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  • Journal article
    Rauber F, da Costa Louzada ML, Steele EM, de Rezende LFM, Millett C, Monteiro CA, Levy RBet al., 2019,

    Ultra-processed foods and excessive free sugar intake in the UK: a nationally representative cross-sectional study

    , BMJ OPEN, Vol: 9, ISSN: 2044-6055
  • Journal article
    Laverty AA, Vamos EP, Millett C, Chang KC-M, Filippidis FT, Hopkinson NSet al., 2019,

    Child awareness of and access to cigarettes: impacts of the point-of-sale display ban in England.

    , Tob Control, Vol: 28, Pages: 526-531

    INTRODUCTION: England introduced a tobacco display ban for shops with >280 m2 floor area ('partial ban') in 2012, then a total ban in 2015. This study assessed whether these were linked to child awareness of and access to cigarettes. METHODS: Data come from the Smoking, Drinking and Drug Use survey, an annual survey of children aged 11-15 years for 2010-2014 and 2016. Multivariate logistic regression models assessed changes in having seen cigarettes on display, usual sources and ease of access to cigarettes in shops RESULTS: During the partial display ban in 2012, 89.9% of children reported seeing cigarettes on display in the last year, which was reduced to 86.0% in 2016 after the total ban (adjusted OR 0.58, 95% CI 0.50 to 0.66). Reductions were similar in small shops (84.1% to 79.3%)%) and supermarkets (62.6% to 57.3%)%). Although the ban was associated with a reduction in the proportion of regular child smokers reporting that they bought cigarettes in shops (57.0% in 2010 to 39.8% in 2016), we did not find evidence of changes in perceived difficulty or being refused sale among those who still did. DISCUSSION: Tobacco point-of-sale display bans in England reduced the exposure of children to cigarettes in shops and coincided with a decrease in buying cigarettes in shops. However, children do not report increased difficulty in obtaining cigarettes from shops, highlighting the need for additional measures to tackle tobacco advertising, stronger enforcement of existing laws and measures such as licencing for tobacco retailers.

  • Journal article
    Souza LEPFD, Barros RDD, Barreto ML, Katikireddi SV, Hone TV, Paes de Sousa R, Leyland A, Rasella D, Millett CJ, Pescarini Jet al., 2019,

    The potential impact of austerity on attainment of the sustainable development goals in Brazil

    , BMJ Global Health, Vol: 4, ISSN: 2059-7908

    In the recent decades, Brazil has outperformed comparable countries in its progress toward meeting the Millennium Development Goals. Many of these improvements have been driven by investments in health and social policies. In this article, we aim to identify potential impacts of austerity policies in Brazil on the chances of achieving the sustainable development goals (SDGs) and its consequences for population health. Austerity’s anticipated impacts are assessed by analysing the change in federal spending on different budget programmes from 2014 to 2017. We collected budget data made publicly available by the Senate. Among the selected 19 programmes, only 4 had their committed budgets increased, in real terms, between 2014 and 2017. The total amount of extra money committed to these four programmes in 2017, above that committed in 2014, was small (BR$9.7 billion). Of the 15 programmes that had budget cuts in the period from 2014 to 2017, the total decrease amounted to BR$60.2 billion (US$15.3 billion). In addition to the overall large budget reduction, it is noteworthy that the largest proportional reductions were in programmes targeted at more vulnerable populations. In conclusion, it seems clear that the current austerity policies in Brazil will probably damage the population’s health and increase inequities, and that the possibility of meeting SDG targets is lower in 2018 than it was in 2015.

  • Journal article
    Jawad M, Vamos E, Najim M, Roberts B, Millett Cet al., 2019,

    Impact of armed conflict on cardiovascular disease risk: a systematic review

    , Heart, Vol: 105, Pages: 1388-1394, ISSN: 1355-6037

    ObjectivesProlonged armed conflict may constrain efforts to address non-communicable disease in some settings. We assessed the impact of armed conflict on cardiovascular disease (CVD) risk among civilians in low- and middle-income countries (LMICs).MethodsIn February 2019 we performed a systematic review (Prospero ID: CRD42017065722) searching Medline, Embase, PsychINFO, Global Health, and Web of Science without language or date restrictions. We included adult, civilian populations in LMICs. Outcomes included CVDs and diabetes, and eight clinical and behavioural factors (blood pressure, blood glucose, lipids, tobacco, alcohol, body mass index, nutrition, physical activity). We systematically re-analysed data from original papers and presented them descriptively.ResultsSixty-five studies analysed 23 conflicts, and 66% were of low quality. We found some evidence that armed conflict is associated with an increased coronary heart disease, cerebrovascular, and endocrine diseases, in addition to increased blood pressure, lipids, alcohol, and tobacco use. These associations were more consistent for mortality from chronic ischaemic heart disease or unspecified heart disease, systolic blood pressure, and tobacco use. Associations between armed conflict and other outcomes showed no change, or had mixed or uncertain evidence. We found no clear patterning by conflict type, length of follow up, and study quality, nor strong evidence for publication bias.ConclusionsArmed conflict may exacerbate CVDs and their risk factors, but the current literature is somewhat inconsistent. Post-conflict reconstruction efforts should deliver low resource preventative interventions through primary care to prevent excess CVD-related morbidity and mortality.

  • Journal article
    Hone T, Gómez-Dantés O, 2019,

    Broadening universal health coverage for children in Mexico

    , The Lancet Global Health, Vol: 7, Pages: e1308-e1309, ISSN: 2214-109X
  • Journal article
    Laverty AA, Kypridemos C, Seferidi P, Vamos EP, Pearson-Stuttard J, Collins B, Capewell S, Mwatsama M, Cairney P, Fleming K, O'Flaherty M, Millett Cet al., 2019,

    Quantifying the impact of the Public Health Responsibility Deal on salt intake, cardiovascular disease and gastric cancer burdens: interrupted time series and microsimulation study

    , Journal of Epidemiology and Community Health, Vol: 73, Pages: 881-887, ISSN: 0143-005X

    Background In 2011, England introduced the PublicHealth Responsibility Deal (RD), a public-privatepartnership (PPP) which gave greater freedom to thefood industry to set and monitor targets for salt intakes.We estimated the impact of the RD on trends in saltintake and associated changes in cardiovascular disease(CVD) and gastric cancer (GCa) incidence, mortality andeconomic costs in England from 2011–2025.Methods We used interrupted time series modelswith 24 hours’ urine sample data and the IMPACTNCDmicrosimulation model to estimate impacts of changes insalt consumption on CVD and GCa incidence, mortalityand economic impacts, as well as equity impacts.Results Between 2003 and 2010 mean salt intake wasfalling annually by 0.20 grams/day among men and 0.12g/d among women (P-value for trend both < 0.001).After RD implementation in 2011, annual declines insalt intake slowed statistically significantly to 0.11 g/damong men and 0.07 g/d among women (P-values fordifferences in trend both P < 0.001). We estimated thatthe RD has been responsible for approximately 9900(interquartile quartile range (IQR): 6700 to 13,000)additional cases of CVD and 1500 (IQR: 510 to 2300)additional cases of GCa between 2011 and 2018. Ifthe RD continues unchanged between 2019 and 2025,approximately 26 000 (IQR: 20 000 to 31,000) additionalcases of CVD and 3800 (IQR: 2200 to 5300) cases ofGCa may occur.Interpretation Public-private partnerships such as theRD which lack robust and independent target setting,monitoring and enforcement are unlikely to produceoptimal health gains.

  • Journal article
    Castro M, Massuda A, Almeida G, Menezes-Filho N, Andrade MV, de Souza Noronha K, Rocha R, Macinko J, Hone T, Tasca R, Giovanella L, Malik AM, Werneck H, Fachini L, Atun Ret al., 2019,

    Brazil's unified health system: the first 30 years and prospects for the future

    , Lancet, Vol: 394, Pages: 345-356, ISSN: 0140-6736

    In 1988, Brazilian Constitution definedhealth as a universal right and stateresponsibility. Progress towards universal health coverage (UHC) has been achievedthrough a Unified Health System (Sistema Único de Saúde, SUS)which was created in 1990. Withsuccesses and setbacksin the implementation of health programmes and organization of its health system, Brazil has achieved nearly-universal access to health servicesfor her citizens. Thetrajectory of the development and expansion of the SUS offers valuable lessons on how to scale UHC in a health system in a highly-unequal country and relatively low resources. Theanalysis of the 30 years since the inception of SUS shows that innovations in the Brazilian health system extendbeyond the development of new models of care and highlightsthe importance of establishing political, legal, organizational and management-related structures, and the role of the federal and local governmentsin the governance, planning, financing, and provision of health services. Theexpansion of SUS has allowed Brazilto rapidly address the changing health needs, withdramatic scaling up health service coverage in justthree decades. However, despite its successes, analysis of future scenarios suggests the urgent need to address lingering geographic inequalities, insufficient funding, and the suboptimal private-public collaboration. Recent fiscal policies that ushered austerity measures, environmental, educational and health policies of the new administraion introduced in Brazilcould reverse the hard-earned achievements of the SUS and threaten itssustainability and its ability to fulfilits constitutional mandate of providing‘health for all’.

  • Journal article
    Patterson RA, Webb E, Millett C, Laverty Aet al., 2019,

    Physical activity accrued as part of public transport use in England

    , Journal of Public Health, Vol: 41, Pages: 222-230, ISSN: 1741-3842

    Background:Walking and cycling for transport (active travel) is an important source of physical activity with established health benefits. However, levels of physical activity accrued during public transport journeys in England are unknown.Methods:Using the English National Travel Survey 2010–14 we quantified active travel as part of public transport journeys. Linear regression models compared levels of physical activity across public transport modes, and logistic regression models compared the odds of undertaking 30 min a day of physical activity.Results:Public transport users accumulated 20.5 min (95% confidence interval=19.8, 21.2) a day of physical activity as part of public transport journeys. Train users accumulated 28.1 min (26.3, 30.0) with bus users 16.0 min (15.3, 16.8). Overall, 34% (32%, 36%) of public transport users achieved 30 min a day of physical activity in the course of their journeys; 21% (19%, 24%) of bus users and 52% (47%, 56%) of train users.Conclusion:Public transport use is an effective way to incorporate physical activity into daily life. One in three public transport users meet physical activity guidelines suggesting that shifts from sedentary travel modes to public transport could dramatically raise the proportion of populations achieving recommended levels of physical activity.

  • Journal article
    Laverty AA, Filippidis FT, Taylor-Robinson D, Millett C, Bush A, Hopkinson NSet al., 2019,

    Smoking uptake in UK children: Analysis of the UK Millennium Cohort Study.

    , Thorax, Vol: 74, Pages: 607-610, ISSN: 0040-6376

    We used data from 11 577 children in the UK Millennium Cohort Study, collected at approximately 14 years of age (early teens), to assess characteristics associated with smoking, and generated regional estimates of numbers of smokers. 13.8% of UK early teens studied had ever smoked; 1.9% were current smokers. This corresponds to 2 28 136 and 39 653 (13-14 year olds) in the UK, respectively. Ever smoking risk increased if caregivers (26.0% vs 10.9%) or friends smoked (35.1% vs 4.0%), with a dose-response effect for friends' smoking. Caregiver and peer-group smoking remain important drivers of child smoking uptake and thus important targets for intervention.

  • Journal article
    Hone T, Szklo AS, Filippidis F, Laverty A, Sattamini I, Been J, Vianna C, de Souza MC, de Almeida LM, Millett Cet al., 2019,

    Smoke-free legislation and neonatal and infant mortality in Brazil: a longitudinal quasi-experimental study

    , Tobacco Control, Vol: 29, Pages: 312-319, ISSN: 0964-4563

    Objective To examine the associations of partial and comprehensive smoke-free legislation with neonatal and infant mortality in Brazil using a quasi-experimental study design.Design Monthly longitudinal (panel) ecological study from January 2000 to December 2016.Setting All Brazilian municipalities (n=5565).Participants Infant populations.Intervention Smoke-free legislation in effect in each municipality and month. Legislation was encoded as basic (allowing smoking areas), partial (segregated smoking rooms) or comprehensive (no smoking in public buildings). Associations were quantified by immediate step and longer term slope/trend changes in outcomes.Statistical analyses Municipal-level linear fixed-effects regression models.Main outcomes measures Infant and neonatal mortality.Results Implementation of partial smoke-free legislation was associated with a −3.3 % (95% CI −6.2% to −0.4%) step reduction in the municipal infant mortality rate, but no step change in neonatal mortality. Comprehensive smoke-free legislation implementation was associated with −5.2 % (95% CI −8.3% to −2.1%) and −3.4 % (95% CI −6.7% to −0.1%) step reductions in infant and neonatal mortality, respectively, and a −0.36 (95% CI −0.66 to−0.06) annual decline in the infant mortality rate. We estimated that had all smoke-free legislation introduced since 2004 been comprehensive, an additional 10 091 infant deaths (95% CI 1196 to 21 761) could have been averted.Conclusions Strengthening smoke-free legislation in Brazil is associated with improvements in infant health outcomes—particularly under comprehensive legislation. Governments should accelerate implementation of comprehensive smoke-free legislation to protect infant health and achieve the United Nation’s Sustainable Development Goal three.

  • Journal article
    Rasella D, Hone T, de Souza LE, Tasca R, Basu S, Millett Cet al., 2019,

    Mortality associated with alternative primary health care policies: a nationwide microsimulation modelling study in Brazil

    , BMC Medicine, Vol: 17, ISSN: 1741-7015

    BackgroundBrazil’s Estratégia Saúde da Família (ESF) is one of the largest and most robustly evaluated primary healthcare programmes of the world, but it could be affected by fiscal austerity measures and by the possible end of the Mais Médicos programme (MMP)—a major intervention to increase primary care doctors in underserved areas. We forecast the impact of alternative scenarios of ESF coverage changes on under-70 mortality from ambulatory care-sensitive conditions (ACSCs) until 2030, the date for achievement of the Sustainable Development Goals (SDGs).MethodA synthetic cohort of 5507 Brazilian municipalities was created for the period 2017–2030. A municipal-level microsimulation model was developed and validated using longitudinal data and estimates from a previous retrospective study evaluating the effects of municipal ESF coverage on mortality rates. Reductions in ESF coverage, and its effects on ACSC mortality, were forecast based on two probable austerity scenarios, compared with the maintenance of the current coverage or the expansion to 100%. Fixed effects longitudinal regression models were employed to account for secular trends, demographic and socioeconomic changes, healthcare-related variables, and programme duration effects.ResultsUnder austerity scenarios of decreasing ESF coverage with and without the MMP termination, mean ACSC mortality rates would be 8.60% (95% CI 7.03–10.21%; 48,546 excess premature/under-70 deaths along 2017–2030) and 5.80% (95% CI 4.23–7.35%; 27,685 excess premature deaths) higher respectively in 2030 compared to maintaining the current ESF coverage.Comparing decreasing ESF coverage and MMP termination with achieving 100% ESF coverage (Universal Health Coverage scenario) in 2030, mortality rates would be 11.12% higher (95% CI 9.47–12.76%; 83,937 premature deaths). Reductions in ESF coverage would have stronger effects on mortality from infectious diseases and

  • Journal article
    Been JV, Millett C, 2019,

    Reducing the global burden of preterm births

    , LANCET GLOBAL HEALTH, Vol: 7, Pages: E414-E414, ISSN: 2214-109X
  • Journal article
    Patterson R, Webb E, Hone T, Millett C, Laverty AAet al., 2019,

    Associations of public transportation use with cardiometabolic health: a systematic review and meta-analysis

    , American Journal of Epidemiology, Vol: 188, Pages: 785-795, ISSN: 1476-6256

    Public transport provides an opportunity to incorporate physical activity into journeys, but potential health impacts have not been systematically examined. Literature searches were carried out up to December 2017 using Medline, Embase, Transport Database, Scopus, Cochrane Library, and Google. We identified longitudinal studies which examined associations between public transport and cardio-metabolic health including: adiposity, type II diabetes, and cardiovascular disease. We assessed study quality using the Newcastle-Ottawa Scale for cohort studies and performed meta-analyses where possible. Ten studies were identified, seven investigating use of public transport and three examining proximity to public transport. Seven studies used individual level data on changes in BMI with objective outcomes measured in six studies. Study follow-up ranged from one to ten years with three studies adjusting for non-transport physical activity. We found a consistent association between public transport use and lower BMI. Meta-analysis of data from five comparable studies found that switching from car to public transport was associated with lower BMI: −0.30 kg/m2 (−0.47, −0.14). Few studies have investigated associations between public transport use and non-adiposity outcomes. These findings suggest that sustainable urban design which promotes public transport use may produce modest reductions in population BMI.

  • Journal article
    Palladino R, Pennino F, Finbarr M, Millett C, Triassi Met al., 2019,

    Multimorbidity and health outcomes in older adults in ten European health systems, 2006-15

    , Health Affairs, Vol: 38, Pages: 613-623, ISSN: 0278-2715

    Despite the increase in awareness of chronic disease, little is known about whether multimorbidity-defined as two or more coexisting chronic conditions-has had a diminished impact on health in Europe in the past decade. We used multiple cross-sectional data from the Survey of Health, Ageing and Retirement in Europe to estimate changes in the prevalence of multimorbidity and in its association with health outcomes in ten European countries between 2006-07 and 2015. We found that the prevalence of multimorbidity rose from 38.2 percent in 2006-07 to 41.5 percent in 2015. Over the ten-year study period we also found a marginal reduction of the impact of multimorbidity on primary care visits and functional capacity. We did not find a reduction of its impact on hospital admissions and quality of life. Austria, the Czech Republic, Germany, and Spain were the countries that showed the largest reduction in the impact of multimorbidity on health outcomes. Multimorbidity continues to pose challenges for European health care systems, with only marginal improvement on health care use and health outcomes since 2006-07.

  • Journal article
    Filippidis FT, Jawad M, Vardavas CI, 2019,

    Trends and correlates of waterpipe use in the European Union: analysis of selected Eurobarometer surveys (2009-2017).

    , Nicotine and Tobacco Research, Vol: 21, Pages: 469-474, ISSN: 1462-2203

    Introduction: To assess the trends and correlates of waterpipe use between 2009 and 2017 in the 28 European Union (EU) member states. Methods: We analysed data from wave 72.3 (2009, n=27,788); wave 77.1 (2012, n=26,751); wave 82.4 (2014, n=27,801); and wave 87.1 (2017, n=27,901) of the Eurobarometer survey. Representative samples of EU residents aged ≥15 years were asked to report ever use of waterpipe. Regular waterpipe use, i.e. at least once a month was also assessed in 2017. Associations of ever and current use with sociodemographic factors were assessed with multi-level logistic regression. Results: The prevalence of ever waterpipe use in the EU increased from 11.6% in 2009 to 16.3% in 2014 before dropping to 12.9% in 2017, but there was wide variation between EU member states, ranging from 2.3% (Croatia, 2009) to 41.7% (Latvia, 2017). Regular waterpipe use was highest in Austria (3.6%), Latvia (2.5%) and Belgium (2.0%) in 2017. Respondents aged 15-24 years were 11.43 times more likely (95% Confidence Interval [CI]: 10.71-12.21) to have ever used waterpipe compared to those 55 years and older. Regular and ever waterpipe use were also more likely among current and former cigarette smokers. Males (adjusted Odds Ratio [aOR]=1.64; 95% CI: 1.58-1.70) and those living in urban areas (aOR=1.36; 95% CI: 1.30-1.42) were more likely to have ever used waterpipe. Conclusion: A substantial proportion of EU citizens, especially young men, have tried waterpipe. Regular use is relatively limited, but more systematic surveillance is required to monitor trends across the EU. Implications: Data on waterpipe use in the European Union (EU) are scarce. The prevalence of ever waterpipe use in the EU increased from 11.6% in 2009 to 16.3% in 2014 before dropping to 12.9% in 2017, with wide variation between EU member states. Males, those living in urban areas, younger respondents and current or former cigarette smokers were more likely to be ever or regular users of waterpipe.

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