The Cost-Effectiveness of Primary Prevention Interventions for Skin Cancer: An Updated Systematic Review.

OBJECTIVE: Preventing the onset of skin malignancies is feasible by reducing exposure to ultraviolet radiation. We reviewed published economic evaluations of primary prevention initiatives in the past decade, to support investment decisions for skin cancer prevention. METHODS: We assessed cost-effectiveness, cost-utility and benefit-cost analyses published from 1 September 2013. Seven databases were searched on 18 July 2023 and updated on 15 November 2023. Studies must have reported outcomes in terms of monetary costs, life years, quality-adjusted life years or variant thereof. A narrative synthesis was undertaken and reporting quality was assessed by three reviewers using the Consolidated Health Economic Evaluation Reporting Standards checklist. RESULTS: In total, 12 studies were included with five studies located in Australia; three in North America and the remaining four in Europe. Interventions included restricting the use of indoor tanning devices (7 studies), television advertising, multi-component sun safety campaigns, shade structures plus protective clothing provision for outdoor workers and provision of melanoma genomic risk information to individuals. Most studies constructed Markov cohort models and adopted a societal cost perspective. Overall, the reporting quality of the studies was high. Studies found highly favourable returns on investment ranging from US$0.35 for every $1 spent on prevention, up to €3.60 for every €1 spent. Other studies showed substantial skin cancers avoided, gains in life years, quality-adjusted survival, and societal cost savings. CONCLUSIONS: From both population health and economic perspectives, allocating limited health care resources to primary prevention of skin cancer is highly favourable.

Feasibility of Amulet occluder implantation after failed left atrial appendage occlusion attempt: Insights from the EMERGE LAA postapproval study.

BACKGROUND: Although expertise in left atrial appendage occlusion (LAAO) has grown, certain intricate anatomies may pose challenges, rendering them unsuitable for LAAO with the selected device. OBJECTIVE: This analysis aimed to characterize outcomes of patients with prior failed percutaneous LAAO procedures who underwent a subsequent attempt with an Amulet occluder in the EMERGE LAA postapproval study. METHODS: Patients enrolled in the National Cardiovascular Data Registry LAAO Registry who had an Amulet occluder implantation attempt between Food and Drug Administration approval (August 14, 2021) and June 30, 2023, were evaluated. A safety end point through 7 days or hospital discharge (whichever was later) and major adverse events through 45 days were reported. RESULTS: A total of 8591 patients underwent attempted Amulet occluder implantation, of whom 244 patients had prior failed LAAO. Implantation success was 88.9% and 96.2% in patients with prior failed LAAO and index LAAO, respectively (P < .001). The safety composite end point was low, occurring in 1.6% and 0.8% of patients with prior failed LAAO and index LAAO, respectively (P = .148). Any major adverse event through 45 days occurred in 7.4% and 6.3% of prior failed LAAO and index LAAO patient cohorts, respectively (P = .497); most adverse events were similar between the groups (P > .05). At 45 days, peridevice leak ≤3 mm was achieved in >90% of patients in either group. CONCLUSION: A high degree of implantation success with a low rate of adverse events can be achieved with the Amulet occluder. The findings imply that the dual occlusive mechanism Amulet occluder facilitates successful closure, even in challenging anatomic scenarios.

Comparison of ten policy options to equitably reduce children's exposure to unhealthy food marketing.

OBJECTIVE: Reducing children's exposure to unhealthy food marketing is crucial to combat childhood obesity. We aimed to estimate the reduction of children's exposure to food marketing under different policy scenarios and assess exposure differences by socio-economic status. DESIGN: Data on children's exposure to unhealthy food marketing were compiled from a previous cross-sectional study in which children (n 168) wore wearable cameras and Global Positioning System (GPS) units for 4 consecutive days. For each exposure, we identified the setting, the marketing medium and food/beverage product category. We analysed the percentage reduction in food marketing exposure for ten policy scenarios and by socio-economic deprivation: (1) no product packaging, (2) no merchandise marketing, (3) no sugary drink marketing, (4) no confectionary marketing in schools, (5) no sugary drink marketing in schools, (6) no marketing in public spaces, (7) no marketing within 400 m of schools, (8) no marketing within 400 m of recreation venues, (9) no marketing within 400 m of bus stops and (10) no marketing within 400 m of major roads. SETTING: Wellington region of New Zealand. PARTICIPANTS: 168 children aged 11-14 years. RESULTS: Exposure to food marketing varied by setting, marketing medium and product category. Among the ten policy scenarios, the largest reductions were for plain packaging (60·3 %), no sugary drink marketing (28·8 %) and no marketing in public spaces (22·2 %). There were no differences by socio-economic deprivation. CONCLUSIONS: The results suggest that plain packaging would result in the greatest decrease in children's exposure to food marketing. However, given that children are regularly exposed to unhealthy food marketing in multiple settings through a range of marketing mediums, comprehensive bans are needed to protect children's health.

Generating political priority for alcohol policy reform: A framework to guide advocacy and research.

INTRODUCTION: While effective policies exist to reduce alcohol-related harm, political will to enact them is low in many jurisdictions. We aimed to identify key barriers and strategies for strengthening political priority for alcohol policy reform. METHODS: A framework synthesis was conducted, incorporating relevant theory, key informant interviews (n = 37) and a scoping review. Thematic analysis informed the development of a framework for understanding and influencing political priority for alcohol policy. RESULTS: Twelve barriers and 14 strategies were identified at multiple levels (global, national and local). Major barriers included neoliberal or free trade ideology, the globalised alcohol industry, limited advocate capacity and the normalisation of alcohol harms. Strategies fell into two categories: sector-specific and system change initiatives. Sector-specific strategies primarily focus on influencing policymakers and mobilising civil society. Examples include developing a clear, unified solution, coalition building and effective framing. System change initiatives target structural change to reduce the power imbalance between industry and civil society, such as restricting industry involvement in policymaking and securing sustainable funding for advocacy. A key example is establishing an international treaty, similar to the Framework Convention on Tobacco Control, to support domestic policymaking. DISCUSSION AND CONCLUSIONS: Our findings provide a framework for understanding and advancing political priority for alcohol policy. The framework highlights that progress can be achieved at various levels and through diverse groups of actors. The importance of upstream drivers of policymaking was a key finding, presenting challenges for time-poor advocates, but offering potential facilitation through effective global leadership.

3-Year Outcomes From the Amplatzer Amulet Left Atrial Appendage Occluder Randomized Controlled Trial (Amulet IDE).

BACKGROUND: The Amulet (Abbott) left atrial appendage occluder investigational device exemption trial is the largest randomized trial evaluating the safety and effectiveness of the Amulet left atrial appendage occluder compared with the Watchman 2.5 device (Boston Scientific) through 5 years. OBJECTIVES: This analysis evaluated the device effect on 3-year outcomes in the Amulet investigational device exemption trial. METHODS: The medication regimen and key clinical outcomes were reported through 3 years including: 1) the composite of ischemic stroke or systemic embolism (SE); 2) the composite of all strokes, SE, or cardiovascular (CV) death; 3) major bleeding; and 4) all-cause death and CV death. RESULTS: A total of 1,878 patients at 108 sites were randomized. A significantly higher percentage of patients were free of oral anticoagulation usage at 3 years with Amulet (96.2%) vs Watchman (92.5%) (P < 0.01). Clinical outcomes were comparable for the composite of ischemic stroke or SE (5.0% vs 4.6%; P = 0.69); the composite of all strokes, SE, or CV death (11.1% vs 12.7%; P = 0.31); major bleeding (16.1% vs 14.7%; P = 0.46); all-cause death (14.6% vs 17.9%; P = 0.08); and CV death (6.6% vs 8.5%; P = 0.14) for Amulet and Watchman, respectively. Through 3 years, device factors (device-related thrombus or peridevice leak ≥3 mm) preceded ischemic stroke events and CV deaths more frequently in Watchman compared with Amulet patients. CONCLUSIONS: The Amulet occluder demonstrated continued safety and effectiveness with over 96% free of oral anticoagulation usage through 3 years in a high-risk population compared to the Watchman device. (AMPLATZER Amulet LAA Occluder Trial [Amulet IDE]; NCT02879448).

Mechanisms, predictors, and evolution of severe peri-device leaks with two different left atrial appendage occluders.

AIMS: Incomplete left atrial appendage occlusion (LAAO) due to peri-device leak (PDL) is a limitation of the therapy. The Amulet IDE trial is the largest randomized head-to-head trial comparing the Amulet and Watchman 2.5 LAAO devices with fundamentally different designs. The predictors and mechanistic factors impacting differences in PDLs within the Amulet IDE trial are assessed in the current analysis. METHODS AND RESULTS: An independent core lab analysed all images for the presence or absence of severe PDL (>5 mm). The incidence, mechanistic factors, predictors using propensity score-matched controls, and evolution of severe PDLs through 18 months were assessed. Of the 1878 patients randomized in the trial, the Amulet occluder had significantly fewer severe PDLs than the Watchman device at 45 days (1.1 vs. 3.2%, P < 0.001) and 12 months (0.1 vs. 1.1%, P < 0.001). Off-axis deployment or missed lobes were leading mechanistic PDL factors in each device group. Larger left atrial appendage (LAA) dimensions including orifice diameter, landing zone diameter, and depth predicted severe PDL with the Watchman device, with no significant anatomical limitations noted with the Amulet occluder. Procedural and device implant predictors were found with the Amulet occluder attributed to the learning curve with the device. A majority of Watchman device severe PDLs did not resolve over time through 18 months. CONCLUSION: The dual-occlusive Amplatzer Amulet LAA occluder provided improved LAA closure compared with the Watchman 2.5 device. Predictors and temporal observations of severe PDLs were identified in the Amulet IDE trial. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov Unique identifier NCT02879448.

Watching the watchers: assessing the nature and extent of children's screen time using wearable cameras.

AIM: Children's screen use has increased rapidly in recent years, yet little is known about this use in real-time due to reliance on self-report or proxy data sources. Screens provide benefits such as educational content and social connection, but also pose health risks including obesity, depression, poor sleep and poor cognitive performance. In this cross-sectional observational study, we aimed to determine the nature and extent of children's after-school screen time using wearable cameras. METHOD: Children aged 11-13 years took part in the New Zealand Kids'Cam project in 2014/2015. Each child wore a camera that passively captured images of their surroundings every 7 seconds. Images from 108 children were manually coded. RESULTS: Children spent over a third of their time on screens, including over half their time after 8pm. Television accounted for the highest proportion of screen time (42.4%), followed by computers (32.0%), mobile devices (13.0%) and tablets (12.6%). Approximately 10% of children's screen time involved multiple screen use. CONCLUSION: Guidelines are needed to promote healthy screen time behaviour among children. Further research is also needed to monitor the impact of screens on children's wellbeing, including any socio-demographic differences, and to identify innovations to protect children from harm in the online space.

The Epidemiology of Domain-Specific Physical Activity in New Zealand Adults: A Nationally Representative Cross-Sectional Survey.

BACKGROUND: Surveillance of domain-specific physical activity (PA) helps to target interventions to promote PA. We examined the sociodemographic correlates of domain-specific PA in New Zealand adults. METHODS: A nationally representative sample of 13,887 adults completed the International PA Questionnaire-long form in 2019/20. Three measures of total and domain-specific (leisure, travel, home, and work) PA were calculated: (1) weekly participation, (2) mean weekly metabolic energy equivalent minutes (MET-min), and (3) median weekly MET-min among those who undertook PA. Results were weighted to the New Zealand adult population. RESULTS: The average contribution of domain-specific activity to total PA was 37.5% for work activities (participation = 43.6%; median participating MET-min = 2790), 31.9% for home activities (participation = 82.2%; median participating MET-min = 1185), 19.4% for leisure activities (participation = 64.7%; median participating MET-min = 933), and 11.2% for travel activities (participation = 64.0%; median MET-min among participants = 495). Women accumulated more home PA and less work PA than men. Total PA was higher in middle-aged adults, with diverse patterns by age within domains. Maori accumulated less leisure PA than New Zealand Europeans but higher total PA. Asian groups reported lower PA across all domains. Higher area deprivation was negatively associated with leisure PA. Sociodemographic patterns varied by measure. For example, gender was not associated with total PA participation, but men accumulated higher MET-min when taking part in PA than women. CONCLUSIONS: Inequalities in PA varied by domain and sociodemographic group. These results should be used to inform interventions to improve PA.

Incidence, Predictors, and Clinical Outcomes of Device-Related Thrombus in the Amulet IDE Trial.

BACKGROUND: Device-related thrombus (DRT) following left atrial appendage occlusion (LAAO) can lead to adverse clinical outcomes. DRT rates and outcomes from randomized trials are limited. OBJECTIVES: This analysis investigated the incidence, predictors, and clinical outcomes of DRT following LAAO in the Amulet IDE (AMPLATZER Amulet LAA Occluder Trial) trial. METHODS: Successful implants occurred in 903 patients with an Amulet occluder (dual occlusive mechanism device) and 885 patients with a Watchman device (single occlusive mechanism device). These patients were then followed through 18 months and DRT was assessed by transesophageal echocardiography. RESULTS: The overall incidence of DRT was 3.9% (n = 70) with 3.4% (n = 30) in dual occlusive mechanism device patients and 4.8% (n = 40) in single occlusive mechanism device patients. Most DRTs (n = 19 of 31) were identified early (≤45 days) on the dual occlusive mechanism device, whereas most of the DRTs (n = 31 of 42) were identified late (>45 days) on the single occlusive mechanism device. Strong predictors of DRT included atrial fibrillation at time of procedure (HR: 2.44; 95% CI: 1.42-4.22; P < 0.01), female sex (HR: 1.65; 95% CI: 1.01-2.71; P = 0.04), and older age (HR: 1.04; 95% CI: 1.01-1.08; P = 0.02). There were no stroke events following DRT in the dual occlusive mechanism device group and 3 stroke events following DRT in the single occlusive mechanism device group. Patients with DRT were at a greater risk for cardiovascular mortality compared with non-DRT patients (8.7% vs 3.9%; HR: 2.33; 95% CI: 1.01-5.39; P = 0.04). CONCLUSIONS: Incidence of DRT following LAAO was low. Early DRTs are seen with the dual occlusive mechanism device and late DRTs are seen with the single occlusive mechanism device. Increased cardiovascular mortality risk in patients with DRT should be further investigated. (AMPLATZER Amulet LAA Occluder Trial; NCT02879448).

Outcomes of the roll-in cohort of the Amulet IDE trial of left atrial appendage occlusion.

Background: Left atrial appendage (LAA) occlusion is an alternative therapy to oral anticoagulants to reduce stroke risk in patients with nonvalvular atrial fibrillation (NVAF). The Amulet IDE trial compared the Amplatzer™ Amulet™ occluder (Abbott) with the Watchman™ 2.5 device (Boston Scientific) for LAA occlusion in patients with NVAF. Objective: The purpose of this study was to describe outcomes of the Amulet IDE trial roll-in cohort. Methods: At US sites up to 3 patients per implanter could be implanted with the Amulet occluder in the roll-in phase. The primary Endpoints in the Amulet IDE trial included safety (composite of procedure-related complications, all-cause death, or major bleeding at 12 months), effectiveness (composite of ischemic stroke or systemic embolism at 18 months), and rate of LAA occlusion at 45 days. Results: A total of 201 roll-in patients were enrolled. Device success occurred in 99% of patients, and device closure (residual jet ≤5 mm) was observed in 98.9% of patients at 45 days. The safety endpoint rate was numerically higher (worse) in the roll-in cohort compared to the randomized Amulet occluder cohort (18.4% vs 14.5%). Six patients (3.1%) experienced an ischemic stroke and 0 patients with a systemic embolism within 18 months, which was similar to the primary effectiveness endpoint rate in the randomized Amulet occluder cohort (2.8%). Conclusions: Despite lack of experience of the operators with the Amulet occluder in the roll-in phase, device implant success was high, a high rate of device closure was achieved, and low stroke rates were observed in patients with NVAF.

Peridevice Leak After Transcatheter Left Atrial Appendage Occlusion: An Analysis of the Amulet IDE Trial.

BACKGROUND: Peridevice leak (PDL) is a limitation of left atrial appendage occlusion. OBJECTIVES: The aim of this study was to assess the incidence of and outcomes associated with PDL in the Amulet IDE (AMPLATZER™ Amulet™ LAA Occluder Trial) randomized controlled trial. METHODS: Patients with atrial fibrillation at increased stroke risk were randomly assigned to undergo either Amulet (dual occlusive mechanism) or Watchman 2.5 (single occlusive mechanism) device implantation. Transesophageal echocardiography was performed at 45 days and 12 months postprocedure. Clinically significant PDL was defined as ≥3 mm. The primary endpoint was ischemic stroke or systemic embolism, and the secondary endpoint was stroke, systemic embolism, or cardiovascular death. The Kaplan-Meier method was used to estimate 18-month cumulative event rates landmarked at day 45 postprocedure. RESULTS: A total of 1,593 patients underwent successful left atrial appendage occlusion and had an evaluable transesophageal echocardiographic studies at 45 days. The dual-occlusive mechanism device provided superior closure (defined as leak <3 mm) compared with the single-occlusive mechanism device at 45 days (88.9% vs 74.1%; P < 0.01) and 12 months (90.5% vs. 78.3%; P < 0.01). Through 18 months, PDL was associated with a higher, but not statistically significant, risk for the primary endpoint (3.6% vs 1.8%; adjusted HR: 1.98; 95% CI: 0.93-4.19; P = 0.07) and a statistically significantly higher risk for the secondary endpoint (8.1% vs. 4.7%; adjusted HR: 1.66; 95% CI: 1.02-2.69; P = 0.04). CONCLUSIONS: The dual-occlusive mechanism device provided superior closure compared with the single-occlusive mechanism device at both 45 days and 1 year postprocedure. PDL ≥3 mm was associated with a significantly increased 18-month risk for the composite of stroke, systemic embolism, or cardiovascular death. Completeness of closure of the left atrial appendage has important implications for patient outcomes. (AMPLATZER™ Amulet™ LAA Occluder Trial [Amulet IDE]; NCT02879448).

Sex Differences in Safety and Effectiveness of LAAO: Insights From the Amulet IDE Trial.

BACKGROUND: Women have higher rates of acute complications after left atrial appendage occlusion (LAAO). However, data on long-term safety and effectiveness are limited. OBJECTIVES: The aim of this study was to examine sex-specific short- and long-term outcomes after LAAO in the Amulet IDE (Amplatzer™ Amulet™ LAA Occluder) trial. METHODS: The following outcomes were compared between men and women: in-hospital complications, device-related outcomes (peridevice leak at 45 days and device-related thrombus at 18 months), and long-term clinical outcomes (death, thromboembolism, and bleeding). Subanalyses for the interaction between sex and device type were performed. RESULTS: A total of 1,833 patients underwent attempted device implantation (917 with the Amulet and 916 with the Watchman), of whom 734 were women (40%). Device success was 97.4% in men and 97.1% in women (P = 0.60). Rates of major in-hospital adverse events were higher in women (4.4% vs 1.9%; P < 0.01), driven by major bleeding (3.7% vs 1.0%; P < 0.01) and pericardial effusion requiring intervention (2.0% vs 0.5%; P < 0.01). Peridevice leak and device-related thrombus were similar in men and women (18.3% vs 18.9% [P = 0.78] and 3.3% vs 5.0% [P = 0.10], respectively). There were no differences between men and women in rates of ischemic stroke or systemic embolism (2.6% vs 2.6%; P = 0.98), transient ischemic attack (1.3% vs 1.6%; P = 0.69), hemorrhagic stroke (0.5% vs 0.4%; P = 0.88), major bleeding (10.1% vs 10.9%; P = 0.49), cardiovascular death (4.3% vs 3.5%; P = 0.45), or all-cause death (8.9% vs 6.9%; P = 0.16). CONCLUSIONS: In the Amulet IDE trial, long-term clinical outcomes including effectiveness following LAAO were comparable in men and women despite the higher rates of in-hospital complications due to major bleeding and pericardial effusion in women. (Amplatzer™ Amulet™ LAA Occluder Trial [Amulet IDE]; NCT02879448).

Food Outlet Access and the Healthiness of Food Available 'On-Demand' via Meal Delivery Apps in New Zealand.

Access to unhealthy commodities is a key factor determining consumption, and therefore influences the prevalence of non-communicable diseases. Recently, there has been an increase in the availability of food 'on-demand' via meal delivery apps (MDAs). However, the public health and equity impacts of this shift are not yet well understood. This study focused on three MDAs in New Zealand and aimed to answer (1) what is the health profile of the foods being offered on-demand, (2) how many food outlets are available and does this differ by physical access or neighbourhood demographics and (3) does the health profile of foods offered differ by physical access or neighbourhood demographics? A dataset was created by sampling a set of street addresses across a range of demographic variables, and recording the menu items and number of available outlets offered to each address. Machine learning was utilised to evaluate the healthiness of menu items, and we examined if healthiness and the number of available outlets varied by neighbourhood demographics. Over 75% of menu items offered by all MDAs were unhealthy and approximately 30% of all menu items across the three MDAs scored at the lowest level of healthiness. Statistically significant differences by demographics were identified in one of the three MDAs in this study, which suggested that the proportion of unhealthy foods offered was highest in areas with the greatest socioeconomic deprivation and those with a higher proportion of Maori population. Policy and regulatory approaches need to adapt to this novel mode of access to unhealthy foods, to mitigate public health consequences and the effects on population groups already more vulnerable to non-communicable diseases.

Objective Assessment of the Nature and Extent of Children's Internet-Based World: Protocol for the Kids Online Aotearoa Study.

BACKGROUND: Children under 18 years of age account for approximately 1 in 3 internet users worldwide. Largely unregulated, the internet-based world is evolving rapidly and becoming increasingly intrusive. There is a dearth of objective research globally on children's real-time experiences of the internet-based world. OBJECTIVE: This paper reports an objective methodology to study the nature and extent of children's internet-based world, their engagement with it, and how this impacts their health and well-being. METHODS: A total of 180 year 8 students from 12 schools will be recruited into the study within the Wellington region of Aotearoa, New Zealand. Children use Zoom video teleconferencing software to record real-time, screen-shared internet-based content, for 4 consecutive days. Data on demographics, health and well-being, and attitudes and perceived behaviors in relation to the internet-based world are collected. Phone screen-time balances are retrieved. Data collection commenced in June 2021 and is anticipated to be completed in 2023. RESULTS: Recordings show children exploring diverse web-based settings and content, including personalized content curated by algorithms on platforms such as TikTok, YouTube, and Instagram. Preliminary analysis shows that the data can be used to study a wide range of topics. Behavioral Observation Research Interaction Software is being used to manually code recordings. Artificial Intelligence techniques are also being applied, including hashtag extraction, optical character recognition, as well as object, pattern, speech, and lyric recognition. CONCLUSIONS: This novel methodology reveals the unique internet-based experiences of children. It is underpinned by a commitment to ensuring that their rights are protected. It seeks to provide concrete evidence on internet usage in this group and to facilitate appropriate political and societal action to effectively regulate the internet-based world to prevent harm to children. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/39017.

Children's perspectives on the wicked problem of child poverty in Aotearoa New Zealand: a wearable camera study.

AIM: Child poverty is a wicked problem and a key determinant of health, but research on child poverty has relied largely on self-report methods and reports from parents or caregivers. In this study we aimed to assess aspects of child poverty using data collected by children using wearable cameras. METHOD: The Kids'Cam Project recruited 168 randomly selected children aged 11-13 from 16 randomly selected schools in the Wellington Region of Aotearoa New Zealand. Each child wore a wearable camera for four consecutive days, recording an image every seven seconds. We used negative binomial regression models to compare measures of household resources, harms, behaviours and built environment characteristics between children living in low socio-economic deprivation households (n=52) and children living in high socio-economic deprivation households (n=26). RESULTS: Compared with children living in conditions of low socio-economic deprivation, children living in conditions of high socio-economic deprivation captured significantly fewer types of fruit (RR=0.46), vegetables (RR=0.25), educational materials (RR = 0.49) and physical activity equipment (RR = 0.66) on camera. However, they lived in homes with more structural deficiencies (RR=4.50) and mould (no mould was observed in low socio-economic deprivation households). They were also less likely to live in households with fixed heating (RR=0.27) and home computers (RR=0.45), and more likely to consume non-core food outside home (RR=1.94). CONCLUSIONS: The children in this study show that children in poverty face disadvantages across many aspects of their lives. Comprehensive policies are urgently needed to address the complex problem of child poverty.

The distribution of harmful product marketing in public outdoor spaces and the effectiveness of marketing bans.

Children's exposure to the marketing of harmful products in public outdoor spaces may influence their consumption of those products and affect health into adulthood. This study aimed to: i) examine the spatial distribution of children's exposure to three types of marketing-related 'harms' (alcohol, unhealthy food, and gambling) in outdoor spaces in the Wellington region, New Zealand/Aotearoa; ii) compare differences in the distribution of harms by socioeconomic deprivation; and iii) estimate the effectiveness of different policies that ban such marketing. Data were from 122 children aged 11-13y who wore wearable cameras and GPS devices for four consecutive days from July 2014 to June 2015. Images were analysed to identify harmful product marketing exposures in public outdoor spaces. Eight policy scenarios were examined to identify the effectiveness of marketing bans, for all children and by socioeconomic deprivation. Children's ratio of harmful marketing was higher for children from high deprivation households and was also found to cluster, with hots spots observed around city centers. The effectiveness of marketing bans depended on the target setting and ban area, with banning 400 m around bus stops leading to the largest reduction. Effectiveness varied also by type of harm and socioeconomic deprivation. For example, banning alcohol marketing in residential areas was estimated to have a larger effect on exposure reduction for children from high deprivation households. Our findings suggest that alcohol, unhealthy food and gambling marketing often cluster outdoors and that targeted bans of such marketing would likely improve child health and, for some banning scenarios, promote equity.

Children's Community Nutrition Environment, Food and Drink Purchases and Consumption on Journeys between Home and School: A Wearable Camera Study.

Children's community nutrition environments are an important contributor to childhood obesity rates worldwide. This study aimed to measure the type of food outlets on children's journeys to or from school, children's food purchasing and consumption, and to determine differences by ethnicity and socioeconomic status. In this New Zealand study, we analysed photographic images of the journey to or from school from a sample of 147 children aged 11-13 years who wore an Autographer camera which recorded images every 7 s. A total of 444 journeys to or from school were included in the analysis. Camera images captured food outlets in 48% of journeys that had a component of active travel and 20% of journeys by vehicle. Children who used active travel modes had greater odds of exposure to unhealthy food outlets than children who used motorised modes; odds ratio 4.2 (95% CI 1.2-14.4). There were 82 instances of food purchases recorded, 84.1% of which were for discretionary foods. Of the 73 food and drink consumption occasions, 94.5% were for discretionary food or drink. Children on their journeys to or from school are frequently exposed to unhealthy food outlets. Policy interventions are recommended to limit the availability of unhealthy food outlets on school routes.

What can Aotearoa New Zealand learn from the Australian Sunsmart Story? A qualitative study.

OBJECTIVE: To explore the views of stakeholders in Australia concerning skin cancer primary prevention and identify successful strategies used that may be translatable to other jurisdictions. METHODS: In-depth stakeholder interviews with experts engaged in skin cancer prevention advocacy and action in Australia. RESULTS: A number of important facilitators were identified including: the use of good scientific evidence (including economic), strong leadership, legislation and strategic documents, engaging the media particularly with the use of personal stories and garnering public support. A number of barriers were also identified including: a lack of funding (particularly nationally), variation by state, apathy and the long latency of skin cancer. CONCLUSIONS: Advocates identified a number of key strategies that were used to gain momentum in achieving Australia's comprehensive Sunsmart program. These included: strong leadership, legislation including that banning solaria and workplace health and safety legislation, a critical mass of key advocates from a range of disciplines including clinicians and patients, and the advantageous use of media to drive change. IMPLICATIONS FOR PUBLIC HEALTH: Australia demonstrates what can be achieved when skin cancer prevention is taken seriously. The challenge for other nations is to apply the lessons learnt in Australia to our own jurisdictions.

An objective assessment of children's exposure to brand marketing in New Zealand (Kids'Cam): a cross-sectional study.

BACKGROUND: Marketing promotes values of consumerism and overconsumption, and negatively affects children's wellbeing and psychological development. The threat marketing poses to planetary health is just being realised. However, little is known about children's exposure to marketing at an aggregate level. Using an objective method of wearable cameras, we aimed to determine the nature and extent of children's exposure to marketing. METHODS: Kids'Cam was a cross-sectional study of children aged 11-13 years in New Zealand, from which we randomly selected a sample of 90 children. Children wore cameras from when they woke up until they went to sleep for four consecutive days (Thursday-Sunday) that captured images at an angle of 136° every 7 s for exposure to marketing. Marketing brands were categorised into three groups: core food and social marketing messages, harmful commodities (eg, non-core food, alcohol, and gambling), or other. Exposure rates by marketing medium, setting, and product category were calculated using negative binomial regression models. FINDINGS: From June 21, 2014, to June 30, 2015, we recruited 168 children, and randomly selected data from 90 children for the present study. Children in this study were exposed to a mean of 554 brands per 10 h day (95% CI 491-625), nearly a brand a minute, through multiple mediums (predominantly brand labels [36% of exposures] and product packaging [22%]) and mostly in schools (43%) and at home (30%). Food and beverages (20% of exposures) were the dominant product category. The most pervasive marketing brands typically sold a range of products across more than one product category (eg, children were exposed to Nike on average 20 exposures per day). Children were exposed to more than twice as many harmful commodities (mean 76 per 10 h day [95% CI 55-105]) as core food and social marketing messages (32 [26-39]) per day. INTERPRETATION: We found that children are repeatedly exposed to marketing through multiple mediums and across all settings, and our findings suggests that marketing privileges particular messages, for example, marketing of harmful commodities. Given the key role marketing plays in establishing and supporting consumption norms, and perpetuating the normalisation of overconsumption which contributes to environmental degradation, these findings suggest an urgent need to reduce marketing to promote planetary health. FUNDING: This research was funded by a University of Otago, Dean's Research Grant. The Kids'Cam study was funded by a Health Research Council of New Zealand Programme Grant (13/724).

Generating political priority for skin cancer primary prevention: A case study from Aotearoa New Zealand.

ISSUES ADDRESSED: Skin cancer is highly prevalent but preventable, yet little research has been done on the challenges in generating political priority for skin cancer prevention. This qualitative study aimed to identify the political challenges to, facilitators of, and strategies to strengthen skin cancer prevention. The focus was on the case of Aotearoa New Zealand (NZ): a country with high skin cancer rates, but limited investment in primary prevention. METHODS: Data sources included 18 national key informant interviews and documentary analysis. Data were analysed inductively for emerging themes and framed using a conceptual framework of political priority. RESULTS: Challenges to advocates for skin cancer primary prevention include limited resources and competing priorities. Political-level challenges include a lack of quick results compared with other initiatives vying for political attention, lack of negative externalities and, in NZ, misalignment with health system priorities. Challenges in the evidence base include the perceived conflict of sun protection with Vitamin D and physical activity, the lack of data on the financial burden of skin cancer and relatively low temperatures in NZ. Facilitators include strong policy community cohesion and issue framing, and weak opposition. Promising strategies to strengthen skin cancer prevention in NZ could include network building, using framing that resonates with policy makers and addressing key knowledge gaps in NZ, such as the financial burden of skin cancer. CONCLUSION: Advocacy for skin cancer prevention faces challenges due to advocates' limited resources, political challenges such as lack of quick results and gaps in evidence. Nonetheless, the initiative encounters little opposition and can be framed in ways that resonate with policy makers. SO WHAT?: Skin cancer is highly preventable, but advocates for prevention initiatives have struggled to gain political traction. This study identifies several strategies that could help raise the political profile for skin cancer prevention.