Stress paper

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Assessment of publication and outcome reporting bias we examined funnel plots for evidence of asymmetry and conducted Egger tests for evidence of small study bias using Stata. 34 In some studies, data on change in mental health were presented incidentally and the aim was to report on other data. In others, the aim of the report was to present data on change in mental health, therefore the decision to publish might have been contingent on the results. We compared effect estimates between studies in which mental health was the primary outcome and those in which it was not to assess if there was evidence of publication bias. When studies had relevant data on change in mental health but did not report sufficient data for meta-analysis, we attempted to estimate the direction of association and compare this with those included as this could indicate reporting bias. Sensitivity analyses and assessment of risk of bias within and across studies we conducted multiple sensitivity analyses to examine if the pooled effect estimate was influenced by including studies in which the risk of bias was greater or was influenced by characteristics of the study. We either performed subgroup analyses or removed studies presenting a risk of bias and compared the pooled estimates with and without the excluded studies.

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We used revman5 to conduct the meta-analyses and sensitivity and subgroup analyses. Studies effect estimates (SMD) were pooled by using the following outcome categories: anxiety, depression, mixed anxiety and depression, positive affect, psychological quality of life, and stress. We used smd because the scales used to measure each outcome varied within category. This is standard practice for meta-analyses as outlined within the cochrane collaboration Handbook of Systematic reviews and Meta-Analyses, 28 and as used in other high quality meta-analyses of continuous mental health outcomes. We also combined studies with different follow-up values periods. We combined each studys longest follow-up period, as suggested by the cochrane collaboration. Heterogeneity between studies follow-up length was accounted for by use of a random effects model. This is standard practice as outlined by the cochrane collaboration, 28 and as used in other high-quality meta-analyses of continuous mental health, with varying follow-up periods. Quality assessment we assessed the quality of the evidence in each study on the association of change in smoking status with change in mental health using the newcastle-Ottawa quality scale, 29 adapted for this study (see appendix 1). This assesses the quality of evidence based on the selection of the comparison groups, reviews the comparability of the groups, and the quality of the measurement of exposure and outcome. The adapted scale rated studies from 0 to 5, and we deemed studies with a rating of 3 or lower as at higher risk of bias.

In other cases, studies reported the mean at baseline and at follow-up for each group. We calculated change and its variance using year a standard formula, 30 imputing a correlation coefficient taken from one of the largest studies included in the review (see appendix 1). In all cases, we also extracted the variance. If the variance was not presented we calculated it from p values, confidence intervals, or f values following standard formula as recommended by the cochrane collaboration. 28 Meta-analysis method we used a generic inverse variance random effects model to pool the standardised mean difference (SMD) between change in mental health in quitters and continuing smokers, from baseline to follow-up. We chose a random effects model as it incorporates heterogeneity both within and between studies. Statistical heterogeneity was assessed with τ2 and I2 tests.

stress paper

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To categorise the mental health outcomes we examined each measures key reference and questionnaire to determine what it was designed to measure. We extracted the change in mental health unadjusted for confounding and adjusted for confounding using multivariable techniques. Other items —we also extracted additional data to investigate clinical and methodological heterogeneity within and across studies (see sensitivity analyses for justification and methods). These items included study design, study quality score (Newcastle-Ottawa scale 29 evidence of outcome reporting bias, follow-up length, covariates adjusted for, mental health management used in the intervention, and number of participants analysed at baseline and follow-up. Statistical methods Data extraction The summary measure was the standardised mean difference (SMD) in change in mental health from baseline to follow-up between continuing smokers and people who managed to stop. Some studies reported either the difference in change or the standardised difference in change between continuing smokers and quitters, and hence data extraction of the effect estimate was straightforward. In some cases, studies presented the mean change for each group and we calculated the differences.

The corresponding authors of studies were contacted for additional data when necessary. Studies were excluded only if we could not obtain data on the change in mental health and its variance. Data items Participants —we recorded tobacco dependence and number of cigarettes smoked a day, age, sex, and motivation to quit, all at baseline. Exposure —we extracted data on classification and bioverification of abstinence. Comparator —The same data items were extracted for continuing smokers. Outcomes —we extracted data on the change in mental health between baseline and follow-up. When such data were not available, we extracted data to calculate this (see statistical methods).

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stress paper

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An smd of 1 represents a difference in change in depression score market of. About 4 sd encompasses 95 of the population. 28 Information sources and searches we used searched Web of Science, cochrane central Register of Controlled Trials, medline, embase, and Psycinfo for studies published from inception to April 2012. We contacted study authors to obtain relevant missing data. We also searched reference lists of included studies. All non-English language studies were translated. We used a combination of text words and indexed terms related to mental health, smoking cessation, and smoking reduction (see appendix 1).

Study selection Our aim was to maximise sensitivity by including studies in initial screens even if data directly relevant to our question were not presented in the abstract. One researcher screened titles of retrieved studies for eligibility. The abstracts of eligible titles were screened twice for inclusion. The researchers met after independently screening abstracts to discuss inclusion/exclusion of each article. If there were disagreements, two researchers obtained and read the full text article. Data collection process Two researchers piloted the data extraction form, and appropriate changes were then made. The same two researchers independently extracted data from each paper and agreed on final data extraction in the case of disagreement.

17 For these reasons, we conducted a systematic review and meta-analysis of observational data to examine the difference in change in mental health between people who stop smoking and people who continue to smoke. Our hypothesis was that smokers who gave up would experience an improvement in mental health as a result because they would no longer experience multiple episodes of negative affect induced by withdrawal. Methods This study followed prisma 26 and moose reporting guidelines. 27 There was no previously published protocol. Eligibility criteria we used broad eligibility criteria to capture all potentially relevant data and then used sensitivity and subgroup analyses to investigate clinical and methodological heterogeneity. Eligibility was decided on based on the following criteria: Population—studies of smokers in the general population or any that had selected smokers from populations defined by the presence of a clinical diagnosis Exposure—studies that reported data on those who had continued smoking and those who.


Language—no exclusions were made based on language Study design— only longitudinal studies (that is, randomised controlled trials and cohort studies). When data on change in mental health were available from different follow-ups within a single study we took the longest. Any type of measure of mental health was included (such as self report and clinician scored). We included studies that provided sufficient data to calculate the standardised mean difference (SMD) and its variance in change in mental health score from baseline to follow-up between quitters and continuing smokers. The standardised mean difference is the difference in change in mental health between baseline and follow-up divided by the standard deviation (SD) of the change. It is used to overcome the issue that depression, for example, can be measured by different questionnaires with different scoring systems. The questionnaires all measure depression but the different scoring means that they cannot be combined by using a simple mean.

Research paper on stress

15 Although smokers think that smoking offers mental health benefits, there is a strong association between smoking and poor mental health, and smokers with mental health disorders tend to be heavier smokers and more dependent. 16 17 Three broad explanations have been proposed to explain these associations: smoking and poor mental health might year have common causes 18 ; people with poor mental health smoke to regulate feelings such as low mood and anxiety 19 ; or smoking might paper cause. 20 Although smokers with and without mental disorders think that smoking provides mental health benefits, they might be misattributing the ability of cigarettes to abolish nicotine withdrawal as a beneficial effect on mental health. Smokers experience irritability, anxiety, and depression when they have not smoked for a while, 21 22 and these feelings are reliably relieved by smoking 20 thus creating the perception that smoking has psychological benefits, while in fact it is smoking that caused these psychological disturbances. Whatever the cause, the association between smoking and poor mental health warrants attention. Smokers might be less likely to stop if they believe their mental health will suffer, and health professionals might be reluctant to intervene with some smokers because they believe that this might be detrimental to their mental health. 23 24 As a result, people with mental health disorders have a life expectancy eight years less than the general population, 25 and much of this difference could be because of smoking.

stress paper

death, estimated to cause more than five million deaths a year, and this is predicted to rise. 1, the worldwide cost of healthcare from tobacco use has been estimated within the billion dollar range. 2 Smoking is a major risk factor for the development of cancers and cardiovascular and respiratory diseases 3 ; stopping smoking substantially reduces these health risks. 4 5 The association between smoking and mental health, however, is less clear cut. Although most smokers report wanting to quit, 6 many continue as they report that smoking provides them with mental health benefits. Both quantitative and qualitative analyses indicate that regular smokers report smoking cigarettes to alleviate emotional problems and feelings of depression and anxiety, to stabilise mood, and for relaxation as well as relieving stress. This pattern of behaviour occurs in smokers with and without diagnosed mental disorders. 9 12 13 Unsurprisingly, views about smoking predict whether or not people attempt to quit 14 and whether or not they are successful.

Reference lists of included studies were hand searched, and authors were contacted when insufficient data were reported. Eligibility criteria friend for selecting studies, longitudinal studies of adults that assessed mental health before smoking cessation and at least six weeks after cessation or baseline in healthy and clinical populations. Results 26 studies that assessed mental health with questionnaires designed to measure anxiety, depression, mixed anxiety and depression, psychological quality of life, positive affect, and stress were included. Follow-up mental health scores were measured between seven weeks and nine years after baseline. Anxiety, depression, mixed anxiety and depression, and stress significantly decreased between baseline and follow-up in quitters compared with continuing smokers: the standardised mean differences (95 confidence intervals) were anxiety.37 (95 confidence interval.70.03 depression.25 (0.37.12 mixed anxiety and depression. Both psychological quality of life and positive affect significantly increased between baseline and follow-up in quitters compared with continuing smokers.22 (0.09.36) and.40 (0.09.71 respectively). There was no evidence that the effect size differed between the general population and populations with physical or psychiatric disorders. Smoking cessation is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke.

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Ccbync open access, research bmj 2014; 348 doi: (Published 13 February 2014) Cite this as: bmj 2014;348:g1151. This article has a correction. Please see: Gemma taylor, doctoral researcher 1 2, ann McNeill, professor of tobacco addiction 2 3, alan Girling, reader in medical statistics 1, amanda farley, lecturer in epidemiology 1 2, nicola lindson-Hawley, research fellow 2 4, paul aveyard, professor of behavioural medicine 2 4 1School. Correspondence to: g taylor and p aveyard. Accepted, abstract, objective, to investigate change in mental health after smoking cessation compared with continuing to smoke. Systematic review and meta-analysis of observational studies. Data summary sources, web of Science, cochrane central Register of Controlled Trials, medline, embase, and Psycinfo for relevant studies from inception to April 2012.


Stress paper
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