Perceptions of risks of smoking among Asian Americans

BACKGROUND: Tobacco use is the single most preventable cause of illness and death in the United States. Few studies focus on Asian Americans, one of the fastest growing but underserved populations in the United States. METHODS: A cross-sectional survey method was used for this study. The study sample was identified by using a stratified-cluster proportional sampling technique. A questionnaire was developed in English, translated into the four Asian languages (Chinese, Koreans, Vietnamese, and Cambodians), and back-translated. The sample consisted of 1174 individuals, distributed as follows: Chinese, 34.9%; Korean, 37.1%, Vietnamese, 16.7%; Cambodian, 8.4%; and others, 2.7%. RESULTS: Findings indicated that attitudes toward tobacco-related dangers were associated with smoking status: former and never smokers held more negative perceptions regarding smoking compared to current smokers. Further, results indicated that the Asian American subgroups differed in their respective attitudes. The study is the first to compare attitudes toward tobacco-related dangers among racial/ethnic and language subgroups of Asian Americans. CONCLUSION: The growing body of empirical data on smoking among Asian Americans indicates that smoking cessation programs should take into account variations in smoking-related perceptions and attitudes across the ethnic subgroups.     

Bladder cancer, tobacco smoking, coffee and alcohol drinking in Brescia, northern Italy

The association between tobacco smoking, the consumption of coffee and alcohol and bladder cancer was investigated in a hospital-based case-control study in Brescia, northern Italy. A total of 172 incident cases (135 men and 37 women) and 578 controls (398 men and 180 women) were enrolled. As expected, cigarette smoking was strongly associated with bladder cancer. The odds ratios (OR) for coffee drinking adjusted for age, education, residence and cigarette smoking in current drinkers were 2.6 (95% confidence interval, CI: 1.1–6.1) in men and 5.2 (95% CI: 1.0–30.4) in women. A dose-response relationship was found in men, with the highest risk in the highest category of exposure: drinkers of more than 5 cups per day had an OR of 4.5 (95% CI: 1.2–16.8). The ORs for current alcohol drinkers were 2.1 (95% CI: 1.0–4.8) in men and 3.4 (95% CI: 1.2–9.7) in women; according to grams of ethanol drunk per day (grams/day, g/d) the ORs were: 1.7 (1–20 g/d), 1.6 (21–40 g/d), 4.3 (41–60 g/d) and 4.6 (61+ g/d) in men and 3.1 (1–20 g/d) and 3.9 (21+ g/d) in women. These results suggest that regular consumption of both coffee and alcohol can be independently associated with an increased bladder cancer risk.     

Factors Related to Tooth Loss Among Community-Dwelling Middle-aged and Elderly Japanese Men

Background

Using data from a large-scale community-based Japanese population, we attempted to identify factors associated with tooth loss in middle-aged and elderly men.

Methods

A total of 8352 men aged 40 to 79 years who lived in the north of the main island of Japan and underwent health checkups were enrolled between 2002 and 2005. Number of teeth was assessed by the question, “How many teeth do you have (0, 1–9, 10–19, or ≥20)?”. On the basis of the answer to this question, participants were classified into 2 groups (≤19 teeth or ≥20 teeth). Using multivariate logistic regression, factors related to having 19 or fewer teeth were estimated.

Results

The numbers (percentages) of participants who had 0, 1 to 9, 10 to 19, and 20 or more teeth were 1764 (21.1%), 1779 (21.3%), 1836 (22.0%), and 2973 (35.6%), respectively. Among the participants overall and those aged 65 to 79 years, having 19 or fewer teeth was significantly associated with older age, smoking status (current smoking and ex-smoking), and low education level. In addition, men with 19 or fewer teeth were more likely to have a low body mass index and low serum albumin level and less likely to be current alcohol drinkers. Among men aged 40 to 64 years, but not men aged 65 to 79 years, those with 19 or fewer teeth were more likely to have a low serum high-density lipoprotein cholesterol level and high glycosylated hemoglobin (HbA1c) level.

Conclusions

Smoking, low education level, and poor nutritional status were associated with tooth loss among middle-aged and elderly Japanese men.Key words: tooth loss, risk indicator, middle-aged men, elderly men, Japanese, cross-sectional study     

Sexual behavior in healthy married elderly men

Sexual behavior was evaluated in 81 men aged 60–71 years (34 men aged 60–65 years and 47 men aged 66–71 years). All subjects were married, physically healthy, and with no psychopathology or marital problems. Sexual function was evaluated by a self-report three-point rating scale. Thirty-six percent of the whole study population reported impotence, with no significant difference between the two age groups. About half of the total population reported regular masturbatory activity. A decline in frequency of sexual intercourse and an increase in frequency of masturbation in subjects aged 66–71 years as compared to subjects aged 60–65 indicates that the interest in sexuality continues in elderly men although the form of sexual expression changes from active sexual intercourse to a self-pleasuring/autoerotic form. Evaluation of sexual activity in advanced age is recommended and appropriate therapy in case of sexual dysfunction should be offered to elderly men.     

Racial/ethnic differences among youths in cigarette smoking and susceptibility to start smoking--United States, 2002-2004

Limited information on cigarette smoking in racial/ethnic subpopulations hinders development and implementation of targeted interventions for smoking prevention and cessation. Because of small sample sizes or inadequate study formats, cigarette smoking among youths has been studied mostly in major racial/ethnic populations (e.g., Asian or Hispanic) instead of subsets of these populations (e.g., Vietnamese or Cuban). Data on major population categories might mask differences in tobacco-use prevalence among subpopulations. To assess the prevalence of cigarette smoking among youths aged 12-17 years in six major racial/ethnic populations and nine Asian or Hispanic subpopulations in the United States, the Substance Abuse and Mental Health Services Administration and CDC analyzed self-reported data collected during 2002-2004 from the National Survey on Drug Use and Health (NSDUH). This report summarizes the results of that analysis, which indicated that the estimated prevalence of cigarette smoking in this age group ranged from 23.1% for American Indians/Alaska Natives (AI/ANs) to 2.2% for Vietnamese. Implementing tobacco-control programs that include culturally appropriate interventions might help reduce cigarette smoking in racial/ethnic subpopulations.     

High density lipoprotein cholesterol distribution and predictive power in some Italian populations studies

Nine Italian population samples, for a total of 12,365 males and 8,043 females aged 11 to 84, were examined. The age and sex distribution of HDL-cholesterol levels were calculated for studying its relationship with major cardiovascular risk factors, and for estimating its predictive power on coronary events and on all causes of mortality.Mean values of HDL-cholesterol in the pool of the samples ranged, according to different age groups, from 46.4 to 56.8 mg/dl in males and from 53.7 to 55.8 mg/dl in females.The linear correlation coefficients between HDL-cholesterol and 10 risk factors did not show high levels except those with triglycerides in men aged 20-34 (–0.33) and 35–64 (–0.34).Using the multiple linear regression model the levels of HDL-cholesterol were estimated as a function of the 10 risk factors solving 4 equations (for males, females and for two age groups, 20–34 and 35–64). The factors showing significant coefficients were body mass index (negative), triglycerides (negative), cigarette smoking (negative), alcohol consumption (positive), physical activity (positive), and non-HDL-cholesterol (negative).The Cox model was used for the prediction of coronary death and all causes of death and the logistic function for the prediction of coronary incidence in two of the studies on men aged 46–65 (6 year follow-up) and aged 60–79 (5 year follow-up), and including 5 other factors as possible confounders. Only the univariate prediction of coronary deaths in one study (men aged 46–65) provided a significant coefficient for HDL-cholesterol (t = –2.7624).Corresponding author.See appendix for the composition of the 6 Research Groups.     

Do we need objective measures to validateself-reported smoking?

This study of objective measurement of smoking behaviour reports the findings from asample of 300 adolescents aged 11–16 years from Nottingham. Saliva thiocyanate determination did not prove satisfactory in the validation of self-reported smoking, probably due to lack of sensitivity at the low levels of cigarette consumption recorded in this age group. Prior knowledge of the saliva test did not affect the level of self-reported smoking significantly. It is considered that adolescents report “truthfully” about their own smoking when anonymous questionnaires are used.     

Health Risk Behaviors Among Five Asian American Subgroups in California: Identifying Intervention Priorities

This analysis assessed the prevalence of excess body weight, physical inactivity and alcohol and tobacco use in Asian American subgroups. Using 2005 California Health Interview Survey data, we estimated the prevalence of body mass index (BMI) categories using both standard and World Health Organization-proposed Asian-specific categories, physical inactivity, and alcohol and tobacco use for Chinese (n = 1,285), Japanese (n = 421), Korean (n = 620), Filipino (n = 659) and Vietnamese (n = 480) Americans in California. About 80% of Japanese and Filipino American men and 70% of Korean American men were "increased/high risk" by Asian-specific BMI categories. Most Asian American subgroups were more likely to walk for transportation than non-Hispanic whites, but less likely to report other physical activities. Highest smoking and binge drinking prevalences were among Korean, Vietnamese and Filipino American men and Japanese and Korean American women. These results suggest risk profiles for each Asian American subgroup to consider when setting priorities for health promotion programs.     

The prediction of future health in healthy middle-aged men

Two cohorts of men aged 49–59 at entry, representing cluster samples of two rural areas in Northern and Central Italy, for a total of 1712 subjects have been followed-up for 20 years within an epidemiological study originally designed for cardiovascular disease. After 20 years, only 41 men have been judged to have remained substancially healthy throughout the observation period, i.e. free from a number of major diseases. Univariate and multivariate analyses trying to predict the maintenance of health status showed that among 21 selected characteristics only the following one had a significant power: age, cigarette smoking (adverse effect) and vital capacity( favourable effect). A minor role was also played by the body mass index (adverse effect) and forced expiratory volume (favourable effect).Those who did not remain healthy exibited a greater increase in blood pressure and body mass index.     

Acculturation and tobacco use among Chinese Americans

OBJECTIVES: We examined the relationship between acculturation and tobacco use behaviors among Chinese Americans. METHODS: Using a Chinese-language instrument based on validated questions from several national surveys, we conducted in-person, household-based interviews with 712 representative adults aged 18-74 years. RESULTS: Observed smoking prevalence was 29% for men and 4% for women. Predictors of smoking cessation included being 35 years and older and having a high level of tobacco-related knowledge. Acculturation was positively associated with a history of never smoking, as was being younger than 35 years and having a high level of tobacco-related knowledge. CONCLUSIONS: Acculturation was positively associated with never smoking among men but not with smoking cessation. However, knowledge of tobacco-related health risks was associated with both. Results indicate a need for language-specific educational interventions.     

Factors Associated With Psychological Distress in a Community-Dwelling Japanese Population: The Ohsaki Cohort 2006 Study

Background

In Asia, there has been no population-based epidemiological study using the K6, a 6-item instrument that assesses nonspecific psychological distress.

Methods

Using cross-sectional data from 2006, we studied 43 716 (20 168 men and 23 548 women) community-dwelling people aged 40 years or older living in Japan. We examined the association between psychological distress and demographic, medical, lifestyle, and social factors by using the K6, with psychological distress defined as 13 or more points out of a total of 24 points.

Results

The following variables were significantly associated with psychological distress among the population: female sex, young and old age, a history of serious disease (hypertension, diabetes mellitus, stroke, myocardial infarction, or cancer), current smoking, former alcohol drinking, low body mass index, shorter daily walking time, lack of social support (4 of 5 components), and lack of participation in community activities (4 of 5 components). Among men aged 40 to 64 years, only “lack of social support for consultation when in trouble” and a history of diabetes mellitus remained significant on multivariate analysis. Among men aged 65 years or older, age was not significantly associated with psychological distress, and the significant association with current smoking disappeared on multivariate analysis. Among women aged 40 to 64 years, a history of stroke was not associated with psychological distress. Among women aged 65 years or older, the significant association with current smoking disappeared on multivariate analysis.

Conclusions

A number of factors were significantly associated with psychological distress, as assessed by the K6. These factors differed between men and women, and also between middle-aged and elderly people.Key words: cross-sectional, K6, population-based, psychological distress     

Determinants of smoking status: cross-sectional data on smoking initiation and cessation

BACKGROUND: Cigarette smoking is known to increase the risk of chronic disease. Improved understanding of factors that contribute to smoking initiation and cessation may help to underpin strategies that lead to smoking behavior change. METHODS: Cross-sectional data obtained from 11,967 men and women, aged 20-65 years, were used to study associations with smoking initiation and smoking cessation within the general population. Information on smoking habits, socio-demographic factors and psychosocial factors were collected through self-administered questionnaires. Multiple logistic regression analyses were undertaken by gender. RESULTS: Adverse childhood experiences and personality characteristics (including extraversion, neuroticism and hostility) were found to be related to smoking initiation. Age, marital status and tobacco-related factors were consistently associated with smoking cessation. Older people, married persons and those who smoked more cigarettes per day had a higher likelihood of quitting, both for men and women. CONCLUSIONS: Smoking initiation was found to be associated with adverse childhood events and with measures of personality whereas smoking cessation was associated predominantly with socio-demographic and tobacco use-related factors.     

The prevalence of obstructive lung disease in a general population sample: The NICECOPD study

Background: There are little data available on the prevalence of chronic obstructive pulmonary disease (COPD) in the United Kingdom. The Northern Ireland Cost and Epidemiology of Chronic Obstructive Pulmonary Disease (NICECOPD) study is a two-stage survey to examine the prevalence of obstructive lung disease in a general population sample in the Greater Belfast area. Methods: In stage one 4000 subjects aged 40–69 years were selected at random from the general population. They were posted a short screening questionnaire concerning respiratory symptoms. Respondents were divided into ‚symptomatic’ and ‚asymptomatic’ groups according to their responses. In stage two, a sample of symptomatic and asymptomatic subjects completed a more intensive assessment that included a detailed questionnaire on medical history, spirometry, skin allergy testing and serial peak flow measurements. Spirometric criteria for airflow obstruction were FEV1/FVC ratio of <70% with FEV1 < 80% predicted. Subjects were assigned diagnoses according to a pre-arranged protocol. Results: The survey was conducted from May 1999 to May 2001. There was a 67% response rate to the stage 1 screening questionnaire and 1330 responders were identified as being eligible to take part in stage 2. In total, 722 subjects completed a detailed assessment (50.8% Male, symptomatic, n = 326; asymptomatic, n = 396). COPD was diagnosed in 12.3% (8.8, 15.8) of the symptomatic and 2.2% (0.8, 3.6) of the asymptomatic group. The estimated prevalence of obstructive lung disease in the total population age 40–69 years was 14.4%: 6.3% COPD; 7.2% asthma; 0.9% with indeterminate airflow obstruction. In men, the prevalence of COPD varied from 4.9% in those aged 40–49 years to 12.3% in those aged 60–69 years and in women, varied from 1.4% in 40–49 years of age to 4.5% in 60–69 years. Conclusion: The data suggest that COPD and asthma are common conditions in the general population and should inform future plans to address the burden of disease     

Ethnic differences in risk markers for heart disease in Bradford and implications for preventive strategies.

OBJECTIVES--To assess and compare the prevalence of established risk markers for ischaemic heart disease in a sample of Asian and non-Asian men and to relate these observations to preventive strategies. SETTING--Two factories in the textile industry in Bradford, West Yorkshire, UK. Subjects--288 male manual workers aged 20 to 65 years. DESIGN--Cross sectional study within one occupational/social class stratum. MEASUREMENTS AND MAIN RESULTS--Age, body mass index, plasma lipids, fibrinogen and serum insulin values, blood pressure, smoking habits, alcohol consumption, and exercise routines were recorded. Plasma total cholesterol concentrations were significantly lower in Asian than non-Asian men (5.3 mmol/l v 5.8 mmol/l respectively, p < 0.0001), as were low density lipoprotein cholesterol concentrations (3.4 mmol/l v 3.7 mmol/l, p = 0.0150), and high density lipoprotein (HDL) cholesterol (1.1 mmol/l v 1.3 mmol/l, p < 0.0001). Hypercholesterolaemia (concentration > 6.5mM) was present in nearly one quarter of non-Asians but less than one eighth of Asian men. Triglyceride values were not significantly higher in Asians. Smoking rates were high in non-Asians (43.8%) and only slightly lower in Asians (39.1%). Asian smokers smoked fewer cigarettes per day on average (9.3 v 16.1, p = 0.0001). Almost a quarter of non-Asian men (23.1%) and 26.6% of Asian men had raised blood pressure. Systolic pressures were higher in non-Asian men (138.3 mmHg v 133.0 mmHg, p = 0.0070), but diastolic pressures showed no ethnic differences. Diabetes was more prevalent in Asian men (10.9% v 4.4% p < 0.05), who also showed higher serum insulin concentrations after glucose loading (22.3 mU/l v 10.2 mU/l, p < 0.0001). Plasma fibrinogen values were higher in non-Asian men (2.9 g/l v 2.6 g/l, p < 0.0001) and these were associated with smoking. Nearly all non-Asians (92.5%) consumed alcohol at some time whereas 62.5% of Asians habitually abstained from alcohol consumption. Among the drinkers, non-Asian men consumed on average, 23.9 units per week and Asian men 18.4 units per week (p = 0.083). The mean body mass index for Asian men was 24.5 kg/m2 which was not significantly different to the mean in non-Asian men (25.2 kg/m2). The frequency of exercise in leisure time was low in both groups with 44.4% of non-Asian and 21.1% of Asian men taking moderate exercise weekly, and even fewer, regular strenuous exercise (16.3% and 8.6% respectively). CONCLUSIONS--The plasma cholesterol and fibrinogen concentrations, prevalence of hypertension, smoking habits, alcohol intakes, and infrequency of exercise in leisure time in these non-Asian men in Bradford were consistent with an increased risk of heart disease. The pattern of risk markers was clearly different in Asian men. Only their lower HDL cholesterol concentrations, marginally higher triglyceride values, higher prevalence of diabetes, and very low frequency of exercise in leisure time would be consistent with a higher risk of heart disease compared with non-Asians. The implications of these observations for heart disease preventive strategies are discussed.     

Prevalence and determinants of smoking in Belarus: A national household survey, 2000

A clear, up-to-date picture of smoking prevalence and its determinants is needed to inform the development of effective tobacco control policy in Belarus and other parts of the former Soviet Union. It is particularly important in view of the way the tobacco industry has targeted this region since transition. A nationally representative household survey designed to explore smoking behaviour and its determinants was undertaken in Belarus in April 2000. Data were available on 1090 individuals aged 18 years and over (response rate 53.4%). Respondents were similar demographically to the population of Belarus. Fifty three percent of men and 9% of women are current smokers and an additional 18% and 7% respectively are ex-smokers. Differences in smoking habits between successive generations were identified. These included a ninefold higher rate of ever-smoking amongst 18–29 years old women compared with those aged over 60 years (p < 0.0001) and a higher proportion of current smokers starting in childhood amongst those aged 18–29 years compared with older smokers (p = 0.0005). Smoking in public places, particularly the workplace where 65% smoke, is common. Smokers are more likely than non-smokers to have positive beliefs about the health impact of active and passive smoking (p < 0.0001). Amongst women the odds of smoking is 13 times higher in those living in large cities compared with those living in villages. In men, disadvantage and a positive attitude to the west appear to increase the likelihood of smoking. To date policy responses have been inadequate. Unless effective tobacco control policies are introduced, tobacco will continue to make an increasingly large contribution to premature morbidity and mortality in Belarus.     

Serum thiocyanate levels as an objective measure of smoking habits in epidemiological studies

The relationship between smoking habits and plasma thiocyanate levels has been evaluated in four adult samples of the general population containing men and women aged 20–84 and in a sample of 11-year-old non-smoking children of both sexes, for a total of 7577 individuals.Mean levels of plasma thiocyanate was found be approximately 20 mol/l in children, 30 mol/l in non-smoking adults and increasingly higher in smoking adults.The slopes of the regression equations of thiocyanate on cigarettes smoked per day range from 3.041 to 5.740, with correlation coefficients of from 0.638 to 0.809. In another occupational sample of 280,2 men aged 46 to 65, where the correlation coefficient (between cigarette consumption and thiocyanate) was only 0.49, plasma thiocyanate was a better predictor of 4 year fatal events than cigarette consumption, 4 other covariates being considered in the same mulivariate model.Corresponding author.     

Smoking and respiratory disease symptoms inrural Bangladesh

Respiratory disease (excluding tuberculosis) is a largely untargetted health problem in Bangladesh. This study emphasises both that existing morbidity is considerable and that it is sure to increase if smoking spreads further. In two poor village populations 71% of men though only 1% of women were current smokers (one or more cigarettes or bidi per day); about one in five had begun smoking before the age of 10 years. Most heavy smokers and all women smoked bidi (hand-rolled coarse tobacco sticks). Expenditure on smoking absorbed up to 5% of household income but, seemingly paradoxically, one of the lowest socio-economic groups had the heaviest consumption.For men the striking effect of smoking in increasing respiratory disease symptom prevalence at all ages is clear. Nearly all male smokers reported “cough” but so did four out of five men and women who had never smoked. There were too few women smokers for meaningful analysis. However, “morning phlegm”, “an episode of increased phlegm” and “wheezing” as well as being common for non-smokers of both sexes, were two to three times more frequent among women than men who had never smoked. In women there must certainly be other causal factors for respiratory symptoms apart from smoking, the most important are likely to be smoke from cooking fires and respiratory infections in childhood. Improving immunization coverage and the treatment of respiratory infections in childhood would be useful preventive strategies for both men and women. The most urgent public health measure is to reduce the prevalence of smoking.     

Randomised controlled trial of anti-smoking advice: final (20 year) results.

STUDY OBJECTIVE--The aim was to measure experimentally the effects in middle aged men of stopping smoking. DESIGN--The study was a randomised controlled trial. SETTING AND SUBJECTS--The subjects were 1445 male smokers, initially aged 40-59 years, who were selected from the Whitehall study survey of 16,016 civil servants on the basis of a high risk of cardiorespiratory disease. MAIN RESULTS--During the next 20 years there were 620 deaths (231 from coronary heart disease), 96 cases of lung cancer, and 159 other cancers. Comparing the intervention with the normal care group, total mortality was 7% lower, fatal coronary heart disease was 13% lower, and lung cancer (deaths+registrations) was 11% lower. An excess rate for other cancers, reported previously, did not persist into the second decade of the trial. CONCLUSIONS--The results are consistent with observational studies, implying that smoking cessation by middle aged men substantially improves their changes of avoiding lung cancer or a fatal heart attack. Our estimate from the trial is that out of every 100 men who stopped smoking, between six and 10 were in consequence alive 20 years later.     

Disability trends in gender and race groups of early retirement ages in the USA

Summary Objectives: To analyse disability trends over the 1980s–1990s in gender and race groups of early retirement ages in USA.Methods: Disability trends for white and black males and females aged 65–69 and 70+ are analysed using the 1982–1999 NLTCS. Disability is analysed at three levels (instrumental activities of daily living (IADL), activities of daily living (ADL), and institutionalisation).Results: 1) A larger increase in proportions of non-disabled blacks aged 65–69 compared with whites and males compared with females. 2) Differences in disability trends among gender and race groups. 3) A faster absolute decline in non-institutionalised disabled aged 65–69. 4) A larger absolute decline and a smaller relative decline in proportions of disabled aged 70+ compared with 65–69. 5) A significant decrease in the proportion of ADL disabled blacks and an increase of ADL disabled white females in the age group 70+.Conclusions: Americans aged 65–69 years manifest a significant improvement in health over the 1980s–1990s but the dynamics differs in gender and race groups. Possible reasons for these differences are discussed.     

Trends in lifestyle coronary risk factors in the Danish MONICA population 1982–1992

Myocardial infarction incidence rate declined 3–5% per year during 1982–1992 in the Danish study population of the WHO MONICA Project. We examined whether smoking habits, alcohol intake, dietary habits and physical activity levels changed in the population during the same period.Data from 6695 men and women of ages 30, 40, 50 and 60 y, examined in 1982–4, in 1986–7, and in 1991–2, were analysed to estimate trends. A summary healthy eating index and six scores derived by factor analysis were used to analyse food frequency data.The percentage of smokers declined 1.6% per year in men, and 1.0% per year in 30-, 40- and 50-y-old women, but increased 0.9% per year in 60-y-old women. The percentages of heavy cigarette smoking men and women nevertheless remained constant and close to 30%. Total alcohol intake declined among 30-y-olds, but appeared constant in other age groups. However, among 60-y-old men and among women over 30, the percentage of wine-drinkers rose from 6–11% in 1982–4 to 9–18% in 1991–2. Only 60-y-old men became more physically active at work and only 30-y-old women more so in leisure times. The percentage of individuals with a low healthy eating index decreased and the percentage with a high index increased. More importantly, dietary factor scores showed trends suggesting that very profound and potentially beneficial changes in dietary habits occurred.Lifestyle in the DAN-MONICA population changed in several ways that may have contributed to the declining incidence of myocardial infarction during the 1980s. Public Health (2002) 116, 81–88