What is wrong with non-respondents? Alcohol-, drug- and smoking-related mortality and morbidity in a 12-year follow-up study of respondents and non-respondents in the Danish Health and Morbidity Survey

Alcohol consumption and labour market participation: a prospective cohort study of transitions between work, unemployment, sickness absence, and social benefits

The aim of this study was to investigate the association of alcohol consumption and problem drinking on transitions between work, unemployment, sickness absence and social benefits. Participants were 86,417 men and women aged 18-60 years who participated in the Danish National Health Survey in 2010. Information on alcohol consumption (units per week) and problem drinking (CAGE-C score of 4-6) was obtained by questionnaire. The primary outcome was labour market attachment. Information on labour market attachment was obtained from the national administrative registers during a 5-year follow-up period. Using Cox proportional hazards models, we estimated hazard ratios (HR) for transitions between work, unemployment, sickness absence and social benefits. Analyses were adjusted for potential confounders associated with demography, health, and socio-economy. High alcohol consumption and problem drinking was associated with higher probability of unemployment, sickness absence and social benefits among participants employed at baseline compared with participants who consumed 1-6 drinks/week. High alcohol consumption and problem drinking was associated with lower probability of returning to work among participants receiving sickness absence at baseline compared with participants who consumed 1-6 drinks/week and with non-problem drinkers: HRs were 0.75 (0.58-0.98) for 35+ drinks per week and 0.81 (0.65-1.00) for problem drinking (CAGE-C score of 4-6). Similar trends for weekly alcohol consumption and problem drinking were observed among participants who were unemployed at baseline. In summary, problem drinking has adverse consequences for labour market participation and is associated with higher probability of losing a job and a lower chance of becoming employed again.

An improved method for counting stressful life events (SLEs) when predicting mental health and wellness

OBJECTIVE

Checklists for registering stressful life events (SLEs) generally correlate negatively, but weakly, with mental health outcome measures. Thus, the present study examined various methodological approaches for improving these relationships.

DESIGN

A total of 1679 participants (women = 943, men = 736, M age-39.8) were randomly drawn from the general Norwegian population (response rate 34%). This prospective cohort study included two follow-ups at 10 (n = 1181) and 23 months (n = 942).

MAIN OUTCOME MEASURES

Satisfaction with life and absence of psychological distress (i.e. anxiety and depression) represented a joint measure for indexing 'mental wellness' (MW).

RESULTS

A simple count of SLEs weakly predicted MW, as expected, whereas the addition of a moderator (i.e. manageability of the event) substantially improved predictive power. Four additional moderators were examined: duration, impact, help-seeking and time since onset, but these were non-significant after inserting manageability into the model. This SLE counting method also retained its predictive power after including multiple criterion-related variables that substantially adjusted the longitudinal statistical model.

CONCLUSION

This new SLE counting method exhibited a considerable improvement to predicting mental health and well-being. It is well suited for use in epidemiological research requiring a short SLE checklist format with high predictive power.

Weight concerns as a predictor of smoking cessation according to nicotine dependence: A population-based study

Background:

Nicotine-dependent smokers find it difficult to quit smoking. Additionally, smoking-specific weight concerns may affect smoking cessation although the evidence is controversial. We investigated whether smoking-specific weight concerns predict the probability of cessation and, if so, whether the effect varies according to the level of nicotine dependence.

Methods:

The study was conducted with a population-based sample of 355 adult daily smokers who participated in the baseline examination in 2007 and in the 2014 follow-up. Baseline nicotine dependence was classified as low or high (Fagerström Test for Nicotine Dependence; 0–3 vs. 4–10 points). Within these groups, we examined whether baseline weight concerns predict smoking status (daily, occasional, ex-smoker) at follow-up by using multinomial logistic regression with adjustment for multiple covariates.

Results:

Among low-dependent participants at baseline, 28.5% had quit smoking, while among highly dependent participants 26.1% had quit smoking. The interaction between weight concerns and nicotine dependence on follow-up smoking status was significant. Among participants with low nicotine dependence per the fully adjusted model, greater weight concerns predicted a lower likelihood of both smoking cessation (relative risk ratio 0.93 [95% CI 0.87–1.00]) and smoking reduction to occasional occurrence (0.89 [95% CI 0.81–0.98]). Weight concerns were not associated with follow-up smoking status among participants with high nicotine dependence.

Conclusions:

Weight concerns are associated with a smaller likelihood of quitting among smokers with low nicotine dependence. Weight concerns should be addressed in smoking cessation interventions, especially with smokers who have low nicotine dependence.

Breakfast in Denmark. Prevalence of Consumption, Intake of Foods, Nutrients and Dietary Quality. A Study from the International Breakfast Research Initiative

Breakfast is considered by many to be the most important meal of the day. This study examined the intake of nutrients and foods at breakfast among Danes and the relation to the overall dietary quality. Data were derived from the Danish National Survey on Diet and Physical Activity 2011–2013, a cross-sectional national food consumption study. A total of 3680 participants aged 6–75 years were included in the analyses of breakfast consumption. The Nutrient Rich Food Index 9.3 method was used to examine the overall dietary quality of the diet. The intake of nutrients and foods at breakfast were compared across dietary quality score tertiles by ANCOVA adjusted for energy and socio economic status. Breakfast was eaten frequently by children and adults and contributed with 18–20% of total energy intake. Breakfast was relatively high in dietary fibre, B vitamins, calcium and magnesium and low in added sugar, total fat, sodium, vitamin A and D. A decrease in the intake of added sugar, total fat and saturated fat and an increase in the intake of dietary fibre and most micronutrients were seen across tertiles of dietary quality scores. Commonly consumed foods provided at breakfast in Denmark included bread, breakfast cereals and dairy products as well as water, coffee and juice, while intakes of fruits, vegetables, cakes and soft drinks were low.

Women's Health in the Lund Area (WHILA) study. Health problems and acute myocardial infarction in women - A 17-year follow-up study

OBJECTIVES

The literature has highlighted the importance of identifying symptoms predictive of acute myocardial infarction (AMI) in women, in addition to traditional cardiovascular risk factors. The objective was to study subjective health problems, in relation to later AMI, in a large sample of women, adjusted for age, educational status, smoking, waist/hip ratio, blood pressure, total cholesterol/HDL ratio, diabetes and neighbourhood socioeconomic status.

STUDY DESIGN

From December 1995 to February 2000 a cohort of 6711 women aged 50-59 years in southern Sweden underwent a physical examination and answered a questionnaire that had 18 items on health problems such as stress symptoms, tiredness and pain.

MAIN OUTCOME MEASURES

Incidence of AMI during a mean follow-up of 17 years, drawn from national registers.

RESULTS

The number of health problems showed a J-shaped relationship with AMI, with the lowest hazard ratio (HR) in women with a median of 4 health problems. The HR for AMI in women with 0 health problems was 1.58 (95% CI: 0.95-2.63) and in those with 13 problems HR 1.65 (95% CI 1.16-2.36), after adjusting for potential confounding factors.

CONCLUSIONS

The presence of several health problems, including pain and stress symptoms, is associated with an increased risk of later AMI in middle-aged women. Awareness among clinicians of predictive risk factors for AMI is important for the early identification of individuals at higher risk.

Text message intervention to reduce frequency of binge drinking among disadvantaged men: the TRAM RCT

Background

Socially disadvantaged men are more likely to binge drink frequently and to experience high levels of alcohol-related harm.

Objectives

To test the effectiveness and cost-effectiveness of a text message intervention in reducing the frequency of binge drinking among disadvantaged men.

Study design

A four-centre, parallel-group, pragmatic, individually randomised controlled trial was conducted. Randomisation was carried out using a secure remote web-based system. It was stratified by participating centre and recruitment method and restricted using block sizes of randomly varying lengths.

Setting

The study was conducted in the community. Members of the public helped to develop the study methods.

Participants

Participants were men aged 25–44 years who had ≥ 2 episodes of binge drinking (> 8 units of alcohol in a single session) in the preceding 28 days. Men were recruited from areas of high deprivation.

Interventions

An empirically and theoretically based text message intervention was delivered by 112 interactive text messages over a 12-week period. The control group received an attentional control comprising 89 text messages on general health.

Primary outcome measure

The primary outcome measure was the proportion of men consuming > 8 units of alcohol on ≥ 3 occasions (in the previous 28 days) at 12 months post intervention.

Results

The recruitment target of 798 was exceeded and 825 men were randomised. Retention was high and similar in the intervention (84.9%) and control (86.5%) groups. Most men in the intervention group engaged enthusiastically with the text messages: almost all (92%) replied to text messages and over two-thirds (67%) replied more than 10 times. The intervention was estimated to have had a modest, statistically non-significant effect on the primary outcome at the 12-month follow-up [odds ratio 0.79, 95% confidence interval (CI) 0.57 to 1.08]. This corresponds to a net reduction of 5.7% in regular binge drinking. Five secondary outcomes showed small non-significant and inconsistent effects on alcohol consumption, with one suggesting a positive effect and four suggesting an adverse effect. Both the short- and the long-term cost per quality-adjusted life-year (QALY) analysis suggested that the brief intervention was dominated by a ‘do-nothing’ option. The intervention’s impacts on patterns of alcohol consumption, QALYs and downstream costs were inconsistent and uncertain.

Limitations

The study used an active control that, combined with the recruitment procedures and baseline assessments, could have biased the treatment effect towards the null. The measurement of alcohol consumption relied on self-reported drinking.

Conclusions

The trial has demonstrated that it is possible to recruit and retain large numbers of socially disadvantaged men in a research study. The text messages delivered a complex theoretically and empirically based intervention that fostered enthusiastic engagement with the key components of the behaviour change sequence. The intervention produced a modest, statistically non-significant effect on the primary outcome, with wide CIs. Further research is needed to reduce uncertainty about the treatment effect. The methods developed for this study provide a platform for the design and testing of interventions to reduce inequalities in health.

Future work

A future trial could reduce the uncertainty around the treatment effect of the intervention.

Trial registration

Current Controlled Trials ISRCTN07695192.

Funding

This study was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 6, No. 6. See NIHR Journals Library website for further information.

How Healthy Are Survey Respondents Compared with the General Population?: Using Survey-linked Death Records to Compare Mortality Outcomes

BACKGROUND

National surveys are used to capture US health trends and set clinical guidelines, yet the sampling frame often includes those in noninstitutional households, potentially missing those most vulnerable for poor health. Declining response rates in national surveys also represent a challenge, and existing inputs to survey weights have limitations. We compared mortality rates between those who respond to surveys and the general population over time.

METHODS

Survey respondents from 20 waves of the National Health Interview Survey from 1990 to 2009 who have been linked to death records through 31 December 2011 were included. For each cohort in the survey, we estimated their mortality rates along with that cohort's mortality rate in the census population using vital statistics records, and differences were examined using Poisson models.

RESULTS

In all years, survey respondents had lower mortality rates compared with the general population when data were both weighted and unweighted. Among men, survey respondents in the weighted sample had 0.86 (95% confidence interval = 0.853, 0.868) times the mortality rate of the general population (among women, RR = 0.887; 95% confidence interval, 0.879, 0.895). Differences in mortality are evident along all points of the life course. Differences have remained relatively stable over time.

CONCLUSION

Survey respondents have lower death rates than the general US population, suggesting that they are a systematically healthier source population. Incorporating nonhousehold samples and revised weighting strategies to account for sample frame exclusion and nonresponse may allow for more rigorous estimation of the US population's health.

Cancer Incidence in Workers Exposed to Styrene in the Danish-reinforced Plastics Industry, 1968-2012

BACKGROUND

Occupational exposure to styrene is widespread and has been suggested to be carcinogenic. The aim of this study was to investigate whether occupational exposure to styrene increases the risk of cancer, in particular lymphohematopoietic cancers.

METHODS

We established a study population of 72,292 workers employed in 443 small and medium-sized companies producing reinforced plastics 1964-2007 by utilizing several national registries, expert assessment, and worker survey data. We identified incident cancer cases from 1968 to 2012 in the national Danish cancer registry and computed standardized incidence rate ratios (SIRs) with 95% confidence intervals (95% CI) based on national rates.

RESULTS

Increasing SIRs of Hodgkin lymphoma, myeloid leukemia, and cancer of nasal cavities and sinuses were inconsistently associated with increasing duration of employment, early year of first employment, or styrene exposure probability. No such trends were observed for cancer of the esophagus, pancreas, lung, kidney, or urinary bladder, which have previously been associated with styrene exposure. Lung cancer showed an overall increased risk that decreased by duration of employment.

CONCLUSION

Occupational styrene exposure may be associated with Hodgkin lymphoma, myeloid leukemia, and cancer of nasal cavities and sinuses. Further studies are needed to evaluate if the observed associations are likely to be causal.

Substance use among Danish psychiatric patients: a cross-sectional study

BACKGROUND

Patients with psychiatric disorders have a greater risk of mortality than the general population. Use or abuse of substances, including alcohol, play a crucial part in this context. Moreover, it is well known that drug use can worsen psychopathology and reduce treatment compliance. However, the magnitude of these problems among Danish psychiatric patients has not been studied previously.

AIMS

The aim of this study is to investigate substance use among psychiatric patients in the Capital Region of Denmark.

METHODS

Outpatients from five psychiatric units were asked to complete a questionnaire regarding their use of alcohol and other drugs of abuse. The questionnaire was based on the Alcohol Use Disorder Identification Test (AUDIT), supplemented by questions regarding use of tobacco and illicit drugs. The results were compared with those uses in the general population.

RESULTS

In total, 412 psychiatric patients participated in the study, and 33% had an AUDIT-score ≥8, indicating problematic alcohol use according to the AUDIT guidelines. The mean weekly alcohol intake was 9.7 ± 28.3 standard drinks, and 47% were current smokers with a mean daily use of 19.9 ± 13.8 cigarette equivalents. Compared to the general population, the psychiatric patients had higher odds of being current smokers and having used illicit drugs within the past month. Women with psychiatric disorders were twice as likely to binge drink on a monthly basis. No significant difference was found in the patients' AUDIT scores compared to the general population.

CONCLUSIONS

Our findings demonstrate a substantial and problematic use of tobacco and illicit drugs among Danish psychiatric patients, greater than in the general population.

Association between Global Life Satisfaction and Self-Rated Oral Health Conditions among Adolescents in Lithuania

Background: This study aims to explore the extent to which the perceived oral conditions predict adolescent global life satisfaction (GLS); Methods: The sample in a cross-sectional survey consisted of 1510 Lithuanian adolescents (41.7% boys) aged 11-18. The survey was conducted by means of self-report questionnaires that were administrated in school classrooms ensuring confidentiality and anonymity of the participants. The schoolchildren rated their GLS and answered the questions about perceptions of their oral health. The relationship between GLS and oral health variables was estimated using unadjusted and adjusted binary logistic regression and nonparametric correlation analyses; Results: The research showed that the majority of adolescents rated their GLS highly; however, girls, older adolescents and adolescents from less affluent families were less likely to report high scores. GLS was significantly associated with subjective overall oral health assessment. The odds of reporting low GLS were 50% higher for adolescents with good oral health (OR = 1.51; p < 0.001; 95% CI = 1.18-1.93), and two and half time as higher for adolescents with perceived fair/poor oral health (OR = 2.78; p < 0.001; 95% CI = 1.72-4.50) compared to adolescents with subjectively excellent/very good oral health. Nonparametric correlations indicated lower GLS to be significantly associated with higher scores of Child Perceptions Questionnaire (.

Adjusting for selective non-participation with re-contact data in the FINRISK 2012 survey

AIMS

A common objective of epidemiological surveys is to provide population-level estimates of health indicators. Survey results tend to be biased under selective non-participation. One approach to bias reduction is to collect information about non-participants by contacting them again and asking them to fill in a questionnaire. This information is called re-contact data, and it allows to adjust the estimates for non-participation.

METHODS

We analyse data from the FINRISK 2012 survey, where re-contact data were collected. We assume that the respondents of the re-contact survey are similar to the remaining non-participants with respect to the health given their available background information. Validity of this assumption is evaluated based on the hospitalisation data obtained through record linkage of survey data to the administrative registers. Using this assumption and multiple imputation, we estimate the prevalences of daily smoking and heavy alcohol consumption and compare them to estimates obtained with a commonly used assumption that the participants represent the entire target group.

RESULTS

When adjusting for non-participation using re-contact data, higher prevalence estimates were observed compared to prevalence estimates based on participants only. Among men, the smoking prevalence estimate was 28.5% (23.2% for participants) and heavy alcohol consumption prevalence was 9.4% (6.8% for participants). Among women, smoking prevalence was 19% (16.5% for participants) and heavy alcohol consumption was 4.8% (3% for participants).

CONCLUSIONS

The utilisation of re-contact data is a useful method to adjust for non-participation bias on population estimates in epidemiological surveys.

Accessibility of fast food outlets is associated with fast food intake. A study in the Capital Region of Denmark

Literature suggests that people living in areas with a wealth of unhealthy fast food options may show higher levels of fast food intake. Multilevel logistic regression analyses were applied to examine the association between GIS-located fast food outlets (FFOs) and self-reported fast food intake among adults (+ 16 years) in the Capital Region of Denmark (N = 48,305). Accessibility of FFOs was measured both as proximity (distance to nearest FFO) and density (number of FFOs within a 1km network buffer around home). Odds of fast food intake ≥ 1/week increased significantly with increasing FFO density and decreased significantly with increasing distance to the nearest FFO for distances ≤ 4km. For long distances (>4km), odds increased with increasing distance, although this applied only for car owners. Results suggest that Danish health promotion strategies need to consider the contribution of the built environment to unhealthy eating.

External adjustment of unmeasured confounders in a case-control study of benzodiazepine use and cancer risk

AIMS

Previous studies have reported diverging results on the association between benzodiazepine use and cancer risk.

METHODS

We investigated this association in a matched case-control study including incident cancer cases during 2002-2009 in the Danish Cancer Registry (n = 94 923) and age- and sex-matched (1:8) population controls (n = 759 334). Long-term benzodiazepine use was defined as ≥500 defined daily doses 1-5 years prior to the index date. We implemented propensity score (PS) calibration using external information on confounders available from a survey of the Danish population. Two PSs were used: The error-prone PS using register-based confounders and the calibrated PS based on both register- and survey-based confounders, retrieved from the Health Interview Survey.

RESULTS

Register-based data showed that cancer cases had more diagnoses, higher comorbidity score and more co-medication then population controls. Survey-based data showed lower self-rated health, more self-reported diseases, and more smokers as well as subjects with sedentary lifestyle among benzodiazepine users. By PS calibration, the odds ratio for cancer overall associated with benzodiazepine use decreased from 1.16 to 1.09 (95% confidence interval 1.00-1.19) and for smoking-related cancers from 1.20 to 1.10 (95% confidence interval 1.00-1.21).

CONCLUSION

We conclude that the increased risk observed in the solely register-based study could partly be attributed to unmeasured confounding.

Adjustment for survey non-representativeness using record-linkage: refined estimates of alcohol consumption by deprivation in Scotland

BACKGROUND AND AIMS

Analytical approaches to addressing survey non-participation bias typically use only demographic information to improve estimates. We applied a novel methodology which uses health information from data linkage to adjust for non-representativeness. We illustrate the method by presenting adjusted alcohol consumption estimates for Scotland.

DESIGN

Data on consenting respondents to the Scottish Health Surveys (SHeSs) 1995-2010 were linked confidentially to routinely collected hospital admission and mortality records. Synthetic observations representing non-respondents were created using general population data. Multiple imputation was performed to compute adjusted alcohol estimates given a range of assumptions about the missing data. Adjusted estimates of mean weekly consumption were additionally calibrated to per-capita alcohol sales data.

SETTING

Scotland.

PARTICIPANTS

13 936 male and 18 021 female respondents to the SHeSs 1995-2010, aged 20-64 years.

MEASUREMENTS

Weekly alcohol consumption, non-, binge- and problem-drinking.

FINDINGS

Initial adjustment for non-response resulted in estimates of mean weekly consumption that were elevated by up to 17.8% [26.5 units (18.6-34.4)] compared with corrections based solely on socio-demographic data [22.5 (17.7-27.3)]; other drinking behaviour estimates were little changed. Under more extreme assumptions the overall difference was up to 53%, and calibrating to sales estimates resulted in up to 88% difference. Increases were especially pronounced among males in deprived areas.

CONCLUSIONS

The use of routinely collected health data to reduce bias arising from survey non-response resulted in higher alcohol consumption estimates among working-age males in Scotland, with less impact for females. This new method of bias reduction can be generalized to other surveys to improve estimates of alternative harmful behaviours.

Optimistic and pessimistic self-assessment of own diets is associated with age, self-rated health and weight status in Danish adults

The aim of this study was to analyse concordance between Danish adults' recorded diet quality and their own assessment of the healthiness and to examine socio-demographic, health and behavioural characteristics associated with an optimistic or pessimistic self-assessment. Data were derived from The Danish National Survey of Diet and Physical Activity 2011-2013 and included a random sample of 3014 adults (18-75 y). Diet quality was evaluated on the basis of seven-day pre-coded food diaries and categorised 'unhealthy', 'somewhat healthy' and 'healthy'. Self-assessment of the healthiness of own diets was registered via personal interviews and categorised healthy enough 'to a high degree', 'to some degree' or 'not at all/only partly'. Highly and somewhat optimistic self-assessment, respectively, were defined as assessing own diets as healthy enough to a high degree or to some degree while having unhealthy diets. Highly and somewhat pessimistic self-assessment, respectively, were defined as assessing own diets as not healthy enough or healthy enough to some degree while having healthy diets. Multiple logistic regression models were used to examine characteristics associated with optimistic and pessimistic self-assessments, respectively. Among individuals with unhealthy diets, 13% were highly optimistic and 42% somewhat optimistic about the healthiness of their diets. Among individuals with healthy diets, 14% were highly pessimistic and 51% somewhat pessimistic about the healthiness of their diets. Highly optimistic self-assessment was associated with increasing age, excellent self-rated health, normal weight and a moderate activity level. Highly pessimistic self-assessment was associated with decreasing age, good self-rated health and being obese. The findings indicate that people seem to use personal health characteristics as important references when assessing the healthiness of their diets.

Positive and negative influences of social participation on physical and mental health among community-dwelling elderly aged 65-70 years: a cross-sectional study in Japan

BACKGROUND

Although numerous investigations have indicated that social participation (SP) has positive effects on the health of older adults, there have been few studies on its negative health consequences. We examined the cross-sectional associations of the type, frequency, and autonomy for SP with physical and mental health.

METHODS

The analytical subjects were 5126 males and 7006 females who were functionally independent, born between 1945 and 1949, and covered by A City's medical insurance system. Physical and mental health were measured using the SF-8 Health Survey. SP was measured through six types of social groups. These social groups included volunteer groups, sports groups, hobby clubs, senior citizens' clubs, neighborhood community associations, and cultural groups. Analysis of covariance was conducted to compare adjusted physical health component summary scores (PCS) and mental health component summary scores (MCS) by the frequency and autonomy of SP. Age, family size, body mass index, chronic conditions, smoking, alcohol intake, depression and cognitive functioning were included as covariates. To examine whether the associations between SP and PCS/MCS are different between genders, we performed analyses stratified by gender.

RESULTS

Overall, positive associations of the frequency and autonomy of SP with PCS and MCS were stronger in females than males. As to frequency, frequent participation in sports groups and hobby clubs had significantly better PCS among both genders and better MCS among females than non-participation. None of the groups differed significantly in the MCS among males. As to autonomy, among both genders, voluntary participation in sports groups and hobby clubs had significantly better PCS than non-participation, and better MCS than not only non-participation, but also obligatory participation. Among females, obligatory participation in all groups had significantly poorer MCS than voluntary participation, and obligatory participation in sports groups had significantly poorer MCS than non-participation.

CONCLUSIONS

Obligatory SP had significantly poorer MCS than voluntary participation, occasionally than non-participation; there is a possibility that obligatory SP has harmful influences on mental health of community-dwelling elderly. Measures to promote SP with consideration for individuals' autonomy may be effective in the public health approach to maintaining mental health.

Smoking status and abdominal obesity among normal- and overweight/obese adults: Population-based FINRISK study

Several studies have reported direct associations of smoking with body mass index (BMI) and abdominal obesity. However, the interplay between them is poorly understood. Our first aim was to investigate the interaction between smoking status and BMI on abdominal obesity (waist circumference, WC). Our second aim was to examine how the association of smoking status with WC varies among normal and overweight/obese men and women. We examined 5833 participants from the National FINRISK 2007 Study. The interactions between smoking and BMI on WC were analyzed. Participants were categorized into eight groups according to BMI (normal weight vs. overweight/obese) and smoking status (never smoker, ex-smoker, occasional/light/moderate daily smoker, heavy daily smoker). The associations between each BMI/smoking status -group and WC were analyzed by multiple regressions, the normal-weight never smokers as the reference group. The smoking status by BMI-interaction on WC was significant for women, but not for men. Among the overweight/obese women, ex-smokers (β = 2.73; 1.99, 3.46) and heavy daily smokers (β = 4.90; 3.35, 6.44) had the highest estimates for WC when adjusted for age, BMI, alcohol consumption and physical activity. In comparison to never smoking overweight/obese women, the β-coefficients of ex-smokers and heavy daily smokers were significantly higher. Among men and normal weight women the β -coefficients did not significantly differ by smoking status. An interaction between smoking status and BMI on abdominal obesity was observed in women: overweight/obese heavy daily smokers were particularly vulnerable for abdominal obesity. This risk group should be targeted for cardiovascular disease prevention.

Temporal changes in sugar-sweetened soft drink intake and variation across municipalities in the Capital Region of Denmark

We aimed to examine the changes in sugar-sweetened soft drink intake across the Capital Region of Denmark from 2007 to 2013 and to examine the association between intake and neighbourhood socioeconomic status. The study included data from three health surveys in 2007 (n = 30,426), 2010 (n = 42,218) and 2013 (n = 34,330) in the Capital Region of Denmark. Frequency of soft drink intake was derived from questionnaires among residents aged 25-79 years and linked with information from central registers. Municipality social groups (MSG) 1-4 of decreasing affluence were defined as a composite measure. Logistic regression analyses were conducted for individuals with an appropriate soft drink intake (< once/week) and for individuals with a frequent soft drink intake (≥ 3 times/week). The proportion of individuals reporting an appropriate soft drink intake increased by 71% during 2007-2013 (p < 0.0001). A corresponding decrease was found in the proportion of individuals reporting a frequent soft drink intake. Compared to MSG 1, odds of an appropriate soft drink intake were significantly lower in MSG 3-4: OR = 0.87 (95%CI 0.83-0.91) and OR = 0.89 (95%CI 0.85-0.92), respectively. Compared to MSG 1, odds of a frequent soft drink intake were significantly higher in MSG 3-4: OR = 1.24 (95%CI 1.63-1.31) and 1.17 (95%CI 1.10-1.25), respectively. A significant interaction between MSG and educational level was found among individuals reporting a frequent soft drink intake (p = 0.02). The results show an encouraging reduction in frequency of soft drink intake among capital residents in the period of 2007-2013. A social gradient was observed in soft drink intake across MSG.

Der Epidemiologische Suchtsurvey 2015

Zusammenfassung. Ziel: Der vorliegende Beitrag beschreibt die Methodik und das Studiendesign des Epidemiologischen Suchtsurveys (ESA) 2015. Methodik: Zielpersonen des ESA waren deutschsprachige und in Privathaushalten lebende Personen im Alter zwischen 18 und 64 Jahren. Die Ziehung der Personenstichprobe erfolgte auf Basis der Einwohnermelderegister disproportional zur Verteilung der Geburtsjahrgänge in einem zweistufigen Zufallsverfahren. Die Befragungen wurden schriftlich, telefonisch und online durchgeführt. Ergebnisse: Insgesamt konnte im ESA 2015 mit n = 9204 Teilnehmern eine Nettoausschöpfung von 52.2 % erreicht werden. Durch die verwendete Gewichtung konnte die Stichprobe hinsichtlich Bundesland, BIK-Gemeindegrößenklasse, Geschlecht, Jahrgangsgruppe und Schulbildung an die Verteilung in der Grundgesamtheit angepasst werden. Mit der Studie nicht erreichte Personen zeigten problematischere Konsummuster als Teilnehmer der Befragung. Schriftlich befragte Personen gaben häufiger Substanzkonsum an als telefonisch und online Befragte. Schlussfolgerungen: Durch den Einsatz verschiedener Befragungsmethoden und die Gewichtung der Daten konnte sichergestellt werden, dass mit dem ESA 2015 bevölkerungsrepräsentative Daten zum (klinisch relevanten) Konsum von legalen und illegalen Substanzen sowie Medikamenten vorliegen.

Current and past smoking patterns in a Central European urban population: a cross-sectional study in a high-burden country

BACKGROUND

Many studies have examined the socioeconomic variations in smoking and quitting rates across the European region; however, data from Central and East European countries, where the tobacco burden is especially high, are sparse. This study aimed to assess the patterns in current and past smoking prevalence based on cross-sectional data from a Central European urban population sample.

METHODS

Data from 2160 respondents aged 25-64 years in Brno, Czech Republic were collected in 2013-2014 using the Czech post-MONICA survey questionnaire to assess the prevalence of cardiovascular risk factors, including smoking status. The age- and sex-stratified randomized sample was drawn using health insurance registries. Descriptive statistics and quit ratios were calculated, and chi-square and multivariate logistic analyses conducted to examine relationships between current and past smoking and demographic (age, gender, marital status) and socioeconomic variables (education, income, occupation).

RESULTS

The prevalence of current and past smoking was 23.6 and 31.3 % among men and 20.5 and 23.2 % among women, respectively. Education reliably predicted smoking and quitting rates in both genders. Among men, being unemployed was associated with greater odds of smoking (OR 3.6; 1.6-8.1) and lower likelihood of quitting (OR 0.2: 0.1-0.6); the likelihood of quitting also increased with age (OR 1.8; 1.2-2.8). Among women, marital status (being married) decreased the odds of current smoking (OR 0.6; 0.4-0.9) and increased the odds of quitting (OR 2.2; 1.2-3.9). Quit ratios were the lowest in the youngest age group (25-34 years) where quitting was more strongly associated with middle income (OR 2.7; 95 % CI 1.2-5.9) than with higher education (OR 2.9; 95 % CI 0.9-8.2).

CONCLUSIONS

Interventions to increase cessation rates and reduce smoking prevalence need to be gender-specific and carefully tailored to the needs of the disadvantaged groups of the population, especially the less well-off young adults. Future studies should examine the equity impact of the tobacco control policies and be inclusive of the Central and East European countries.

Five year change in alcohol intake and risk of breast cancer and coronary heart disease among postmenopausal women: prospective cohort study

OBJECTIVE

To test the hypothesis that postmenopausal women who increase their alcohol intake over a five year period have a higher risk of breast cancer and a lower risk of coronary heart disease compared with stable alcohol intake.

DESIGN

Prospective cohort study.

SETTING

Denmark, 1993-2012.

PARTICIPANTS

21 523 postmenopausal women who participated in the Diet, Cancer, and Health Study in two consecutive examinations in 1993-98 and 1999-2003. Information on alcohol intake was obtained from questionnaires completed by participants.

MAIN OUTCOME MEASURES

Incidence of breast cancer, coronary heart disease, and all cause mortality during 11 years of follow-up. Information was obtained from the Danish Cancer Register, Danish Hospital Discharge Register, Danish Register of Causes of Death, and National Central Person Register. We estimated hazard ratios according to five year change in alcohol intake using Cox proportional hazards models.

RESULTS

During the study, 1054, 1750, and 2080 cases of breast cancer, coronary heart disease, and mortality occurred, respectively. Analyses modelling five year change in alcohol intake with cubic splines showed that women who increased their alcohol intake over the five year period had a higher risk of breast cancer and a lower risk of coronary heart disease than women with a stable alcohol intake. For instance, women who increased their alcohol intake by seven or 14 drinks per week (corresponding to one or two drinks more per day) had hazard ratios of breast cancer of 1.13 (95% confidence interval 1.03 to 1.23) and 1.29 (1.07 to 1.55), respectively, compared to women with stable intake, and adjusted for age, education, body mass index, smoking, Mediterranean diet score, parity, number of births, and hormone replacement therapy. For coronary heart disease, corresponding hazard ratios were 0.89 (0.81 to 0.97) and 0.78 (0.64 to 0.95), respectively, adjusted for age, education, body mass index, Mediterranean diet score, smoking, physical activity, hypertension, elevated cholesterol, and diabetes. Results among women who reduced their alcohol intake over the five year period were not significantly associated with risk of breast cancer or coronary heart disease. Analyses of all cause mortality showed that women who increased their alcohol intake from a high intake (≥14 drinks per week) to an even higher intake had a higher mortality risk that women with a stable high intake.

CONCLUSION

In this study of postmenopausal women over a five year period, results support the hypotheses that alcohol intake is associated with increased risk of breast cancer and decreased risk of coronary heart disease.

Investigating Respondents and Nonrespondents of a Postal Breast Cancer Questionnaire Survey Regarding Differences in Age, Medical Conditions, and Therapy

BACKGROUND

Collecting patient-reported data via postal questionnaires is a common and frequently used technique. Selection bias may occur through lost data from nonrespondents. This study investigated differences in characteristics between respondents and nonrespondents of a postal breast cancer survey.

PATIENTS AND METHODS

The investigation was based on a cross-sectional postal questionnaire survey for the mandatory annual routine (re-)certification of accredited breast centers in North Rhine-Westphalia in 2010. Out of 4,444 patients meeting the inclusion criteria who gave their consent to participate, 3,856 respondents sent back a questionnaire and 588 nonrespondents did not. Using logistic regression, differences between respondents and nonrespondents regarding information gathered through hospital staff concerning age, affected breast, UICC (Union for International Cancer Control) staging and grading, ASA (American Society of Anesthesiologists) classification, neoadjuvant chemotherapy, and type of surgery were assessed.

RESULTS

Very young and very old patients sent back their questionnaire significantly less frequently, as did patients who showed a later cancer stage and poorer general health and those who underwent mastectomy.

CONCLUSION

Differences exist between respondents and nonrespondents with regard to age, disease, and therapy characteristics that need to be considered for the interpretation and generalizability of survey results due to selection bias.

Cannabis use, depression and anxiety: A 3-year prospective population-based study

BACKGROUND

Whether or not cannabis use may increase the risk for depression and/or anxiety is not clear. For one thing, it has not been possible to draw a definitive conclusion regarding the direction of causality, i.e. whether cannabis use increases the risk for depression/anxiety or vice versa. This study aimed at examining possible associations between cannabis use, depression and anxiety, using all three measures as both exposure and outcome.

METHODS

Data were obtained from a longitudinal cohort study comprising 8598 Swedish men and women, aged 20-64, with a three-year-follow-up.

RESULTS

Adjusted for sex and age, cannabis use at baseline was associated with an increased relative risk (RR) for depression and anxiety at follow-up, with RR=1.22 [1.06-1.42 Cl 95%] for depression and RR=1.38 [1.26-1.50 Cl 95%] for anxiety. Adjusted for all confounders (alcohol and illicit drug use, education, family tension, place of upbringing), the associations were no longer statistically significant; RR=0.99 [0.82-1.17 Cl 95%] for depression and RR=1.09 [0.98-1.20 Cl 95%] for anxiety. Age-adjusted, reporting depression or anxiety at baseline increased the risk of cannabis onset at follow-up three years later; RR=1.62 [1.28-2.03 CI 95%] and RR=1.63 [1.28-2.08 CI 95%] respectively. However, adjusted for other illicit drug use the associations were no longer statistically significant.

LIMITATIONS

Lack of information on frequency of cannabis use and of age of initiation of use.

CONCLUSIONS

We found no longitudinal associations between cannabis use and incidence of depression/anxiety, or between depression/anxiety and later cannabis use onset.

Women's health in the Lund area (WHILA)--Alcohol consumption and all-cause mortality among women--a 17 year follow-up study

Background

Alcohol consumption contributes to many negative health consequences and is a risk factor for death. Some previous studies however suggest a J-shaped relationship between the level of alcohol consumption and all-cause mortality. These findings have in part been suggested to be due to confounders. The aim of our study was to analyze the relationship between self-reported alcohol intake and all-cause mortality in women, adjusted for sociodemographic, lifestyle factors and diseases such as diabetes and previous ischemic heart disease.

Methods

All women aged 50–59 years (born between 1935 and 1945) that lived in any of the five municipalities in southern Sweden were invited to participate in a health survey. From December 1995 to February 2000 a total of 6916 women (out of 10,766, the total population of women in 1995) underwent a physical examination and answered a questionnaire. We followed the women from the day of screening until death, or if no event occurred until May 31st 2015. Mortality was ascertained through the national cause-of-death register.

Results

In this study a total of 6353 women were included. Alcohol consumption showed a J-formed relationship with mortality, when adjusted for education, marital status, smoking, BMI, physical fitness, diabetes and ischemic heart disease before screening. Non consumption of alcohol was associated with increased mortality as well as higher levels of consumption, from 12 grams per day and upwards.

Conclusions

There was a clear J-shaped relation between the amount of alcohol consumption and all-cause mortality even after controlling for sociodemography, lifestyle factors and diseases such as diabetes and previous ischemic heart disease. The observed protective effect of light drinking (1–12 grams/day) could thus not be attributed to any of these known confounders.

Non-response in a cross-sectional study of respiratory health in Norway

OBJECTIVES

Declining participation in epidemiological studies has been reported in recent decades and may lead to biased prevalence estimates and selection bias. The aim of the study was to identify possible causes and effects of non-response in a population-based study of respiratory health in Norway.

DESIGN

The Telemark study is a longitudinal study that began with a cross-sectional survey in 2013.

SETTING

In 2013, a random sample of 50,000 inhabitants aged 16-50 years, living in Telemark county, received a validated postal questionnaire. The response rate was 33%. In this study, a random sample of 700 non-responders was contacted first by telephone and then by mail.

OUTCOME MEASURES

Response rates, prevalence and OR of asthma and respiratory symptoms based on exposure to vapours, gas, dust or fumes (VGDF) and smoking. Causes of non-response.

RESULTS

A total of 260 non-responders (37%) participated. Non-response was associated with younger age, male sex, living in a rural area and past smoking. The prevalence was similar for responders and non-responders for physician-diagnosed asthma and several respiratory symptoms. The prevalence of chronic cough and use of asthma medication was overestimated in the Telemark study, and adjusted prevalence estimates were 17.4% and 5%, respectively. Current smoking was identified as a risk factor for respiratory symptoms among responders and non-responders, while occupational VGDF exposure was a risk factor only among responders. The Breslow-Day test detected heterogeneity between productive cough and occupational VGDF exposure among responders.

CONCLUSIONS

The Telemark study provided valid estimates for physician-diagnosed asthma and several respiratory symptoms, while it was necessary to adjust prevalence estimates for chronic cough and use of asthma medication. Reminder letters had little effect on risk factor associations. Selection bias should be considered in future investigations of the relationship between respiratory outcomes and exposures.

Cannabis Use as Risk or Protection for Type 2 Diabetes: A Longitudinal Study of 18 000 Swedish Men and Women

Aims. Whether or not cannabis use may increase or decrease the risk of type 2 diabetes is not clear. We analyzed the association between cannabis and subsequent type 2 diabetes and if a potential positive or reverse association persisted after controlling for potential confounders. Methods. In this population-based cohort study, 17,967 Swedish men and women (aged 18-84 years), who answered an extensive questionnaire in 2002 (including questions on cannabis use), were followed up for new cases of type 2 diabetes (n = 608) by questionnaire (in 2010) and in health registers during 2003-2011. Odds ratios (ORs) with 95% CIs were estimated in a multiple logistic regression analysis. Potential confounders included age, sex, BMI, physical inactivity, smoking, alcohol use, and occupational position. Results. The crude association showed that cannabis users had a reduced risk of type 2 diabetes OR = 0.68 (95% CIs: 0.47-0.99). However, this inverse association attenuated to OR = 0.94 (95% CIs: 0.63-1.39) after adjusting for age. Conclusions. The present study suggests that there is no association between cannabis use and subsequent type 2 diabetes after controlling for age. To make more robust conclusions prospective studies, with longer periods of follow-up and more detailed information about cannabis use, are needed.

The importance of post hoc approaches for overcoming non-response and attrition bias in population-sampled studies

Population-based health studies are critical resources for monitoring population health and related factors such as substance use, but reliable inference can be compromised in various ways. Non-response and attrition are major methodological problems which reduce power and can hamper the generalizability of findings if individuals who participate and who remain in a study differ systematically from those who do not. In this issue of SPPE, McCabe et al. studied participants of the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions, comparing attrition in Wave 2 across participants with different patterns of substance use at Wave 1. The implications of differential follow-up and further possibilities for addressing selective participation are discussed.

What is wrong with non-respondents? Alcohol-, drug- and smoking-related mortality and morbidity in a 12-year follow-up study of respondents and non-respondents in the Danish Health and Morbidity Survey

AIM

Response rates in health surveys have diminished over the last two decades, making it difficult to obtain reliable information on health and health-related risk factors in different population groups. This study compared cause-specific mortality and morbidity among survey respondents and different types of non-respondents to estimate alcohol-, drug- and smoking-related mortality and morbidity among non-respondents.

DESIGN

Prospective follow-up study of respondents and non-respondents in two cross-sectional health surveys.

SETTING

Denmark.

PARTICIPANTS

A total sample of 39 540 Danish citizens aged 16 years or older.

MEASUREMENTS

Register-based information on cause-specific mortality and morbidity at the individual level was obtained for respondents (n = 28 072) and different types of non-respondents (refusals n = 8954; illness/disabled n = 731, uncontactable n = 1593). Cox proportional hazards models were used to examine differences in alcohol-, drug- and smoking-related mortality and morbidity, respectively, in a 12-year follow-up period.

FINDINGS

Overall, non-response was associated with a significantly increased hazard ratio (HR) of 1.56 [95% confidence interval (CI) = 1.36-1.78] for alcohol-related morbidity, 1.88 (95% CI = 1.38-2.57) for alcohol-related mortality, 1.55 (95% CI = 1.27-1.88) for drug-related morbidity, 3.04 (95% CI = 1.57-5.89) for drug-related mortality and 1.15 (95% CI = 1.03-1.29) for smoking-related morbidity. The hazard ratio for smoking-related mortality also tended to be higher among non-respondents compared with respondents, although no significant association was evident (HR = 1.14; 95% CI = 0.95-1.36). Uncontactable and ill/disabled non-respondents generally had a higher hazard ratio of alcohol-, drug- and smoking-related mortality and morbidity compared with refusal non-respondents.

CONCLUSION

Health survey non-respondents in Denmark have an increased hazard ratio of alcohol-, drug- and smoking-related mortality and morbidity compared with respondents, which may indicate more unfavourable health behaviours among non-respondents.