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  • Journal article
    Hone T, Powell-Jackon T, Santos LMP, Soares RDS, Proenço de Oliveira F, Niskier Sanchez M, Harris M, Santos F, Millett Cet al., 2020,

    Impact of the Programa Mais Medicos (More Doctors Programme) on Primary Care Doctor Supply and Amenable Mortality: Quasi-Experimental Study of 5565 Brazilian Municipalities

    , BMC Health Services Research, ISSN: 1472-6963
  • Journal article
    Jawad M, Hone T, Vamos E, Roderick P, Sullivan R, Millett Cet al., 2020,

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

    , BMC Medicine, ISSN: 1741-7015

    BackgroundArmed 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. ResultsWe identified 1,118 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

  • Journal article
    Jawad M, Blanchet K, Leaning J, 2020,

    Revisiting public health response in times of war.

    , J Public Health (Oxf), Vol: 42, Pages: e285-e286
  • Journal article
    van Schalkwyk M, McKee M, Been J, Millett C, Filippidis Fet al., 2020,

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

    , PLoS One, Vol: 15, ISSN: 1932-6203

    IntroductionThe 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.MethodsWe 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).ResultsCigarette 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.ConclusionImplementation 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.

  • Journal article
    Crookes C, Palladino R, Seferidi P, Hirve R, Siskou O, Filippidis Fet al., 2020,

    The impact of the economic crisis on household health expenditure in Greece: an interrupted time series analysis

    , BMJ Open, Vol: 10, Pages: 1-11, ISSN: 2044-6055

    Objectives and setting The 2008 financial crisis had a particularly severe impact onGreece. To contain spending, the government capped public health expenditure andintroduced increased cost-sharing. The Greek case is important for studying theimpact of recessions on health systems. This study analysed changes in householdhealth expenditure in Greece over the economic crisis and explored whether theimpact differed across socioeconomic groups.Participants We used data from the Greek Household Budget Survey for the years2004 and 2008-2017. The dataset comprised 51,654 households, with a total of128,111 members.Design We compared pre- and post-crisis trends in Greek household out-of-pocketpayments for healthcare from 2004-2017 using an interrupted time series analysis.This study explored spending in Euros and as a share of total household purchases.Results Our results indicated that the population level trend in household healthspending was reversed after the crisis began (pre-crisis trend:€0.040 decrease perquarter (95% CI: -0.785 to -0.022), post-crisis trend:€0.315 increase per quarter(95% CI: -0.004 to 0.635)). We also found that spending on inpatient services andpharmaceuticals has been increasing since the start of the crisis, whereas outpatientservices expenditure has been decreasing. Across all households, out-of-pocketpayments incurred a greater financial burden after the crisis relative to pre-existingtrends, but the poorest households incurred a disproportionately higher burden.Conclusions This was the first study to use an interrupted time series analysis toassess the impact of the economic crisis on household health expenditure in Greece.Our findings suggest that there was an erosion of financial protection for Greekhouseholds as a consequence of the economic crisis. This effect was particularlypronounced amongst poorer households, which is indicative of a regressivefinancing system.

  • Journal article
    Seferidi P, Laverty AA, Collins B, Bandosz P, Capewell S, O'Flaherty M, Millett C, Pearson-Stuttard Jet al., 2020,

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

    , BMJ Nutrition, Prevention & Health, Vol: 3, ISSN: 2516-5542

    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.

  • Journal article
    Laverty AA, Millett C, Majeed A, Vamos EPet al., 2020,

    COVID-19 presents opportunities and threats to transport and health

    , Journal of the Royal Society of Medicine, Vol: 113, Pages: 251-254, ISSN: 0141-0768
  • Journal article
    Laverty A, Millett C, Filippidis FT, 2020,

    Associations between cigarette prices and consumption in Europe 2004 - 2014

    , Tobacco Control, ISSN: 0964-4563

    IntroductionWhile tobacco price increases are known to reduce smoking prevalence, these relationships may be blunted by the availability of budget cigarettes, promoted by the tobacco industry to maintain profits. There has been limited previous research on the impact of budget cigarettes on cigarette consumption and used data from Europe 2004-2014 to investigate this.MethodsAnnual population-weighted cigarette consumption per adult data come from the International Cigarette Consumption Database. Annual tobacco price data come from Euromonitor International for 23 European countries. We examined median prices as well as price differentials, operationalised as percentages obtained by dividing the difference between median and minimum prices by median price. We used a linear random-effects model to assess associations between these and cigarette consumption within-year and with a one-year time lag.ResultsCigarette consumption per capita has declined over the study period (-29.5 cigarettes per capita per year, 95% Confidence Intervals -46.8 to -12.1). Our analysis suggests that increases in cigarette price differentials, a marker of opportunities for smokers to switch to less expensive cigarettes, are associated with greater consumption in the same year (+6.4 for a 10% increase in differential, -40.0 to 52.6) and are associated with greater consumption the following year (+67.6, 25.8 to 109.5). ConclusionThese analyses suggest that even in Europe where tobacco taxes are relatively high compared with other regions, differential cigarette pricing strategies may undermine tobacco control. Further research is needed on links between tobacco price structures and consumption and policy design to maximise the effectiveness of tobacco tax.

  • Journal article
    Anindya K, Lee JT, McPake B, Wilopo SA, Millett C, Carvalho Net al., 2020,

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

    , JOURNAL OF GLOBAL HEALTH, Vol: 10, ISSN: 2047-2978
  • Journal article
    McKay A, Negi NS, Murukutla N, Laverty A, Puri P, Uttekar BV, Mullin S, Millett Cet al., 2020,

    Trends in tobacco, alcohol and branded fast-food imagery in Bollywood films, 1994-2013

    , PLoS One, Vol: 15, ISSN: 1932-6203

    Background and aimsExposure to tobacco, alcohol and fast-food use in films is associated with initiation of these behaviours. India is the world’s largest film producer, but the extent of such imagery in Bollywood (Hindi cinema) films is unclear. We therefore aimed to describe the extent of and trends in tobacco, alcohol and fast-food imagery in Bollywood films, between 1994–2013.MethodsFor the 15 top-grossing films each year between 1994–2013, the number of five-minute intervals containing product images were determined separately for tobacco, alcohol and fast-food. Both the proportion of films containing at least one image occurrence, and occurrences per film, were described overall and by year. Negative binomial regression described associations between film rating and occurrences/film, and estimated time-trends in occurrences/film, adjusted for rating.ResultsWe analysed 93 U-rated (unrestricted), 150 U/A-rated (parental guidance for children aged <12 years) and 55 A-rated (restricted to adult audience) films, containing 9,226 five-minute intervals (mean intervals/film 30.8, SD 4.0). 70% (n = 210), 93% (n = 278) and 21% (n = 62) of films contained at least one tobacco, alcohol and fast-food occurrence, respectively. Corresponding total mean occurrences/film were 4.0 (SD 4.9), 7.0 (4.7) and 0.4 (0.9). Tobacco occurrences were more common in U/A films (incidence rate ratio 1.49, 95% confidence interval 1.06–2.09) and A films (2.95; 1.95–4.48) than U-rated films. Alcohol occurrences were also more common in A-rated films than U-rated films (1.48; 1.15–1.85). Tobacco occurrences/film became less common over the observed period (adjusted trend -4% per annum; -2 to -7%; p <0.001), while alcohol (+2%; 0–3%; p = 0.02), and fast food (+8%; 2–14%; p = 0.01) occurrences/film became more common.ConclusionsAlthough the extent of tobacco imagery in Bollywood films fell over 1994–2013, it is still frequently observed.

  • Journal article
    Jawad M, Millett C, Sullivan R, Alturki F, Roberts B, Vamos Eet al., 2020,

    The impact of armed conflict on cancer among civilian populations in low- and middle-income countries: a systematic review

    , Ecancermedicalscience, Vol: 14, ISSN: 1754-6605

    Commitee On Publication EthicsecancermedicalscienceSubmit articleArticlesEditorialsSpecial issuesAuthor interviewsCategorySub-categoryArticle typeVolumeKeywordBookmark and ShareArticle metrics: 204 views | Full Article | PDFReviewThe impact of armed conflict on cancer among civilian populations in low- and middle-income countries: a systematic reviewMohammed Jawad1, Christopher Millett1, Richard Sullivan2, Fadel Alturki3, Bayard Roberts4 and Eszter P Vamos11Public Health Policy Evaluation Unit, Imperial College London, Hammersmith, London W6 8RP, UK2Institute of Cancer Policy, Cancer Epidemiology, Population and Global Health, King's College London and Guy's & St Thomas' NHS Trust, London, UK3Faculty of Medicine, American University of Beirut, Lebanon4Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UKAbstractBackground: Armed conflicts are increasingly impacting countries with a high burden of cancer. The aim of this study is to systematically review the literature on the impact of armed conflict on cancer in low- and middle-income countries (LMICs).Methods: In November 2019, we searched five medical databases (Embase, Medline, Global Health, PsychINFO and the Web of Science) without date, language or study design restrictions. We included studies assessing the association between armed conflict and any cancer among civilian populations in LMICs. We systematically re-analysed the data from original studies and assessed quality using the Newcastle-Ottawa Scale. Data were analysed descriptively by cancer site.Results: Of 1,543 citations screened, we included 20 studies assessing 8 armed conflicts and 13 site-specific cancers (total study population: 70,172). Two-thirds of the studies were of low methodological quality (score <5) and their findings were often conflicting. However, among outcomes assessed by three or more studies, we found some evi

  • Journal article
    Rauber F, Steele EM, Louzada MLC, Millett C, Monteiro CA, Levy RBet al., 2020,

    Ultra-processed food consumption and indicators of obesity in the United Kingdom population (2008-2016)

    , PLOS ONE, Vol: 15, ISSN: 1932-6203
  • Journal article
    Patterson R, Panter J, Vamos EP, Cummins S, Millett C, Laverty AAet al., 2020,

    Associations between commute mode and cardiovascular disease, cancer, and all-cause mortality, and cancer incidence, using linked Census data over 25 years in England and Wales: a cohort study

    , Lancet Planetary Health, Vol: 4, Pages: E186-E194, ISSN: 2542-5196

    BackgroundActive travel is increasingly recognised as an important source of physical activity. We aimed to describe associations between commute mode and cardiovascular disease, cancer, and all-cause mortality.MethodsWe analysed data from the Office for National Statistics Longitudinal Study of England and Wales (ONS-LS), which linked data from the Census of England and Wales (henceforth referred to as the Census) for 1991, 2001, and 2011 to mortality and cancer registrations. The cohort included individuals traced in the ONS-LS who were economically active (ie, aged ≥16 years, not retired from work, and not a full-time carer). Commuting by private motorised transport, public transport, walking, and cycling were compared in terms of all-cause mortality, cancer mortality, cardiovascular disease mortality, and cancer incidence, using Cox proportional-hazards models with time-varying covariates. Models were adjusted for age, sex, housing tenure, marital status, ethnicity, university education, car access, population density, socioeconomic classification, Carstairs index quintile, long-term illness, and year entered the study, and were additionally stratified by socioeconomic group.FindingsBetween the 1991 Census and the 2011 Census, 784 677 individuals contributed data for at least one Census, of whom 394 746 were included in the ONS-LS and were considered to be economically active working-age individuals. 13 983 people died, 3172 from cardiovascular disease and 6509 from cancer, and there were 20 980 incident cancer cases. In adjusted models, compared with commuting by private motorised vehicle, bicycle commuting was associated with a 20% reduced rate of all-cause mortality (hazard ratio [HR] 0·80, 95% CI 0·73–0·89), a 24% decreased rate of cardiovascular disease mortality (0·76, 0·61–0·93), a 16% lower rate of cancer mortality (0·84, 0·73–0·98), and an 11% reduced rate of incident ca

  • Journal article
    Chambers T, Millett C, Sassi F, 2020,

    New Zealand's Public Services Act: a policy opportunity for cross-government action on unhealthy products

    , PERSPECTIVES IN PUBLIC HEALTH, Vol: 140, Pages: 144-145, ISSN: 1757-9139
  • Journal article
    Palladino R, Tabak A, Khunti K, Valabhji J, Majeed F, Millett C, Vamos Eet al., 2020,

    Association between pre-diabetes and microvascular and macrovascular disease in newly diagnosed type 2 diabetes

    , BMJ Open Diabetes Research and Care, Vol: 8, ISSN: 2052-4897

    Objective The associated risk of vascular disease following diagnosis of type 2 diabetes in people previously identified as having pre-diabetes in real-world settings is unknown. We examined the presence of microvascular and macrovascular disease in individuals with newly diagnosed type 2 diabetes by glycemic status within 3 years before diagnosis.Research design and methods We identified 159 736 individuals with newly diagnosed type 2 diabetes from the UK Clinical Practice Research Datalink database in England between 2004 and 2017. We used logistic regression models to compare presence of microvascular (retinopathy and nephropathy) and macrovascular (acute coronary syndrome, cerebrovascular and peripheral arterial disease) disease at the time of type 2 diabetes diagnosis by prior glycemic status.Results Half of the study population (49.9%) had at least one vascular disease, over one-third (37.4%) had microvascular disease, and almost a quarter (23.5%) had a diagnosed macrovascular disease at the time of type 2 diabetes diagnosis.Compared with individuals with glycemic values within the normal range, those detected with pre-diabetes before the diagnosis had 76% and 14% increased odds of retinopathy and nephropathy (retinopathy: adjusted OR (AOR) 1.76, 95% CI 1.69 to 1.85; nephropathy: AOR 1.14, 95% CI 1.10 to 1.19), and 7% higher odds of the diagnosis of acute coronary syndrome (OR 1.07, 95% CI 1.03 to 1.12) in fully adjusted models at time of diabetes diagnosis.Conclusions Microvascular and macrovascular diseases are detected in 37%–24% of people with newly diagnosed type 2 diabetes. Pre-diabetes before diagnosis of type 2 diabetes is associated with increased odds of microvascular disease and acute coronary syndrome. Detection of pre-diabetes might represent an opportunity for reducing the burden of microvascular and macrovascular disease through heightened attention to screening for vascular complications.

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