Stuart Gilmour

Global trends and projections for tobacco use, 1990–2025: an analysis of smoking indicators from the WHO Comprehensive Information Systems for Tobacco Control

BACKGROUND Countries have agreed on reduction targets for tobacco smoking stipulated in the WHO global monitoring framework, for achievement by 2025. In an analysis of data for tobacco smoking prevalence from nationally representative survey data, we aimed to provide comprehensive estimates of recent trends in tobacco smoking, projections for future tobacco smoking, and country-level estimates of probabilities of achieving tobacco smoking targets. METHODS We used a Bayesian hierarchical meta-regression modelling approach using data from the WHO Comprehensive Information Systems for Tobacco Control to assess trends from 1990 to 2010 and made projections up to 2025 for current tobacco smoking, daily tobacco smoking, current cigarette smoking, and daily cigarette smoking for 173 countries for men and 178 countries for women. Modelling was implemented in Python with DisMod-MR and PyMC. We estimated trends in country-specific prevalence of tobacco use, projections for future tobacco use, and probabilities for decreased tobacco use, increased tobacco use, and achievement of targets for tobacco control from posterior distributions. FINDINGS During the most recent decade (2000-10), the prevalence of tobacco smoking in men fell in 125 (72%) countries, and in women fell in 156 (88%) countries. If these trends continue, only 37 (21%) countries are on track to achieve their targets for men and 88 (49%) are on track for women, and there would be an estimated 1·1 billion current tobacco smokers (95% credible interval 700 million to 1·6 billion) in 2025. Rapid increases are predicted in Africa for men and in the eastern Mediterranean for both men and women, suggesting the need for enhanced measures for tobacco control in these regions. INTERPRETATION Our findings show that striking between-country disparities in tobacco use would persist in 2025, with many countries not on track to achieve tobacco control targets and several low-income and middle-income countries at risk of worsening tobacco epidemics if these trends remain unchanged. Immediate, effective, and sustained action is necessary to attain and maintain desirable trajectories for tobacco control and achieve global convergence towards elimination of tobacco use. FUNDING Ministry of Health, Labour and Welfare, Japan; Ministry of Education, Culture, Sports and Technology, Japan; Department of Health, Australia; Bloomberg Philanthropies.

Internal Radiation Exposure After the Fukushima Nuclear Power Plant Disaster

Author Affiliations: Department of Psychiatry, National Defense Medical College, Saitama, Japan (Drs Shigemura and Nomura); and Department of Public Health, Ehime University Graduate School of Medicine, Ehime, Japan (Drs Tanigawa [tt9178tt9178@gmail.com] and Saito). Author Contributions: Drs Shigemura and Tanigawa had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Shigemura, Tanigawa, Nomura. Acquisition of data: Shigemura, Tanigawa. Analysis and interpretation of data: Shigemura, Tanigawa, Saito. Drafting of the manuscript: Shigemura, Tanigawa, Saito. Critical revision of the manuscript for important intellectual content: Shigemura, Tanigawa, Nomura. Statistical analysis: Shigemura, Tanigawa, Saito. Obtained funding: Shigemura, Tanigawa, Nomura. Administrative, technical, or material support: Tanigawa. Study supervision: Tanigawa, Nomura. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Drs Shigemura and Nomura provided voluntary mental health assistance to Tokyo Electric Company Fukushima Daiichi and Daini nuclear power plant employees according to official requests from Daini and a Japanese government cabinet order to the Ministry of Defense. Dr Tanigawa is a Daini part-time occupational physician. Dr Saito reported no conflict of interest disclosures. Funding/Support: This work was supported by Health and Labour Sciences Research Grants (Research on Occupational Safety and Health H24-001) from the Ministry of Health Labour and Welfare of Japan. Role of the Sponsor: The funding organization had no role in the design and conduct of the study; in the collection, management, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript. Disclaimer: The views expressed in this article are those of the authors and do not reflect the position or policy of Tokyo Electric Company, Ehime University, National Defense Medical College, the Ministry of Defense, or the Japanese government. Additional Contributions: We thank Tomoko Yamamoto, RN (Tokyo Electric Company [TEPCO] Fukushima Daini nuclear power plant), the medical team employees of Daiichi and Daini plants, and Yoshiko Kage (TEPCO R&D Center) for their invaluable cooperation. We also thank the plant workers for their study participation and dedicated recovery efforts. No compensation was received for their services.

Explaining variation in referral from primary to secondary care: Cohort study

Objectives To determine the extent to which referral for defined symptoms from primary care varies by age, sex, and social deprivation and whether any sociodemographic variations in referral differ according to the presence of national referral guidance and the potential of the symptoms to be life threatening. Design Cohort study using individual patient data from the health improvement network database in primary care. Setting United Kingdom. Participants 5492 patients with postmenopausal bleeding, 23 121 with hip pain, and 101 212 with dyspepsia from 326 general practices, 2001-7. Main outcome measures Multivariable associations between odds of immediate referral for postmenopausal bleeding and age and social deprivation; hazard rates of referral for hip pain or dyspepsia and age, sex, and social deprivation. Analyses for dyspepsia were stratified for people aged less than and more than 55 years because referral guidance differs by age. Results 61.4% (3374/5492) of patients with postmenopausal bleeding, 17.4% (4019/23 121) with hip pain, and 13.8% (13 944/101 212) with dyspepsia were referred. The likelihood of referral for postmenopausal bleeding declined with increasing age: the adjusted odds ratio for patients aged 85 or more compared with those aged 55-64 was 0.39 (95% confidence interval 0.31 to 0.49). Patients aged 85 or more with hip pain were also less likely to be referred than those aged 55-64 (0.68, 0.57 to 0.81). Women were less likely than men to be referred for hip pain (hazard ratio 0.90, 95% confidence interval 0.84 to 0.96). More deprived patients with hip pain or dyspepsia (if aged <55) were less likely to be referred. Adjusted hazard ratios for those in the most deprived Townsend fifth compared with the least deprived were 0.72 (95% confidence interval 0.62 to 0.82) and 0.76 (0.68 to 0.85), respectively. No socioeconomic gradient was evident in referral for postmenopausal bleeding. Conclusions Inequalities in referral associated with socioeconomic circumstances were more likely to occur in the absence of both explicit guidance and potentially life threatening conditions, whereas inequalities with age were evident for all conditions.

The temporal dynamics of relationships between cannabis, psychosis and depression among young adults with psychotic disorders: findings from a 10-month prospective study.

BACKGROUND The aim was to examine the temporal relationships over 10 months between cannabis use and symptoms of psychosis and depression in people with schizophrenia and related disorders. The design was a prospective study of 101 patients with schizophrenia and related disorders who were assessed monthly over 10 months on medication compliance, cannabis and other drug use, symptoms of depression and symptoms of psychosis. METHOD Linear regression methods to assess relationships between cannabis use and symptoms of psychosis and depression while adjusting for serial dependence, medication compliance and other demographic and clinical variables. RESULTS Cannabis use predicted a small but statistically significant increase in symptoms of psychosis, but not depression, after controlling for other differences between cannabis users and non-users. Symptoms of depression and psychosis did not predict cannabis use. CONCLUSION Continued cannabis use by persons with schizophrenia predicts a small increase in psychotic symptom severity but not vice versa.

Clearance of hepatitis C virus after newly acquired infection in injection drug users.

A retrospective cohort of injection drug users with newly acquired hepatitis C virus (HCV) infection was established to examine viral clearance. Newly acquired HCV infection was defined by anti-HCV antibody seroconversion within a 2-year interval. Stored serum samples were tested for HCV RNA, with viral clearance defined as >/=2 consecutive negative HCV RNA test results after infection. Ninety-nine cases of HCV infection were identified; 57 had >/=2 HCV RNA test results after infection. Viral clearance occurred in 24 (42%) cases, with Kaplan-Meier estimated probabilities of 23%, 38%, and 40% at 6, 12, and 24 months, respectively.

Mortality Risk amongst Nursing Home Residents Evacuated after the Fukushima Nuclear Accident: A Retrospective Cohort Study

Background Safety of evacuation is of paramount importance in disaster planning for elderly people; however, little effort has been made to investigate evacuation-related mortality risks. After the Fukushima Daiichi Nuclear Plant accident we conducted a retrospective cohort survival survey of elderly evacuees. Methods A total of 715 residents admitted to five nursing homes in Minamisoma city, Fukushima Prefecture in the five years before 11th March 2011 joined this retrospective cohort study. Demographic and clinical characteristics were drawn from facility medical records. Evacuation histories were tracked until the end of 2011. The evacuations impact on mortality was assessed using mortality incidence density and hazard ratios in Cox proportional hazards regression. Results Overall relative mortality risk before and after the earthquake was 2.68 (95% CI: 2.04–3.49). There was a substantial variation in mortality risks across the facilities ranging from 0.77 (95% CI: 0.34–1.76) to 2.88 (95% CI: 1.74–4.76). No meaningful influence of evacuation distance on mortality was observed although the first evacuation from the original facility caused significantly higher mortality than subsequent evacuations, with a hazard ratio of 1.94 (95% CI: 1.07–3.49). Conclusion High mortality, due to initial evacuation, suggests that evacuation of the elderly was not the best life-saving strategy for the Fukushima nuclear disaster. Careful consideration of the relative risks of radiation exposure and the risks and benefits of evacuation is essential. Facility-specific disaster response strategies, including in-site relief and care, may have a strong influence on survival. Where evacuation is necessary, careful planning and coordination with other nursing homes, evacuation sites and government disaster agencies is essential to reduce the risk of mortality.

Trends in cause specific mortality across occupations in Japanese men of working age during period of economic stagnation, 1980-2005: retrospective cohort study.

Objective To assess the temporal trends in occupation specific all causes and cause specific mortality in Japan between 1980 and 2005. Design Longitudinal analysis of individual death certificates by last occupation before death. Data on population by age and occupation were derived from the population census. Setting Government records, Japan. Participants Men aged 30-59. Main outcome measures Age standardised mortality rate for all causes, all cancers, cerebrovascular disease, ischaemic heart disease, unintentional injuries, and suicide. Results Age standardised mortality rates for all causes and for the four leading causes of death (cancers, ischaemic heart disease, cerebrovascular disease, and unintentional injuries) steadily decreased from 1980 to 2005 among all occupations except for management and professional workers, for whom rates began to rise in the late 1990s (P<0.001). During the study period, the mortality rate was lowest in other occupations such as production/labour, clerical, and sales workers, although overall variability of the age standardised mortality rate across occupations widened. The rate for suicide rapidly increased since the late 1990s, with the greatest increase being among management and professional workers. Conclusions Occupational patterns in cause specific mortality changed dramatically in Japan during the period of its economic stagnation and resulted in the reversal of occupational patterns in mortality that have been well established in western countries. A significant negative effect on the health of management and professional workers rather than clerks and blue collar workers could be because of increased job demands and more stressful work environments and could have eliminated or even reversed the health inequality across occupations that had existed previously.

Maternal anemia and risk of adverse birth and health outcomes in low- and middle-income countries: systematic review and meta-analysis

BACKGROUND Anemia is a leading cause of maternal deaths and adverse pregnancy outcomes in developing countries. OBJECTIVES We conducted a systematic review and meta-analysis to estimate the pooled prevalence of anemia, the association between maternal anemia and pregnancy outcomes, and the population-attributable fraction (PAF) of these outcomes that are due to anemia in low- and middle-income countries. DESIGN PubMed, EMBASE, CINAHL, and the British Nursing Index were searched from inception to May 2015 to identify cohort studies of the association between maternal anemia and pregnancy outcomes. The anemic group was defined as having hemoglobin concentrations <10 or <11 g/dL or hematocrit values <33% or <34% depending on the study. A metaregression and stratified analysis were performed to assess the effects of study and participant characteristics on adverse pregnancy risk. The pooled prevalence of anemia in pregnant women by region and country-income category was calculated with the use of a random-effects meta-analysis. RESULTS Of 8182 articles reviewed, 29 studies were included in the systematic review, and 26 studies were included in the meta-analysis. Overall, 42.7% (95% CI: 37.0%, 48.4%) of women experienced anemia during pregnancy in low- and middle-income countries. There were significantly higher risks of low birth weight (RR: 1.31; 95% CI: 1.13, 1.51), preterm birth (RR: 1.63; 95% CI: 1.33, 2.01), perinatal mortality (RR: 1.51; 95% CI: 1.30, 1.76), and neonatal mortality (RR: 2.72; 95% CI: 1.19, 6.25) in pregnant women with anemia. South Asian, African, and low-income countries had a higher pooled anemia prevalence than did other Asian and upper-middle-income countries. Overall, in low- and middle-income countries, 12% of low birth weight, 19% of preterm births, and 18% of perinatal mortality were attributable to maternal anemia. The proportion of adverse pregnancy outcomes attributable to anemia was higher in low-income countries and in the South Asian region. CONCLUSION Maternal anemia remains a significant health problem in low- and middle-income countries.

Health-Related Financial Catastrophe, Inequality and Chronic Illness in Bangladesh

Background Bangladesh has a high proportion of households incurring catastrophic health expenditure, and very limited risk sharing mechanisms. Identifying determinants of out-of-pocket (OOP) payments and catastrophic health expenditure may reveal opportunities to reduce costs and protect households from financial risk. Objective This study investigates the determinants of high healthcare expenditure and healthcare- related financial catastrophe. Methods A cross-sectional household survey was conducted in Rajshahi city, Bangladesh, in 2011. Catastrophic health expenditure was estimated separately based on capacity to pay and proportion of non-food expenditure. Determinants of OOP payments and financial catastrophe were estimated using double hurdle and Poisson regression models respectively. Results On average households spent 11% of their total budgets on health, half the residents spent 7% of the monthly per capita consumption expenditure for one illness, and nearly 9% of households faced financial catastrophe. The poorest households spent less on health but had a four times higher risk of catastrophe than the richest households. The risk of financial catastrophe and the level of OOP payments were higher for users of inpatient, outpatient public and private facilities respectively compared to using self-medication or traditional healers. Other determinants of OOP payments and catastrophic expenses were economic status, presence of chronic illness in the household, and illness among children and adults. Conclusion Households that received inpatient or outpatient private care experienced the highest burden of health expenditure. The poorest members of the community also face large, often catastrophic expenses. Chronic illness management is crucial to reducing the total burden of disease in a household and its associated increased risk of level of OOP payments and catastrophic expenses. Households can only be protected from these situations by reducing the health systems dependency on OOP payments and providing more financial risk protection.

Maternal body mass index and risk of birth and maternal health outcomes in low‐ and middle‐income countries: a systematic review and meta‐analysis

We conducted a systematic review and meta‐analysis of population‐based cohort studies of maternal body mass index (BMI) and risk of adverse birth and health outcomes in low‐ and middle‐income countries. PubMed, Embase, CINAHL and the British Nursing Index were searched from inception to February 2014. Forty‐two studies were included. Our study found that maternal underweight was significantly associated with higher risk of preterm birth (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.01–1.27), low birthweight (OR, 1.66; 95% CI, 1.50–1.84) and small for gestational age (OR, 1.85; 95% CI, 1.69–2.02). Compared with mothers with normal BMI, overweight or obese mothers were at increased odds of gestational diabetes, pregnancy‐induced hypertension, pre‐eclampsia, caesarean delivery and post‐partum haemorrhage. The population‐attributable risk (PAR) indicated that if women were entirely unexposed to overweight or obesity during the pre‐pregnancy or early pregnancy period, 14% to 35% fewer women would develop gestational diabetes, pre‐eclampsia or pregnancy‐induced hypertension in Brazil, China, India, Iran or Thailand. The highest PAR of low birthweight attributable to maternal underweight was found in Iran (20%), followed by India (18%), Thailand (10%) and China (8%). Treatment and prevention of maternal underweight, overweight or obesity may help reduce the burden on maternal and child health in developing countries.