Smoker's face: an underrated clinical sign?

In a prospective survey of patients attending a general medical outpatient clinic roughly half the current cigarette smokers who had smoked for 10 years or more were identified, using defined criteria, by their facial features alone. These facial features, designated "smoker''s face," were present in three (8%) of those who had smoked cigarettes for 10 years or more in the past and in none of the non-smokers. The association of smoker''s face with current smoking that had continued for 10 years or more was significant (p less than 0.001) and remained after the patient''s age, social class, exposure to sunlight, recent change of weight, and estimated lifetime consumption of cigarettes were controlled for. Smoker''s face may be a helpful indicator in antismoking campaigns.     

Understanding Community Norms Surrounding Tobacco Sales

Background

In the US, denormalizing tobacco use is key to tobacco control; less attention has been paid to denormalizing tobacco sales. However, some localities have placed limits on the number and type of retailers who may sell tobacco, and some retailers have abandoned tobacco sales voluntarily. Understanding community norms surrounding tobacco sales may help accelerate tobacco denormalization.

Methods

We conducted 15 focus groups with customers of California, New York, and Ohio retailers who had voluntarily discontinued tobacco sales to examine normative assumptions about where cigarettes should or should not be sold, voluntary decisions to discontinue tobacco sales, and government limits on such sales.

Results

Groups in all three states generally agreed that grocery stores that sold healthy products should not sell tobacco; California groups saw pharmacies similarly, while this was a minority opinion in the other two states. Convenience stores were regarded as a natural place to sell tobacco. In each state, it was regarded as normal and commendable for some stores to want to stop selling tobacco, although few participants could imagine convenience stores doing so. Views on government''s role in setting limits on tobacco sales varied, with California and New York participants generally expressing support for restrictions, and Ohio participants expressing opposition. However, even those who expressed opposition did not approve of tobacco sales in all possible venues. Banning tobacco sales entirely was not yet normative.

Conclusion

Limiting the ubiquitous availability of tobacco sales is key to ending the tobacco epidemic. Some limits on tobacco sales appear to be normative from the perspective of community members; it may be possible to shift norms further by problematizing the ubiquitous presence of cigarettes and drawing connections to other products already subject to restrictions.     

Environmental tobacco smoke exposure and ischaemic heart disease: an evaluation of the evidence.

OBJECTIVES: To estimate the risk of ischaemic heart disease caused by exposure to environmental tobacco smoke and to explain why the associated excess risk is almost half that of smoking 20 cigarettes per day when the exposure is only about 1% that of smoking. DESIGN: Meta-analysis of all 19 acceptable published studies of risk of ischaemic heart disease in lifelong non-smokers who live with a smoker and in those who live with a non-smoker, five large prospective studies of smoking and ischaemic heart disease, and studies of platelet aggregation and studies of diet according to exposure to tobacco smoke. RESULTS: The relative risk of ischaemic heart disease associated with exposure to environmental tobacco smoke was 1.30 (95% confidence interval 1.22 to 1.38) at age 65. At the same age the estimated relative risk associated with smoking one cigarette per day was similar (1.39 (1.18 to 1.64)), while for 20 per day it was 1.78 (1.31 to 2.44). Two separate analyses indicated that non-smokers who live with smokers eat a diet that places them at a 6% higher risk of ischaemic heart disease, so the direct effect of environmental tobacco smoke is to increase risk by 23% (14% to 33%), since 1.30/1.06 = 1.23. Platelet aggregation provides a plausible and quantitatively consistent mechanism for the low dose effect. The increase in platelet aggregation produced experimentally by exposure to environmental tobacco smoke would be expected to have acute effects increasing the risk of ischaemic heart disease by 34%. CONCLUSION: Breathing other people''s smoke is an important and avoidable cause of ischaemic heart disease, increasing a person''s risk by a quarter.     

The Winnipeg Children's Hospital child protection centre: a provincial medical initiative.

The Winnipeg Children''s Hospital child protection centre is a hospital-based provincial protection program that focuses on the diagnosis, treatment and prevention of child abuse and neglect in Manitoba. The multidisciplinary group of professionals working in the centre differs from most hospital-based teams in that it has a strong government liaison both functionally and financially, has strong ties to the welfare system and has legal counsel relating to the court system. The centre represents the philosophy that medical participation in welfare matters relating to children need not be relegated to the sidelines. This paper describes the centre''s history and structure, and it outlines some of its research projects.     

Bilingualism Accentuates Children's Conversational Understanding

Background

Although bilingualism is prevalent throughout the world, little is known about the extent to which it influences children''s conversational understanding. Our investigation involved children aged 3–6 years exposed to one or more of four major languages: English, German, Italian, and Japanese. In two experiments, we examined the children''s ability to identify responses to questions as violations of conversational maxims (to be informative and avoid redundancy, to speak the truth, be relevant, and be polite).

Principal Findings

In Experiment 1, with increasing age, children showed greater sensitivity to maxim violations. Children in Italy who were bilingual in German and Italian (with German as the dominant language L1) significantly outperformed Italian monolinguals. In Experiment 2, children in England who were bilingual in English and Japanese (with English as L1) significantly outperformed Japanese monolinguals in Japan with vocabulary age partialled out.

Conclusions

As the monolingual and bilingual groups had a similar family SES background (Experiment 1) and similar family cultural identity (Experiment 2), these results point to a specific role for early bilingualism in accentuating children''s developing ability to appreciate effective communicative responses.     

Study of 8-year-old children with a history of respiratory syncytial virus bronchiolitis in infancy.

Thirty-five children known to have had respiratory syncytial virus bronchiolitis in infancy were examined at the age of 8 and their respiratory function tested. The results were compared with those in 35 controls matched for age, sex, and social class. Although 18 of the children who had had bronchiolitis in infancy had experienced subsequent episodes of wheezing, these were neither severe nor frequent in most cases and had apparently ceased by the age of 8. Nevertheless, the mean exercise bronchial lability of the children who had had bronchiolitis was significantly higher than that of the control children and the mean peak expiratory flow rate at rest significantly lower. Atopy, assessed by family and personal history alone, did not seem to be related to either bronchiolitis or wheezing episodes after bronchiolitis. The parents of the children who had had bronchiolitis smoked significantly more cigarettes during the infant''s first year of life than those of the control children. The results suggest that bronchiolitis and childhood asthma are not closely related. Bronchial hyperreactivity might be inherited independently of atopy, but environmental factors seem the most likely link between severe respiratory infection in infancy and chronic or recurrent respiratory illness in adult life.     

Should the health community promote smokeless tobacco (snus) as a harm reduction measure?

BACKGROUND TO THE DEBATE: The tobacco control community is divided on whether or not to inform the public that using oral, smokeless tobacco (Swedish snus) is less hazardous to health than smoking tobacco. Proponents of "harm reduction" point to the Swedish experience. Snus seems to be widely used as an alternative to cigarettes in Sweden, say these proponents, contributing to the low overall prevalence of smoking and smoking-related disease. Harm reduction proponents thus argue that the health community should actively inform inveterate cigarette smokers of the benefits of switching to snus. However, critics of harm reduction say that snus has its own risks, that no form of tobacco should ever be promoted, and that Sweden's experience is likely to be specific to that culture and not transferable to other settings. Critics also remain deeply suspicious that the tobacco industry will use snus marketing as a "gateway" to promote cigarettes. In the interests of promoting debate, the authors (who are collaborators on a research project on the future of tobacco control) have agreed to outline the strongest arguments for and against promoting Swedish snus as a form of harm reduction.     

Mobilizing physicians to conduct clinical intervention in tobacco use through a medical-association program: 5 years' experience in British Columbia.

During the last 5 years, a program run by the medical association in British Columbia has recruited 23% of the province''s general practitioners (GPs) to take an active, systematic approach to clinical intervention in tobacco use. Another 9% of GPs (considered "semi-active") regularly use the program''s educational materials for patients, and another 25% have been trained in intervention or have been given intervention materials or both. If the cessation rate (rate of patients who quit smoking who would not otherwise have done so) was 4% among physicians actively involved in intervention and 2% among physicians considered semi-active, in 1995 an estimated 4700 smokers quit and were followed by their GPs as a result of the program. Another 135,000 smokers received brief counselling from their GPs and were also followed. This article reviews the strategies and methods used in this program to mobilize physicians.     

High prevalence of asthma symptoms in Warao Amerindian children in Venezuela is significantly associated with open-fire cooking: a cross-sectional observational study

Background

The International Study on Asthma and Allergies in Childhood (ISAAC) reported a prevalence of asthma symptoms in 17 centers in nine Latin American countries that was similar to prevalence rates reported in non-tropical countries. It has been proposed that the continuous exposure to infectious diseases in rural populations residing in tropical areas leads to a relatively low prevalence of asthma symptoms. As almost a quarter of Latin American people live in rural tropical areas, the encountered high prevalence of asthma symptoms is remarkable. Wood smoke exposure and environmental tobacco smoke have been identified as possible risk factors for having asthma symptoms.

Methods

We performed a cross-sectional observational study from June 1, 2012 to September 30, 2012 in which we interviewed parents and guardians of Warao Amerindian children from Venezuela. Asthma symptoms were defined according to the ISAAC definition as self-reported wheezing in the last 12 months. The associations between wood smoke exposure and environmental tobacco smoke and the prevalence of asthma symptoms were calculated by means of univariate and multivariable logistic regression analyses.

Results

We included 630 children between two and ten years of age. Asthma symptoms were recorded in 164 of these children (26%). The prevalence of asthma symptoms was associated with the cooking method. Children exposed to the smoke produced by cooking on open wood fires were at higher risk of having asthma symptoms compared to children exposed to cooking with gas (AOR 2.12, 95% CI 1.18 - 3.84). Four percent of the children lived in a household where more than ten cigarettes were smoked per day and they had a higher risk of having asthma symptoms compared to children who were not exposed to cigarette smoke (AOR 2.69, 95% CI 1.11 - 6.48).

Conclusion

Our findings suggest that children living in rural settings in a household where wood is used for cooking or where more than ten cigarettes are smoked daily have a higher risk of having asthma symptoms.     

Bone Mineral Density of the Spine in 11,898 Chinese Infants and Young Children: A Cross-Sectional Study

Background

Bone mineral density (BMD) increases progressively during childhood and adolescence and is affected by various genetic and environmental factors. The aim of this study was to establish reference values for lumbar BMD in healthy Chinese infants and young children and investigate its influencing factors.

Methods and Findings

Healthy children aged 0 to 3 years who underwent regular physical examinations at the Child Health Care Clinic of Hubei Maternal and Child Health Hospital (N = 11,898) were recruited for this study. We also chose 379 preterm infants aged 0 to 1 years to preliminarily explore the development of BMD in this special population. BMD (g/cm²) measurements of the lumbar spine (L2–L4) were carried out with dual-energy X-ray absorptiometry and a questionnaire was administered to full-term children''s parents to gather information on various nutritional and lifestyle factors as well as mothers'' nutritional supplement use during pregnancy. Lumbar BMD significantly increased with age among both boys and girls (p<0.05), with fastest growth observed during the first postnatal year. There was no significant difference in lumbar BMD between boys and girls of similar age (p>0.05), either among healthy reference children or preterm infants. However, BMD values in preterm infants were significantly lower than those in term infants 3 to 8 months old (p<0.05) after adjustment for gestational age. Multivariable linear regression analysis indicated significant positive associations between lumbar BMD of healthy children and the child''s age and current weight, mother''s weight gain during pregnancy, birth weight, children''s outdoor activity duration and children''s physical activity duration.

Conclusion

Our study provides reference values of lumbar BMD for healthy Chinese children aged 0 to 3 years and identifies several influencing factors.     

Factors associated with HIV/AIDS diagnostic disclosure to HIV infected children receiving HAART: a multi-center study in Addis Ababa, Ethiopia

Background

Diagnostic disclosure of HIV/AIDS to a child is becoming an increasingly common issue in clinical practice. Nevertheless, some parents and health care professionals are reluctant to inform children about their HIV infection status. The objective of this study was to identify the proportion of children who have knowledge of their serostatus and factors associated with disclosure in HIV-infected children receiving HAART in Addis Ababa, Ethiopia.

Methods

A cross-sectional study was conducted in five hospitals in Addis Ababa from February 18, 2008–April 28, 2008. The study populations were parents/caretakers and children living with HIV/AIDS who were receiving Highly Active Antiretroviral Therapy (HAART) in selected hospitals in Addis Ababa. Univariate and multivariate logistic regression analysis were carried out using SPSS 12.0.1 statistical software.

Results

A total of 390 children/caretaker pairs were included in the study. Two hundred forty three children (62.3%) were between 6–9 years of age. HIV/AIDS status was known by 68 (17.4%) children, 93 (29%) caretakers reported knowing the child''s serostatus two years prior to our survey, 180 (46.2%) respondents said that the child should be told about his/her HIV/AIDS status when he/she is older than 14 years of age. Children less than 9 years of age and those living with educated caregivers are less likely to know their results than their counterparts. Children referred from hospital''s in-patient ward before attending the HIV clinic and private clinic were more likely to know their results than those from community clinic.

Conclusion

The proportion of disclosure of HIV/AIDS diagnosis to HIV-infected children is low. Strengthening referral linkage and health education tailored to educated caregivers are recommended to increase the rate of disclosure.     

Influence of passive smoking on admissions for respiratory illness in early childhood.

An association was sought between passive smoking and inpatient admissions for respiratory illness in 1058 children born between 1 June and 31 December 1981 and living in the neighborhoods of Nan-Jing Western Road and Yan-An Western Road in Jing-An District, Shanghai. The admission rate for first episodes of respiratory illness was positively correlated with the total daily cigarette consumption of family members during the children''s first 18 months of life. The relative risk of developing a first episode of respiratory illness was 1.80 for children living in families including people who smoked 10 or more cigarettes a day compared with those living in non-smoking families. Multiple logistic regression analysis showed that the effect of passive smoking on inpatient admission for respiratory illness was independent of the child''s birth weight, type of feeding, father''s education, size of the home, and chronic respiratory disease among adults in the family. The adjusted odds ratios compared with the non-smoking group were 1.17 in families smoking 1.9 cigarettes daily and 1.89 in families smoking 10 or more cigarettes daily. These data suggest that exposure to household cigarette smoke of children in early life increases the risk of severe respiratory illness.     

Health inequalities: new concerns about the children of single mothers.

OBJECTIVES--To show that the exclusion from conventional class based analyses of child mortality of children whose parents are classified as "unoccupied" produces a misleading picture of health inequalities. DESIGN--Reanalysis of data published in the childhood supplement of the registrar general''s decennial supplement on occupational mortality in England and Wales, which compares numerator data for registrations of deaths in children over the age of 1 but below their 16th birthday in 1979, 1980, 1982, and 1983 with data about children aged 1-15 who were enumerated at the 1981 census. RESULTS--Parents who are classified as "unoccupied" largely consist of economically inactive single mothers. Their children are estimated to represent 89% of the 614,000 aged 1-15 classified as "unoccupied" in the childhood supplement. They have the worst mortality record of all social groups--an age specific death rate of 68.8/100,000 a year, 42% worse than in social class V (48.4/100,000) and worse than that of social class I (22.8) by a factor of 3. At older ages (10-15 years) these children have a relative risk of death of 4.14 relative to classes I and II; the risk is 2.58 in children 0-4 and 2.56 in those 5-9. Relative risks of child mortality in social classes I and II in comparison to classes IV and V suggests a progressive shallowing from 2.08 at ages 1-4 to 1.37 at ages 10-15. When unoccupied parents were combined with classes IV and V and compared with classes I and II, however, inequalities seemed to be pervasive throughout childhood; the relative risks were 2.21 for those aged 1-4 and 1.98 for those aged 10-15. CONCLUSION--Children classified as unoccupied are almost certainly living in poverty as well as experiencing relatively high risks of mortality. Class based analyses which exclude them therefore produce a misleading picture of inequalities in child health. The implications for health policy are profound. Strategies to promote the nation''s health should acknowledge the importance of material and social deprivation more explicitly.     

Tobacco Industry Manipulation of Tobacco Excise and Tobacco Advertising Policies in the Czech Republic: An Analysis of Tobacco Industry Documents

Background

The Czech Republic has one of the poorest tobacco control records in Europe. This paper examines transnational tobacco companies'' (TTCs'') efforts to influence policy there, paying particular attention to excise policies, as high taxes are one of the most effective means of reducing tobacco consumption, and tax structures are an important aspect of TTC competitiveness.

Methods and Findings

TTC documents dating from 1989 to 2004/5 were retrieved from the Legacy Tobacco Documents Library website, analysed using a socio-historical approach, and triangulated with key informant interviews and secondary data. The documents demonstrate significant industry influence over tobacco control policy. Philip Morris (PM) ignored, overturned, and weakened various attempts to restrict tobacco advertising, promoting voluntary approaches as an alternative to binding legislation. PM and British American Tobacco (BAT) lobbied separately on tobacco tax structures, each seeking to implement the structure that benefitted its own brand portfolio over that of its competitors, and enjoying success in turn. On excise levels, the different companies took a far more collaborative approach, seeking to keep tobacco taxes low and specifically to prevent any large tax increases. Collective lobbying, using a variety of arguments, was successful in delaying the tax increases required via European Union accession. Contrary to industry arguments, data show that cigarettes became more affordable post-accession and that TTCs have taken advantage of low excise duties by raising prices. Interview data suggest that TTCs enjoy high-level political support and continue to actively attempt to influence policy.

Conclusion

There is clear evidence of past and ongoing TTC influence over tobacco advertising and excise policy. We conclude that this helps explain the country''s weak tobacco control record. The findings suggest there is significant scope for tobacco tax increases in the Czech Republic and that large (rather than small, incremental) increases are most effective in reducing smoking. Please see later in the article for the Editors'' Summary     

Passive exposure to tobacco smoke: saliva cotinine concentrations in a representative population sample of non-smoking schoolchildren.

Saliva cotinine concentrations in 569 non-smoking schoolchildren were strongly related to the smoking habits of their parents. When neither parent smoked the mean concentration was 0.44 ng/ml, rising to 3.38 ng/ml when both parents were cigarette smokers. Mothers'' smoking had a stronger influence than did fathers'' (p less than 0.01). In addition, there was a small independent effect of number of siblings who smoked (p less than 0.01). The dose of nicotine received from fathers'' smoking was estimated as equivalent to the active smoking of 30 cigarettes a year, that from mothers'' smoking as equivalent to smoking 50 cigarettes a year, and that from both parents smoking as equivalent to smoking 80 cigarettes a year. This unsolicited burden may be prolonged throughout childhood and poses a definite risk to health.     

Cigarette smoking among school-going adolescents in Lithuania: Results from the 2005 Global Youth Tobacco Survey

Background

The majority of people who suffer morbidity due to smoking may have initiated smoking during adolescent period. The aim of this study is to determine the prevalence and associated factors for cigarette smoking among school-going adolescents in Lithuania.

Findings

Data from the Global Youth Tobacco Survey (GYTS) 2005 were used to conduct this study. Data were analyzed using SUDAAN software 9.03. Comparisons for categorical variables were done using the Pearson's Chi-square test. The cut of point for statistical significance was set at 5% level. Logistic regression analyses were conducted to determine factors associated with the outcome. Unadjusted odds ratios (OR) and adjusted odds ratios (AOR) together with their 95% confidence intervals (CI) are reported. Of the 1822 respondents, 35.8% males and 27.1% females reported being current cigarette smokers (p < 0.001). Having friends who smoke cigarettes was associated with smoking after controlling for age, gender, parental smoking status, and perception of risks of smoking (AOR = 3.76; 95% CI [2.33, 6.90] for some friends using tobacco; and AOR = 17.18; 95% CI [10.46, 28.21] for most or all friends using tobacco). Male gender and having one or both parents who smoke cigarettes were associated with smoking (AOR = 1.31; 95% CI [1.03, 1.66]) and AOR = 1.76; 95% CI [1.37, 2.27]) respectively).

Conclusions

There is a high prevalence of cigarette smoking among Lithuanian adolescents. Male adolescents and adolescents who have friends or parents who smoke should be the main target for tobacco control in Lithuania.     

Winnipeg pediatrician prepares to assume CMA presidency

The CMA''s incoming president is Dr. Jack Armstrong, a Winnipeg pediatrician with a particular interest in aboriginal issues. Armstrong, who graduated from the University of Manitoba in 1966, considers himself a team player. “You have to be a part of a team. My job is to try to be as good a spokesperson as possible, along with the other team members, for the physicians of the country.”     

Changes of smoking habits and cough in men smoking cigarettes with 30% NSM tobacco substitute.

The effects of smoking cigarettes with 30% of the tobacco replaced by NSM tobacco substitute, which lowered their tar and nicotine delivery, were studied by comparing them with the effects of conventional cigarettes in a controlled crossover trial lasting 20 months. Chest symptoms, cigarette consumption, and forced expiratory volume in one second (FEV1) were measured each month. Two-hundred men began the trial and 159 completed it. The test cigarettes were acceptable to all but one of the men. In a subsample of 35 men estimates of nicotine intake were obtained from monthly analyses of cigarette stubs. On changing from NSM to control cigarettes six of the 17 men, who were accustomed to low nicotine, kept their nicotine intake down by some change in smoking habit. Before the crossover and this change in smoking habit the men smoking NSM cigarettes had a small but significant reduction of cough. Cigarettes containing 30% NSM and delivering only 1 mg of nicotine are likely to be acceptable to smokers and may reduce coughing. Further trials are needed to confirm these findings and establish what long-term effects such cigarettes may have on smokers'' health.     

"They're doing people a service"-qualitative study of smoking, smuggling, and social deprivation

ObjectivesTo examine the behaviour and attitudes related to smoking and contraband tobacco products among smokers in two socially deprived areas.DesignCross sectional study with qualitative semistructured interviews, augmented by smokers'' day grid.SettingTwo areas of socioeconomic deprivation in Edinburgh.Participants50 male and 50 female smokers aged 25-40 years randomly selected from general practitioners'' lists from two health centres, each located in an area of deprivation.ResultsMost smokers wanted to quit but felt unable to because of the importance of smoking in their daily routine and their addiction to nicotine. Strategies for maintaining consumption levels in the face of increasing cigarette prices and low income included purchasing contraband cigarettes and tobacco. Vendors were contacted through social networks, family, and friends as well as common knowledge of people and places, particularly pubs where contraband was available. Most users of contraband considered that smugglers were providing a valuable service. Purchasing contraband tobacco was viewed as rational in the face of material hardship. Many smokers criticised the government for its high tobacco taxation and the lack of local services to help them to stop smoking.ConclusionsSmokers in deprived areas perceive a lack of support to help them to stop smoking. Cigarette and tobacco smuggling is therefore viewed positively by low income smokers as a way of dealing with the increasing cost of cigarettes. Smokers in areas of deprivation may thus show little support for tackling smuggling until more action is taken to deal with the material and personal factors that make it difficult for them to quit.

What is already known on this topic

Areas of deprivation have the highest rates of smoking and lowest levels of cessationAround 25-30% of cigarettes consumed in the United Kingdom are contrabandWe know little about the attitudes of smokers in these areas to smuggled cigarettes or whether and how they access them

What this study adds

In such areas the easy availability of cheap tobacco products through contraband networks works against many smokers'' desire to quitGiven the perceived lack of support to help them to stop smoking, this smuggling network is viewed positively by low income smokers as a way of dealing with the increasing cost of cigarettesSmokers in areas of deprivation may thus show little support for tackling smuggling until more action is taken to address the material and personal factors that make it difficult for them to quit     

Parental attitudes toward pediatric organ donation: a survey.

We conducted a telephone survey of parents in the National Capital Region to assess their intention to donate their child''s organs and to provide physicians with information that could help alleviate their concerns about approaching parents for consent. Of 339 parents who agreed to answer questions after being given details of their child''s "death" 288 (85%) said that they would be willing to donate their child''s organs. The degree of willingness was associated with the certainty of death, altruism and empathy toward children in need of an organ, previous discussion of organ donation with a family member and knowledge of an adolescent or adult child''s attitude toward donation. Factors that inhibited the intention to donate included uncertainty of death, insufficient information from medical professionals and fear of multilation. The child''s age was not significantly associated with intention to donate. Concordance between the results and actual donation rates in Canada and the United States supports the generalizability of the survey findings.