclusively vape is to switch to smoking; under a hypothetical federal ban, it is to quit all tobacco. IMPLICATIONS: This is the first national survey to directly ask young adults who use flavored e-cigarettes about their responses to real-world changes in flavored e-cigarette availability due to state and local flavor restrictions. The survey also asked individuals to predict their responses under a hypothetical federal e-cigarette flavor ban. Most who use flavored e-cigarettes would continue vaping following e-cigarette flavor restrictions, but many would switch to or continue using combustible tobacco, highlighting potential negative public health consequences of these policies. Policymakers must consider the impact of e-cigarette flavor bans on both e-cigarette and cigarette use.
Subject(s)
Electronic Nicotine Delivery Systems , Flavoring Agents , Vaping , Humans , Electronic Nicotine Delivery Systems/statistics & numerical data , Young Adult , Adult , Male , Female , Adolescent , Vaping/epidemiology , United States , Surveys and Questionnaires , Smoking Cessation/methodsABSTRACT
INTRODUCTION: Half of adult cigar users report flavored cigars as their usual brand. The FDA proposed prohibiting "all characterizing flavors in cigars" and "menthol in cigarettes." We provide evidence on cigar and cigarette transitions and a framework to assess the impact of a U.S. flavored cigar ban. METHODS: Using PATH Waves 1-4, we estimated use patterns and annual transitions among flavored cigars, non-flavored cigars, cigarettes, and among adults aged 18-34 and aged 35+. We also consider ENDS-related transitions. We developed a decision-theoretic framework for examining the impact of a flavored cigar ban alone, and the impact of a flavored cigar with a menthol cigarette ban with and without a non-tobacco flavored ENDS ban. RESULTS: Cigar users exhibited less stable use than cigarette users, with a large portion of cigar users switching to cigarette use each year. Past studies provide limited information on transitions between cigar and ENDS use. Our policy framework suggests that imposing a flavored cigar ban alone may be partially undermined by the substitution of menthol cigarettes for flavored cigars. While adding a menthol cigarette to a flavored cigar ban is expected to improve public health, a simultaneously implemented ENDS may offset some of the gains. DISCUSSION: Our analysis suggests the information necessary to gauge the public health impact of a cigar flavor ban alone and with flavor bans on cigarettes and ENDS. Further research is needed on ENDS vis-a'-vis cigar use, and the impact of enforcement and non-flavor-related policies on flavor ban effectiveness. IMPLICATIONS: Unlike menthol cigarette use and menthol bans, flavored cigar use and flavored cigar bans have received minimal attention. Transitions from cigars, especially dual and flavored use, are generally common compared to cigarettes. Our policy framework suggests important public health impacts. A flavored cigar ban absent a menthol cigarette ban may be partially undermined by the substitution of menthol cigarettes for flavored cigars. Adding a menthol cigarette ban is expected to offset such substitution and improve public health. However, simultaneously adding an ENDS with a flavored cigar and menthol cigarette ban may reduce the public health impact of a menthol cigarette and cigar flavor ban since flavored cigar users would be less able to substitute a lower-risk alternative.
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INTRODUCTION: Oral nicotine pouches (ONPs) are a new class of nicotine products. This scoping review summarizes evidence on ONPs and explores their potential public health impact. AIMS AND METHODS: We conducted a structured literature search for empirical studies across three electronic databases through January 10, 2024. Outcomes included ONP product characteristics, use patterns, beliefs and perceptions, toxicity, and marketing and sales. RESULTS: Sixty-two studies were included, 17 were industry-funded. Most studies were from the United States. While large variations across studies were observed in ONP youth prevalence estimates, nationally representative U.S. studies find current use at 1.5% and lifetime use below 2.5% through 2023. Between 35% and 42% of U.S. adolescents and young adults have heard of ONPs, and 9-21% of tobacco-naïve youth were susceptible to trying them. U.S. adult-use estimates varied widely (0.8%-3% current; 3%-16% lifetime use) and were limited to populations with a history of tobacco use. The chemical composition of ONPs suggests fewer harmful/potentially harmful compounds at lower levels than cigarettes and smokeless tobacco (SLT), except formaldehyde. Industry-funded studies find substantially less cytotoxicity compared to cigarettes and suggest that higher nicotine-strength ONPs can deliver nicotine at levels comparable to or higher than SLT or cigarettes, although with slower nicotine release than cigarettes. Evidence on the cytotoxicity of ONPs relative to SLT is mixed. CONCLUSIONS: ONPs appear to be less toxic than cigarettes and deliver comparable nicotine, presenting an alternative for combustible product users, although key data are mainly available from industry-funded studies. Data from independent research is critically needed. Industry marketing of ONPs may encourage initiation in youth and situational and dual use in adults. IMPLICATIONS: The review provides an initial assessment of the potential role of ONPs in harm reduction and aims to determine unintended consequences of their use (youth uptake and dual-use) and identify populations that disproportionately use the product. This information is essential for tobacco regulatory bodies in determining the net public health impact of nicotine pouches.
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INTRODUCTION: Achieving cessation in people with established smoking patterns remains a challenge. Increasing cigarette prices has been one of the most successful strategies for lowering smoking rates. The extent to which it has remained effective in encouraging cessation among adults in recent years and how the effectiveness has varied by sociodemographic characteristics is unclear. AIMS AND METHODS: Using repeated cross-sectional data collected by the Tobacco Use Supplement of the Current Population Survey, we investigate the relationship between cigarette prices and cessation from 2003 to 2019 in adults at least 25 years old. We examine the associations between price and cessation in the population overall and by sex, race and ethnicity, and socioeconomic status. RESULTS: We found mixed support for associations between greater local prices and cessation. Unadjusted models showed that greater local prices were associated with greater odds of cessation, but the associations did not persist after controlling for sociodemographic characteristics. The associations did not significantly differ by respondent characteristics. Sensitivity analysis using alternative specifications and retail state price as the main predictor showed similar results. Sensitivity analysis with controls for e-cigarette use in the 2014-2019 period showed that greater local price was associated with cessation among adults with less than a high school degree. When stratified by year of data collection, results show that greater local prices were associated with cessation after 2009. CONCLUSIONS: Overall, the study adds to the conflicting evidence on the effectiveness of increasing prices on smoking cessation among adults with established smoking patterns. IMPLICATIONS: Higher cigarette prices have been one of the most successful tools for lowering smoking prevalence. It remains unclear how effective they have been in recent years in encouraging adults with established smoking patterns to quit. The study's results show that greater local prices were associated with higher odds of cessation, but the association did not persist after sociodemographic adjustment. In a sensitivity analysis, greater local price was associated with cessation among people with less than a high school degree in models controlling for e-cigarette use. We also found evidence that greater local price was associated with cessation after 2009. More comprehensive smoke-free coverage was also associated with greater odds of cessation. The study's results highlight that encouraging cessation among adults with an established smoking pattern remains a challenging policy problem even when cigarette prices rise.
Subject(s)
Commerce , Smoking Cessation , Tobacco Products , Humans , Smoking Cessation/economics , Smoking Cessation/statistics & numerical data , United States/epidemiology , Male , Female , Adult , Tobacco Products/economics , Cross-Sectional Studies , Middle Aged , Commerce/statistics & numerical data , Commerce/economicsABSTRACT
INTRODUTION: Studies have reported that the rapid rise in heated tobacco product (HTP) sales in Japan accompanied an accelerated decline in cigarette sales. However, these studies do not distinguish whether those who previously smoked cigarettes became dual users with HTPs (smoking fewer cigarettes) or instead switched completely to HTPs. If HTPs present lower health risks than cigarettes, replacing cigarettes with HTPs is more likely to improve public health than cigarette users continuing as dual users. METHODS: To evaluate the role of HTP introduction relative to smoking prevalence, we examine trends in cigarette prevalence as related to trends in HTP use using Japan's National Health and Nutrition Survey (NHNS) from 2011 to 2019. We develop measures of relative changes in smoking prevalence use by age and gender in the pre-HTP and post-HTP periods. We then analyse prevalence data by year using joinpoint regression to statistically distinguish changes in trend. RESULTS: Compared with the pre-HTP 2011-2014 period, cigarette prevalence decreased more rapidly during the post-HTP 2014-2017 period, particularly among younger age groups. However, the changing format of NHNS questions limits our ability to determine the impact on smoking prevalence, particularly after 2017. CONCLUSIONS: While suggesting that HTPs helped some people who smoke to quit smoking, this study also shows the difficulties in eliciting accurate survey responses about product use and distinguishing the impact of a potentially harm-reducing product in an environment subject to rapidly evolving patterns of use.
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BACKGROUND: The health consequences of polytobacco use are not well understood. We evaluated prospective associations between exclusive, dual, and polytobacco use and diagnosed bronchitis, pneumonia, or chronic cough among US youth. METHODS: Data came from Waves 1-5 of the Population Assessment of Tobacco and Health Study. We categorized time-varying past 30-day tobacco use into seven categories: (1) non-current use; exclusive use of 2) cigarettes, 3) e-cigarettes, and 4) other combustible products (OC; pipes, hookah, and cigars); dual use of 5) e-cigarettes + cigarettes or e-cigarettes + OC, and 6) cigarettes + OC; and 7) polyuse of all three products. The outcome was parent-reported diagnosis of bronchitis, pneumonia, or chronic cough among youth. We conducted weighted multilevel Poisson models (person n = 17,517, 43,290 observations) to examine the longitudinal exposure-outcome relationship, adjusting for covariates: sex, age, race and ethnicity, parental education, body mass index, secondhand smoke exposure, and household use of combustible products. RESULTS: Compared to nonuse, exclusive cigarette use (Risk Ratio (RR) = 1.83, 95% CI 1.25-2.68), exclusive e-cigarette use (RR = 1.53, 95% CI 1.08-2.15), combustible product + e-cigarette dual use (RR = 1.90, 95% CI 1.18-3.04), cigarettes + OC dual use (RR = 1.96, 95% CI 1.11-3.48), and polytobacco use (RR = 3.06 95% CI 1.67-5.63) were associated with a higher risk of bronchitis, pneumonia, or chronic cough. In additional analyses, we found that the risk ratio for polytobacco use was higher compared to exclusive e-cigarette use (RR 2.01 CI 95% 1.02-3.95), but not higher compared to exclusive cigarette use (RR 1.67 CI 95% 0.85-3.28). CONCLUSION: We found that exclusive, dual, and poly tobacco use were all associated with higher risk of bronchitis, pneumonia, or chronic cough compared to non-current use.
Subject(s)
Electronic Nicotine Delivery Systems , Humans , Male , Female , Adolescent , Longitudinal Studies , United States/epidemiology , Child , Prospective Studies , Electronic Nicotine Delivery Systems/statistics & numerical data , Cough/epidemiology , Tobacco Use/epidemiology , Tobacco Use/adverse effects , Bronchitis/epidemiology , Pneumonia/epidemiologyABSTRACT
BACKGROUND: In their 2021 lung cancer screening recommendation update, the U.S. Preventive Services Task Force (USPSTF) evaluated strategies that select people based on their personal lung cancer risk (risk model-based strategies), highlighting the need for further research on the benefits and harms of risk model-based screening. OBJECTIVE: To evaluate and compare the cost-effectiveness of risk model-based lung cancer screening strategies versus the USPSTF recommendation and to explore optimal risk thresholds. DESIGN: Comparative modeling analysis. DATA SOURCES: National Lung Screening Trial; Surveillance, Epidemiology, and End Results program; U.S. Smoking History Generator. TARGET POPULATION: 1960 U.S. birth cohort. TIME HORIZON: 45 years. PERSPECTIVE: U.S. health care sector. INTERVENTION: Annual low-dose computed tomography in risk model-based strategies that start screening at age 50 or 55 years, stop screening at age 80 years, with 6-year risk thresholds between 0.5% and 2.2% using the PLCOm2012 model. OUTCOME MEASURES: Incremental cost-effectiveness ratio (ICER) and cost-effectiveness efficiency frontier connecting strategies with the highest health benefit at a given cost. RESULTS OF BASE-CASE ANALYSIS: Risk model-based screening strategies were more cost-effective than the USPSTF recommendation and exclusively comprised the cost-effectiveness efficiency frontier. Among the strategies on the efficiency frontier, those with a 6-year risk threshold of 1.2% or greater were cost-effective with an ICER less than $100 000 per quality-adjusted life-year (QALY). Specifically, the strategy with a 1.2% risk threshold had an ICER of $94 659 (model range, $72 639 to $156 774), yielding more QALYs for less cost than the USPSTF recommendation, while having a similar level of screening coverage (person ever-screened 21.7% vs. USPSTF's 22.6%). RESULTS OF SENSITIVITY ANALYSES: Risk model-based strategies were robustly more cost-effective than the 2021 USPSTF recommendation under varying modeling assumptions. LIMITATION: Risk models were restricted to age, sex, and smoking-related risk predictors. CONCLUSION: Risk model-based screening is more cost-effective than the USPSTF recommendation, thus warranting further consideration. PRIMARY FUNDING SOURCE: National Cancer Institute (NCI).
Subject(s)
Lung Neoplasms , Humans , Middle Aged , Aged, 80 and over , Lung Neoplasms/diagnostic imaging , Cost-Effectiveness Analysis , Early Detection of Cancer/methods , Cost-Benefit Analysis , Lung , Quality-Adjusted Life Years , Mass Screening/methodsABSTRACT
BACKGROUND: In Mexico, obesity prevalence among adults increased from 23% in 2000 to 36% in 2018, approximately. Mexico has not defined short- or long-term obesity goals, obscuring the level of effort required to achieve a relevant impact. We aimed to explore potential obesity goals for 2030 and 2040 in Mexico and to estimate the required caloric reductions to achieve them. METHODS AND FINDINGS: We obtained anthropometric and demographic information on the Mexican adult population (age ≥20 years) from the Health and Nutrition Surveys conducted in 2000, 2006, 2012, 2016, and 2018 (n = 137,907). Each survey wave is cross-sectional, multistage, and representative of the Mexican population at the national, regional, and urban/rural levels. Obesity prevalence was projected for 2030 and 2040 by combining population projections of energy intake by socioeconomic status (SES) with a weight-change microsimulation model taking into account individual-level information on sex, age, physical activity, and initial body weight and height. If current trends continue, Mexico's obesity prevalence is expected to increase from 36% (95% CI 35% to 37%) in 2018 to 45% (uncertainty interval [UI] 41% to 48%) in 2030 and to 48% (UI 41% to 55%) in 2040. Based on expert opinion, we identified 3 obesity goals scenarios: (1) plausible (38% in 2030 and 36% in 2040); (2) intermediate (33% in 2030 and 29% in 2040); and (3) ideal based on the average prevalence of Organization for Economic Co-operation and Development countries (OECD; 19%). We estimated the caloric reductions needed to achieve the goal scenarios using the microsimulation model. Obesity was projected to increase more rapidly in the low SES (around 34% in 2018 to 48% (UI 41% to 55%) in 2040), than in the middle (around 38% to 52% (UI 45% to 56%)), or high SES group (around 36% to 45% (UI 36% to 54%)). Caloric reductions of 40 (UI 13 to 60), 75 (UI 49 to 95), and 190 (UI 163 to 215) kcal/person/day would be needed to reach the plausible, intermediate, and the ideal (OECD) average scenarios for 2030, respectively. To reach the 2040 goals, caloric reductions of 74 (UI 28 to 114), 124 (UI 78 to 169), and 209 (UI 163 to 254) kcal/person/day would be required, respectively. Study limitations include assuming a constant and sedentary physical activity level, not considering cohort-specific differences that could occur in the future, and assuming the same caloric trends under no intervention and the obesity goal scenarios. CONCLUSIONS: To reach the 3 obesity goals in 2040, caloric reductions between 74 and 209 kcal/day/person would be needed in Mexico. A package of new and stronger interventions should be added to existing efforts such as food taxes and warning labels on non-nutritious food.
Subject(s)
Goals , Obesity , Adult , Humans , Young Adult , Mexico/epidemiology , Cross-Sectional Studies , Obesity/epidemiology , Obesity/prevention & control , Energy IntakeABSTRACT
BACKGROUND: Lung cancer is made up of distinct subtypes, including non-small-cell lung cancer (NSCLC) and small-cell lung cancer (SCLC). Although overall mortality from lung cancer has been declining in the United States, little is known about mortality trends according to cancer subtype at the population level because death certificates do not record subtype information. METHODS: Using data from Surveillance, Epidemiology, and End Results (SEER) areas, we assessed lung-cancer mortality and linked deaths from lung cancer to incident cases in SEER cancer registries. This allowed us to evaluate population-level mortality trends attributed to specific subtypes (incidence-based mortality). We also evaluated lung-cancer incidence and survival according to cancer subtype, sex, and calendar year. Joinpoint software was used to assess changes in incidence and trends in incidence-based mortality. RESULTS: Mortality from NSCLC decreased even faster than the incidence of this subtype, and this decrease was associated with a substantial improvement in survival over time that corresponded to the timing of approval of targeted therapy. Among men, incidence-based mortality from NSCLC decreased 6.3% annually from 2013 through 2016, whereas the incidence decreased 3.1% annually from 2008 through 2016. Corresponding lung cancer-specific survival improved from 26% among men with NSCLC that was diagnosed in 2001 to 35% among those in whom it was diagnosed in 2014. This improvement in survival was found across all races and ethnic groups. Similar patterns were found among women with NSCLC. In contrast, mortality from SCLC declined almost entirely as a result of declining incidence, with no improvement in survival. This result correlates with limited treatment advances for SCLC in the time frame we examined. CONCLUSIONS: Population-level mortality from NSCLC in the United States fell sharply from 2013 to 2016, and survival after diagnosis improved substantially. Our analysis suggests that a reduction in incidence along with treatment advances - particularly approvals for and use of targeted therapies - is likely to explain the reduction in mortality observed during this period.
Subject(s)
Carcinoma, Non-Small-Cell Lung/mortality , Lung Neoplasms/mortality , Carcinoma, Non-Small-Cell Lung/epidemiology , Female , Humans , Incidence , Lung Neoplasms/epidemiology , Male , Mortality/trends , SEER Program , Sex Factors , United States/epidemiologyABSTRACT
OBJECTIVE: The presence of macroscopic residual disease after primary cytoreductive surgery (PCS) is an important factor influencing survival for patients with high-grade serous ovarian cancer (HGSC). More research is needed to identify factors associated with having macroscopic residual disease. We analyzed 12 lifestyle and personal exposures known to be related to ovarian cancer risk or inflammation to identify those associated with having residual disease after surgery. METHODS: This analysis used data on 2054 patients with advanced stage HGSC from the Ovarian Cancer Association Consortium. The exposures were body mass index, breastfeeding, oral contraceptive use, depot-medroxyprogesterone acetate use, endometriosis, first-degree family history of ovarian cancer, incomplete pregnancy, menopausal hormone therapy use, menopausal status, parity, smoking, and tubal ligation. Logistic regression models were fit to assess the association between these exposures and having residual disease following PCS. RESULTS: Menopausal estrogen-only therapy (ET) use was associated with 33% lower odds of having macroscopic residual disease compared to never use (OR = 0.67, 95%CI 0.46-0.97, p = 0.033). Compared to nulliparous women, parous women who did not breastfeed had 36% lower odds of having residual disease (OR = 0.64, 95%CI 0.43-0.94, p = 0.022), while there was no association among parous women who breastfed (OR = 0.90, 95%CI 0.65-1.25, p = 0.53). CONCLUSIONS: The association between ET and having no macroscopic residual disease is plausible given a strong underlying biologic hypothesis between this exposure and diagnosis with HGSC. If this or the parity finding is replicated, these factors could be included in risk stratification models to determine whether HGSC patients should receive PCS or neoadjuvant chemotherapy.
Subject(s)
Cytoreduction Surgical Procedures , Ovarian Neoplasms , Pregnancy , Humans , Female , Retrospective Studies , Ovarian Neoplasms/drug therapy , Carcinoma, Ovarian Epithelial , ParityABSTRACT
Cigarette smoking rates are significantly higher among people with serious psychological distress (SPD) compared to the general population. US simulation models that project future smoking disparities by SPD status could inform policy interventions, but have not been developed. We calibrated two compartmental models to the National Health Interview Survey 1997-2018 for populations with and without SPD, calculating smoking prevalence, mortality, and life-years lost by SPD status under different scenarios from 2023 to 2100. Under the Status Quo, smoking prevalence among women with SPD falls from 27.0% in 2023 to 10.7% in 2100 (men: 30.1% to 12.2%). For women without SPD, it declines from 9.4% to 3.1% (men: 11.5% to 4.0%). The absolute difference in smoking prevalence between those with and without SPD decreases over time, whereas the relative smoking prevalence ratio increases. From 2023 to 2100, 609,000 premature smoking-attributable deaths would occur in the SPD population, with 8 million life-years lost. Under an ideal tobacco control scenario for people with SPD, in which all smokers quit in 2023 and no new smoking initiation occurs thereafter, up to 386,000 of these premature deaths could be averted with 4.9 million life-years gained. Preventing smoking initiation could avert up to 18% of these deaths, while improving smoking cessation could avert up to 82%. Smoking-related disparities for people with SPD will persist unless a shift in tobacco control substantially improves cessation and prevents initiation in this subpopulation. Smoking disparities by SPD may widen in relative but narrow in absolute terms, so both perspectives should be evaluated.
Subject(s)
Cigarette Smoking , Psychological Distress , Smoking Cessation , Male , Humans , Female , United States/epidemiology , Cigarette Smoking/epidemiology , Stress, Psychological/psychology , Smokers/psychology , PrevalenceABSTRACT
Little is known about the respiratory health effects of dual (two products) and polytobacco (three or more products) use among youth in the United States. Thus, we followed a longitudinal cohort of youth into adulthood using data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study, examining incident asthma at each follow-up (Waves 2-5). We classified past 30-day tobacco use as 1) no products (never/former use), 2) exclusive cigarettes, 3) exclusive electronic nicotine delivery systems (ENDS), 4) exclusive other combustible (OC) tobacco products (cigars, hookah, pipe), 5) dual cigarettes/OC and ENDS, 6) dual cigarettes and OCs, and 7) polytobacco use (cigarettes, OCs, and ENDS). Using discrete time survival models, we analyzed the incidence of asthma across Waves 2-5, predicted by time-varying tobacco use lagged by one wave, and adjusted for potential baseline confounders. Asthma was reported by 574 of the 9141 respondents, with an average annual incidence of 1.44% (range 0.35% to 2.02%, Waves 2-5). In adjusted models, exclusive cigarette use (HR: 1.71, 95% CI: 1.11-2.64) and dual cigarette and OC use (HR: 2.78, 95% CI: 1.65-4.70) were associated with incident asthma compared to never/former use, while exclusive ENDS use (HR: 1.50, 95% CI: 0.92-2.44) and polytobacco use (HR: 1.95, 95% CI: 0.86-4.44) were not. To conclude, youth who use cigarettes with or without OCs had higher risk of incident asthma. Further longitudinal studies on the respiratory health effects of ENDS and dual/polytobacco use are needed as products continue to evolve.
Subject(s)
Asthma , Electronic Nicotine Delivery Systems , Tobacco Products , Tobacco Use Disorder , Humans , Adolescent , United States/epidemiology , Tobacco Use/epidemiology , Tobacco Use Disorder/epidemiology , Longitudinal Studies , Asthma/epidemiologyABSTRACT
INTRODUCTION: Cigar use is common in the United States; however, knowledge about trends and longitudinal patterns of premium and non-premium cigar use is limited. We analyzed cross-sectional and transition patterns of cigar use in the United States by cigar type, age, race/ethnicity, and socioeconomic status. AIMS AND METHODS: Using data from the Population Assessment of Tobacco and Health (PATH) Study, we compared characteristics of cigar users by Wave (1-5) and type; premium versus non-premium traditional cigars, cigarillos, and filtered cigars. We then calculated longitudinal transition rates of cigar and cigarette use between PATH Study Waves and longitudinal trajectories across all five Waves. RESULTS: Premium cigars were predominantly used by males, non-Hispanic White individuals, and those with high educational attainment. Premium cigar use was mostly non-daily and less likely to be dual with cigarettes or other cigar types. About three-quarters of exclusive premium cigar users remained so after one year. However, dual-use of premium cigars with either other cigar types or cigarettes was transient. Those who smoked premium cigars fairly regularly for at least one year were more likely to be exclusive premium cigar users or have dropped combustible tobacco product use by Wave 5. CONCLUSIONS: Cigar use patterns vary significantly by cigar type. Premium cigar users have distinctive characteristics compared to other cigar-type users. When studying cigar use and related health outcomes, it is critical to distinguish cigar type. IMPLICATIONS: Continuous monitoring of longitudinal use patterns of premium and non-premium cigar use and their co-use and transitions to other tobacco products, including inhalation and a more precise measure of the intensity of use, is essential for a better assessment of their health implications.
Subject(s)
Tobacco Products , Tobacco Use Disorder , Male , Humans , United States/epidemiology , Smoking/epidemiology , Cross-Sectional Studies , Tobacco Use/epidemiologyABSTRACT
INTRODUCTION: Sociodemographic disparities in tobacco use are prevalent and persistent in the United States. Nevertheless, few studies have examined disparities in tobacco use from an intersectionality perspective. We developed a visualization tool to identify disparities in cigarette, e-cigarette, cigar, and smokeless tobacco use at the intersection of multiple social identities. AIMS AND METHODS: We used the 2018-2019 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) to estimate the prevalence of tobacco product use at the intersection of age (18-34, 35-54, ≥55 years), sex (male, female), race/ethnicity (Non-Hispanic [NH] White, NH Black, Hispanic, NH Other), and annual household income (<$50 000, $50 000-$99 999, and ≥$100 000). Estimates accounted for the complex survey design. RESULTS: For cigarettes, the most defining characteristic was income, with the highest prevalence among low-income NH White male adults aged 35-54 years (30.7%) and low-income NH White female adults aged 35-54 years (29.7%). For e-cigarettes, the most defining characteristic was age, with adults 18-34 years old having the highest prevalence. High prevalence groups for cigars included young- and middle-aged NH Black and NH White males, while NH White males had the highest prevalence of smokeless tobacco use. CONCLUSIONS: Our intersectionality visualization tool is helpful to uncover complex patterns of tobacco use, facilitating the identification of high-risk groups. IMPLICATIONS: We created a visualization tool to identify disparities in cigarette, e-cigarette, cigar, and smokeless tobacco use at the intersection of age, sex, race/ethnicity, and income. Our visualization tool helps uncover complex patterns of tobacco use, facilitating the identification of high-risk population groups that would otherwise be masked. These results can be used to implement tobacco control policies targeted at factors that promote or sustain tobacco use disparities.