The association of diet quality and physical activity with cardiovascular disease and mortality in 85,545 older Australians: A longitudinal study.

BACKGROUND: A quality diet and an active lifestyle are both important cornerstones of cardiovascular disease (CVD) prevention. However, despite their interlinked effects on metabolic health, the 2 behaviors are rarely considered jointly, particularly within the context of CVD prevention. We examined the independent, interactive, and joint associations of diet and physical activity with CVD hospitalization, CVD mortality, and all-cause mortality. METHODS: CVD-free Australian participants aged 45-74 years (n = 85,545) reported physical activity, diet, and sociodemographic and lifestyle characteristics at baseline (2006-2009) and follow-up (2012-2015), and data were linked to hospitalization and death registries (03/31/2019 for CVD hospitalization and all-cause mortality and 12/08/2017 for CVD mortality). Diet quality was categorized as low, medium, and high based on meeting dietary recommendations. Physical activity was operationalized as (a) total moderate-to-vigorous physical activity (MVPA) as per guidelines, and (b) the composition of MVPA as the ratio of vigorous-intensity physical activity (VPA) to total MVPA. We used a left-truncated cause-specific Cox proportional hazards model using time-varying covariates. RESULTS: During a median of 10.7 years of follow-up, 6581 participants were admitted to the hospital for CVD and 6586 died from all causes (879 from CVD during 9.3 years). A high-quality diet was associated with a 17% lower risk of all-cause mortality than a low-quality diet, and the highest MVPA category (compared with the lowest) was associated with a 44% and 48% lower risk of CVD and all-cause mortality, respectively. Multiplicative interactions between diet and physical activity were non-significant. For all outcomes, the lowest risk combinations involved a high-quality diet and the highest MVPA categories. Accounting for total MVPA, some VPA was associated with further risk reduction of CVD hospitalization and all-cause mortality. CONCLUSION: For CVD prevention and longevity, one should adhere to both a healthy diet and an active lifestyle and incorporate some VPA when possible.

High but decreasing rates of reconstruction after total proctocolectomy for ulcerative colitis, and evidence of a direct volume outcome relationship.

BACKGROUND: Total (procto)colectomy is indicated in 15%-20% of ulcerative colitis(UC) patients during their disease course. Reconstruction options to avoid a permanent ileostomy include an ileoanal pouch anastomosis (IPAA) or ileorectal anastomosis (IRA). This study aimed to investigate reconstruction rates using Australian-based population-level data, and factors influencing reconstruction. METHODS: A retrospective data linkage study of the NSW population over a 19-year period was performed. Patients with UC who underwent total (procto)colectomy with a minimum of 1-year follow up were included. The main outcome was reconstruction with either IPAA or IRA. The influence of hospital and patient factors on reconstruction rates was assessed by Cox regression. RESULTS: Overall, 1047 patients underwent a (procto)colectomy for UC (mean age 45.9 years [SD ± 18.3], 640 [61.1%] male). The 5-year reconstruction rate was 55% (IPAA 89%). Advanced age, emergent colectomy, higher comorbidity burden, and geographical remoteness were significantly associated with lower reconstruction rates. A lower reconstruction rate was also observed in the most recent time-period (2014-2019) (aHR 0.68[95% CI 0.54-0.86]), and where index (procto)colectomy was performed in low-volume (<1 pouch/year) pouch hospitals (aHR 0.60 [95% CI 0.43-0.82]). CONCLUSIONS: NSW Australia has the highest reported rate of reconstruction following UC (procto)colectomy globally. However, rates reduced in the most recent time-period. There was variation in reconstruction rates across centres, with primary and overall reconstruction rates proportionate to hospital pouch volume. Reconstruction rates were also lower for patients living outside major cities. To ensure equitable opportunities for reconstruction, patients being considered for IBD pouch surgery should be centralized to a limited number of specialist pouch centres.

Reducing rate of total colectomies for ulcerative colitis but higher morbidity in the biologic era: an 18-year linked data study from New South Wales Australia.

BACKGROUND: This study aims to investigate the trends in UC surgery in New South Wales (NSW) at a population level. METHODS: A retrospective data linkage study of the NSW population was performed. Patients of any age with a diagnosis of UC who underwent a total abdominal colectomy (TAC) ± proctectomy between Jul-2001 and Jun-2019 were included. The age adjusted population rate was calculated using Australian Bureau of Statistics data. Multivariable linear regression modelled the trend of TAC rates, and assessed the effect of infliximab (listed on the Pharmaceutical Benefits Scheme for UC in Apr-2014). RESULTS: A total of 1365 patients underwent a TAC ± proctectomy (mean age 47.0 years (±18.6), 59% Male). Controlling for differences between age groups, the annual rate of UC TACs decreased by 2.4% each year (95% CI 1.4%-3.4%) over the 18-year period from 1.30/100000 (2002) to 0.84/100000 (2019). An additional incremental decrease in the rate of TACs was observed after 2014 (OR 0.83, 95% CI 0.69-1.00). There was no change in the proportion of TACs performed emergently over the study period (OR 1.02, 95% CI 0.998-1.04). The odds of experiencing any perioperative surgical complication (aOR 1.54, 95% CI 1.01-2.33, P = 0.043), and requiring ICU admission (aOR 1.85, 95% CI 1.24-2.76, P = 0.003) significantly increased in 2014-2019 compared to 2002-2007. CONCLUSIONS: The rate of TACs for UC has declined over the past two decades. This rate decrease may have been further influenced by the introduction of biologics. Higher rates of complications and ICU admissions in the biologic era may indicate poorer patient physiological status at the time of surgery.

Population outcomes, trends and the future of pouch surgery for ulcerative colitis: a 19-year New South Wales data linkage study.

BACKGROUND: Ileal pouch-anal anastomosis (IPAA) is considered the gold standard reconstructive option in ulcerative colitis (UC). Recent efforts to improve pouch outcomes have seen a push towards centralisation of surgery. This study aimed to document outcomes following pouch surgery at a population level within New South Wales (NSW), and identify factors associated with, and temporal trends of these outcomes. METHODS: A retrospective data linkage study of the NSW population over a 19-year period was performed. The primary outcome was pouch failure in patients with UC who underwent IPAA. The influence of hospital level factors (including annual volume) and patient demographic variables on this outcome were assessed using Cox proportional hazards modelling. Temporal trends in annual volume and evidence for centralisation over the studied period were assessed using Poisson regression analysis. RESULTS: The annual volume of UC pouches reduced over the study period. The pouch failure rates were 8.6% (95% CI 6.3-10.8%) and 10.6% (95% CI 8.0-13.1%) at 5- and 10-years, respectively. Increasing age and non-elective admission were associated with higher failure rates. One-third of UC pouches (31.6%) were performed in a single institution, which averaged 6.5 pouches/year throughout the study period. Three-quarters (19/25) of NSW public hospitals who performed pouches performed less than one UC pouch annually. CONCLUSIONS: The outcomes following UC pouch surgery in NSW are comparable with global standards. Concentrating IBD pouch surgery with the aim of producing specialist surgical teams may be a reasonable way forward in NSW and would ensure equity of access and facilitate research and training collaboration.

The impact of the 2019/2020 Australian landscape fires on infant feeding and contaminants in breast milk in women with asthma.

BACKGROUND: The 2019/2020 Australian landscape fires (bushfires) resulted in prolonged extreme air pollution; little is known about the effects on breastfeeding women and their infants. This study aimed to examine the impact of prolonged landscape fires on infant feeding methods and assess the concentration of polycyclic aromatic hydrocarbons (PAHs) and elements in breast milk samples. METHODS: From May - December 2020, women with asthma, who were feeding their infants during the fires, were recruited from an existing cohort. Data on infant feeding and maternal concern during the fires were retrospectively collected. Breast milk samples were collected from a sample of women during the fire period and compared with samples collected outside of the fire period for levels of 16 PAHs (gas chromatography coupled with mass spectrometry), and 20 elements (inductively coupled plasma-mass spectrometry). RESULTS: One-hundred-and-two women who were feeding infants completed the survey, and 77 provided 92 breast milk samples. Two women reported concern about the impact of fire events on their infant feeding method, while four reported the events influenced their decision. PAHs were detected in 34% of samples collected during, versus no samples collected outside, the fire period (cross-sectional analysis); specifically, fluoranthene (median concentration 0.015 mg/kg) and pyrene (median concentration 0.008 mg/kg) were detected. Women whose samples contained fluoranthene and pyrene were exposed to higher levels of fire-related fine particulate matter and more fire days, versus women whose samples had no detectable fluoranthene and pyrene. Calcium, potassium, magnesium, sodium, sulphur, and copper were detected in all samples. No samples contained chromium, lead, nickel, barium, or aluminium. No statistically significant difference was observed in the concentration of elements between samples collected during the fire period versus outside the fire period. CONCLUSIONS: Few women had concerns about the impact of fire events on infant feeding. Detection of fluoranthene and pyrene in breast milk samples was more likely during the 2019/2020 Australian fire period; however, levels detected were much lower than levels expected to be related to adverse health outcomes.

Acute health effects of bushfire smoke on mortality in Sydney, Australia.

BACKGROUND: Bushfire smoke is a major ongoing environmental hazard in Australia. In the summer of 2019-2020 smoke from an extreme bushfire event exposed large populations to high concentrations of particulate matter (PM) pollution. In this study we aimed to estimate the effect of bushfire-related PM of less than 2.5 µm in diameter (PM2.5) on the risk of mortality in Sydney, Australia from 2010 to 2020. METHODS: We estimated concentrations of PM2.5 for three subregions of Sydney from measurements at monitoring stations using inverse-distance weighting and cross-referenced extreme days (95th percentile or above) with satellite imagery to determine if bushfire smoke was present. We then used a seasonal and trend decomposition method to estimate the Non-bushfire PM2.5 concentrations on those days. Daily PM2.5 concentrations above the Non-bushfire concentrations on bushfire smoke days were deemed to be Bushfire PM2.5. We used distributed-lag non-linear models to estimate the effect of Bushfire and Non-bushfire PM2.5 on daily counts of mortality with sub-analyses by age. These models controlled for seasonal trends in mortality as well as daily temperature, day of week and public holidays. RESULTS: Within the three subregions, between 110 and 134 days were identified as extreme bushfire smoke days within the subregions of Sydney. Bushfire-related PM2.5 ranged from 6.3 to 115.4 µg/m3. A 0 to 10 µg/m3 increase in Bushfire PM2.5 was associated with a 3.2% (95% CI 0.3, 6.2%) increase in risk of all-cause death, cumulatively, in the 3 days following exposure. These effects were present in those aged 65 years and over, while no effect was observed in people under 65 years. CONCLUSION: Bushfire PM2.5 exposure is associated with an increased risk of mortality, particularly in those over 65 years of age. This increase in risk was clearest at Bushfire PM2.5 concentrations up to 30 µg/m3 above background (Non-bushfire), with possible plateauing at higher concentrations of Bushfire PM2.5.

How many days of indoor positioning system data are required to characterise typical movement behaviours of office workers?

Indoor Positioning Systems (IPS) appear to offer great potential to study the movement and interaction of people and their working environment, including office workplaces. But little is known about appropriate durations for data collection. In this study, location observations collected from 24 office workers on a 1220 m2 office floor over a 3-month period, were analysed to determine how many days are required to estimate their typical movement and spatial behaviours. The analysis showed that up to 8 days of data was sufficient to characterise participants' typical daily movement behaviours and 10 days were required to estimate their typical spatial mobility. However, the results also indicate that 5 weeks of data collection are required to gather the necessary 10 days of data from each participant. These findings will help researchers and workplace professionals to understand the capabilities and requirements of IPS when considering their use in indoor work environments.

The impact of prolonged landscape fire smoke exposure on women with asthma in Australia.

BACKGROUND: Little is known about the physical and mental health impact of exposure to landscape fire smoke in women with asthma. This study examined the health impacts and information-seeking behaviours of women with asthma exposed to the 2019/2020 Australian fires, including women who were pregnant. METHODS: Women with asthma were recruited from the Breathing for Life Trial in Australia. Following the landscape fire exposure period, self-reported data were collected regarding symptoms (respiratory and non-respiratory), asthma exacerbations, wellbeing, quality of life, information seeking, and landscape fire smoke exposure mitigation strategies. Participants' primary residential location and fixed site monitoring was used to geolocate and estimate exposure to landscape fire-related fine Particulate Matter (PM2.5). RESULTS: The survey was completed by 81 pregnant, 70 breastfeeding and 232 non-pregnant and non-breastfeeding women with asthma. Participants had a median daily average of 17 µg/m3 PM2.5 and 105 µg/m3 peak PM2.5 exposure over the fire period (October 2019 to February 2020). Over 80% of participants reported non-respiratory and respiratory symptoms during the fire period and 41% reported persistent symptoms. Over 82% reported asthma symptoms and exacerbations of asthma during the fire period. Half the participants sought advice from a health professional for their symptoms. Most (97%) kept windows/doors shut when inside and 94% stayed indoors to minimise exposure to landscape fire smoke. Over two in five (43%) participants reported that their capacity to participate in usual activities was reduced due to prolonged smoke exposure during the fire period. Participants reported greater anxiety during the fire period than after the fire period (mean (SD) = 53(13) versus 39 (13); p < 0.001). Two in five (38%) pregnant participants reported having concerns about the effect of fire events on their pregnancy. CONCLUSION: Prolonged landscape fire smoke exposure during the 2019/2020 Australian fire period had a significant impact on the health and wellbeing of women with asthma, including pregnant women with asthma. This was despite most women taking actions to minimise exposure to landscape fire smoke. Effective and consistent public health messaging is needed during landscape fire events to guard the health of women with asthma.

Correction: Standen et al. Aboriginal Population and Climate Change in Australia: Implications for Health and Adaptation Planning. Int. J. Environ. Res. Public Health 2022, 19, 7502

In the original publication [...].

Physical activity, diet quality and all-cause cardiovascular disease and cancer mortality: a prospective study of 346 627 UK Biobank participants.

OBJECTIVES: To examine independent and interactive associations of physical activity and diet with all-cause, cardiovascular disease (CVD) and physical activity, diet and adiposity-related (PDAR) cancer mortality. METHODS: This population-based prospective cohort study (n=346 627) is based on the UK Biobank data with linkage to the National Health Service death records to 30 April 2020. A left-truncated Cox proportional hazards model was fitted to examine the associations between exposures (self-reported total moderate-to-vigorous intensity physical activity (MVPA), vigorous-intensity physical activity (VPA) and a diet quality index (score ranged 0-3)) and outcomes (all-cause, CVD and PDAR cancer mortality). RESULTS: During a median follow-up of 11.2 years, 13 869 participants died from all causes, 2650 from CVD and 4522 from PDAR cancers. Compared with quartile 1 (Q1, 0-210 min/week), Q2-Q4 of MVPA were associated with lower risks of all-cause (HR ranged from 0.87 (95% CI: 0.83 to 0.91) to 0.91 (95% CI: 0.87 to 0.96)), CVD (HR ranged from 0.85 (95% CI: 0.76 to 0.95) to 0.90 (95% CI: 0.81 to 1.00)) and PDAR cancer mortality (HR ranged from 0.86 (95% CI: 0.79 to 0.93) to 0.94 (95% CI: 0.86 to 1.02)). Compared with no VPA, any VPA was associated with lower risk for all-cause and CVD mortality (HR ranged from 0.85 (95% CI: 0.80 to 0.89) to 0.88 (95% CI: 0.84 to 0.93) and from 0.75 (95% CI: 0.68 to 0.83) to 0.90 (95% CI: 0.80 to 1.02), respectively). Although not reaching statistical significance for all-cause and CVD mortality, being in the best dietary category (diet quality index=2-3) was associated with a reduction in PDAR cancer mortality (HR=0.86, 95% CI: 0.78 to 0.93). No additive or multiplicative interactions between physical activity categories and dietary quality was found. When comparing across physical activity and diet combinations, the lowest risk combinations consistently included the higher levels of physical activity and the highest diet quality score. CONCLUSIONS: Adhering to both quality diet and sufficient physical activity is important for optimally reducing the risk of mortality from all causes, CVD and PDAR cancers.

Aboriginal Population and Climate Change in Australia: Implications for Health and Adaptation Planning.

The health impacts of climate are widely recognised, and extensive modelling is available on predicted changes to climate globally. The impact of these changes may affect populations differently depending on a range of factors, including geography, socioeconomics and culture. This study reviewed current evidence on the health risks of climate change for Australian Aboriginal populations and linked Aboriginal demographic data to historical and projected climate data to describe the distribution of climate-related exposures in Aboriginal compared to non-Aboriginal populations in New South Wales (NSW), Australia. The study showed Aboriginal populations were disproportionately exposed to a range of climate extremes in heat, rainfall and drought, and this disproportionate exposure was predicted to increase with climate change over the coming decades. Aboriginal people currently experience higher rates of climate-sensitive health conditions and socioeconomic disadvantages, which will impact their capacity to adapt to climate change. Climate change may also adversely affect cultural practices. These factors will likely impact the health and well-being of Aboriginal people in NSW and inhibit measures to close the gap in health between Aboriginal and non-Aboriginal populations. Climate change, health and equity need to be key considerations in all policies at all levels of government. Effective Aboriginal community engagement is urgently needed to develop and implement climate adaptation responses to improve health and social service preparedness and secure environmental health infrastructure such as drinking water supplies and suitably managed social housing. Further Aboriginal-led research is required to identify the cultural impacts of climate change on health, including adaptive responses based on Aboriginal knowledges.

Hepatitis C testing in general practice settings: A cross-sectional study of people who inject drugs in Australia.

BACKGROUND: People who inject drugs (PWID) often do not receive confirmatory RNA testing following positive HCV antibody testing. Expanding access to adequate testing and assessment will improve the progression of patients through the HCV care cascade with the potential to improve diagnosis as well as linkage to treatment. We aimed to determine current utilisation of general practitioners (GPs) by PWID in Australia compared to other settings for HCV testing and post-test discussions. METHODS: A national sample (n=888) of people who had injected drugs regularly in the past 6 months was interviewed about HCV antibody, RNA testing, and post-test discussions, and the settings where these took place. RESULTS: The majority of participants (n=735; 93%) reported antibody testing. Among participants who reported a positive result (n=435), 54% identified their regular GP as the setting where their most recent antibody test was conducted. Confirmatory RNA testing was reported by 60% (n=274) of those who reported being antibody positive. Among those who reported RNA testing (n=257), the most common setting reported was their regular GP (48%). There were no differences in the proportions who recalled post-test discussions at GPs compared to other settings. CONCLUSION: HCV testing was most frequently undertaken by participants' regular GP. GPs are currently providing testing and post-test discussions at similar proportions to other more specialised settings. However, RNA testing is incomplete for more than one-third of the antibody positive PWID interviewed. Our findings suggest that the general practice setting is a common and accessible setting for PWID to access HCV testing. Targeting GPs to improve follow-up of positive antibody tests may help to improve patient progression through the HCV care cascade.

The recovery of online drug markets following law enforcement and other disruptions.

INTRODUCTION: Online drug markets operating on the 'darknet' ('cryptomarkets') facilitate the trade of illicit substances at an international level. The present study assessed the longitudinal impact on cryptomarket trading of two major disruptions: a large international law enforcement operation, 'Operation Onymous'; and the closure of the largest cryptomarket, Evolution. METHODS: Almost 1150 weekly snapshots of a total of 39 cryptomarkets were collected between October 2013 and November 2015. Data were collapsed by month and the number of unique vendor aliases operating across markets was assessed using interrupted time series regression. RESULTS: Following both Operation Onymous and the closure of Evolution, significant drops of 627 (p=0.014) and 910 vendors (p<0.001) were observed, respectively. However, neither disruption significantly affected the rate at which vendor numbers increased overall. CONCLUSIONS: Operation Onymous and the closure of Evolution were associated with considerable, though temporary, reductions in the number of vendors operating across cryptomarkets. Vendor numbers, however, recovered at a constant rate. While these disruptions likely impacted cryptomarket trading at the time, these markets appear resilient to disruption long-term.

I like the old stuff better than the new stuff? Subjective experiences of new psychoactive substances.

BACKGROUND: Over the past decade, monitoring systems have identified the rapid emergence of new psychoactive substances (NPS). While the use of many NPS is minimal and transitory, little is known about which products have potential for capturing the attention of significant proportions of the drug consuming market. The aim of this study was to explore self-reported experiences of three commonly used NPS classes within the Australian context (synthetic cathinones, hallucinogenic phenethylamines and hallucinogenic tryptamines) relative to traditional illicit drug counterparts. METHODS: Frequent psychostimulant consumers interviewed for the Australian Ecstasy and related Drugs Reporting System (EDRS) (n=1208) provided subjective ratings of the pleasurable and negative (acute and longer-term) effects of substances used in the last six months on the last occasion of use, and the likelihood of future use. RESULTS: Stimulant-type NPS (e.g., mephedrone, methylone) were rated less favourably than ecstasy and cocaine in terms of pleasurable effects and likelihood of future use. DMT (a hallucinogenic tryptamine) showed a similar profile to LSD in terms of pleasurable effects and the likelihood of future use, but negative effects (acute and comedown) were rated lower. Hallucinogenic phenethylamines (e.g., 2C-B) showed a similar negative profile to LSD, but were rated as less pleasurable and less likely to be used again. CONCLUSION: The potential for expanded use of stimulant-type NPS may be lower compared to commonly used stimulants such as ecstasy and cocaine. In contrast, the potential of DMT may be higher relative to LSD given the comparative absence of negative effects.

Who sells what? Country specific differences in substance availability on the Agora cryptomarket.

BACKGROUND: To date monitoring of cryptomarkets operating on the dark net has largely focused on market size and substance availability. Less is known of country specific differences in these indicators and how they may corroborate population prevalence estimates for substance use in different countries. METHODS: All substance listings from the cryptomarket Agora were recorded over seven time points throughout February and March 2015. Agora was chosen due to its size as the second largest cryptomarket operating and the level of detail of information provided in individual substance listings. Data were collated and the number of unique sellers selling each substance by country of origin was analysed. RESULTS: An average of 14,456.7 substance listings were identified across sampled days from 868.7 unique sellers. The top five countries by number of listings were the USA, United Kingdom, Australia, China and the Netherlands, collectively accounting for 61.8% of all identified listings and 68% of all unique sellers. Australia was over represented in terms of sellers per capita, while China was over represented in new psychoactive substance (NPS) listings. When examined by number of listings per seller, the Netherlands and China stood out as particularly large, likely due to these countries' role in the local production of various illicit and new psychoactive substances. CONCLUSIONS: Numbers of sellers by country of origin appear to be influenced by several factors. Australia's overrepresentation in sellers per capita may indicate its relative geographical isolation and the potential for profit margins from selling online, while China's overrepresentation in NPS listings may reflect domestic production of these substances. Continued monitoring will provide enhanced understanding of the increasingly complex and globalised nature of illicit drug markets.

Characterising dark net marketplace purchasers in a sample of regular psychostimulant users.

BACKGROUND: The past five years has seen a proliferation in marketplaces operating on the 'dark net' selling licit and illicit substances. While monitoring systems have investigated the specific substances for sale on these marketplaces, less is known about consumer motivations for accessing these marketplaces and factors associated with their use. METHODS: An Australian national sample (n=800) recruited on the basis of regular psychostimulant use was recruited and asked about purchasing substances from dark net marketplaces and the reasons for doing so. Respondents who had purchased any drug from a dark net marketplace in the preceding year were compared to those who had not in terms of demographic information and factors including drug use, criminal activity, and sexual and mental health. RESULTS: Nine percent (n=68) of the sample had purchased from dark net markets in the past year. MDMA, LSD and cannabis were the three most commonly purchased substances, and the main benefits cited for purchasing online were the better quality and lower cost of drugs available. Controlling for other factors, participants who purchased from dark net marketplaces in the past year tended to be younger, more likely to be involved in recent property crime and to have used more classes of drugs in the preceding six months, specifically psychedelics and 'new psychoactive drugs'. CONCLUSIONS: Though a small minority of participants reported having purchased drugs online in the preceding six months, these appeared to be a more 'entrenched' group of consumers, with more diverse substance use and rates of criminal activity. For consumers in the current sample reporting recent dark net usage, country borders are now less of a significant barrier to purchase and there is a wider range of substances available than ever before.

The rise of new psychoactive substance use in Australia.

New Psychoactive Substances are now a feature of Australia's recreational drug market. Little is known, however, about the prevalence of use, the characteristics of people who use them and the relationship between the NPS and ecstasy markets. This study examined the prevalence and correlates of NPS use amongst a group of regular ecstasy users in Australia. Participants were recruited if they had used ecstasy at least six times in the previous six months, lived in a capital city and were over 16 years of age. Purposive sampling was used, recruiting through universities and colleges, word of mouth and street press. 654 participants were recruited in 2013. Respondents who had used an NPS in the past six months were compared to those who had not. NPS were used by 44% of the total sample. In 2013 2C-I (14%) and 2C-B (8%) were the most prevalent NPS. Respondents in the NPS group were younger and reported more frequent use of more types of drugs. They were also more likely to rate the purity of ecstasy as low relative to those in the no NPS group. NPS are now an established part of Australia's recreational drug scene and NPS with hallucinogenic effects are now used most commonly. Monitoring systems need to develop capacity to monitor this highly dynamic market.