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Background: In the United States, over-testing and over-treatment are recognised causes of excess cost and patient harm. Healthcare value, defined as health outcomes achieved relative to the costs of care, has become a focus to improve the quality and affordability of healthcare., Aim: To describe the rationale for, and development of a standardised clinical preoperative decision-support tool. Program description: An evidence-based, preoperative clinical decision tool was developed to guide preoperative testing and management of high-risk medications. Program evaluation: Patient data before and after implementation of the tool will be analysed to determine its effectiveness in reducing preoperative testing., Discussion: Preoperative testing is an area that presents an opportunity to increase healthcare value and decrease healthcare spending. Guidelines are available to standardise preoperative assessment but their adoption and acceptance into practice has been slow. To systematise preoperative assessment within our healthcare system, we reviewed current published literature and guidelines and synthesised them into an electronic, evidence-based, decision-support tool. After distribution of the tool to clinicians in our healthcare system, we will assess its impact on healthcare value, costs and outcomes. We believe that an evidence-based preoperative tool, seamlessly and efficiently integrated into clinician workflow, can improve preoperative patient care.

Introduction: This study aimed to systematically examine whether having health conditions or concerns related to smoking are associated with quitting activities among smokers across four western countries., Methods: Data came from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey conducted in Australia, Canada, England and US. We asked smokers and recent quitters (n=11838) whether they had a medical diagnosis for heart disease, cancer, chronic lung disease, depression, anxiety, alcohol problems, diabetes, severe obesity and chronic pain (nine conditions), and whether they believed smoking had harmed/would harm their health, along with questions on quitting activities., Results: General concerns about smoking harming health and all specific health conditions, except for alcohol problems, were positively associated with quit attempts, but the relationships between health conditions and other quitting measures (being abstinent, planning to quit, use of quitting medications) were less consistent. Positive associations between conditions and use of quitting medications were only significant for depression, anxiety and chronic pain (adjusted odds ratios ranged from 1.4 to 1.5). There was a general tendency to report lower self-efficacy for quitting among those with the health conditions., Conclusions: While those with smoking related conditions are somewhat more aware of the links to their smoking, and are largely taking more action, the extent of this is lower than one might reasonably expect. Enhanced awareness campaigns are needed and health professionals need to do more to use health conditions to motivate quit attempts and to ensure they are made with the most effective forms of help., Competing Interests: The authors have each completed and submitted an ICMJE form for disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. RJO reports personal fees from World Health Organization, grants and personal fees from Food and Drug Administration, grants and personal fees from National Institutes of Health, outside the submitted work. KMC has received payment as a consultant to Pfizer, Inc., for service on an external advisory panel to assess ways to improve smoking cessation delivery in health care settings. KMC has also served as paid expert witness in litigation filed against the tobacco industry., (© 2019 Li L.)

Objective: Countries around the world have increasingly adopted pictorial health warning labels (HWLs) for tobacco packages to warn consumers about smoking-related risks. Research on how pictorial HWLs work has primarily analysed self-reported responses to HWLs; studies at the neural level comparing the brain's response to different types of HWLs may provide an important complement to prior studies, especially if self-reported responses are systematically biased. In this study we characterise the brain's response to three types of pictorial HWLs for which prior self-report studies indicated different levels of efficacy., Methods: Current smokers rated pictorial HWLs and then observed the same HWLs during functional MRI (fMRI) scanning. Fifty 18-50-year-old current adult smokers who were free from neurological disorders were recruited from the general population and participated in the study. Demographics, smoking-related behaviours and self-reported ratings of pictorial HWL stimuli were obtained prior to scanning. Brain responses to HWLs were assessed using fMRI, focusing on a priori regions of interest., Results: Pictorial HWL stimuli elicited activation in a broad network of brain areas associated with visual processing and emotion. Participants who rated the stimuli as more emotionally arousing also showed greater neural responses at these sites., Conclusions: Self-reported ratings of pictorial HWLs are correlated with neural responses in brain areas associated with visual and emotional processing. Study results cross-validate self-reported ratings of pictorial HWLs and provide insights into how pictorial HWLs are processed., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Aims: To examine perceptions of risk related to type of cigarette brand., Design and Setting: Cross-sectional findings from wave 5 of the ITC Four Country Survey, conducted with nationally representative samples of smokers in 2006., Participants: A total of 8243 current and former adult (≥18 years) smokers from Canada (n=2022), the United States (n=2034), the United Kingdom (n=2019) and Australia (n=2168)., Measurements: Outcomes included beliefs about the relative risks of cigarettes, including perceptions of 'own' brand. Correlates included socio-demographic, smoking-related covariates and brand characteristics., Findings: One-fifth of smokers believed incorrectly that 'some cigarette brands could be less harmful' than others. False beliefs were higher in both the United States and United Kingdom compared to Canada and Australia. Smokers of 'light/mild', 'slim' and 100 mm/120 mm cigarettes were more likely to believe that some cigarettes could be less harmful [odds ratio (OR)=1.29, 95% confidence interval (CI)=1.12-1.48 and that their own brand might be a little less harmful (OR=2.61, 95% CI=2.01-3.41). Smokers of 'gold', 'silver', 'blue' or 'purple' brands were more likely to believe that their 'own brand might be a little less harmful' compared to smokers of 'red' or 'black' brands (OR=12.48, 95% CI=1.45-107.31)., Conclusions: Despite current prohibitions on the words 'light' and 'mild', smokers in western countries continue to falsely believe that some cigarette brands may be less harmful than others. These beliefs are associated with descriptive words and elements of package design that have yet to be prohibited, including the names of colours and long, slim cigarettes., (© 2011 The Authors, Addiction © 2011 Society for the Study of Addiction.)

Previous studies have demonstrated a modest association between smoking and leukemia particularly for myeloid disorders. Our objective was to examine whether changing trends in cigarette smoking prevalence nationally and within selected states parallel similar trends in mortality from leukemia. Trends in national smoking rates were correlated with trends in leukemia mortality rates obtained from the Centers for Disease Control and Prevention and the Surveillance Epidemiology and End Results registry, respectively. State-specific correlations were assessed from 1984 to 2004 using smoking prevalence data from the Behavioral Risk Factor Surveillance System and leukemia mortality data from National Vital Statistics System. Correlations were computed using the Spearman rank correlation coefficient. Leukemia mortality decreased overall in the United States in parallel with decreased smoking. Analyzed on a state-specific basis, leukemia mortality decreased in states where smoking rates declined markedly but remained unchanged where smoking prevalences were relatively stable. The findings suggest that declining rates of leukemia mortality are associated with changing patterns of smoking behavior.