Cigarette warning labels are about to get even harder to ignore

Ottawa, ON - Health Canada has announced new warning labels to be printed directly on cigarettes in an effort to deter new smokers, encourage quitting and reduce tobacco-related deaths — a world first that experts hope will have a significant impact.  There will be multiple sets of six warnings on the cigarettes themselves that will change in rotation with messages like: "Cigarettes cause cancer," "Cigarettes damage your organs," "Tobacco smoke harms children" and "Poison in every puff."  Health Canada will also include new health warnings on cigarette packaging, taking up a minimum of 75 per cent of the main display area of the package, that can be updated with the latest research available without having to change the regulations.  "Having a warning on every cigarette sold in Canada is a world precedent-setting measure," said Rob Cunningham, senior policy analyst at the Canadian Cancer Society. "The health warning is going to be there during every smoke break. And for youth who experiment by borrowing a cigarette from a friend, they'll have exposure to the health warning there as well. I expect that many countries internationally will follow this Canadian world first." Health Canada has announced new warning labels to be printed directly on cigarettes in an effort to deter new smokers, encourage quitting and reduce tobacco-related deaths. (Health Canada) The regulations will begin to come into effect as of Aug. 1. Tobacco companies will be required to implement the first sets of restrictions for retail on king-size cigarettes (83-85 millimetres in length) by July 31, 2024, on regular-size cigarettes (70-73 millimetres in length) and on small cigars by April 30, 2025.  Health Canada's new cigarette-labelling regulations come into effect starting Aug. 1. (Health Canada) The federal government's decision was announced on World No Tobacco Day and is part of Canada's Tobacco Strategy, which aims to achieve less than five per cent tobacco use by 2035. 

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Canada has some of the highest teen vaping rates in the world, new data shows  

Waterloo, ON - Almost 1 in 4 older Canadian high school students reported vaping in past month. New national data shows the number of Canadian teenagers regularly using e-cigarettes ranks among the highest in the world, and experts say a lack of action from the federal government and the widespread availability of flavoured vapes is fuelling a growing crisis.  The latest results from Health Canada's Canadian Student Tobacco, Alcohol and Drugs Survey, which surveyed 61,096 teenagers in grades 7 to 12 from nine provinces between September 2021 and June 2022, found that 29 per cent of Canadian students had ever tried an e-cigarette.  That number is down slightly overall in Canada, from 34 per cent in 2018-19, but is higher in older age groups — with 41 per cent of students in grade 10 to 12 ever having vaped. Regular use of e-cigarettes also continues to be widespread in Canada, with 17 per cent of students having used an e-cigarette in the past month, down slightly from 20 per cent in 2018-19, but is again higher in grades 10 to 12 with over 24 per cent being monthly users.  Daily vaping rates were eight per cent across all students surveyed and close to 12 per cent among those in grades 10 to 12 — which experts say are some of the highest ever reported globally.  "The numbers have confirmed that Canada has one of the highest youth vaping rates in the world, especially as it relates to daily vaping," said David Hammond, a public health professor at the University of Waterloo and a leading Canadian youth vaping researcher.  "We've essentially plateaued at historically high levels of daily vaping … this is maybe the best indication out there that we're in for a long haul of regular youth vaping — we've crossed the threshold of this being a fad."  Australia has moved to ban vaping without a doctor’s prescription and several provinces have already banned flavoured products, but Health Canada has stalled on passing sweeping legislation. The numbers are higher than they were five years ago, when just 10 per cent of students had used an e-cigarette in the past 30 days and 11 per cent reported daily use in 2016-2017 — signalling a growing problem showing no signs of slowing down.  The new youth vaping survey data also partially predates the widespread availability of disposable vapes that came onto the market last year and hold thousands of pre-loaded puffs, don't require refilling or cartridges and are linked to a surge in youth vaping. "We're very concerned by the long-term issue that e-cigarette use by teenagers continues to be very high — unacceptably high," said Rob Cunningham, senior policy analyst at the Canadian Cancer Society. "And we need the federal government to move immediately to ban flavoured e-cigarettes, a factor that is contributing to these high rates." When asked what flavour they preferred, the survey showed 63 per cent of students in grades 7 to 12 who vaped in the past month had used a fruit flavour most often. "There is no doubt that flavours are a very big part of youth vaping — they appeal to kids, they're one of the reasons why they start trying vaping in the first place, and fruit flavours and candy flavours are a big part of that," said Hammond.  "The main reason adults vape is to help them quit or not to die from smoking — flavours has a much bigger relative influence in youth vaping than it does for adults." When asked what flavour they preferred, the survey showed 63 per cent of students in grades 7 to 12 who vaped in the past month had used a fruit flavour most often. Here, a flavoured vaping device is seen in a downtown Toronto vape shop on April 25, 2023. (Evan Mitsui/CBC) In contrast, youth cigarette smoking rates have continued to drop significantly in Canada — with just 14 per cent of Canadian high school students reporting ever having had a cigarette, down from 19 per cent in 2018-19, and only one per cent smoking daily.  "We have seen over time some decreases in youth smoking. That's because of high taxes, high prices, plain packaging and menthol bans," Cunningham said.  "But unfortunately, overall nicotine use when you include both smoking and e-cigarettes, is going up. We have an enormous problem, a new generation is becoming addicted to nicotine and we need government action immediately to respond to that."  

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FDA denies marketing of nearly 6,500 flavored e-cigarette products

Silver Spring, Maryland - The FDA has issued marketing denial orders to 10 companies that manufacture and market approximately 6,500 flavored e-liquid and e-cigarette products. The companies, including Imperial Vapors LLC, Savage Enterprises, Big Time Vapes, SWT Global Supply Inc., Great Lakes Vapor, DNA Enterprise LLC dba Mech Sauce, Absolute Vapor Inc., ECBlend LLC, among others, cannot market or distribute the products in the U.S. and retailers who sell them risk FDA enforcement action, according to a press release from the agency. FDA denies marketing of nearly 6,500 flavored e-cigarette products. Image: Adobe Stock The FDA stated in the release that “premarket tobacco product applications (PMTAs) submitted for various flavored e-cigarette products did not provide sufficient evidence to show that permitting the marketing of these products would be appropriate for public health.” This marketing denial order is among recent efforts the FDA has taken to review and issue decisions on applications for more than 26 million new tobacco products, the majority of which include e-cigarette products. “Science is a cornerstone of FDA’s tobacco product review process,” Matthew Farrelly, PhD, director of the Office of Science within FDA’s Center for Tobacco Products, said in the release. “Today’s decision to deny approximately 6,500 products was based on the lack of scientific evidence provided in the applications. We will continue to ensure all new tobacco products undergo robust, scientific premarket evaluation to determine whether they meet the appropriate public health standard to be legally marketed.” 

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CDC reports that cigarette smoking in 2021 lowest since 1965

Atlanta, GA - Although prevalence of cigarette smoking decreased, cigarettes were still the most used tobacco product in 2021. Compared with 2020, e-cigarette use increased in 2021. Among the estimated 46 million U.S. adults who used tobacco products in 2021, cigarette smoking prevalence decreased while e-cigarette use increased, according to CDC data published in Morbidity and Mortality Weekly Report. “Although cigarette smoking decreased over the past year, e-cigarette use increased, from 3.7% to 4.5%, largely driven by higher prevalence in use among persons aged 18 to 24 years,” Monica E. Cornelius, PhD, an epidemiologist and associate service fellow at the CDC, and colleagues wrote. “Further, declines in cigarette smoking among populations with diagnosed depression represent important successes in tobacco control. However, disparities in tobacco use remain.” Among the estimated 46 million U.S. adults who used tobacco products in 2021, cigarette smoking prevalence decreased while e-cigarette use increased, according to CDC data published in Morbidity and Using data from the 2021 National Health Interview Survey, Cornelius and colleagues evaluated tobacco usage of 29,482 adults in the U.S. and weighted data to determine national prevalence estimates of current usage for the year. Researchers assessed use of cigarettes, cigars, pipes, e-cigarettes and smokeless tobacco, and calculated differences in use from past years. Based on the weighted data, 46 million adults (18.7%) were estimated to be current users of a tobacco product and 35.6 million (14.5%) were estimated to be users of a combustible tobacco product. Use of at least two tobacco products was estimated in 8.3 million adults (3.4%). Researchers also reported 66.5% of adults had quit smoking. Of the five tobacco products, most people used cigarettes (28.3 million), followed by e-cigarettes (11.1 million), cigars (8.6 million), smokeless tobacco (5.2 million) and pipes (2.3 million), according to researchers. From 2020 to 2021, prevalence of cigarette use dropped from 12.5% to 11.5%, although e-cigarette use jumped from 3.7% to 4.5%. Among users of more than two tobacco products, 31.4% used both cigarettes and e-cigarettes, researchers reported. Other common combinations included cigarettes and cigars (21%), cigarettes and smokeless tobacco (7.9%), e-cigarettes and cigars (7%) and cigarettes and pipes (3.7%). Notably, 14% of adults used three or more products. According to researchers, cigarette use in 2019 was higher among those diagnosed with depression compared with those who did not have depression (22.9% vs. 12.3%), with similar reports in 2020 (20.5% vs. 10.9%) and 2021 (19.4% vs. 9.9%); still, overall smoking declined among Black, white and Hispanic adults during this time, regardless of depression status. Among those with depression, cigarette use was highest in Black adults in 2021, a departure from 2019 and 2020 when non-Hispanic adults of other races had the highest usage. However, non-Hispanic adults of other races who had not been diagnosed with depression had the highest prevalence of cigarette smoking in 2021 “Continued surveillance of tobacco product use, implementation of evidence-based tobacco control strategies (eg, hard-hitting media campaigns, smoke-free policies and tobacco price increases), conducting linguistically and culturally appropriate educational campaigns, and FDA regulation of tobacco products will aid in reducing tobacco-related disease, death and disparities among U.S. adults,” Cornelius and colleagues wrote. 

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FDA approves first vaccine against RSV

Silver Spring, Maryland; GSK’s vaccine against RSV was approved by the FDA and is expected to be available for people aged 60 and older this fall. A second RSV vaccine, from Pfizer, could also be approved by the FDA this month. The FDA approved the world’s first vaccine against respiratory syncytial virus, which followed years of failed attempts by scientists to develop one. The vaccine, GSK’s Arexvy, is approved in the United States to prevent lower respiratory tract disease caused by RSV in adults aged 60 years or older. “Older adults, in particular those with underlying health conditions, such as heart or lung disease or weakened immune systems, are at high risk for severe disease caused by RSV,” Peter Marks, MD, PhD, director of the FDA’s Center for Biologics Evaluation and Research, said in a press release. “Today’s approval of the first RSV vaccine is an important public health achievement to prevent a disease which can be life-threatening.” The FDA’s Vaccines and Related Biological Products Advisory Committee recommended the approval of GSK’s shot in March, in addition to a second RSV vaccine made by Pfizer. The FDA is expected to issue a decision on Pfizer’s vaccine at some point this month. RSV is common, affecting people of all ages, but can cause serious infections, especially in older adults and infants. It kills up to 10,000 adults aged 65 years or older each year in the U.S., according to the CDC. The U.S. experienced a surge in RSV this past winter — part of a “tripledemic” of respiratory infections that also included influenza and COVID-19, both vaccine-preventable diseases. “We are pleased that we can now add a respiratory syncytial virus vaccine to providers’ options for patient care,” John Kennedy, MD, president of the American Medical Group Association, said in a press release issued by GSK. The FDA’s approval was based on data from an ongoing randomized, placebo-controlled phase 3 trial, for which participants will remain enrolled for three RSV seasons to assess the duration of efficacy and safety of repeat vaccination. In the trial, researchers found the vaccine reduced risk for developing RSV-related lower respiratory tract disease by 82.6% and reduced the risk for developing severe RSV-related lower respiratory tract disease by 94.1%. The vaccine was generally well-tolerated by trial participants, with the most common side effects being injection site pain, fatigue, muscle pain, headache and joint stiffness or pain. GSK is also conducting a clinical trial among people aged 50 to 59 years, including people with underlying comorbidities. It expects results from that trial sometime this year. Results from two other trials testing co-administration with influenza vaccines are expected in the next several weeks, ahead of a June meeting of the CDC’s Advisory Committee on Immunization Practices, which will make recommendations on the use of the vaccine in the U.S. GSK said the vaccine should be available before the start of the 2023-2024 RSV season. RSV vaccine research has ramped up over the past decade after a long delay in activity following a deadly vaccine trial in the 1960.

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Toronto, ON - MPP France Gelinas of the Nickle Belt introduced a private members bill, legislation that will reduce youth vaping. The Bill makes various amendments to the Smoke-Free Ontario Act, 2017. The main highlights of the act are to to prohibit the promotion of vapour products. The Act is amended to provide that no person shall sell or supply a tobacco product, vapour product or prescribed product or substance to a person who is less than 21 years old. Currently, the Act prohibits the sale at retail or the sale for the purposes of sale at retail of vapour products prescribed as a flavoured vapour product. The Act is amended to provide that this restriction applies with respect to flavoured vapour products generally, unless the flavour or flavouring agent contained in the vapour product is a tobacco flavour or tobacco flavouring agent. The Act is also amended to provide that this prohibition applies to vapour products that contain more than specified amounts of nicotine. The Act is also amended to provide that vapour products can only be sold in specialty vape stores or designated stores in remote or rural communities, as well as to provide that no person may operate a specialty vape store or sell vapour products at a designated store in a remote or rural community without the approval of the board of health of the area in which the store is to be located. Corresponding offences are added to the Act. It will also provide that the Minister may direct that tax revenue generated from the sale of vapour products at specialty vape stores and at designated stores in remote and rural communities be used for the purpose of educating the public about the health risks associated with vaping, provided that the Legislature has appropriated funds for this purpose. Ontario Health to prepare an annual report to the Minister respecting youth vaping that sets out information and recommendations to assist the Minister in developing policies to reduce youth vaping. This Act comes into force 120 days after it receives Royal Assent. 

For more information: www.ola.org/en/legislative-business/bills/parliament-42/session-2/bill-85

Mint-flavored E-cigarettes linked to worse lung function

Pittsburgh, PA - Use of electronic cigarettes with added menthol flavoring increased the number of inhaled particles and was associated with worse lung function in current or former combustion cigarette smokers, according to a study that used a specially designed robotic system that mimics the mechanics of breathing. Compared with e-cigarettes with liquids that were not flavored with menthol, menthol-flavored products produced a significantly higher level of 1-10 µm particles when inhaled, reported Kambez H. Benam, DPhil, of the University of Pittsburgh, and co-authors. In a retrospective analysis of data from the COPDGene cohort, menthol product users had an average 0.06 lower forced expiratory volume in the first second to the forced vital capacity of the lungs (FEV1/FVC) when compared with those who used other flavors (95% CI -0.01 to -0.12, P=0.01), they said in Respiratory Research. The addition of menthol flavor to the liquid base in e-cigarettes, measured as propylene glycol (PG) to vegetable glycerin (VG), led to increased particle counts across all particle size ranges (300 nm to 10 µm) even at a 0.01% dosage. When Benam and team compared popular product Vuse Alto Menthol with its non-menthol counterpart, Vuse Alto Golden Tobacco, they found that Vuse Alto Menthol produced larger amounts of 1-2.5 μm, 2.5-4 μm, and 4-10 μm particles when aerosolized. Menthol remains a popular option among those who vape, particularly younger users. As of October 2022, over 2.5 million middle and high school students in the U.Sopens in a new tab or window. reported use of e-cigarettes in the previous 30 days, with 85% using flavored products. One NIH study among adolescent and young adult users of flavored e-cigarettes found that the largest group (34%) selected mint as their flavor of choiceopens in a new tab or window. Menthol and other cooling flavors have only increased in popularity over the years, from 1.5 million units sold in 2017 to 12 million in 2021opens in a new tab or window. "Menthol is a substance naturally found in mint plants (and is added to some food/beverages), so some may assume it would be fine to inhale it," Benam said. "Just because something is or considered safe orally, does not mean it would be safe if inhaled." "For a middle/high schooler who has not smoked combustion cigarettes in the past and thinks it is cool to try a menthol-flavored vaping product, they should know that not only are they exposing their lungs to irritants and toxins in e-cigarette aerosols, but they are getting more particles into their lungs, just because of the menthol," he added. In their paper, the authors noted that an increase in the number of particles from the added menthol flavoring will increase aerosols -- known to contain many harmful substances such as nicotine and multi-functional carbonyls, including formaldehyde -- delivered to the lungs. 

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Inhaled corticosteroids lower risk for all-cause mortality in patients with COPD

Chengdu, China - Inhaled corticosteroids were associated with lower odds for mortality in patients with COPD. An eosinophil count of 200 cells/μL or more was the greatest predictor of this association. Patients with COPD treated with inhaled corticosteroids for more than 6 months had a decreased risk for all-cause mortality, according to study results published in CHEST. Further, several demographic characteristics were identified as predictors of lower odds for mortality when receiving inhaled corticosteroids, according to researchers. “Inhaled therapy containing inhaled corticosteroids [ICSs], especially triple therapy, should be used in the maintenance treatment of patients with COPD, especially in those with eosinophil counts of [at least 200 cells/μL],” Hong Chen, MD, of the department of respiratory and critical care medicine at Chengdu Second People’s Hospital, and colleagues wrote. In a systematic review and meta-analysis, Chen and colleagues found and assessed 60 randomized controlled trials from a database search that included a total of 103,034 patients with COPD to find out how inhaled therapy including ICSs and the risk for all-cause mortality are related to each other. Researchers also looked for predictors of this association. Of the total cohort, 60,552 patients had inhaled therapy with ICSs and 42,482 patients had inhaled therapy without them. Compared with inhaled therapy not containing ICSs, researchers found a decreased risk for all-cause mortality linked to therapy with  “More studies are needed to identify the exact subgroups of patients with COPD who could benefit from the inhaled therapy containing ICSs for a reduction in the all-cause mortality risk and the relevant mechanisms,” Chen and colleagues wrote. This study by Chen and colleagues contributes to growing literature on mortality risk associations with ICS for patients with COPD, but it has several limitations that should be considered when viewing the findings, according to an accompanying editorial by Darcy D. Marciniuk, MD, professor of respirology, critical care and sleep medicine at the University of Saskatchewan, and Luigino Calzetta, PhD, of the department of medicine and surgery at the University of Parma. “Although the results of this study were positive, the findings provided by Chen et al should be interpreted with thoughtfulness, because the analysis was affected by substantial heterogeneity resulting not only from the inclusion of several studies that enrolled heterogeneous populations of COPD patients, but also because several formulations characterized by different regimens of administrations (once daily vs. twice daily) were compared and administered via different inhaler devices,” Marciniuk and Calzetta wrote. “Moreover, several formulations were compared, although there was not consistency between the bronchodilators included in each combination.” 

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Raritan, NJ - A model predicted 17.5 to 22.6 million symptomatic RSV cases per year among adults in the U.S. without a vaccine. Overall, 2 million symptomatic cases could be prevented each year with a hypothetical vaccine. Vaccinating older adults for respiratory syncytial virus could reduce the burden of disease by millions, according to approximations made by a disease transmission model. “Respiratory syncytial virus (RSV) is one of the most frequent causes of lower respiratory infections with 3.5 million cases in the U.S., causing the highest burden of disease in children and older adults,” Thierry Van Effelterre, PhD, scientific director at Janssen, told Healio. A disease transmission model showed that approximately 2 million symptomatic respiratory syncytial virus acute respiratory infections could be prevented each year among older adults after a hypothetical vaccine is introduced. “Although the burden of RSV in the older adult population has been studied, the true burden of RSV in adults may be underestimated due to lack of awareness amongst health care providers of RSV as a potential cause of influenza-like illnesses,” Van Effelterre said. According to Van Effelterre, the full burden of RSV in adults needs to be determined to accurately gauge the population-level impact of the adult RSV vaccines currently in development. These data would also be timely, as two of the vaccines in development — Pfizer's RSVpreF and GSK's RSVpreF3 OA — have been recommended for older adults by an FDA committee. The FDA is expected to make its decision for both vaccines on May 3. Van Effelterre added that, to date, only one disease transmission model examined the population-level effects of adult and infant vaccination programs in the U.S., although this model does not account for the “progressive build-up of immunity” beyond the first infection. Van Effelterre and colleagues developed an RSV disease transmission model using a sequential acquisition of immunity approach to understand and predict the population-level burden of symptomatic RSV acute respiratory infections (ARIs) in the U.S. According to the study, RSV ARI cases were projected with and without vaccination of older adults aged 60 and older using assumed vaccine efficacy and vaccine coverage. Van Effelterre said that the team also investigated the potential long-term population-level public health impact of RSV vaccination of older U.S. adults. Using a model that made estimates based on a scenario with no RSV vaccine, there would be a projected 17.5 to 22.6 million symptomatic RSV ARI cases per year among people aged 18 years and older in the U.S., according to the study. Approximately 3.6 to 4.8 million of these cases were projected to occur in adults aged 60 years and older. Additional modeling demonstrated that up to 2 million symptomatic RSV ARI cases could be prevented each year among this older population with a hypothetical vaccine that is 70% effective against symptomatic ARI with 60% coverage. Modeling also showed that up to 0.69 million cases per year could also be prevented in the nonvaccinated population with 50% vaccine impact on infectiousness. “The model projects a substantial RSV burden in adults and older adults in the absence of an intervention, indicating that the true burden of RSV in adults may be underestimated,” Van Effelterre said. “The model projects that vaccinating the 60-year-old-or-older adult population could reduce the burden of disease substantially, with additional indirect effect expected in the nonvaccinated aged-younger-than-60-year-old population if the vaccine reduces infectiousness.” 

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Persistent smoking linked to risk for CV events, death after acute ischemic stroke

Charleston, SC - In patients with acute ischemic stroke, persistent smoking conferred elevated risk for CV events and death vs. never smoking. Former smokers and those who quit after their stroke did not have elevated risk. Smoking consistently after acute ischemic stroke was associated with increased risk for CV events and death compared with never smoking, researchers reported. “In this study, we demonstrated an association between persistent smoking after stroke and higher risk of composite outcome of death, stroke and myocardial infarction. In addition, persistent smokers had double the risk of death compared to never smokers,” Mohammad Anadani, MD, of the department of neurosurgery at the Medical University of South Carolina, and colleagues wrote. “Interestingly, there was no significant difference in the risk of cardiovascular events or death between patients who were former smokers at baseline or those who quit smoking compared to never smokers, which implies that smoking cessation after stroke may reduce the risk of death and cardiovascular events.” In patients with acute ischemic stroke, persistent smoking conferred elevated risk for CV events and death vs. never smoking. A total of 2,874 individuals with acute ischemic stroke were included in the post hoc analysis of Secondary Prevention of Small Subcortical Strokes (SPS3), a randomized, multicenter trial conducted in 82 centers between March 2003 and April 2011 in Spain, North America and Latin America. The primary outcome was major adverse CV events, defined as stroke, MI and mortality, at 18 months, according to the study. Secondary outcomes included stroke, MI and death as individual outcomes. Outcomes were adjusted after the third month of enrollment until an outcome event or the end of the study follow-up. Individuals were stratified based on smoking status: never smokers, former smokers, smokers who quit at 3 months and persistent smokers. Of those included, 570 individuals (20%) were smokers when enrolled, of whom 408 (71.5%) continued smoking and 162 (28.4%) quit smoking by 3 months, the researchers wrote. Smoking status was assessed at baseline, 3 months and every 3 months following. The researchers found that 28.4% of smokers at baseline quit at 3 months and 34% quit at 18 months, whereas of those who quit smoking by 3 months, 14.2% had resumed smoking by 6 months and 20.4% had resumed by 12 months. A major adverse CV event occurred in 18.4% of persistent smokers, 12.4% of smokers who quit, 16.2% of prior smokers and 14.4% of never smokers at 18 months. After  adjustment for age, sex, race, ethnicity, education, employment history, hypertension, diabetes, MI, hyperlipidemia and randomization arm of the trial, risk for the primary outcome was higher in persistent smokers compared with never smokers (adjusted HR = 1.56; 95% CI, 1.16-2.09), whereas those who quit smoking by 3 months did not have significantly different risk for the primary outcome compared with never smokers (aHR = 1.25; 95% CI, 0.77-2.02), according to the study. “Persistent smoking compared to never smoking after lacunar stroke was associated with a significant increase in the risk of major cardiovascular events and death,” Anadani and colleagues wrote. “The overall rate of smoking cessation after ischemic stroke was low, highlighting the need for more targeted and effective smoking cessation strategies.”

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Sanofi, Regeneron unveil 'blow-out' smoker's lung drug data 

Paris, France - Sanofi's asthma drug Dupixent met all targets in a trial to treat "smoker's lung", potentially adding billions to the French drugmaker's growth prospects, but also underscoring a heavy reliance on its bestseller. In a late stage trial Dupixent, jointly developed with Regeneron, led to a 30% reduction in moderate or severe acute exacerbations of chronic obstructive pulmonary disease (COPD) smokers also showed improvements in lung function, quality of life and respiratory symptoms. "COPD is an urgent global health concern and a notoriously difficult-to-treat disease due to its heterogeneity, with no novel treatments approved in more than a decade," said Regeneron Chief Scientific Officer George Yancopoulos. Sanofi added its "bold" decision to go without earlier-stage clinical COPD trials had shaved years off the development time. JP Morgan analyst Richard Vosser said the trial update had "blow-out data" in store for investors, and that market consensus for 2027 Dupixent sales of 15.7 billion euros would likely be topped-up by between 1 and 2 billion euros. "We see Dupixent data in COPD exceeding any expectations in the market for benefit," the analyst said. Jefferies analysts said the update yielded "perhaps best case efficacy" to treat the disease. Sanofi previously forecast Dupixent would generate up to 13 billion euros ($14.2 billion) in sales in its best year as it seeks to widen its use across several inflammatory conditions, but it has excluded COPD from its sales target. Sanofi said earlier it was too early to update its sales estimate for the product, which is also used to ease eczema. The anti-inflammatory drug accounted for 8.3 billion euros, or more than 19% of the French group's overall sales of 43 billion euros, last year. That was a currency-adjusted increase of 44% from a year earlier. Sanofi reports combined global Dupixent sales from its alliance with Regeneron. The companies said that full efficacy and safety results would be presented later. They added a second late-stage COPD Dupixent trial was ongoing, with the first data read-out expected next year. Overall rates of adverse events in the trial reporting results were 77% for Dupixent and 76% for placebo. Sanofi and Regeneron on Tuesday announced the European Commission had approved Dupixent to treat severe atopic dermatitis in young children. Prior to that, the drug was also approved in Europe to treat a type of esophagus inflammation. 

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Researchers rethink e-cigarettes' role in treating cigarette smokers' nicotine addiction

An Arbor, MI - Should electronic cigarettes, or vapes, be accepted more widely as an effective and respected tool for treating adult smokers' nicotine addiction? Kenneth Warner, dean emeritus and the Avedis Donabedian Distinguished University Professor Emeritus at the University of Michigan's School of Public Health, says there is enough evidence to support e-cigarettes' use as a first-line aid for smoking cessation in adults. "Far too many adults who want to quit smoking are unable to do so," Warner said. "E-cigarettes constitute the first new tool to help them in decades. Yet relatively few smokers and indeed health care professionals appreciate their potential value." In a study published in Nature Medicine, Warner and colleagues took a global view of vaping, examining countries that promote vaping as a smoking cessation and countries that don't. While agencies in the United States and Canada acknowledge the potential benefit of e-cigarette use, they deem the evidence to recommend e-cigarettes for smoking cessation as insufficient, according to the authors. However, in the United Kingdom and New Zealand there is high-level support and promotion of e-cigarettes as a first-line smoking cessation treatment option. "We believe that governments, medical professional groups and individual health care professionals in countries such as the U.S., Canada and Australia should give greater consideration to the potential of e-cigarettes for increasing smoking cessation," Warner said. "E-cigarettes are not the magic bullet that will end the devastation wrought by cigarette smoking, but they can contribute to that lofty public health goal." Warner's previous research has found considerable evidence suggesting e-cigarettes are an effective smoking-cessation tool for adults in the U.S., where hundreds of thousands of people die of smoking-related illness each year. Electronic cigarettes are hand-held, battery-operated devices that heat a liquid containing propylene glycol and/or glycerin, flavoring compounds and typically nicotine to produce an aerosol that users inhale or vape. In addition to evaluating differences in regulatory activities across countries, the researchers examined evidence that vaping increases smoking cessation, the health consequences of e-cigarettes and the implications for clinical care. They also cite the Food and Drug Administration's designating some e-cigarette brands as "appropriate for the protection of the public health"—the standard required to receive approval for marketing. This action, the researchers say, implies indirectly that the FDA believes e-cigarettes can help some individuals quit smoking who would not do so otherwise. Warner and colleagues concluded that "acceptance of the promotion of e-cigarettes as a tool for smoking cessation will likely depend on continuing efforts to reduce access to, and use of, the products by young people who have never smoked. The two objectives can and should co-exist." 

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Primary acre COPD screening tool shows mixed results

New York, NY - The five-question CAPTURE window screening tool showed high specificity but low sensitivity in detecting undiagnosed chronic obstructive pulmonary disease (COPD) in primary care. Of 110 patients with undiagnosed but clinically significant COPD, 53 had a positive result on CAPTURE with a specificity of 88.6% (95% CI 87.6%-89.6%) and a sensitivity of 48.2% (95% CI 38.6%-57.9%), reported Fernando J. Martinez, MD, MS, of Weill Cornell Medicine in New York City, and colleagues, in JAMA. The area under the receiving operator curve (AUC) was 0.81 (95% CI 0.77-0.85) for various positive screening thresholds. "The goal with trying to find COPD is to treat it earlier, which will help make patients feel better and hopefully prevent their disease from progressing," Martinez said in a statement. COPD is underdiagnosed in primary care and is the leading cause of death and morbidity, the researchers noted. "Undiagnosed patients experience impaired health status and greater risk of acute respiratory events, health care use, and all-cause mortality," they wrote. "Although there is insufficient evidence to support COPD screening in asymptomatic individuals, identifying patients with respiratory symptoms has been suggested." Whether the CAPTURE (COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk) screening tool is up to that task remains to be seen. "Sensitivity was influenced by the high proportion of individuals with airflow obstruction but limited respiratory symptoms; specificity was influenced by high prevalence of respiratory symptoms among those with a normal spirometry result," Martinez and co-authors noted. "Overall, this study demonstrates the challenge of identifying undiagnosed patients with COPD in primary care." For the cross-sectional study, 4,679 primary care patients (mean age 61.6; 63% female; predominantly white) without a prior COPD diagnosis were enrolled at seven U.S. primary care-based research networks from October 2018 to April 2022. A total of 4,325 people had data adequate for analysis. Of these, 44.6% had ever smoked cigarettes, 18.3% had a prior asthma diagnosis or used inhaled respiratory medications, 13.2% currently smoked cigarettes, and 10% reported at least one cardiovascular comorbidity. CAPTURE included questions on a patient's ability to breathe during physical activity; exposure to forms of smoke, dust, or pollution; change in breathing as a result of seasons, air quality, or weather; ease of fatigue versus peers; and lapses in work, school, or other activities due to colds, bronchitis, or pneumonia. Questionnaire scores can range from 0-6 with larger scores indicating symptoms, acute respiratory illness, or greater respiratory exposure. Positive results were defined as scores at ≥5, or scores 2, 3, or 4 that were accompanied by further spirometry and a peak expiratory flow rate (PEFR) below 350 L/min for males or below 250 L/min for females. Clinically significant COPD was defined as spirometry-defined COPD combined with either forced expiratory volume in the first second of expiration (FEV1), less than 60% of the predicted value, or a self-reported history of acute respiratory illness in the past year. Martinez's group noted this definition "was based on older criteria that focused on the severity of airflow obstruction and prior respiratory illnesses," whereas more up-to-date Global Initiative for Chronic Obstructive Lung Disease (GOLD) therapeutic strategies are dependent on symptoms and respiratory illness. Overall, 12.3% of all patients received a positive result for clinically significant for COPD via CAPTURE; of those, 43.8% obtained a result based solely on the questionnaire, while 56.2% received a positive result from CAPTURE plus PEFR. Among patients with a positive screening result, 88.7% had either COPD, a preserved ratio impaired spirometry result, or were symptomatic but with a normal spirometry result compared with 43.4% of patients with a negative screening result. One benefit of CAPTURE is that it can push physicians to escalate assessment of patients with respiratory symptoms, particularly if spirometry is too difficult to integrate into a brief primary care office visit, the researchers noted. "CAPTURE was designed to be easy for physicians to use," said Antonello Punturieri, MD, PhD, of the National Heart, Lung, and Blood Institute, which helped develop the tool. "The screening is simple, takes less than a minute, and helps identify adults with trouble breathing who should be evaluated further," he said in a statement. The sensitivity of CAPTURE needs improvement, Martinez and colleagues acknowledged. One possible strategy for boosting results "would be to consider using an alternate definition of clinically significant COPD that would be congruent with the current GOLD recommendations for treatment initiation," they wrote. "Evaluation is ongoing to optimize the approach and composition  of the CAPTURE screening tool's questions." 

For more information: https://tinyurl.com/mrxu2knd 

COPD World News - Week of March 5, 2023

Geneva, Switzerland: The European Respiratory Society (ERS) is supporting an ambitious goal of the European Citizens’ Initiative to achieve a tobacco-free environment and the first European tobacco-free generation by 2030. ERS calls on its network to join the new campaign, launched recently by the European Citizens’ Initiative, which urges European Union citizens to get behind calls for a tobacco-free environment and generation. The campaign has until January 2024 to gather one million signatures across the European Union. Once it reaches one million validated signatures, the European Commission is obliged to respond and take action. Any EU citizen, who is old enough to vote in European Parliament elections, can sign. The campaign aims to achieve several key objectives, including: Promote the first tobacco-free European generation by 2028, ending the sale of tobacco and nicotine products to citizens born since 2010. Create a European Net of tobacco-free and butts-free beaches and riverbanks, making this spaces more healthy and environmentally sustainable. Establish a European Net of tobacco-free and butts-free National Parks, making them healthier, reducing contamination and risk of fires. Extend outdoor smoke and vapor-free spaces, especially those frequented by minors (parks, swimming pools, sports events and centers, shows and restaurants terraces). Eliminate tobacco advertising and presence in audiovisual productions, social media, specially addressing covert advertising through influencers and product placement. Finance research and development projects for diseases caused by tobacco use to improve their prognosis and make them curable. Tobacco usage is the leading cause of preventable disease and premature death across Europe. The European Citizens’ Initiative’s campaign aligns with ERS policy on Tobacco Control. Prof. Carlos Robalo Cordeiro, ERS President, said: “Smoking/tobacco use remains to be a major concern for ERS, considering it is one of the main three factors which cause respiratory illness.” Helping people to stop smoking and cutting tobacco use is the most cost-effective health intervention we can make to prevent illnesses such as lung cancer, chronic lung diseases and countless other health problems. Estimates from the European Cancer Information System (ECIS), indicate that in 2020, almost 260,000 people may have died in the EU from lung cancer. Cigarette smoking is also estimated to cause 82 percent of lung cancer cases in Europe (EC/IARC 2015), and exposure to SHS has also been established to cause lung cancer. Globally, the WHO European Region has the highest prevalence of tobacco smoking among adults (28 percent). The WHO also estimates that the proportion of deaths from non-communicable diseases attributable to tobacco use in Europe was 18 percent in 2015, meaning that almost one in every five of deaths from non-communicable diseases could be avoided if tobacco use was eliminated altogether from the region. 

For more information: https://tinyurl.com/fyv6wajr

Chicago, IL - Quality of care for patients with acute exacerbations of COPD did not improve after the Hospital Readmissions Reduction Program was put in place compared with the period prior to the program’s implementation, according to study results. “Our hypothesis was that the Medicare Hospital Readmission Reduction Penalty would facilitate improved quality of care for patients with COPD through efforts to reduce readmissions,” Valerie G. Press, MD, MPH, FACP, FAAP, SFHM, ATSF, associate professor of medicine and pediatrics and executive medical director of specialty value-based care at The University of Chicago, told Healio. “While it was not unexpected that quality of care was improving prior to the implementation of the Medicare penalty, we did not expect that the rate of improvement would slow post-penalty implementation.” In a retrospective cohort study published in American Journal of Respiratory and Critical Care Medicine, Press and colleagues used data from the Premier Healthcare database to analyze the quality of care patients hospitalized with acute exacerbations of COPD aged older than 40 years received across 995 U.S. hospitals before and after COPD exacerbations became a condition of the Hospital Readmissions Reduction Program (HRRP) in October 2014. Researchers tracked changes in quality of care by evaluating adherence to recommended inpatient care treatments (including chest radiography, systemic corticosteroids, bronchodilators, and antibiotics) and non-recommended care (sputum examinations, acute spirometry, mucolytic agents or methylxanthine bronchodilators). They defined ideal care as receiving only the recommended care. The analysis included data of 662,842 patients (mean age, 67 years; 60% women; 75% white) before HRRP was implemented from January 2010 to September 2014 and 285,508 patients (mean age, 67 years; 61% women; 77% white) after HRRP was implemented from October 2014 to December 2018. Based on the findings, HRRP did not improve quality of care. Researchers found that use of recommended care only increased by 0.01% per month with HRRP compared with an increase of 0.16% per month before HRRP (P < .001). Per month, patients receiving non-recommended care decreased by 0.13% after HRRP, which was less than the decrease of 0.15% per month before HRRP implementation. Compared with the rate before HRRP, HRRP implementation was related to a lower increase in ideal care per month (0.11% vs. 0.24%; P < .001). Two important findings came out of these results. “First, clinicians need to remain vigilant about providing ideal care to our patients hospitalized with COPD exacerbations including providing guideline-recommended care and not providing care that is not recommended,” she said. “Second, policy only may not be sufficient to galvanize improved adherence to clinical guidelines such that system-based approaches are needed to facilitate providing high quality and value of care. “Ideally, future studies on the quality of care provided to patients hospitalized with COPD can evaluate both the clinical inpatient treatments as well as the care transition interventions provided across in-patient and outpatient settings to better ensure patients with COPD are supported to have high quality of life without repeat COPD exacerbations and/or the need to be re-hospitalized,” Press added. 

For more information: https://tinyurl.com/yfed4xsv

Study finds new association between social isolation and dementia risk factors

Montreal, PQ - Social lifestyle determinants, including social isolation, are associated with neurodegeneration risk factors, according to a new study published this week in the open-access journal PLOS ONE by Kimia Shafighi of McGill University, Canada, and colleagues. Alzheimer's disease and related dementias (ADRD) is a growing public health crisis, with an annual global cost of more than $1 trillion US. There has been increasing evidence that social isolation is associated with an increased risk of ADRD, but the links between social lifestyle and other known ADRD risk factors are less well understood. In the new work, the researchers studied data on 502,506 UK Biobank participants and 30,097 people enrolled in the Canadian Longitudinal Study of Aging. Both studies had questionnaires that included questions about loneliness, frequency of social interaction and social support. The study found a large array of associations between potentially modifiable ADRD risk factors and both loneliness and lack of social support. Individuals who smoked more, excessively drank alcohol, experienced sleep disturbances, and failed to frequently participate in light to vigorous physical activities—all known risk factors for ADRD—had greater odds of being lonely and lacking social support. For instance, in the CLSA, increased regular participation in physical exercise with other people was associated with a 20.1% decrease in the odds of feeling lonely and 26.9% decrease in having poor social support. Physical and mental health factors previously linked to ADRD, such as cardiovascular disease, vision or hearing impairment, diabetes and neurotic and depressive behaviors, were also associated with both subjective and objective social isolation. In the UKBB, for instance, difficulty to hear with background noise corresponded to a 29.0% increase in the odds of feeling lonely and a 9.86% increase in the odds of lacking social support. The odds of feeling lonely and lacking social support were also 3.7 and 1.4 times greater, respectively, as a function of a participant's score for neuroticism. The authors conclude that social isolation, which can be modified more easily than genetic or underlying health risk factors, might be a promising target for preventive clinical action and policy interventions. The authors add, "Given the uncertain impact of social distancing measures imposed by COVID-19, our findings underscore the importance of investigating the multiscale effect of social isolation to inform public health interventions for ADRD." 

For more information: https://tinyurl.com/3yum8bby

Chest sensors allow remote 6-minute walk testing for lung patients

Rochester, NY - Chest sensors that measured heart rate and accelerometry enabled patients with pulmonary artery hypertension to undergo 6-minute walk tests remotely with similar data as those collected in clinic, according to study results in CHEST. Measuring cardiac effort rather than distance walked can overcome prior limitations of exercise tolerance home assessment, according to researchers. “We think this home 6-minute walk test could complement telemedicine or help when assessing clinical status or titrating a drug,” Daniel J. Lachant, DO, assistant professor of medicine at University of Rochester Medical Center, told Healio. In a single-center, prospective observational study, Lachant and colleagues evaluated 20 patients (median age, 59 years; 80% women) with PAH to see if a chest-based accelerometer (BioStamp nPoint, MC10 Inc.) that collects ECG heart rate data can accurately and safely estimate 6-minute walk test (6MWT) distance at home. Researchers also evaluated if cardiac effort — measured as the total number of heart beats during the test divided by the total distance walked — served as a better remote measure than distance walked. In the span of 2 weeks, patients took two 6MWTs in the clinic (first and last) and two to four 6MWTs remotely on their own schedules while wearing the sensors. Researchers compared the clinic and remote data using Wilcoxon matched-pairs signed rank tests, Spearman correlation coefficients and Bland-Altman plots. Of the patients, 30% had idiopathic PAH, 60% had connective tissue disease-related PAH and 10% had repaired congenital heart disease-related PAH. Based on data from 38 clinic 6MWTs, researchers found a strong correlation between walk distance estimated by the accelerometer-derived count of laps and directly measured distance (r = 0.99; P < .0001). Similarly, researchers observed a strong correlation between both estimated and reported remote 6MWTs distances (r = 0.81; P < .0001), with an average difference between the two of 2.8% (± 12.9%), which researchers wrote could reflect patient counting error or premature turns. When comparing median sensor-estimated walk test distances, the remote 6MWT was shorter compared with the clinic 6MWT (389 m vs. 405 m; P = .002). In terms of cardiac effort, researchers observed no difference between clinic measurements and remote measurements (1.75 beats/m; 95% CI, 1.48-2.2 vs. 1.85 beats/m; 95% CI, 1.57-2.14), which they said suggests cardiac effort is a less variable measure than distance walked and can correct for several factors such as more turns taken in smaller walking spaces or having no staff. “We started this in the first year of the COVID-19 pandemic when there was still a lot of uncertainties,” Lachant told Healio. “Our patients were very creative in the places they chose to complete the home 6-minute walk test. We were happy to find out that after adjusting for heart rate there was a similar measurement obtained in the clinic and home setting. “[In terms of future studies,] this data opens the idea of doing decentralized clinical trial with physiologic assessment remotely,” Lachant added. 

For more information:https://tinyurl.com/yk67x6yv

Exacerbations hasten emphysema progression in former smokers with COPD

Birmingham, AL - Former smokers with COPD who experienced exacerbations had larger lung density declines than those without exacerbations, according to a letter to the editor published in Annals of the American Thoracic Society. “We found a stepwise greater loss of lung density with increasing exacerbation frequency, predominantly in former smokers who already had some pre-existing emphysema,” Surya P. Bhatt, MD, MSPH, associate professor of medicine in the division of pulmonary, allergy and critical care medicine at the University of Alabama School of Medicine and medical director of the UAB Pulmonary Function and Exercise Physiology Lab, and colleagues wrote. Data were derived from Bhatt SP, et al. Ann Am Thoracic Soc. 2022; doi:10.1513/Annals ATS.202112-1385RL. Using data from the COPDGene study, Bhatt and colleagues analyzed 3,874 adults (mean age, 63.4 years; 50.2% women; 25% African American)  with COPD, either current (n = 1,522) or former persistent (n = 2,352) smokers, to find out if acute exacerbations are related to quicker emphysema progression. Patients underwent spirometry and CT at study enrollment and after 5 years, and researchers tracked patients’ interval exacerbations every 3 to 6 months within the study period. Of the total cohort, 1,829 patients had Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 0, 357 had GOLD stage 1, 756 had GOLD stage 2, 365 had GOLD stage 3 and 87 had GOLD stage 4 disease at baseline. Researchers characterized patients based on exacerbation frequency over 5 years: 2,590 (67%) patients had no exacerbations, 1,284 (33%) had at least one exacerbation, 864 (22%) had one to four exacerbations and 420 (11%) had at least five exacerbations. Adjusting for variables such as age, sex, race and BMI, researchers found that a higher number of exacerbations was linked to larger adjusted lung density declines among patients who formally smoked. Former smokers who had five or more exacerbations had a –5.22 g/L (95% CI, –6.23 to –4.21) change in lung density compared with a change of –4.16 g/L (95% CI, –4.91 to –3.41) among those who had one to four exacerbations and a change of –3.27 g/L (95% CI, –3.81 to –2.74) among those with no exacerbations (P < .0001 for all). Adjusted lung density estimates include aging effects, which researchers estimated to be 0.36 g/L per year. Researchers reported similar findings when evaluating former smokers with at least 5% emphysema (5 exacerbations, –5.92 g/L, 95% CI, –7.13 to –4.71; 1-4 exacerbations, –4.68 g/L, 95% CI –5.67 to –3.69; no exacerbations, –3.73 g/L, 95% CI, –4.6 to –2.87), although this association did not occur for those with less than 5% emphysema at baseline regardless of smoking status. On the other hand, patients who actively smoked had greater mean adjusted lung density changes than former smokers ( 5 exacerbations, –5.61 g/L, 95% CI, –7.39 to –3.83; 1-4 exacerbations, –5.58 g/L, 95% CI –6.84 to –4.32; no exacerbations, –4.89 g/L, 95% CI, –5.63 to –4.16), but researchers did not find the same effect modification that they found in the former smoker group. “Exacerbations are related to emphysema progression in a dose-dependent manner,” Bhatt and colleagues wrote. “Even low exacerbation frequency is associated with a high risk of emphysema progression, especially once emphysema has already set in. As emphysema is irreversible, these results underscore the importance of preventing exacerbations.” 

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Patients with COPD face high mortality risk, costs in year after surgery

Toronto, ON - One year after surgery, patients with COPD had a greater risk for mortality and higher health care costs than those without COPD, according to a study published in Canadian Medical Association Journal. “A big take-away from this study is that these patients are at increased risk of death and incur higher health care costs beyond 30 days after surgery,” said Ashwin Sankar, MD, MSc, FRCPC, clinician investigator in anesthesiology and perioperative medicine at St. Michael’s Hospital and University of Toronto. “Other studies of outcomes in patients who undergo surgery have typically focused on the first 30 days, and this outcome may not adequately capture the overall burden of surgery and how long it may take patients to recover.” Data were derived from Sankar A, et al. CMAJ. 2022;doi:10.1503/cmaj.220733. In a retrospective population-based cohort study, Sankar and colleagues used linked health administrative databases to evaluate 932,616 patients (median age, 65 years; 59.9% women) aged 35 years or older undergoing an elective noncardiac surgery in Ontario from 2005 to 2019, including 170,482 (18.3%) patients with COPD. They used Cox proportional hazard models to determine differences in survival and a linear regression model with log-transformed costs to determine differences in health system costs 1 year after surgery between patients with and without COPD. Of the total cohort, a greater percentage of patients with COPD died within the 1-year study period (10.6% vs. 4.5%) and within 30-days after surgery (3.4% vs. 1.2%) than those without COPD. Compared with those without COPD, those with COPD had a higher risk for death in models partially adjusted for sociodemographic factors and procedure type (adjusted HR = 1.61; 95% CI, 1.58-1.64) and fully models that additionally considered comorbidities (aHR = 1.26; 95% CI, 1.24-1.29). Further, patients with COPD had 13.1% (95% CI, 12.7%-13.4%) greater total health care costs in partially adjusted models and 4.6% (95% CI, 4.3%-5%) greater total costs in fully adjusted models. Depending on the type of surgical procedure, the impact of COPD on cost differed; researchers noted that cost for these patients was greater after orthopedic and lower abdominal surgery. Researchers also found that frailty, cancer and procedure type altered the association between COPD and outcomes. “As a follow-up to this study, we are currently working on identifying whether there are subsets of COPD patients or specific features of COPD which make certain patients high risk for complications after surgery,” Sankar told Healio. “This work would also be informative to clinicians on which patients require further assessment prior to surgery, and potentially also need additional support after surgery.” Because these findings impact the everyday clinician, Sankar told Healio a few things they should keep in mind when treating patients with COPD. “First, our study quantifies the additional risks faced by patients with COPD,” he said. “Informing patients of risk of surgery is an important component of the informed-consent process prior to surgery. We would suggest that clinicians and patients weigh these risks when deciding to proceed with surgery. “Next, we found that COPD often coexists with other conditions like diabetes, coronary artery disease and frailty. What we would suggest to clinicians is to use COPD as a flag for other conditions, and to ensure that modifiable risk factors are optimized prior to surgery,” Sankar continued. “Lastly, our finding that patients with COPD are at risk beyond 30 days after surgery suggests that it may be worthwhile to additionally support these patients' recovery beyond the first month after surgery.” 

For more information: https://tinyurl.com/3ukpju93

Cutting back on smoking no help for dementia risk

Seoul, Korea - Quitting smoking was associated with a lower risk of dementia but cutting back was linked with an even higher risk, according to a Korean cohort study. In the study of nearly 800,000 participants, most of whom were men with a long history of smoking, those who quit over a median follow-up of 6.3 years had a significantly lower risk of all dementia compared with those who sustained their smoking habits (adjusted HR 0.92, 95% CI 0.87-0.97), reported Dong Wook Shin, MD, DrPH, MBA, of Sungkyunkwan University School of Medicine in Seoul, and co-authors. However, smoking reduction -- decreasing the number of cigarettes smoked by at least 50% per day -- was associated with an increased risk of dementia versus those who sustained their smoking intensity (aHR 1.25, 95% CI 1.18-1.33), while a more modest increased risk was seen for those who started smoking more (aHR 1.12, 95% CI 1.06-1.18), they noted in JAMA Network. "One possible explanation for this finding is the sick quitter phenomenon. A reduction or cessation of cigarette smoking could suggest behavioral changes toward a healthy lifestyle because of health concerns, considering the higher number of prevalent comorbidities in the reducer group than the sustainer group," Shin and team wrote. "In this context, the decreased risk of dementia associated with smoking cessation could be underestimated because of the sick quitter phenomenon. However, the protective association between smoking cessation and dementia despite the high number of comorbid conditions in those who quit suggests that the sick quitter or reducer phenomenon cannot solely explain the findings," they continued. Those who reduced their number of cigarettes by 20-50% per day saw a dementia risk that was not significantly different than the sustained smoking group (aHR 1.06, 95% CI 1.00-1.12). Shin and colleagues emphasized the need for encouragement and support for patients’ intent on quitting smoking, rather than focusing on reducing their cigarette use. "Despite the lack of benefits from smoking reduction for risk of dementia, a reduction-to-quit intervention may be an important first step toward smoking cessation," they noted. In analyses stratified by age, sex, and alcohol drinking, results were consistent with the main findings. The decreased risk of all dementia in participants who quit smoking was greater in those younger than 65 compared with those 65 and older (aHR 0.81 vs 0.97, P=0.003 for interaction), while there was no significant difference between men and women. The decreased risk of all dementia for those who quit smoking was also more prominent among alcohol drinkers compared with non-drinkers (aHR 0.84 vs 1.02, P<0.001 for interaction). This study included 789,532 participants ages 40 and older from the National Health Insurance Service database of Korea (95.8% men, mean age 52.2). They underwent biennial health exams in 2009 and 2011 and were current smokers at the first exam. They were followed until the end of 2018. Nearly 35% had been smokers for 30 years or longer, and 80.2% had been smoking for 20 years or more. At the time of the 2011 examination, 14.6% of participants had quit smoking, 21.9% had reduced smoking habits, and 15.9% had increased cigarette use. They were put into five groups, based on the changes made to their smoking intensity from the time of their first examination to their second: quitter, reducer I (at least 50% fewer cigarettes per day), reducer II (20-50% fewer per day), sustainer, or increaser (20% or more per day). During the median 6.3-year follow-up, 11,912 dementia events, including 8,880 cases of Alzheimer's disease and 1,889 cases of vascular dementia, were observed. Smoking cessation was associated with a significantly lower risk of vascular dementia (HR 0.84, 95% CI 0.73-0.97) but not Alzheimer's disease (HR 0.94, 95% CI 0.88-1.01). Shin and team acknowledged that the study being made up almost entirely of men was a limitation. In addition, they were unable to collect some information on dementia risk factors, such as education level and apolipoprotein E ε4 level. Information on second-hand smoking or use of products like electronic cigarettes was also not available. In addition, they noted that "because dementia progresses insidiously during the early stages, a follow-up duration of 6 years may not be sufficient to fully elucidate the associations between changes in smoking and risk of dementia." 

For more information: https://tinyurl.com/2s4jypf4

Most older patients with Chronic Obstructive Pulmonary Disease in good mental health

Toronto, ON - A majority of adults older than 50 years with COPD had no psychiatric disorders and had good mental health, according to a study published in International Journal of Environmental Research and Public Health. “Most of the previous research on COPD, including my own, has focused on those who are not doing well with respect to depression and anxiety,” Esme Fuller-Thomson, PhD, director of the Institute for Life Course and Aging at the University of Toronto and professor in the Factor-Inwentash Faculty of Social Work, told Healio. “The nationally representative findings of our current study are good news that should be shared with patients and their families. Knowing that most people with COPD are happy and mentally healthy may be very reassuring for the newly diagnosed. Results from this study suggest that many patients with COPD are “mentally flourishing” with more than four in every five without any psychiatric disorders and two-thirds in good mental health, according to the researchers. “However, since one in eight older adults with COPD are dealing with a mental illness, it is still important for clinicians to screen their COPD patients and to refer those who are struggling for therapy,” Fuller-Thomson added. “Individuals who are depressed or anxious can benefit from efficacious talk therapy such as cognitive behavioral therapy.” Fuller-Thomson and colleagues used data from the 2012 Canadian Community Health Survey–Mental Health to identify adults aged 50 years or older, 703 of whom (55.9% women) had COPD and 10,189 of whom (50.2% women) did not have COPD. Researchers performed bivariate and logistic regression analyses to compare the mental health — measured via the absence of psychiatric disorders (APD) and complete mental health (CMH) or being free from mental illness — between these two groups. They also sought to determine the factors linked to having no psychiatric disorders and being in good mental health among patients with COPD. To measure APD, individuals reported whether they had experienced depressive disorders, anxiety disorders, bipolar disorders, substance dependence or suicidal ideation in the past year. CMH was classified as APD in the past year plus nearly daily emotional well-being (such as life satisfaction or happiness) and high accounts of social and psychological well-being in the past month, as assessed by the Mental Health Continuum-Short Form (MHC-SF). Overall, researchers found that patients with COPD had a significantly lower frequency of APD (86.7% vs. 95%) and CMH (66.7% vs. 77%; P < .001 for both) than individuals without COPD. Despite these differences, these results suggest that many patients with COPD are “mentally flourishing” with more than four in every five without any psychiatric disorders and two-thirds in good mental health, according to the researchers. “COPD is a very serious and potentially fatal condition, so we were amazed to learn that the vast majority of older adults with COPD were free of any mental illness,” said Fuller-Thomson. 

For more information: https://tinyurl.com/2pnhmbex

Nearly half of deaths for 12 cancers in California are due to tobacco, higher than previously reported

Sacramento, CA - Despite California's success in reducing tobacco use, a new study published today in JAMA Network Open demonstrates the continued and significant burden tobacco inflicts on people with cancer. The study was conducted by researchers at UC Davis Comprehensive Cancer Center who used data collected from the California Cancer Registry, a state-mandated population-based cancer surveillance system managed by UC Davis. The study looked at people diagnosed with one of 12 tobacco-related cancers from 2014-2019 in California. The analyses showed that close to half of the cancer deaths over two years between 2017-2019, totaling 93,764 Californians, were associated with tobacco use. "This is almost double what was previously estimated in a study that looked at 2014 data," said California Cancer Registry researcher Frances Maguire, who is the lead author of the study. "However, we believe this is a more accurate representation since tobacco use data came directly from individual patients with cancer rather than estimates based on general population surveys. This study is also specific to the 12 tobacco-related cancers." From 2014-2016 to 2017-2019, there was a decline in the proportion of deaths due to smoking from 48% to 45%, with larger declines for women compared with men. The overall number of smoking-attributed cancer deaths declined by approximately 10%. "Our analyses of changes over the two time periods suggest promising trends in tobacco behavior among Californians newly diagnosed with cancer, which could be related to the state's ongoing tobacco control efforts," senior author of the study UC Davis Health internist and tobacco researcher Elisa Tong said. In November 2016, a $2 per pack tobacco tax was passed by California voters, which also helps support the activities of the California Tobacco Control Program. However, a separate study did not find that the smoking behavior in the general population had decreased significantly. However, the overall quit ratio in the study, at 69.6%, is a little higher than the general population in California of 65.9%. There was also an increase in this ratio over the two time periods, which reflects improvement after the implementation of the state tax. "Current tobacco use among the people diagnosed with cancer was higher than among the general population but decreased over time," said Maguire. "This suggests that tobacco control efforts have contributed to a decline in cancer mortality in California, but smoking cessation efforts targeted at patients with cancer are needed." Over half (57.6%) of Californians in the cancer study had used tobacco at some point and current tobacco use was higher than the general population (17.5% vs. 11%), totaling 69,103 patients. "What is important to note in the study findings is the number of Californians diagnosed with these 12 types of cancers that still use tobacco: about 1 in 5 men (19.6%) and 1 in 7 women (14.5%). Some people with lung cancer or laryngeal cancer had even higher use rates at 30-37%," Tong said. "It's important to remember that it's never too late to quit smoking even after a cancer diagnosis because quitting can improve cancer treatment outcomes and significantly reduce mortality." Tobacco status data used in the study included use of cigarettes, other smoked tobacco products (such as cigars and pipes) and smokeless tobacco products (such as chewing tobacco and snuff). The use of vaping products is not yet collected by the registry. The study results showed that among the nearly 400,000 patients diagnosed with a tobacco-related cancer from 2014-2019, most were over 60 years old (72.3%). The majority (57.7%) were non-Hispanic white, were men (58%) and nearly half (46.6%) had lung or colorectal cancers. The greatest number of deaths attributable to tobacco, for both men and women, were from cancers of the lung and bladder.  "Smoking remains the largest preventable cause of death from cancer and other diseases," said UC Davis researcher Theresa Keegan, study co-author and co-principal investigator with the California Cancer Registry. "This study shows that tobacco continues to kill Californians with cancer at an alarming rate. Cancer registries can play an important role in monitoring progress for this priority population." 

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2023 GOLD report reflects COPD field that is improving on a trajectory for the better

Philadelphia, PA - The 2023 Global Initiative for Chronic Obstructive Lung Disease report defines several changes regarding definitions, assessment tools and treatments for COPD, all of which underscore recent advances in the field.“ COPD is not a stagnant disease,” Gerard J. Criner, MD, FACP, FACCP,  director of the Global  Initiative for Chronic Obstructive Lung Disease (GOLD) International COPD conference, told Healio. “The report identifies disease-modification therapies because we’re improving outcomes and we’re changing mortality, which should give patients and clinicians hope that the field is improving on a trajectory for the better.” To learn more about the updates made in the 2023 GOLD COPD report, “Global Strategy for the Diagnosis, Management and Prevention of COPD,” Healio spoke with Criner about the key changes that were presented at the conference. One overarching significant change in the report is a revised definition of COPD that is more all-encompassing of the demographic that can develop COPD, according to Criner, who also serves as chair and professor of thoracic medicine and surgery at Lewis Katz School of Medicine at Temple University. “The modification of the definition acknowledged that it’s not just people who have been exposed to cigarette smoke but other types of exposures, such as biomass fuels,” Criner said. “The definition also includes people who work in jobs that expose them to a variety of conditions or poor climate. Additionally, it addresses a variety of host factors that may occur in the U.S., as well as non-U.S., such as being born premature or having a lot of childhood infections.” Along with this change in definition, the report also gives more attention to the roles chronic bronchitis and mucus hypersecretion play in the development of COPD and the pathogenesis of airflow obstruction. The 2023 report also has more information on the role of imaging and CT in diagnosing and managing COPD, highlighting the fact that CT has become increasingly available, leading to greater understand of COPD phenotypes, severity and outcomes. The report specifically recommends considering CT for patients with COPD and: persistent exacerbations; symptoms that exceed disease severity based on lung function testing; FEV1 less than 45% predicted with significant hyperinflation; who meet criteria for lung cancer screening. “We have written more about imaging and the importance of imaging to detect abnormalities that may exist in people with COPD that doesn’t cause airflow obstruction in its earlier stages,” Criner said. “The changes reflect that the importance of imaging is more ubiquitous, especially since the imaging with lung cancer screening and people who have been smoke-exposed determine structural abnormalities that may occur and may indicate people who are at greater risk to develop airflow obstruction. “The hope is to determine factors that may contribute to COPD earlier in life, so we can intercede and maybe transform the development or alter the trajectory,” he added. 

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