Publications by authors named "Christopher Millett"

239 Publications

Effect of smoke-free policies in outdoor areas and private places on children's tobacco smoke exposure and respiratory health: a systematic review and meta-analysis.

Lancet Public Health 2021 Jul 15. Epub 2021 Jul 15.

Division of Neonatology, Department of Paediatrics, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands; Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands; Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, UK. Electronic address:

Background: Smoke-free policies in outdoor areas and semi-private and private places (eg, cars) might reduce the health harms caused by tobacco smoke exposure (TSE). We aimed to investigate the effect of smoke-free policies covering outdoor areas or semi-private and private places on TSE and respiratory health in children, to inform policy.

Methods: In this systematic review and meta-analysis, we searched 13 electronic databases from date of inception to Jan 29, 2021, for published studies that assessed the effects of smoke-free policies in outdoor areas or semi-private or private places on TSE, respiratory health outcomes, or both, in children. Non-randomised and randomised trials, interrupted time series, and controlled before-after studies, without restrictions to the observational period, publication date, or language, were eligible for the main analysis. Two reviewers independently extracted data, including adjusted test statistics from each study using a prespecified form, and assessed risk of bias for effect estimates from each study using the Risk of Bias in Non-Randomised Studies of Interventions tool. Primary outcomes were TSE in places covered by the policy, unplanned hospital attendance for wheezing or asthma, and unplanned hospital attendance for respiratory tract infections, in children younger than 17 years. Random-effects meta-analyses were done when at least two studies evaluated policies that regulated smoking in similar places and reported on the same outcome. This study is registered with PROSPERO, CRD42020190563.

Findings: We identified 5745 records and assessed 204 full-text articles for eligibility, of which 11 studies met the inclusion criteria and were included in the qualitative synthesis. Of these studies, seven fit prespecified robustness criteria as recommended by the Cochrane Effective Practice and Organization of Care group, assessing smoke-free cars (n=5), schools (n=1), and a comprehensive policy covering multiple areas (n=1). Risk of bias was low in three studies, moderate in three, and critical in one. In the meta-analysis of ten effect estimates from four studies, smoke-free car policies were associated with an immediate TSE reduction in cars (risk ratio 0·69, 95% CI 0·55-0·87; 161 466 participants); heterogeneity was substantial (I 80·7%; p<0·0001). One additional study reported a gradual TSE decrease in cars annually. Individual studies found TSE reductions on school grounds, following a smoke-free school policy, and in hospital attendances for respiratory tract infection, following a comprehensive smoke-free policy.

Interpretation: Smoke-free car policies are associated with reductions in reported child TSE in cars, which could translate into respiratory health benefits. Few additional studies assessed the effect of policies regulating smoking in outdoor areas and semi-private and private places on children's TSE or health outcomes. On the basis of these findings, governments should consider including private cars in comprehensive smoke-free policies to protect child health.

Funding: Dutch Heart Foundation, Lung Foundation Netherlands, Dutch Cancer Society, Dutch Diabetes Research Foundation, Netherlands Thrombosis Foundation, and Health Data Research UK.
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http://dx.doi.org/10.1016/S2468-2667(21)00097-9DOI Listing
July 2021

Racial and socioeconomic disparities in multimorbidity and associated healthcare utilisation and outcomes in Brazil: a cross-sectional analysis of three million individuals.

BMC Public Health 2021 Jul 1;21(1):1287. Epub 2021 Jul 1.

Public Health Policy Evaluation Unit, Imperial College London, Charing Cross Hospital, St Dunstan's Road, London, W6 8R, UK.

Background: Evidence is limited on racial/ethnic group disparities in multimorbidity and associated health outcomes in low- and middle-income countries hampering effective policies and clinical interventions to address health inequalities.

Methods: This study assessed race/ethnic and socioeconomic disparities in the prevalence of multimorbidity and associated healthcare utilisation, costs and death in Rio de Janeiro, Brazil. A cross-sectional analysis was carried out of 3,027,335 individuals registered with primary healthcare (PHC) services. Records included linked data to hospitalisation, mortality, and welfare-claimant (Bolsa Família) records between 1 Jan 2012 and 31 Dec 2016. Logistic and Poisson regression models were carried out to assess the likelihood of multimorbidity (two or more diagnoses out of 53 chronic conditions), PHC use, hospital admissions and mortality from any cause. Interactions were used to assess disparities.

Results: In total 13,509,633 healthcare visits were analysed identifying 389,829 multimorbid individuals (13%). In adjusted regression models, multimorbidity was associated with lower education (Adjusted Odds Ratio (AOR): 1.26; 95%CI: 1.23,1.29; compared to higher education), Bolsa Família receipt (AOR: 1.14; 95%CI: 1.13,1.15; compared to non-recipients); and black race/ethnicity (AOR: 1.05; 95%CI: 1.03,1.06; compared to white). Multimorbidity was associated with more hospitalisations (Adjusted Rate Ratio (ARR): 2.75; 95%CI: 2.69,2.81), more PHC visits (ARR: 3.46; 95%CI: 3.44,3.47), and higher likelihood of death (AOR: 1.33; 95%CI: 1.29,1.36). These associations were greater for multimorbid individuals with lower educational attainment (five year probability of death 1.67% (95%CI: 1.61,1.74%) compared to 1.13% (95%CI: 1.02,1.23%) for higher education), individuals of black race/ethnicity (1.48% (95%CI: 1.41,1.55%) compared to 1.35% (95%CI: 1.31,1.40%) for white) and individuals in receipt of welfare (1.89% (95%CI: 1.77,2.00%) compared to 1.35% (95%CI: 1.31,1.38%) for non-recipients).

Conclusions: The prevalence of multimorbidity and associated hospital admissions and mortality are greater in individuals with black race/ethnicity and other deprived socioeconomic groups in Rio de Janeiro. Interventions to better prevent and manage multimorbidity and underlying disparities in low- and middle-income country settings are needed.
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http://dx.doi.org/10.1186/s12889-021-11328-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8252284PMC
July 2021

Effect of COVID-19 response policies on walking behavior in US cities.

Nat Commun 2021 06 16;12(1):3652. Epub 2021 Jun 16.

Connection Science, Institute for Data Science and Society, MIT, Cambridge, MA, USA.

The COVID-19 pandemic is causing mass disruption to our daily lives. We integrate mobility data from mobile devices and area-level data to study the walking patterns of 1.62 million anonymous users in 10 metropolitan areas in the United States. The data covers the period from mid-February 2020 (pre-lockdown) to late June 2020 (easing of lockdown restrictions). We detect when users were walking, distance walked and time of the walk, and classify each walk as recreational or utilitarian. Our results reveal dramatic declines in walking, particularly utilitarian walking, while recreational walking has recovered and even surpassed pre-pandemic levels. Our findings also demonstrate important social patterns, widening existing inequalities in walking behavior. COVID-19 response measures have a larger impact on walking behavior for those from low-income areas and high use of public transportation. Provision of equal opportunities to support walking is key to opening up our society and economy.
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http://dx.doi.org/10.1038/s41467-021-23937-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8209100PMC
June 2021

Record linkage under suboptimal conditions for data-intensive evaluation of primary care in Rio de Janeiro, Brazil.

BMC Med Inform Decis Mak 2021 06 15;21(1):190. Epub 2021 Jun 15.

Centro de Estudos Estratégicos, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.

Background: Linking Brazilian databases demands the development of algorithms and processes to deal with various challenges including the large size of the databases, the low number and poor quality of personal identifiers available to be compared (national security number not mandatory), and some characteristics of Brazilian names that make the linkage process prone to errors. This study aims to describe and evaluate the quality of the processes used to create an individual-linked database for data-intensive research on the impacts on health indicators of the expansion of primary care in Rio de Janeiro City, Brazil.

Methods: We created an individual-level dataset linking social benefits recipients, primary health care, hospital admission and mortality data. The databases were pre-processed, and we adopted a multiple approach strategy combining deterministic and probabilistic record linkage techniques, and an extensive clerical review of the potential matches. Relying on manual review as the gold standard, we estimated the false match (false-positive) proportion of each approach (deterministic, probabilistic, clerical review) and the missed match proportion (false-negative) of the clerical review approach. To assess the sensitivity (recall) to identifying social benefits recipients' deaths, we used their vital status registered on the primary care database as the gold standard.

Results: In all linkage processes, the deterministic approach identified most of the matches. However, the proportion of matches identified in each approach varied. The false match proportion was around 1% or less in almost all approaches. The missed match proportion in the clerical review approach of all linkage processes were under 3%. We estimated a recall of 93.6% (95% CI 92.8-94.3) for the linkage between social benefits recipients and mortality data.

Conclusion: The adoption of a linkage strategy combining pre-processing routines, deterministic, and probabilistic strategies, as well as an extensive clerical review approach minimized linkage errors in the context of suboptimal data quality.
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http://dx.doi.org/10.1186/s12911-021-01550-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8204416PMC
June 2021

Association Between Childhood Consumption of Ultraprocessed Food and Adiposity Trajectories in the Avon Longitudinal Study of Parents and Children Birth Cohort.

JAMA Pediatr 2021 Jun 14:e211573. Epub 2021 Jun 14.

Public Health Policy Evaluation Unit, Imperial College London, London, United Kingdom.

Importance: Reports of associations between higher consumption of ultraprocessed foods (UPF) and elevated risks of obesity, noncommunicable diseases, and mortality in adults are increasing. However, associations of UPF consumption with long-term adiposity trajectories have never been investigated in children.

Objective: To assess longitudinal associations between UPF consumption and adiposity trajectories from childhood to early adulthood.

Design, Setting, And Participants: This prospective birth cohort study included children who participated in the Avon Longitudinal Study of Parents and Children (ALSPAC) in Avon County, southwest England. Children were followed up from 7 to 24 years of age during the study period from September 1, 1998, to October 31, 2017. Data were analyzed from March 1, 2020, to January 31, 2021.

Exposures: Baseline dietary intake data were collected using 3-day food diaries. Consumption of UPF (applying the NOVA food classification system) was computed as a percentage of weight contribution in the total daily food intake for each participant and categorized into quintiles.

Main Outcomes And Measures: Repeated recordings of objectively assessed anthropometrics (body mass index [BMI; calculated as weight in kilograms divided by height in meters squared], weight, and waist circumference) and dual-energy x-ray absorptiometry measurements (fat and lean mass indexes [calculated as fat and lean mass, respectively, divided by height in meters squared] and body fat percentage). Associations were evaluated using linear growth curve models and were adjusted for study covariates.

Results: A total of 9025 children (4481 [49.7%] female and 4544 [50.3%] male) were followed up for a median of 10.2 (interquartile range, 5.2-16.4) years. The mean (SD) UPF consumption at baseline was 23.2% (5.0%) in quintile 1, 34.7% (2.5%) in quintile 2, 43.4% (2.5%) in quintile 3, 52.7% (2.8%) in quintile 4, and 67.8% (8.1%) in quintile 5. Among those in the highest quintile of UPF consumption compared with their lowest quintile counterpart, trajectories of BMI increased by an additional 0.06 (95% CI, 0.04-0.08) per year; fat mass index, by an additional 0.03 (95% CI, 0.01-0.05) per year; weight, by an additional 0.20 (95% CI, 0.11-0.28) kg per year; and waist circumference, by an additional 0.17 (95% CI, 0.11-0.22) cm per year.

Conclusions And Relevance: These findings suggest that higher UPF consumption is associated with greater increases in adiposity from childhood to early adulthood. Robust public health measures that promote minimally processed foods and discourage UPF consumption among children are urgently needed to reduce obesity in England and globally.
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http://dx.doi.org/10.1001/jamapediatrics.2021.1573DOI Listing
June 2021

The impacts of health systems financing fragmentation in low- and middle-income countries: a systematic review protocol.

Syst Rev 2021 06 2;10(1):164. Epub 2021 Jun 2.

Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, Exhibition Rd, South Kensington, London, SW7 2BU, UK.

Background: Health systems are often fragmented in low- and middle-income countries (LMICs). This can increase inefficiencies and restrict progress towards universal health coverage. The objective of the systematic review described in this protocol will be to evaluate and synthesize the evidence concerning the impacts of health systems financing fragmentation in LMICs.

Methods: Literature searches will be conducted in multiple electronic databases, from their inception onwards, including MEDLINE, EMBASE, LILACS, CINAHL, Scopus, ScienceDirect, Scielo, Cochrane Library, EconLit, and JSTOR. Gray literature will be also targeted through searching OpenSIGLE, Google Scholar, and institutional websites (e.g., HMIC, The World Bank, WHO, PAHO, OECD). The search strings will include keywords related to LMICs, health system financing fragmentation, and health system goals. Experimental, quasi-experimental, and observational studies conducted in LMICs and examining health financing fragmentation across any relevant metric (e.g., the presence of different health funders/insurers, risk pooling mechanisms, eligibility categories, benefits packages, premiums) will be included. Studies will be eligible if they compare financing fragmentation in alternative settings or at least two-time points. The primary outcomes will be health system-related goals such as health outcomes (e.g., mortality, morbidity, patient-reported outcome measures) and indicators of access, services utilization, equity, and financial risk protection. Additional outcomes will include intermediate health system objectives (e.g., indicators of efficiency and quality). Two reviewers will independently screen all citations, abstract data, and full-text articles. Potential conflicts will be resolved through discussion and, when necessary, resolved by a third reviewer. The methodological quality (or risk of bias) of selected studies will be appraised using established checklists. Data extraction categories will include the studies' objective and design, the fragmentation measurement and domains, and health outcomes linked to the fragmentation. A narrative synthesis will be used to describe the results and characteristics of all included studies and to explore relationships and findings both within and between the studies.

Discussion: Evidence on the impacts of health system fragmentation in LMICs is key for identifying evidence gaps and priority areas for intervention. This knowledge will be valuable to health system policymakers aiming to strengthen health systems in LMICs.

Systematic Review Registration: PROSPERO CRD42020201467.
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http://dx.doi.org/10.1186/s13643-021-01714-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8170990PMC
June 2021

Global Patterns and Prevalence of Dual and Poly-Tobacco Use: A Systematic Review.

Nicotine Tob Res 2021 May 2. Epub 2021 May 2.

Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, United Kingdom.

Introduction: Improving understanding of the epidemiology of dual and poly-tobacco product use is essential for tobacco control policy and practice. The present study aimed to systematically review existing epidemiologic evidence on current dual and poly-tobacco use among adults globally.

Methods: We systematically searched online databases for studies published up to 30 June 2020. We included quantitative studies with measures of nationally representative prevalence of current dual or poly-tobacco use among adults. Prevalence estimates for each country were extracted manually and stratified by WHO regions and World Bank income classifications.

Results: Twenty studies with nationally representative prevalence data on current dual or poly-tobacco use in the adult population across 48 countries were included. Definitions of dual and poly-tobacco use varied widely. Prevalence of dual and poly-tobacco use was higher in low- and lower-middle-income countries compared to other higher-income countries. Current dual use of smoked and smokeless tobacco products among males ranged from 0.2% in Ukraine (2010) and Mexico (2009) to 17.9% in Nepal (2011). Poly-tobacco use among males ranged from 0.8% in Mexico (2009) and 0.9% in Argentina (2010) to 11.4% in the UK and 11.9% in Denmark in 2012. Dual tobacco use was generally higher in South-East Asia; poly-tobacco use was prevalent in Europe as well as in South-East Asia.

Conclusions: This is the first systematic review of the prevalence estimates of dual and poly-tobacco use among adults globally. The results of the current study could significantly help health policy makers to implement effective tobacco control policies.
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http://dx.doi.org/10.1093/ntr/ntab084DOI Listing
May 2021

Impacts of the 2008 Great Recession on dietary intake: a systematic review and meta-analysis.

Int J Behav Nutr Phys Act 2021 04 29;18(1):57. Epub 2021 Apr 29.

Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, Charing Cross Campus; The Reynolds Building, St Dunstan's Road, London, W6 8RP, UK.

Background: The 2008 Great Recession significantly impacted economies and individuals globally, with potential impacts on food systems and dietary intake. We systematically reviewed evidence on the impact of the Great Recession on individuals' dietary intake globally and whether disadvantaged individuals were disproportionately affected.

Methods: We searched seven databases and relevant grey literature through June 2020. Longitudinal quantitative studies with the 2008 recession as the exposure and any measure of dietary intake (energy intake, dietary quality, and food/macronutrient consumption) as the outcome were eligible for inclusion. Eligibility was independently assessed by two reviewers. The Newcastle Ottawa Scale was used for quality and risk of bias assessment. We undertook a random effects meta-analysis for changes in energy intake. Harvest plots were used to display and summarise study results for other outcomes. The study was registered with PROSPERO (CRD42019135864).

Results: Forty-one studies including 2.6 million people met our inclusion criteria and were heterogenous in both methods and results. Ten studies reported energy intake, 11 dietary quality, 34 food intake, and 13 macronutrient consumption. The Great Recession was associated with a mean reduction of 103.0 cal per adult equivalent per day (95% Confidence Interval: - 132.1, - 73.9) in high-income countries (5 studies) and an increase of 105.5 cal per adult per day (95% Confidence Interval: 72.8, 138.2) in middle-income countries (2 studies) following random effects meta-analysis. We found reductions in fruit and vegetable intake. We also found reductions in intake of fast food, sugary products, and soft drinks. Impacts on macronutrients and dietary quality were inconclusive, though suggestive of a decrease in dietary quality. The Great Recession had greater impacts on dietary intake for disadvantaged individuals.

Conclusions: The 2008 recession was associated with diverse impacts on diets. Calorie intake decreased in high income countries but increased in middle income countries. Fruit and vegetable consumption reduced, especially for more disadvantaged individuals, which may negatively affect health. Fast food, sugary products, and soft drink consumption also decreased which may confer health benefits. Implementing effective policies to mitigate adverse nutritional changes and encourage positive changes during the COVID-19 pandemic and other major economic shocks should be prioritised.
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http://dx.doi.org/10.1186/s12966-021-01125-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8084260PMC
April 2021

The relationship between austerity and food insecurity in the UK: A systematic review.

EClinicalMedicine 2021 Mar 15;33:100781. Epub 2021 Mar 15.

Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, Charing Cross Campus; The Reynolds Building; St Dunstan's Road; London W6 8RP, UK.

Background: In 2010, the UK government implemented austerity measures, involving reductions to public spending and welfare reform. We aimed to systematically review the relationship of austerity policies with food insecurity including foodbank use in the UK.

Methods: We undertook a narrative systematic review (CRD42020164508) and searched seven databases, grey literature, and reference lists through September 2020. Studies with austerity policies (including welfare reform) as exposure and food insecurity (including foodbank use as a proxy) as study outcome were included. We included quantitative longitudinal and cross-sectional studies. Two reviewers assessed eligibility, extracted data directly from studies, and undertook quality assessment.

Findings: Eight studies were included: two individual-level studies totalling 4129 participants and six ecological studies. All suggested a relationship between austerity and increased food insecurity. Two studies found that austerity policies were associated with increased food insecurity in European countries including the UK. Six studies found that the welfare reform aspect of UK austerity policies was associated with increased food insecurity and foodbank use. Sanctions involving delays to benefits as a response to a claimant not actively seeking work may increase food insecurity, with studies finding that increases of 100 sanctions per 100,000 people may have led to increases of between 2 and 36 food parcels per 100,000 population.

Interpretation: UK austerity policies were consistently linked to food insecurity and foodbank use. Policymakers should consider impacts of austerity on food insecurity when considering how to reduce budget deficits.

Funding: NIHR School for Public Health Research.
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http://dx.doi.org/10.1016/j.eclinm.2021.100781DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020142PMC
March 2021

The association of migration with multiple tobacco product use among male adults in 15 low- and middle-income countries.

Eur J Public Health 2021 Jul;31(3):500-502

Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK.

Little is known about the impact of migration on tobacco use patterns among men in low- and middle-income countries (LMICs). This study aims to explore the association between migration and tobacco use among men in LMICs. We used multilevel regression models to analyze data of 154 425 men from 15 countries from the latest wave of the Demographic and Health Survey. Results showed higher risk of single tobacco product use [relative risk ratio (RRR) = 1.22; 95% confidence interval (CI): 1.19-1.26], but importantly of dual (RR = 1.41, 95% CI: 1.36-1.49) and poly-tobacco use (RR = 1.71, 95% CI: 1.57-1.86) among migrant men compared with non-migrants.
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http://dx.doi.org/10.1093/eurpub/ckab003DOI Listing
July 2021

Tobacco-control challenges among adolescents in the Eastern Mediterranean region.

Lancet Child Adolesc Health 2021 04 2;5(4):234-235. Epub 2021 Feb 2.

Department of Health Promotion and Community Health, American University of Beirut, Beirut, Lebanon.

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http://dx.doi.org/10.1016/S2352-4642(21)00025-0DOI Listing
April 2021

Direct from the COVID-19 crisis: research and innovation sparks in Brazil.

Health Res Policy Syst 2021 Jan 21;19(1):10. Epub 2021 Jan 21.

Universidade de Brasília (UnB), Brasília, DF, Brazil.

Background: The coronavirus disease 2019 (COVID-19) pandemic has spread throughout more than 160 countries, infecting millions of people worldwide. To address this health emergency, countries have organized the flow of production and innovation to reduce the impact on health. This article shows the response of the Brazilian scientific community to meet the urgent needs of the public unified health system [SUS], aiming to guarantee universal access to an estimated population of 211 million. By December 2020, Brazil had recorded more than six million cases and approximately 175,000 deaths.

Methods: We collected data on research, development and innovation projects carried out by 114 public universities (plus Oswaldo Cruz Foundation [Fiocruz] and Butantan Institute), as reported on their websites. Additionally, we examined the studies on COVID-19 approved by the National Comission for Research Ethics, as well as those reported on the Ministry of Education website as of May 15, 2020.

Results: The 789 identified projects were classified according to research categories as follows: development and innovation (n = 280), other types of projects (n = 226), epidemiologic research (n = 211), and basic research on disease mechanisms (n = 72). Most proposals focused on the development and innovation of personal protective equipment, medical devices, diagnostic tests, medicines and vaccines, which were rapidly identified as research priorities by the scientific community. Some promising results have been observed from phase III vaccine trials, one of which is conducted in partnership with Oxford University and another of which is performed with Sinovac Biotech. Both trials involve thousands of volunteers in their Brazilian arms and include technology transfer agreements with Fiocruz and the Butantan Institute, respectively. These vaccines proved to be safe and effective and were immediately licensed for emergency use. The provision of doses for the public health system, and vaccination, started on January 17, 2021.

Conclusions: The mobilized Brazilian scientific community has generated comprehensive research, development and innovation proposals to meet the most urgent needs. It is important to emphasize that this response was only possible due to decades of investment in research, development and innovation in Brazil. We need to reinforce and protect the Brazilian science, technology and innovation system from austerity policies that disregard health and knowledge as crucial investments for Brazilian society, in line with the constitutional right of universal health access and universal health coverage.
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http://dx.doi.org/10.1186/s12961-020-00674-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7819618PMC
January 2021

Associations of active travel with adiposity among children and socioeconomic differentials: a longitudinal study.

BMJ Open 2021 01 12;11(1):e036041. Epub 2021 Jan 12.

Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK.

Objectives: Examine longitudinal associations between modes of travel to school and adiposity.

Setting: The UK.

Participants: 8432 children surveyed at ages 7, 11 and 14 years from the UK Millennium Cohort Study.

Primary And Secondary Outcomes: Objective percentage body fat and body mass index (BMI). Transport mode was categorised as private motorised transport, public transport and active transport (walking or cycling). Socioeconomic position (SEP) was measured by household income group and occupational social class. We adjusted analyses for changes in the country of UK, frequency of eating breakfast, self-reported growth spurts, hours of screen time and days per week of moderate-to-vigorous physical activity. Longitudinal (panel) regression models adjusting for individual fixed effects examined associations in changes in mode of travel to school and adiposity, controlling for both time-varying and time-invariant potential confounders. Interaction tests and stratified analyses investigated differences by markers of SEP.

Results: At age 14 years, 26.1% of children (2198) reported using private motorised transport, 35.3% (2979) used public transport and 38.6% (3255) used active transport to get to school. 36.6% (3083) of children changed mode two times between the three waves and 50.7% (4279) changed once. Compared with continuing to use private transport, switching to active transport was associated with a lower BMI (-0.21 kg/m, 95% CI -0.31 to -0.10) and body fat (-0.55%, 95% CI -0.80% to -0.31%). Switching to public transport was associated with lower percentage body fat (-0.43%, 95% CI -0.75% to -0.12%), but associations with BMI did not reach statistical significance (-0.13 kg/m, 95% CI -0.26 to 0.01). Interaction tests showed a trend for these effects to be stronger in more deprived groups, but these interactions did not reach statistical significance.

Conclusion: This longitudinal study during a key life course period found switching to physically active forms of travel can have beneficial adiposity impacts; these associations may be more apparent for more disadvantaged children. Increasing active travel has potential to ameliorate inequalities.
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http://dx.doi.org/10.1136/bmjopen-2019-036041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7805367PMC
January 2021

Industry self-regulation fails to deliver healthier diets, again.

BMJ 2021 01 6;372:m4762. Epub 2021 Jan 6.

Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK

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http://dx.doi.org/10.1136/bmj.m4762DOI Listing
January 2021

Ultra-processed food consumption and type 2 diabetes incidence: A prospective cohort study.

Clin Nutr 2021 May 28;40(5):3608-3614. Epub 2020 Dec 28.

Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, W6 8RP, United Kingdom.

Background: Ultra-processed foods account for more than 50% of daily calories consumed in several high-income countries, with sales of ultra-processed foods soaring globally, especially in middle-income countries. The objective of this study is to investigate the association between ultra-processed food (UPF) consumption and risk of type 2 diabetes (T2D) in a UK-based prospective cohort study.

Methods: Participants of the UK Biobank (2007-2019) aged 40-69 years without diabetes at recruitment who provided 24-h dietary recall and follow-up data were included. UPFs were defined using the NOVA food classification. Multivariable Cox proportional hazards regression models were used to evaluate the association between UPF consumption and the risk of T2D adjusting for socio-demographic, anthropometric and lifestyle characteristics.

Results: A total of 21,730 participants with a mean age of 55.8 years and mean UPF intake of 22.1% at baseline were included. During a mean follow-up of 5.4 years (116,956 person-years), 305 incident T2D cases were identified. In the fully adjusted model, compared with the group in the lowest quartile of UPF intake, the hazard ratio for T2D was 1.44, 1.04-2.02 in the group with the highest quartile of UPF consumption. A gradient of elevated risk of T2D associated with increasing quartiles of UPF intake was consistently observed (p value for trend < 0.028). A significantly increased risk of T2D was observed per 10 percentage points increment in UPF consumption ([adjusted HR]: 1.12, 95% confidence interval [CI]: 1.04-1.20).

Conclusions: Our findings demonstrate that a diet high in UPFs is associated with a clinically important increased risk of T2D. Identifying and implementing effective public health actions to reduce UPF consumption in the UK and globally are urgently required.
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http://dx.doi.org/10.1016/j.clnu.2020.12.018DOI Listing
May 2021

Prevalence and determinants of dual and poly-tobacco use among males in 19 low-and middle-income countries: Implications for a comprehensive tobacco control regulation.

Prev Med 2021 01 17;142:106377. Epub 2020 Dec 17.

Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, United Kingdom. Electronic address:

Despite their implications for tobacco control, data on concurrent dual (using two tobacco products) and poly-tobacco use (using more than two products) are relatively scarce globally. This study aimed to estimate the prevalence of dual and poly-tobacco use among men in 19 low-and middle-income countries (LMICs) and assess potential associations with individual and country level factors. Data from 19 LMICs were obtained from the most recent wave of the Demographic and Health Survey (DHS), collected between 2015 and 2016 comprising 235,975 men aged 15-49 years. The prevalence of current single, dual and poly-tobacco use were estimated using available sample weights. Mixed-effect multilevel models were used to estimate associations of individual and country level factors with tobacco use. Results showed that the prevalence of dual or poly-tobacco use among men was highest in Timor Leste (27.1%), Nepal (18.3%), Lesotho (13.2%) and India (9.3%). Factors associated with dual and poly-tobacco use were older age, low academic achievement, low income status, being divorced, living in urban areas and high frequency of media use. Among country-level characteristics, national wealth was not associated with dual and poly-tobacco use. Implementation of MPOWER measures was inversely associated with single tobacco use; this was not the case for dual and poly-tobacco use. Findings suggest that dual and poly-tobacco use are common among men especially in South-East Asian countries. This study highlights the need for MPOWER measures to be expanded and strengthened to address all tobacco products and explicitly consider dual and poly use.
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http://dx.doi.org/10.1016/j.ypmed.2020.106377DOI Listing
January 2021

Potential impacts of post-Brexit agricultural policy on fruit and vegetable intake and cardiovascular disease in England: a modelling study.

BMJ Nutr Prev Health 2020 14;3(1):3-10. Epub 2020 Jan 14.

Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK.

Background: Current proposals for post-Brexit agricultural policy do not explicitly incorporate public health goals. The revised agricultural policy may be an opportunity to improve population health by supporting domestic production and consumption of fruits and vegetables (F&V). This study aims to quantify the potential impacts of a post-Brexit agricultural policy that increases land allocated to F&V on cardiovascular disease (CVD) mortality and inequalities in England, between 2021 to 2030.

Methods: We used the previously validated IMPACT Food Policy model and probabilistic sensitivity analysis to translate changes in land allocated to F&V into changes in F&V intake and associated CVD deaths, stratified by age, sex and Index of Multiple Deprivation. The model combined data on F&V agriculture, waste, purchases and intake, CVD mortality projections and appropriate relative risks. We modelled two scenarios, assuming that land allocated to F&V would gradually increase to 10% and 20% of land suitable for F&V production.

Results: We found that increasing land use for F&V production to 10% and 20% of suitable land would increase fruit intake by approximately 3.7% (95% uncertainty interval: 1.6% to 8.6%) and 17.4% (9.1% to 36.9%), and vegetable intake by approximately 7.8% (4.2% to 13.7%) and 37% (24.3% to 55.7%), respectively, in 2030. This would prevent or postpone approximately 3890 (1950 to 7080) and 18 010 (9840 to 28 870) CVD deaths between 2021 and 2030, under the first and second scenario, respectively. Both scenarios would reduce inequalities, with 16% of prevented or postponed deaths occurring among the least deprived compared with 22% among the most deprived.

Conclusion: Post-Brexit agricultural policy presents an important opportunity to improve dietary intake and associated cardiovascular mortality by supporting domestic production of F&V as part of a comprehensive strategy that intervenes across the supply chain.
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http://dx.doi.org/10.1136/bmjnph-2019-000057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7664506PMC
January 2020

Road user charging: a policy whose time has finally arrived.

Lancet Planet Health 2020 11;4(11):e499-e500

Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London W6 8RP, UK.

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http://dx.doi.org/10.1016/S2542-5196(20)30244-8DOI Listing
November 2020

Primary healthcare expansion and mortality in Brazil's urban poor: A cohort analysis of 1.2 million adults.

PLoS Med 2020 10 30;17(10):e1003357. Epub 2020 Oct 30.

Centro de Estudos Estratégicos, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.

Background: Expanding delivery of primary healthcare to urban poor populations is a priority in many low- and middle-income countries. This remains a key challenge in Brazil despite expansion of the country's internationally recognized Family Health Strategy (FHS) over the past two decades. This study evaluates the impact of an ambitious program to rapidly expand FHS coverage in the city of Rio de Janeiro, Brazil, since 2008.

Methods And Findings: A cohort of 1,241,351 low-income adults (observed January 2010-December 2016; total person-years 6,498,607) with linked FHS utilization and mortality records was analyzed using flexible parametric survival models. Time-to-death from all-causes and selected causes were estimated for FHS users and nonusers. Models employed inverse probability treatment weighting and regression adjustment (IPTW-RA). The cohort was 61% female (751,895) and had a mean age of 36 years (standard deviation 16.4). Only 18,721 individuals (1.5%) had higher education, whereas 102,899 (8%) had no formal education. Two thirds of individuals (827,250; 67%) were in receipt of conditional cash transfers (Bolsa Família). A total of 34,091 deaths were analyzed, of which 8,765 (26%) were due to cardiovascular disease; 5,777 (17%) were due to neoplasms; 5,683 (17%) were due to external causes; 3,152 (9%) were due to respiratory diseases; and 3,115 (9%) were due to infectious and parasitic diseases. One third of the cohort (467,155; 37.6%) used FHS services. In IPTW-RA survival analysis, an average FHS user had a 44% lower hazard of all-cause mortality (HR: 0.56, 95% CI 0.54-0.59, p < 0.001) and a 5-year risk reduction of 8.3 per 1,000 (95% CI 7.8-8.9, p < 0.001) compared with a non-FHS user. There were greater reductions in the risk of death for FHS users who were black (HR 0.50, 95% CI 0.46-0.54, p < 0.001) or pardo (HR 0.57, 95% CI 0.54-0.60, p < 0.001) compared with white (HR 0.59, 95% CI 0.56-0.63, p < 0.001); had lower educational attainment (HR 0.50, 95% CI 0.46-0.55, p < 0.001) for those with no education compared to no significant association for those with higher education (p = 0.758); or were in receipt of conditional cash transfers (Bolsa Família) (HR 0.51, 95% CI 0.49-0.54, p < 0.001) compared with nonrecipients (HR 0.63, 95% CI 0.60-0.67, p < 0.001). Key limitations in this study are potential unobserved confounding through selection into the program and linkage errors, although analytical approaches have minimized the potential for bias.

Conclusions: FHS utilization in urban poor populations in Brazil was associated with a lower risk of death, with greater reductions among more deprived race/ethnic and socioeconomic groups. Increased investment in primary healthcare is likely to improve health and reduce health inequalities in urban poor populations globally.
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http://dx.doi.org/10.1371/journal.pmed.1003357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7598481PMC
October 2020

Introduction of standardised packaging and availability of illicit cigarettes: a difference-in-difference analysis of European Union survey data 2015-2018.

Thorax 2021 01 22;76(1):89-91. Epub 2020 Oct 22.

Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK.

Standardised packaging of tobacco products is intended to reduce the appeal of smoking, but the tobacco industry claims this increases illicit trade. We examined the percentage of people reporting being offered illicit cigarettes before and after full implementation of standardised packaging in the UK, Ireland and France and compared this to other European Union countries. Reported ever illicit cigarette exposure fell from 19.8% to 18.1% between 2015 and 2018 in the three countries fully implementing the policy, and from 19.6% to 17.0% in control countries (p for difference=0.320). Standardised packaging does not appear to increase the availability of illicit cigarettes.
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http://dx.doi.org/10.1136/thoraxjnl-2020-215708DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803897PMC
January 2021

Science misuse and polarised political narratives in the COVID-19 response.

Lancet 2020 11 19;396(10263):1635-1636. Epub 2020 Oct 19.

Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, UK; Instituto de Estudos para Politicas de Saúde, São Paulo, Brazil. Electronic address:

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http://dx.doi.org/10.1016/S0140-6736(20)32168-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7572063PMC
November 2020

Impact of expanding smoke-free policies beyond enclosed public places and workplaces on children's tobacco smoke exposure and respiratory health: protocol for a systematic review and meta-analysis.

BMJ Open 2020 10 19;10(10):e038234. Epub 2020 Oct 19.

Department of Paediatrics, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands

Introduction: Tobacco smoke exposure (TSE) has considerable adverse respiratory health impact among children. Smoke-free policies covering enclosed public places are known to reduce child TSE and benefit child health. An increasing number of jurisdictions are now expanding smoke-free policies to also cover outdoor areas and/or (semi)private spaces (indoor and/or outdoor). We aim to systematically review the evidence on the impact of these 'novel smoke-free policies' on children's TSE and respiratory health.

Methods And Analysis: 13 electronic databases will be searched by two independent reviewers for eligible studies. We will consult experts from the field and hand-search references and citations to identify additional published and unpublished studies. Study designs recommended by the Cochrane Effective Practice and Organisation of Care (EPOC) group are eligible, without restrictions on the observational period, publication date or language. Our primary outcomes are: self-reported or parental-reported TSE in places covered by the policy; unplanned hospital attendance for wheezing/asthma and unplanned hospital attendance for respiratory infections. We will assess risk of bias of individual studies following the EPOC or Risk Of Bias In Non-randomised Studies of Interventions tool, as appropriate. We will conduct separate random effects meta-analyses for smoke-free policies covering (1) indoor private places, (2) indoor semiprivate places, (3) outdoor (semi)private places and (4) outdoor public places. We will assess whether the policies were associated with changes in TSE in other locations (eg, displacement). Subgroup analyses will be conducted based on country income classification (ie, high, middle or low income) and by socioeconomic status. Sensitivity analyses will be undertaken via broadening our study design eligibility criteria (ie, including non-EPOC designs) or via excluding studies with a high risk of bias. This review will inform policymakers regarding the implementation of extended smoke-free policies to safeguard children's health.

Ethics And Dissemination: Ethical approval is not required. Findings will be disseminated to academics and the general public.

Prospero Registration Number: CRD42020190563.
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http://dx.doi.org/10.1136/bmjopen-2020-038234DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577335PMC
October 2020

 Ultra-processed food consumption and risk of obesity: a prospective cohort study of UK Biobank.

Eur J Nutr 2021 Jun 18;60(4):2169-2180. Epub 2020 Oct 18.

Center for Epidemiological Research in Nutrition and Health, University of São Paulo, São Paulo, 01246-904, Brazil.

Objective: The objective of this study was to examine the associations between ultra-processed food consumption and risk of obesity among UK adults.

Methods: Participants aged 40-69 years at recruitment in the UK Biobank (2006-2019) with dietary intakes collected using 24-h recall and repeated measures of adiposity--body mass index (BMI), waist circumference (WC) and percentage of body fat (% BF)--were included (N = 22,659; median follow-up: 5 years). Ultra-processed foods were identified using the NOVA classification and their consumption was expressed as a percentage of total energy intake. Multivariable Cox proportional hazards regression models were used to estimate hazard ratios (HR) of several indicators of obesity according to ultra-processed food consumption. Models were adjusted for sociodemographic and lifestyle characteristics.

Results: 947 incident cases of overall obesity (BMI ≥ 30 kg/m) and 1900 incident cases of abdominal obesity (men: WC ≥ 102 cm, women: WC ≥ 88 cm) were identified during follow-up. Participants in the highest quartile of ultra-processed food consumption had significantly higher risk of developing overall obesity (HR 1.79; 95% CI 1.06─3.03) and abdominal obesity (HR 1.30; 95% CI 1.14─1.48). They had higher risk of experiencing a ≥ 5% increase in BMI (HR 1.31; 95% CI 1.20─1.43), WC (HR 1.35; 95% CI 1.25─1.45) and %BF (HR 1.14; 95% CI 1.03─1.25), than those in the lowest quartile of consumption.

Conclusions: Our findings provide evidence that higher consumption of ultra-processed food is strongly associated with a higher risk of multiple indicators of obesity in the UK adult population. Policy makers should consider actions that promote consumption of fresh or minimally processed foods and reduce consumption of ultra-processed foods.
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http://dx.doi.org/10.1007/s00394-020-02367-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8137628PMC
June 2021

The neglected environmental impacts of ultra-processed foods.

Lancet Planet Health 2020 10;4(10):e437-e438

Public Health Policy Evaluation Unit, School of Public Heath, Imperial College London, London SW7 2AZ, UK.

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http://dx.doi.org/10.1016/S2542-5196(20)30177-7DOI Listing
October 2020

Climate change and cancer: converging policies.

Mol Oncol 2021 03 22;15(3):764-769. Epub 2020 Sep 22.

International Agency for Research on Cancer, Lyon, France.

Intervening on risk factors for noncommunicable diseases (including cancer) in industrialized countries could achieve a reduction of between 30% and 40% of premature deaths. In the meantime, the need to intervene against the threat of climate change has become obvious. CO emissions must be reduced by 45% by the year 2030 and to zero by 2050 according to recent agreements. We propose an approach in which interventions are designed to prevent diseases and jointly mitigate climate change, the so-called cobenefits. The present article describes some examples of how climate change mitigation and cancer prevention could go hand in hand: tobacco control, food production, and transportation (air pollution). Many others can be identified. The advantage of the proposed approach is that both long-term (climate) and short-term (health) benefits can be accrued with appropriate intersectoral policies.
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http://dx.doi.org/10.1002/1878-0261.12781DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7931120PMC
March 2021

Impact of the Programa Mais médicos (more doctors Programme) on primary care doctor supply and amenable mortality: quasi-experimental study of 5565 Brazilian municipalities.

BMC Health Serv Res 2020 Sep 15;20(1):873. Epub 2020 Sep 15.

Public Health Policy Evaluation Unit, Imperial College London, London, UK.

Background: Investing in human resources for health (HRH) is vital for achieving universal health care and the Sustainable Development Goals. The Programa Mais Médicos (PMM) (More Doctors Programme) provided 17,000 doctors, predominantly from Cuba, to work in Brazilian primary care. This study assesses whether PMM doctor allocation to municipalities was consistent with programme criteria and associated impacts on amenable mortality.

Methods: Difference-in-differences regression analysis, exploiting variation in PMM introduction across 5565 municipalities over the period 2008-2017, was employed to examine programme impacts on doctor density and mortality amenable to healthcare. Heterogeneity in effects was explored with respect to doctor allocation criteria and municipal doctor density prior to PMM introduction.

Results: After starting in 2013, PMM was associated with an increase in PMM-contracted primary care doctors of 15.1 per 100,000 population. However, largescale substitution of existing primary care doctors resulting in a net increase of only 5.7 per 100,000. Increases in both PMM and total primary care doctors were lower in priority municipalities due to lower allocation of PMM doctors and greater substitution effects. The PMM led to amenable mortality reductions of - 1.06 per 100,000 (95%CI: - 1.78 to - 0.34) annually - with greater benefits in municipalities prioritised for doctor allocation and where doctor density was low before programme implementation.

Conclusions: PMM potential health benefits were undermined due to widespread allocation of doctors to non-priority areas and local substitution effects. Policies seeking to strengthen HRH should develop and implement needs-based criteria for resource allocation.
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http://dx.doi.org/10.1186/s12913-020-05716-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7491024PMC
September 2020

Estimating indirect mortality impacts of armed conflict in civilian populations: panel regression analyses of 193 countries, 1990-2017.

BMC Med 2020 09 10;18(1):266. Epub 2020 Sep 10.

Public Health Policy Evaluation Unit, Imperial College London, 3rd Floor, Reynold's Building, St Dunstan's Road, Hammersmith, London, W6 8RP, UK.

Background: Armed conflict can indirectly affect population health through detrimental impacts on political and social institutions and destruction of infrastructure. This study aimed to quantify indirect mortality impacts of armed conflict in civilian populations globally and explore differential effects by armed conflict characteristics and population groups.

Methods: We included 193 countries between 1990 and 2017 and constructed fixed effects panel regression models using data from the Uppsala Conflict Data Program and Global Burden of Disease study. Mortality rates were corrected to exclude battle-related deaths. We assessed separately four different armed conflict variables (capturing binary, continuous, categorical, and quintile exposures) and ran models by cause-specific mortality stratified by age groups and sex. Post-estimation analyses calculated the number of civilian deaths.

Results: We identified 1118 unique armed conflicts. Armed conflict was associated with increases in civilian mortality-driven by conflicts categorised as wars. Wars were associated with an increase in age-standardised all-cause mortality of 81.5 per 100,000 population (β 81.5, 95% CI 14.3-148.8) in adjusted models contributing 29.4 million civilian deaths (95% CI 22.1-36.6) globally over the study period. Mortality rates from communicable, maternal, neonatal, and nutritional diseases (β 51.3, 95% CI 2.6-99.9); non-communicable diseases (β 22.7, 95% CI 0.2-45.2); and injuries (β 7.6, 95% CI 3.4-11.7) associated with war increased, contributing 21.0 million (95% CI 16.3-25.6), 6.0 million (95% CI 4.1-8.0), and 2.4 million deaths (95% CI 1.7-3.1) respectively. War-associated increases in all-cause and cause-specific mortality were found across all age groups and both genders, but children aged 0-5 years had the largest relative increases in mortality.

Conclusions: Armed conflict, particularly war, is associated with a substantial indirect mortality impact among civilians globally with children most severely burdened.
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http://dx.doi.org/10.1186/s12916-020-01708-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7487992PMC
September 2020

Size matters: An analysis of cigarette pack sizes across 23 European Union countries using Euromonitor data, 2006 to 2017.

PLoS One 2020 13;15(8):e0237513. Epub 2020 Aug 13.

Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, London, United Kingdom.

Introduction: The tobacco industry (TI) has used small cigarette pack sizes to encourage brand-switching and consumption, and to mitigate the impacts of tobacco tax increases. Since 2016, the European Union (EU) Tobacco Products Directive (TPD) specifies a minimum pack size of 20 cigarettes. We examined cigarette pack sizes in the EU and whether pack size composition differed between cheap and expensive price segments, as well as the impact of the revised TPD.

Methods: We conducted a longitudinal analysis of pricing data from 23 EU countries between 2006-2017. We examined pack sizes over time to assess the impact of the TPD, differences in pack size composition between cheap and expensive price segments, and compared gaps in median prices between products using actual and 'expected' prices (price if all packs contained 20 sticks).

Results: Cigarette pack sizes changed over time, across the EU. The distribution of pack sizes varied between price segments, with small pack sizes especially frequent in the cheap segment of the cigarette market, but this varied over time and across countries. Packs of <20 cigarettes almost disappeared from the data samples after implementation of the TPD.

Conclusion: Implementation of the TPD appears to have virtually eliminated packs with <20 cigarettes, restricting their use by the TI. Our analysis suggests pack sizes have been used differentially across the EU. Country-level analyses on the industry's use of pack sizes, consumer responses, and evaluations of restricting certain pack sizes are needed to confirm our findings and strengthen policy.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0237513PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7425903PMC
October 2020

COVID-19 presents opportunities and threats to transport and health.

J R Soc Med 2020 07;113(7):251-254

Department of Primary Care, Imperial College London, London W6 8RP, UK.

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http://dx.doi.org/10.1177/0141076820938997DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7495662PMC
July 2020

Impact of Indonesia's national health insurance scheme on inequality in access to maternal health services: A propensity score matched analysis.

J Glob Health 2020 Jun;10(1):010429

Centre for Health Policy & Global Burden of Disease Group, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia.

Background: Reducing inequality in maternal, neonatal and infant mortality are key targets in the Sustainable Development Goals. This study is the first to evaluate the impact of Indonesia's national health insurance scheme, (JKN), on access to maternal health services by sociodemographic status.

Methods: Using data from the 2017 Indonesia Demographic and Health Survey (IDHS) on women with live births in 2016-2017, we conducted propensity score matching (PSM) analysis to evaluate the association of JKN enrollment on the following maternal health care utilisation outcomes: (1) at least four antenatal care (ANC4+) visits; (2) ANC4+ visits and received essential components of ANC; (3) skilled birth attendance; (4) facility-based delivery; (5) post-natal care (PNC); and (6) PNC with skilled provider. Analyses were conducted at the national level and by economic subgroup and region of residence. Additionally, we investigated the potential negative impact of JKN on access to maternal health services among the uninsured population by looking at trends over time using data from the 2012 and 2017 IDHS.

Results: Of the 5429 women who had recently given birth, 61% were insured by JKN in 2017. After matching treated and untreated women on key sociodemographic characteristics, enrollment in JKN was associated with a higher prevalence of receiving ANC4+ visits (7.4%, 95% confidence interval (CI) = 4.8-9.39); ANC4+ visits and received essential components of ANC (5.6%, 95% CI = 3.3-7.9); skilled birth attendance (3.0%, 95% CI = 1.5-4.5; facility-based delivery (10.2%, 95% CI = 7.5-12.7); PNC (4.0%, 95% CI = 2.2-5.7); PNC with skilled provider (4.5%, 95% CI = 2.6-6.5). Effect sizes were larger among the poor and those living in less-developed areas, such as Eastern Indonesia and Sulawesi, except for at least ANC4+ and received clinical components.

Conclusions: Expansion of health insurance coverage was associated with reductions in sociodemographic inequalities in access to maternal health services in Indonesia. However, large differences in utilisation persist across regions and by economic subgroup. Accelerating progress toward universal health coverage may reduce health inequalities in other low and middle-income countries.
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http://dx.doi.org/10.7189/jogh.10.010429DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7298736PMC
June 2020