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OBJECTIVE Little is known about changes in alcohol and cannabis co-use over time in adolescents and young adults. We sought to describe the natural course of alcohol and cannabis co-use from age 12 to 17 and 20 to 31 and to describe frequent (i.e., ≥ once/month) binge drinking (i.e., ≥ 5 drinks/occasion) and cannabis use from age 20 to 31. METHOD Data were drawn from two longitudinal studies conducted in Montreal, Canada: AdoQuest (n = 1,852) and the Nicotine Dependence in Teens (NDIT) study (n = 1,293). Complete data on alcohol and cannabis were available for 620 12-17-year-olds (58% female) followed from 2005 to 2011 in AdoQuest, and 673 20-31-year-olds (56% female) followed from 2007 to 2020 in NDIT. We reported proportions of co-use, exclusive drinking ("drinking"), exclusive cannabis use ("cannabis use"), frequent co-use, frequent binge drinking, and frequent cannabis use by age and sex. RESULTS Co-use rose from 2% at age 12-13 to 23% at age 17, was stable at 44% at age 20 and 24, and then decreased to 37% at age 31. Drinking rose from 20% to 51%, and cannabis use was consistently rare (< 2%). During young adulthood, frequent co-use declined from 21% at age 20 to 12% at age 31, and frequent binge drinking declined from 29% at age 20 to 22% at age 31. Frequent cannabis use increased from 6% at age 20 to 11% at age 31. CONCLUSIONS Alcohol and cannabis use should be studied as time-varying behaviors. Co-use patterns should be monitored over time in this population. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background Osteoarthritis-related insomnia is the most common form of comorbid insomnia among older Americans. A randomized clinical trial found that six sessions of telephone-delivered cognitive behavioral therapy for insomnia (CBT-I) improved sleep outcomes in this population. Using these data, we evaluated the incremental cost-effectiveness of CBT-I from a healthcare sector perspective. Methods The study was based on 325 community-dwelling older adults with insomnia and osteoarthritis pain enrolled with Kaiser Permanente of Washington State. We measured quality-adjusted life years (QALYs) using the EuroQol 5-dimension scale. Arthritis-specific quality of life was measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Insomnia-specific quality of life was measured using the Insomnia Severity Index (ISI) and nights without clinical insomnia (i.e., "insomnia-free nights"). Total healthcare costs included intervention and healthcare utilization costs. Results Over the 12 months after randomization, CBT-I improved ISI and WOMAC by -2.6 points (95% CI: -2.9 to -2.4) and -2.6 points (95% CI: -3.4 to -1.8), respectively. The ISI improvement translated into 89 additional insomnia-free nights (95% CI: 79 to 98) over the 12 months. CBT-I did not significantly reduce total healthcare costs (-$1072 [95% CI: -$1968 to $92]). Improvements in condition-specific measures were not reflected in QALYs gained (-0.01 [95% CI: -0.01 to 0.01]); at a willingness-to-pay of $150,000 per QALY, CBT-I resulted in a positive net monetary benefit of $369 with substantial uncertainty (95% CI: -$1737 to $2270). Conclusion CBT-I improved sleep and arthritis function without increasing costs. These findings support the consideration of telephone CBT-I for treating insomnia among older adults with comorbid OA. Our findings also suggest potential limitations of the general quality of life measures in assessing interventions designed to improve sleep and arthritis outcomes.

Given the dangers posed by tobacco use and tobacco smoke exposure, pediatricians should address tobacco use and exposure with patients and parents at every opportunity, but this is not consistently done in practice. One reason may be that many medical residents do not receive education on how to address tobacco use and tobacco smoke exposure with patients and their parents. In a 2012 survey of U.S. pediatric program directors, 65% of programs reported covering tobacco control in their curricula, but most training programs focused on tobacco's health effects and not intervention strategies for clinical practice. Since that survey, electronic health records have been implemented broadly nationwide and utilized to address tobacco smoke exposure. Investigators surveyed U.S. program directors in 2018 and residents in 2019 to explore the ways in which the residents learn about tobacco use and tobacco smoke exposure, components and use of the electronic record specific to tobacco use and tobacco smoke exposure, and perceived resident effectiveness in this area. All the program directors and 85% of the residents valued training, but 21% of the residents reported receiving none. Moreover, a minority of the residents assessed themselves as effective at counseling parents (19%) or adolescents (23%), and their perceived effectiveness was related to small group learning and active learning workshops, modalities that were infrequently implemented in training. Respondents also reported infrequent use of electronic health record prompts regarding tobacco and the absence of prompts about critical issues (e.g., addressing tobacco smoke exposure in vehicles or other settings or offering treatment or referrals to parents who smoke). This paper provides recommendations about augmenting pediatric resident training in simple ways.

Supplemental Digital Content is available in the text., We use simulated data to examine the consequences of depletion of susceptibles for hazard ratio (HR) estimators based on a propensity score (PS). First, we show that the depletion of susceptibles attenuates marginal HRs toward the null by amounts that increase with the incidence of the outcome, the variance of susceptibility, and the impact of susceptibility on the outcome. If susceptibility is binary then the Bross bias multiplier, originally intended to quantify bias in a risk ratio from a binary confounder, also quantifies the ratio of the instantaneous marginal HR to the conditional HR as susceptibles are depleted differentially. Second, we show how HR estimates that are conditioned on a PS tend to be between the true conditional and marginal HRs, closer to the conditional HR if treatment status is strongly associated with susceptibility and closer to the marginal HR if treatment status is weakly associated with susceptibility. We show that associations of susceptibility with the PS matter to the marginal HR in the treated (ATT) though not to the marginal HR in the entire cohort (ATE). Third, we show how the PS can be updated periodically to reduce depletion-of-susceptibles bias in conditional estimators. Although marginal estimators can hit their ATE or ATT targets consistently without updating the PS, we show how their targets themselves can be misleading as they are attenuated toward the null. Finally, we discuss implications for the interpretation of HRs and their relevance to underlying scientific and clinical questions. See video Abstract: http://links.lww.com/EDE/B727.

In a primary care population of 327 older adults (age 60+) with chronic osteoarthritis (OA) pain and insomnia, we examined the relationship between short-term improvement in sleep or pain and long-term sleep, pain, depression, and fatigue by secondary analyses of randomized controlled trial data. Study participants, regardless of trial arm, were classified as Sleep or Pain Improvers with ≥30% baseline to 2-month reduction on the Insomnia Severity Index or the Brief Pain Inventory, respectively, or Sleep or Pain Non-Improvers. After controlling for trial arm and potential confounders, both Sleep and Pain Improvers showed significant (p < .01) sustained improvements across 12 months compared to respective Non-Improvers for the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index, Brief Pain Inventory-short form (total, Interference, and Severity subscales), Patient Health Questionnaire, and Flinders Fatigue Scale. The effect sizes (Cohen’s f2) for the sustained benefits in both Sleep and Pain Improvers compared to their respective Non-Improvers for all variables were small ( Trial Registration: OsteoArthritis and Therapy for Sleep (OATS) NCT02946957: https://clinicaltrials.gov/ct2/show/NCT02946957.

Background Young adulthood is characterized by major life changes that can promote or inhibit cigarette smoking. Gaps in knowledge on the natural course of, and factors associated with quitting impede progress in designing effective cessation interventions targeting this age group. We describe the natural course of cessation among students who smoked cigarettes in their last year of high school and we identify predictors of quit status at age 30. Methods Data were drawn from an ongoing investigation of 1294 grade 7 students age 12-13 recruited in 1999-2000 in 10 high schools in Montreal, Canada. Using data collected at ages 17, 20, 24 and 30, grade 11 cigarette smokers were categorized as quitters or current smokers at age 30. Results Among 245 grade 11 smokers, 48% (55% of females; 33% of males) had quit by age 30. Among 106 quitters with complete data, 27% were consistently abstinent during young adulthood, 33% were intermittently abstinent and 40% were abstinent at age 30 only. Smokers at age 30 had higher impulsivity scores in grade 11 than quitters and were more likely to report nicotine dependence symptoms and have family members who smoked. Quitters rated self-control and social influences as more important reasons to quit than smokers. Although 85% of smokers wanted to quit, only 45% had used a cessation strategy in the past year. Conclusions Adolescents likely to be smokers at age 30 are identifiable in high school. Cessation assistance must be offered early in high school to provide adolescents with opportunities to quit before smoking becomes intractable. Key messages Among grade 11 smokers, 27% were consistently abstinent in young adulthood, 33% were intermittently abstinent, and 40% were abstinent at age 30 only. Cessation programs are needed early in high school to prevent intractable smoking.

ObjectivesWe compared discrete time measures with trajectories of adolescent drinking frequency as predictors of sustained binge drinking in young adulthood.DesignProspective longitudinal study.Setting10 high schools in Montréal, Canada.Participants1293 high-school students followed from mean (SD) age 12 (0.6) to 24 (0.7) years.Primary outcome measuresPatterns of drinking frequency (self-reports every 3 months from ages 12 to 17) identified using group-based trajectory modelling. Sustained binge drinking was defined as binging monthly or more often at both ages 20 and 24.AnalysesUsing logistic regression, sustained binge drinking was regressed on trajectory group membership and on four discrete time measures (frequency of drinking at age 12; frequency of drinking at age 17; age at drinking onset; age at onset of drinking monthly or more often).ResultsWe identified seven drinking trajectories: late triers (15.2%), decreasers (9.5%), late escalators (10.4%), early slow escalators (16.5%), steady drinkers (14.4%), early rapid escalators (15.8%) and early frequent drinkers (18.2%). Sustained binge drinking was reported by 260 of 787 participants (33.0%) with complete data at both ages 20 and 24. Decreasers did not differ from late triers; all other patterns were associated with higher odds of sustained binge drinking (adjusted ORs: AORs=1.4–17.0). All discrete time measures were associated with sustained binge drinking, notably frequency at age 12 (a bit to try and drinking monthly: (AORs=2.6 (1.7; 3.9) and 2.8 (1.3; 6.1), respectively), age of drinking onset ConclusionYouth at risk of sustained binge drinking as young adults can be identified with indicators of early drinking as early as 7th grade (aged 12–13 years). Identification of easy-to-obtain indicators can facilitate screening and intervention efforts.

Sengwee Toh,1 Robert Wellman,2 R Yates Coley,2 Casie Horgan,1 Jessica Sturtevant,1 Erick Moyneur,3 Cheri Janning,4 Roy Pardee,2 Karen J Coleman,5 David Arterburn,2 Kathleen McTigue,6 Jane Anau,2 Andrea J Cook2 On behalf of the PCORnet Bariatric Study Collaborative 1Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA; 2Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA; 3StatLog Econometrics, Inc., Montreal, QC, Canada; 4Duke Clinical and Translational Science Institute, Durham, NC, USA; 5Kaiser Permanente Southern California, Pasadena, CA, USA; 6Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA Purpose: Sharing of detailed individual-level data continues to pose challenges in multicenter studies. This issue can be addressed in part by using analytic methods that require only summary-level information to perform the desired multivariable-adjusted analysis. We examined the feasibility and empirical validity of 1) conducting multivariable-adjusted distributed linear regression and 2) combining distributed linear regression with propensity scores, in a large distributed data network.Patients and methods: We compared percent total weight loss 1-year postsurgery between Roux-en-Y gastric bypass and sleeve gastrectomy procedure among 43,110 patients from 36 health systems in the National Patient-Centered Clinical Research Network. We adjusted for baseline demographic and clinical variables as individual covariates, deciles of propensity scores, or both, in three separate outcome regression models. We used distributed linear regression, a method that requires only summary-level information (specifically, sums of squares and cross products matrix) from sites, to fit the three ordinary least squares linear regression models. A comparison set of analyses that used pooled deidentified individual-level data from sites served as the reference.Results: Distributed linear regression produced results identical to those from the corresponding pooled individual-level data analysis for all variables in all three models. The maximum numericaldifference in the parameter estimate or standard error for all the variables was 3×10−11 across three models.Conclusion: Distributed linear regression analysis is a feasible and valid analytic method in multicenter studies for one-time continuous outcomes. Combining distributed regression with propensity scores via modeling offers more privacy protection and analytic flexibility. Keywords: distributed regression, propensity score, distributed data networks, privacy-protecting methods

There may be sex differences in the response to nicotine, according to findings of studies in animals; however, sex differences in the natural course of cigarette smoking and nicotine dependence are documented in few studies. Prevalent (n = 240 girls; n = 184 boys) and incident (n = 231 girls; n = 184 boys) cigarette smokers from the Nicotine Dependence in Teens Study were followed up to 5 years after first puff, from age 12 to 18 years (1999-2005). We used Cox proportional hazards models to compare time to development of 3 cigarette-use (i.e., whole cigarette; 100 cigarettes lifetime; regular smoking), and 3 nicotine-dependence symptom (i.e., "really need a cigarette"; mentally addicted; physically addicted) milestones across sex. Girls were at higher risk than boys of attaining all milestones; hazard ratios (95% confidence intervals) ranged from 1.35 (1.06, 1.72) for 100 cigarettes lifetime to 1.74 (1.44, 2.10) for "really need a cigarette." Among nonregular smokers, 26% (8%; 43%) and 25% (6%; 44%) more girls than boys reported "really need a cigarette" 1 and 2 years, respectively, after first puff. Preventive interventions may need adjustment to incorporate these findings. Additional research should clarify the relative contribution of biological and social underpinnings of these sex differences.

Background Although most young adult smokers want to quit smoking, few can do so successfully. Increased understanding of reasons to quit in this age group could help tailor interventions, but few studies document reasons to quit in young adults or examine reasons to quit by smoker characteristics. Methods In 2011–12, 311 current smokers (age 22–28, M = 24.1; 48.9% male, 51.1% female; 50.4% daily smokers) from the Nicotine Dependence in Teens Study completed the Adolescent Reasons for Quitting scale. We assessed differences in the importance of 15 reasons to quit by sex, education, smoking frequency, quit attempt in the past year, perceived difficulty in quitting, and motivation to quit. We also examined differences between participants who discounted the importance of long-term health risks and those who acknowledged such risks. Results Concerns about getting sick or still smoking when older were considered very important by > 70% of participants. Median scores were higher among daily smokers, those who had tried to quit or who expressed difficulty quitting, and those with strong motivation to quit. Discounters (14.5% of participants) were primarily nondaily, low-consumption smokers. Their Fagerstrom Test for Nicotine Dependence scores did not differ from non-discounters', and 11% (vs. 35.7% of non-discounters) were ICD-10 tobacco dependent. Conclusions Novel smoking cessation interventions are needed to help young adult smokers quit by capitalizing on their health concerns. Discounters may need educational intervention to better understand the impact of even “light” smoking on their health before or in conjunction with quit interventions.

Despite limited evidence on the association between physical activity (PA) and blood pressure (BP) in youth, experts recommend that adolescents engage regularly in moderate-to-vigorous PA. We examined the relationships between PA intensity and frequency and the likelihood of having high BP in a population-based cohort of adolescents from Montreal, Canada. PA was self-reported every 3 months from grade 7 to 11, and BP was measured at ages 12.8, 15.2, and 17.0 years on average. We analyzed data from 993 participants (mean [SD] age = 16.0 [1.0], 51.6% female) with BP data at ages 15.2 and/or 17.0 years, using pooled ordinal logistic regression. BP (normal/elevated/hypertensive range) was the outcome, and past-year PA intensity and frequency were potential predictors. Eight percent of participants had elevated BP (120-129/

OBJECTIVE: In Canada, the home has become the primary locale in which children are exposed to tobacco smoke. Single parents are less likely than two-parent families to ban smoking at home, but the extent to which this relates to economic inequalities across family structures is unclear. Our objective was to estimate the association between household structure (single- vs. non-single-parent family) and smoke-free home rules, accounting for indicators of economic disadvantage. METHODS: Data were available in a telephone survey conducted in 2011–2012 in Québec, Canada, of 567 daily smokers (mean (SD) age 38.3 (8.1); 56.6% female) who lived with children. Poisson regression models with robust variance were used to determine whether single-parent status was independently associated with living in a smoke-free home after accounting for age, sex, language, household size, age of youngest child, neighbourhood material deprivation, socio-economic status and employment status. RESULTS: Of 122 participants living in a single-parent family, 33 (27%) reported that their home was smoke-free, compared with 250 of 445 participants (56.2%) living in non-single-parent families. Single parents were approximately 40% less likely to live in smoke-free homes than other daily smokers, even after accounting for indicators of economic disadvantage. CONCLUSIONS: Single parents, regardless of income or level of neighbourhood material deprivation, were less likely to report smoke-free home rules. These smokers represent a distinct subgroup that warrants targeted interventions to help them implement such rules by addressing their specific needs against a backdrop of creating more equitable access to the social determinants of health.

Purpose In young people, alcohol consumption and depressive symptoms are related, but the temporal ordering of the relationship is an open question. Previous studies have not disaggregated influences of interindividual and intraindividual components affecting the relationship. We investigated whether a reciprocal relationship between frequency of alcohol use and depressive symptoms exists in the general population of adolescents after removing interindividual influences. Methods A total of 1,293 Canadian adolescents provided data on depressive symptoms and frequency of alcohol use every 3 months from grade 7 to 11 (1999–2005) for a total of 20 cycles. We used latent curve models with structured residuals, which disaggregate interindividual and intraindividual components to assess the directionality of the relationship. Results Both drinking frequency and depressive symptoms increased linearly and quadratically over time, with significant interindividual variation around the origin and rate of change. Intercepts and slopes for drinking frequency and depressive symptoms differed by sex and age. After controlling for sex, age, maternal education, sensation seeking, impulsivity and clustering by school, a significant positive association was observed between depressive symptoms and drinking frequency 3 months later (.032 [.004, .060]; p = .024), but no association was observed between drinking frequency and subsequent depressive symptoms (.011 [−.006 to .029]; p = .193). Conclusions Our data provide longitudinal evidence that changes in depressive symptoms exceeding one's “normal” level predict increases in drinking frequency. This suggests that teaching youth to recognize and cope with mood changes would be worthwhile.

The OsteoArthritis and Therapy for Sleep (OATS) study is a population-based randomized controlled trial of cognitive behavioral therapy for insomnia (CBTI) with four innovative methodological aims. These are to: (1) Enroll representative participants across Washington state, including those from medically underserved communities; (2) Enroll persons with persistent insomnia and chronic osteoarthritis (OA) pain; (3) Test a scalable CBT-I intervention; and (4) Evaluate patient-reported outcomes (insomnia, pain severity, fatigue, depression) and cost-effectiveness over one year. This paper describes progress towards achieving these aims. The target population was persons age 60+ who had received OA care within the Kaiser Permanente Washington (KPW) health care system. We employed a two-phase screening via mail survey and telephone follow-up, with a 3-week interval between screens to exclude persons with spontaneous improvement in sleep or pain symptoms. Participants were randomized to a 6-session telephone-delivered CBT-I intervention or a 6-session telephone education only control condition (EOC). Blinded outcome assessments (completed online or on mailed paper forms) included primary and secondary sleep and pain outcome measures and quality of life measures. We obtained healthcare utilization from administrative claims data. Intent to treat analyses, including all participants randomized when they scheduled the first telephone session, will be conducted to compare CBT-I and EOC outcomes. The trial will be the largest experimental evaluation of telephone CBT-I to date, and the first to evaluate its cost-effectiveness. Trial registration: ClinicalTrials.gov identifier: NCT02946957.

IMPORTANCE: Scalable delivery models of cognitive behavioral therapy for insomnia (CBT-I), an effective treatment, are needed for widespread implementation, particularly in rural and underserved populations lacking ready access to insomnia treatment. OBJECTIVE: To evaluate the effectiveness of telephone CBT-I vs education-only control (EOC) in older adults with moderate to severe osteoarthritis pain. DESIGN, SETTING, AND PARTICIPANTS: This is a randomized clinical trial of 327 participants 60 years and older who were recruited statewide through Kaiser Permanente Washington from September 2016 to December 2018. Participants were double screened 3 weeks apart for moderate to severe insomnia and osteoarthritis (OA) pain symptoms. Blinded assessments were conducted at baseline, after 2 months posttreatment, and at 12-month follow-up. INTERVENTIONS: Six 20- to 30-minute telephone sessions provided over 8 weeks. Participants submitted daily diaries and received group-specific educational materials. The CBT-I instruction included sleep restriction, stimulus control, sleep hygiene, cognitive restructuring, and homework. The EOC group received information about sleep and OA. MAIN OUTCOMES AND MEASURES: The primary outcome was score on the Insomnia Severity Index (ISI) at 2 months posttreatment and 12-month follow-up. Secondary outcomes included pain (score on the Brief Pain Inventory-short form), depression (score on the 8-item Patient Health Questionnaire), and fatigue (score on the Flinders Fatigue Scale). RESULTS: Of the 327 participants, the mean (SD) age was 70.2 (6.8) years, and 244 (74.6%) were women. In the 282 participants with follow-up ISI data, the total 2-month posttreatment ISI scores decreased 8.1 points in the CBT-I group and 4.8 points in the EOC group, an adjusted mean between-group difference of −3.5 points (95% CI, −4.4 to −2.6 points; P

Context The onset of cigarette smoking typically occurs during childhood or early adolescence. Nicotine dependence symptoms can manifest soon after onset, contributing to sustained, long-term smoking. Previous reviews have not clarified the determinants of onset. Evidence acquisition In 2015, a systematic review of the literature in PubMed and EMBASE was undertaken to identify peer-reviewed prospective longitudinal studies published between January 1984 and August 2015 that investigated predictors of cigarette smoking onset among youth aged Evidence synthesis Ninety-eight conceptually different potential predictors were identified in 53 studies. An increased risk of smoking onset was consistently (i.e., in four or more studies) associated with increased age/grade, lower SES, poor academic performance, sensation seeking or rebelliousness, intention to smoke in the future, receptivity to tobacco promotion efforts, susceptibility to smoking, family members' smoking, having friends who smoke, and exposure to films, whereas higher self-esteem and high parental monitoring/supervision of the child appeared to protect against smoking onset. Methodologic weaknesses were identified in numerous studies, including failure to account for attrition or for clustering in samples, and misidentification of potential confounders, which may have led to biased estimates of associations. Conclusions Predictors of smoking onset for which there is robust evidence should be considered in the design of interventions to prevent first puff in order to optimize their effectiveness. Future research should seek to define onset clearly as the transition from never use to first use (e.g., first few puffs).

Background Whether polytobacco use or nicotine dependence (ND) change when cigarette smoking status changes in young adults is an understudied issue. Our objective was to describe use of other tobacco products (OTPs) and ND according to change in cigarette smoking status over four years in young adults. Methods We drew data from a longitudinal study of 1294 adolescents age 12–13 at inception in 1999–2000 and followed into young adulthood. Among 790 participants with data at age 20 and 24, 22% had never smoked cigarettes; 37% were “sustained smokers”; 9% were “relapsers”; 10% had quit 1–3 years ago; and 22% had quit ≥4 years ago. We described past-year OTP (i.e., cigars/cigarillos, waterpipe, sundry tobacco products (i.e., pipe, bidis, chewing tobacco, snuff)) use and ND over 4 years in these groups. Results At age 20, sustained smokers reported using a mean(SD) of 1.1(0.9) OTP in the past-year; relapsers reported 0.5(0.6); shorter-term quitters reported 0.9(0.7); longer-term quitters reported 0.3(0.6); and never smokers reported 0.2(0.4). There was no change in OTP use or ND in never smokers and longer-term quitters. Shorter-term quitters reduced the number of OTPs by −0.5(95% confidence interval: −0.7,−0.3) on average over 4 years; sustained smokers decreased by −0.2(−0.3,−0.1). Relapsers increased by 0.6(0.4,0.7) on average. Conclusions OTP use and ND were stable in early adulthood among never smokers, sustained smokers and longer-term quitters, but fluctuated in parallel with stopping and starting to smoke. Research is needed to ascertain the underpinnings of these fluctuations and whether they help or hinder cessation.

Importance Bariatric surgery can lead to substantial improvements in type 2 diabetes (T2DM), but outcomes vary across procedures and populations. It is unclear which bariatric procedure has the most benefits for patients with T2DM. Objective To evaluate associations of bariatric surgery with T2DM outcomes. Design, Setting, and Participants This cohort study was conducted in 34 US health system sites in the National Patient-Centered Clinical Research Network Bariatric Study. Adult patients with T2DM who had bariatric surgery between January 1, 2005, and September 30, 2015, were included. Data analysis was conducted from April 2017 to August 2019. Interventions Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Main Outcome and Measures Type 2 diabetes remission, T2DM relapse, percentage of total weight lost, and change in glycosylated hemoglobin (hemoglobin A1c). Results A total of 9710 patients were included (median [interquartile range] follow-up time, 2.7 [2.9] years; 7051 female patients [72.6%]; mean [SD] age, 49.8 [10.5] years; mean [SD] BMI, 49.0 [8.4]; 6040 white patients [72.2%]). Weight loss was significantly greater with RYGB than SG at 1 year (mean difference, 6.3 [95% CI, 5.8-6.7] percentage points) and 5 years (mean difference, 8.1 [95% CI, 6.6-9.6] percentage points). The T2DM remission rate was approximately 10% higher in patients who had RYGB (hazard ratio, 1.10 [95% CI, 1.04-1.16]) than those who had SG. Estimated adjusted cumulative T2DM remission rates for patients who had RYGB and SG were 59.2% (95% CI, 57.7%-60.7%) and 55.9% (95% CI, 53.9%-57.9%), respectively, at 1 year and 86.1% (95% CI, 84.7%-87.3%) and 83.5% (95% CI, 81.6%-85.1%) at 5 years postsurgery. Among 6141 patients who experienced T2DM remission, the subsequent T2DM relapse rate was lower for those who had RYGB than those who had SG (hazard ratio, 0.75 [95% CI, 0.67-0.84]). Estimated relapse rates for those who had RYGB and SG were 8.4% (95% CI, 7.4%-9.3%) and 11.0% (95% CI, 9.6%-12.4%) at 1 year and 33.1% (95% CI, 29.6%-36.5%) and 41.6% (95% CI, 36.8%-46.1%) at 5 years after surgery. At 5 years, compared with baseline, hemoglobin A1cwas reduced 0.45 (95% CI, 0.27-0.63) percentage points more for patients who had RYGB vs patients who had SG. Conclusions and Relevance In this large multicenter study, patients who had RYGB had greater weight loss, a slightly higher T2DM remission rate, less T2DM relapse, and better long-term glycemic control compared with those who had SG. These findings can help inform patient-centered surgical decision-making.

Background There has been a dramatic shift in use of bariatric procedures, but little is known about their long-term comparative effectiveness. Objective To compare weight loss and safety among bariatric procedures. Design Retrospective observational cohort study, January 2005 to September 2015. (ClinicalTrials.gov: NCT02741674). Setting 41 health systems in the National Patient-Centered Clinical Research Network. Participants 65 093 patients aged 20 to 79 years with body mass index (BMI) of 35 kg/m2 or greater who had bariatric procedures. Intervention 32 208 Roux-en-Y gastric bypass (RYGB), 29 693 sleeve gastrectomy (SG), and 3192 adjustable gastric banding (AGB) procedures. Measurements Estimated percent total weight loss (TWL) at 1, 3, and 5 years; 30-day rates of major adverse events. Results Total numbers of eligible patients with weight measures at 1, 3, and 5 years were 44 978 (84%), 20 783 (68%), and 7159 (69%), respectively. Thirty-day rates of major adverse events were 5.0% for RYGB, 2.6% for SG, and 2.9% for AGB. One-year mean TWLs were 31.2% (95% CI, 31.1% to 31.3%) for RYGB, 25.2% (CI, 25.1% to 25.4%) for SG, and 13.7% (CI, 13.3% to 14.0%) for AGB. At 1 year, RYGB patients lost 5.9 (CI, 5.8 to 6.1) percentage points more weight than SG patients and 17.7 (CI, 17.3 to 18.1) percentage points more than AGB patients, and SG patients lost 12.0 (CI, 11.6 to 12.5) percentage points more than AGB patients. Five-year mean TWLs were 25.5% (CI, 25.1% to 25.9%) for RYGB, 18.8% (CI, 18.0% to 19.6%) for SG, and 11.7% (CI, 10.2% to 13.1%) for AGB. Patients with diabetes, those with BMI less than 50 kg/m2, those aged 65 years or older, African American patients, and Hispanic patients lost less weight than patients without those characteristics. Limitation Potential unobserved confounding due to nonrandomized design; electronic health record databases had missing outcome data. Conclusion Adults lost more weight with RYGB than with SG or AGB at 1, 3, and 5 years; however, RYGB had the highest 30-day rate of major adverse events. Small subgroup differences in weight loss outcomes were observed. Primary funding source Patient-Centered Outcomes Research Institute.

BACKGROUND: The STarT Back strategy for categorizing and treating patients with low back pain (LBP) improved patients’ function while reducing costs in England. OBJECTIVE: This trial evaluated the effect of implementing an adaptation of this approach in a US setting. DESIGN: The Matching Appropriate Treatments to Consumer Healthcare needs (MATCH) trial was a pragmatic cluster randomized trial with a pre-intervention baseline period. Six primary care clinics were pair randomized, three to training in the STarT Back strategy and three to serve as controls. PARTICIPANTS: Adults receiving primary care for non-specific LBP were invited to provide data 2 weeks after their primary care visit and follow-up data 2 and 6 months (primary endpoint) later. INTERVENTIONS: The STarT Back risk-stratification strategy matches treatments for LBP to physical and psychosocial obstacles to recovery using patient-reported data (the STarT Back Tool) to categorize patients’ risk of persistent disabling pain. Primary care clinicians in the intervention clinics attended six didactic sessions to improve their understanding LBP management and received in-person training in the use of the tool that had been incorporated into the electronic health record (EHR). Physical therapists received 5 days of intensive training. Control clinics received no training. MAIN MEASURES: Primary outcomes were back-related physical function and pain severity. Intervention effects were estimated by comparing mean changes in patient outcomes after 2 and 6 months between intervention and control clinics. Differences in change scores by trial arm and time period were estimated using linear mixed effect models. Secondary outcomes included healthcare utilization. KEY RESULTS: Although clinicians used the tool for about half of their patients, they did not change the treatments they recommended. The intervention had no significant effect on patient outcomes or healthcare use. CONCLUSIONS: A resource-intensive intervention to support stratified care for LBP in a US healthcare setting had no effect on patient outcomes or healthcare use. TRIAL REGISTRATION: National Clinical Trial Number NCT02286141.

Introduction We investigated whether secondhand smoke (SHS) exposure is associated with depressive symptoms in a population-based sample of children. Methods Never-smoking students from 29 French-language elementary schools in Greater Montreal, Canada, were followed from 5th to 11th grade (2005-2011) in five waves: 1 (5th grade), 2 (spring 6th grade), 3 (7th grade), 4 (9th grade), and 5 (11th grade). Associations between depressive symptoms and SHS exposure at home and in cars were examined in cross-sectional and longitudinal gamma generalized regression models adjusted for sex, maternal education, and neighborhood socioeconomic status. Results The sample comprised 1553 baseline never-smokers (mean [SD] age = 10.7 [0.5] years; 44% male; 89% French-speaking). SHS exposure at home and in cars was associated with higher depressive symptom scores in cross-sectional analyses pooled across grades and adjusted for demographics (B [95% confidence interval (CI)] = 0.041 [0.017 to 0.068] for home exposure; 0.057 [0.030 to 0.084] for car exposure). In longitudinal analyses from fifth to sixth grade, B (95% CI), adjusted for demographics and baseline depressive symptoms, was 0.042 (0.003 to 0.080) for home exposure and 0.061 (0.019 to 0.103) for car exposure. From sixth to seventh grade, B (95% CI) was 0.057 (0.003 to 0.110) for home exposure and 0.074 (0.015 to 0.133) for car exposure. SHS exposure at any age did not predict depressive symptoms 2 years later. Conclusions SHS exposure is associated with depressive symptoms in young persons, both concurrently and 1 year later. This finding adds to the evidence base supporting that children should be protected from SHS exposure. Implications SHS exposure has deleterious effects on physical health and results of this study raise concerns that such exposure might also affect the mental health of young persons. Clearly, protecting children from SHS in all locations is a critical public health priority. Although research is needed to determine if the association between SHS exposure and depressive symptoms is causal, continued implementation of smoking bans and educational efforts to discourage smoking in vehicles when children are present are warranted.

Introduction The Autonomy over Tobacco Scale (AUTOS), a 12-item self-administered questionnaire, was designed to measure autonomy in three correlated lower-order symptom domains: withdrawal, psychological dependence, and cue-induced craving. The factor structure of the AUTOS remains an open question; confirmatory analyses in adolescents supported the hierarchical structure, while exploratory analyses in adolescents and adults yield single-factor solutions. Here we seek to determine whether the hypothesized hierarchical structure is valid in adult smokers. Methods The AUTOS was administered to two independent convenience samples of adult current smokers: a calibration sample recruited in the US for online studies, and a confirmation sample drawn from the prospective Nicotine Dependence in Teens study in Montreal. We tested competing hierarchical and single-factor models using the robust weighted least-squares (WLSMV) estimation method. Results A single-factor model that allowed correlated error variances between theoretically related items fit well in the calibration sample ( n = 434), χ 2 SB (52) = 165.71; χ 2 / df = 3.19; SRMR = 0.03; CFI = 0.96; NNFI = 0.95; RMSEA = 0.07 (95% CI: 0.06, 0.08). Reliability of the single factor was high (ω B = 0.92) and construct validity was adequate. In the confirmation sample ( n = 335), a similar model fit well:χ 2 SB (53) = 126.94; χ 2 /df = 2.44; SRMR = 0.04; CFI = 0.95; NNFI = 0.93; RMSEA = 0.07 (95% CI: 0.05, 0.08). Reliability of the single factor was again high (ω B = 0.92) and construct validity was adequate. Conclusion The AUTOS is unidimensional in adult smokers.

The Autonomy over Tobacco Scale (AUTOS) is composed of 12-symptoms of nicotine dependence. While it has demonstrated excellent reliability and validity, several psychometric properties have yet to be investigated. We aimed to determine (1) whether items functioned differently across demographic groups, (2) the likelihood that individual symptoms would be endorsed by smokers at different levels of diminished autonomy, and (3) the degree of information provided by each item and the reliability of the full AUTOS across the range of diminished autonomy.Data for this study come from two convenience samples of American adult current smokers (n=777; 69% female; 88% white; Mage=34 years, range: 18-78), of whom 66% were daily smokers (Mcigarettes/smoking day=10.1, range:1-70). Participants completed the AUTOS online as part of "a research study about the experiences people have when they smoke."After p value correction, items remained invariant across sex and minority status, while two items functioned differently according to age, with minimal impact on the total AUTOS score. Discriminative power of the items was high. The greatest amount of information is provided at just under one-half SD above the mean and the least at the extremes of diminished autonomy. The AUTOS maintains acceptable reliability (0.70) across the range of diminished autonomy within which more than 95% of smokers' scores could be anticipated to fall.The AUTOS is a versatile and psychometrically sound instrument for measuring the loss of autonomy over tobacco use.

Background Bariatric surgery has been used for treatment of severe obesity in adolescents but most studies have been small and limited in follow-up. Objectives We hypothesized that electronic health record data could be used to compare effectiveness of bariatric procedures in adolescents. Setting Data were obtained from clinical research networks using a common data model to extract data from each site. Methods Adolescents who underwent a primary bariatric procedure from 2005 through 2015 were identified. The percent change in body mass index (BMI) at 1, 3, and 5 years was estimated using random effects linear regression for patients undergoing all operations. Propensity score adjusted estimates and 95% confidence intervals were estimated for procedures with >25 patients at each time period. Results This cohort of 544 adolescents was predominantly female (79%) and White (66%), with mean (±standard deviation) age of 17.3 (±1.6) years and mean BMI of 49.8 (± 7.8) kg/m2. Procedures included Roux-en-Y gastric bypass (RYGB; n = 177), sleeve gastrectomy (SG; n = 306), and laparoscopic adjustable gastric banding (n = 61). For those undergoing RYGB, SG, and laparoscopic adjustable gastric banding, mean (95% confidence interval) BMI changes of −31% (−30% to −33%), −28% (−27% to −29%), and −10% (−8% to −12%), were estimated at 1 year. For RYGB and SG, BMI changes of −29% (−26% to −33%) and −25% (−22% to −28%) were estimated at 3 years. Conclusions Adolescents undergoing SG and RYGB experienced greater declines in BMI at 1- and 3-year follow-up time points, while laparoscopic adjustable gastric banding was significantly less effective for BMI reduction. (Surg Obes Relat Dis 2018;000:1–13.)

To investigate whether the prevalence or co-occurrence of risk factors for cigarette smoking initiation differ by socioeconomic status (SES) and whether SES interacts with risk factors to increase initiation. In 2005, 1451 5th grade never smokers (mean age 10.7 years) in Montreal, Canada, provided baseline data, with follow-up in 6th and/or 7th grade (2005–2007). Poisson regression analyses estimated the association between 13 risk factors and initiation. Excess risk of each risk factor in low vs. moderate–high SES participants was assessed. Cigarette smoking was initiated by 9.4% of participants (n = 137). Low SES was associated with a higher prevalence and co-occurrence of risk factors. The estimated association of most risk factors with initiation was similar across SES, although participants from low SES neighborhoods whose mothers had no university education had three times the risk of initiation [ARR = 3.10 (1.19, 8.08)] compared to more affluent peers. Tobacco control efforts must address the higher prevalence and co-occurrence of risk factors in lower SES contexts since these may render initiation highly probable in many lower SES youth.

Importance Additional data comparing longer-term problems associated with various bariatric surgical procedures are needed for shared decision-making. Objective To compare the risks of intervention, operation, endoscopy, hospitalization, and mortality up to 5 years after 2 bariatric surgical procedures. Design, Setting, and Participants Adults who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between January 1, 2005, and September 30, 2015, within the National Patient-Centered Clinical Research Network. Data from 33 560 adults at 10 centers within 4 clinical data research networks were included in this cohort study. Information was extracted from electronic health records using a common data model and linked to insurance claims and mortality indices. Analyses were conducted from January 2018 through October 2019. Exposures Bariatric surgical procedures. Main Outcomes and Measures The primary outcome was time until operation or intervention. Secondary outcomes included endoscopy, hospitalization, and mortality rates. Results Of 33 560 adults, 18 056 (54%) underwent RYGB, and 15 504 (46%) underwent SG. The median (interquartile range) follow-up for operation or intervention was 3.4 (1.6-5.0) years for RYGB and 2.2 (0.9-3.6) years for SG. The overall mean (SD) patient age was 45.0 (11.5) years, and the overall mean (SD) patient body mass index was 49.1 (7.9). The cohort was composed predominantly of women (80%) and white individuals (66%), with 26% of Hispanic ethnicity. Operation or intervention was less likely for SG than for RYGB (hazard ratio, 0.72; 95% CI, 0.65-0.79;P Conclusions and Relevance Interventions, operations, and hospitalizations were relatively common after bariatric surgical procedures and were more often associated with RYGB than SG. Trial Registration ClinicalTrials.gov identifier:NCT02741674

Background: Research shows the profound impact of social factors on health, lead many healths systems to incorporate social risk screening. To help healthcare systems select among various screening tools we compared two tools, the Your Current Life Situation (YCLS) and the Accountable Health Communities (AHC) Screening tools, on key psychometric properties. Method: Kaiser Permanente Southern California subsidized exchange members (n = 1008) were randomly invited to complete a survey containing either the YCLS or the AHC tool, as well as other measures related to care experience and health. Healthcare use was measured through the electronic health record. Agreement between the AHC and YCLS was assessed using adjusted kappas for six domains (food – worry, food – pay, insecure housing, housing quality, transportation, utilities). To assess predictive validity, items on the AHC and YCLS were compared to self-rated health and receipt of a flu shot. Results: Responders (n = 450) and non-responders (n = 558) significantly differed on sex, language, and depression (P < 0.05) but not anxiety, race/ethnicity, or healthcare use. Agreement between the AHC and YCLS tools was substantial on all items (kappas > 0.60) except for housing quality (kappa 0.52). Four out of six screening questions on the AHC tool and four out of seven on the YCLS tool were associated with self-rated health (P < 0.03). No social needs were associated with flu shot receipt except utilities on the AHC tool (P = 0.028). Conclusion: In this sample, the AHC and YCLS tools are similar in their ability to screen for social risks. Differences observed likely stem from the timeframe and wording of the questions, which can be used to guide selection in healthcare systems.

Background Nicotine dependence (ND) symptoms can occur soon after first puff, so that stopping smoking becomes difficult well before 100 cigarettes lifetime is attained. Yet some surveillance systems do not monitor ND symptoms and 100-cigarettes lifetime is used in at least one surveillance system to define current smokers. To assess whether these features limit interpretation of grade-specific data in surveillance, we described smoking and ND symptoms across grade in incident vs. prevalent smokers, and in smokers according to 100-cigarettes lifetime. Methods Data were available in an investigation of 1294 grade 7 students from 10 Montreal-area high schools followed every 3 months from grade 7 to 11. Analyses described cigarette consumption, 100-cigarette lifetime consumption, cravings, withdrawal symptoms, mFTQ nicotine dependence and ICD-10 tobacco dependence by grade among past 3-month smokers. Results Despite low cigarette consumption, 21–30% of grade 7 smokers reported ND symptoms. This increased to 27–44% in grade 8 and remained stable thereafter despite increased cigarette consumption. In grade 7, 10% of all smokers had not attained the 100-cigarette milestone but were already dependent. In grade 8, 9, 10 and 11, these proportions were 12%, 8%, 6% and 6%, respectively. Conclusions ND symptoms should be monitored in youth surveillance systems since they tell a different “story” than cigarettes and their appearance may represent a critical “point-of-no-return.” Interventions for incident smokers are needed across grades to stop smoking before ND manifests. Without a shift in focus toward incident rather than established smokers, many children who try cigarettes will become addicted.

Although the Fagerström Test for Nicotine Dependence (FTND) and the Heaviness of Smoking Index (HSI) are widely used, there is a uncertainty regarding what is measured by these scales. We examined associations between these instruments and items assessing different aspects of dependence. Adult current smokers (, mean age 33.3 years, 61.9% female) completed a web-based survey comprised of items related to demographics and smoking behavior plus (1) the FTND and HSI; (2) the Autonomy over Tobacco Scale (AUTOS) with subscales measuring Withdrawal, Psychological Dependence, and Cue-Induced Cravings; (3) 6 questions tapping smokers’ wanting, craving, or needing experiences in response to withdrawal and the latency to each experience during abstinence; (4) 3 items concerning how smokers prepare to cope with periods of abstinence. In regression analyses the Withdrawal subscale of the AUTOS was the strongest predictor of FTND and HSI scores, followed by taking precautions not to run out of cigarettes or smoking extra to prepare for abstinence. The FTND and its six items, including the HSI, consistently showed the strongest correlations with withdrawal, suggesting that the behaviors described by the items of the FTND are primarily indicative of a difficulty maintaining abstinence because of withdrawal symptoms.

Purpose Little is known about age-related differences in risk factors for cigarette smoking initiation. We identified predictors of initiation in early, middle, and late adolescence from among sociodemographic factors, indicators of smoking in the social environment, psychological characteristics, lifestyle indicators, and perceived need for cigarettes. Methods Data were drawn from a longitudinal study of 1,801 children recruited at age 10–11 years from 29 elementary schools in Montreal, Canada. Multivariable logistic regression within a generalized estimating equations framework was used to identify predictors among never smokers across three 2-year windows: age 11–13 years (n = 1,221); age 13–15 years (n = 737); and age 15–17 years (n = 690). Results Among the 18 risk factors investigated, two differed across age. Friends' smoking, a strong risk factor in early adolescence (odds ratio [95% confidence interval] = 5.78 [3.90–8.58]), lost potency in late adolescence (1.83 [1.31–2.57]). Depressive symptoms, a risk factor in early and middle adolescence (1.60 [1.26–2.02] and 1.92 [1.45–2.54], respectively), were inversely associated in late adolescence (.76 [.58–1.00]). Sex, TV viewing, and weight-related goals were not associated with initiation at any age. All other factors were significant in two or three age groups. Conclusions Most risk factors for smoking initiation were stable across age. Tobacco control interventions may be robust for risk factors across age groups and may not need adjustment. At all ages, interventions should focus on eliminating smoking in the social environment and on reducing the availability of tobacco products.

Introduction We investigated whether established risk factors for initiating cigarette smoking during adolescence (parents, siblings, friends smoke; home smoking rules, smokers at home, exposure to smoking in cars, academic performance, susceptibility to smoking, depressive symptoms, self-esteem, school connectedness, use of other tobacco products) are associated with initiation in preadolescents, and whether the effects of these factors differ by gender. Methods In spring 2005, baseline data were collected in self-report questionnaires from 1801 5th grade students including 1553 never-smokers (mean age = 10.7 years), in the longitudinal AdoQuest I Study in Montreal, Canada. Follow-up data were collected in the fall and spring of 6th grade (2005–2006). Poisson regression analyses with robust variance estimated the effects of each risk factor on initiation and additive interactions with gender were computed to assess the excess risk of each risk factor in girls compared to boys. Results 101 of 1399 participants in the analytic sample (6.7% of boys; 7.7% of girls) initiated smoking during follow-up. After adjustment for age, gender and maternal education, all risk factors except academic performance and school connectedness were statistically significantly associated with initiation. Paternal and sibling smoking were associated with initiation in girls only, and girls with lower self-esteem had a significant excess risk of initiating smoking in 6th grade. Conclusions Risk factors for smoking initiation in preadolescents mirror those in adolescents; their effects do not differ markedly by gender. Preventive programs targeting children should focus on reducing smoking in the social environment and the dangers of poly-tobacco use.

The autonomy over tobacco scale (AUTOS) is a 12-item theory-based instrument used to measure tobacco dependence in smokers. It provides separate measures of three factors that make smoking cessation more difficult: withdrawal symptoms, psychological dependence, and cue-induced urges to use tobacco. We compared the internal reliability and concurrent validity of the AUTOS to those of the Fagerstrom test for nicotine dependence (FTND). Adult current smokers (n=422; 62% female; 86.8% white; mean age 33.3 years, SD=13.7; 57% daily smokers) completed an anonymous web-based survey that included the AUTOS, the FTND and 11 smoking-related behavioral measures. Cronbach's α was .94 for the AUTOS and α>.75 for each of the 3 subscales; α=.73 for the FTND. The AUTOS and its subscales correlated with all measures of concurrent validity (r=.70 between AUTOS & FTND). The AUTOS correlated better than the FTND with the Hooked on Nicotine Checklist, the longest period of abstinence, latency to wanting, percentage of time a person smokes because of momentary need, pleasure from smoking, days smoked per month, and concern about deprivation. The measures showed similar correlations with the latencies to craving and needing. The FTND correlated better with the duration of smoking and cigarettes smoked per day. Based on these results and those from prior studies, we conclude that the AUTOS offers researchers a valid and highly reliable, theory-based measure that is more versatile in its applications than the FTND.

Background/Aims: We investigated the psychometric properties of a German translation of the 12-item Autonomy over Tobacco Scale (AUTOS) among 1,195 eighth-grade students. Methods: Data for this study were collected as part of the fourth wave of data collection of the Smokefree Class Competition intervention in the Saxony-Anhalt region of Germany. Students from the control arm of the Smokefree Class Competition study who indicated that they had ever smoked ‘at least a few puffs’ on a cigarette were classified as ever-smokers. They self-completed questionnaires distributed by teachers. Results: AUTOS scores ranged from 0 to 36 with a distribution highly skewed toward lower-response categories. Inter-item correlations ranged from 0.65 to 0.89 (mean = 0.79, SD = 0.06). Composite reliability for the AUTOS was high (Ω = 0.96) and 3 lower-order factors were also reliable (withdrawal: 0.89, psychological dependence: 0.91, cue-induced cravings: 0.87). Concurrent validity was supported by strong relationships between the AUTOS and both lifetime cigarette consumption and current smoking frequency. Youths were 18 times more likely to be current smokers (95% CI = 11.9–27.2, p < 0.001) if they endorsed any AUTOS item. Conclusion: The German AUTOS is reliable and valid, and the results are consistent with the English AUTOS for use with adolescents.

With physical addiction to tobacco, abstinence triggers a desire to smoke. As physical addiction advances, the desire to smoke changes in quality and intensity from wanting, to craving, to needing. A prior study in adolescents suggested that this progression signifies increasing addiction.We sought to determine if the sequential appearance of wanting, craving and needing provides an indication of the intensity of other markers of tobacco addiction including psychological and behavioral indicators.A web-based survey was completed by 422 smokers ages 18-78 years. Subjects were assigned to one of four qualitatively distinct stages of physical addiction based on their most advanced symptom: 1-none, 2-wanting, 3-craving, or 4-needing. Using linear Chi square and ANOVA, we determined if higher stages were associated with higher levels of tobacco addiction on more than a dozen measures.16.8% of subjects were in stage 1, 26.1% in stage 2, 17.1% in stage 3 and 40.0% in stage 4. Each step up in stage was associated with higher levels of addiction as measured by the Fagerström Test for Nicotine Dependence, the Hooked on Nicotine Checklist, the Autonomy over Tobacco Scale, and higher levels of psychological dependence, duration of tobacco use, frequency of tobacco use, daily cigarette consumption, and 10 additional measures.In this cross-sectional study, each sequential stage of physical addiction was associated with higher levels of every indicator of addiction. The data suggest that the stages of progression of physical addiction provide a global indication of the severity of tobacco addiction.

Addicted smokers experience nicotine withdrawal anytime they go too long without smoking. Withdrawal presents as a continuum of symptoms of escalating severity described by smokers as “wanting,” then “craving,” and eventually “needing” to smoke. These may be followed by irritability, impatience, moodiness, difficulty concentrating, restlessness, and sleep disturbances. This spectrum of intensifying withdrawal symptoms creates a compulsion to smoke that makes quitting difficult. The compulsion to smoke is the core feature of nicotine addiction accounting for its clinical course, physiological characteristics, prognosis, and behavioral manifestations. A compulsion can develop quickly, having been experienced by one third of youth who have smoked only 3 or 4 cigarettes. Its physiologic basis is evident in neurophysiological measures and its recurrence after each cigarette at a characteristic interval. At first, a single cigarette can keep withdrawal at bay for weeks, but as addiction progresses, cigarettes must be smoked at progressively shorter intervals to suppress withdrawal symptoms. The physiologic need to repeatedly self-administer nicotine at shorter intervals explains a full spectrum of addictive symptoms ranging from the prodromal symptom of wanting, to chain smoking. The early process of nicotine addiction is recognized if a person experiences regular wanting for a cigarette. When symptoms include craving or needing, the now addicted patient is experiencing a compulsion to smoke. This simple diagnostic approach covers the full spectrum of addiction in smokers of all ages and levels of tobacco use, and is more valid than a clinical diagnosis based on the current Diagnostic and Statistical Manual criteria.

Contexte : Bien que l’usage de la cigarette demeure courant parmi les jeunes, on en sait encore bien peu sur la façon de les aider à cesser de fumer. Seulement quelques revues systématiques d’essais comparatifs randomisés (ECR) ont évalué l’efficacité des interventions d’abandon du tabac chez les jeunes.Objectif : Résumer les connaissances sur l’efficacité des interventions visant à aider les jeunes à cesser de fumer en se basant sur des données probantes provenant d’ECR.Sélection des études et extraction des données : Nous avons retenu tous les ECR publiés qui évaluaient les interventions d’abandon du tabac ciblant les jeunes âgés de 20 ans et moins et qui rapportaient l’abstinence au tabac selon une analyse en intention de traiter. Nous avons relevé les études pertinentes provenant de huit revues de synthèse décrivant des études portant sur des interventions d’abandon du tabac publiées entre 2002 et 2006, ainsi qu’une recherche menée dans les bases de données PubMed et PsycINFO entre 2001 et novembre 2006. Nous rapportons l’abstinence au tabagisme au moment du suivi le plus prolongé. Les auteurs ont sélectionné d’un commun accord les données retenues pour cette revue.Résultats : Nous avons identifié 16 ECR auxquels ont participé 6 623 jeunes ; 11 études évaluant des interventions comportementales qui comprenaient 5 764 participants; quatre examinant des interventions pharmacologiques qui comptaient 529 participants ; et une se penchant sur l’acupuncture au laser qui comportait 330 participants. Trois interventions comportementales menées en milieu scolaire sur quatre et une intervention réalisée en milieu de soins de santé sur quatre ont fait augmenter de façon significative l’abstinence au tabac, quatre semaines à 24 mois suivant les interventions. Parmi les quatre ERC qui évaluaient les interventions pharmacologiques réalisées à l’aide soit de bupropion, de timbres ou de gommes à la nicotine, une étude, où le timbre à la nicotine a été utilisé en combinaison avec un counseling cognitivo-comportemental, a montré une hausse marquée, quoique non significative, de l’abstinence six mois après la date d’abandon.Conclusion : Il existe encore peu de preuves démontrant l’efficacité des interventions d’abandon du tabac chez les jeunes. Quatre programmes en milieu scolaire et une intervention dans un établissement de santé ont mis en évidence une certaine efficacité, tandis que pour la thérapie pharmacologique, les résultats ne sont pas encore concluants., Background: Cigarette use remains common among young people but little is known about how to help adolescent smokers quit. There are few systematic reviews of randomized controlled trials (RCTs) that evaluate the effectiveness of cessation interventions for youth.Objective: To synthesize knowledge on the effectiveness of cessation interventions targeted to youth based on evidence from RCTs.Selection of studies and data extraction: We retained all published RCTs with intention to treat analyses that evaluated cessation interventions targeted to youth aged ≤ 20 years. Relevant studies were identified from eight review articles of smoking cessation intervention studies published between 2002 and 2006, and from a search conducted in PubMed and PsycINFO databases from 2001 to November 2006. The outcome of primary interest was abstinence at the longest reported follow-up. Extraction of data was by consensus of the authors. Results: We identified 16 RCTs with a total of 6623 participants; 11 studies that included 5764 participants evaluated behavioural interventions, four with 529 participants evaluated pharmacological interventions, and one with 330 participants evaluated a laser acupuncture intervention. Three of four behavioural interventions conducted in school settings, and one of four conducted in a health care setting significantly increased abstinence four weeks to 24 months after the interventions. Of four RCTs that evaluated pharmacological interventions using either bupropion or nicotine patch or gum, one study using the nicotine patch coupled with cognitive-behavioural counselling showed a marked albeit non-significant increase in abstinence six months after quit date.Conclusion: There is still limited evidence demonstrating the efficacy of smoking cessation interventions in youth. Four school-based programs and one intervention in a health care setting have shown efficacy, while results for pharmacological therapy are inconsistent across studies., Contexto: si bien el tabaco sigue siendo de uso corriente entre los jóvenes, todavía no se sabe mucho sobre cómo ayudarlos a dejar de fumar. Solamente algunas revisiones sistemáticas de ensayos comparativos aleatorizados han evaluado la eficacia de las intervenciones dirigidas a lograr el abandono del tabaco entre los jóvenes.Objetivo: resumir los conocimientos sobre la eficacia de las intervenciones destinadas a ayudar a jóvenes a dejar de fumar sobre la base de los datos probados de los ensayos comparativos aleatorizados.Selección de estudios y extracción de datos: hemos retenido todos los ensayos comparativos aleatorizados publicados, que evalúan las intervenciones de abandono del tabaco en los jóvenes de 20 años y menos, y que informan sobre la abstinencia de tabaco, según un análisis que tiene la intención de tratar. Hemos seleccionado los trabajos pertinentes provenientes de ocho revistas de síntesis, que describen estudios referidos a intervenciones de abandono del tabaco publicados entre 2002 y 2006, así como una investigación llevada a cabo en las bases de datos PubMed et PsycINFO, realizada entre 2001 y noviembre de 2006. Informamos sobre la abstinencia del tabaquismo en el momento de seguimiento más prolongado. Los autores han seleccionado de común acuerdo los datos retenidos por esta revista.Resultados: hemos identificado dieciséis estudios comparativos aleatorizados en los que participaron 6.623 jóvenes; once estudios que evalúan las intervenciones comportamentales, con 5.764 participantes; cuatro que examinan las intervenciones farmacológicas en las que intervienen 529 participantes y uno que se centra en la acupuntura al láser, con 330 participantes. Tres intervenciones comportamentales realizadas en medio escolar de cada cuatro y una intervención realizada en el medio de la atención sanitaria de cada cuatro, aumentaron de manera significativa la abstinencia al tabaco, cuatro semanas a 24 meses después de las intervenciones. Entre los cuatro estudios comparativos aleatorizados que evaluaban las intervenciones farmacológicas, realizadas ya sea con ayuda de bupropion, de parches o de gomas de mascar a la nicotina, uno de ellos, en el que se utilizó un parche de nicotina en combinación con orientación psicológica cognitivo-comportamental, indicó un aumento marcado, aunque no significativo, de la abstinencia, seis meses después de la fecha de abandono.Conclusión: existen todavía pocas pruebas que demuestren la eficacia de las intervenciones de abandono del tabaco entre los jóvenes. Cuatro programas en medio escolar y una intervención en un establecimiento de salud evidenciaron una cierta eficacia, mientras que los resultados no son todavía concluyentes en lo que se refiere a la terapia farmacológica.

Objectives. As smoking is very common in R-rated films, we sought to determine if viewing R-rated films is associated with adolescent smoking. Methods. Three annual cross-sectional surveys conducted of 88,505 Year 10 students of largely European, Maori, Asian or Pacific Islander ethnicity in secondary schools in New Zealand between 2002 and 2004. Outcomes of interest were: intention to smoke among never smokers; past experimentation with smoking among current non-smokers; current smoking status; and current frequency of smoking. Results. Dose–response relationships were observed between the frequency of viewing R-rated films and all outcome measures controlling for age, gender, ethnicity, peer smoking, parental smoking, socioeconomic status, pocket money and household smoking rules. Compared to never viewing R-rated films, viewing at least weekly nearly tripled the relative risk (2.81; 95% confidence interval 2.57, 3.09) of never smokers being susceptible to smoking, and more than doubled the risk of both past experimentation (2.28; 95% CI 2.12, 2.45) and smoking ≥ monthly (2.31; 95% CI 2.10, 2.54). Each of these risks was seen across all ethnic groups. Conclusions. Our results extend the association that has been demonstrated between viewing R-rated films and current smoking in American youth by demonstrating the same association in youth of different ethnic and cultural backgrounds in New Zealand.