Is the hair nicotine level a more accurate biomarker of environmental tobacco smoke exposure than urine cotinine?

STUDY OBJECTIVE

The aim of this study was to compare the two biomarkers of exposure to environmental tobacco smoke (ETS); urine cotinine and hair nicotine, using questionnaires as the standard.

DESIGN

A cross sectional study of children consecutively admitted to hospital for lower respiratory illnesses during the period of the study.

SETTINGS

Three regional hospitals in the larger Wellington area, New Zealand.

PARTICIPANTS

Children aged 3-27 months and admitted to the above hospitals during August 1997 to October 1998. A total of 322 children provided 297 hair samples and 158 urine samples.

MAIN RESULTS

Hair nicotine levels were better able to discriminate the groups of children according to their household's smoking habits at home (no smokers, smoke only outside the home, smoke inside the house) than urine cotinine (Kruskall-Wallis; chi(2)=142.14, and chi(2)=49.5, respectively (p<0.0001)). Furthermore, hair nicotine levels were more strongly correlated with number of smokers in the house, and the number of cigarettes smoked by parents and other members of the child's households. Hair nicotine was better related to the questionnaire variables of smoking in a multivariate regression model (r(2)=0.55) than urine cotinine (r(2)=0.31).

CONCLUSIONS

In this group of young children, hair nicotine was a more precise biomarker of exposure to ETS than urine cotinine levels, using questionnaire reports as the reference. Both biomarkers indicate that smoking outside the house limits ETS exposure of children but does not eliminate it.

Third sector primary care for vulnerable populations

This paper aims to describe and explain the development of third sector primary care organisations in New Zealand. The third sector is the non-government, non-profit sector. International literature suggests that this sector fulfils an important role in democratic societies with market-based economies, providing services otherwise neglected by the government and private for-profit sectors. Third sector organisations provided a range of social services throughout New Zealand's colonial history. However, it was not until the 1980s that third sector organisations providing comprehensive primary medical and related services started having a significant presence in New Zealand. In 1994 a range of union health centres, tribally based Mäori health providers, and community-based primary care providers established a formal network -- Health Care Aotearoa. While not representing all third sector primary care providers in New Zealand, Health Care Aotearoa was the best-developed example of a grouping of third sector primary care organisations. Member organisations served populations that were largely non-European and lived in deprived areas, and tended to adopt population approaches to funding and provision of services. The development of Health Care Aotearoa has been consistent with international experience of third sector involvement -- there were perceived "failures" in government policies for funding primary care and private sector responses to these policies, resulting in lack of universal funding and provision of primary care and continuing patient co-payments. The principal policy implication concerns the role of the third sector in providing primary care services for vulnerable populations as a partial alternative to universal funding and provision of primary care. Such an alternative may be convenient for proponents of reduced state involvement in funding and provision of health care, but may not be desirable from the point of view of equity and social cohesion insofar as the role of the welfare state is diminished.

How many deaths are caused by second hand cigarette smoke?

OBJECTIVES

To estimate the number of deaths attributable to second hand smoke (SHS), to distinguish attributable and potentially avoidable burdens of mortality, and to identify the most important sources of uncertainty in these estimates.

METHOD

A case study approach, using exposure and mortality data for New Zealand.

RESULTS

In New Zealand, deaths caused by past exposures to second hand smoke currently number about 347 per year. On the basis of present exposures, we estimate there will be about 325 potentially avoidable deaths caused by SHS in New Zealand each year in the future. We have explored the effect of varying certain assumptions on which the calculations are based, and suggest a plausible range (174-490 avoidable deaths per year).

CONCLUSION

Attributable risk estimates provide an indication for policy makers and health educators of the magnitude of a health problem; they are not precise predictions. As a cause of death in New Zealand, we estimate that second hand smoke lies between melanoma of the skin (200 deaths per year) and road crashes (about 500 deaths per year).

Use of a computer model to identify potential hotspots for dengue fever in New Zealand

AIMS

To describe the areas of potential dengue fever risk in New Zealand for present climatic conditions and projected scenarios of climate change.

METHODS

A computer model, the HOTSPOTS System, was developed. This allowed the integration of climatic, topographical, entomological, demographic, trade and travel data to generate spatial information describing vector introduction risk, potential vector distribution and dengue fever risk.

RESULTS

Under present climatic conditions, Auckland and Northland, and some coastal areas of other northern parts of the North Island, have a potential risk for dengue outbreaks supported by the vector Aedes albopictus. Greenhouse gas induced climate change could make these areas also receptive to Aedes aegypti--the more efficient tropical dengue vector--and increase the potential distribution of A. albopictus to much of the South Island.

CONCLUSIONS

Given the introduction of a competent vector, there is an appreciable risk of dengue fever occurring in New Zealand under present climatic conditions. Greenhouse gas induced climate change would substantially increase the magnitude and spatial extent of this risk.

Is testicular cancer an occupational disease of fire fighters?

BACKGROUND

A previous investigation showed an increased risk of testicular cancer among fire fighters in Wellington City, New Zealand, during the 1980s. Other studies of fire fighters had not identified testicular cancer as an occupational disease.

METHODS

This was an historical cohort study of mortality and cancer incidence in all paid New Zealand fire fighters, from 1977 to 1995.

RESULTS

The only cancer for which this study provided evidence of an increased risk was testicular cancer, even after excluding cases from the previous investigation. The standardized incidence ratio for 1990-96 was 3.0 (95% confidence interval: 1.3-5.90). There was no evidence that fire fighters were at increased risk from any particular cause of death.

CONCLUSIONS

This study confirmed that New Zealand fire fighters are at increased risk of testicular cancer, although the reason is unknown. Other incidence studies of cancer in fire fighters are needed to confirm this finding.

Early effects of climate change: do they include changes in vector-borne disease?

The world's climate appears now to be changing at an unprecedented rate. Shifts in the distribution and behaviour of insect and bird species indicate that biological systems are already responding to this change. It is well established that climate is an important determinant of the spatial and temporal distribution of vectors and pathogens. In theory, a change in climate would be expected to cause changes in the geographical range, seasonality (intra–annual variability), and in the incidence rate (with or without changes in geographical or seasonal patterns). The detection and then attribution of such changes to climate change is an emerging task for scientists. We discuss the evidence required to attribute changes in disease and vectors to the early effects of anthropogenic climate change. The literature to date indicates that there is a lack of strong evidence of the impact of climate change on vector–borne diseases (i.e. malaria, dengue, leishmaniasis, tick–borne diseases). New approaches to monitoring, such as frequent and long–term sampling along transects to monitor the full latitudinal and altitudinal range of specific vector species, are necessary in order to provide convincing direct evidence of climate change effects. There is a need to reassess the appropriate levels of evidence, including dealing with the uncertainties attached to detecting the health impacts of global change.

Early effects of climate change: do they include changes in vector-borne disease?

The world's climate appears now to be changing at an unprecedented rate. Shifts in the distribution and behaviour of insect and bird species indicate that biological systems are already responding to this change. It is well established that climate is an important determinant of the spatial and temporal distribution of vectors and pathogens. In theory, a change in climate would be expected to cause changes in the geographical range, seasonality (intra-annual variability), and in the incidence rate (with or without changes in geographical or seasonal patterns). The detection and then attribution of such changes to climate change is an emerging task for scientists. We discuss the evidence required to attribute changes in disease and vectors to the early effects of anthropogenic climate change. The literature to date indicates that there is a lack of strong evidence of the impact of climate change on vector-borne diseases (i.e. malaria, dengue, leishmaniasis, tick-borne diseases). New approaches to monitoring, such as frequent and long-term sampling along transects to monitor the full latitudinal and altitudinal range of specific vector species, are necessary in order to provide convincing direct evidence of climate change effects. There is a need to reassess the appropriate levels of evidence, including dealing with the uncertainties attached to detecting the health impacts of global change.

Delayed presentation of an ingested foreign body causing gastric perforation

Ingested foreign bodies may lead to perforation of the gastrointestinal tract. We present a case of a 14-month-old boy who presented with an unusual abdominal mass secondary to ingesting a foreign body 4 months previously. Abdominal computerized tomography scan was valuable in making this diagnosis.

Passive smoking and lung cancer: a cumulative meta-analysis

OBJECTIVE

To review the epidemiological evidence for the association between passive smoking and lung cancer.

METHOD

Primary studies and meta-analyses examining the relationship between passive smoking and lung cancer were identified through a computerised literature search of Medline and Embase, secondary references, and experts in the field of passive smoking. Primary studies meeting the inclusion criteria were meta-analysed.

RESULTS

From 1981 to the end of 1999 there have been 76 primary epidemiological studies of passive smoking and lung cancer, and 20 meta-analyses. There were 43 primary studies that met the inclusion criteria for this meta-analysis; more studies than previous assessments. The pooled relative risk (RR) for never-smoking women exposed to environmental tobacco smoke (ETS) from spouses, compared with unexposed never-smoking women was 1.29 (95% CI 1.17-1.43). Sequential cumulative meta-analysed results for each year from 1981 were calculated: since 1992 the RR has been greater than 1.25. For Western industrialised countries the RR for never-smoking women exposed to ETS compared with unexposed never-smoking women, was 1.21 (95% CI 1.10-1.33). Previously published international spousal meta-analyses have all produced statistically significant RRs greater than 1.17.

CONCLUSIONS

The abundance of evidence in this paper, and the consistency of findings across domestic and workplace primary studies, dosimetric extrapolations and meta-analyses, clearly indicates that non-smokers exposed to ETS are at increased risk of lung cancer.

IMPLICATIONS

The recommended public health policy is for a total ban on smoking in enclosed public places and work sites.

Nicotine in hair of bar and restaurant workers

AIM

To measure the relation between workplace smoking policies and exposures to Environmental Tobacco Smoke (ETS) of workers in bars and restaurants.

METHODS

114 workers in Wellington and Auckland were questioned about sources of exposure to ETS and smoking habits, and details of the smoke-free policy in their work place were recorded. A hair sample was collected from each participant and tested for nicotine.

RESULTS

Among non-smoking workers, hair nicotine levels varied strongly according to the smoke free policy at their place of work (Kruskall-Wallis, chi2 = 26.38, p < 0.0001). Those working in 100% smoke free restaurants had much lower levels than staff working in bars with no restrictions on smoking, and levels were intermediate for staff working in places with a partial smoking ban. These findings were not changed when adjustments were made for other sources of ETS exposure. Hair nicotine levels among nonsmokers working in places with no restriction on smoking were similar to hair nicotine levels of active smokers.

CONCLUSION

The present New Zealand Smoke Free Environment Act does not protect workers in the hospitality industry from exposure to ETS. The findings from this study highlight the substantial levels of exposure of bar and restaurant staff from patrons' smoking.

Passive smoking in children: effect of avoidance strategies, at home as measured by hair nicotine levels

Hair nicotine levels were studied among children, relative to their caregivers' reported exposure to environmental tobacco smoke. A total of 117 children, aged 3 months to 10 years, were recruited consecutively from hospital inpatients, and their respective parents or caregivers were interviewed. Degree of exposure to environmental tobacco smoke was assessed via questionnaire. Scalp hair samples were collected from children and were assayed for nicotine. Levels of nicotine in hair among children reportedly exposed to smokers were higher than levels among unexposed children (chi2 = 26.46, p < .0001). In addition, hair nicotine levels were higher among children with mothers who smoked, compared with those whose mothers did not smoke. Whether household members smoked outside or inside the house had no significant effect on hair nicotine levels of children. Hair nicotine levels differed between children who were reportedly unexposed to environmental tobacco smoke at home and those who were exposed. Smoking outside the home, as reported by parents, did not cause a reduction in nicotine levels in the hair of children.

A serological survey of antibodies to rabbit haemorrhagic disease virus (rabbit calicivirus disease) in two rural Central Otago communities

AIMS

To determine whether individuals from two rural communities with heavy exposure to the Rabbit Haemorrhagic Disease Virus (RHDV) developed antibodies to this virus.

METHODS

Sera were assayed using competition ELISA (cELISA) and solid phase ELISA (spELISA). Exposure estimates were based on answers to an interviewer administered questionnaire.

RESULTS

Of the 104 participants, 79 were considered to have experienced high or medium exposure, many of whom described specific exposures. There were 58 people who reported contact with RHDV infected bait, organ homogenate mixtures or rabbit body fluids. A one-way analysis of variance (Kruskal Wallis) found that human cELISA results were differently distributed from both strongly RHDV positive rabbits (chi2(1) = 27.37, p < 0.001) and weakly RHDV positive rabbits (chi2(1) = 27.35, p < 0.001). The distribution of assay results in each exposure group did not differ in either cELISA (chi2(2) = 2.49, p = 0.29) or spELISA (chi2(2) = 1.70, p = 0.43). Relatively fewer results were categorised as reactive (two 'barely' positive and two doubtful) than in a previous survey of 493 unexposed people. None of the five positive results categorised by the less specific spELISA occurred in people described as 'barely' positive or doubtful by cELISA. CONCLUSIONS. No serological evidence of infection with RHDV was found in a cohort including many heavily exposed individuals.

Why reduce health inequalities?

It is well known that social, cultural and economic factors cause substantial inequalities in health. Should we strive to achieve a more even share of good health, beyond improving the average health status of the population? We examine four arguments for the reduction of health inequalities.1 Inequalities are unfair. Inequalities in health are undesirable to the extent that they are unfair, or unjust. Distinguishing between health inequalities and health inequities can be contentious. Our view is that inequalities become "unfair" when poor health is itself the consequence of an unjust distribution of the underlying social determinants of health (for example, unequal opportunities in education or employment).2 Inequalities affect everyone. Conditions that lead to marked health disparities are detrimental to all members of society. Some types of health inequalities have obvious spillover effects on the rest of society, for example, the spread of infectious diseases, the consequences of alcohol and drug misuse, or the occurrence of violence and crime.3 Inequalities are avoidable. Disparities in health are avoidable to the extent that they stem from identifiable policy options exercised by governments, such as tax policy, regulation of business and labour, welfare benefits and health care funding. It follows that health inequalities are, in principle, amenable to policy interventions. A government that cares about improving the health of the population ought therefore to incorporate considerations of the health impact of alternative options in its policy setting process.3 Interventions to reduce health inequalities are cost effective. Public health programmes that reduce health inequalities can also be cost effective. The case can be made to give priority to such programmes (for example, improving access to cervical cancer screening in low income women) on efficiency grounds. On the other hand, few programmes designed to reduce health inequalities have been formally evaluated using cost effectiveness analysis. We conclude that fairness is likely to be the most influential argument in favour of acting to reduce disparities in health, but the concept of equity is contested and susceptible to different interpretations. There is persuasive evidence for some outcomes that reducing inequalities will diminish "spill over" effects on the health of society at large. In principle, you would expect that differences in health status that are not biologically determined are avoidable. However, the mechanisms giving rise to inequalities are still imperfectly understood, and evidence remains to be gathered on the effectiveness of interventions to reduce such inequalities.

Utilisation rates in capitated primary care centres serving low income populations

AIM

To measure utilisation rates in capitated primary care organisations serving low income populations with low or zero co-payments, and to examine the relationship between utilisation rates and organisation, age group, sex, ethnicity, community services card (CSC) holding rates, high use health card (HUHC) holding rates and deprivation of area of residence (NZDep96).

METHODS

Data were collected during 1997/98, from eleven primary care organisations. Utilisation data were collected from practice computer information systems.

RESULTS

53.9% of registered patients were recorded as having consulted in a twelve-month period. Utilisation rates for doctor, nurse and midwife combined were higher amongst the young, elderly, and CSC holders. For males, they were higher amongst those living in the most socioeconomically deprived areas, but not for females. Utilisation rates were highest amongst the 'other' ethnic group, and lowest in the Pacific Island ethnic group. Organisation, age group, sex, ethnicity, CSC, HUHC and NZDep96 were independently predictive of total utilisation.

CONCLUSIONS

Utilisation rates in capitated practices tended to be lower than those in fee-for-service practices. If equitable needs-based capitation funding formulas are to be developed, utilisation data from capitated practices in a range of cultural and socioeconomic settings is urgently required.

Questionnaire and hair measurement of exposure to tobacco smoke

To assess the relation between nicotine and cotinine levels in hair and reported exposure to environmental tobacco smoke (ETS), hair samples from 112 children (aged 3 months to 10 years) and 76 of their mothers were analyzed and information on the smoking habits of household adults in the preceding 6 months recorded. It was found that the levels of nicotine in children's hair were related to the number of smokers in the house, and increased with the total number of cigarettes smoked by all household adults (P<0.0001). In a multiple regression analysis, mother's smoking was much more a contributor to children's nicotine levels than smoking by the father or other household adults. Cotinine levels were less strongly associated with reported ETS exposure than nicotine. There was a strong correlation between nicotine hair levels in children and mothers (r(s)=0.7, P<0.0001). However, nicotine levels in the hair of active smokers were not correlated with the reported number of cigarettes they smoked per day. In this population, there was a consistent relation between exposure to ETS (assessed by questionnaire) and dose (as measured by nicotine in hair). We conclude that hair nicotine levels rather than hair cotinine levels provide an informative and objective measure of ETS exposure. The number of cigarettes smoked by active smokers may not be an accurate measure of the total nicotine levels in their bodies.

Domestic fire injuries treated in New Zealand hospitals 1988-1995

AIM

To describe demographic features of people discharged from New Zealand hospitals following injury caused by fire and flame in domestic locations.

METHOD

Review of hospital discharge data for the years 1988-1995.

RESULTS

From 1988-1995 there were 1493 discharges from New Zealand hospitals with injury as the result of fire and flame in domestic locations. Age-standardised hospitalisation rates for fire related injury over the period have been stable, with an overall discharge rate of 5.45 hospitalisations per 100000 person years. Male discharges exceeded female in all years (RR 1.97, 95% CI 1.73-2.14). Stratification by age indicated that discharge rates were highest among New Zealanders aged over 75 years and under fifteen years. Maori discharge rates exceeded non-Maori over all age groups (RR 3.3, 95% CI 2.82-3.58).

CONCLUSION

Maori discharge rates for fire related injury in the home are substantially higher than non-Maori in all age groups, and highlight the importance of developing culturally appropriate injury prevention strategies. Social and material determinants of injury need to be addressed through public policy, provision of quality housing and community development initiatives.

Socioeconomic deprivation and ethnicity are both important for anti-tobacco health promotion

The aim of the study was to explore the relative importance of socioeconomic deprivation and ethnicity for smoking in New Zealand in order to assist with the design and evaluation of health promotion programs. Smoking data were derived from the 1996 census. Socioeconomic deprivation was measured using the NZDep96 index of socioeconomic deprivation for small areas, which combines nine variables from the 1996 census. There was a strong and consistent relationship between area-level socioeconomic deprivation and the proportion of regular smokers. In all age-groups, at each level of deprivation, Maöri smoked more than the "European and Other" ethnic group. The findings of this study support the view that effective tobacco control activities should address ethnic differences in smoking behavior as well as socioeconomic deprivation, and must operate at the levels of populations, places and environments, as well as individuals.

Why do Australians live longer than New Zealanders?

The aim of this study was to compare patterns of mortality in Australia and New Zealand, using routinely collected data. Life expectancy at birth is greater in Australia than in New Zealand (in 1996 the gap was 1.5 years for women and 1.1 years for men). Prior to 1970, mortality was lower in New Zealand than Australia. Possible reasons for the divergence in life expectancies include slower economic growth in New Zealand, more marked increases in economic inequalities which have affected Maöri in particular and, to a modest extent, differentials in health care.