Analysis of Multiple Causes of Death: A Review of Methods and Practices.

BACKGROUND: Research and reporting of mortality indicators typically focus on a single underlying cause of death selected from multiple causes recorded on a death certificate. The need to incorporate the multiple causes in mortality statistics-reflecting increasing multimorbidity and complex causation patterns-is recognized internationally. This review aims to identify and appraise relevant analytical methods and practices related to multiple causes. METHODS: We searched Medline, PubMed, Scopus, and Web of Science from their incept ion to December 2020 without language restrictions, supplemented by consultation with international experts. Eligible articles analyzed multiple causes of death from death certificates. The process identified 4,080 items of which we reviewed 434 full-text articles. RESULTS: Most articles we reviewed (76%, n = 332) were published since 2001. The majority of articles examined mortality by "any- mention" of the cause of death (87%, n = 377) and assessed pairwise combinations of causes (57%, n = 245). Since 2001, applications of methods emerged to group deaths based on common cause patterns using, for example, cluster analysis (2%, n = 9), and application of multiple-cause weights to re-evaluate mortality burden (1%, n = 5). We describe multiple-cause methods applied to specific research objectives for approaches emerging recently. CONCLUSION: This review confirms rapidly increasing international interest in the analysis of multiple causes of death and provides the most comprehensive overview, to our knowledge, of methods and practices to date. Available multiple-cause methods are diverse but suit a range of research objectives. With greater availability of data and technology, these could be further developed and applied across a range of settings.

Electronic cigarettes and health outcomes: umbrella and systematic review of the global evidence.

OBJECTIVE: To review and synthesise the global evidence regarding the health effects of electronic cigarettes (e-cigarettes, vapes). STUDY DESIGN: Umbrella review (based on major independent reviews, including the 2018 United States National Academies of Sciences, Engineering, and Medicine [NASEM] report) and top-up systematic review of published, peer-reviewed studies in humans examining the relationship of e-cigarette use to health outcomes published since the NASEM report. DATA SOURCES: Umbrella review: eight major independent reviews published 2017-2021. Systematic review: PubMed, MEDLINE, Scopus, Web of Science, the Cochrane Library, and PsycINFO (articles published July 2017 - July 2020 and not included in NASEM review). DATA SYNTHESIS: Four hundred eligible publications were included in our synthesis: 112 from the NASEM review, 189 from our top-up review search, and 99 further publications cited by other reviews. There is conclusive evidence linking e-cigarette use with poisoning, immediate inhalation toxicity (including seizures), and e-cigarette or vaping product use-associated lung injury (EVALI; largely but not exclusively for e-liquids containing tetrahydrocannabinol and vitamin E acetate), as well as for malfunctioning devices causing injuries and burns. Environmental effects include waste, fires, and generation of indoor airborne particulate matter (substantial to conclusive evidence). There is substantial evidence that nicotine e-cigarettes can cause dependence or addiction in non-smokers, and strong evidence that young non-smokers who use e-cigarettes are more likely than non-users to initiate smoking and to become regular smokers. There is limited evidence that freebase nicotine e-cigarettes used with clinical support are efficacious aids for smoking cessation. Evidence regarding effects on other clinical outcomes, including cardiovascular disease, cancer, development, and mental and reproductive health, is insufficient or unavailable. CONCLUSION: E-cigarettes can be harmful to health, particularly for non-smokers and children, adolescents, and young adults. Their effects on many important health outcomes are uncertain. E-cigarettes may be beneficial for smokers who use them to completely and promptly quit smoking, but they are not currently approved smoking cessation aids. Better quality evidence is needed regarding the health impact of e-cigarette use, their safety and efficacy for smoking cessation, and effective regulation. REGISTRATION: Systematic review: PROSPERO, CRD42020200673 (prospective).

Smokers Increasingly Motivated and Able to Quit as Smoking Prevalence Falls: Umbrella and Systematic Review of Evidence Relevant to the "Hardening Hypothesis," Considering Transcendence of Manufactured Doubt.

INTRODUCTION: The "hardening hypothesis" proposes that as the prevalence of smoking in a population declines, there will be a "hardening" of the remaining smoker population. This review examines the evidence regarding smokers' motivation, dependence, and quitting behavior as smoking prevalence declines, to assess whether population "hardening" (decreasing propensity to quit) or "softening" (the converse) is occurring. METHODS: MEDLINE, PsychINFO, Scopus, Web of Science, and Cochrane Library were searched to July 2019, using terms related to smoking and hardening, for reviews and large, population-based repeat cross-sectional studies. There were additional searches of reference lists and citations of key research articles. Two reviewers screened half the titles and abstracts each, and two reviewers screened full texts independently using tested criteria. Four reviewers independently and systematically extracted data from eligible publications, with one reviewer per study, checked by another reviewer. RESULTS: Of 265 titles identified, three reviews and ten repeat cross-sectional studies were included. Reviews concluded that hardening has not occurred among the general smoking population over time. Among repeated cross-sectional studies, five examined motivation, nine examined dependence, five examined hardcore smoking, and two examined quit outcomes. All but one study found a lack of hardening. Most found softening within the smoking population, consistent across hardening indicators, definitions, countries (and tobacco control environments), and time periods examined. CONCLUSIONS: Tobacco control reduces smoking prevalence and fosters a smoking population more amenable to evidence-based interventions. Based on the weight of the available evidence, the "hardening hypothesis" should be rejected and the reality of softening accepted. IMPLICATIONS: This umbrella review and systematic review provides a critical consideration of evidence from epidemiology and psychology and other fields regarding the "hardening hypothesis"-a persistent myth undermining tobacco control. It reaches the conclusion that the sum-total of the worldwide evidence indicates either "softening" of the smoking population, or a lack of hardening. Hence, tobacco control reduces smoking prevalence and fosters a smoking population more amenable to evidence-based interventions. The review indicates that the time has come to take active steps to combat the myth of hardening and to replace it with the reality of "softening."

Framework for the public health assessment of electronic cigarettes.

BACKGROUND: Electronic cigarettes (e-cigarettes) are relatively new products with substantial public health impacts. Evidence on their effects is diverse and emerging rapidly, presenting challenges to high-quality policymaking and decision-making. This paper addresses these challenges by developing and presenting a framework for the public health assessment of e-cigarettes, using the Australian context as an example. METHODS: Framework development involved stakeholder engagement, development of guiding principles, and consideration of existing relevant frameworks and the evidence requirements of current policy options, identified in published and grey literature. RESULTS: Guiding principles include the need for the framework to: be evidence based; include consideration of the likely balance of benefits and risks of e-cigarettes, uncertainty and safety; support equity; support the ongoing application of evidence to high-quality policy and practice; and consider potential competing interests. The framework draws upon: health technology assessment; health impact assessment; environmental health risk assessment; healthcare recommendations evidence evaluation; consumer goods regulation; medicine and chemical scheduling; tobacco product evaluation; previous reviews and the precautionary principle. Final framework components are: (1) characterisation of products under consideration; (2) definition of populations of interest; (3) characterisation of tobacco smoking, control and impacts on health and well-being; (4) review of evidence on patterns of e-cigarette use; (5) review of evidence on e-cigarette use and health outcomes; (6) assessment of likely risks, benefits and safety; (7) identification and assessment of policy options to optimise health outcomes. CONCLUSIONS: Structured and ongoing public health assessment of e-cigarette use is likely to support health through enhancing evidence-based decision-making.

Staff and client preferences for the design and delivery of an outcomes monitoring system in a mental health service.

BACKGROUND: Outcome monitoring can support the delivery of quality service that meets the needs of clients, clinicians and services. However, few studies have examined client or staff perspectives on the design and implementation of outcomes monitoring within a service. Implementation of outcomes monitoring requires understanding the preferences and expectations of relevant stakeholders. OBJECTIVE: Informed by the Consolidated Framework for Implementation Research, this study aimed to investigate the preferences and priorities of relevant staff, clients and family members to inform the design and implementation of an effective outcomes monitoring system in the context of a mental health service for military veterans and their families. METHOD: Twenty-nine staff participated across five online focus groups, including clinical staff, peer workers, policy staff and supervisors. Ten clients participated in online or telephone semi-structured interviews. Thematic analysis was used to develop themes from the data. RESULTS: Clients and staff agreed that outcomes monitoring should cover more than symptoms, particularly by incorporating functional outcomes. Assessing mental health over time was considered a valuable tool for supporting treatment processes and providing actionable information. Challenges identified by clients and staff included the need for efficient processes, ensuring measures are relevant and acceptable, and maintaining client privacy. The ability to personalise data collection and have a streamlined, responsive system were key attributes of a quality outcomes monitoring framework. CONCLUSIONS: Findings suggest that an effective outcome monitoring framework should be client-led, tailored to the individual's needs, and provide feedback on progress. Outcomes monitoring should also be efficient, accessible and allow for safe information sharing.

Differences between men and women in the use of preventive medications following a major cardiovascular event: Australian prospective cohort study.

Most cardiovascular disease (CVD) events can be prevented with appropriate risk management. Existing evidence suggests women are less likely than men to receive guideline-recommended medications, however data on sex-differences in preventive medication use following a CVD event are lacking. Relative risks (RRs) comparing use of blood pressure- and lipid-lowering medications in men and women at 3-, 6-, 9- and 12-months following hospitalisation for myocardial infarction (MI) or stroke from 2012 to 2017 were quantified using linked data from 8,278 participants enrolled in the Australian 45 and Up Study. Overall, 51% of women and 58% of men were using both blood-pressure- and lipid-lowering medications three months after a MI or stroke event, decreasing to 48% and 53%, respectively, at 12 months after an event. Adjusting for potential confounders, women were 9% less likely than men (RR = 0.91 [95% CI: 0.87, 0.95]) to be using both medications and 19% more likely (RR = 1.19 [95% CI: 1.07, 1.32]) to use neither medication three months after a MI or stroke event. At the 12-month mark, women were 8% less likely (RR = 0.92 [95% CI: 0.88, 0.97]) to be using both medications and 14% more likely (RR = 1.14 [95% CI: 1.03, 1.26]) to use neither medication. Women were consistently less likely to use both preventive medications and more likely to use neither medication at each follow-up time point. Overall, there were major shortfalls in basic preventive medication use post-CVD event and sex disparities are likely to further jeopardise efforts to reduce CVD events in the community.

Comparison of cardiovascular disease risk factors, assessment and management in men and women, including consideration of absolute risk: a nationally representative cross-sectional study.

OBJECTIVES: Cardiovascular disease (CVD) is highly preventable and optimal treatments based on absolute risk can halve risk of future events. Compared with women, men have higher risks of developing CVD. However, women can experience suboptimal treatment. We aimed to quantify sex differences in CVD risk, assessment and treatment in Australian adults. DESIGN, PARTICIPANTS, SETTING: Cross-sectional analysis of nationally representative data from interview, physical measures, medication review and blood and urine samples, from 2011 to 2012 Australian Health Survey participants aged 45-74 (n=11 518). OUTCOME MEASURES: CVD risk factors, absolute 5-year risk of a primary CVD event, blood pressure and cholesterol assessment in the previous 2 and 5 years and use of recommended CVD preventive medications were compared using Poisson regression to estimate age-adjusted male versus female prevalence ratios (PRs). RESULTS: Women had a generally more favourable CVD risk factor profile than men, including lower: current smoking prevalence (women=14.5%; men=18.4%, PR=0.78, 95% CI=0.70 to 0.88); body mass index (women (mean)=28.3 kg/m2; men (mean)=28.8 kg/m2, p<0.01); systolic and diastolic blood pressure (systolic: women (mean)=127.1 mm Hg; men (mean)=130.5 mm Hg, p<0.001); blood glucose (women (mean)=5.2 mmol/L; men (mean)=5.5 mmol/L); diabetes prevalence (women=6.8%; men=12.5%, PR=0.55, 95% CI=0.44 to 0.67); prior CVD (women=7.9%; men=11.3%) and absolute primary CVD risk (absolute 5-year CVD risk >15%: women=6.6%, 95% CI=5.4 to 7.8; men=15.4%, 95% CI=13.9% to 16.9%). Compared with men, women had higher low-density lipoprotein, high-density lipoprotein and total cholesterol and sedentary behaviour and lower physical activity. Blood pressure and cholesterol assessment were common in both sexes. Among those at high absolute risk, age-adjusted proportions receiving recommended CVD medications were low, without sex differences (women=21.3%; men=23.8%, PR=0.93, 95% CI=0.49 to 1.78). Fewer women than men with prior atherosclerotic CVD were receiving recommended treatment (women=21.8%, men=41.4%, PR=0.55, 95% CI=0.31 to 0.96). CONCLUSION: Women have a more favourable CVD risk factor profile than men. Preventive treatment is uncommon and women with prior atherosclerotic CVD are around half as likely as men to be receiving recommended treatment.