Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.

FINDINGS

The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.

INTERPRETATION

Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.

FUNDING

Bill & Melinda Gates Foundation.

Evaluation of an obstetric and neonatal care upskilling program for community health workers in Papua New Guinea

BACKGROUND

60% of women in Papua New Guinea (PNG) give birth unsupervised and outside of a health facility, contributing to high national maternal and perinatal mortality rates. We evaluated a practical, hospital-based on-the-job training program implemented by local health authorities in PNG between 2013 and 2019 aimed at addressing this challenge by upskilling community health workers (CHWs) to provide quality maternal and newborn care in rural health facilities.

METHODS

Two provinces, the Eastern Highlands and Simbu Provinces, were included in the study. In the Eastern Highlands Province, a baseline and end point skills assessment and post-training interviews 12 months after completion of the 2018 training were used to evaluate impacts on CHW knowledge, skills, and self-reported satisfaction with training. Quality and timeliness of referrals was assessed through data from the Eastern Highlands Province referral hospital registers. In Simbu Province, impacts of training on facility births, stillbirths and referrals were evaluated pre- and post-training retrospectively using routine health facility reporting data from 2012 to 2019, and negative binomial regression analysis adjusted for potential confounders and correlation of outcomes within facilities.

RESULTS

The average knowledge score increased significantly, from 69.8% (95% CI:66.3-73.2%) at baseline, to 87.8% (95% CI:82.9-92.6%) following training for the 8 CHWs participating in Eastern Highlands Province training. CHWs reported increased confidence in their skills and ability to use referral networks. There were significant increases in referrals to the Eastern Highlands provincial hospital arriving in the second stage of labour but no significant difference in the 5 min Apgar score for children, pre and post training. Data on 11,345 births in participating facilities in Simbu Province showed that the number of births in participating rural health facilities more than doubled compared to prior to training, with the impact increasing over time after training (0-12 months after training: IRR 1.59, 95% CI: 1.04-2.44, p-value 0.033, > 12 months after training: IRR 2.46, 95% CI:1.37-4.41, p-value 0.003). There was no significant change in stillbirth or referral rates.

CONCLUSIONS

Our findings showed positive impacts of the upskilling program on CHW knowledge and practice of participants, facility births rates, and appropriateness of referrals, demonstrating its promise as a feasible intervention to improve uptake of maternal and newborn care services in rural and remote, low-resource settings within the resourcing available to local authorities. Larger-scale evaluations of a size adequately powered to ascertain impact of the intervention on stillbirth rates are warranted.

Electronic cigarette social norms among adolescents in New South Wales, Australia

The use of electronic cigarettes (e-cigarettes) is common and increasing, especially among youth. In 2022/2023, 30% of 12- to 17-year-olds reported ever using e-cigarettes in Australia-a >50% increase from 2017 (14%). Several adverse e-cigarette health effects have been identified and most effects remain unknown. Social norms, rules that govern social behaviours, are associated with current and future adolescent e-cigarette use. Understanding social norms in Australian adolescents is critical to the development of targeted and effective e-cigarette prevention activities. This study aims to explore e-cigarette social norms among adolescents living in New South Wales, Australia. A total of 32 online single or paired semi-structured qualitative interviews were conducted involving 46 participants aged 14-17 years, as part of the Generation Vape project. Reflexive thematic analysis was applied within a constructivist perceptive. Adolescents perceived e-cigarettes use as prolific among their peers, with use considered common, acceptable and normal. Fuelled by social exposure to e-cigarettes, 'everyone' was generally thought to be using them (descriptive norms). E-cigarette use was considered so entrenched that it was part of adolescent identity, with abstinence regarded as atypical. Use was driven by an internalised desire to fit it (injunctive norm), rather than being attributed to overt/external 'peer-pressure'. Positive e-cigarette norms exist among Australian adolescents with norm formation strongly influenced by social exposure, including e-cigarette promotion. Prevention efforts should include limiting adolescent exposure to e-cigarette marketing to help redefine existing pro-e-cigarette social norms and protect health.

Who smokes in Australia? Cross-sectional analysis of Australian Bureau of Statistics survey data, 2017-19

OBJECTIVES

To assess the socio-demographic and health-related characteristics of people who smoke daily, people who formerly smoked, and people who have never smoked in Australia.

STUDY DESIGN

Cross-sectional analysis of Australian Bureau of Statistics (ABS) survey data.

SETTING, PARTICIPANTS

Adult participants (16 370 people aged 18 years or older) in the ABS 2017-18 National Health Survey (NHS); adult participants in the ABS 2018-19 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) (6423 people aged 18 years or older).

MAIN OUTCOME MEASURES

Socio-demographic and health-related characteristics of people who smoke daily, people who formerly smoked, and people who have never smoked, expressed as population-weighted proportions, overall and by Indigeneity.

RESULTS

Among adult NHS respondents, an estimated 58.8% of people who smoked daily (95% confidence interval [CI], 56.2-61.4%) were men, 61.3% (95% CI, 58.7-63.9%) were 25-54 years old, 72.5% (95% CI, 70.0-74.8%) were born in Australia, and 65.4% (95% CI, 62.8-67.8%) lived in major cities and 54.3% (95% CI, 51.6-57.0%) in areas in the two socio-economically most disadvantaged quintiles; 75.9% (95% CI, 73.5-78.1%) reported good to excellent health, 73.0% (95% CI, 70.5-75.4%) reported low to moderate psychological distress, 69.0% of those aged 25-64 years (ie, of working age) had completed year 12 (high school), and 68.5% were currently employed. An estimated 2.57 million people smoke daily in Australia: 2.37 million non-Indigenous people (92%) and 195 700 Aboriginal or Torres Strait Islander people (8%).

CONCLUSIONS

While smoking is more frequent among people living in socio-economically disadvantaged areas and in certain population sub-groups, this first quantitative national profile indicates that most people who smoke daily are in paid employment, are non-Indigenous, are in good physical and mental health, and have completed year 12. Improved comprehensive structural supply- and demand-based tobacco control, informed by the needs of priority groups and the overall profile of people who smoke, is needed to reduce daily smoking prevalence among adults to the 2030 targets of 5% or less for all Australians and 27% or less for Aboriginal and Torres Strait Islander people.

Health behaviours associated with healthy body composition among Aboriginal adolescents in Australia in the 'Next Generation: Youth Well-being study'

This study described the distribution of healthy body composition among Aboriginal adolescents in Australia aged 10-24 years and examined associations with health behaviours and self-rated health. Data were cross-sectional from the 'Next Generation: Youth Well-being study' baseline (N = 1294). We used robust Poisson regression to quantify associations of self-reported health behaviours (physical activity, screen time, sleep, consumption of vegetables, fruit, soft drinks and fast food, and tobacco smoking and alcohol) and self-rated health to healthy body mass index (BMI) and waist/height ratio (WHtR). Overall, 48% of participants had healthy BMI and 64% healthy WHtR, with healthy body composition more common among younger adolescents. Higher physical activity was associated with healthy body composition (5-7 days last week vs none; adjusted prevalence ratio (aPR) healthy BMI 1.31 [95% CI 1.05-1.64], and healthy WHtR 1.30 [1.10-1.54]), as was recommended sleep duration (vs not; aPR healthy BMI 1.56 [1.19-2.05], and healthy WHtR 1.37 [1.13-1.67]). There was a trend for higher proportion of healthy body composition with more frequent fast food consumption. Healthy body composition was also associated with higher self-rated health ('very good/excellent' vs 'poor/fair'; aPR healthy BMI 1.87 [1.45-2.42], and healthy WHtR 1.71 [1.40-2.10]). Culturally appropriate community health interventions with a focus on physical activity and sleep may hold promise for improving body composition among Aboriginal adolescents.

Pain and its interference with daily living in relation to cancer: a comparative population-based study of 16,053 cancer survivors and 106,345 people without cancer

BACKGROUND

Pain is a common, debilitating, and feared symptom, including among cancer survivors. However, large-scale population-based evidence on pain and its impact in cancer survivors is limited. We quantified the prevalence of pain in community-dwelling people with and without cancer, and its relation to physical functioning, psychological distress, and quality of life (QoL).

METHODS

Questionnaire data from participants in the 45 and Up Study (Wave 2, n = 122,398, 2012-2015, mean age = 60.8 years), an Australian population-based cohort study, were linked to cancer registration data to ascertain prior cancer diagnoses. Modified Poisson regression estimated age- and sex-adjusted prevalence ratios (PRs) for bodily pain and pain sufficient to interfere with daily activities (high-impact pain) in people with versus without cancer, for 13 cancer types, overall and according to clinical, personal, and health characteristics. The relation of high-impact pain to physical and mental health outcomes was quantified in people with and without cancer.

RESULTS

Overall, 34.9% (5,436/15,570) of cancer survivors and 31.3% (32,471/103,604) of participants without cancer reported bodily pain (PR = 1.07 [95% CI = 1.05-1.10]), and 15.9% (2,468/15,550) versus 13.1% (13,573/103,623), respectively, reported high-impact pain (PR = 1.13 [1.09-1.18]). Pain was greater with more recent cancer diagnosis, more advanced disease, and recent cancer treatment. High-impact pain varied by cancer type; compared to cancer-free participants, PRs were: 2.23 (1.71-2.90) for multiple myeloma; 1.87 (1.53-2.29) for lung cancer; 1.06 (0.98-1.16) for breast cancer; 1.05 (0.94-1.17) for colorectal cancer; 1.04 (0.96-1.13) for prostate cancer; and 1.02 (0.92-1.12) for melanoma. Regardless of cancer diagnosis, high-impact pain was strongly related to impaired physical functioning, psychological distress, and reduced QoL.

CONCLUSIONS

Pain is common, interfering with daily life in around one-in-eight older community-dwelling participants. Pain was elevated overall in cancer survivors, particularly for certain cancer types, around diagnosis and treatment, and with advanced disease. However, pain was comparable to population levels for many common cancers, including breast, prostate and colorectal cancer, and melanoma.

Analysis of Multiple Causes of Death: A Review of Methods and Practices

BACKGROUND

Research and reporting of mortality indicators typically focus on a single underlying cause of death selected from multiple causes recorded on a death certificate. The need to incorporate the multiple causes in mortality statistics-reflecting increasing multimorbidity and complex causation patterns-is recognized internationally. This review aims to identify and appraise relevant analytical methods and practices related to multiple causes.

METHODS

We searched Medline, PubMed, Scopus, and Web of Science from their incept ion to December 2020 without language restrictions, supplemented by consultation with international experts. Eligible articles analyzed multiple causes of death from death certificates. The process identified 4,080 items of which we reviewed 434 full-text articles.

RESULTS

Most articles we reviewed (76%, n = 332) were published since 2001. The majority of articles examined mortality by "any- mention" of the cause of death (87%, n = 377) and assessed pairwise combinations of causes (57%, n = 245). Since 2001, applications of methods emerged to group deaths based on common cause patterns using, for example, cluster analysis (2%, n = 9), and application of multiple-cause weights to re-evaluate mortality burden (1%, n = 5). We describe multiple-cause methods applied to specific research objectives for approaches emerging recently.

CONCLUSION

This review confirms rapidly increasing international interest in the analysis of multiple causes of death and provides the most comprehensive overview, to our knowledge, of methods and practices to date. Available multiple-cause methods are diverse but suit a range of research objectives. With greater availability of data and technology, these could be further developed and applied across a range of settings.

Electronic cigarettes and health outcomes: umbrella and systematic review of the global evidence

OBJECTIVE

To review and synthesise the global evidence regarding the health effects of electronic cigarettes (e-cigarettes, vapes).

STUDY DESIGN

Umbrella review (based on major independent reviews, including the 2018 United States National Academies of Sciences, Engineering, and Medicine [NASEM] report) and top-up systematic review of published, peer-reviewed studies in humans examining the relationship of e-cigarette use to health outcomes published since the NASEM report.

DATA SOURCES

Umbrella review: eight major independent reviews published 2017-2021. Systematic review: PubMed, MEDLINE, Scopus, Web of Science, the Cochrane Library, and PsycINFO (articles published July 2017 - July 2020 and not included in NASEM review).

DATA SYNTHESIS

Four hundred eligible publications were included in our synthesis: 112 from the NASEM review, 189 from our top-up review search, and 99 further publications cited by other reviews. There is conclusive evidence linking e-cigarette use with poisoning, immediate inhalation toxicity (including seizures), and e-cigarette or vaping product use-associated lung injury (EVALI; largely but not exclusively for e-liquids containing tetrahydrocannabinol and vitamin E acetate), as well as for malfunctioning devices causing injuries and burns. Environmental effects include waste, fires, and generation of indoor airborne particulate matter (substantial to conclusive evidence). There is substantial evidence that nicotine e-cigarettes can cause dependence or addiction in non-smokers, and strong evidence that young non-smokers who use e-cigarettes are more likely than non-users to initiate smoking and to become regular smokers. There is limited evidence that freebase nicotine e-cigarettes used with clinical support are efficacious aids for smoking cessation. Evidence regarding effects on other clinical outcomes, including cardiovascular disease, cancer, development, and mental and reproductive health, is insufficient or unavailable.

CONCLUSION

E-cigarettes can be harmful to health, particularly for non-smokers and children, adolescents, and young adults. Their effects on many important health outcomes are uncertain. E-cigarettes may be beneficial for smokers who use them to completely and promptly quit smoking, but they are not currently approved smoking cessation aids. Better quality evidence is needed regarding the health impact of e-cigarette use, their safety and efficacy for smoking cessation, and effective regulation.

REGISTRATION

Systematic review: PROSPERO, CRD42020200673 (prospective).

Social and Behavioural Correlates of High Physical Activity Levels among Aboriginal Adolescent Participants of the Next Generation: Youth Wellbeing Study

Physical activity typically decreases during teenage years and has been identified as a health priority by Aboriginal adolescents. We examined associations between physical activity levels and sociodemographic, movement and health variables in the Aboriginal led 'Next Generation: Youth Well-being (NextGen) Study' of Aboriginal people aged 10-24 years from Central Australia, Western Australia and New South Wales. Baseline survey data collected by Aboriginal researchers and Aboriginal youth peer recruiters from 2018 to 2020 examined demographics and health-related behaviours. Logistic regression was used to estimate odds ratios (OR) for engaging in high levels of physical activity in the past week (3-7 days; 0-2 days (ref), or 'don't remember') associated with demographic and behavioural factors. Of 1170 adolescents, 524 (41.9%) had high levels of physical activity; 455 (36.4%) had low levels; 191 (15.3%) did not remember. Factors independently associated with higher odds of physical activity 3-7 days/week were low weekday recreational screen time [55.3% vs. 44.0%, OR 1.79 (1.16-2.76)], having non-smoking friends [50.4% vs. 25.0%, OR 2.27 (1.03-5.00)] and having fewer friends that drink alcohol [48.1% vs. 35.2%, OR 2.08 (1.05-4.14)]. Lower odds of high physical activity were independently associated with being female [40.2% vs. 50.9%, OR 0.57 (0.40-0.80)] and some findings differed by sex. The NextGen study provides evidence to inform the co-design and implementation of strategies to increase Aboriginal adolescent physical activity such as focusing on peer influences and co-occurring behaviours such as screen time.

Healthcare experiences of people with advanced colorectal cancer: A qualitative study

PURPOSE

Qualitative research examining healthcare experiences and needs of people with advanced (metastatic or recurrent) colorectal cancer CRC-A is limited. This study aimed to fill this gap in CRC-A survivors treated with surgical or palliative chemotherapy, through a qualitative study.

METHOD

Australian adults treated for CRC-A were recruited 0.5-2 years post-surgery or post-diagnosis of CRC-A (for palliative chemotherapy groups). Semi-structured telephone interviews, analysed via framework analysis, explored healthcare experiences. Demographic, clinical, and quality of life data characterised the sample and informed framework analyses. Data was compared against the Institute of Medicine's framework for quality healthcare.

RESULTS

Interviews from 38 participants (22 female) of median age 59 years (range 27-84) revealed six overarching themes relating to the safety, effectiveness, timeliness, patient-centredness, efficiency, and equity of CRC-A care: 1) Early experiences influence later perceptions; 2) Trusting the system, trusting the professionals; 3) The benefits of multidisciplinary care co-ordination; 4) Feeling lost in follow-up; 5) Whose role is it anyway? Gaps in responsibility for survivorship care; and 6) Useful or useless? Perceptions of psychosocial support.

CONCLUSIONS

Healthcare systems for CRC-A can be improved through delivery of repeated information, upskilling general practitioners and/or implementing written survivorship care plans or survivorship clinics, to ensure quality healthcare.

The 45 and Up Study: reflecting on contributions to global evidence using case studies on cardiovascular disease and smoking

BACKGROUND/OBJECTIVE

To describe the attributes that have underscored the success of the 45 and Up Study (the Study) and demonstrate its value by reflecting on two case studies: our research on socioeconomic inequalities in cardiovascular disease; and the harms of smoking. Type of program or service: The Study is the largest study of healthy ageing in Australia, and one of the biggest in the world; it recruited 267 357 participants aged 45 years and older from NSW, Australia from 2005 to 2009. For more than 15 years, it has provided high-quality evidence on a broad range of public health related issues. We reflect on its value using two research case studies.

RESULTS

Four key attributes have enabled the success of the Study: its establishment as a collaborative resource, including early and ongoing engagement with researchers and policy and practice partners; its large scale, which makes it ideally suited to quantify associations between risk factors and health outcomes, including for high priority populations; high quality self-reported survey data; and linkage to routinely collected administrative data, including specialised data. Novel Australian findings on cardiovascular disease (CVD) and smoking illustrate how the Study has contributed to national and international evidence, informing policy and practice. Results on CVD demonstrated individual-level education-related inequalities in CVD incidence and mortality, and greater use of pharmacotherapy for secondary prevention of CVD, in people with low versus high socioeconomic status. In terms of smoking, Study data showed that current smokers have around three times the mortality of never-smokers; that even "light" smoking of <14 cigarettes per day doubles mortality; that quitting is beneficial at any age; that smoking increases the risk of multiple cancer types; and that smoking causes half of deaths in Aboriginal and Torres Strait Islander adults aged 45 years and over and more than one-third of all deaths in the population. This evidence has been used by more than 50 government and non-government organisations, including contributing to legislation, policy and national and international monitoring and reporting.

LESSONS LEARNT

The Study has fulfilled a vital role in public health research and practice in Australia, providing locally relevant data to enable research on health issues of importance, including health inequity. Through ongoing partnerships, the Study's data has contributed to international scientific evidence and been used to inform public health policy and practice. It has also been used as a focus for collaboration and capacity building.

Population-level contribution of interpersonal discrimination to psychological distress among Australian Aboriginal and Torres Strait Islander adults, and to Indigenous-non-Indigenous inequities: cross-sectional analysis of a community-controlled First Nations cohort study

BACKGROUND

International and population-specific evidence identifies elevated psychological distress prevalence among those experiencing interpersonal discrimination. We aim to quantify the potential whole-of-population contribution of interpersonal discrimination to psychological distress prevalence and Indigenous-non-Indigenous gaps in Australia.

METHODS

We did a cross-sectional analysis of data from Mayi Kuwayu: the National Study of Aboriginal and Torres Strait Islander Wellbeing. Baseline surveys were completed between June 8, 2018, and Sept 28, 2022. We analysed responses from participants who were aged 18 years or older at survey completion, whose surveys were processed between Oct 1, 2018, and May 1, 2021. Sample weights were developed on the basis of national population benchmarks. We measured everyday discrimination using an eight-item measure modified from the Everyday Discrimination Scale and classified experiences as racial discrimination if participants attributed these experiences to their Indigeneity. Psychological distress was measured using a validated, modified Kessler-5 scale. Applying logistic regression, we calculated unadjusted odds ratios (ORs), to approximate incident rate ratios (IRRs), for high or very high psychological distress in relation to everyday discrimination and everyday racial discrimination across age-gender strata. Population attributable fractions (PAFs), under the hypothetical assumption that ORs represent causal relationships, were calculated using these ORs and population-level exposure prevalence. These PAFs were used to quantify the contribution of everyday racial discrimination to psychological distress gaps between Indigenous and non-Indigenous adults.

FINDINGS

9963 survey responses were eligible for inclusion in our study, of which we analysed 9951 (99·9%); 12 were excluded due to responders identifying as a gender other than man or woman (there were too few responses from this demographic to be included as a category in stratified tables or adjusted analyses). The overall prevalence of psychological distress was 48·3% (95% CI 47·0-49·6) in those experiencing everyday discrimination compared with 25·2% (23·8-26·6) in those experiencing no everyday discrimination (OR 2·77 [95% CI 2·52-3·04]) and psychological distress prevalence was 49·0% (95% CI 47·3-50·6) in those experiencing everyday racial discrimination and 31·8% (30·6-33·1) in those experiencing no everyday racial discrimination (OR 2·06 [95% CI 1·88-2·25]. Overall, 49·3% of the total psychological distress burden among Aboriginal and Torres Strait Islander adults could be attributable to everyday discrimination (39·4-58·8% across strata) and 27·1% to everyday racial discrimination. Everyday racial discrimination could explain 47·4% of the overall gap in psychological distress between Indigenous and non-Indigenous people (40·0-60·3% across strata).

INTERPRETATION

Our findings show that interpersonal discrimination might contribute substantially to psychological distress among Aboriginal and Torres Strait Islander adults, and to inequities compared with non-Indigenous adults. Estimated PAFs include contributions from social and health disadvantage, reflecting contributions from structural racism. Although not providing strictly conclusive evidence of causality, this evidence is sufficient to indicate the psychological harm of interpersonal discrimination. Findings add weight to imperatives to combat discrimination and structural racism at its core. Urgent individual and policy action is required of non-Indigenous people and colonial structures, directed by Aboriginal and Torres Strait Islander peoples.

FUNDING

National Health and Medical Research Council of Australia, Ian Potter Foundation, Australian Research Council, US National Institutes of Health, and Sierra Foundation.

Quantifying cause-related mortality in Australia, incorporating multiple causes: observed patterns, trends and practical considerations

BACKGROUND

Mortality statistics using a single underlying cause of death (UC) are key health indicators. Rising multimorbidity and chronic disease mean that deaths increasingly involve multiple conditions. However, additional causes reported on death certificates are rarely integrated into mortality indicators, partly due to complexities in data and methods. This study aimed to assess trends and patterns in cause-related mortality in Australia, integrating multiple causes (MC) of death.

METHODS

Deaths (n = 1 773 399) in Australia (2006-17) were mapped to 136 ICD-10-based groups and MC indicators applied. Age-standardized cause-related rates (deaths/100 000) based on the UC (ASRUC) were compared with rates based on any mention of the cause (ASRAM) using rate ratios (RR = ASRAM/ASRUC) and to rates based on weighting multiple contributing causes (ASRW).

RESULTS

Deaths involved on average 3.4 causes in 2017; the percentage with >4 causes increased from 20.9 (2006) to 24.4 (2017). Ischaemic heart disease (ASRUC = 73.3, ASRAM = 135.8, ASRW = 63.5), dementia (ASRUC = 51.1, ASRAM = 98.1, ASRW = 52.1) and cerebrovascular diseases (ASRUC = 39.9, ASRAM = 76.7, ASRW = 33.5) ranked as leading causes by all methods. Causes with high RR included hypertension (ASRUC = 2.2, RR = 35.5), atrial fibrillation (ASRUC = 8.0, RR = 6.5) and diabetes (ASRUC = 18.5, RR = 3.5); the corresponding ASRW were 12.5, 12.6 and 24.0, respectively. Renal failure, atrial fibrillation and hypertension ranked among the 10 leading causes by ASRAM and ASRW but not by ASRUC. Practical considerations in working with MC data are discussed.

CONCLUSIONS

Despite the similarities in leading causes under the three methods, with integration of MC several preventable diseases emerged as leading causes. MC analyses offer a richer additional perspective for population health monitoring and policy development.

Observed and predicted premature mortality in Australia due to non-communicable diseases: a population-based study examining progress towards the WHO 25X25 goal

BACKGROUND

The World Health Organization's (WHO) 25X25 goal aims for a 25% relative reduction in premature death due to four non-communicable diseases (NCD4)-cancer, cardiovascular disease, chronic respiratory diseases and diabetes-by 2025 compared to 2010. This study aimed to quantify the premature mortality in the Australian population due to NCD4, quantify the variation in mortality rates by age and sex, predict the premature mortality due to NCD4 in 2025 and evaluate the progress towards the WHO 25X25 goal.

METHODS

A population-based study using cause-specific mortality data of all deaths which occurred in Australia from 2010 to 2016 and registered up to 2017, for adults aged 30-69 years, was conducted. Age-specific and age-standardised mortality rates (ASMR) and probability of death for NCD4 were calculated for each year. ASMRs in 2016 were calculated for men and women. Deaths and the probability of death in 2025 were predicted using Poisson regression based on data from 2006 to 2016. To assess the progress against the WHO 25X25 goal, the relative reduction in the probability of death from NCD4 conditions in 2025 compared to 2010 was calculated.

RESULTS

ASMRs for NCD4 decreased from 2010 to 2016, except for diabetes which increased on average by 2.5% per year. Across sociodemographic factors, ASMRs were highest in males and increased with age. The projected probability of premature death in 2025 was 7.36%, equivalent to a relative reduction of 25.16% compared to 2010 levels.

CONCLUSIONS

Premature mortality due to cancer, cardiovascular disease, respiratory diseases and diabetes declined in Australia from 2010 to 2016. This trend is consistent across age groups and by sex, and higher mortality rates were observed in males and at older ages. Nationally, if the current trends continue, we estimate that Australia will achieve a 25.16% relative reduction in premature deaths due to NCD4 in 2025 compared to 2010, signifying substantial progress towards the WHO 25X25 goal. Concerted efforts will need to continue to meet the 25X25 goal, especially in the context of the COVID-19 pandemic.

Education-related inequalities in cause-specific mortality: first estimates for Australia using individual-level linked census and mortality data

BACKGROUND

Socioeconomic inequalities in mortality are evident in all high-income countries, and ongoing monitoring is recommended using linked census-mortality data. Using such data, we provide the first estimates of education-related inequalities in cause-specific mortality in Australia, suitable for international comparisons.

METHODS

We used Australian Census (2016) linked to 13 months of Death Registrations (2016-17). We estimated relative rates (RR) and rate differences (RD, per 100 000 person-years), comparing rates in low (no qualifications) and intermediate (secondary school) with high (tertiary) education for individual causes of death (among those aged 25-84 years) and grouped according to preventability (25-74 years), separately by sex and age group, adjusting for age, using negative binomial regression.

RESULTS

Among 13.9 M people contributing 14 452 732 person-years, 84 743 deaths occurred. All-cause mortality rates among men and women aged 25-84 years with low education were 2.76 [95% confidence interval (CI): 2.61-2.91] and 2.13 (2.01-2.26) times the rates of those with high education, respectively. We observed inequalities in most causes of death in each age-sex group. Among men aged 25-44 years, relative and absolute inequalities were largest for injuries, e.g. transport accidents [RR = 10.1 (5.4-18.7), RD = 21.2 (14.5-27.9)]). Among those aged 45-64 years, inequalities were greatest for chronic diseases, e.g. lung cancer [men RR = 6.6 (4.9-8.9), RD = 57.7 (49.7-65.8)] and ischaemic heart disease [women RR = 5.8 (3.7-9.1), RD = 20.2 (15.8-24.6)], with similar patterns for people aged 65-84 years. When grouped according to preventability, inequalities were large for causes amenable to behaviour change and medical intervention for all ages and causes amenable to injury prevention among young men.

CONCLUSIONS

Australian education-related inequalities in mortality are substantial, generally higher than international estimates, and related to preventability. Findings highlight opportunities to reduce them and the potential to improve the health of the population.

923Quantifying multiple causes of death: Observed patterns in Australia, 2006–2017

Background

Four fifths of deaths in Australia involve multiple causes, but statistics typically use a single underlying cause of death (UC). The UC approach alone is insufficient for understanding the impact of non-underlying causes and identifying comorbid disease associations at death. Analysis of multiple causes of death (MC) is needed to measure the impact of all causes. We described MC patterns, considering cause-of-death coding and certification practices in Australia.

Methods

Using deaths registered in Australia from 2006 to 2017 (n = 1773525) coded to the International Classification of Diseases (ICD) and an extended classification (n = 136 causes) based on a World Health Organization short list, we described MCoD data by cause. Age-standardised rates based on UC and MC were compared using the standardised ratio of multiple to underlying causes (SRMU) to estimate the contribution of the cause to mortality compared to using the UC approach. Comorbidity was explored using the cause of death association indicator (CDAI) to compare the observed joint frequency of a contributory-underlying cause combined with expected frequency of the contributory cause (with any UC).

Results

On average 3.4 conditions caused each death and 24.4% of deaths had 5 plus causes. Largest SRMUs were for genitourinary diseases (8.0), blood diseases (7.8) and musculoskeletal conditions (6.7). CDAIs showed high associations between, for example, accidental alcohol and opioid poisoning, septicaemia and skin infections, and traumatic brain injury and falls.

Conclusions

MC indicators enhance measures of mortality and reassess the role of causes of death for descriptive and analytical epidemiology.

Key messages

This research demonstrates the value of MC analysis for Australian mortality data.

892Quantification of mortality incorporating multiple causes of death: Application of weighting strategies to Australian data

Background

Mortality statistics are typically based on a single underlying cause of death (UCoD). Although UCoD provides a useful construct, the relevance of assuming that a single disease caused the death is diminishing, especially with increased life expectancy and high proportions of deaths in older ages from chronic/degenerative diseases. Focussing on common underlying causes of death in Australia, we quantified mortality incorporating weighting strategies for multiple causes of death (MCoD).

Methods

All deaths registered in Australia from 2015-2017 (478,396 deaths) and coded using International Classification of Diseases Version 10 were classified using an extended cause list (n = 136 causes) based on a World Health Organization short list. Age-standardised rates (ASR) were estimated using three weighting methods: (1) traditional approach using UCoD alone; (2) UCoD and associated causes of death (ACoDs) equally weighted and (3) UCoD weighted 0.5 arbitrarily and remaining 0.5 apportioned to the remaining ACoDs.

Results

Common UCoD were ischaemic heart diseases, cerebrovascular diseases, dementia; 57671, 31515 and 27377 deaths respectively. There were substantial changes in ASR depending on the weighting method used. Variation in mortality patterns estimated using the three weighting methods and challenges to further refinement of the weighting strategy will be discussed.

Conclusions

Mortality indicators incorporating MCoD enhance traditional measures of mortality and provide a means to reassess the role of diseases in causing death. Further disease specific methods are required to refine current weighting strategies.

Key messages

Weighting strategies for are useful for quantifying mortality incorporating MCoD, but methodological challenges exist.

424Person-centred outcomes among 22,205 cancer survivors and 244,000 people without cancer: a population-based Australian study

Background

With the majority of people with cancer surviving long-term, holistic consideration of health and wellbeing outcomes is critical to optimise survivorship. We quantified short- and long-term physical and mental health-related outcomes in people with and without cancer, including according to cancer type and clinical characteristics.

Methods

45 and Up Study (n = 267,153) baseline survey data (2006-2009) were linked to cancer registrations (by the Centre for Health Record Linkage) and cancer diagnoses up to enrolment identified. Modified Poisson regression estimated age-and-sex-adjusted prevalence ratios (PRs) for adverse person-centred outcomes - severe physical functioning limitations, moderate/high psychological distress and fair/poor quality of life - in participants with versus without cancer.

Results

Cancer survivors (n = 22,205) had significantly higher prevalence of physical functioning limitations compared to participants without cancer (21% versus 13%) PR = 1.28(95%CI=1.25-1.32), overall and in all population subgroups examined. Corresponding estimates were 22% versus 24% (1.05(1.02-1.08)) for psychological distress and 15% versus 10% (1.28(1.24-1.32) for fair/poor quality of life. Outcomes varied by cancer type, being worse for multiple myeloma, lung cancer and non-Hodgkin’s lymphoma; worse outcomes were also associated with recent diagnosis, recent treatment and advanced stage. Physical functioning limitations in cancer survivors were major contributors to adverse distress and quality of life outcomes.

Conclusions

Cancer survivors experience adverse physical and mental health outcomes; substantial parts of elevated distress and poor quality of life are likely attributable to physical disability.

Key messages

In addition to routine screening for psychological distress, management of physical disability and other symptoms are important to optimise cancer survivorship.

778Risk of 27 cancer types in relation to tobacco smoking: cohort study involving 229,028 Australians

Background

Tobacco smoke is a known carcinogen and the magnitude of smoking-related cancer risk varies according to time and population. Local, contemporary evidence can drive appropriate tobacco control. We provide comprehensive cancer risk estimates related to smoking in the population-based, New South Wales (NSW) 45 and Up Study.

Methods

We estimated smoking-related hazard ratios (HR) for cancer using Cox proportional hazards regression using linked questionnaire (2006-2009) and incident cancer data (n ≥ 50 cases per cancer type), from the NSW Cancer Registry (to December 2013) (via CHeReL).

Results

Of 18,475 cancers among 229,028 participants aged ≥45 years, current smokers had significantly increased risks of cancers of the lung, larynx, head and neck, oesophagus, liver, bladder, pancreas, stomach, colorectum, and cancers with unknown primary site, compared to never-smokers; lung cancer risk was markedly elevated, including for current-smokers of 1-5 cigarettes/day (HR = 9.25, 95%CI=5.2-16.6), increasing to 38.39 (26.2-56.2) for current-smokers of &gt; 30 cigarettes/day. Quitting substantively decreased cancer risk compared to continued smoking, with lung cancer risk decreasing with decreasing age at quitting (p(trend)&lt;0.05), however risks remained elevated for those quitting aged &gt;25 compared to never-smokers (1.73, 1.1-2.6 for age 26-30 years). An estimated 20% of current-smokers in Australia will get lung cancer during their lifetime versus 1.6% of never-smokers.

Conclusions

Smoking-attributable cancer risks in Australia are significant, comparable to contemporary risks from other developed nations.

Key messages

Smokers – including “light” smokers – are at high cancer risk, with ∼one-fifth of Australian lifetime smokers developing lung cancer. Quitting is beneficial. Continued investment in tobacco control is essential.

1000Quantifying multiple causes of death: A systematic review and audit of methods and practice

Background

Mortality reporting and research are typically focused on a single underlying cause of death (UCoD) selected from multiple reported causes. The need to incorporate multiple causes of death (MCoD) in mortality statistics is now recognised internationally, but there is scant methodological work to guide analytical approaches. This review aims to identify and appraise current methods and practices used to analyse MCoD data.

Methods

The Web of Science, Medline, Pubmed and Scopus (from inception to December 2019) were queried. Studies reporting MCoD alone or in comparison with single UCoD were included. The review is supplemented by qualitative interview with international experts.

Results

3491 studies were identified; 141 full texts were included in the review. The measures usually estimated when analysing MCoD can be broadly categorised into descriptive measures (n = 93 studies), measures of associations between diseases (n = 46 studies) and advanced statistical methods (n = 11 studies). Descriptive statistics commonly used include standardized ratio of multiple to underlying cause (SRMU) and mortality rates based on any mention of a disease. Approaches used to assess measures of associations between diseases include the Cause-of-Death Association Indicator (CDAI) and social network analysis. The advanced statistical methods include weighting MCoD and lethal defect-wear model of mortality. Audit results will be discussed.

Conclusions

This review provides a comprehensive and updated summary of methodological approaches used to analyse MCoD data. The merit of each analytical framework is discussed.

Key messages

More work is needed to develop methodological frameworks that could be used to support routine consideration of MCoD in practice.

896Quantifying cause-related mortality incorporating multiple causes: challenges and opportunities

Key contact person

Dr Grace Joshy, Fellow, Research School of Population Health, Australian National University.

Focus and outcomes for participants

Mortality statistics are typically based on a single underlying cause of death (UCoD), derived from multiple conditions on the death certificate, and have provided critical evidence for policy and practice for over a century. There have been radical shifts in patterns of death in the past couple of decades; deaths in older ages are increasingly from chronic and degenerative diseases. The relevance of assuming that a single disease is causing the death is diminishing, especially with an aging population structure and increasing life expectancy. This symposium will enable participants to understand the complexities associated with mortality reporting/coding, strengths and limitations of available statistical methods for using multiple causes of death (MCoD) and the importance of quantifying mortality incorporating MCoD.

Rationale for the symposium, including for its inclusion in the Congress

The use of a single UCoD rather than MCoD means that vast amounts of potentially useful data are largely ignored, which is likely to bias mortality estimates (including under- and over-reporting of the importance of certain causes of death). Despite global recognition of the urgent need to better integrate data on MCoD into mortality statistics, use of these data are challenging and limited. Complexities arise from the way mortality information is reported on death certificates and coded to form mortality collections; limited understanding of available statistical methods also adds to the complexity.

International Classification of Diseases 10th Revision (ICD-10) has been translated into 43 languages and it is being used by over 100 countries to report mortality data, a primary indicator of health status. The 2018 release of the 11th revision of the International Classification of Diseases, enriching data on multiple parameters including comorbidity, confers further urgency and a unique opportunity to optimise the use of MCoD in mortality reporting.

The World Congress of Epidemiology 2020 will provide a unique platform for wider discussions on the challenges and opportunities for using MCoD data. The symposium will provide a deeper understanding and enhanced the use of MCoD data. The speakers are engaged in cutting-edge NHMRC-funded research on mortality incorporating MCoD and development of novel statistical methods.

Presentation program

The symposium will feature presentations from six speakers.

Names of presenters

James Eynstone-Hinkins, Lauren Moran, Saliu Balogun, Karen Bishop, Margarita Moreno-Betancur, Grace Joshy

1025Social interaction of middle-aged and older people with and without cardiovascular disease in Australia

Background

Social interaction is important for social wellbeing and may be adversely affected in people with cardiovascular disease (CVD). Large-scale evidence on social interaction among older people with versus without CVD is limited. We quantified and compared social interaction in older people with and without CVD.

Methods

Survey data (2006-2009) from the 45 and Up Study were linked to hospitalisations data through CHeReL to ascertain CVD status. Four items from the Duke Social Support Index (social-visits/week, telephone-contacts/week, social-group-contact/week, and number of people to depend on) were examined, using generalised linear models to estimate prevalence ratios (PRs) of no social interaction in people with versus without CVD, adjusting for relevant factors, and separately according to CVD subtype and level of physical disability.

Results

There were 266,504 study participants, 21.4% had CVD. People with CVD were 8%, (95%CI: 5-11%), 7% (2-12%), 4% (3-5%) and 7% (3-11%) more likely than people without CVD to have no social-visits/week, telephone-contacts/week, social-group-meetings/week and people to depend on respectively. The magnitude but not direction of results varied by CVD subtype. People with CVD and severe physical functioning limitations were 30-80% more likely than those with neither of these to have no social interaction.

Conclusions

Levels of social interaction were slightly lower in people with versus without CVD, but they varied by social interaction items, CVD subtypes, population characteristics and physical disability.

Key messages

Management to improve quality of life for people living with CVD should consider the role of physical disability for social connectedness.

863Alcohol and cancer in an Australian cohort of 226,162 participants aged 45 years and over

Background

Australia has a relatively high level of alcohol consumption. Although alcohol consumption is known to increase the risk of several cancer types internationally, local evidence for Australia is limited.

Methods

Cox proportional hazards regressions were used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for cancer risk in relation to weekly alcohol consumption among 226,162 participants aged ≥45 years (2006-2009) in the 45 and Up Study, an Australian prospective cohort study. Incident cancer cases were ascertained by linkage to the New South Wales Cancer Registry to December 2013 by the Centre for Health Record Linkage.

Results

Over a median 5.4 years, 17,332 cancers were diagnosed. Increasing levels of alcohol intake were associated with increased risk of any cancer (HR per seven drink increase in weekly consumption: 1.02; 95% CI: 1.00-1.04), and cancers of the upper aerodigestive tract (1.19;1.10-1.29), mouth/pharynx (1.18;1.08-1.29), oesophagus (1.22;1.04-1.43), colorectum (1.09;1.04-1.15), colon (1.13;1.06-1.20), liver (1.22;1.04-1.44), breast (1.09;1.00-1.18), and melanoma (1.05;1.00-1.10); whereas an inverse association was observed for thyroid cancer (0.80;0.64-1.00). We estimated that by age 85 years, Australian men and women who consume &gt;14 drinks/week increase their absolute risk of alcohol-attributable cancer by 4.4% and 5.4%, respectively, compared to non-drinkers.

Conclusions

We report relative risks of cancer incidence in relation to alcohol consumption that match the international evidence. In Australia, a nation with relatively high alcohol consumption, these risks may translate into a significant public health burden.

Key messages

We have generated estimates for the relationship between alcohol consumption and cancer risk in Australia.

Tobacco smoking and mortality among Aboriginal and Torres Strait Islander adults in Australia

Background

Despite generally high smoking prevalences, stemming from colonization, the relationship of smoking to mortality has not been quantified reliably in an Indigenous population. We investigate smoking and mortality among Aboriginal and Torres Strait Islander adults in Australia, where current adult daily smoking prevalence is 40.2%.

Methods

A prospective study of 1388 cardiovascular disease- and cancer-free Aboriginal adults aged ≥45 years, of the 267 153 45 and Up Study participants randomly sampled from the New South Wales general population over 2006–09. Questionnaire and mortality data were linked (through the Centre for Health Record Linkage) to mid-2019. Adjusted hazard ratios (called relative risks, RRs) for all-cause mortality—among current- and past- versus never-smokers—were estimated overall, by smoking intensity and by age at cessation. Smoking-attributable fractions and associated deaths were estimated.

Results

Over 14 586 person-years’ follow-up (median 10.6 years), 162 deaths accrued. Mortality RRs [95% confidence interval (CI)] were 3.90 (2.52–6.04) for current- and 1.95 (1.32–2.90) for past- versus never-smokers, with age heterogeneity. RRs increased with smoking intensity, to 4.29 (2.15–8.57) in current-smokers of ≥25 cigarettes/day. Compared with never-smokers, RRs were 1.48 (0.85–2.57) for those quitting at <45 years of age and 2.21 (1.29–3.80) at 45–54 years. Never-smokers lived an average >10 years longer than current-smokers. Around half of deaths among adults aged ≥45 years were attributable to smoking, exceeding 10 000 deaths in the past decade.

Conclusions

In this population, >80% of never-smokers would survive to 75 years, versus ∼40% of current-smokers. Quitting at all ages examined had substantial benefits versus continuing smoking; those quitting before age 45 years had mortality risks similar to never-smokers. Smoking causes half of deaths in older Aboriginal and Torres Strait Islander adults; Indigenous tobacco control must receive increased priority.

Cancer incidence and cancer death in relation to tobacco smoking in a population-based Australian cohort study

Tobacco smoke is a known carcinogen, but the magnitude of smoking-related cancer risk depends on country-specific, generational smoking patterns. We quantified cancer risk in relation to smoking in a population-based cohort, the 45 and Up Study (2006-2009) in New South Wales, Australia. Cox proportional hazards regressions estimated adjusted hazard ratios (HR) by self-reported smoking history at baseline (2006-2009) for incident, primary cancers via linkage to cancer registry data to 2013 and cancer death data to 2015. Among 229 028 participants aged ≥45 years, 18 475 cancers and 5382 cancer deaths occurred. Current-smokers had increased risks of all cancers combined (HR = 1.42, 95% confidence interval [CI], 1.34-1.51), cancers of the lung (HR = 17.66, 95%CI, 14.65-21.29), larynx (HR = 11.29, 95%CI, 5.49-23.20), head-and-neck (HR = 2.53, 95%CI, 1.87-3.41), oesophagus (HR = 3.84, 95%CI, 2.33-6.35), liver (HR = 4.07, 95%CI, 2.55-6.51), bladder (HR = 3.08, 95%CI, 2.00-4.73), pancreas (HR = 2.68, 95%CI, 1.93-3.71), colorectum (HR = 1.31, 95%CI, 1.09-1.57) and unknown primary site (HR = 3.26, 95%CI, 2.19-4.84) versus never-smokers. Hazards increased with increasing smoking intensity; compared to never-smokers, lung cancer HR = 9.22 (95%CI, 5.14-16.55) for 1-5 cigarettes/day and 38.61 (95%CI, 25.65-58.13) for >35 cigarettes/day. Lung cancer risk was lower with quitting at any age but remained higher than never-smokers for quitters aged >25y. By age 80y, an estimated 48.3% of current-smokers (41.1% never-smokers) will develop cancer, and 14% will develop lung cancer, including 7.7% currently smoking 1-5 cigarettes/day and 26.4% for >35 cigarettes/day (1.0% never-smokers). Cancer risk for Australian smokers is significant, even for 'light' smokers. These contemporary estimates underpin the need for continued investment in strategies to prevent smoking uptake and facilitate cessation, which remain key to reducing cancer morbidity and mortality worldwide.

Workforce participation in relation to cancer diagnosis, type and stage: Australian population-based study of 163,556 middle-aged people

PURPOSE

To quantify the relationship of cancer diagnosis to workforce participation in Australia, according to cancer type, clinical features and personal characteristics.

METHODS

Questionnaire data (2006-2009) from participants aged 45-64 years (n=163,556) from the population-based 45 and Up Study (n=267,153) in New South Wales, Australia, were linked to cancer registrations to ascertain cancer diagnoses up to enrolment. Modified Poisson regression estimated age- and sex-adjusted prevalence ratios (PRs) for non-participation in the paid workforce-in participants with cancer (n=8,333) versus without (n=155,223), for 13 cancer types.

RESULTS

Overall, 42% of cancer survivors and 29% of people without cancer were out of the workforce (PR=1.18; 95%CI=1.15-1.21). Workforce non-participation varied substantively by cancer type, being greatest for multiple myeloma (1.83; 1.53-2.18), oesophageal (1.70; 1.13-2.58) and lung cancer (1.68; 1.45-1.93) and moderate for colorectal (1.23; 1.15-1.33), breast (1.11; 1.06-1.16) and prostate cancer (1.06; 0.99-1.13). Long-term survivors, 5 or more years post-diagnosis, had 12% (7-16%) greater non-participation than people without cancer, and non-participation was greater with recent diagnosis, treatment or advanced stage. Physical disability contributed substantively to reduced workforce participation, regardless of cancer diagnosis.

CONCLUSIONS

Cancer survivors aged 45-64 continue to participate in the workforce. However, participation is lower than in people without cancer, varying by cancer type, and is reduced particularly around the time of diagnosis and treatment and with advanced disease.

IMPLICATIONS FOR CANCER SURVIVORS

While many cancer survivors continue with paid work, participation is reduced. Workforce retention support should be tailored to survivor preferences, cancer type and cancer journey stage.

Physical, mental, and social wellbeing and their association with death by suicide and self-harm in older adults: a community-based cohort study

OBJECTIVE

To assess associations between physical, mental, and social well-being and suicide and self-harm in a community-based sample of older adults.

METHODS

Using a cohort design, questionnaire data from 102,880 individuals aged 65 years or older living in New South Wales, Australia during 2006-2009 were linked to hospital and cause-of-death databases until 2017. Poisson regressions obtained adjusted incidence rate ratios (IRRs).

RESULTS

One hundred nine suicides and 191 deliberate self-harm (DSH) events occurred. Compared to those reporting excellent/good overall health, older adults reporting fair overall health had higher suicide rates (IRR = 2.8, 95% confidence interval: 1.8-4.4). Also, suffering from physical limitations was associated with higher rates of suicide. A fair versus excellent/good memory was associated with higher rates of suicide (IRR = 2.0, 1.3-3.3). Male erectile dysfunction was linked to self-harm (IRR = 2.8, 1.0-7.7). Suicide rates were elevated with baseline Kessler-10 scores of 20-50 versus 10-15 (IRR = 5.0, 2.9-8.9); the corresponding IRR for DSH was 2.9 (1.8-4.8). Elevated rates were observed for both self-reported depression and anxiety. Poor versus excellent/good quality of life was associated with suicide (IRR = 4.3, 1.7-10.7) and achieving less than desired to due to emotional problems was linked to self-harm (IRR = 1.8 1.3-2.4). Rates of suicide ande DSH were lower in those with ≥5 people to depend on versus one (suicide: IRR = 0.5, 0.3-0.9; DSH: IRR = 0.5, 0.3-0.7).

CONCLUSIONS

Older adults experiencing health problems, including those relating to overall health or memory, and those with psychological distress had elevated rates of suicidal behavior. Rates of subsequent self-harm and/or death by suicide were elevated in participants with small social networks.

Cardiovascular disease subtypes, physical disability and workforce participation: A cross-sectional study of 163,562 middle-aged Australians

Background

Workforce participation is reduced among people with cardiovascular disease (CVD). However, detailed quantitative evidence on this is limited. We examined the relationship of CVD to workforce participation in older working-age people, by CVD subtype, within population subgroups and considering the role of physical disability.

Methods

Questionnaire data (2006–2009) for participants aged 45–64 years (n = 163,562) from the population-based 45 and Up Study (n = 267,153) were linked to hospitalisation data through the Centre for Health Record Linkage. Prior CVD was from self-report or hospitalisation. Modified Poisson regression estimated adjusted prevalence ratios (PRs) for non-participation in the workforce in people with versus without CVD, adjusting for sociodemographic factors.

Results

There were 19,161 participants with CVD and 144,401 without. Compared to people without CVD, workforce non-participation was greater for those with CVD (40.0% vs 23.5%, PR = 1.36, 95%CI = 1.33–1.39). The outcome varied by CVD subtype: myocardial infarction (PR = 1.46, 95%CI = 1.36–1.55); cerebrovascular disease (PR = 1.92, 95%CI = 1.80–2.06); heart failure (PR = 1.83, 95%CI = 1.68–1.98) and peripheral vascular disease (PR = 1.76, 95%CI = 1.65–1.88). Workforce non-participation in those with CVD versus those without was at least 21% higher in all population subgroups examined, with PRs ranging from 1.75 (95%CI = 1.65–1.85) in people aged 50–55 years to 1.21 (95%CI = 1.19–1.24) among those aged 60–64. Compared to people with neither CVD nor physical functioning limitations, those with physical functional limitations were around three times as likely to be out of the workforce regardless of CVD diagnosis; participants with CVD but without physical functional limitations were 13% more likely to be out of the workforce (PR = 1.13, 95%CI = 1.07–1.20).

Conclusions

While many people with CVD participate in the workforce, participation is substantially lower, especially for people with cerebrovascular disease, than for people without CVD, highlighting priority areas for research and support, particularly for people experiencing physical functioning limitations.

E-cigarette use and combustible tobacco cigarette smoking uptake among non-smokers, including relapse in former smokers: umbrella review, systematic review and meta-analysis

OBJECTIVE

To review and summarise the current evidence on the uptake of combustible cigarette smoking following e-cigarette use in non-smokers-including never-smokers, people not currently smoking and past smokers-through an umbrella review, systematic review and meta-analysis.

DESIGN

Umbrella review, systematic review and meta-analysis.

DATA SOURCES

PubMed, Scopus, Web of Science, PsychINFO (Ovid), Medline (Ovid) and Wiley Cochrane Library up to April 2020.

RESULTS

Of 6225 results, 25 studies of non-smokers-never, not current and former smokers-with a baseline measure of e-cigarette use and an outcome measure of combustible smoking uptake were included. All 25 studies found increased risk of smoking uptake with e-cigarette exposure, although magnitude varied substantially. Using a random-effects model, comparing e-cigarette users versus non-e-cigarette users, among never-smokers at baseline the OR for smoking initiation was 3.25 (95% CI 2.61 to 4.05, I2 85.7%) and among non-smokers at baseline the OR for current smoking was 2.87 (95% CI 1.97 to 4.19, I2 90.1%). Among former smokers, smoking relapse was higher in e-cigarette users versus non-users (OR=2.40, 95% CI 1.50 to 3.83, I2 12.3%).

CONCLUSIONS

Across multiple settings, non-smokers who use e-cigarettes are consistently more likely than those avoiding e-cigarettes to initiate combustible cigarette smoking and become current smokers. The magnitude of this risk varied, with an average of around three times the odds. Former smokers using e-cigarettes have over twice the odds of relapse as non-e-cigarettes users. This study is the first to our knowledge to review and pool data on the latter topic.

PROSPERO REGISTRATION NUMBER

CRD42020168596.

Differences between men and women in the use of preventive medications following a major cardiovascular event: Australian prospective cohort study

Most cardiovascular disease (CVD) events can be prevented with appropriate risk management. Existing evidence suggests women are less likely than men to receive guideline-recommended medications, however data on sex-differences in preventive medication use following a CVD event are lacking. Relative risks (RRs) comparing use of blood pressure- and lipid-lowering medications in men and women at 3-, 6-, 9- and 12-months following hospitalisation for myocardial infarction (MI) or stroke from 2012 to 2017 were quantified using linked data from 8,278 participants enrolled in the Australian 45 and Up Study. Overall, 51% of women and 58% of men were using both blood-pressure- and lipid-lowering medications three months after a MI or stroke event, decreasing to 48% and 53%, respectively, at 12 months after an event. Adjusting for potential confounders, women were 9% less likely than men (RR = 0.91 [95% CI: 0.87, 0.95]) to be using both medications and 19% more likely (RR = 1.19 [95% CI: 1.07, 1.32]) to use neither medication three months after a MI or stroke event. At the 12-month mark, women were 8% less likely (RR = 0.92 [95% CI: 0.88, 0.97]) to be using both medications and 14% more likely (RR = 1.14 [95% CI: 1.03, 1.26]) to use neither medication. Women were consistently less likely to use both preventive medications and more likely to use neither medication at each follow-up time point. Overall, there were major shortfalls in basic preventive medication use post-CVD event and sex disparities are likely to further jeopardise efforts to reduce CVD events in the community.

Does psychological distress directly increase risk of incident cardiovascular disease? Evidence from a prospective cohort study using a longer-term measure of distress

OBJECTIVE

Cardiovascular disease (CVD) incidence is elevated among people with psychological distress. However, whether the relationship is causal is unclear, partly due to methodological limitations, including limited evidence relating to longer-term rather than single time-point measures of distress. We compared CVD relative risks for psychological distress using single time-point and multi-time-point assessments using data from a large-scale cohort study.

DESIGN

We used questionnaire data, with data collection at two time-points (time 1: between 2006 and 2009; time 2: between 2010 and 2015), from CVD-free and cancer-free 45 and Up Study participants, linked to hospitalisation and death records. The follow-up period began at time 2 and ended on 30 November 2017. Psychological distress was measured at both time-points using Kessler 10 (K10), allowing assessment of single time-point (at time 2: high (K10 score: 22-50) vs low (K10 score: <12)) and multi-time-point (high distress (K10 score: 22-50) at both time-points vs low distress (K10 score: <12) at both time-points) measures of distress. Cox regression quantified the association between distress and major CVD, with and without adjustment for sociodemographic and health-related characteristics, including functional limitations.

RESULTS

Among 83 906 respondents, 7350 CVD events occurred over 410 719 follow-up person-years (rate: 17.9 per 1000 person-years). Age-adjusted and sex-adjusted rates of major CVD were elevated by 50%-60% among those with high versus low distress for both the multi-time-point (HR=1.63, 95% CI 1.40 to 1.90) and single time-point (HR=1.53, 95% CI 1.39 to 1.69) assessments. HRs for both measures of distress attenuated with adjustment for sociodemographic and health-related characteristics, and there was little evidence of an association when functional limitations were taken into account (multi-time-point HR=1.09, 95% CI 0.93 to 1.27; single time-point HR=1.14, 95% CI 1.02 to 1.26).

CONCLUSION

Irrespective of whether a single time-point or multi-time-point measure is used, the distress-CVD relationship is substantively explained by sociodemographic characteristics and pre-existing physical health-related factors.

Measures of mental, physical, and social wellbeing and their association with death by suicide and self-harm in a cohort of 266,324 persons aged 45 years and over

PURPOSE

The aim of this study was to examine the relation of mental, physical, and social wellbeing measures to death by suicide and self-harm (SH).

METHODS

Using a cohort design, questionnaire data on 266,324 responders aged ≥ 45 years, living in NSW, Australia were linked to hospital and death databases during 2006-2017. Adjusted incidence rate ratios (IRR) were calculated.

RESULTS

Overall, 212 suicides and 723 SH episodes were observed. A dose-response relationship with suicidal behaviour was found for Kessler-10 Psychological Distress Scale; IRRs of 4.5 (95% CI 2.4-8.3) for suicide and 8.3 (95% CI 6.5-10.7) for SH were observed for scores of high versus low distress. Elevated rates were also observed for those reporting poor versus good or excellent health (suicide, IRR: 3.8, 95% CI 2.2-6.9; SH, IRR: 4.5 95% CI 3.4-6.1); being dependent versus not dependent on help with daily tasks (suicide, IRR: 2.4 95% CI 1.5-3.7; SH, IRR: 2.6 95% CI 2.0-3.3); being a current smoker (suicide, IRR: 1.8, 95% CI 1.1-2.9; SH, IRR: 2.9 95% CI 2.3-3.5) having versus not having male erectile problems (SH, IRR: 1.9 95% CI 1.4-2.5). Participants with ≥ 5 people versus one person to depend on had reduced suicidal behaviour (suicide, IRR: 0.5 95% CI 0.3-0.7, SH, IRR: 0.5 95% CI 0.4-0.6).

CONCLUSIONS

An active social network was linked to lower rates of suicide and self-harm. Adverse health, dependence on help, psychological distress were associated with higher rates of suicide and self-harm, while erectile problems were linked to an elevated rate of self-harm.

Comparison of cardiovascular disease risk factors, assessment and management in men and women, including consideration of absolute risk: a nationally representative cross-sectional study

OBJECTIVES

Cardiovascular disease (CVD) is highly preventable and optimal treatments based on absolute risk can halve risk of future events. Compared with women, men have higher risks of developing CVD. However, women can experience suboptimal treatment. We aimed to quantify sex differences in CVD risk, assessment and treatment in Australian adults.

DESIGN, PARTICIPANTS, SETTING

Cross-sectional analysis of nationally representative data from interview, physical measures, medication review and blood and urine samples, from 2011 to 2012 Australian Health Survey participants aged 45-74 (n=11 518).

OUTCOME MEASURES

CVD risk factors, absolute 5-year risk of a primary CVD event, blood pressure and cholesterol assessment in the previous 2 and 5 years and use of recommended CVD preventive medications were compared using Poisson regression to estimate age-adjusted male versus female prevalence ratios (PRs).

RESULTS

Women had a generally more favourable CVD risk factor profile than men, including lower: current smoking prevalence (women=14.5%; men=18.4%, PR=0.78, 95% CI=0.70 to 0.88); body mass index (women (mean)=28.3 kg/m²; men (mean)=28.8 kg/m², p<0.01); systolic and diastolic blood pressure (systolic: women (mean)=127.1 mm Hg; men (mean)=130.5 mm Hg, p<0.001); blood glucose (women (mean)=5.2 mmol/L; men (mean)=5.5 mmol/L); diabetes prevalence (women=6.8%; men=12.5%, PR=0.55, 95% CI=0.44 to 0.67); prior CVD (women=7.9%; men=11.3%) and absolute primary CVD risk (absolute 5-year CVD risk >15%: women=6.6%, 95% CI=5.4 to 7.8; men=15.4%, 95% CI=13.9% to 16.9%). Compared with men, women had higher low-density lipoprotein, high-density lipoprotein and total cholesterol and sedentary behaviour and lower physical activity. Blood pressure and cholesterol assessment were common in both sexes. Among those at high absolute risk, age-adjusted proportions receiving recommended CVD medications were low, without sex differences (women=21.3%; men=23.8%, PR=0.93, 95% CI=0.49 to 1.78). Fewer women than men with prior atherosclerotic CVD were receiving recommended treatment (women=21.8%, men=41.4%, PR=0.55, 95% CI=0.31 to 0.96).

CONCLUSION

Women have a more favourable CVD risk factor profile than men. Preventive treatment is uncommon and women with prior atherosclerotic CVD are around half as likely as men to be receiving recommended treatment.

Using Linked Whole-Of-Population Data to Estimate Education-Related Inequalities in Cause-Specific Mortality in Australia

IntroductionOfficial Australian estimates of socioeconomic inequalities in cause-specific mortality have been based on area-level socioeconomic measures. Using area-level measures is known to underestimate inequalities. Objectives and ApproachUsing recently released census linked to mortality data, we estimate education-related inequalities in cause-specific mortality for Australia. We used 2016 Australian Census and Death Registration data (2016-17) linked via a Person Linkage Spine (linkage rates: 92% and 97%, respectively) from the Multi-Agency Data Integration Project (MADIP). Education, from the Census, was categorised as low (no secondary school graduation or other qualification), intermediate (secondary graduation with/without other non-tertiary qualifications) and high (tertiary qualification). Cause of death was coded according to the underlying cause of death using the ICD-10. We used negative binomial regression to estimate relative rates (RR) for cause-specific mortality at ages 25-84 years, in the 12-months following Census, comparing low vs high education, separately by sex and 20-year age group, adjusting for age. Results80,317 deaths occurred among 13,856,202 people. For those aged 25-44 years, relative inequalities were large for causes related to injury and smaller for lesspreventable deaths (e.g. for men, suicide RR=5.6, 95%CI: 4.1-7.5 and brain cancer RR=1.3, 0.6-3.1). For those aged 45-64, inequalities were large for causes related to health behaviours and amenable to medical intervention, e.g. lung cancer (men RR= 6.4, 4.7-8.8) and ischaemic heart disease (women RR=5.0, 3.2-7.7), and were small for less preventable causes e.g. brain cancer (women RR=0.9, 0.6-1.3). Patterns among those aged 65-84years were similar to those aged 45-64 years. Conclusion / ImplicationsIn Australia, inequalities in mortality are substantial. Our findings highlight the health burden from inequalities, opportunities for prevention and provide insights on targets to effectively reduce them.

Disability, psychological distress and quality of life in relation to cancer diagnosis and cancer type: population-based Australian study of 22,505 cancer survivors and 244,000 people without cancer

BACKGROUND

Improved survival means that cancer is increasingly becoming a chronic disease. Understanding and improving functional outcomes are critical to optimising survivorship. We quantified physical and mental health-related outcomes in people with versus without cancer, according to cancer type.

METHODS

Questionnaire data from an Australian population-based cohort study (45 and Up Study (n = 267,153)) were linked to cancer registration data to ascertain cancer diagnoses up to enrolment. Modified Poisson regression estimated age- and sex-adjusted prevalence ratios (PRs) for adverse person-centred outcomes-severe physical functional limitations (disability), moderate/high psychological distress and fair/poor quality of life (QoL)-in participants with versus without cancer, for 13 cancer types.

RESULTS

Compared to participants without cancer (n = 244,000), cancer survivors (n = 22,505) had greater disability (20.6% versus 12.6%, respectively, PR = 1.28, 95%CI = (1.25-1.32)), psychological (22.2% versus 23.5%, 1.05 (1.02-1.08)) and poor/fair QoL (15.2% versus 10.2%; 1.28 (1.24-1.32)). The outcomes varied by cancer type, being worse for multiple myeloma (PRs versus participants without cancer for disability 3.10, 2.56-3.77; distress 1.53, 1.20-1.96; poor/fair QoL 2.40, 1.87-3.07), lung cancer (disability 2.81, 2.50-3.15; distress 1.67, 1.46-1.92; poor/fair QoL 2.53, 2.21-2.91) and non-Hodgkin's lymphoma (disability 1.56, 1.37-1.78; distress 1.20, 1.05-1.36; poor/fair QoL 1.66, 1.44-1.92) and closer to those in people without cancer for breast cancer (disability 1.23, 1.16-1.32; distress 0.95, 0.90-1.01; poor/fair QoL 1.15, 1.05-1.25), prostate cancer (disability 1.11, 1.04-1.19; distress 1.09, 1.02-1.15; poor/fair QoL 1.15, 1.08-1.23) and melanoma (disability 1.02, 0.94-1.10; distress 0.96, 0.89-1.03; poor/fair QoL 0.92, 0.83-1.01). Outcomes were worse with recent diagnosis and treatment and advanced stage. Physical disability in cancer survivors was greater in all population subgroups examined and was a major contributor to adverse distress and QoL outcomes.

CONCLUSIONS

Physical disability, distress and reduced QoL are common after cancer and vary according to cancer type suggesting priority areas for research, and care and support.

Alcohol consumption, drinking patterns and cancer incidence in an Australian cohort of 226,162 participants aged 45 years and over

BACKGROUND

Although overall alcohol consumption is known to increase the risk of a number of cancers internationally, evidence for Australia and evidence regarding the pattern of drinking and cancer risk is limited.

METHODS

Adjusted hazard ratios (HR) and 95% confidence intervals (CI) for cancer risk in relation to overall alcohol consumption (drinks/week) and pattern of drinking were calculated using Cox proportional hazard regressions for 226,162 participants aged ≥45 years (2006-2009) in the 45 and Up Study, an Australian prospective cohort study. Incident primary cancer cases were ascertained by linkage to the New South Wales Cancer Registry to 2013 by the Centre for Health Record Linkage.

RESULTS

Over a median of 5.4 years, 17,332 cancers were diagnosed. Increasing levels of alcohol intake were associated with increased risk of cancers of the upper aerodigestive tract (1.19; 1.10-1.29), mouth and pharynx (1.18; 1.08-1.29), oesophagus (1.22; 1.04-1.43), colorectum (1.09; 1.04-1.15), colon (1.13; 1.06-1.20), liver (1.22; 1.04-1.44) and breast (1.11; 1.02-1.21). Breast cancer risk was marginally associated with drinking pattern, with higher risk when intake was concentrated on 1-3 days/week compared to the same amount spread over 4-7 days (P_interaction = 0.049).

CONCLUSIONS

Alcohol consumption confers a significant risk of cancer, and drinking pattern may be independently related to breast cancer risk.

Education-related variation in coronary procedure rates and the contribution of private health care in Australia: a prospective cohort study

Background

Contemporary Australian evidence on socioeconomic variation in secondary cardiovascular disease (CVD) care, a possible contributor to inequalities in cardiovascular disease outcomes, is lacking. This study examined the relationship between education, an individual-level indicator of socioeconomic position, and receipt of angiography and revascularisation procedures following incident hospitalisation for acute myocardial infarction (AMI) or angina, and the role of private care in this relationship.

Methods

Participants aged ≥45 from the New South Wales population-based 45 and Up Study with no history of prior ischaemic heart disease hospitalised for AMI or angina were followed for receipt of angiography or revascularisation within 30 days of hospital admission, ascertained through linked hospital records. Education attainment, measured on baseline survey, was categorised as low (no school certificate/qualifications), intermediate (school certificate/trade/apprenticeship/diploma) and high (university degree). Cox regression estimated the association (hazard ratios [HRs]) between education and coronary procedure receipt, adjusting for demographic and health-related factors, and testing for linear trend. Private health insurance was investigated as a mediating variable.

Results

Among 4454 patients with AMI, 68.3% received angiography within 30 days of admission (crude rate: 25.8/person-year) and 48.8% received revascularisation (rate: 11.7/person-year); corresponding figures among 4348 angina patients were 59.7% (rate: 17.4/person-year) and 30.8% (rate: 5.3/person-year). Procedure rates decreased with decreasing levels of education. Comparing low to high education, angiography rates were 29% lower among AMI patients (adjusted HR = 0.71, 95% CI: 0.56–0.90) and 40% lower among angina patients (0.60, 0.47–0.76). Patterns were similar for revascularisation among those with angina (0.78, 0.61–0.99) but not AMI (0.93, 0.69–1.25). After adjustment for private health insurance status, the HRs were attenuated and there was little evidence of an association between education and angiography among those admitted for AMI.

Conclusions

There is a socioeconomic gradient in coronary procedures with the most disadvantaged patients being less likely to receive angiography following hospital admission for AMI or angina, and revascularisation procedures for angina. Unequal access to private health care contributes to these differences. The extent to which the remaining variation is clinically appropriate, or whether angiography is being underused among people with low socioeconomic position or overused among those with higher socioeconomic position, is unclear.

Breastfeeding and Cardiovascular Disease Hospitalization and Mortality in Parous Women: Evidence From a Large Australian Cohort Study

Background

Few studies have investigated the longitudinal association between breastfeeding and maternal cardiovascular disease (CVD) outcomes. This study examined the association between breastfeeding and CVD hospitalization and mortality in a large Australian cohort.

Methods and Results

Baseline questionnaire data (2006–2009) from a sample of 100 864 parous women aged ≥45 years from New South Wales, Australia, were linked to hospitalization and death data until June 2014 and December 2013, respectively. Analysis was restricted to women without self‐reported medically diagnosed CVD at baseline or without past CVD hospitalization 6 years before study entry. Never versus ever breastfeeding and average breastfeeding duration per child, derived from self‐reported lifetime breastfeeding duration and number of children, and categorized as never breastfed, <6, >6 to 12, or >12 months/child, were assessed. Cox proportional hazards models were used to explore the association between breastfeeding and CVD outcomes. Covariates included sociodemographic characteristics, lifestyle risk factors, and medical and reproductive history. There were 3428 (3.4%) first CVD‐related hospital admissions and 418 (0.4%) deaths during a mean follow‐up time of 6.1 years for CVD hospitalization and 5.7 years for CVD mortality. Ever breastfeeding was associated with lower risk of CVD hospitalization (adjusted hazard ratio [95% CI]: 0.86 [0.78, 0.96]; P=0.005) and CVD mortality (adjusted hazard ratio [95% CI]: 0.66 [0.49, 0.89]; P=0.006) compared with never breastfeeding. Breastfeeding ≤12 months/child was significantly associated with lower risk of CVD hospitalization.

Conclusions

Breastfeeding is associated with lower maternal risk of CVD hospitalization and mortality in middle‐aged and older Australian women. Breastfeeding may offer long‐term maternal cardiovascular health benefits.

Physical functional limitations and psychological distress in people with and without colorectal cancer: findings from a large Australian study

PURPOSE

To quantify physical disability and psychological distress in people with and without colorectal cancer (CRC).

METHODS

Questionnaire data (2006-2009) from 267,153 Australian general population members aged ≥ 45 years participating in the 45 and Up Study (n = 213,231 following exclusions) were linked to cancer registry and hospital admission data, to ascertain CRC status. Modified Poisson regression estimated adjusted prevalence ratios (PRs) for physical disability and psychological distress in participants with CRC versus those without.

RESULTS

Compared with participants without CRC (n = 210,836), CRC survivors (n = 2395) had significantly higher physical disability prevalence (11.9% versus 19.5%, respectively), PR = 1.11 (95% CI = 1.03-1.20); and a similar prevalence of distress (23.1% versus 20.2%), PR = 1.03 (0.94-1.20). Adverse outcomes were associated with certain clinical characteristics. Compared with participants without CRC, CRC survivors diagnosed 5-< 10 and ≥ 10 years, with regional spread, and without recent cancer treatment had broadly similar outcomes; survivors with metastatic CRC and recent treatment had 30-60% higher prevalence of disability and distress. Compared with participants with neither CRC nor disability, PRs for distress were 4.71 (4.22-5.26) for those with disability and CRC; and 4.22 (4.13-4.31) for those with disability without CRC.

CONCLUSIONS

Physical disability is elevated in CRC survivors. Psychological distress is elevated 4- to 5-fold with disability, regardless of CRC diagnosis, with lesser increases around diagnosis and treatment.

IMPLICATIONS FOR CANCER SURVIVORS

CRC survivors with less advanced disease and who have not been recently diagnosed or treated have physical disability and psychological distress comparable to the general population. Survivors with disability are at particularly high risk of psychological distress.

Identifying young Aboriginal and Torres Strait Islander children in linked administrative data: A comparison of methods

Background

In the ongoing debate on optimum methods for identification of Indigenous people within linked administrative data, few studies have examined the impacts of method on population counts and outcomes in family-based linkage studies of Aboriginal children.

Objective

To quantify differences between three algorithms in ascertaining Aboriginal and Torres Strait Islander children in linked administrative data.

Methods

Linked administrative health data for children born in Western Australia (WA) from 2000-2013, were used to examine the cohorts identified by three methods: A) the Indigenous Status Flag (ISF, derived by the WA Data Linkage Branch using a multistage-median approach) for the children alone; B) the ISF of the children, their parents and grandparents; and C) Indigenous status of the child, mother or father on either of the child's perinatal records (Midwives or birth registration), to determine differing characteristics of each cohort.

Results

Method B established a larger cohort (33,489) than Method C (33,306) and Method A (27,279), with all methods identifying a core group of 26,790 children (80-98%). Compared with children identified by Method A, additional children identified by Methods B or C, were from less-disadvantaged and more urban areas, and had better perinatal outcomes (e.g. lower proportions of small-for-gestational age, 10% vs 16%). Differences in demographics and health outcomes between Methods C and B were minimal.

Conclusions

Demographic and perinatal health characteristics differ by Aboriginal identification method. Using perinatal records or the ISF of parents and grandparents (in addition to the ISF of the child) appear to be more inclusive methods for identifying young Indigenous children in administrative datasets.

Keywords

Aboriginal health, identification, data linkage, Indigenous, child, methodology.

Identifying long-term psychological distress from single measures: evidence from a nationally representative longitudinal survey of the Australian population

BACKGROUND

Single time-point assessments of psychological distress are often used to indicate chronic mental health problems, but the validity of this approach is unclear. The aims of this study were to investigate how a single assessment of distress relates to longer-term assessment and quantify misclassification from using single measures to indicate chronic distress.

METHODS

Data came from the Household, Income and Labour Dynamics in Australia Survey, a nationally representative study of Australian adults. Psychological distress, measured with the Kessler10 and categorised into low (scores:10- < 12), mild (12- < 16), moderate (16- < 22) and high (22-50), has been assessed in the Survey biennially since wave 7. Among respondents who were aged ≥25 years and participated in all waves in which distress was measured, we describe agreement in distress categories, and using a mixed linear model adjusting for age and sex we estimate change in scores, over a two-, four-, six- and eight-year follow-up period. We applied weights, benchmarked to the Australian population, to all analyses.

RESULTS

Two-years following initial assessment, proportions within identical categories of distress were 66.0% for low, 54.5% for mild, 44.0% for moderate and 50.3% for high, while 94.1% of those with low distress initially had low/mild distress and 81.4% with high distress initially had moderate/high distress. These patterns did not change materially as follow-up time increased. Over the full eight-year period, 77.3% of individuals with high distress initially reported high distress on ≥1 follow-up occasion. Age-and sex- adjusted change in K10 scores over a two-year period was 1.1, 0.5, - 0.7 and - 4.9 for low, mild, moderate and high distress, respectively, and also did not change materially as follow-up time increased.

CONCLUSION

In the absence of repeated measures, single assessments are useful proxies for chronic distress. Our estimates could be used in bias analyses to quantify the magnitude of the bias resulting from use of single assessments to indicate chronic distress.

Variation in coronary angiography and revascularisation procedures in relation to psychological distress among patients admitted to hospital with myocardial infarction or angina

OBJECTIVE

Cardiac patients with psychological distress have a poorer prognosis than patients without distress; which may in part reflect differences in treatment. We quantified variation in coronary angiography and revascularisation procedures according to psychological distress among patients admitted with incident acute myocardial infarction (AMI) or angina.

METHODS

Questionnaire data (collected 2006-09) from 45 and Up Study participants were linked to hospitalisation and mortality data, to 30 June 2016. Among patients free from ischaemic heart disease at baseline and subsequently hospitalised with AMI or angina, Cox regression was used to model the association between distress (Kessler-10 scores: low [10-<12], mild [12-<16], moderate [16-<22] and high [22-50]) - assessed on the questionnaire - and coronary angiography and revascularisation procedures (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) within 30 days of admission, adjusting for personal characteristics, including physical functioning.

RESULTS

Proportions receiving angiography and PCI/CABG were 71.4% and 51.7% following AMI (n = 3749), and 61.3% and 31.3% for angina patients (n = 3772), respectively. Following AMI, age-sex-adjusted rates of PCI/CABG were lower with higher levels of distress (test for trend: p = .037), as were rates of angiography and PCI/CABG (p < .01) following admission with angina. After additional adjustment for personal characteristics, associations between distress and procedure rates attenuated substantively and were no longer significant, except that PCI/CABG rates remained lower among angina patients with high versus low distress (HR = 0.76, 95%CI: 0.59-0.99).

CONCLUSION

Distress-related variation in coronary procedures largely reflects differences in personal characteristics. Whether lower revascularisation rates among angina patients with high compared to low distress are clinically appropriate or represent under-treatment remains unclear.

Psychological distress and medication use for secondary prevention of cardiovascular events: Evidence from a large-scale population-based cohort study

OBJECTIVE

Cardiac patients with psychological distress have a poorer prognosis than patients without distress, potentially reflecting differences in preventive care. We aimed to examine distress-related variation in guideline-recommended medication use for secondary prevention of cardiovascular disease (CVD).

METHODS

Baseline questionnaire data from the 45 and Up Study (collected 2006-2009) were linked to hospitalisation, pharmaceutical dispensing and death records (to exclude those who died). Among participants hospitalised with myocardial infarction, angina, stroke/transient ischaemic attack in the six years before the questionnaire, Modified Poisson regression was used to estimate relative risks (RR) for distress (Kessler 10 scores: low[10- < 12], mild[12- < 16], moderate[16- < 22] and high[22-50]) and use of both blood pressure- and lipid-lowering medications, and use of neither medication in the three months following the questionnaire, adjusting for sociodemographic and health characteristics.

RESULTS

Among 7598 participants, 34.0% had low, 35.4% mild, 18.3% moderate and 12.3% high psychological distress. Around two-thirds (63.4%) were using both medications and the proportion declined with increasing levels of distress: RRs were 1.01(95%CI:0.97-1.05), 0.95(0.90-1.00) and 0.91(0.86-0.97) for mild, moderate and high compared to low distress, respectively (p(trend) = 0.001). The proportion using neither medication was 9.1% and increased with increasing distress: RRs for mild, moderate and high compared to low distress were 0.99(0.82-1.19), 1.30(1.06-1.59) and 1.60(1.28-1.98), respectively (p(trend) < 0.001).

CONCLUSION

Patients with psychological distress may need more support to optimise their use of secondary CVD prevention medications. Increasing the use of these medications for distressed patients may improve prognosis for patients with distress and improve population-level secondary prevention of CVD more broadly.

Tobacco smoking and risk of 36 cardiovascular disease subtypes: fatal and non-fatal outcomes in a large prospective Australian study

BACKGROUND

Tobacco smoking is a leading cause of cardiovascular disease (CVD) morbidity and mortality. Evidence on the relation of smoking to different subtypes of CVD, across fatal and non-fatal outcomes, is limited.

METHODS

A prospective study of 188,167 CVD- and cancer-free individuals aged ≥ 45 years from the Australian general population joining the 45 and Up Study from 2006 to 2009, with linked questionnaire, hospitalisation and death data up to the end of 2015. Hazard ratios (HRs) for hospitalisation with or mortality from CVD among current and past versus never smokers were estimated, including according to intensity and recency of smoking, using Cox regression, adjusting for age, sex, urban/rural residence, alcohol consumption, income and education. Population-attributable fractions were estimated.

RESULTS

During a mean 7.2 years follow-up (1.35 million person-years), 27,511 (crude rate 20.4/1000 person-years) incident fatal and non-fatal major CVD events occurred, including 4548 (3.2) acute myocardial infarction (AMI), 3991 (2.8) cerebrovascular disease, 3874 (2.7) heart failure and 2311 (1.6) peripheral arterial disease (PAD) events. At baseline, 8% of participants were current and 34% were past smokers. Of the 36 most common specific CVD subtypes, event rates for 29 were increased significantly in current smokers. Adjusted HRs in current versus never smokers were as follows: 1.63 (95%CI 1.56-1.71) for any major CVD, 2.45 (2.22-2.70) for AMI, 2.16 (1.93-2.42) for cerebrovascular disease, 2.23 (1.96-2.53) for heart failure, 5.06 (4.47-5.74) for PAD, 1.50 (1.24-1.80) for paroxysmal tachycardia, 1.31 (1.20-1.44) for atrial fibrillation/flutter, 1.41 (1.17-1.70) for pulmonary embolism, 2.79 (2.04-3.80) for AMI mortality, 2.26 (1.65-3.10) for cerebrovascular disease mortality and 2.75 (2.37-3.19) for total CVD mortality. CVD risks were elevated at almost all levels of current smoking intensity examined and increased with smoking intensity, with HRs for total CVD mortality in current versus never smokers of 1.92 (1.11-3.32) and 4.90 (3.79-6.34) for 4-6 and ≥ 25 cigarettes/day, respectively. Risks diminished with quitting, with excess risks largely avoided by quitting before age 45. Over one third of CVD deaths and one quarter of acute coronary syndrome hospitalisations in Australia aged < 65 can be attributed to smoking.

CONCLUSIONS

Current smoking increases the risk of virtually all CVD subtypes, at least doubling the risk of many, including AMI, cerebrovascular disease and heart failure. Paroxysmal tachycardia is a newly identified smoking-related risk. Where comparisons are possible, smoking-associated relative risks for fatal and non-fatal outcomes are similar. Quitting reduces the risk substantially. In an established smoking epidemic, with declining and low current smoking prevalence, smoking accounts for a substantial proportion of premature CVD events.

Primary Absolute Cardiovascular Disease Risk and Prevention in Relation to Psychological Distress in the Australian Population: A Nationally Representative Cross-Sectional Study

People who experience psychological distress have an elevated risk of incident cardiovascular disease (CVD). However, the extent to which traditional CVD prevention strategies could be used to reduce the CVD burden in this group is unclear because population-level data on CVD risk profiles and appropriate management of risk in relation to distress are currently not available. The aim of this study was to use nationally representative data to quantify variation in CVD risk and appropriate management of risk according to level of psychological distress in the Australian population. Data were from 2,618 participants aged 45-74 years without prior CVD who participated in the 2011-12 Australian Health Survey, a cross-sectional and nationally representative study of Australian adults. Age-and sex-adjusted prevalence of 5-year absolute risk of primary CVD (low <10%, moderate 10-15%, or high >15%), CVD risk factors, blood-pressure, and cholesterol assessments, and appropriate treatment (combined blood pressure- and lipid-lowering medication) if at high primary risk, were estimated. Prevalence ratios (PR) quantified variation in these outcomes in relation to low (Kessler-10 score: 10-<12), mild (12-<16), moderate (16-<22) and high (22-50) psychological distress, after adjusting for sociodemographic characteristics. The prevalence of high absolute risk of primary CVD for low, mild, moderate and high distress was 10.9, 12.3, 11.4, and 18.6%, respectively, and was significantly higher among participants with high compared to low distress (adjusted PR:1.62, 95%CI:1.04-2.52). The prevalence of CVD risk factors was generally higher in those with higher psychological distress. Blood pressure and cholesterol assessments were reported by the majority of participants (>85%) but treatment of high absolute risk was low (<30%), and neither were related to psychological distress. Our findings confirm the importance of recognizing people who experience psychological distress as a high risk group and suggest that at least part of the excess burden of primary CVD events among people with high psychological distress could be reduced with an absolute risk approach to assessment and improved management of high primary CVD risk.