Factors Associated with Adolescents' Support for Product Information and Health Messaging on Alcohol Packaging: A Cross-Sectional Study in the United Kingdom.

AIMS: Adolescents in the UK are among the heaviest drinkers in Europe. The World Health Organization recommends alcohol product labelling to inform consumers about product information and health risks associated with alcohol use. This study investigates support for product information and health messaging on alcohol packaging among UK adolescents. METHODS: The 2019 UK Youth Alcohol Policy Survey was an online cross-sectional survey among 3388 adolescents aged 11-19. Participants indicated their support for seven forms of messaging on packaging (e.g. number of alcohol units, links to health conditions). Logistic regression models investigated associations between support for each of the seven forms and alcohol use, perceived risks of alcohol use, and previous exposure to messaging. RESULTS: Between 60 and 79% of adolescents were supportive of different aspects of product labelling. Compared to lower-risk drinkers, higher-risk drinkers (AUDIT-C 5+) had higher odds of supporting including the number of alcohol units (OR: 1.82, 95% CI: 1.31-2.54), calories (OR: 1.52, 95% CI: 1.04-1.68), and strength of the product (OR: 1.73, 95% CI: 1.19-2.52) but lower odds of supporting including information on alcohol-related health conditions (OR: 0.68, 95% CI: 0.53-0.87). Adolescents who perceived risks of alcohol use more strongly were more likely to support all forms of product information and messaging. CONCLUSIONS: The majority of adolescents supported improved alcohol labelling. Higher-risk drinkers were supportive of improved product information but less supportive of health-related messaging. Adolescents who believe alcohol carries health risks were more likely to support messaging.

Unacceptable failures: the final report of the Lancet Commission into liver disease in the UK.

This final report of the Lancet Commission into liver disease in the UK stresses the continuing increase in burden of liver disease from excess alcohol consumption and obesity, with high levels of hospital admissions which are worsening in deprived areas. Only with comprehensive food and alcohol strategies based on fiscal and regulatory measures (including a minimum unit price for alcohol, the alcohol duty escalator, and an extension of the sugar levy on food content) can the disease burden be curtailed. Following introduction of minimum unit pricing in Scotland, alcohol sales fell by 3%, with the greatest effect on heavy drinkers of low-cost alcohol products. We also discuss the major contribution of obesity and alcohol to the ten most common cancers as well as measures outlined by the departing Chief Medical Officer to combat rising levels of obesity-the highest of any country in the west. Mortality of severely ill patients with liver disease in district general hospitals is unacceptably high, indicating the need to develop a masterplan for improving hospital care. We propose a plan based around specialist hospital centres that are linked to district general hospitals by operational delivery networks. This plan has received strong backing from the British Association for Study of the Liver and British Society of Gastroenterology, but is held up at NHS England. The value of so-called day-case care bundles to reduce high hospital readmission rates with greater care in the community is described, along with examples of locally derived schemes for the early detection of disease and, in particular, schemes to allow general practitioners to refer patients directly for elastography assessment. New funding arrangements for general practitioners will be required if these proposals are to be taken up more widely around the country. Understanding of the harm to health from lifestyle causes among the general population is low, with a poor knowledge of alcohol consumption and dietary guidelines. The Lancet Commission has serious doubts about whether the initiatives described in the Prevention Green Paper, with the onus placed on the individual based on the use of information technology and the latest in behavioural science, will be effective. We call for greater coordination between official and non-official bodies that have highlighted the unacceptable disease burden from liver disease in England in order to present a single, strong voice to the higher echelons of government.

The Frequency and Content of Discussions About Alcohol Use in Primary Care and Application of the Chief Medical Officer's Low-Risk Drinking Guidelines: A Cross-Sectional Survey of General Practitioners and Practice Nurses in the UK.

AIMS: To examine how often general practitioners (GPs) and practice nurses (PNs) working in primary care discuss alcohol with patients, what factors prompt discussions, how they approach patient discussions and whether the Chief Medical Officers' (CMO) revised low-risk drinking guidelines are appropriately advised. METHODS: Cross-sectional survey with GPs and PNs working in primary care in the UK, conducted January-March 2017 (n = 2020). A vignette exercise examined what factors would prompt a discussion about alcohol, whether they would discuss before or after a patient reported exceeded the revised CMO guidelines (14 units per week) and whether the CMO drinking guidelines were appropriately advised. For all patients, participants were asked how often they discussed alcohol and how they approached the discussion (e.g. used screening tool). RESULTS: The most common prompts to discuss alcohol in the vignette exercise were physical cues (44.7% of participants) or alcohol-related symptoms (23.8%). Most practitioners (70.1%) said they would wait until a patient was exceeding CMO guidelines before instigating discussion. Two-fifths (38.1%) appropriately advised the CMO guidelines in the vignette exercise, with PNs less likely to do so than GPs (odds ratio [OR] = 0.77, P = 0.03). Less than half (44.7%) reportedly asked about alcohol always/often with all patients, with PNs more likely to ask always/often than GPs (OR = 2.22, P < 0.001). Almost three-quarters said they would enquire by asking about units (70.3%), compared to using screening tools. CONCLUSION: Further research is required to identify mechanisms to increase the frequency of discussions about alcohol and appropriate recommendation of the CMO drinking guidelines to patients.

Awareness of marketing for high fat, salt or sugar foods, and the association with higher weekly consumption among adolescents: a rejoinder to the UK government's consultations on marketing regulation.

OBJECTIVE: Exposure to marketing for foods high in fat, salt or sugar (HFSS) reportedly influences consumption, nutritional knowledge and diet-related health among adolescents. In 2018/2019, the UK government held two consultations about introducing new restrictions on marketing for HFSS foods. To reinforce why these restrictions are needed, we examined adolescents' awareness of marketing for HFSS foods, and the association between past month awareness and weekly HFSS food consumption. DESIGN: Cross-sectional survey that measured past month awareness of ten marketing activities for HFSS foods (1 = everyday; 6 = not in last month). Frequencies were converted into aggregate past month awareness across marketing activities and grouped into three categories (low/medium/high). Consumption was self-reported for fifteen foods (twelve HFSS) (1 = few times/d; 9 = never). For each food, frequency was divided into higher/lower weekly consumption. SETTING: United Kingdom. PARTICIPANTS: 11-19-year-olds (n 3348). RESULTS: Most adolescents (90·8 %) reported awareness of a least one marketing activity for HFSS foods, and at least half reported seeing ≥70 instances in the past month. Television, social media and price offers were the marketing activities most frequently reported. Awareness was associated with higher weekly consumption for ten of the twelve HFSS foods. For example, those reporting medium marketing awareness were 1·5 times more likely to report higher weekly consumption of cakes/biscuits compared with those reporting low awareness (AOR = 1·51, P = 0·012). The likelihood of higher weekly HFSS food consumption increased relative to the level of marketing awareness. CONCLUSIONS: Assuming there is a causal relationship between marketing awareness and consumption, the restrictions proposed by the UK government are likely to help reduce HFSS consumption.

Awareness of product-related information, health messages and warnings on alcohol packaging among adolescents: a cross-sectional survey in the United Kingdom.

BACKGROUND: Alcohol packaging can be used to communicate product-related information, health messages and health warnings to consumers. We examined awareness and recall of such information and messaging among adolescents in the United Kingdom. METHOD: A cross-sectional survey was conducted with 11-19 year olds in the United Kingdom (n = 3399), with participants asked if they had seen any information, health messages or warnings on alcohol packaging in the past month (Yes/No) and, if so, what they recalled. We also assessed higher-risk drinking among current drinkers (≥5 Alcohol Use Disorders Identification Test-Consumption) and susceptibility to consume among never-drinkers. RESULTS: One-third (32%) of participants had seen information, health messages or warnings on alcohol packaging. Chi-Square tests showed awareness was greater for current drinkers than non-drinkers (46% vs. 19%; P < 0.001), higher-risk drinkers than lower-risk drinkers (55% vs. 39%; P < 0.001), and susceptible never-drinkers than non-susceptible never-drinkers (21% vs. 16%; P = 0.01). Ten messages were recalled, with drinking responsibly (18%) and not drinking during pregnancy (13%) most recalled. CONCLUSION: Most young drinkers, including almost half of higher-risk drinkers, did not recall seeing any information, health messages or warnings on alcohol packaging in the past month, suggesting that current labelling is failing to reach this key audience.

Weight assessment and the provision of weight management advice in primary care: a cross-sectional survey of self-reported practice among general practitioners and practice nurses in the United Kingdom.

BACKGROUND: Although primary care settings provide a large-scale and high-reach opportunity for weight management and obesity prevention, the proportion of adults in the United Kingdom (UK) who report receiving weight management advice is limited. This study examines the self-reported frequency of assessing weight and providing weight management advice by General Practitioners (GPs) and Practice Nurses (PNs) working in primary care in the UK, and differences by practitioner characteristics. METHODS: Cross-sectional survey with GPs and PNs in the UK (n = 2020), conducted January-March 2017. A mock consultation exercise assessed what factors led to calculating a patient's Body Mass Index (BMI) and whether weight management advice was given after determining the patient had an obese BMI. For all patients, practitioners were asked how often they calculated BMI, how often they gave weight management advice to patients with an obese BMI, and how often they utilised different advice or referral options (each: Always/Often vs. Less often/Never). Binary logistic regressions examined whether frequency of assessing weight and providing advice was associated with practitioner characteristics. RESULTS: In the mock consultation, physical cues (40%) were most likely to prompt calculation of BMI, and half of practitioners (56%) provided weight management advice after determining the patient had an obese BMI, with GPs less likely to do so than PNs (Odds Ratio [OR] = 0.59, 95% CI: 0.47-0.75). Half of practitioners (58%) said they calculated the BMI of all patients Always/Often, with GPs less likely to do so than PNs (OR = 0.27, 95% CI: 0.21-0.34). Three quarters (78%) said they provided weight management advice to patients with an obese BMI Always/Often, with GPs less likely to do so than PNs (OR = 0.63, 95% CI: 0.47-0.85). Weight management advice was provided more frequently than referrals, particularly suggesting increased physical activity (93%) and diet modification (89%). CONCLUSIONS: Consistent with previous research, the findings suggest that opportunities to provide weight management advice in primary care, including to patients with an obese BMI, are potentially missed. Future research should test alternative mechanisms to increase weight assessment and advice provision, examine the effectiveness of advice frequently given, and seek solutions to reported barriers for providing weight management advice.

Gathering momentum for the way ahead: fifth report of the Lancet Standing Commission on Liver Disease in the UK.

This report presents further evidence on the escalating alcohol consumption in the UK and the burden of liver disease associated with this major risk factor, as well as the effects on hospital and primary care. We reiterate the need for fiscal regulation by the UK Government if overall alcohol consumption is to be reduced sufficiently to improve health outcomes. We also draw attention to the effects of drastic cuts in public services for alcohol treatment, the repeated failures of voluntary agreements with the drinks industry, and the influence of the industry through its lobbying activities. We continue to press for reintroduction of the alcohol duty escalator, which was highly effective during the 5 years it was in place, and the introduction of minimum unit pricing in England, targeted at the heaviest drinkers. Results from the introduction of minimum unit pricing in Scotland, with results from Wales to follow, are likely to seriously expose the weakness of England's position. The increasing prevalence of obesity-related liver disease, the rising number of people diagnosed with type 2 diabetes and its complications, and increasing number of cases of end-stage liver disease and primary liver cancers from non-alcoholic fatty liver disease make apparent the need for an obesity strategy for adults. We also discuss the important effects of obesity and alcohol on disease progression, and the increased risk of the ten most common cancers (including breast and colon cancers). A new in-depth analysis of the UK National Health Service (NHS) and total societal costs shows the extraordinarily large expenditures that could be saved or redeployed elsewhere in the NHS. Excellent results have been reported for new antiviral drugs for hepatitis C virus infection, making elimination of chronic infection a real possibility ahead of the WHO 2030 target. However, the extent of unidentified cases remains a problem, and will also apply when new curative drugs for hepatitis B virus become available. We also describe efforts to improve standards of hospital care for liver disease with better understanding of current service deficiencies and a new accreditation process for hospitals providing liver services. New commissioning arrangements for primary and community care represent progress, in terms of effective screening of high-risk subjects and the early detection of liver disease.

Clustering of behavioural risk factors for health in UK adults in 2016: a cross-sectional survey.

BACKGROUND: Foods high in fat, sugar and salt (HFSS) are known to contribute to overweight and obesity. In addition to overweight and obesity, smoking, alcohol consumption and physical inactivity are known risk factors for non-communicable diseases, including several cancers and cardiovascular disease. METHODS: Secondary analysis of UK-representative cross-sectional survey data of 3293 adults aged 18+. Regression analyses were undertaken to understand the relationship between consumption of HFSS food and soft drinks, alcohol and tobacco and socio-demographics. Clustering analysis identified groupings of health risk factors. RESULTS: Males, those aged 18-24 and those from the more deprived groups consumed ready meals and fast food most frequently. Most of the sample (77.3%) engaged in at least one health risk behaviour. Six clusters were identified in the clustering analysis. Older (65+) female respondents were more likely to be inactive. Smokers exhibiting additional risk behaviours were more likely to be of working age from more deprived groups, and men over 65 were more likely to consume harmful levels of alcohol with additional risk factors. CONCLUSION: Policies and services in the UK tend to focus on changing behaviour to address individual risk factors. This study shows that policies and interventions need to address multiple risk factors.

Participation with alcohol marketing and user-created promotion on social media, and the association with higher-risk alcohol consumption and brand identification among adolescents in the UK.

Aim: To explore participation with alcohol marketing (i.e. commenting on brand statuses) and user-created promotion on social media (i.e. photos of peers drinking) by young people in the United Kingdom (UK), and what association this has with higher-risk consumption and brand identification. Method: Online cross-sectional survey with 11-19-year olds in the UK (n = 3,399) (average age: 15 years old). Past-month participation was measured for five forms of alcohol marketing on social media and one form of user-created promotion (all Yes/No). Past-month awareness of nine wider alcohol marketing activities, social media apps used at least weekly, and ownership of branded merchandise were included as covariates. Outcomes included higher-risk consumption in current drinkers (≥5 AUDIT-C) and brand identification in all respondents (8 pictures with brand names removed). Results: Over one-in-ten respondents (13.2%) had participated with at least one form of marketing on social media or participated with user-created promotion (12.2%). For both, participation was greater in current drinkers and those of legal purchasing age. A logistic regression found that participation with two or more forms of marketing on social media (AOR = 1.96, p < .01) and participation with user-created promotion (AOR = 3.46, p < .001) were associated with higher-risk drinking. Respondents, on average, identified 2.58 (SD = 2.12) alcohol brands. A linear regression found participation with marketing on social media was not associated with brand identification (ß = 0.01, p = .42) but participation with user-created promotion was (ß = 0.05, p < .001). Conclusion: Social media provides opportunities for adolescents to participate with commercial marketing and user-created promotion and this is associated with higher-risk consumption and brand identification.

New national alcohol guidelines in the UK: public awareness, understanding and behavioural intentions.

Background: Alcohol consumption places a significant burden on the NHS and is an important risk factor for cancer, associated with 12 800 UK cases/year. New alcohol guidelines were published in 2016, taking into account the increasing evidence of the health harms of alcohol. Methods: A survey of the UK drinker population (n = 972) was conducted 1 week before and 1 month after the release of the guidelines to capture drinking habits, guideline awareness and intended behaviour change. Results: Overall, 71% were aware of the new alcohol guidelines, however, just 8% knew what the recommended limits were. Higher socioeconomic groups were more likely to know these limits (ABC1 = 9% versus C2DE = 4%, P = 0.009). Participants who recognized the message that alcohol causes cancer were more likely to correctly identify the new guidelines (message recognition = 12% versus no recognition = 6%, P = 0.004); and were more likely to self-report an intention to reduce their alcohol consumption (message recognition = 10% versus no recognition = 6%, P = 0.01). Conclusion: The majority of the population knew the guidelines had been updated, however, communication of the new limits needs to be improved. Raising awareness of the links between alcohol and cancer may improve understanding of alcohol guidelines and could prompt behaviour change for those motivated to reduce their alcohol consumption.

Public awareness and healthcare professional advice for obesity as a risk factor for cancer in the UK: a cross-sectional survey.

Background: Overweight and obesity is the second biggest preventable cause of cancer after smoking, causing ~3.4 million deaths worldwide. This study provides current UK data on awareness of the link between obesity and cancer by socio-demographic factors, including BMI, and explores to what degree healthcare professionals provide weight management advice to patients. Methods: Cross-sectional survey of 3293 adults completed an online survey in February/March 2016, weighted to be representative of the UK population aged 18+. Results: Public awareness of the link between obesity and cancer is low (25.4% unprompted and 57.5% prompted). Higher levels of awareness existed for least deprived groups (P < 0.001), compared to more deprived groups. Most respondents had seen a healthcare practitioner in the past 12 months (91.6%) and 17.4% had received advice about their weight, although 48.4% of the sample were overweight/obese. Conclusion: Cancer is not at the forefront of people's minds when considering health conditions associated with overweight or obesity. Socio-economic disparities exist in health knowledge across the UK population, with adults from more affluent groups being most aware. Healthcare professionals are uniquely positioned to provide advice about weight, but opportunities for intervention are currently under-utilized in healthcare settings.

Correction: Critchlow, N., et al. Adolescents' Reactions to Adverts for Fast-Food and Confectionery Brands That Are High in Fat, Salt, and/or Sugar (HFSS), and Possible Implications for Future Research and Regulation: Findings from a Cross-Sectional Survey of 11-19 Year Olds in the United Kingdom. Int. J. Environ. Res. Public Health 2020, 17, 1689.

It has come to our attention that there are two errors in our recent article [...].

Indirect Associations Between Commercial Television Exposure and Child Body Mass Index.

OBJECTIVE: To formally test a hierarchy of effects model linking exposure to television (TV) advertising for unhealthy foods with child body weight through purchase requests, purchases, and consumption. DESIGN: A nationally representative cross-sectional online study in the United Kingdom. PARTICIPANTS: A total of 2,260 parent-child dyads (children aged 7-11 years) recruited via online research panel; 55.7% boys, mean age 8.9 ± 1.4 years, mean body mass index z-score 1.25 ± 2.1. MAIN OUTCOME MEASURES: Parents reported on child TV exposure and child height and weight. Children self-reported their frequency of (1) pestering for advertised foods, (2) purchase of unhealthy foods, and (3) consumption of unhealthy foods. ANALYSIS: A structural equation model was applied to data. RESULTS: As predicted, commercial TV exposure was indirectly associated with children's body mass index through purchasing and consumption through purchase requests. It was also directly associated with children's purchase requests, purchasing, and consumption of unhealthy foods. Associations between noncommercial TV and behavior or body weight outcomes, when found, were significantly weaker than for commercial exposure. CONCLUSIONS AND IMPLICATIONS: This study provides insight into the likely behavioral pathways underpinning the effects of food marketing on diet and potentially body weight in children. Future longitudinal analyses would provide insight into causal inferences.

Adolescents' Reactions to Adverts for Fast-Food and Confectionery Brands That are High in Fat, Salt, and/or Sugar (HFSS), and Possible Implications for Future Research and Regulation: Findings from a Cross-Sectional Survey of 11-19 Year Olds in the United Kingdom.

The influence that marketing for foods high in fat, salt, and/or sugar (HFSS) has on adolescents extends beyond a dose-response relationship between exposure and consumption. It is also important to explore how marketing shapes or reinforces product/brand attitudes, and whether this varies by demography and Body Mass Index (BMI). To examine this, a cross-sectional survey was conducted with 11-19 year olds in the United Kingdom (n = 3348). Participants watched 30 s video adverts for a fast-food and confectionery brand. For each advert, participants reported reactions on eight measures (e.g., 1 = Makes [product] seem unpopular choice-5 = Makes [product] seem popular choice), which were binary coded based on whether a positive reaction was reported (Yes/No). At least half of adolescents had positive reactions to both adverts for 5/8 measures. Positive reactions had associations with age, gender and, to a lesser extent, BMI. For example, 11-15 year olds were more likely than 16-19 year olds to report appeal to their age group for the fast-food (OR = 1.33, 95% CI: 1.13-1.58) and confectionery advert (OR= 1.79, 95% CI: 1.51-2.11). If these reactions are typical of other HFSS products, future research and regulatory change should examine whether additional controls on the content of HFSS marketing, for example mandated health or nutritional information and revised definitions of youth appeal, offer additional protection to young people.

Awareness of alcohol marketing, ownership of alcohol branded merchandise, and the association with alcohol consumption, higher-risk drinking, and drinking susceptibility in adolescents and young adults: a cross-sectional survey in the UK.

OBJECTIVES: To explore awareness of alcohol marketing and ownership of alcohol branded merchandise in adolescents and young adults in the UK, what factors are associated with awareness and ownership, and what association awareness and ownership have with alcohol consumption, higher-risk drinking and susceptibility. DESIGN: Online cross-sectional survey conducted during April-May 2017. SETTING: The UK. PARTICIPANTS: Adolescents and young adults aged 11-19 years in the UK (n=3399). MAIN OUTCOME MEASURES: Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) (0-12) and indication of higher-risk consumption (>5 AUDIT-C) in current drinkers. Susceptibility to drink (yes/no) in never drinkers. RESULTS: Eighty-two per cent of respondents were aware of at least one form of alcohol marketing in the past month and 17% owned branded merchandise. χ2 tests found that awareness of marketing and ownership of branded merchandise varied within drinking variables. For example, higher awareness of alcohol marketing was associated with being a current drinker (χ2=114.04, p<0.001), higher-risk drinking (χ2=85.84, p<0.001), and perceived parental (χ2=63.06, p<0.001) and peer approval of consumption (χ2=73.08, p<0.001). Among current drinkers, multivariate regressions (controlling for demographics and covariates) found that marketing awareness and owning branded merchandise was positively associated with AUDIT-C score and higher-risk consumption. For example, current drinkers reporting medium marketing awareness were twice as likely to be higher-risk drinkers as those reporting low awareness (adjusted OR (AOR)=2.18, 95% CI 1.39 to 3.42, p<0.001). Among never drinkers, respondents who owned branded merchandise were twice as likely to be susceptible to drinking as those who did not (AOR=1.98, 95% CI 1.20 to 3.24, p<0.01). CONCLUSIONS: Young people, above and below the legal purchasing age, are aware of a range of alcohol marketing and almost one in five own alcohol branded merchandise. In current drinkers, alcohol marketing awareness was associated with increased consumption and greater likelihood of higher-risk consumption. In never drinkers, ownership of branded merchandise was associated with susceptibility.

Area deprivation, screen time and consumption of food and drink high in fat salt and sugar (HFSS) in young people: results from a cross-sectional study in the UK.

OBJECTIVES: To investigate associations between deprivation in young people and consumption of foods high in fat, salt and sugar (HFSS), screen time exposure and health knowledge. DESIGN: An online cross-sectional survey with people aged 11-19 years in the UK, where participants reported consumption behaviours across 13 HFSS and two non-HFSS groups; screen time for commercial television and streaming services; and knowledge of health conditions and their links to obesity. SETTING: UK PARTICIPANTS: A total of 3348 young people aged 11-19 years across the UK. MAIN OUTCOME MEASURES: The study assessed the consumption behaviours, commercial screen time exposure and the health knowledge of 3348 people aged 11-19 years. Multivariate binary regression analysis, controlling for age and gender, was performed. RESULTS: Deprivation level was associated with increases in consumption of six of the HFSS products including energy drinks (OR: 2.943, p<0.001) and sugary drinks (OR: 1.938, p<0.001) and a reduction in consumption in the two non-HFSS products included in the study, fruit (OR: 0.668, p=0.004) and vegetables (OR: 0.306, p<0.001). Deprivation was associated with high weekly screen time of both television (OR: 2.477, p<0.001) and streaming (OR: 1.679, p=0.001). Health knowledge was also associated with deprivation. There was lower awareness of the association of obesity and cancer (OR: 0.697, p=0.003), type 2 diabetes (OR: 0.64, p=0.004) and heart disease (OR: 0.519, p<0.001) in the most deprived. CONCLUSIONS: Young people from the more deprived areas of the UK were more likely to consume a range of HFSS products, report increased exposure to HFSS advertising and have a poorer awareness of health conditions associated with overweight and obesity. The findings suggest that population-level measures addressing childhood obesity should account for consumption patterns among different groups of children and young people and the factors that may influence these.

Socioeconomic position in childhood and cancer in adulthood: a rapid-review.

BACKGROUND: The relationship of childhood socioeconomic position (SEP) to adult cancer has been inconsistent in the literature and there has been no review summarising the current evidence focused solely on cancer outcomes. METHODS AND RESULTS: We performed a rapid review of the literature, which identified 22 publications from 13 studies, primarily in the UK and northern European countries that specifically analysed individual measures of SEP in childhood and cancer outcomes in adulthood. Most of these studies adjusted for adult SEP as a critical mediator of the relationship of interest. CONCLUSIONS: Results confirm that childhood socioeconomic circumstances have a strong influence on stomach cancer and are likely to contribute, along with adult circumstances, to lung cancer through cumulative exposure to smoking. There was also some evidence of increased risk of colorectal, liver, cervical and pancreatic cancers with lower childhood SEP in large studies, but small numbers of cancer deaths made these estimates imprecise. Gaps in knowledge and potential policy implications are presented.