How Do Active and Passive Cigarette Smokers in Iran Evaluate Their Health? A Sex-Specific Analysis on the Full-Spectrum of Quality of Life.

INTRODUCTION: This study aimed to determine the sex-specific effects of active and passive cigarette smoking on the full spectrum of health-related quality of life (HRQoL) among a sizeable adult population. METHODS: This study was conducted within the Tehran Lipid and Glucose Study (TLGS) framework. Participants included 7478 adults in the last examination of the TLGS. We used a quantile regression model to compare sex-specific HRQoL distributions among non-, current, and passive smokers. Two-step cluster analysis was used to consider the synergic effects of confounder variables. RESULTS: In men, current smoking was negatively associated with only mental HRQoL in all percentiles of its distribution with a decrease in absolute estimation values from the lowest (5 th: ß=-6.59, p<0.001) to the highest (90 th: ß=-0.93, p=0.027). Also, passive smoking was negatively associated with men's physical HRQoL in the upper percentiles of its distribution (75 th: ß=-1.12, p=0.010; 90 th: ß=-1.26, p=0.016). In women, the current (ß= -4.17 to -4.45 for 25 th to 90 th percentiles) and passive smokers (ß= -2.05 to -4.25 for 10 th to 90 th percentiles) had lower mental HRQoL in the mentioned percentiles. Also, the current smoking had a negative association with the 5 th percentile (ß=-2.04, p=0.008), and a positive association with the 50 th (ß=1.94, p< 0.008) and 75 th percentile of physical HRQoL (ß=2.25, p=0.004). CONCLUSIONS: The present study showed the harmful effect of smoking on mental HRQol in all participants. In contrast, the physical effect of smoking was only observed in female active smokers and at the extreme levels of the physical HRQoL spectrum. IMPLICATIONS: According to the harmful effect of smoking on HRQoL, understanding active and passive smokers' perceptions of how smoking impacts their health is critical for tobacco control programs. Since most previous studies of smoking and HRQoL have mainly focused on the extreme parts or central values of the HRQoL distribution, the use of a multiple regression approach enables the evaluation of other parts of the conditional distribution of the outcome variable. This study demonstrated the prominent effect of smoking on the mental HRQoL as well as the more serious public health burden of passive smoking in women.

A pragmatic multi-setting lifestyle intervention to improve leisure-time physical activity from adolescence to young adulthood: the vital role of sex and intervention onset time.

BACKGROUND: The long-term effectiveness of healthy lifestyle interventions on improving leisure-time physical activity (LTPA) in adolescents and its factors in low- and middle-income communities is unclear. This study is the first to investigate LTPA trends in a population of Iranian adolescents who underwent a multi-setting lifestyle intervention, considering sex and the time of intervention onset. METHODS: Participants were 2374 adolescents (57.2% girls), aged 12-18 years, who participated in the Tehran Lipid and Glucose Study (TLGS) during 1999-2001 and followed for a median follow-up of 15.9 over five data points every 3 years. Adolescent participants were assigned to the intervention or control groups based on their residential areas. Boys and girls were categorized into 12-15 or 16-18 years old to minimize participants' bio-psychological differences, facilitate environmental interventions by more compliance with the Iranian educational system and identify the best time to start the intervention. All adolescents in the intervention area received healthy lifestyle interventions via the school-, family-, and community-based programs. LTPA was assessed using the reliable and validated Iranian Modifiable Activity Questionnaire (MAQ) version over the five data points. The Generalized Estimating Equations method was used to evaluate educational intervention's effect on LTPA in adolescents during the follow-up. RESULTS: In boys who experienced the early onset of intervention (12-15 years), the interaction effect of follow-up examinations and the intervention was significant where the impact of the intervention differed over time. In this group, LTPA was higher in the control group than in the intervention group at the first follow-up examination (ß = - 1088.54). However, an increasing trend of LTPA was observed in the intervention group until the third follow-up examination (ß = 1278.21, p = 0.08, and ß = 1962.81, p = 0.02, respectively), with borderline significance levels at the 2nd (P = 0.08) and the 4th (P = 0.08) measurements. The interaction terms and main effects of intervention and follow-up examinations were not significant in boys with late intervention onset. Although older boys in the intervention group had higher LTPA than the control group, there were no significant differences among study groups in all follow-up examinations. Regarding girls, LTPA did not differ significantly between intervention and control groups in all follow-up examinations (P > 0.05). CONCLUSION: Our results showed that a multi-setting practical lifestyle intervention could improve long-term energy expenditure in LTPA in adolescent boys who have experienced an early onset intervention. Findings emphasized the vital role of gender and the onset of these interventions. The current results would be valuable to plan tailored interventions to improve LTPA and community health. TRIAL REGISTRATION: This study is registered at Iran Registry for Clinical Trials (IRCT), a WHO primary registry ( http://irct.ir ). The TLGS clinical trial was the very first registration in the IRCT (Iran Registry of Clinical Trials). it was registered on 2008-10-29 by the registration number IRCT138705301058N1 . Based on the international committee of medical journal Editors (ICMJE), "retrospective registration" is acceptable for trials that began before July 1, 2005.

Effectiveness of a practical multi-setting lifestyle intervention on the main BMI trajectories from childhood to young adulthood: A community-based trial.

BACKGROUND: Preventing overweight in childhood and subsequent stages of life is still a global challenge. Despite numerous relevant lifestyle interventions, data on their impact on different BMI change pathways over time is rare. The present study aimed to investigate the effect of a multi-setting lifestyle intervention on BMI trajectories from childhood to young adulthood. METHODS: A multi-setting lifestyle intervention at the school, family, and community levels have been conducted in the Tehran Lipid and Glucose Study framework. A total of 2145 children (4-18 years, 49% boys, and 18% intervention) were recruited for the baseline assessment and were followed through five follow-up examinations during a median of 16.1 years. Using a group-based trajectory model, BMI trajectories from childhood to young adulthood were identified, and their association with the implemented intervention was assessed. RESULTS: Four trajectory groups of BMI from childhood to young adulthood were identified, including Normal weight (41%), Young adulthood overweight (36%), Early childhood increasing overweight and adulthood obesity (19%), and Early childhood increasing obesity (4%). Only Young adulthood overweight and Early childhood increasing obesity were affected by the intervention and were concomitant with lower BMI levels than the control group, with the highest estimated effect in the latter (ß=-0.52 and p = 0.018; ß=-1.48 and p < 0.001, respectively). CONCLUSION: The current findings indicate the highest effectiveness of a practical, healthy lifestyle intervention on those whose obesity started in the early years of life or youth. Our results could help policymakers and planners design more targeted lifestyle modification and weight control interventions. TRIAL REGISTRATION: This study is registered at Iran Registry for Clinical Trials, a WHO primary registry ( http://irct.ir ). The Iran Registry for Clinical Trials ID and date are IRCTID:IRCT138705301058N1, 29/10/2008.

Risk of hypertension in school-aged children undergoing a long-term community-based lifestyle intervention: Tehran Lipid and Glucose Study.

Childhood hypertension which increases the risk of cardiovascular diseases in adulthood is becoming more prevalent. For the first time in the Middle-East region, this study aimed to assess the long-term effectiveness of a community-based lifestyle intervention on the incidence of hypertension in school-aged children during 16 years of follow-up. This study was conducted within the framework of the Tehran Lipid and Glucose Study (TLGS). Participants were 2080 children aged 8-18 years with normal blood pressure who were under the coverage of three health care centers selected using multistage cluster random sampling method. One of the health care centers far from the other two was selected for implementing lifestyle intervention (1053 children, 48.2% boys). Triennial examinations were conducted, and survival Cox models were used to assess intervention effects on the incidence of hypertension in boys and girls. Crude incidence rates (per 1000 person-years) of hypertension were 8.11, 3.7, and 5.8 among boys, girls, and the total sample, respectively. Our results showed that HTN has occurred significantly less (P = 0.025) in the intervention group than in the control group, only in female participants. These results remained significant even after adjusting for individuals' and parental characteristics (P = 0.033). Although the risk of hypertension in boys was more than twice that observed in girls, the effectiveness of the recent community-based healthy lifestyle intervention was observed only in girls and not in boys. Further studies are needed to understand gender differences in promoting the effectiveness of similar future programs. The TLGS is registered at Iran Registry for Clinical Trials, a WHO primary registry (http://irct.ir; IRCTID: IRCT138705301058N1).

The Cigarette Smoking Initiation and Continuation in Adolescents Undergoing a Long-Term Behavioral Intervention.

INTRODUCTION: Targeting adolescents' smoking reduces its burden on health systems. We investigated the effects of the first multidisciplinary community-based lifestyle intervention in the Eastern Mediterranean region, on smoking initiation, continuation, and risk of current smoking in Iranian adolescents. METHODS: The current analyses were conducted on 945 nonsmoker adolescents (12-18 years) who participated in Phase II of Tehran Lipid and Glucose Study (TLGS) and were examined four times in 12 years. The lifestyle intervention including school-based and public programs was implemented, focusing on all components of healthy lifestyle. Using a two-step cluster analysis, families were classified as high and low risk, based on parental risk factors of adolescents' smoking. Participants who failed to complete all the follow-ups (n = 99) and those with missing smoking data were excluded. Subsequently, 872 adolescents (538 control, 334 intervention) were included in the Cox model on smoking initiation, and 674 adolescents (414 control, 260 intervention) were included in the logistic regression on smoking status. RESULTS: Mean age of adolescents was 15.08 ± 1.94 years at baseline. The hazard of the smoking initiation was significantly lower in the intervention (hazard ratio = 0.71, 95% confidence interval: 0.51-0.99; p = .044) compared with control group. At the end of the fourth follow-up, intervention reduced the odds of current cigarette smoking by 29%. Within the intervention group, the high-risk cluster was at a 35% lower risk of initiating smoking and had 37% lower odds of becoming a current smoker. However, the intervention could not make a difference in preventing those who initiated smoking from maintaining it during the follow-ups. CONCLUSIONS: Our results demonstrate that lifestyle modification programs targeting at-risk populations could reduce risk of smoking initiation and current smoking in adolescents in long term. IMPLICATIONS: Experiencing cigarette smoking at the critical period of adolescence could result in adulthood habitual smoking. Therefore, identifying adolescents who are more at risk of smoking initiation and implementing targeted interventions are of great importance in public health. Our findings highlight the long-term effectiveness of a multidisciplinary community-based behavioral intervention on forming smoking behaviors in adolescents. The current intervention was successful in reducing smoking uptake in adolescents living in high-risk families.

Long-term incidence of cardiovascular outcomes in the middle-aged and elderly with different patterns of physical activity: Tehran lipid and glucose study.

BACKGROUND: Following the global upward trend of cardiovascular diseases (CVD/CHD), much attention has been paid to lifestyle behaviors such as physical activity (PA). However, most of previous studies were conducted in developed countries and with just one measurement of physical activity. The aim of the current study is to assess the effect of changes in the PA on the incidence of CVD/CHD in middle-aged and older men and women in an Eastern-Mediterranean population, over a decade follow-up. METHODS: This study has been conducted within the framework of the Tehran Lipid and Glucose Study (TLGS) including 4073 (57% women) participants without CVD/CHD at baseline. The participants were followed up for an average period of 12 years. The Iranian version of Modified Activity Questionnaire (MAQ) was used to measure PA at baseline and at the closest follow-up to the outcome. Subsequently, participants were categorized as "compliers", "non-compliers", "adopters" and "relapsers", based on their adherence to the PA guideline recommendations. All analysis has been conducted in two separate age groups including middle-aged and elderly in both men and women. The effect of PA patterns on incidence of CVD/CHD was investigated using Cox proportional hazard model. Variables including marital status, job status, education, smoking, and family history of CVD/CHD were adjusted in the models. RESULTS: Adherence to guideline recommendation increased from 63.5 to 66.6% between the two measurements. At the second measurement of PA, the percentages of compliers, non-compliers, adopters and relapsers were 48.4, 18.3, 18.2, and 15.1%, respectively. In fully adjusted models, HRs of CVD and CHD for men aged 40-60 years in the complier group were 0.58 (95% CI: 0.38-0.87, P = 0.008) and 0.58 (95% CI: 0.38-0.89, P = 0.01), respectively. HRs of CVD and CHD for men aged 40-60 years in adopter group were 0.61 (95% CI: 0.38-0.96, P = 0.03) and 0.60 (95% CI: 0.37-0.97, P = 0.04) respectively. The corresponding values were not significant in women. CONCLUSIONS: Adhering to established PA recommendations have a protective effect on the incidence of CVD/CHD among middle-aged men; findings which need to be considered in reducing cardiovascular outcomes in this population.

The First Cigarette Smoking Experience and Future Smoking Behaviors Among Adolescents with Different Parental Risk: a Longitudinal Analysis in an Urban Iranian Population.

BACKGROUND: Longitudinal research among Iranian adolescent smoking is limited. The current study aimed to investigate (1) the first smoking experience (FSE) and future smoking behaviors of adolescents with different parental risk factors and (2) the association between age of the FSE and future smoking behaviors over a 12-year follow-up. METHOD: Based on Tehran Lipid and Glucose Study (TLGS) database, 1487 adolescents (12-18 years) with complete baseline parental data were recruited. Using two-step cluster analysis, families were classified as either high or low risk; these were based on parental risk factors including age, education, employment, and smoking status. Participants were examined four times in 12 years and their data were used for survival analysis. After exclusion of 24 cases who were smokers at baseline, Cox proportional hazard modeling was used to evaluate the effect of parental clusters on the FSE in 1463 nonsmoking adolescents who completed all prospective follow-ups. Logistic regression analysis was used to examine the effect of the age of FSE on future smoking behaviors. RESULTS: The mean age of adolescents was 14.63 ± 2.07 years at baseline. Adolescents in the high-risk cluster group were 49% more likely to try smoking for their first time, and 55% more likely to smoke in the future. Compared with girls, boys had 83% higher chance of trying their first cigarette. Moreover, 1-year delay in the FSE resulted in 25% reduction in the probability of smoking in the future. CONCLUSION: The findings show that compared with adolescents living in low-risk families, teenagers living in high-risk families are at greater risk of smoking at an earlier age; therefore, this group could benefit from gender- and culture specific preventive interventions.

Cardiometabolic Profile in Young Adults With Diverse Cigarette Smoking Histories: A Longitudinal Study From Adolescence.

BACKGROUND: For the first time, the present study investigated smoking trajectory and cardiometabolic profile from adolescence to young adulthood in a middle-income developing country facing a high prevalence of smoking and cardiovascular disease-related outcomes. METHODS AND RESULTS: Data on 1082 adolescents (12-18 years of age) who participated in the TLGS (Tehran Lipid and Glucose Study) were gathered, and participants were followed for a median of 12.5 years (baseline: 1999-2002, last follow-up: 2014-2017). Participants were categorized as non/rare smokers, experimenters, and escalators using group-based trajectory models. Statistical analysis was used to compare the trajectory groups' cardiometabolic components, clinical characteristics, and cardiometabolic changes due to the individuals' placement in experimenter and escalator groups compared with non/rare smokers. The smoking trajectory groups in young adulthood differ significantly in blood pressure, triglycerides, high-density lipoprotein cholesterol, waist circumference, and body mass index, with the escalator group having the highest risk values for each component. Significant differences were observed in blood pressure (P=0.014), triglycerides (P<0.001), and waist circumference (P<0.001) status after using clinical cut points. The adjusted linear regression revealed that the escalator group had 3.16 mm Hg-lower systolic blood pressure SBP (P=0.016), 2.69 mm Hg-lower diastolic blood pressure (P=0.011), and 4.42 mg/dL-lower high-density lipoprotein cholesterol (P=0.002), compared with the non/rare smoker group. CONCLUSIONS: Despite elevated risks in unadjusted analyses for all cardiometabolic components among smokers, our study identified a modest protective link between early smoking and blood pressure in addition to a remarkable harmful association with high-density lipoprotein cholesterol levels exclusively in the escalator group during the developmental stage to young adulthood, using adjusted analyses.

Men's Smoking Trajectories and Health-Related Quality of Life in the Whole Family: Tehran Lipid and Glucose Study.

Background: We aimed to investigate the latent smoking classes in men and their association with health-related quality of life (HRQoL) of themselves, their wives and offspring. Methods: Using Tehran Lipid and Glucose Study (TLGS), 1781 men with marital stability and 8-18-year-old offspring were followed for 15 years (1999-2014). Latent class growth modeling (LCGM) was used to identify men's smoking patterns in 1139 men with at least three non-missing measurements of cigarettes per day (CPD); they had 1908 children (8-18 years at baseline). HRQoL and its physical and mental component summaries (PCS and MCS) was measured at the last follow-up using the SF-12v2 questionnaire. The associations of men's smoking classes with HRQoL of the family members were examined using generalized linear model. Results: LCGM revealed four trajectories for men's smoking patterns; non/rare smokers, decreasing light, persistent moderate smokers, and persistent heavy smokers. Persistent smoking men, regardless of the amount of smoking (light or heavy), had lower scores in general health (ß= -7.80 for moderate and ß= -10.71 for heavy class) but not overall PCS. Al three trajectories of smoker men had poorer overall MCS than non/rare smokers. Living with persistent heavy smoker men was associated with decreased overall MCS in women (ß= -4.20), in particular role emotional (ß= -8.82) and mental health (ß= -9.42). No significant association was detected between fathers' smoking patterns and offspring HRQoL in young adulthood. Conclusion: Our results show men's heavy and persistent smoking worsens their own and their spouses' HRQoL, mainly in mental health dimensions.

Active and Passive Smoking in Adults Undergoing a Long-Term Multi-Setting Healthy Lifestyle Education: Tehran Lipid and Glucose Study.

We aimed to investigate the effects of a multi-setting lifestyle education on men's cigarette, hookah, and passive smoking, and women's passive smoking, in Iran. Data of Tehran Lipid and Glucose Study (TLGS) were used. TLGS started in 1999 with every-3-year follow-ups. Multi-stage cluster random sampling was used to recruit participants under the coverage of three health centers. One health center implemented multi-setting lifestyle education at school, family, and community setting. Our analytic sample for generalized estimating equation was restricted to 1322 and 3593 adults (respectively as intervention and control) who were followed for 15.8 years. Intervention reduced the odds of men's cigarette smoking by 27%. The estimated mean cigarettes/day was 1.58 lower in intervention men. The intervention reduced the odds of men's hookah use by 42% in short term. Intervention women had 33% lower odds of passive smoking. Lifestyle education with community outreach can help achieve pragmatic tobacco control goals.

Cigarette smoking trajectories among adolescents and young adults in the Islamic Republic of Iran.

Background: Cigarette smoking follows a progressive pattern throughout the lifetime; most adult smokers started smoking during adolescence. Aim: To understand the cigarette smoking trajectories and their predictors among adolescents and young adults in the Islamic Republic of Iran. Methods: Using data from the Tehran Lipid and Glucose Study, we followed 1169 adolescents (12-18 years old) into their young adulthood (28-32 years old), from 2002 to 2016. We used cigarette smoking as the outcome variable for group-based trajectory modelling. After detecting the trajectories, we investigated the effects of independent variables, namely, individual employment; education; physical activity; and paternal smoking, employment and education, on the trajectories. We analysed the data using STATA version 16 and SPSS version 26. Results: Three trajectories were detected: non-smokers (79%), experimenters (12%) and escalators (9%). Boys were approximately 3 times (OR = 2.94, 95% CI: 2.32-3.24, P < 0.001) and 25 times (OR = 25.00, 95% CI: 23.92-26.08, P < 0.001), respectively, more likely than girls to be in the experimenter and escalator groups. Receiving a university education decreased the odds of being in the escalator trajectory for 18% (OR = 0.82, 95% CI: -0.04-0.96, P = 0.002) of the study participants. Employment after high school increased the odds by approximately two folds for the experimenter (OR = 2.00, 95% CI: 1.42-2.50, P = 0.01) and escalator (OR = 2.33, 95% CI: 1.33-2.93, P = 0.03) trajectories. Paternal smoking was associated with 1.88 and 2.23, respectively, increased odds of experimenting and escalating smoking among the adolescents. Conclusion: Iranian adolescents follow 3 cigarette smoking trajectories into young adulthood: non-smokers, experimenters and escalators. Male sex, employment after high school, and living with a smoker father were associated with unfavourable smoking patterns. Findings from this study provide valuable insights for designing targeted interventions to reduce cigarette smoking among adults and adolescents in the Islamic Republic of Iran.

The Long-Term Effectiveness of a Multisetting Lifestyle Intervention on Tobacco-Related Habits in Adolescent Boys and Girls: Tehran Lipid and Glucose Study.

BACKGROUND: This study assesses the long-term effectiveness of a lifestyle intervention on cigarette, passive, and hookah smoking in adolescent boys and girls. METHODS: One thousand one hundred and fifty-nine adolescent participants of Tehran Lipid and Glucose Study (TLGS) (2001-2004) were followed for 12 years. Participants in the intervention area received lifestyle interventions in family, schools, and community settings, with the largest part implemented in schools. After excluding those with missing baseline parental data (n = 66), complete parental data of 1093 adolescents was used for cluster analysis. Families were classified as low- and high-risk. Two hundred and ninety-six individuals who did not complete intervention/follow-ups were excluded, GEE was performed on 797 adolescents (369 boys, 192 intervention) to assess the intervention effect on tobacco-related habits. RESULTS: Adolescents' mean baseline age was 15.21 ± 1.95. Those living in high-risk families were more at risk of cigarette, passive, and hookah smoking. Intervention decreased odds of cigarette and passive smoking by 38% and 57%, respectively. Intervention did not reduce hookah smoking in adolescents. After sex-specific analysis, the intervention reduced current cigarette smoking by 40% only in boys and passive smoking in both sexes. CONCLUSIONS: Targeting lifestyle behaviors in school-aged adolescents and their families reduces cigarette smoking in boys and protects both sexes from secondhand smoke.

Time-varying association between physical activity and risk of diabetes in the early and late adulthood: A longitudinal study in a West-Asian country.

BACKGROUND: The time-varying association between physical activity (PA) and incidence of type 2 diabetes (T2DM) is still unclear. The present study aimed to investigate this association in the early- and late-adulthood during a 9-year follow-up. METHODS: This study was conducted on 3905 participants in early and late adulthood, using the Tehran Lipid and Glucose Study (TLGS) dataset. PA was assessed via the Iranian version of Modified Activity Questionnaire (MAQ). The association between trend of PA and incident T2DM was investigated using time-varying Cox's proportional hazard model. Variables including job, education, smoking and body mass index (BMI) were adjusted in the final model. RESULTS: The distribution of sex- and age-specific levels of PA changed significantly over time. Compared with physically inactive women, for older women with high level of PA, the risk of T2DM was 0.64 (95% CI: 0.43-0.95, P = 0.02) in adjusted model. Moreover, hazard for low PA group was significantly higher than the moderate group, and for these two groups were significantly higher than high PA level (P < 0.05). CONCLUSION: High PA level can postpone the incident T2DM in early-aged and elderly women, over time. Therefore, gender and age are of great importance in designing the PA modifying programs to prevent T2DM.