Abstract Choices for the treatment of type 2 diabetes mellitus (T2DM) have multiplied as our understanding of the underlying pathophysiologic defects has evolved. Treatment should target multiple ...defects in T2DM and follow a patient-centered approach that considers factors beyond glycemic control, including cardiovascular risk reduction. The American Association of Clinical Endocrinologists/American College of Endocrinology and the American Diabetes Association recommend an initial approach consisting of lifestyle changes and monotherapy, preferably with metformin. Therapy choices are guided by glycemic efficacy, safety profiles, particularly effects on weight and hypoglycemia risk, tolerability, patient comorbidities, route of administration, patient preference, and cost. Balancing management of hyperglycemia with the risk of hypoglycemia and consideration of the effects of pharmacotherapy on weight figure prominently in US-based T2DM recommendations, whereas less emphasis has been placed on the ability of specific medications to affect cardiovascular outcomes. This is likely because, until recently, specific glucose-lowering agents have not been shown to affect cardiorenal outcomes. The Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients–Removing Excess Glucose (EMPA-REG OUTCOME), the Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER) trial, and the Trial to Evaluate Cardiovascular and Other Long-term Outcomes with Semaglutide in Subjects with Type 2 Diabetes 6 (SUSTAIN-6) recently showed a reduction in overall cardiovascular risk with empagliflozin, liraglutide, and semaglutide treatment, respectively. Moreover, empagliflozin has become the first glucose-lowering agent indicated to reduce the risk of cardiovascular death in adults with T2DM and established cardiovascular disease. Results from cardiovascular outcomes trials have prompted an update to the 2017 American Diabetes Association standards of care, which now recommend consideration of empagliflozin or liraglutide for patients with suboptimally controlled long-standing T2DM and established atherosclerotic cardiovascular disease because these agents have been shown to reduce cardiovascular and all-cause mortality when added to standard care.
Choices for the treatment of type 2 diabetes mellitus (T2DM) have multiplied as our understanding of the underlying pathophysiologic defects has evolved. Treatment should target multiple defects in ...T2DM and follow a patient-centered approach that considers factors beyond glycemic control, including cardiovascular risk reduction. The American Association of Clinical Endocrinologists/American College of Endocrinology and the American Diabetes Association recommend an initial approach consisting of lifestyle changes and monotherapy, preferably with metformin. Therapy choices are guided by glycemic efficacy, safety profiles, particularly effects on weight and hypoglycemia risk, tolerability, patient comorbidities, route of administration, patient preference, and cost. Balancing management of hyperglycemia with the risk of hypoglycemia and consideration of the effects of pharmacotherapy on weight figure prominently in US-based T2DM recommendations, whereas less emphasis has been placed on the ability of specific medications to affect cardiovascular outcomes. This is likely because, until recently, specific glucose-lowering agents have not been shown to affect cardiorenal outcomes. The Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients–Removing Excess Glucose (EMPA-REG OUTCOME), the Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER) trial, and the Trial to Evaluate Cardiovascular and Other Long-term Outcomes with Semaglutide in Subjects with Type 2 Diabetes 6 (SUSTAIN-6) recently showed a reduction in overall cardiovascular risk with empagliflozin, liraglutide, and semaglutide treatment, respectively. Moreover, empagliflozin has become the first glucose-lowering agent indicated to reduce the risk of cardiovascular death in adults with T2DM and established cardiovascular disease. Results from cardiovascular outcomes trials have prompted an update to the 2017 American Diabetes Association standards of care, which now recommend consideration of empagliflozin or liraglutide for patients with suboptimally controlled long-standing T2DM and established atherosclerotic cardiovascular disease because these agents have been shown to reduce cardiovascular and all-cause mortality when added to standard care.
Background and aims
Social norms towards smoking are a key concept in tobacco control policy and research. However, the influence and strength of different types of social norms on youth smoking ...uptake is unclear. This study aimed to examine, quantify and compare evidence of the longitudinal associations between different types of social norms towards smoking and youth smoking uptake (initiation and escalation).
Methods
Systematic review searching four databases (MEDLINE, EMBASE, PsycInfo, CINAHL) from January 1998 to October 2020. Evidence synthesis via narrative review, meta‐analysis pooling unadjusted associations (initiation only, due to heterogeneity in escalation outcomes) and meta‐regression comparing effect sizes by norm type and study characteristics. Studies included observational prospective cohort studies using survey methodology with youth aged ≤24 years. Measurements included longitudinal associations between descriptive norms (perceived smoking behaviour) and injunctive norms (perceived approval/disapproval of smoking) among social network(s) and subsequent smoking initiation or escalation.
Results
Thirty articles were identified. In the narrative review, smoking initiation (but not escalation) was consistently predicted by two norms: parental and close friend smoking. Associations between smoking uptake and other descriptive norms (smoking among siblings, family/household, partner, peers, adults) and all injunctive norms (perceived approval of smoking among parents, siblings, close friends/peers, partner, teachers, people important to you, the public) were less consistent or inconclusive. In the meta‐analysis pooling unadjusted associations, 17 articles were included (n = 27 767). Smoking initiation was predicted by the following descriptive norms: smoking among parents Odds Ratio (OR) = 1.88, 95% Confidence Interval (CI) = 1.56–2.28, close friends (OR = 2.53, 95% CI = 1.99–3.23), siblings (OR = 2.44, 95% CI = 1.93–3.08), family/household (OR = 1.55, 95% CI = 1.36–1.76) and adults (OR = 1.34, 95% CI = 1.02–1.75), but not peers (OR = 1.14, 95% CI = 0.92–1.42). Smoking initiation was also predicted by two injunctive norms, perceived approval of smoking among parents (OR = 1.74, 95% CI = 1.27–2.38) and the public (OR = 4.57, 95% CI = 3.21–6.49), but not close friends/peers (OR = 2.36, 95% CI = 0.86–6.53) or people important to the individual (OR = 1.24, 95% CI = 0.98–1.58).
Conclusions
In this systematic review (narrative and meta‐analysis), descriptive norms of parents’ and close friends’ smoking behaviour appeared to be consistent predictors of youth smoking initiation, more so than the descriptive norms of more distal social networks and injunctive norms.
Tobacco smoking is often more prevalent among those with lower socio-economic status (SES) in high-income countries, which can be driven by the inequalities in initiation and cessation of smoking. ...Smoking is a leading contributor to socio-economic disparities in health. To date, the evidence for any socio-economic inequality in smoking cessation is lacking, especially in low- and middle-income countries (LMICs). This study examined the association between cessation behaviours and SES of smokers from eight LMICs.
Data among former and current adult smokers aged 18 and older came from contemporaneous Global Adult Tobacco Surveys (2008-2011) and the International Tobacco Control Surveys (2009-2013) conducted in eight LMICs (Bangladesh, Brazil, China, India, Mexico, Malaysia, Thailand and Uruguay). Adjusted odds ratios (AORs) of successful quitting in the past year by SES indicators (household income/wealth, education, employment status, and rural-urban residence) were estimated using multivariable logistic regression controlling for socio-demographics and average tobacco product prices. A random effects meta-analysis was used to combine the estimates of AORs pooled across countries and two concurrent surveys for each country.
Estimated quit rates among smokers (both daily and occasional) varied widely across countries. Meta-analysis of pooled AORs across countries and data sources indicated that there was no clear evidence of an association between SES indicators and successful quitting. The only exception was employed smokers, who were less likely to quit than their non-employed counterparts, which included students, homemakers, retirees, and the unemployed (pooled AOR≈0.8, p<0.10).
Lack of clear evidence of the impact of lower SES on adult cessation behaviour in LMICs suggests that lower-SES smokers are not less successful in their attempts to quit than their higher-SES counterparts. Specifically, lack of employment, which is indicative of younger age and lower nicotine dependence for students, or lower personal disposable income and lower affordability for the unemployed and the retirees, may be associated with quitting. Raising taxes and prices of tobacco products that lowers affordability of tobacco products might be a key strategy for inducing cessation behaviour among current smokers and reducing overall tobacco consumption. Because low-SES smokers are more sensitive to price increases, tobacco taxation policy can induce disproportionately larger decreases in tobacco consumption among them and help reduce socio-economic disparities in smoking and consequent health outcomes.
Abstract Purpose Assess the prevalence and correlates of e-cigarette perceptions and trial among adolescents in Mexico, where e-cigarettes are banned. Methods Cross-sectional data were collected in ...2015 from a representative sample of middle-school students (n = 10,146). Prevalence of e-cigarette awareness, relative harm, and trial were estimated, adjusting for sampling weights and school-level clustering. Multilevel logistic regression models adjusted for school-level clustering to assess correlates of e-cigarette awareness and trial. Finally, students who had tried only e-cigarettes were compared with students who had tried: (1) conventional cigarettes only; (2) both e-cigarettes and conventional cigarettes (dual triers); and (3) neither cigarette type (never triers). Results Fifty-one percent of students had heard about e-cigarettes, 19% believed e-cigarettes were less harmful than conventional cigarettes, and 10% had tried them. Independent correlates of e-cigarette awareness and trial included established risk factors for smoking, as well as technophilia (i.e., use of more media technologies) and greater Internet tobacco advertising exposure. Exclusive e-cigarette triers (4%) had significantly higher technophilia, bedroom Internet access, and Internet tobacco advertising exposure compared to conventional cigarette triers (19%) and never triers (71%) but not compared to dual triers (6%), although dual triers had significantly stronger conventional cigarette risk factors. Conclusions This study suggests that adolescent e-cigarette awareness and use is high in Mexico, in spite of its e-cigarette ban. A significant number of medium-risk youth have tried e-cigarettes only, suggesting that e-cigarettes could lead to more intensive substance use. Strategies to reduce e-cigarette use should consider reducing exposures to Internet marketing.
AbstractObjectiveTo examine differences in vaping and smoking prevalence among adolescents in Canada, England, and the United States.DesignRepeat cross sectional surveys.SettingOnline surveys in ...Canada, England, and the US.ParticipantsNational samples of 16 to 19 year olds in 2017 and 2018, recruited from commercial panels in Canada (n=7891), England (n=7897), and the US (n=8140).Main outcome measuresPrevalence of vaping and smoking was assessed for use ever, in the past 30 days, in the past week, and on 15 days or more in the past month. Use of JUUL (a nicotine salt based electronic cigarette with high nicotine concentration) and usual vaping brands were also assessed. Logistic regression models examined differences in vaping and smoking between countries and over time.ResultsThe prevalence of vaping in the past 30 days, in the past week, and on 15 days or more in the past month increased in Canada and the US between 2017 and 2018 (P<0.001 for all), including among non-smokers and experimental smokers, with no changes in England. Smoking prevalence increased in Canada (P<0.001 for all measures), with modest increases in England, and no changes in the US. The percentage of ever vapers who reported more frequent vaping increased in Canada and the US (P<0.01 for all), but not in England. The use of JUUL increased in all countries, particularly the US and Canada—for example, the proportion of current vapers in the US citing JUUL as their usual brand increased threefold between 2017 and 2018.ConclusionsBetween 2017 and 2018, among 16 to 19 year olds the prevalence of vaping increased in Canada and the US, as did smoking in Canada, with little change in England. The rapidly evolving vaping market and emergence of nicotine salt based products warrant close monitoring.
•Early adolescents, who have tried e-cigarettes, but not cigarettes, were more likely to try conventional cigarettes 20 months later.•Dual trial of conventional cigarettes and e-cigarettes at ...baseline was associated with marijuana use at follow-up.•Trial of only e-cigarettes at baseline was not independently associated with marijuana use at follow-up.
This study evaluated whether e-cigarette trial among Mexican adolescents increased the likelihood of trial and use of conventional cigarettes or marijuana use at follow-up.
A school-based longitudinal survey was conducted in 60 public middle schools from the three largest cities in Mexico. Students (12–13 years old) were surveyed in 2015 and followed up 20 months later (n = 6574). Generalized estimating equations models were used to evaluate the association between e-cigarette trial at baseline and conventional cigarettes smoking and marijuana use at follow-up.
Adolescents who had tried e-cigarettes (but not cigarettes) at baseline were more likely to have tried conventional cigarettes at followup compared to adolescents who had tried neither e-cigarettes nor cigarettes (43% vs. 24%, respectively; RR 1.41, 95% CI 1.18-1.70). We also found that adolescents who had tried both conventional cigarettes and e-cigarettes at baseline were more likely to have tried marijuana at follow-up compared to adolescents who had tried neither tobacco product (20% vs. 4%, respectively; RR 2.67, 95% CI 1.78–4.02). Trial of only e-cigarettes was not independently associated with marijuana use at followup.
Adolescents who had tried e-cigarettes were more likely to have tried conventional cigarettes and marijuana 20 months later. Although e-cigarettes have been banned in Mexico, it is likely that additional policies and public health campaigns are needed to reduce adolescent use of e-cigarettes and its consequences.
Breastfeeding is recommended exclusively for the first 6 months after birth, with continued breastfeeding for at least 2 years. Yet prevalence of these recommendations is low globally, although it is ...an effective and cost-effective way to prevent serious infections and chronic illness. Previous studies have reported that social support greatly influences breastfeeding, but there is little evidence on perceived social norms in Mexico and how they affect actual behavior.
Our objective was to investigate breastfeeding intention, practices, attitudes, and beliefs, particularly normative, among low-resource communities in central and southern Mexico.
We performed a secondary analysis using the theory of planned behavior with cross-sectional data, which included semi-structured individual interviews with fathers (n 10), 8 focus groups with mothers (n 50), and 8 focus groups with women community leaders (n 44) with a total of 104 participants. Our data also included a quantitative survey among pregnant women and mothers (n 321).
Women reported supplementing breast milk with water and teas soon after birth, as well as introducing small bites of solid food a few months after birth. Social norms appeared to support breastfeeding, but not exclusive breastfeeding or breastfeeding for periods longer than about a year. This may be partially explained by: a) behavioral beliefs that for the first 6 months breast milk alone is insufficient for the baby, and that water in addition to breast milk is necessary to hydrate an infant and b) normative beliefs related to the appropriateness of breastfeeding in public and as the child gets older.
Future strategies should focus on positively influencing social norms to support recommended practices, and emphasize the specific reasons behind the recommendations. Future efforts should take a multi-pronged approach using a variety of influences, not only directed at healthcare providers but close family members, including fathers.
Countries have adopted various regulations to limit youth exposure to vaping product advertising. This study aims to examine youth exposure to and perceptions of vaping ads in Canada, England, and ...the US, three countries with varying vaping product advertising regulations. Data were analyzed from the 2017 ITC Youth Tobacco and Vaping Survey, an online survey of youth aged 16 to 19 years from a consumer panel (n = 12,064). The survey assessed vaping product ad exposure in the prior month, including channels, perceived appeal, and perceived target audience. Most young people reported some vaping product ad exposure in the past 30 days (Canada = 74%, England = 83%, US = 81%). Among those exposed to vaping product ads, more than one-third found them appealing (Canada = 36%, England = 38%, US = 43%). Stores that sell cigarettes were the most common venue for vaping ad exposure, although it was less common in Canada (46%) than in England (60%) or the US (60%), both of which had less restrictive regulatory environments. Ad exposure through websites or social media did not differ by country (Canada = 38%, England = 40%, US = 41%). Compared to those who never smoked or used vaping products, youth who reported smoking and/or vaping were more likely to report ad exposure through most channels. More than one-third of youth perceived that vaping product ads target non-smokers (Canada = 47%, England = 36%, US = 48%). Our study suggests most youth are exposed to vaping product ads, which may promote product use. Except for online channels, cross-country differences in the channels of ad exposure may reflect contrasting regulatory environments.
•Most youth (aged 16–19) reported vaping ad exposure in the prior month.•For most channels, ad exposure was more prevalent in countries with weaker policy.•For online channels, vaping ad exposure was similar across countries.•Youth who smoked or vaped were more likely to report exposure to vaping ads.•More than one-third of youth perceived ads as appealing and targeting non-smokers.
Some researchers have raised concerns that pictorial health warning labels (HWLs) on cigarette packages may lead to message rejection and reduced effectiveness of HWL messages. This study aimed to ...determine how state reactance (i.e., negative affect due to perceived manipulation) in response to both pictorial and text-only HWLs is associated with other types of HWL responses and with subsequent cessation attempts.
Survey data were collected every 4 months between September 2013 and 2014 from online panels of adult smokers in Australia, Canada, Mexico, and the US were analyzed. Participants with at least one wave of follow-up were included in the analysis (n = 4,072 smokers; 7,459 observations). Surveys assessed psychological and behavioral responses to HWLs (i.e., attention to HWLs, cognitive elaboration of risks due to HWLs, avoiding HWLs, and forgoing cigarettes because of HWLs) and cessation attempts. Participants then viewed specific HWLs from their countries and were queried about affective state reactance. Logistic and linear Generalized Estimating Equation (GEE) models regressed each of the psychological and behavioral HWL responses on reactance, while controlling for socio-demographic and smoking-related variables. Logistic GEE models also regressed having attempted to quit by the subsequent survey on reactance, each of the psychological and behavioral HWL responses (analyzed separately), adjustment variables. Data from all countries were initially pooled, with interactions between country and reactance assessed; when interactions were statistically significant, country-stratified models were estimated.
Interactions between country and reactance were found in all models that regressed psychological and behavioral HWL responses on study variables. In the US, stronger reactance was associated with more frequent reading of HWLs and thinking about health risks. Smokers from all four countries with stronger reactance reported greater likelihood of avoiding warnings and forgoing cigarettes due to warnings, although the association appeared stronger in the US. Both stronger HWLs responses and reactance were positively associated with subsequent cessation attempts, with no significant interaction between country and reactance.
Reactance towards HWLs does not appear to interfere with quitting, which is consistent with its being an indicator of concern, not a systematic effort to avoid HWL message engagement.
PDF
