Enhancing global capacity in the surveillance, prevention, and control of chronic diseases: seven themes to consider and build upon.

BACKGROUND: Chronic diseases are now a major health problem in developing countries as well as in the developed world. Although chronic diseases cannot be communicated from person to person, their risk factors (for example, smoking, inactivity, dietary habits) are readily transferred around the world. With increasing human progress and technological advance, the pandemic of chronic diseases will become an even bigger threat to global health. METHODS: Based on our experiences and publications as well as review of the literature, we contribute ideas and working examples that might help enhance global capacity in the surveillance of chronic diseases and their prevention and control. Innovative ideas and solutions were actively sought. RESULTS: Ideas and working examples to help enhance global capacity were grouped under seven themes, concisely summarised by the acronym "SCIENCE": Strategy, Collaboration, Information, Education, Novelty, Communication and Evaluation. CONCLUSION: Building a basis for action using the seven themes articulated, especially by incorporating innovative ideas, we presented here, can help enhance global capacity in chronic disease surveillance, prevention and control. Informed initiatives can help achieve the new World Health Organization global goal of reducing chronic disease death rates by 2% annually, generate new ideas for effective interventions and ultimately bring global chronic diseases under greater control.

Transscleral red laser cyclophotocoagulation for the treatment of therapy-resistant inflammatory glaucoma.

PURPOSE: To evaluate in a retrospective study the long-term usefulness of red 647 nm krypton and 670 nm diode laser for transscleral contact cyclophotocoagulation (CPC) in the treatment of therapy-resistant inflammatory glaucoma. METHODS: The authors treated 48 eyes of 38 consecutive patients (mean age 36.8 years, range 6-81 years) with therapy-resistant inflammatory glaucoma secondary to chronic uveitis (45/48), chronic scleritis (1/48), or combined scleritis with keratouveitis (2/48) using transscleral red 647 nm Krypton or 670 nm Diode laser. All eyes had failed maximum tolerated medical therapy and 19/48 (40%) eyes also previous antiglaucoma surgery. Laser power at the scleral surface was 0.35 to 0.45 W and the application time 10 seconds each. The follow-up was 42.8+/- 40.0 (range 2-145) months. RESULTS: The mean preoperative intraocular pressure (IOP) of 35.6+/-8.1 mmHg fell to 6-21 mmHg level in 75% after one or repeated CPC. Among adult patients this was achieved in 85%, among children in 54%. More than one treatment was needed in 52%. No cases of hypotony, phthisis bulbi, or other devastating complications occurred. CONCLUSIONS: Transscleral CPC using red 647 nm krypton or 670 nm diode laser is an effective and well-tolerated procedure for the treatment of therapy-resistant inflammatory glaucoma in adults. CPC can be considered before incisional antiglaucoma surgery with a shunt or antimetabolites is undertaken.

The participation of health professionals in a smoking-cessation programme positively influences the smoking cessation advice given to patients.

This study assessed the degree of smoking cessation advice given by health professionals, before and after their participation in a smoking cessation study using bupropion-sustained release (bupropion SR, Zyban). A total of 690 physicians and nurses who had smoked an average of 10 cigarettes/day over the previous year and were motivated to quit smoking, were randomised in a double-blind manner to receive bupropion SR (days 1-3, 150 mg/day; days 4-49, 150 mg twice daily) or placebo for 7 weeks, with follow-up to week 52. All subjects received regular follow-up and brief motivational support throughout the study. Questions regarding their smoking cessation advice formed part of the study, with the aim of determining whether study participants became more proactive with their smoking cessation advice. A positive shift from baseline to end of study was observed with respect to the advice and support they gave to their smoking patients. These changes were not related to study treatment or current smoking status. An increase in advising patients to quit smoking and in offering cessation counselling was observed. Participation in a smoking-cessation study by physicians and nurses who smoke has a positive effect, regardless of study medication, in smoking cessation advice and counselling given to their patients.

[Primary prevention of non-communicable diseases. Experiences from population based intervention in Finland for the global work of WHO]. / Primärprävention von nicht übertragbaren Krankheiten. Erfahrungen von bevölkerungsbasierten Interventionen in Finnland bis zur globalen Arbeit der WHO.

Globally most people die from noncommunicable diseases. Especially in developing countries noncommunicable diseases are on the rise, effecting especially poorer societal segments. The noncommunicable diseases contribute greatly to societal and economic losses and inequities in health status. The North Karelia Project was started in Finland to prevent noncommunicable diseases and with the main aim to curb the high mortality from cardiovascular diseases. In collaboration with the community, the health sector, the food industry and mass media, initiatives were started to promote a healthy diet, physical activity and reduce smoking. Over the last 25 years, the age adjusted mortality rate among men of 25-64 years of age from cardiovascular diseases fell by 73%, from lung cancer by 71% and total mortality fell 49%. Each country should plan and implement its own prevention programs, but lessons can be learned from the North Karelia Project. The paper discusses some key lessons and recommendation from the project for countries and for global work. In the last few years WHO has started to up-grade its work to fight noncommunicable diseases. Some initiatives are presented and discussed.

Smoking trends in hypertensive and normotensive Finns during 1982-1997.

Despite the evidence that smoking is one of the main predictors of the cardiovascular disease risk among hypertensive subjects, there are very few data available of the smoking trends of these subjects at public health level. This study assesses the trends in smoking and in smoking cessation advice given by physicians in the hypertensive and normotensive population in Finland during 1982-1997. The data were derived from four independent cross-sectional standardised population surveys conducted in 1982, 1987, 1992 and 1997 in the provinces of North Karelia and Kuopio in eastern Finland and the region of Turku-Loimaa in south-western Finland. Men and women aged 25-64 years, selected randomly from the national population register, were classified to four groups according to their blood pressure level and antihypertensive treatment status: normotensive, unaware hypertensive, aware but not treated hypertensive and treated hypertensive. The total number of participants was 24 083. In men, the prevalence of smoking decreased significantly in both treated hypertensive patients and normotensive subjects during 1982-1997, whereas it increased significantly in treated hypertensive women. The proportion of current smokers who had been advised to stop smoking by their physician was significantly higher in treated hypertensive men compared to the other subgroups of men (P < 0.001). The observed decreasing trend in smoking in men is encouraging, but the increase in smoking among hypertensive women taking antihypertensive medication warrants concern. In the future, the methods used for smoking cessation advice given by health care personnel should be intensified to make this effort more effective.

Validation of self reported smoking by serum cotinine measurement in a community-based study.

STUDY OBJECTIVE: The validity of self reported smoking in population surveys remains an important question. An associated question is what would be the value of measuring serum cotinine concentrations in such surveys to obtain validated smoking data. DESIGN: Cross sectional analysis of data on self reported smoking and serum cotinine among a random population sample of 5846 persons aged 25 to 64 years, who participated in the FINRISK-92 survey. MAIN RESULTS: Among self reported regular smokers, 97.2% of men and 94.9% of women had a cotinine concentration of 10 ng/ml or higher in serum. Of those participants who reported to have smoked at any time during their life but not during the previous month, 6.3% of men and 5.2% of women had a serum cotinine concentration of at least 10 ng/ml. Among never smokers 2.5% of men and 2.7% of women had detectable level of cotinine in their serum. The validity of self reporting was similar among subjects from different areas, ages, and socioeconomic groups. CONCLUSIONS: In a sample of the general population in Finland the validity of self reported smoking is high, and most of the few self reported non-smokers who had cotinine in their serum had only low or moderate levels.

Exfoliation syndrome as a risk factor for cataract development: five-year follow-up of lens opacities in exfoliation syndrome.

PURPOSE: To ascertain whether the exfoliation syndrome (EXS) is a risk factor for cataract development. SETTING: Helsinki University Eye Hospital, Helsinki, Finland. METHODS: This prospective study examined the development of lens opacities using the Lens Opacity Meter. Visual acuity and refraction were measured in both eyes of 63 nonglaucomatous patients with clinically unilateral EXS. After 5 years, 46 patients were available for follow-up. Case histories of 14 patients were recorded. RESULTS: During the 5 year study, the rate of conversion to bilateral disease was 22% and to exfoliative glaucoma, 30%. At the beginning of the study, the mean lens opacity was 23.5 opacity units (OU) +/- 6.7 (SD) in EXS eyes and 22.9 +/- 7.2 OU in fellow, initially nonexfoliative (NE) eyes; the difference was not significant. After 5 years, the mean opacity was 30.0 +/- 8.8 OU in EXS eyes and 26.9 +/- 8.3 OU in NE eyes (P <.001). In patients who remained unilaterally affected, the EXS eye had a higher opacity value than the NE eyes at the start of the study (23.6 +/- 7.3 OU and 22.7 +/- 7.2 OU, respectively) (P <.05) and after 5 years (29.9 +/- 9.0 OU and 27.0 +/- 8.5 OU) (P <.01). There was a significant myopic change in refraction over time in both groups. The mean refraction in EXS eyes was +1.02 +/- 2.48 diopters (D) at the start and + 0.11 +/- 3.06 D after 5 years (P =.0001) and in NE eyes, +0.99 +/- 2.25 D and +0.43 +/- 2.55 D, respectively (P <.01). At the start of the study, the mean difference in refraction between fellow eyes (refraction in NE eye - refraction in EXS eye) was -0.27 +/- 1.00 D. After 5 years, it was +0.32 +/- 1.44 D (P =.016), showing a greater myopic change in EXS eyes. CONCLUSION: The results show that EXS is a risk factor for lens opacification.

Smoking and passive smoking in Estonia, Lithuania and Finland. Identifying target groups of tobacco policy.

BACKGROUND: The aim of this study was to identify population groups which are the most crucial as targets for anti-tobacco action. METHODS: A comparison was made of the prevalence and patterns of smoking and passive smoking in Estonia, Finland and Lithuania. RESULTS: Total exposure to smoking, both one's own and passive smoking, was more common in two Baltic countries than in Finland. In these Baltic countries passive smoking was notably common among women. In all countries the exposure was more prevalent among the younger and less educated, but no difference emerged between urban and rural areas. CONCLUSIONS: The following target groups were identified as priorities for anti-tobacco actions: i) men of all ages in Estonia and Lithuania to stop their already established tobacco use, ii) young women in all three countries to prevent their starting a career of tobacco use and iii) young and less educated women in Estonia and Lithuania to prevent passive smoking, i.e. their exposure to environmental tobacco smoke.

Smoking cessation between teenage years and adulthood.

Most smokers begin smoking in adolescence. It is less well known how young people quit smoking and the factors that are associated with this process. A 15-year follow-up study on the North Karelia Youth Project has made it possible to assess these factors using a longitudinal study design. The project began in 1978 with students in Grade 7 of junior high school (age 13 years) and concluded in 1980 when the students reached Grade 9 (age 15 years). The follow-up study included four additional surveys. The present analyses are based on the data collected at ages 15, 21 and 28. The original sample comprised 903 students and the response rate of the last survey was 71%. A quarter (26%) of daily smokers and about half (46%) of occasional smokers at age of 15 had quit by the age of 28. The cessation rate was higher among females than males (P = 0.006). The cessation rate was higher among married (P = 0.015), employed (P = 0.01) and white-collar workers (P = 0.006). Cessation was less prevalent among those who had friends (P < 0.001) and family (P = 0.012) members who smoked. The cessation rate was lower among those who consumed fatty milk (P = 0.050), had less leisure-time physical activity (P = 0.032) and consumed more alcohol (P < 0.001). One-third of all teenage smokers stop smoking before the age of 28, averaging a 2.3% annual decline. Cessation is greater among occasional than daily smokers and greater overall among females.

Trends in cigarette smoking in 36 populations from the early 1980s to the mid-1990s: findings from the WHO MONICA Project.

OBJECTIVES: This report analyzes cigarette smoking over 10 years in populations in the World Health Organization (WHO) MONICA Project (to monitor trends and determinants of cardiovascular disease). METHODS: Over 300,000 randomly selected subjects aged 25 to 64 years participated in surveys conducted in geographically defined populations. RESULTS: For men, smoking prevalence decreased by more than 5% in 16 of the 36 study populations, remained static in most others, but increased in Beijing. Where prevalence decreased, this was largely due to higher proportions of never smokers in the younger age groups rather than to smokers quitting. Among women, smoking prevalence increased by more than 5% in 6 populations and decreased by more than 5% in 9 populations. For women, smoking tended to increase in populations with low prevalence and decrease in populations with higher prevalence; for men, the reverse pattern was observed. CONCLUSIONS: These data illustrate the evolution of the smoking epidemic in populations and provide the basis for targeted public health interventions to support the WHO priority for tobacco control.

East-west differences in reported preventive practices. A comparative study of six European areas of the WHO-CINDI programme.

BACKGROUND: Differences have been reported in life expectancy and mortality between Eastern and Western European countries. Also, disparities have been found among different European countries or populations concerning the implementation of preventive practices by health professionals. This study analysed the patterns of reported preventive practices in three Eastern European areas and three Western ones. METHODS: Health surveys were carried out in particular geographical area of six countries participating in the project (three Eastern European countries; Russia, Poland and Hungary and three Western European countries; Finland, Germany and Spain). All of them are partners in the WHO-CINDI (Countrywide Integration Non-communicable Diseases Intervention) Programme. Three preventive practices are analysed: reported blood pressure and blood cholesterol measurements and reported antismoking counseling during the last year. Data are presented separately for the general population and for people reporting specific chronic conditions (cardiovascular disease, respiratory disease and/or diabetes mellitus). RESULTS: Blood pressure measurement and antismoking counseling are more frequently reported to be carried out by primary health care physicians in the Eastern European areas while blood cholesterol measurement is more frequently reported in Western European countries. All these preventive activities are more frequently reported to be done among people with chronic conditions than in the population as a whole. CONCLUSIONS: Major differences have been found in reported preventive practices between Eastern and Western European countries. Great potential exists for chronic disease prevention among them.

Occasional smoking increases total and cardiovascular mortality among men.

The aim was to study whether occasional smoking increases mortality risk. The mortality of random samples of the Finnish Adult Health Behavior surveys from 1978 to 1991 were followed for 18 years from 1978 to 1995. Poisson models were used to determine the risk of total and cardiovascular mortality. It was found that occasional smokers were less often sedentary and had less often unhealthy diet than other smoking status groups. Occasional smoking among men was significantly related to the risk of both total (age-adjusted relative risk, RR, 1.6, 95% confidence interval, CI, 1.3-2.1) and cardiovascular mortality (age-adjusted RR 1.5, 95% CI 1.0-2.3). Controlling for education, period and chronic morbidity did not change results. Among women no significant associations could be established; when adjusted for age, period, education and morbidity the RR for cardiovascular mortality was 1.4 (95% CI 0.6-3.4) and total mortality 1.0 (95% CI 0.6-1.6). Occasional smoking is associated with increased risk of premature death, at least among men. Although occasional smoking is a less dangerous practice than regular smoking, it is not a safe alternative for daily smoking.

Nutrition and mortality: the Finnish experience.

This paper reviews the Finnish experience concerning nutrition and mortality. In the early 70's major activities were started to change national nutritional habits, particularly in view of reducing the high mortality of cardiovascular diseases. At the same time a comprehensive monitoring system was developed. During the period from 1972 to 1997 major changes took place in national nutrition, in accordance with the set objectives. Associated with this, major reduction was observed in national CVD mortality. The Finnish experience gives great support to the hypothesis that population rates of cardiovascular diseases can be substantially influenced by changes in people's dietary habits.

International Quit and Win 1996: comparative evaluation study in China and Finland.

OBJECTIVES: To compare background and process variables, as well as follow up status, of the participants in the International Quit and Win '96 contests of China and Finland, and analyse factors contributing to sustained maintenance. DESIGN: A standardised 12 month follow up was conducted in both countries with random samples of participants. The sample sizes were 3119 in China and 1448 in Finland, with response rates of 91.2% and 65.2%, respectively. INTERVENTIONS: The International Quit and Win '96 contest was the second coordinated, multinational smoking cessation campaign targeted at adult daily smokers. Altogether 25 countries participated, including China with 15 000 and Finland with 6000 smokers registered. MAIN OUTCOME MEASURES: Conservative (considering all non-respondents relapsed) and non-conservative (based on respondents only) estimates were calculated for one month abstinence, 12 month continuous abstinence, and point abstinence at the time point of follow up. RESULTS: Great differences were found in the background and process variables, as well as in the outcome measures. At one year follow up, the conservative continuous abstinence rates show that the Chinese participants maintained their abstinence better (38%) compared to the Finnish ones (12%). In China women reached higher abstinence rate (50%) than men (36%), whereas in Finland men achieved a better result (14%) than women (9%). CONCLUSIONS: The Quit and Win contest is a mass smoking cessation method feasible in countries showing great variance in smoking habits and rates. However, in countries with different stages of anti-smoking development, such as China and Finland, different practical implementation strategies may be needed.

Relation of adult height to cause-specific and total mortality: a prospective follow-up study of 31,199 middle-aged men and women in Finland.

The purpose of this study was to analyze the association of adult height with cause-specific and total mortality. The study included 31,199 men and women aged 25-64 years who participated in a risk factor survey in 1972, 1977, 1982, or 1987 in eastern Finland. The cohorts were followed until the end of 1994. The relation between height and mortality was assessed by using Cox proportional hazard models. The authors found that height was associated inversely with most of the measured risk factors and directly with socioeconomic status. For both genders, height was inversely associated with cardiovascular and total mortality; the age- and birth-cohort-adjusted risk ratios per 5 cm increase in height were 0.89 and 0.91 for men and 0.86 and 0.90 for women, respectively. The inverse association also remained after adjustment for the other known risk factors. For men, an independent inverse association also was found between height and mortality from chronic obstructive pulmonary disease and from violence and accidents. Cancer mortality was not associated with height. Thus, genetic factors, and environmental factors during the fetal period, childhood, and adolescence, which determine adult height, appear to be related to a person's health later in life.

International Quit and Win: successful global action for smoking cessation.

Quit and Win has rapidly grown in popularity as a practical international smoking cessation activity. This is likely to be due to Quit and Win's unique, positive approach to a problem that is receiving increasing attention worldwide as a major health threat. The campaign is also a concrete channel for large international health collaboration, which is necessary considering the global nature of marketing efforts of the tobacco industry. Based on encouraging experiences of three previous international campaigns in 1994, 1996 and 1998, the next International Quit and Win will be organized in 2000. It will be larger than ever and support the new WHO Tobacco-Free Initiative.

Cardiovascular risk factor changes in Finland, 1972-1997.

BACKGROUND: The cardiovascular risk factor levels of the population have been assessed in Finland since 1972. In the beginning the surveys were done to evaluate the North Karelia Project, which was a community-based preventive programme. A national cardiovascular disease (CVD) prevention strategy was developed and implemented during the late 1970s. Subsequently, a national cardiovascular risk factors monitoring system was developed to assess the effectiveness of the national strategy. METHODS: Cross-sectional population samples were studied in 1972 and 1977 in North Karelia and Kuopio provinces in eastern Finland. An area in southwestern Finland was included in 1982, followed by the Helsinki metropolitan area in 1992 and Oulu province in northern Finland in 1997. A total of 19 761 men and 20 761 women aged 30-59 participated in the six surveys (1972, 1977, 1982, 1987, 1992, 1997). RESULTS: The serum cholesterol levels of both genders have continuously declined. Systolic blood pressure levels have declined since 1972, but no further decline in diastolic blood pressure was found in 1997. Smoking prevalence among men continued to decline mainly due to an increase in the percentage of never-smokers. For the first time the increase in smoking prevalence among women levelled off and started to decline, mainly because the number of female quitters had increased. CONCLUSIONS: These data suggest that the cardiovascular health programme in Finland has succeeded in decreasing the general risk factor level of the population.