The association between risk perceptions, anxiety, and self-reported changes in tobacco and nicotine product use due to COVID-19 in May-June 2020 in Israel.

BACKGROUND: Early in the COVID-19 pandemic, reports about a possible protective effect of nicotine on COVID-19 conflicted with messaging by public health organizations about increased risks of COVID-19 due to smoking. The ambiguous information the public received, combined with COVID-19-induced anxiety, may have led to changes in tobacco or other nicotine product use. This study examined changes in use of combustible cigarettes (CCs), nargila (hookah/waterpipe), e-cigarettes, and IQOS and home-smoking behaviors. We also assessed COVID-19 related anxiety and perceptions regarding changes in risk of COVID-19 severity due to smoking. METHODS: We used cross-sectional data from a population telephone survey that was conducted in Israel in the early phase of the COVID-19 pandemic (May-June 2020) and included 420 adult (age 18+) individuals who reported having ever used CCs (n = 391), nargila (n = 193), and/or electronic cigarettes (e-cigarettes)/heated tobacco products (e.g., IQOS) (n = 52). Respondents were asked about the effect that COVID-19 had on their nicotine product use (quit/reduced use, no change, increased use). We assessed changes in product use, risk perceptions, and anxiety using adjusted multinomial logistic regression analyses. RESULTS: Most respondents did not change their frequency of product use (CCs: 81.0%, nargila: 88.2%, e-cigarettes/IQOS: 96.8%). A small percentage either decreased use (CCs: 7.2%, nargila: 3.2%, e-cigarettes/IQOS:2.4%) or increased use (CCs:11.8%, nargila:8.6%, e-cigarettes/IQOS:+ 0.9%). 55.6% of respondents used a product in the home prior to COVID-19; but during the first lockdown COVID-19 period, a greater percentage increased (12.6%) than decreased (4.0%) their home use. Higher levels of anxiety due to COVID-19 were associated with increased home smoking (aOR = 1.59, 95% CI:1.04-2.42, p = 0.02). Many respondents believed that increased severity of COVID-19 illness was associated with CCs (62.0%) and e-cigarettes/vaping (45.3%), with uncertainty about the association being lower for CCs (20.5%) than for vaping (41.3%). CONCLUSIONS: While many respondents believed that nicotine product use (particularly CCs and e-cigarettes) was associated with increased risk of COVID-19 disease severity, the majority of users did not change their tobacco/nicotine use. The confusion about the relationship between tobacco use and COVID-19 calls for clear evidence-based messaging from governments. The association between home smoking and increased COVID-19-related stress suggests the need for campaigns and resources to prevent smoking in the home, particularly during times of stress.

Efficient study design to estimate population means with multiple measurement instruments.

Outcomes from studies assessing exposure often use multiple measurements. In previous work, using a model first proposed by Buonoccorsi (1991), we showed that combining direct (eg, biomarkers) and indirect (eg, self-report) measurements provides a more accurate picture of true exposure than estimates obtained when using a single type of measurement. In this article, we propose a tool for efficient design of studies that include both direct and indirect measurements of a relevant outcome. Based on data from a pilot or preliminary study, the tool, which is available online as a shiny app at https://michalbitan.shinyapps.io/shinyApp/, can be used to compute: (1) the sample size required for a statistical power analysis, while optimizing the percent of participants who should provide direct measures of exposure (biomarkers) in addition to the indirect (self-report) measures provided by all participants; (2) the ideal number of replicates; and (3) the allocation of resources to intervention and control arms. In addition we show how to examine the sensitivity of results to underlying assumptions. We illustrate our analysis using studies of tobacco smoke exposure and nutrition. In these examples, a near-optimal allocation of the resources can be found even if the assumptions are not precise.

Protecting Children From Tobacco Smoke Exposure: A Randomized Controlled Trial of Project Zero Exposure.

INTRODUCTION: Young children are vulnerable to harm from tobacco smoke exposure (TSE). This study assessed the effect of Project Zero Exposure-an intervention program designed to help parents protect children from TSE-on children's exposure. METHODS: Randomized controlled trial of a home-based, theory-driven intervention. Parents of young children (<8 y) in families with a smoking parent were eligible. The intervention included feedback on child TSE (hair nicotine), and home air quality (PM2.5), with motivational interviewing. Families were randomized to: intervention group (IG, N = 69), regular control group (RCG, N = 70), or to a secondary enhanced control group, (ECG, N = 20). Child hair samples were taken at baseline and follow-up. We report on child TSE in the IG versus RCG at six months. RESULTS: Most enrolled families completed the trial (IG: 98.6%[68/69], RCG: 97.1%[68/70]). Log hair nicotine (LHN [ng/mg]) decreased in both the IG (Baseline: -1.78 ± 1.91, Follow-up: -2.82 ± 1.87, p = .003) and RCG (Baseline: -1.79 ± 1.54, Follow-up: -2.85 ± 1.73, p = .002), but did not differ between groups at study end (p = .635). Three of five parentally-reported outcomes showed improvement over time in the IG, and one in the RCG. Among IG participants, 90% found hair nicotine feedback useful. CONCLUSIONS: No difference between the intervention and control groups was found on the objective biomarker, LHN. Child TSE decreased during the trial in intervention and control groups. Trial participation, which included hair nicotine monitoring, may have contributed to decreasing exposure in both groups. Concurrent control group improvements may partially explain lack of proven intervention benefit. Biomarker monitoring warrants further investigation for reduction of child TSE. IMPLICATIONS: Project Zero Exposure is an intervention program designed to help parents protect their children from TSE. Results from the randomized controlled trial of the program showed no difference between groups at study end, but a clear and substantial reduction in child exposure to tobacco smoke from beginning to end of the trial, in both intervention and control groups. Biomarker monitoring, a key element of the trial, was used with all participants. Biomarker monitoring of child exposure to tobacco smoke may help parents become aware of their child's exposure and better protect them, and should be explored as a means to reduce child TSE. Clinical Trial Registration: NCT02867241.

Anti-diabetic drug use and reduced risk of Parkinson's disease: A community-based cohort study.

BACKGROUND: Emerging evidence suggests a potential association between certain anti-diabetic drugs and a reduced risk of Parkinson's disease (PD). Limited population-based studies have investigated users of newer anti-diabetic drugs such as GLP-1 agonists or SGLT2 inhibitors. OBJECTIVE: The aim of this study was to assess the risk of PD among individuals with type 2 diabetes mellitus (T2DM) who were treated with various types of anti-diabetic drugs over time. METHODS: A population-based cohort comprising T2DM patients aged over 30 who used metformin, GLP-1 agonists, thiazolidinediones, sulfonylureas, DPP4 inhibitors, SGLT2 inhibitors, or meglitinides between January 1, 1999 and December 31, 2018. Data were obtained between the diabetes registration and drug purchase databases of Maccabi Healthcare Services. Time-dependent Cox regression models, adjusted for sex, age, and comorbidities were employed to calculate the adjusted hazard ratios (HRs) for the PD risk associated with different anti-diabetic drugs over time. RESULTS: The study population comprised 86,229 T2DM patients, with 53.9 % males. The mean age at the first anti-diabetic drug purchase was 59.0 ± 11.0 and 62.0 ± 11.0 years for men and women respectively. Compared to metformin, several drug types were associated with a significantly lower PD risk: thiazolidinediones (HR = 0.91, 95 % CI:0.074-1.14); DPP4 inhibitors (HR = 0.60, 95 % CI:0.53-0.67); meglitinides (HR = 0.63, 95 % CI:0.53-0.74); GLP-1 agonists (HR = 0.54, 95 % CI:0.39-0.73); and SGLT2 inhibitors (HR = 0.15, 95 % CI:0.10-0.21). CONCLUSIONS: Our results suggest a reduced risk of PD with certain anti-diabetic drugs, particularly SGLT2 inhibitors and GLP-1 agonists. Validation through extensive big-data studies is essential to confirm these results and to optimize PD prevention and management.

Incidence of cardiovascular morbidity among Parkinson's disease patients; a large-scale cohort study in a 16-year time window around disease onset.

OBJECTIVES: To examine the risk of any or specific types of cardiovascular diseases (CVDs) in patients with Parkinson's disease (PD), in the 16 years around disease onset, and to compare it to that in the general population. METHODS: This is a large-scale population-based retrospective cohort study of newly diagnosed PD patients, members of Maccabi Health Services (MHS), who started taking anti-parkinsonian drugs (APD) between 1/1/2000-31/12/2019 (study period). We collected information about CVD incidence (Congestive heart failure-CHF, Myocardial infarction-MI, Stroke) from MHS-CVD registry. We applied Cox regression to estimate adjusted-HR and 95%CI of CVD risks. We calculated Standardized-Incidence-Ratio (SIR) comparing CVD risks in the PD cohort to that of MHS population. RESULTS: The PD cohort comprised 10,840 patients. During a mean follow up of 16.3 ± 4.3y around disease onset, 20.7% (n = 2241) were diagnosed with any CVD: 7.9% with CHF; 6.7% with MI, and 10.5% with stroke. Risks were higher for men: HR = 1.95 (95%CI 1.58-2.40), and for above age 75y at first APD treatment, HR = 2.00 (95% CI 1.65-2.43). Compared to the MHS population, the PD cohort exhibited a significantly lower risk for CVDs, especially for men: SIRmen = 0.21 (95%CI 0.20-0.22), SIRwomen = 0.29 (95% CI 0.27-0.31). These trends were similar for the specific CVDs. CONCLUSIONS: The findings suggest that the risks that PD patients and particularly men, will develop any type of CVD are lower than those of the general population. Further studies are needed to confirm this finding and examine the underlying mechanisms.

Tobacco Smoke Exposure According to Location of Home Smoking in Israel: Findings from the Project Zero Exposure Study.

Young children are particularly vulnerable to harms from tobacco smoke exposure (TSE). This study aimed to compare TSE: (1) between children who live in smoking families and those who do not; and (2) among children who live in smoking households with varying smoking locations. The data came from two studies that were conducted concurrently in Israel (2016-2018). Study 1: a randomized controlled trial of smoking families (n = 159); Study 2: a cohort study of TSE among children in non-smoking families (n = 20). Hair samples were collected from one child in each household. Baseline hair nicotine data were analyzed for 141 children in Study 1 and 17 children in Study 2. Using a logistic regression analysis (exposed vs. not exposed as per laboratory determination) and a linear regression (log hair nicotine), we compared TSE between: (1) children in Study 1 vs. Study 2; (2) children in families with different smoking locations in Study 1: balcony; garden, yard, or other place outside of the home; or inside the home (designated smoking areas within the home (DSAs) or anywhere). A higher proportion of children living in smoking households were measurably exposed to tobacco smoke (68.8%) compared to children living in non-smoking households (35.3%, p = 0.006). Among children from smoking families, 75.0% of those whose parents smoked in the house were exposed, while 61.8% of children whose parents restricted smoking to the porch (n = 55) were exposed, and 71.4% of those whose parents smoked outside the home (including gardens and yards) (n = 42) were exposed. In univariable and multivariable models, smoking location was not significantly associated with exposure. The majority of children in smoking families were measurably exposed to TSE, even if smoking was restricted to designated areas in the home, balconies, orgarden/yard/other outdoor areas. Reducing population smoking rates, particularly among parents, restricting smoking to at least 10 meters from homes and children, and denormalizing smoking around others are recommended to reduce population-level child TSE and tobacco-attributable disease and death.

Tobacco smoke incursion into private residences in Israel: a cross-sectional study examining public perceptions of private rights and support for governmental policies.

BACKGROUND: Tobacco smoke incursion (TSI) into private residences is a widespread problem in many countries. We sought to assess the prevalence of self-reported TSI and public attitudes about TSI in Israel, a country with a relatively high smoking prevalence and high population density. METHODS: We conducted a random digit dial survey among residents in Israel (N = 285) in 2017, which examined the frequency, source, correlates of, and attitudes towards TSI and potential regulatory options. The cooperation rate was 63.9%. RESULTS: Among respondents, 44.7% reported ever experiencing home TSI, with higher exposure among residents of multi-unit housing (MUH) (MUH versus private homes: aOR (Adjusted Odds Ratio): 3.60, CI (Confidence Interval): [1.96, 6.58], p < .001). Most respondents (69.8%), including nearly half of smokers, prioritized the right of individuals to breath smoke-free air in their apartments over the right of smokers to smoke in their apartments. Women and non-smokers were more likely to support the right to breathe smoke-free air (Women versus men: aOR: 2.77 CI: [1.48, 5.16], p = .001; Nonsmokers versus smokers: aOR: 3.21 CI [1.59, 6.48], p = .001). However, only about a quarter (24.8%) of respondents who ever experienced TSI raised the issue with the neighbor who smoked, the neighbor's landlord, or the building committee. The vast majority (85.2%) of all respondents, including three-quarters of smokers, supported smoke-free legislation for multi-unit housing (MUH), with those ever-exposed to TSI and non-smokers more likely to support legislation (ever-exposed versus never-exposed aOR = 2.99, CI [1.28, 6.97], p = 0.011; nonsmokers versus smokers aOR = 3.00, CI [1.28, 7.01], p = 0.011). CONCLUSIONS: Among study participants, tobacco smoke incursion was a common, yet unwelcome experience. Most respondents believed that the right to breathe smoke-free air in one's apartment superseded that of neighbors to smoke anywhere in their home, and most supported legislation to prevent TSI. Though further study is needed to understand better TSI and effective methods for its prevention, our findings suggest that policy interventions, including legal action at the level of the Supreme Court and/or the Knesset, are needed. Regulation, policy initiatives and campaigns to denormalize smoking in proximity to other people and private residences globally could reduce the scope of this widespread problem, protect individuals from home TSI, and improve population health.

A meta-analysis identifies factors predicting the future development of freezing of gait in Parkinson's disease.

Freezing of gait (FOG) is a debilitating problem that is common among many, but not all, people with Parkinson's disease (PD). Numerous attempts have been made at treating FOG to reduce its negative impact on fall risk, functional independence, and health-related quality of life. However, optimal treatment remains elusive. Observational studies have recently investigated factors that differ among patients with PD who later develop FOG, compared to those who do not. With prediction and prevention in mind, we conducted a systematic review and meta-analysis of publications through 31.12.2022 to identify risk factors. Studies were included if they used a cohort design, included patients with PD without FOG at baseline, data on possible FOG predictors were measured at baseline, and incident FOG was assessed at follow-up. 1068 original papers were identified, 38 met a-priori criteria, and 35 studies were included in the meta-analysis (n = 8973; mean follow-up: 4.1 ± 2.7 years). Factors significantly associated with a risk of incident FOG included: higher age at onset of PD, greater severity of motor symptoms, depression, anxiety, poorer cognitive status, and use of levodopa and COMT inhibitors. Most results were robust in four subgroup analyses. These findings indicate that changes associated with FOG incidence can be detected in a subset of patients with PD, sometimes as long as 12 years before FOG manifests, supporting the possibility of predicting FOG incidence. Intriguingly, some of these factors may be modifiable, suggesting that steps can be taken to lower the risk and possibly even prevent the future development of FOG.

Clinicians' Perceptions of Parent-Child Arts Therapy with Children with Autism Spectrum Disorders: The Milman Center Experience.

Different types of arts offer a wide variety of modes of nonverbal communication and expressive tools for children with Autism Spectrum Disorders (ASD). The present study was designed to characterize therapists' perspectives on the implementation of a parent-child arts therapy model for children with ASD. Semi-structured interviews were conducted with 13 arts therapists who participated in the study. The thematic analysis (qualitative analysis) approach yielded seven themes: (1) Therapeutic goals. (2) Adjusting the therapeutic intervention. (3) The advantages of parent-child arts therapy. (4) Difficulties in parent-child arts therapy. (5) The unique contribution of the participants to parent-child arts therapy. (6) The different types of arts in the therapy room. (7) The arts therapists' assessment of the progress of therapy. The discussion focuses on the four central components of parent-child arts therapy room: the child in therapy, the parent, the arts therapist, and the creative arts.

The Association between the Sense of Coherence and the Self-Reported Adherence to Guidelines during the First Months of the COVID-19 Pandemic in Israel.

(1) Background: Social distancing became a central strategy employed to limit the spread of the SARS-CoV-2 virus. We explore self-reported adherence (SRA) and factors associated with SRA among Israeli adults at the end of the first national lockdown in Israel. (2) Methods: We conducted a cross-sectional consumer panel survey of 820 Israeli adults aged 18 to 70 in May and June 2020. We collected data on the SRA to the social distancing measures, sociodemographic variables, perceptions of pandemic-related danger and of protection provided by the social distancing measures, as well as Sense of Coherence (SoC). (3) Results: 60% of respondents reported complying with 7 measures. Higher SoC was associated with higher SRA (p = 0.04), and was related to income, marital status, age, profession, and education. The SRA was higher among Jews than Arabs (Jews: Mean = 10.5, SD = 4.5; Arabs: Mean = 9.1, SD = 4.1, p < 0.001) and among males (Males: Mean = 10.8, SD = 4.7; Females: Mean = 9, SD = 4.1; p = 0.003). SoC, perception of protection and perception of danger were associated with higher SRA (p = 0.42, p < 0.001 and p = 0.005 respectively). Single people reported higher levels of SRA than people in relationships (Partnered: Mean = 9.7, SD = 4.2, Non-partnered: Mean = 10.9, SD = 4.7, p = 0.033). (4) Conclusions: At the time of exit from the first lockdown, compliance with social distancing measures was high, with Jewish, single and male Israelis more likely to adhere to the guidelines. We identified the populations at risk for non-adherence and associated factors, reporting for the first time the correlation between SoC and SRA. Further research is needed to assess the role of these factors in Jewish and Arab populations.

Excess mortality in Israel associated with COVID-19 in 2020-2021 by age group and with estimates based on daily mortality patterns in 2000-2019.

BACKGROUND: We aimed to build a basic daily mortality curve in Israel based on 20-year data accounting for long-term and annual trends, influenza-like illness (ILI) and climate factors among others, and to use the basic curve to estimate excess mortality during 65 weeks of the COVID-19 pandemic in 2020-2021 stratified by age groups. METHODS: Using daily mortality counts for the period 1 January 2000 to 31 December 2019, weekly ILI counts, daily climate and yearly population sizes, we fitted a quasi-Poisson model that included other temporal covariates (a smooth yearly trend, season, day of week) to define a basic mortality curve. Excess mortality was calculated as the difference between the observed and expected deaths on a weekly and periodic level. Analyses were stratified by age group. RESULTS: Between 23 March 2020 and 28 March 2021, a total of 51 361 deaths were reported in Israel, which was 12% higher than the expected number for the same period (expected 45 756 deaths; 95% prediction interval, 45 325-46 188; excess deaths, 5605). In the same period, the number of COVID-19 deaths was 6135 (12% of all observed deaths), 9.5% larger than the estimated excess mortality. Stratification by age group yielded a heterogeneous age-dependent pattern. Whereas in ages 90+ years (11% excess), 100% of excess mortality was attributed to COVID-19, in ages 70-79 years there was a greater excess (21%) with only 82% attributed to COVID-19. In ages 60-69 and 20-59 years, excess mortality was 14% and 10%, respectively, and the number of COVID-19 deaths was higher than the excess mortality. In ages 0-19 years, we found 19% fewer deaths than expected. CONCLUSION: The findings of an age-dependent pattern of excess mortality may be related to indirect pathways in mortality risk, specifically in ages <80 years, and to the implementation of the lockdown policies, specifically in ages 0-19 years with lower deaths than expected.

Association between objective measures and parent-reported measures of child tobacco smoke exposure: A secondary data analysis of four trials.

INTRODUCTION: Tobacco smoke exposure (TSE) harms children and adults. Studies of childhood TSE exposure often relies on parental reports, but may benefit from objective measures. The objective of our study was to study the relationship between reported and objective measures of TSE. METHODS: We analyzed data from four intervention trials, conducted in clinical or community settings, to identify objective measures most closely associated with parent-reported measures and the optimal set of parent-reported measures for predicting objective measures. We also assessed whether there was a learning curve in reported exposure over time, and the importance of replicate biomarker measures. RESULTS: Correlations between objective and parent-reported measures of child TSE were modest at best, ranging from zero to 0.41. Serum cotinine and urinary cotinine were most strongly associated with parental reports. Parental questions most closely related to biomarkers were number of cigarettes and home smoking rules; together these formed the best set of predictive questions. No trial included all objective measures and all questions, precluding definitive statements about relative advantages. Within-subject repeatability of biomarker measures varied across studies, suggesting that direct pilot data are needed to assess the benefit of replicate measurements. CONCLUSIONS: Improvements in objective and parent-reported child exposure measurements are needed to accurately monitor child TSE, evaluate efforts to reduce such exposure, and better protect child health.

Parents' attitudes toward children's vaccination as a marker of trust in health systems.

Children's vaccination is a major goal in health-care systems worldwide; nevertheless, disparities in vaccination coverage expose socio-demographic accessibility gaps, unawareness, physicians' disapproval and parents' incomplete adherence reflecting insufficient public-provider trust. Our goal was to analyze parents' attitude toward children's vaccination in correlation with trust among stakeholders. A total of 1031 parents replied to a "snowball" questionnaire; 72% reported high trust in their physician, 42% trusted the authorities, 11% trusted internet groups. Among minorities, parents who fully vaccinate their children were younger, live in urban areas, eat all kinds of foods and trust the authorities, similar to the general population. Low adherence to children's vaccination was correlated with trusting internet groups. Females complied significantly more to child vaccination, although in our study mothers were more highly educated and trusted authorities more than males. The results enable to draw a profile of the "vaccination compliant parent" (with an academic degree, young, urban, eats all kinds of foods, uses conservative medicine). Trust is a major factor influencing vaccination, yet external forces such as community voices, social trends and opinions of religious leaders may play a role in vaccination adherence, beyond personal beliefs, individual habits and self-care. In Israel, education and "healthy behavior" perception alongside generous coverage encourage most parents to comply with the routine vaccination program. In the shade of pandemic outbreaks, we suggest a social-determinant transparent approach to encourage parents to vaccinate their children. Social and religious leaders can pose as agents of change, especially in the case of less educated parents.