Abstractboek. Prof. dr. Marc Willemsen Trends in tabaksonderzoek in Nederland van 2000 tot 2012

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1 Abstractboek Hartelijk welkom! Het Nederlands Netwerk voor Tabaksonderzoek (NNvT) is in 2013 opgericht om een platform te bieden aan het wetenschappelijk tabaksonderzoek in Nederland. Het is een netwerk van onderzoekers uit verschillende wetenschappelijk disciplines, van (pre-)klinisch onderzoek en farmacologie van nicotineverslaving tot epidemiologische studies en beleidsonderzoek. Het netwerk wordt mogelijk gemaakt door financiële ondersteuning van KWF Kankerbestrijding, de Nederlandse Hartstichting en het Longfonds. Jaarlijks wordt er een wetenschappelijk congres georganiseerd, waarvan dit het eerste is! Via de NNvT website kan je gericht zoeken naar individuele wetenschappers of collega wetenschappers die in Nederland actief zijn op het brede terrein van tabaksonderzoek ten behoeve van verbetering van de volksgezondheid. De aanvang van het congres is 9.30 u en de afsluiting is rond u. In de ochtend spreken, onder leiding van dagvoorzitter Prof. dr. Onno van Schayck, hoogleraar preventieve geneeskunde: Prof. dr. Marc Willemsen Trends in tabaksonderzoek in Nederland van 2000 tot 2012 Dr. Jacqueline Vink Genetische aspecten van tabaksverslaving Prof. dr. Arie Dijkstra Theoretische en praktische innovaties in stoppen-met-roken onderzoek: de Leer Abstinentie Theorie Direct na het lunchbuffet blijven we op de begane grond, waar Onno van Schayck de plenaire posterpitch begeleidt. Voor en na het lunchbuffet zijn parallelsessies gepland die verschillende disciplines van het tabaksonderzoek bestrijken. Er zijn sessies georganiseerd rondom uiteenlopende thema s, waarvan je hierna de volledige abstract informatie kunt vinden. Wij nodigen je graag uit voor de afsluiting met een informele receptie om u in de Kroonzaal. Vergeet voor je naar huis gaat niet het evaluatieformulier in te leveren, en ontvang in ruil daarvoor een cadeau in de vorm van een must-have voor iedere tabaksonderzoeker! Wij wensen je een inspirerende en leerzame dag toe! De Programma Commissie: Prof. dr. M. (Marc) Willemsen, UM Dr. J. (Jacqueline) Vink, VU Dr. Z. (Zeena) Harakeh, UU Dr. D. (Daniel) Kotz, UM Dr. M. (Margriet) van der Laar, Trimbos instituut Drs. R. (Regina) van der Meer, STIVORO 1

2 Abstracts De sessies die tijdens dit congres worden gehouden zijn in het programma chronologisch genummerd. Deze nummering komt overeen met de nummering van de abstracts. 1. Trends in tabaksonderzoek in Nederland van 2000 tot 2012 Marc Willemsen, Gera Nagelhout Universiteit van Maastricht, vakgroep Gezondheidsbevordering, en STIVORO Marc Willemsen, De effectiviteit van tabaksontmoediging hangt samen met de omvang en de kwaliteit van het wetenschappelijk onderzoek op dit gebied. In deze presentatie wordt deze Nederlandse wetenschappelijke output in de afgelopen 12 jaar beschreven. De Nederlandse output wordt vergeleken met de rest van Europa, zodat inzicht ontstaat in de onderzoeksthema s waar Nederland in vergelijking met andere Europese landen vóór- of achterloopt. De Nederlandse wetenschappelijke output is onderzocht voor de jaren 2000, 2004, 2008 en 2012 door middel van een inhoudsanalyse van de abstracts van tijdschriftpublicaties. Aan de hand van tabaksgerelateerde zoektermen in het titelveld werden alle tijdschriftpublicaties die een Engelstalige abstract bevatten geselecteerd uit PubMed, Web of Science, PsycInfo en Scopus. Na excludering van artikelen die geen betrekking hadden op tabaksontmoediging (bijvoorbeeld bosbranden, plantenonderzoek) en verwijdering van duplicaten bleven er 4,665 artikelen over voor codering. Belangrijke indelingen waren: epidemiologisch raamwerk ( agent, host, environment, vector ), soort product ( nicotine, tobacco, smokeless, electronic ), studie focus ( secondhand smoke, smoking initiation, smoking cessation, harm reduction ), maatregel ( smoking ban, taxation, advertising, warnings, campaigns ), en of de publicatie een van de volgende onderwerpen betrof : gezondheidsschade, socio-economisch verschillen, farmacotherapie, fundamenteel onderzoek ( basic science ). Het aantal tabaksgerelateerde publicaties in de 31 Europese landen nam toe van 780 in 2000 tot in In de presentatie zal een gedetailleerde beschrijving worden gegeven van inhoudelijke veranderingen binnen het Nederlandse tabaksonderzoek, in vergelijking met de andere Europese landen. Op basis van de resultaten van deze bibliometrische studie zullen aanbevelingen worden gedaan voor een Nederlandse tabaksonderzoeksagenda. 2. Genetische aspecten van tabaksverslaving Auteur: Jacqueline Vink Afdeling Biologische Psychologie, Vrije Universiteit Jacqueline Vink, jm.vink@vu.nl 2

3 Inleiding: Ondanks dat de schadelijke gevolgen van roken bekend zijn, rookt nog steeds een aanzienlijk deel van de Nederlandse bevolking. Wat zijn de oorzaken van individuele verschillen i n rookgedrag? Waarom beginnen sommige mensen wel met roken en anderen niet. En waarom kan de ene persoon gemakkelijk stoppen en begint de ander steeds opnieuw met roken? Speelt erfelijke aanleg hier een rol bij, of wordt rookgedrag met name beïnvloed door de omgeving? Methode: Met behulp van de gegevens van tweelingen en hun familie leden is onderzocht hoe groot de invloed van erfelijke aanleg is op de individuele verschillen in rookgedrag. In de afgelopen jaren is er ook veel onderzoek gedaan naar het in kaart brengen van de specifieke genen, onder andere door het doen van genoom-wijde associatie studies. Discussie: Wat is er tot nu toe bekend met betrekking tot de rol van erfelijke aanleg voor rookgedrag. Welke studies zijn er gedaan en hoe moeten we de resultaten interpreteren? Wat zijn de volgende stappen bij het in kaart brengen van de genetische aspecten van tabaksverslaving? En wat betekent dit voor mensen die willen stoppen met roken en voor hulpverleners? 3. Theoretische en praktische innovaties in stoppen-metroken onderzoek en terugvalpreventie: De Leer Abstinentie Theorie Auteur: Arie Dijkstra Rijksuniversiteit Groningen Arie Dijkstra, Arie.dijkstra@rug.nl De vooruitgang in kennis over terugval en succesvolle abstinentie bij stoppen met roken is in de afgelopen 20 jaar gestagneerd. Een oorzaak daar van is dat er na het Relapse Prevention Model van Marlatt nauwelijks nieuwe theoretische perspectieven zijn ontwikkeld en getoetst. Basale vragen als hoe werkt de motivatie bij ex-rokers om abstinent te blijven en hoe kan het dat stoppen met roken steeds gemakkelijker wordt worden door de bestaande modellen niet bevredigend beantwoord. Het beantwoorden van deze vragen kan de praktijk van stoppen met roken echt vooruit helpen. De Leer Abstinentie Theorie (LAT) is ontwikkeld om meer inzicht te krijgen in continue abstinentie en de processen die daar bij betrokken zijn. De kern van de LAT ligt in het leren van ex-rokers over roken en niet-roken. Enerzijds leren exrokers concreet in leersituaties. Wat ze leren is afhankelijk van de state of mind in die situatie. Anderzijds leren ex-rokers op een abstracter niveau over de voortgang naar hun einddoel van gemakkelijke en continue abstinentie: Op grond van verzamelde informatie e creëren ze een beeld van hun voortgang, dat bepalend is voor hun motivatie. De vaardigheden die ex-rokers gebruiken moeten dit leren ondersteunen: In de LAT staat daarom het leren centraal, niet de abstinentie. Dit impliceert dat op grond van de LAT rokers geen stoppoging doen maar starten met het afleren van het roken en het aanleren van niet-roken. Zo heeft de LAT belangrijke consequenties voor het begeleiden van stoppen met roken in de praktijk. 3

4 4. Stoppen met roken. Rijp voor de nieuwe richtlijn? Inleider: Margriet van Laar, Trimbos instituut In 2009 verscheen de update van de Richtlijn Behandeling van Tabaksverslaving uit Sindsdien schrijdt het wetenschappelijk onderzoek voort. Er verschijnen met regelmaat nieuwe Cochrane reviews over effectiviteit van interventies en (ook) Nederlandse tabaksonderzoekers laten zich niet onbetuigd. in deze sessie zult u 4 aansprekende voorbeelden horen van recent onderzoek naar stoppen-met-roken interventies voor verschillende doelgroepen. Tot welke nieuwe inzichten leiden zij en verdienen zij een plaats in de nieuwe richtlijn? Of niet. Oordeelt u zelf. 5. Economic evaluation of multiple web-based smoking cessation interventions Eline Smit, Silvia Evers, Ciska Hoving, Nicola Stanczyk, Hein de Vries Departments of Health Promotion and Health Services Research, Maastricht University/School for Public Health and Primary Care (CAPHRI) Eline Smit, es.smit@maastrichtuniversity.nl Introduction While evidence exists for their effectiveness, the current tobacco dependence treatment guideline pays little attention to web-based interventions. As economic evaluations of these interventions are still scarce, results will be discussed of two economic evaluations studies investigating the cost-effectiveness of web-based computer-tailored smoking cessation interventions. While up to now most of these interventions were text-based, we also investigated an intervention delivered via video, especially aimed to increase attention for these interventions among low SES smokers. Methods Both economic evaluation studies were embedded in a randomized controlled trial, in which 2099 and 414 Dutch adult smokers participated, respectively. Self-reported societal cost and health-related quality of life were assessed during a 12- month follow-up period; behavior specific outcome measures were assessed during the 12-month follow-up measurement only. Both studies were conducted from a societal perspective. Uncertainty was accounted for by bootstrapping and sensitivity analyses. Results Both cost-effectiveness analyses, using smoking abstinence as outcome measure, were in favor of the web-based smoking cessation interventions. However, cost-utility analyses, using quality of life as outcome measure, showed results that were in favor of the interventions received by the control groups. Discussion While both web-based computer-tailored smoking cessation interventions seemed to be most cost-effective, the cost-utility of the interventions received by the control groups was probably highest. These findings will be discussed in light of potential challenges for the economic evaluation of lifestyle behavior change interventions, such as the interpretation of these findings without information on society s willingness to pay per additional ex-smoker. 4

5 6. Intensieve counseling effectiefst voor laag opgeleide en minder gemotiveerde hartpatiënt: implicaties voor herziening richtlijnen Catherine Bolman, Nadine Berndt, Aart Mudde, Hein de Vries, Lilian Lechner Open Universiteit, faculteit Psychologie, Ministerie van Sociale Zaken Luxemburg, Universiteit Maastricht, faculteit Health, Medicine and Life Sciences, Capaciteitsgroep Gezondheidsbevordering Catherine Bolman, Inleiding Roken is een belangrijke risicofactor voor coronaire hartziekten. Problematisch is dat meer dan 50% van de hartpatiënten die rookten voor ziekenhuisopname, blijft roken of terugvalt. Omdat van laag intensieve stoppen-met-roken begeleidingsvormen de effectiviteit wordt betwijfeld, onderzoekt deze studie de (kosten -)effectiviteit van intensieve begeleiding door stoppen-met-roken professionals gecombineerd met nicotinepleisters (NP). Afdelingsverpleegkundigen pasten hierbij de Vraag-Advies-Verwijsmethode (VAV) toe in plaats van zelf stopondersteuning te geven. Naast toetsing van het overall effect werd nagegaan of effectiviteit verschilde in subgroepen qua stopmotivatie en opleidingsni veau. Methode Cardiologiepatiënten die rookten werden ad random toegewezen aan telefonische coaching (TC, n=223), persoonlijke coaching (PC, n=157) (beide gecombineerd met NP)of gebruikelijke stopondersteuning (UC, n=245). Patiënten werden geworven in 8 verpleegafdelingen cardiologie. Resultaten De twaalf maanden intention-to-treat gedragsmeting laat zien dat TC en PC vooral effectief zijn bij patiënten met een laag opleidingsniveau en een lage stopmotivatie (TC: OR 2.95, 95% CI , p=.02; FC: OR 5.05, 95% CI , p=.<001). De OR s van TC en PC verschilden niet significant van elkaar. Voor hoog opgeleide gemotiveerde patiënten zijn de OR s niet significant. TC bleek het meest kosteneffectief. Discussie Vooral bij lager opgeleide patiënten die twijfelen over stoppen is toepassen van VAV gecombineerd met counseling (TC of PC) en NP zinvol. Hoger opgeleide gemotiveerde patiënten stoppen vaker uit zichzelf; maar hoe ook hen te kunnen ondersteunen dient te worden onderzocht. De Richtlijn Tabaksverslaving en de Multidisciplinaire Richtlijn Hartrevalidatie worden deels onderschreven, maar laag gemotiveerde patiënten dienen zeker te worden doorverwezen naar stoppen-metroken gerelateerde counseling. 5

6 7. Can a NRT supported reduced smoking intervention remotivate therapy-resistant COPD smokers to stop smoking? Marcel Pieterse, Petra Hagens, Paul van der Valk, Huib Kerstjens, Job van der Palen Department of Psychology, Health & Technology, University of Twente, Medisch Spectrum Twente, UMC Groningen Marcel Pieterse, m.e.pieterse@utwente.nl Introduction Smoking cessation is the most effective means of favorably modifying the course of COPD. However, many smoking COPD patients have given up trying after numerous failed attempts. A novel strategy to re -motivate these therapy-resistant smokers may be a reduced smoking intervention, allowing participants to rebuild self-control towards quitting. Methods The REDUQ study is a multicenter RCT with 18 months follow-up, including 130 smoking COPD outpatients, who were not ready to quit. REDUQ patients received an intensive reduction -to-quit program, combining counselling and NRT. Existing behavioural change techniques as well as specific reduction techniques were applied in eight small-group sessions and four intermediate telephone contacts, delivered by pulmonary nurses. NRT was offered free of charge for 12 weeks, in d osages initially increasing with progressive cigarette reduction, and then gradually fading out. Control patients received a single information meeting and a self-help manual with reduction strategies. As soon as patients in both groups expressed readiness to quit, they were referred to an intensive smoking cessation program. Results Preliminary analyses involving N=110 participants revealed that REDUQ intervention successfully increased 50% self - reported reduction at 6 months (55.3% vs. 28.2%; p=.016), but failed to increase self-reported 7-days point prevalence abstinence at both 6 months (16.7% vs. 12.5%; p=.54) and 12 months (14.8% vs. 12.5%; p=.72). Biochemically validated outcomes, including continuous abstinence, are presented at the conference. Discussion Preliminary outcomes suggest that an intensive reduction-to-quit intervention for COPD smokers unmotivated to quit, is ineffective in increasing long-term abstinence rates, in spite of initially achieving reduced smoking levels. 6

7 8. Stoppen met roken interventies voor rokers met een depressie: rijp voor de nieuwe richtlijn? Regina van der Meer, Marc Willemsen, Filip Smit, Pim Cuijpers, Gerard Schippers STIVORO, Universiteit Maastricht, Trimbos Instituut, VU, UvA Inleiding Regina van der Meer, In de huidige richtlijn voor de behandeling van tabaksverslaving wordt op minimale wijze aandacht besteed aan stoppenmet-roken interventies (SMRIs) voor subpopulaties. Een belangrijke groep is rokers met een depressie. Deze studie beoogt de effectiviteit te evalueren van SMRIs voor rokers met een huidige depressie of depressieverleden. Methode Wij voeren een meta analyse uit van gerandomiseerde trials volgens het Cochrane protocol. Depressie was gedefinieerd als klinische depressie of depressieve symptomen. De uitkomstmaat was abstinentie van roken na tenminste 6 maanden follow-up en werd uitgedrukt als een relatieve kans (RR) op een positief behandelresultaat. De meta-analytisch gecombineerde RR s werden met de Mantel-Haenszel methode geschat. Resultaten 49 trials werden geïncludeerd. Meta-analyses lieten een positief effect zien voor het toevoegen van een psychosociale mood management component aan een standaard SMRI voor rokers met een huidige depressie (11 studies RR 1.47, 95%CI ) of met een depressieverleden (13 studies RR 1.41, 95%CI ) in vergelijking met een standaard SMRI alleen. Ook werd een voorzichtig te interpreteren positief effect gevonden voor het farmacologische middel bupropion bij rokers met een depressieverleden (4 studies RR 2.04, 95%CI ) in vergelijking met placebo. Er waren te weinig studies voor het evalueren van de effectiviteit van de andere antidepressiva en NRT. Discussie Het toevoegen van een psychosociale mood management component aan SMRIs vergroot de kans op abstinentie voor rokers met een depressie. 7

8 9. Van fundamenteel tot toegepast: een selectie uit het NNvT network Inleiders: Jacqueline Vink, Marc Willemsen VU Amsterdam, Universiteit Maastricht Tijdens dit congres besteden we in 4 subsessies aandacht aan 4 belangrijke actuele thema s. Het Nederlands Netwerk voor Tabaksonderzoek is echter een heel breed netwerk, van fundamenteel onderzoek tot toegepast beleidsonderzoek. Deze sessie geeft hiervan een sterke selectie, met de nieuwste resultaten van Nederlands tabaksonderzoek uit uiteenlopende onderzoekdisciplines die in het NNvT vertegenwoordigd zijn. 10. Impact of smoke-free legislation on perinatal and child health: systematic review and meta-analysis Jasper Been, Ulugbek Nurmatov, Bianca Cox, Tim Nawrot, Onno van Schayck, Aziz Sheikh School for Public Health and Primary Care (CAPHRI), Maastricht University, Allergy and Respiratory Research Group, Centre for Population Health Sciences, The University of Edinburgh, Department of Paediatrics, Maastricht University Medical Centre, Unit of Environmental Sciences, Hasselt University, Department of Public Health, University of Leuven, Division of General Internal Medicine and Primary Care, Brigham and Women s Hospital/Harvard Medical School. Jasper Been, jasper.been@mumc.nl Background Smoke-free legislation has the potential to reduce the substantive disease burden associated with second -hand smoke exposure, particularly in children. We investigated the impact of smoke-free legislation on perinatal and child health. Methods We searched 14 online databases ( ), screened the World Health Organization (WHO) International Clinical Trials Registry Platform and relevant citations and references, and contacted an international expert panel to identify additional studies. We included studies undertaken using the Cochrane Effective Practice and Organisation of Care approved designs that reported associations between smoking bans in public places and one or more predefined perinatal and paediatric health indicators. Primary outcomes were: preterm birth, low birth weight, and hospital attendances for asthma. Effect estimates were pooled using random-effects meta-analysis. Findings We identified 11 eligible studies, involving >2,541,389 births and 247,168 asthma exacerbations. All employed interrupted time series designs. Five North-American studies described local bans and six European studies described national bans. Risk of bias was high for one, moderate for six, and low for four studies. Smoke-free legislation was associated with reductions in preterm birth (4 studies, 1,366,862 subjects: -10.4% (95%CI -18.8;-2.0, p=0.016)) and asthma hospitalisations/emergency department visits (3 studies, 225,753 events: -10.1% (95%CI -15.2;-5.0), p<0.001). No significant effect on low birth weight was identified (6 studies, >1,952,397 subjects: -1.7% (95%CI -5.1;1.6), p=0.31). 8

9 Interpretation Smoke-free legislation is associated with substantial reductions in preterm births and hospital attendance for asthma exacerbations. Together with the health benefits in adults, this work provides strong support for WHO recommendations to create smoke-free public places. 11. Young adult smokers behaviours and reactions on peer discouragement Zeena Harakeh, Wilma Vollebergh, Carol van Nijnatten Universiteit Utrecht, Algemene Sociale Wetenschappen Zeena Harakeh, Introduction This study investigates the impact of antismoking peer pressure on the smoking behavior and reactions of daily-smoking young adults. Method An experiment (consisting of four conditions) was conducted among 59 daily-smoking young adults aged years. During the session, the confederate and participant sat in a camper van and had to do a 30-min joint music task. The participants smoking behavior and reaction were observed. Result The findings showed that young adults smoked fewer cigarettes in the presence of a nonsmoking model pressuring the young adult not to smoke compared to a heavy-smoking model not using any pressure. At the same time, the results indicated that the total number of cigarettes smoked did not differ significantly for nonsmoking peers verbally pressuring the young adult not to smoke compared to nonsmoking peers not verbally pressuring the young adult. Furthermore, we focused on the two conditions regarding antismoking peer pressure: the 44 responses in the active and 34 responses in the passive condition were analyzed in a discourse analyses. The participants in the passive condition were more elaborative about smoking while in the active condition participants show more passive resistance. Open resistance does not significantly differ in these two conditions but occurs, for both, primarily at the third discouragement. Conclusion Our findings indicate that the protective effect of peer influence merely lies in that the peer does not smoke. However, passive discouragement seems to be more effective in stimulating young adults to take an active role in the dialogue with their peers a bout smoking. 9

10 12. A randomized controlled trial testing the efficacy of nicotine replacement therapy among adolescents: the role of the therapy compliance Charlotte Scherphof, Regina van den Eijnden, Rutger Engels, Wilma Vollebergh Universiteit Utrecht, Faculteit Sociale Wetenschappen, ASW Diversiteit en Jeugd, Radboud Universiteit Nijmegen, Behavioral Science Institute Regina van den Eijnden, r.j.j.m.vandeneijnden@uu.nl Previous research among adolescents showed limited evidence for the short-term efficacy of Nicotine Replacement Therapy (NRT) and generally low medication compliance. Since higher compliance rates are associated with improved abstinence rates, we examined in a randomized controlled trial 1) the efficacy of NRT and 2) the role of compliance. Participants (N=257, age: years) attended an information meeting followed by a 6- or 9-week treatment with either a nicotine patch or a placebo patch. Data were required by means of 6 online questionnaires during treatment. Intention-to-treat analyses showed that the nicotine patch significantly increased the chances of quitting 2 weeks after quit date. At end-of-treatment we found that the efficacy of NRT was moderated by compliance, that is, the nicotine patch significantly increased the chances of quitting, but only in high -compliant participants. No main effects of NRT, or any moderating effect of compliance were found for abstinence at 6 and 12 months follow-up. To go more deeply into the course of compliance, we subsequently investigated whether different adolescents NRT compliance trajectories can be distinguished and whether these trajectories can be predicted by demographic factors, smoking (cessation) related factors and personality characteristics. Three trajectories were found, i.e. the compliers, the moderate decreasers and the strong decreasers. The differences in the development of these trajectories were predicted by three factors: the level of conscientiousness and extraversion, and the number of previous quit attempts. Implications in terms of personalitytargeted interventions aiming to enhance compliance rates and suggestions for future research will be discussed. 13. Smoking during adolescence as a risk factor for attention problems Jorien Treur, Gonneke Willemsen, Meike Bartels, Lot Geels, Jenny van Beek, Charlotte Huppertz, Catharina van Beijsterveldt, Dorret Boomsma, Jacqueline Vink Department of Biological Psychology, VU University Amsterdam Jorien Treur, j.l.treur@vu.nl Introduction Cigarette smoking and attention deficit hyperactivity disorder (ADHD) are highly co -morbid. Animal studies reported that exposure to nicotine during adolescence can affect the developing brain and negatively impacts on attention. Ours is the first human study exploring short- and long-term consequences of smoking during adolescence on ADHD-symptoms. 10

11 Methods Data were available for 1,987 adult and 648 adolescent monozygotic (MZ) twin pairs from the Netherlands Twin Register. Because MZ twins are genetically (almost) identical and (usually) grow up in the same family, a causal effect of smoking on ADHD-symptoms can be identified with the discordant MZ co-twin design. Pairs were classified as concordant/discordant for smoking initiation and compared on ADHD-symptoms using the ADHD index (Conners) and the Youth Self Report attention scale. Short-/long-term effects were investigated using data of multiple surveys from adolescence and/or adulthood. Results Adults who never smoked scored significantly lower on ADHD-symptoms than smokers. In 123 adult pairs discordant for smoking, ADHD-symptoms increased more from adolescence to adulthood in the smoking versus the nonsmoking twin (p:0.033). In adolescents, 71 pairs scored similar on ADHD-symptoms when both didn t smoke at age 15, while the smoking twin tended to score higher than his/her co-twin after becoming discordant at age 17 (p:0.079). In 21 pairs discordant at age 15, the smoking twin tended to score higher than the co-twin (p:0.147), while both scored (similarly) high after becoming concordant smokers at age 17. Conclusion Results suggest that smoking during adolescence causes a higher score on attention problems, lasting into adulthood. 14. Profielen onder hardcore rokers Jeroen Bommelé, Marloes Kleinjan, Tim Schoenmakers, William Burke, Regina van den Eijnden, Dike van de Mheen IVO, ErasmusMC, Radboud Universiteit Nijmegen, Universiteit Utrecht Jeroen Bommelé, bommele@ivo.nl Inleiding Hardcore rokers zijn rokers die al vele jaren roken (>15 jaar) en niet van plan zijn te stoppen. Zij zijn erg moeilijk te bereiken en te beïnvloeden door de huidige preventiemaatregelen. We onderzoeken of er in deze specifieke populatie verschillende subgroepen (profielen) te vinden zijn. Zulke profielen zouden ons kunnen helpen hardcore rokers beter te bereiken en te beïnvloeden. Methode In een eerder kwalitatief onderzoek hebben hardcore rokers in focusgroepen voor- en nadelen van roken en stoppen aangegeven. In de huidige studie hebben we deze voor- en nadelen onder 510 hardcore rokers in een online survey uitgevraagd. Vervolgens hebben we gemiddelde scores op de voor-en nadelen berekend. Deze gemiddelden hebben we vervolgens gebruikt om met een latente profielen analyse verschillende profielen te onderscheiden. Resultaten We hebben drie profielen gevonden onder de hardcore rokers. Het meest voorkomende profiel (59%) bestond uit rokers die erg ambivalent tegenover roken en stoppen stonden. Zij zagen weinig voor- en nadelen van zowel roken als stoppen. Het tweede profiel (36%) bestond uit rokers die relatief positief waren over stoppen. Rokers in dit profiel hadden veel nadelen van roken en zagen veel voordelen van stoppen. Het derde profiel (5%) was juist uitgesproken negatief over stoppen. Zij zagen weinig nadelen van roken en ook weinig voordelen van stoppen. Conclusie De resultaten laten zien dat er onder hardcore rokers drie verschillende profielen te vinden zijn. Kennis over de profielen kan ons helpen bij het beter bereiken en beïnvloeden van hardcore rokers. 11

12 15. National tobacco control policies and socioeconomic inequalities in adolescent smoking: international comparisons of 13 European countries in Mirte Kuipers 1 ; Karin Monshouwer 2,3 ; Anton Kunst 1 1 Department of Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands 2 Department of Interdisciplinary Social Science, Utrecht University, Utrecht, the Netherlands 3 Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, the Netherlands Mirte Kuipers, m.a.kuipers@amc.uva.nl Objective Tobacco control policies in Europe have been through major development over the past decade. We investigated the effect of tobacco control policies on adolescent smoking inequalities in Europe. Methods Data of 77, year old adolescents from 13 European countries were obtained from the ESPAD 2003, 2007, 2011 databases. We performed multilevel logistic regression analyses with daily smoking as the outcome variable. Tobacco Control Policy Index (TCPI) measured a sum score for national tobacco control policy. TCPI b and TCPI t indicated respectively the between countries and over time associations between policies and smoking. Socioeconomic position (SEP) was based on paternal education and interaction with TCPI b and TCPI t was tested. Results In all studied countries, except Portugal, adolescent smoking prevalence rates were highest amon g low SEP respondents. TCPI b was inversely associated with smoking (OR=0.78 [ ]). An increasing TCPI t over time was not associated with smoking rates (OR=0.95 [ ]). Interaction between TCPI components and SEP was not significant. No evidence was found for a time lag effect of TCPI, associations were similar when TCPI scores of up to four years previous were used in the regression models. Conclusion We found no evidence for an effect of tobacco control policies on smoking rates over time. H owever, countries with a stronger tobacco control policy had lower smoking rates. This indicates that tobacco control policies only have a long term effect. The between countries effect was similar among low and high SEP respondents, suggesting that tobacco control policies did not increase inequalities in adolescent smoking. 12

13 16. The association between political orientation, government effectiveness and tobacco control policy development in the EU Jizzo Bosdriesz 1 ; Marc Willemsen 2 ; Karien Stronks 1 ; Anton Kunst 1 1 Department of Public Health, Academic Medical Center, University of Amsterdam 2 Department of Health Promotion, Maastricht University Jizzo Bosdriesz, j.bosdriesz@amc.uva.nl Background Much has been achieved in tobacco control policy in Europe over the past decades, but the progress has been marked by a large degree of variation between countries. Quantitative analyses of factors that influence the policy development process are lacking. This study aims to provide an insight in the political contextual factors that shaped tobacco control policy development. Methods This study used data from 11 European countries from 1996 through The Tobacco Control Scale (TCS) was the policy outcome. Political contextual variables included were political orientation and government effectiveness. Multilevel linear regression modelling was used to investigate associations between the contextual variables and the TCS, while controlling for gross domestic product and overall smoking prevalence. Results In the analysis for the entire study period, we did not observe the expected associations between the TCS and political orientation or government effectiveness. Analyses per year showed positive associations between a left political orientation and TCS from 1996 through 2003 and positive associations between government effectiveness and the TCS between 2001 and Further, we found that TCS values from 2005 onwards were higher than would be expected based on these contextual political factors. Discussion The results suggest that in the early stages of tobacco control policy development, left governments had a pioneering role by implementing new policies when overall development was slow. Since around 2002, international factors like the Framework Convention on Tobacco Control (FCTC) seem to have become the driving force behind tobacco control policy development. 17. Smoke-free legislation and childhood hospitalisations for respiratory tract infections in England: a national quasi-experimental study Jasper Been 1,2,3 ; Christopher Millett 4 ; John Tayu Lee 4, Onno van Schayck 1,2 ; Aziz Sheikh 1,2,5 1 School for Public Health and Primary Care (CAPHRI), Maastricht University, 2 Allergy and Respiratory Research Group, Centre for Population Health Sciences, The University of Edinburgh, 3 Department of Paediatrics, Maastricht University Medical Centre, 13

14 4 Department of Primary Care and Public Health, School of Public Health, Imperial College, London, 5 Division of General Internal Medicine and Primary Care, Brigham and Women s Hospital/Harvard Medical School, Boston. Jasper Been, jasper.been@mumc.nl Background Respiratory tract infections (RTIs) are the leading cause of child morbidity and mortality worldwide, and second -hand smoke exposure is a major risk factor. Increasing evidence suggests important early-life population health benefits of smoke-free public environments. We investigated the impact of the English 2007 smoke-free legislation on childhood hospital-admissions for RTIs. Methods We used the Hospital Episode Statistics database to obtain nationwide data on unplanned hospital-admissions for acute RTIs among children (<15 years) from Data were disaggregated by month, age-group, sex, and area, and linked to urbanisation level, region, deprivation index, and corresponding population estimates. Negative binomial regression analysis was performed, adjusting for confounders, seasonal variation, and population -size changes. Models accounted for underlying incidence trends, and allowed for sudden and gradual changes following the smoke-free law. Findings We analysed 1,651,675 hospital-admissions. The introduction of smoke -free legislation was followed by an instant reduction in RTI admissions: -2.9% (95%CI: -4.0,-1.7), this mainly being attributable to a decrease in lower RTI admissions: % (95%CI: -12.6,-9.1). In contrast, the reductions in admissions for upper RTIs were more incremental and sustained, and were therefore responsible for the majority of the estimated 24,098 RTI admissions cumulatively prevented over the five years following the smoke -free legislation. Interpretation Introduction of national smoke-free legislation in England was associated with approximately 5000/year fewer hospitaladmissions for RTIs among children. Whilst causality is difficult to establish from this quasi-experimental analysis, when taken together with related work the findings strengthen recommendations for global implementation of smoke-free public places. 18. Op school steek je niks op! Het voortgezet onderwijs rookvrij: Onderzoek naar de implementatie van rookvrije schoolterreinen Andrea Rozema, Jolanda Mathijssen, Hans van Oers, Benjamin van Wijngaarden Tilburg University, department Tranzo, RIVM, Longfonds Andrea Rozema, a.d.rozema@uvt.nl Aanleiding Tegenwoordig mag er op steeds meer plekken niet meer gerookt worden, bijvoorbeeld in openbare gebouwen, op werkplekken en in de horeca. Daarnaast worden ook steeds meer openbare ruimtes rookvrij, zoals treinstations. Een logische vervolgstap zou een rookverbod op schoolterreinen zijn in het voortgezet onderwijs. Vaak steken jongeren namelijk hier hun eerste sigaret op en raken ze verslaafd doordat ze erg gevoelig zijn voor nicotine. Momenteel zegt een kwart (26%) van alle schoollocaties in Nederlands een rookvrij schoolterrein te hebben. Rookvrije schoolterreinen zijn dus 14

15 nog niet vanzelfsprekend. Dit onderzoek richt zich op het ontwikkelen van effectieve strategieën en methoden om scholen te ondersteunen in de adoptie-, implementatie- en continueringsfase bij het invoeren van rookvrije schoolterreinen. Aanpak Deze ontwikkeling zal vormgegeven worden door 1) het omschrijven, wetenschappelijk onderbouwen en verder ontwikkelen van een aanpak die ontwikkeld is door de Alliantie Nederland Rookvrij!, 2) een landelijke procesevaluatie van de adoptie-, implementatie- en continueringfasen bij scholen die al een rookvrij schoolterrein gerealiseerd hebben, 3) regionaal: behoeftepeiling bij minder gemotiveerde scholen in drie GGD-regio s, 4) regionaal: ontwikkelen en evalueren van een aanpak om minder gemotiveerde scholen te bewegen tot adoptie en implementatie en 5) een landelijke effectevaluatie (quasi experimenteel design) om te onderzoeken of minder jongeren beginnen met roken of op l atere leeftijd pas beginnen met roken. Het onderzoek wordt uitgevoerd in een samenwerkingsverband van de Academische Werkplaatsen Publieke Gezondheid in Brabant, Zuid-Limburg en Amsterdam. Resultaten De eerste resultaten zullen in de zomer van 2014 bekend zijn. 19. Wanting to come isn t only wanting to quit: Why do some disadvantaged smokers regularly attend smoking cessation therapy while others do not? Fiona Benson, Karien Stronks, Marc Willemsen, Vera Nierkens Academisch Medisch Centrum, Afd. Sociale Geneeskunde, Amsterdam en Maastricht University, Dept. Health Promotion Fiona Benson, f.e.benson@amc.uva.nl Background Attendance of a behavioural therapy course facilitates smoking cessation. Disadvantaged smokers have been shown to attend less than their advantaged peers. This study explores the underlying motivations, barriers and social support of smokers exhibiting different patterns of attendance at a free smoking-cessation treatment program in a disadvantaged neighbourhood of The Netherlands. Methods In 29 smokers undertaking smoking cessation therapy in a disadvantaged neighbourhood, qualitative interviews were completed, coded and analysed. Motivations and barriers to attend and social support, were analysed with reference to the Self-Determination Theory. Results We saw two patterns of attendance: those who missed two sessions ( frequent attenders ), and > two sessions ( infrequent attenders ). These two groups differed in motivations and barriers to attend, and level of social support received. Compared with infrequent attenders, frequent attenders more often felt intrinsic motivation to attend (e.g. enjoyed attending), and named more self-determined extrinsic motivations to attend, such as making time for the course and wanting to quit. Most of those mentioning intrinsic motivation did not mention a desire to quit as a motivation for attendance. Frequent attenders mentioned no organizational barriers to attendance. Frequent attenders experienced more social support. Conclusion We conclude that motivation to attend, as distinct from motivation to quit, is an important factor in attendance of smoking cessation therapy courses in disadvantaged areas. Some focus on increasing motivation to attend may help to prevent participants dropping out or missing sessions. Also, increasing social support within the course may impact on attendance. 15

16 20. Do differences in gender among high and low socioeconomic status clarify children s smoking intentions? Paul Cremers, Liesbeth Mercken, Hein de Vries, Anke Oenema Department of Health Promotion, School for Public Health and Primary Care (CAPHRI), Maastricht University Paul Cremers, p.cremers@maastrichtuniversity.nl Objective Socioeconomic status (SES) and gender are known to be associated to the intention of smoking. The present exploratory study aims to identify gender differences in low SES and high SES children, since evidence on this topic is lacking. Design Data for this longitudinal study was gathered from a smoking prevention intervention study. A total of 1,801 children (aged years) of 133 Dutch primary schools completed a web-based questionnaire concerning their smoking intentions and other smoking related factors (e.g. attitude, social influence and self-efficacy) at baseline and one year follow-up. Logistic regression analyses were performed to assess differential effects to identify potential differences between SES and gender. Main results Separate analyses of SES and gender were warranted, since a 3-way interaction effect was present (B=-1.63 (p=0.05)). High SES boys were more willing to initiate in smoking if they had positive smoking attitudes, whereas high SES girls indicated to have the intention to start smoking if they perceived less disadvantages (B=-0.86 (p=0.01)) of smoking. For low SES boys the perceived social norm (B=-0.72 (p=0.03)) was most strongly associated with their intention to start smoking. Low SES girls indicated to be most influenced to engage in smoking by the smoking behavior of people in their environment (B=1.71 (p<0.01)). Conclusion This study indicated that different factors are associated with the smoking intentions of boys and girls in high and low SES groups. More knowledge about this discrepancy increases the opportunity to develop subgroup specific smoking prevention programs and may reduce youth smoking. 21. Rectangularization of survival curves and smoking: an empirical study in ten high income countries Fanny Janssen 1, Valentin Rousson 2 and Fred Paccaud 2 1 Population Research Centre, University of Groningen 2 Institut Universitaire de Médicine Sociale et Preventive, Lausanne Fanny Jansen, f.janssen@rug.nl Background With the general increase in life expectancy at birth in Europe, changes to the age distribution of dying occurred. This paper examines the role of smoking in the two dimensions behind changes over time in adult mortality, i.e. rectangularization of the survival curve (decline of premature deaths) and longevity extension (delay of the maximum age of death). We do so for ten European countries since the 1950s. 16

17 Methods For all-cause mortality and non-smoking-related mortality, we examined the trends in life expectancy, rectangularization and longevity extension from 1950 to These trends were correlated with indirectly estimated smoking prevalence. We studied the national sex-specific populations from Denmark, Finland, France, West Germany, Italy, the Netherlands, Norway, Sweden, Switzerland and the United Kingdom, aged 50 and over. Results For all-cause mortality, rectangularization accelerated almost simultaneously around 1980 among males. Both deceleration and acceleration were observed among females. Trends in smoking prevalence correlated negatively with rectangularization. A negative correlation was observed with longevity extension as well, although less marked. When considering only non-smoking-related mortality, rectangularization among males no longer accelerated around Among females, differences between all-cause mortality and non-smoking-related mortality were smaller than among males, but more visible for rectangularization than longevity extension. Rectangularization contributed less to the increase in life expectancy than longevity extension. For males, more so for n on-smoking-related mortality than for all-cause mortality. Conclusions For both males and females, smoking affects the rectangularization of the survival curve more than the shift of the survival curve to the right. 22. Future smoking-attributable mortality in the Netherlands Lenny Stoeldraijer, Luc Bonneux, Coen van Duin, Leo van Wissen, Fanny Janssen Statistics Netherlands, Den Haag; physician in elderly care ; Netherlands Interdisciplinary Demographic Institute (NIDI), Den Haag; Population Research Centre, Faculty of Spatial Sciences, University of Groningen; Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), Department of Pharmacy, University of Groningen. Lenny Stoeldraijer, l.stoeldraijer@cbs.nl Within Europe, smoking is the leading risk factor of premature mortality and it is also the most important non-linear determinant of mortality in recent decades. Providing an estimate of the future burden of smoking is therefore important for tobacco control programs, updating and extending the descriptive smoking epidemic model, and the projection of allcause mortality. Our objective is to project smoking-attributable mortality into the future for the Netherlands. Past trends in lung cancer mortality ( ) and smoking prevalence in Denmark, England & Wales and the Netherlands and the generalities from the descriptive smoking epidemic model, are used to formulate assumptions. We then extrapolate lung cancer mortality using different extrapolation techniques. By applying a simplified and adapted version of the Peto-Lopez method to the future lung cancer mortality, we obtain the future smoking-attributable mortality. The past trends showed clear convergence between men and women, a close link between the timing of the decline for women and the declining trend for men, and necessitated a cohort approach for the increase and a period approach for the decrease. The smoking-attributable mortality fraction for men is expected to further decline to 14% in For women, the fraction will first increase to a maximum of 23% in 2033, but then decline to 19%. Smoking-attributable mortality will remain important for the future, especially for women. The projected smokingattributable mortality fractions can easily be incorporated in the projection of all-cause mortality. 17

18 23. Transitions in smoking behaviour and the design of cessation schemes Johan Grasman 1 ; Raoul Grasman 2 ; Han van der Maas 2 1 Biometris, Wageningen Universiteit, 2 Departement Psychologie, UvA Johan Grasman, Johan.Grasman@wur.nl The intake of nicotine by smoking cigarettes is modelled by a dynamical system of d ifferential equations. The variables are the internal level of nicotine and the level of craving. The model is based on the dynamics of neural receptors and the way they enhance craving. Lighting of a cigarette is parametrised by a time-dependent Poisson process. The nicotine intake rate is assumed to be proportional with the parameter of this stochastic process. The effect of craving is damped by a control mechanism in which awareness of the risks of smoking and societal measures play a role. Fluctuations in this damping may cause transitions from smoking to non-smoking and vice versa. With the use of Monte Carlo simulation the effect of abrupt and gradual cessation therapies are evaluated. Combination of the two in a mixed scheme yields a therapy with a duration that can be set at wish ( 24. The "missing=smoking" assumption: a fallacy in internet-based tobacco cessation intervention RCTs? Matthijs Blankers, Margriet van Laar Trimbos instituut Matthijs Blankers, mblankers@trimbos.nl Introduction Missingness of follow-up data in RCTs of smoking cessation interventions is a common yet potentially impactful nuisance. Internet-based RCTs often cope with higher attrition rates than face-to-face interventions. A common approach to dealing with missing smoking outcomes is to recode missing data points as smoking ( missing=smoking ), assumed a conservative approach compared to complete case analysis. We will scrutinize the assumption that missing=smoking yields conservative effect estimates in comparison to complete case analysis when data were generated by internet-based RCTs. Methods Data from 22 studies included in a meta-analysis of internet-based smoking cessation interventions (Civljak, 2013), attrition rates, relative attrition (difference in attrition rate between trial arms), and associations with outcome were re-assessed under the missing=smoking assumption and under a complete case approach. Results The averaged weighted attrition rate across the 22 studies is 51% at follow-up. Missing=smoking relative risk (RR) results (RR=1.15 [1.00; 1.33]) were almost identical to results under complete case analysis (RR=1.14 [0.98; 1.32]). The attrition rate was found to be significantly negatively associated with RR (R-Squared=0.24, p=0.03).the difference in RR under missing=smoking and complete case analysis was strongly associated with the interaction attrition rate relative attrition (R-Squared=0.74, p<0.001). When attrition was relatively higher in the experimental arm, missing=smoking led to a lower RR estimate than complete case analysis; however when attrition was relatively higher in the control arm, missing=smoking led to a higher RR estimate than complete case analysis. This effect was stronger in studies with higher attrition rates. 18

19 Discussion Based on our meta-analytic re-analysis of 22 internet-based smoking cessation interventions, we demonstrate the contraintuitive consequences of the missing=smoking assumption. We advise researchers to use contemporary missing data approaches, for example multiple imputation, to reduce the impact of attrition on outcome estimates. 25. Implementatie van stoppen-met-roken begeleiding en de rol van negatieve reacties van rokers: een analyse van videoconsulten in de huisartsenpraktijk Marjolein Verbiest 1 ; Niels Chavannes 1 ; Esther Passchier 1 ; Janneke Noordman 2 ; Margreet Scharloo 3 ; Ad Kaptein 3; Pim Assendelft 1;4 ; Matty Crone 1 1 LUMC, afdeling Public Health en Eerstelijnsgeneeskunde 2 NIVEL 3 LUMC, afdeling Medische Psychologie 4 UMC St Radboud, afdeling Eerstelijnsgeneeskunde Marjolein Verbiest, m.e.a.verbiest@lumc.nl Inleiding Huisartsen en praktijkondersteuners (POH s) ervaren negatieve reacties van patiënten t.a.v. het stoppen met roken als barrière bij de implementatie van richtlijnen voor tabaksontmoediging. De studie ging na in hoeverre huisartsen en POH s deze richtlijn implementeren en hoe patiënten hierop reageren tijdens het consult. Methode We selecteerden 52 videoconsulten (20 huisarts, 32 POH) waarin professionals het gesprek over roken initieerden en we transcribeerden gespreksfragmenten over roken. Gesprekseenheden van professionals (5 A s: Ask, Advise, Assess, Assist, Arrange) en patiënten (negatieve/positieve reacties t.a.v. stoppen) werden gecodeerd en geanalyseerd met sequentieanalyses. Resultaten Indien de richtlijn werd geïmplementeerd, vroegen huisartsen relatief vaker naar de rookstatus van patiënten dan POH s (42.2% vs. 26.2%; p<0.000) en ondersteunden POH s vaker een stoppoging (55.2% vs. 25.4%; p<0.000). Over het algemeen reageerden rokers vaker negatief dan positief t.a.v. stoppen met roken (23.3% vs. 11.9%; p<0.000). De kans op een negatieve reactie van de patiënt was significant groter nadat POH s vroegen naar de stopmotivatie (OR % BI ) of nadat POH s ondersteuning bood bij een stoppoging (OR % BI ) in vergelijking met elk andere voorgaande gesprekseenheid van POH s. In het laatste geval was de kans ook significant groter dat patiënten positief reageerden t.a.v stoppen (OR % BI ). Discussie Op basis van de bevindingen adviseren wij een Ask-Advise-Arrange aanpak voor de huisarts. Deze aanpak leidt tot de minste kans op negatieve reacties van patiënten t.a.v. stoppen en sluit goed aan bij het takenpakket en de vaardigheden van POH s. 19

20 26. Young Adult Smoking in Peer Groups: An Experimental Observational Study Zeena Harakeh, Wilma Vollebergh Universiteit Utrecht, Algemene Sociale Wetenschappen Zeena Harakeh, Introduction The aim of this experimental observational study is to examine whether, in a group setting (same-sex triads), passive peer influence (imitation) in the context of homogeneous and heterogeneous (contradictory) behavior of peer models affects young adults smoking behavior. Methods An experiment was conducted among 48 daily-smoking college and university students aged Participants had to complete a 30-min music task with two same-sex confederates. We tested the following three conditions: (a) neither of the confederates is smoking, (b) one confederate is smoking and the other is not, and (c) both confederates are smoking. The primary outcome tested was the total number of cigarettes smoked during the task. Results Students in the condition with two smoking peer models and in the condition with one smoking peer model and one nonsmoking peer model smoked significantly more cigarettes than those in the condition with two nonsmoking peer models. However, results for the condition with two smoking peer models did not differ significantly from the condition with one smoking peer model and one nonsmoking peer model. Conclusion Our findings show that in a group setting, the impact of the homogeneity of smoking peers on young adults smoking behavior is not greater than the impact of the heterogeneity of smoking and nonsmoking peers. This would suggest that the smoking peer in the group has a greater impact on the daily-smoking young adult, thus reducing or even eliminating the protective effect of the nonsmoking peer model. 20