Time to positivity is a risk factor for death among patients with bloodstream infections: a population-based cohort.

OBJECTIVES: Studies examining time to positivity (TTP) of blood cultures as a risk factor for death have shown conflicting results. The study objective was to examine the effect of TTP on all-cause-30-day case-fatality among a population-based cohort of patients with bloodstream infections (BSI). METHODS: A retrospective cohort study including all residents of Queensland, Australia with incident monomicrobial BSI managed in the publicly funded healthcare system from 2000 to 2019 was performed. Clinical, TTP and all-cause 30-day case-fatality information was obtained from state-wide sources. RESULTS: A cohort of 88 314 patients was assembled. The median TTP was 14 hours, with 5th, 25th, 75th, and 95th percentiles of 4, 10, 20, and 53 hours, respectively. The TTP varied significantly by BSI aetiology. The 30-day all-cause case-fatality rate was 2606/17 879 (14.6%), 2834/24 272 (11.7%), 2378/20 359 (11.7%), and 2752/22 431 (12.3%) within the first, second, third, and fourth TTP quartiles, respectively (p < 0.0001). After adjustment for age, sex, onset, comorbidity, and focus of infection, TTP within 10 hours (first quartile) was associated with a significantly increased risk for death (odds ratio 1.43; 95% CI, 1.35-1.50; p < 0.001). After adjustment for confounding variables (odds ratio; 95% CI), TTP within the first quartile for Staphylococcus aureus (1.56; 1.41-1.73), Streptococcus pneumoniae (1.91; 1.49-2.46), ß-hemolytic streptococci (1.23; 1.00-1.50), Pseudomonas species (2.23; 1.85-2.69), Escherichia coli (1.37; 1.23-1.53), Enterobacterales (1.38; 1.16-1.63), other Gram-negatives (1.68; 1.36-2.06), and anaerobes (1.58; 1.28-1.94) increased the risk for case-fatality. DISCUSSION: This population-based analysis provides evidence that TTP is an important determinant of mortality among patients with BSI.

Effectiveness of a Regenerative Epithelial Suspension (RES), on the pigmentation of split-thickness skin graft donor sites in children: the dRESsing pilot randomised controlled trial protocol.

BACKGROUND: Paediatric donor site wounds are often complicated by dyspigmentation following a split-thickness skin graft. These easily identifiable scars can potentially never return to normal pigmentation. A Regenerative Epidermal Suspension (RES) has been shown to improve pigmentation in patients with vitiligo, and in adult patients following a burn injury. Very little is known regarding the efficacy of RES for the management of donor site scars in children. METHODS AND ANALYSIS: A pilot randomised controlled trial of 40 children allocated to two groups (RES or no RES) standard dressing applied to donor site wounds will be conducted. All children aged 16 years or younger requiring a split thickness skin graft will be screened for eligibility. The primary outcome is donor site scar pigmentation 12 months after skin grafting. Secondary outcomes include re-epithelialisation time, pain, itch, dressing application ease, treatment satisfaction, scar thickness and health-related quality of life. Commencing 7 days after the skin graft, the dressing will be changed every 3-5 days until the donor site is ≥ 95% re-epithelialised. Data will be collected at each dressing change and 3, 6 and 12 months post skin graft. ETHICS AND DISSEMINATION: Ethics approval was confirmed on 11 February 2019 by the study site Human Research Ethics Committee (HREC) (HREC/18/QCHQ/45807). Study findings will be published in peer-reviewed journals and presented at national and international conferences. This study was prospectively registered on the Australian New Zealand Clinical Trials Registry (available at https://anzctr.org.au/ACTRN12620000227998.aspx). TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry [Available at https://anzctr.org.au/ACTRN12620000227998.aspx].

The relationship between practice environment, job satisfaction and intention to leave in critical care nurses.

BACKGROUND: Recent studies in the Kingdom of Saudi Arabia (KSA) have shown that the increasing nursing turnover in the health care industry has become a great source of concern. The overdependence on the supply of expatriate nurses (74%) and coronavirus disease 2019 (COVID-19) travel restrictions have exacerbated this staffing issue. AIMS: To examine the relationship between perception of nursing practice environment (NPE), job satisfaction and intention to leave (ITL) among critical care nurses working in the state of Ha'il in KSA. DESIGN: Cross-sectional correlational (observational) design. METHODS: Data were collected via electronic online survey distributed to registered critical care nurses working in King Khalid Hospital (KKH), Ha'il, KSA, between July and August 2020. Participant demographics and key variables data related to NPE, job satisfaction and ITL respectively were collected from the participants using existing and validated questionnaires. Descriptive statistics and correlational analysis and multivariable analyses were conducted. RESULTS: A response rate of 98% was achieved (152/160) for the study. Findings showed that the NPE was largely favourable (M = 2.89, SD = 0.44); however, nurse participation in hospital affairs (M = 2.83, SD = 0.47) and staffing and resource adequacy (M = 2.88, SD = 0.47) scored lowest. NPE was found to be significantly correlated with job satisfaction (rs = .287, P < .01). A significant negative relationship was found between NPE and ITL (rs = -0.277**, P < .01). However, job satisfaction was associated with ITL (rs = -.007, P = .930). CONCLUSIONS: Maintaining a healthy work environment and job satisfaction levels in critical care units is key to improving, recruitment and retention of nursing staff. RELEVANCE TO CLINICAL PRACTICE: Critical care and hospital leaders should implement programs that enhance the quality of the practice environment. This will improve nurse participation in unit and hospital affairs, job satisfaction and intention to stay.

Early non-excisional debridement of paediatric burns under general anaesthesia reduces time to re-epithelialisation and risk of skin graft.

Reported advantages of early excision for larger burn injuries include reduced morbidity, mortality, and hospital length of stay for adult burn patients. However, a paucity of evidence supports the best option for paediatric burns and the advantages of non-excisional (mechanical) debridement. Procedural sedation and analgesia in the emergency department is a popular alternative to debridement in operating theatres under general anaesthesia. This study aims to evaluate the association between early (< 24 h post-injury) non-excisional debridement under general anaesthesia with burn wound re-epithelialisation time and skin graft requirements. Cohort study of children younger than 17 years who presented with burns of five percent total body surface area or greater. Data from January 2013 to December 2019 were extracted from a prospectively collected state-wide paediatric burns' registry. Time to re-epithelialisation was tested using survival analysis, and binary logistic regression for odds of skin graft requirementto analyse effects of early non-excisional debridement in the operating theatre. Overall, 292 children met eligibility (males 55.5%). Early non-excisional debridement under general anaesthesia in the operating theatre, significantly reduced the time to re-epithelialisation (14 days versus 21 days, p = 0.029)) and the odds of requiring a skin graft in comparison to paediatric patients debrided in the emergency department under Ketamine sedation (OR: 6.97 (2.14-22.67), p < 0.001. This study is the first to demonstrate that early non-excisional debridement under general anaesthesia in the operating theatre significantly reduces wound re-epithelialisation time and subsequent need for a skin graft in paediatric burn patients. Analysis suggests that ketamine procedural sedation and analgesia in the emergency department used for burn wound debridement is not an effective substitute for debridement in the operating theatre.

Building a sustainable rural physician workforce.

CHAPTER 1: CHARACTERISING AUSTRALIA'S RURAL SPECIALIST PHYSICIAN WORKFORCE: THE PROFESSIONAL PROFILE AND PROFESSIONAL SATISFACTION OF JUNIOR DOCTORS AND CONSULTANTS: Objective: To assess differences in the demographic characteristics, professional profile and professional satisfaction of rural and metropolitan junior physicians and physician consultants in Australia. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional, population level national survey of the Medicine in Australia: Balancing Employment and Life longitudinal cohort study (collected 2008-2016). Participants were specialist physicians from four career stage groups: pre-registrars (physician intent); registrars; new consultants (< 5 years since Fellowship); and consultants. MAIN OUTCOME MEASURES: Level of professional satisfaction across various job aspects, such as hours worked, working conditions, support networks and educational opportunities, comparing rural and metropolitan based physicians. RESULTS: Participants included 1587 pre-registrars (15% rural), 1745 physician registrars (9% rural), 421 new consultants (20% rural) and 1143 consultants (13% rural). Rural physicians of all career stages demonstrated equivalent professional satisfaction across most job aspects, compared with metropolitan physician counterparts. Some examples of differences in satisfaction included rural pre-registrars being less likely to agree they had good access to support and supervision from qualified consultants (odds ratio [OR], 0.6; 95% CI, 0.3-0.9) and rural consultants being more likely to agree they had a poorer professional support network (OR, 1.9; 95% CI, 1.2-2.9). In terms of demographics, relatively more rural physicians had a rural background or were trained overseas. Although most junior physicians were women, female consultants were less likely to be working in a rural location (OR, 0.6; 95% CI, 0.4-0.8). CONCLUSION: Junior physicians in metropolitan or rural settings have a similar professional experience, which is important in attracting future trainees. Increased opportunities for rural training should be prioritised, along with addressing concerns about the professional isolation and poorer support network of those in rural areas, not only among junior doctors but also consultants. Finally, making rural practice more attractive to female junior physicians could greatly improve the consultant physician distribution. CHAPTER 2: GENERAL PHYSICIANS AND PAEDIATRICIANS IN RURAL AUSTRALIA: THE SOCIAL CONSTRUCTION OF PROFESSIONAL IDENTITY: Objective: To explore the construction of professional identity among general physicians and paediatricians working in non-metropolitan areas. DESIGN, SETTING AND PARTICIPANTS: In-depth qualitative interviews were conducted with general physicians and paediatricians, plus informants from specialist colleges, government agencies and academia who were involved in policy and programs for the training and recruitment of specialists in rural locations across three states and two territories. This research is part of the Training Pathways and Professional Support for Building a Rural Physician Workforce Study, 2018-19. MAIN OUTCOME MEASURES: Individual and collective descriptors of professional identity. RESULTS: We interviewed 36 key informants. Professional identity for general physicians and paediatricians working in regional, rural and remote Australia is grounded in the breadth of their training, but qualified by location - geographic location, population served or specific location, where social and cultural context specifically shapes practice. General physicians and paediatricians were deeply engaged with their local community and its economic vulnerability, and they described the population size and dynamics of local economies as determinants of viable practice. They often complemented their practice with formal or informal training in areas of special interest, but balanced their practice against subspecialist availability, also dependent on demographics. While valuing their professional roles, they showed limited inclination for industrial organisation. CONCLUSION: Despite limited consensus on identity descriptors, rural general physicians and paediatricians highly value generalism and their rural engagement. The structural and geographic bias that preferences urban areas will need to be addressed to further develop coordinated strategies for advanced training in rural contexts, for which collective identity is integral. CHAPTER 3: SUSTAINABLE RURAL PHYSICIAN TRAINING: LEADERSHIP IN A FRAGILE ENVIRONMENT: Objectives: To understand Royal Australasian College of Physicians (RACP) training contexts, including supervisor and trainee perspectives, and to identify contributors to the sustainability of training sites, including training quality. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional mixed-methods design was used. A national sample of RACP trainees and Fellows completed online surveys. Survey respondents who indicated willingness to participate in interviews were purposively recruited to cover perspectives from a range of geographic, demographic and training context parameters. MAIN OUTCOME MEASURES: Fellows' and trainees' work and life satisfaction, and their experiences of supervision and training, respectively, by geographic location. RESULTS: Fellows and trainees reported high levels of satisfaction, with one exception - inner regional Fellows reported lower satisfaction regarding opportunities to use their abilities. Not having a good support network was associated with lower satisfaction. Our qualitative findings indicate that a culture of undermining rural practice is prevalent and that good leadership at all levels is important to reduce negative impacts on supervisor and trainee availability, site accreditation and viability. Trainees described challenges in navigating training pathways, ensuring career development, and having the flexibility to meet family needs. The small number of Fellows in some sites poses challenges for supervisors and trainees and results in a blurring of roles; accreditation is an obstacle to provision of training at rural sites; and the overlap between service and training roles can be difficult for supervisors. CONCLUSION: Our qualitative findings emphasise the distinctive nature of regional specialist training, which can make it a fragile environment. Leadership at all levels is critical to sustaining accreditation and support for supervisors and trainees. CHAPTER 4: PRINCIPLES TO GUIDE TRAINING AND PROFESSIONAL SUPPORT FOR A SUSTAINABLE RURAL SPECIALIST PHYSICIAN WORKFORCE: Objective: To draw on research conducted in the Building a Rural Physician Workforce project, the first national study on rural specialist physicians, to define a set of principles applicable to guiding training and professional support action. DESIGN: We used elements of the Delphi approach for systematic data collection and codesign, and applied a hybrid participatory action planning approach to achieve consensus on a set of principles. RESULTS: Eight interconnected foundational principles built around rural regions and rural people were identified: FP1, grow your own "connected to" place; FP2, select trainees invested in rural practice; FP3, ground training in community need; FP4, rural immersion - not exposure; FP5, optimise and invest in general medicine; FP6, include service and academic learning components; FP7, join up the steps in rural training; and FP8, plan sustainable specialist roles. CONCLUSION: These eight principles can guide training and professional support to build a sustainable rural physician workforce. Application of the principles, and coordinated action by stakeholders and the responsible organisations, are needed at national, state and local levels to achieve a sustainable rural physician workforce.

Measuring Quality of Maternal and Newborn Care in Developing Countries Using Demographic and Health Surveys.

BACKGROUND: One of the greatest obstacles facing efforts to address quality of care in low and middle income countries is the absence of relevant and reliable data. This article proposes a methodology for creating a single "Quality Index" (QI) representing quality of maternal and neonatal health care based upon data collected as part of the Demographic and Health Survey (DHS) program. METHODS: Using the 2012 Indonesian Demographic and Health Survey dataset, indicators of quality of care were identified based on the recommended guidelines outlined in the WHO Integrated Management of Pregnancy and Childbirth. Two sets of indicators were created; one set only including indicators available in the standard DHS questionnaire and the other including all indicators identified in the Indonesian dataset. For each indicator set composite indices were created using Principal Components Analysis and a modified form of Equal Weighting. These indices were tested for internal coherence and robustness, as well as their comparability with each other. Finally a single QI was chosen to explore the variation in index scores across a number of known equity markers in Indonesia including wealth, urban rural status and geographical region. RESULTS: The process of creating quality indexes from standard DHS data was proven to be feasible, and initial results from Indonesia indicate particular disparities in the quality of care received by the poor as well as those living in outlying regions. CONCLUSIONS: The QI represents an important step forward in efforts to understand, measure and improve quality of MNCH care in developing countries.

A framework for the economic analysis of data collection methods for vital statistics.

BACKGROUND: Over recent years there has been a strong movement towards the improvement of vital statistics and other types of health data that inform evidence-based policies. Collecting such data is not cost free. To date there is no systematic framework to guide investment decisions on methods of data collection for vital statistics or health information in general. We developed a framework to systematically assess the comparative costs and outcomes/benefits of the various data methods for collecting vital statistics. METHODOLOGY: The proposed framework is four-pronged and utilises two major economic approaches to systematically assess the available data collection methods: cost-effectiveness analysis and efficiency analysis. We built a stylised example of a hypothetical low-income country to perform a simulation exercise in order to illustrate an application of the framework. FINDINGS: Using simulated data, the results from the stylised example show that the rankings of the data collection methods are not affected by the use of either cost-effectiveness or efficiency analysis. However, the rankings are affected by how quantities are measured. CONCLUSION: There have been several calls for global improvements in collecting useable data, including vital statistics, from health information systems to inform public health policies. Ours is the first study that proposes a systematic framework to assist countries undertake an economic evaluation of DCMs. Despite numerous challenges, we demonstrate that a systematic assessment of outputs and costs of DCMs is not only necessary, but also feasible. The proposed framework is general enough to be easily extended to other areas of health information.

Socioeconomic and geographical disparities in under-five and neonatal mortality in Uttar Pradesh, India.

As a part of the Millennium Development Goals, India seeks to substantially reduce its burden of childhood mortality. The success or failure of this goal may depend on outcomes within India's most populous state, Uttar Pradesh. This study examines the level of disparities in under-five and neonatal mortality across a range of equity markers within the state. Estimates of under-five and neonatal mortality rates were computed using five datasets, from three available sources: sample registration system, summary birth histories in surveys, and complete birth histories. Disparities were evaluated via comparisons of mortality rates by rural-urban location, ethnicity, wealth, and districts. While Uttar Pradesh has experienced declines in both rates of under-five (162-108 per 1,000 live births) and neonatal (76-49 per 1,000 live births) mortality, the rate of decline has been slow (averaging 2 % per annum). Mortality trends in rural and urban areas are showing signs of convergence, largely due to the much slower rate of change in urban areas. While the gap between rich and poor households has decreased in both urban and rural areas, trends suggest that differences in mortality will remain. Caste-related disparities remain high and show no signs of diminishing. Of concern are also the signs of stagnation in mortality amongst groups with greater ability to access services, such as the urban middle class. Notwithstanding the slow but steady reduction of absolute levels of childhood mortality within Uttar Pradesh, the distribution of the mortality by sub-state populations remains unequal. Future progress may require significant investment in quality of care provided to all sections of the community.

Do strategies to improve quality of maternal and child health care in lower and middle income countries lead to improved outcomes? A review of the evidence.

OBJECTIVES: Efforts to scale-up maternal and child health services in lower and middle income countries will fail if services delivered are not of good quality. Although there is evidence of strategies to increase the quality of health services, less is known about the way these strategies affect health system goals and outcomes. We conducted a systematic review of the literature to examine this relationship. METHODS: We undertook a search of MEDLINE, SCOPUS and CINAHL databases, limiting the results to studies including strategies specifically aimed at improving quality that also reported a measure of quality and at least one indicator related to health system outcomes. Variation in study methodologies prevented further quantitative analysis; instead we present a narrative review of the evidence. FINDINGS: Methodologically, the quality of evidence was poor, and dominated by studies of individual facilities. Studies relied heavily on service utilisation as a measure of strategy success, which did not always correspond to improved quality. The majority of studies targeted the competency of staff and adequacy of facilities. No strategies addressed distribution systems, public-private partnership or equity. Key themes identified were the conflict between perceptions of patients and clinical measures of quality and the need for holistic approaches to health system interventions. CONCLUSION: Existing evidence linking quality improvement strategies to improved MNCH outcomes is extremely limited. Future research would benefit from the inclusion of more appropriate indicators and additional focus on non-facility determinants of health service quality such as health policy, supply distribution, community acceptability and equity of care.

Investment case for improving maternal and child health: results from four countries.

BACKGROUND: Without addressing the constraints specific to disadvantaged populations, national health policies such as universal health coverage risk increasing equity gaps. Health system constraints often have the greatest impact on disadvantaged populations, resulting in poor access to quality health services among vulnerable groups. METHODS: The Investment Cases in Indonesia, Nepal, Philippines, and the state of Orissa in India were implemented to support evidence-based sub-national planning and budgeting for equitable scale-up of quality MNCH services. The Investment Case framework combines the basic setup of strategic problem solving with a decision-support model. The analysis and identification of strategies to scale-up priority MNCH interventions is conducted by in-country planners and policymakers with facilitation from local and international research partners. RESULTS: Significant variation in scaling-up constraints, strategies, and associated costs were identified between countries and across urban and rural typologies. Community-based strategies have been considered for rural populations served predominantly by public providers, but this analysis suggests that the scaling-up of maternal, newborn, and child health services requires health system interventions focused on 'getting the basics right'. These include upgrading or building facilities, training and redistribution of staff, better supervision, and strengthening the procurement of essential commodities. Some of these strategies involve substantial early capital expenditure in remote and sparsely populated districts. These supply-side strategies are not only the 'best buys', but also the 'required buys' to ensure the quality of health services as coverage increases. By contrast, such public supply strategies may not be the 'best buys' in densely populated urbanised settings, served by a mix of public and private providers. Instead, robust regulatory and supervisory mechanisms are required to improve the accessibility and quality of services delivered by the private sector. They can lead to important maternal mortality reductions at relatively low costs. CONCLUSIONS: National strategies that do not take into consideration the special circumstances of disadvantaged areas risk disempowering local managers and may lead to a "business-as-usual" acceptance of unreachable goals. To effectively guide health service delivery at a local level, national plans should adopt typologies that reflect the different problems and strategies to scale up key MNCH interventions.

Context-specific, evidence-based planning for scale-up of family planning services to increase progress to MDG 5: health systems research.

BACKGROUND: Unmet need for family planning is responsible for 7.4 million disability-adjusted life years and 30% of the maternity-related disease burden. An estimated 35% of births are unintended and some 200 million couples state a desire to delay pregnancy or cease fertility but are not using contraception. Unmet need is higher among the poorest, lesser educated, rural residents and women under 19 years. The barriers to, and successful strategies for, satisfying all demand for modern contraceptives are heavily influenced by context. Successfully overcoming this to increase the uptake of family planning is estimated to reduce the risk of maternal death by up to 58% as well as contribute to poverty reduction, women's empowerment and educational, social and economic participation, national development and environmental protection. METHODS: To strengthen health systems for delivery of context-specific, equity-focused reproductive, maternal, newborn and child health services (RMNCH), the Investment Case study was applied in the Asia-Pacific region. Staff of local and central government and non-government organisations analysed data indicative of health service delivery through a supply-demand oriented framework to identify constraints to RMNCH scale-up. Planners developed contextualised strategies and the projected coverage increases were modelled for estimates of marginal impact on maternal mortality and costs over a five year period. RESULTS: In Indonesia, Philippines and Nepal the constraints behind incomplete coverage of family planning services included: weaknesses in commodities logistic management; geographical inaccessibility; limitations in health worker skills and numbers; legislation; and religious and cultural ideologies. Planned activities included: streamlining supply systems; establishment of Community Health Teams for integrated RMNCH services; local recruitment of staff and refresher training; task-shifting; and follow-up cards. Modelling showed varying marginal impact and costs for each setting with potential for significant reductions in the maternal mortality rate; up to 28% (25.1-30.7) over five years, costing up to a marginal USD 1.34 (1.32-1.35) per capita in the first year. CONCLUSION: Local health planners are in a prime position to devise feasible context-specific activities to overcome constraints and increase met need for family planning to accelerate progress towards MDG 5.

Tobacco consumption and pancreatic cancer mortality: what can we conclude from historical data in Australia?

BACKGROUND: Tobacco consumption is an established risk factor for pancreatic cancer yet studies of long-term mortality trends have not statistically analysed this relationship. We sought evidence for this relationship based on an analysis of long-term population-level data in Australia. METHODS: Pancreatic cancer mortality data from 1931, tobacco consumption data and fruit and vegetable consumption data for Australia were utilized. Log-linear Poisson regression models were used to analyse pancreatic cancer mortality from 1931 with cumulative cohort and lagged time-specific tobacco consumption data and fruit and vegetable consumption data. RESULTS: Pancreatic cancer mortality rose steadily for males until it began falling from the 1970s, and continued rising for females until 2006. These trends correspond with a long-term rise in male tobacco consumption until the 1960s and a later peak for females. Our models show that cumulative tobacco consumption predicts pancreatic cancer mortality for both sexes but with time lags only being significant for males. Fruit and vegetable consumption provides a protective effect against mortality in some of the models. CONCLUSION: The success of smoking reduction programmes in Australia has contributed to the decline in pancreatic cancer mortality for males, providing important evidence about the need for tobacco control measures in populations where it is still increasing. Continued declines in female tobacco consumption should lead to a reversal of the long-term rise in female pancreatic cancer mortality.

Trends in oral, pharyngeal and oesophageal cancer mortality in Australia: the comparative importance of tobacco, alcohol and other risk factors.

OBJECTIVE: The relationship of long-term population-level trends in oral, pharyngeal and oesophageal cancer mortality with major risk factors such as tobacco consumption have not been statistically analysed in Australia. We have demonstrated the long-term implications using historical data. METHODS: Estimated age and sex-specific tobacco consumption back-extrapolated to 1887 were used together with alcohol and fruit and vegetable consumption data to examine their association with trends in oral, pharyngeal and oesophageal cancer mortality. Log-linear Poisson regression models were applied to specify the relationship with oesophageal and pharyngeal mortality data. RESULTS: Oral cancer mortality for males decreased sharply in the first half of the 20th Century in contrast to steadily rising tobacco consumption. Female oral and pharyngeal cancer remained steady at low levels. Post-World War II male and female oesophageal and male pharyngeal cancer mortality rose, then either fell or stabilised, without a clear relationship with risk factors. CONCLUSIONS: Tobacco and alcohol consumption have influenced post-World War II trends in oral, pharyngeal and oesophageal cancer mortality. However, the challenges in using historical population level data prevent precise interpretation of findings. IMPLICATIONS: There is increased exposure to risk factors for these cancers in many low- and middle-income countries. In particular, smoking cessation programs are needed to prevent increases in mortality from these cancers in such countries.

Reconstruction of long-term tobacco consumption trends in Australia and their relationship to lung cancer mortality.

OBJECTIVES: Analysis of long-term trends in smoking and causes of death in Australia are prevented by a lack of detailed tobacco consumption data prior to World War II. The objective of this study was to reconstruct data on tobacco consumption in Australia back to 1887 and examine its relationship with population-level lung cancer mortality, corrected for biases and miscoding. METHODS: Back-extrapolation techniques and existing tobacco sales data were combined to estimate tobacco consumption prior to the 1940s. The relationship of tobacco and lung cancer mortality was examined with descriptive period and cohort analyses and log-linear Poisson regression models of cumulative cohort consumption. RESULTS: The results show that tobacco consumption rose steadily in Australia for the majority of years from 1887 to World War II, before increasing drastically in the following years and then falling sharply to the present day. Lung cancer mortality was strongly influenced by tobacco consumption, peaking 20-25 years after the peak in tobacco consumption for men and 25-30 years for women. Regression models found cumulative consumption a very strong predictor of mortality. CONCLUSIONS: Period and cohort trends in smoking and lung cancer were similar to many other Western countries. The effectiveness of smoking reduction campaigns in Australia clearly reduced male lung cancer mortality and provides guidance for other countries, such as China, where smoking prevalence remains high.