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1.  Geographical clustering of risk factors and lifestyle for coronary heart disease in the Scottish Heart Health Study. 
British Heart Journal  1990;64(3):199-203.
A large cross sectional study, the Scottish Heart Health Study, of 10,359 men and women from 22 districts of Scotland was undertaken to try to explain the geographical variation of coronary heart disease mortality. Analysis by district showed that of the classic risk factors only cigarette smoking was strongly associated with heart disease mortality among both men and women. Mean diastolic blood pressure was weakly associated with rates among men and high density lipoprotein cholesterol showed a strong negative association among women. Total cholesterol showed a weak negative association with heart disease mortality, but, because the serum concentrations of cholesterol were uniformly high in all districts, a strong association with mortality would not be expected. In both men and women many dietary factors showed moderate or strong associations with mortality from coronary heart disease in a district--of these a low consumption of vitamin C was most notable. Other factors associated with heart disease included alcohol consumption and serum triglycerides among men, and obesity, physical activity, and serum triglycerides among women. Many factors associated with heart disease showed strong intercorrelations. Clustering of risk factors (including smoking, alcohol, and diet among men, and smoking, diet, and obesity among women) was associated with much of the regional variation in heart disease mortality in Scotland.
PMCID: PMC1024372  PMID: 2206712
2.  Trends in suicide and unemployment in Scotland, 1976-86. 
BMJ : British Medical Journal  1989;298(6676):782-784.
To establish whether a correlation exists between unemployment and suicide the trends in the rates of both among men in Scotland during 1976-86 were studied. Both rates showed rapid increases in the late 1970s and then much slower increases after 1982. In contrast, among women, although the rate of unemployment followed a similar pattern, there was a gradual fall in the rate of suicide. The trends in regional unemployment for men during 1971-81 were compared with the suicide rates for the period before the increase (1974-7) and the period after the rapid increase (1983-6). No association was observed between trends in suicide and unemployment when analysed by health board areas or aggregates of local government districts. These data do not support the hypothesis that the rise in unemployment is a direct cause of the rise in suicide rates among men.
PMCID: PMC1836067  PMID: 2496856
3.  Perindopril improves six minute walking distance in older patients with left ventricular systolic dysfunction: a randomised double blind placebo controlled trial 
Heart  2002;88(4):373-377.
Objective: To evaluate the effects of the angiotensin converting enzyme inhibitor perindopril on six minute walking distance and quality of life in very old patients with left ventricular systolic dysfunction.
Design: Prospective, double blind placebo controlled trial.
Setting: Medicine for the elderly day hospital.
Patients: 66 patients (average age 81) with left ventricular systolic dysfunction identified by echocardiography.
Interventions: 10 weeks of treatment with titrated doses of perindopril or placebo.
Main outcome measures: Six minute walking distance 10 weeks following treatment, quality of life measurements including the Minnesota living with heart failure questionnaire and the 36 item short form health survey.
Results: In patients with left ventricular systolic dysfunction, six minute walking distance was significantly increased in the treatment group (37.1 m) compared with the placebo group (−0.3 m, p < 0.001). The medication was well tolerated and there were no significant adverse events.
Conclusions: Six minute walking distance is improved considerably by treatment with perindopril in older patients with heart failure caused by left ventricular systolic dysfunction.
PMCID: PMC1767356  PMID: 12231595
heart failure; six minute walking distance; elderly; quality of life; perindopril; tolerability
4.  What determines levels of passive smoking in children with asthma? 
Thorax  1997;52(9):766-769.
BACKGROUND: Children with parents who smoke are often exposed to high levels of environmental tobacco smoke, and children with asthma are particularly susceptible to the detrimental effects of passive smoking. Data were collected from parents who smoke and from their asthmatic children. The families are currently taking part in a randomised controlled trial to test an intervention designed to reduce passive smoking in children with asthma. This paper reports on the baseline data. Questionnaire data and cotinine levels were compared in an attempt to assess exposure and to identify factors which influence exposure of the children. The aim of the study was to identify the scope for a reduction in passive smoking by these children. METHODS: A sample of 501 families with an asthmatic child aged 2-12 years was obtained. Factors influencing passive smoking were assessed by interviewing parents. Cotinine levels were measured from saliva samples using gas liquid chromatography with nitrogen phosphorous detection. RESULTS: Cotinine levels in children were strongly associated with the age of the child, the number of parents who smoked, contact with other smokers, the frequency of smoking in the same room as the child, and crowding within the home. Parental cotinine levels, the amount smoked in the home, and whether the home had a garden also exerted an independent effect on cotinine levels in the children. CONCLUSIONS: Many children are exposed to high levels of environmental tobacco smoke and their cotinine levels are heavily dependent upon proximity to the parent who smokes. Parents who smoke have a unique opportunity to benefit their child's health by modifying their smoking habits within the home. 



PMCID: PMC1758643  PMID: 9371205
5.  Does the availability of prescribed drugs affect rates of self poisoning? 
The British Journal of General Practice  1998;48(433):1505-1506.
The trends in self-poisoning rates and in rates of prescribing of the major drug groups were compared. Over the period 1981-91, barbiturate prescribing and self poisoning both fell by 80%; for antidepressants, prescribing increased by over 40% and self poisoning by 30%; for antipsychotics, both rose by 30%; for benzodiazepines, poisoning fell by 30% and prescribing by 20%. Even for analgesic drugs, which are also available over the counter, there was a correspondence between changes in self poisoning and prescribing. The availability of prescribed drugs is directly related to their use for self poisoning. Restricting the availability of these drugs is a possible preventative strategy, although further research on this is needed.
PMCID: PMC1313200  PMID: 10024711
6.  Effect of asthma and its treatment on growth: four year follow up of cohort of children from general practices in Tayside, Scotland 
BMJ : British Medical Journal  1998;316(7132):668-672.
Objective: To investigate whether asthma or its treatment impairs children’s growth, after allowing for socioeconomic group.
Design: 4 year follow up of a cohort of children aged 1-15.
Setting: 12 general practices in the Tayside region of Scotland.
Subjects: 3347 children with asthma or features suggestive of asthma registered with the general practices.
Main outcome measures: Height and weight standard deviation scores.
Results: Children who lived in areas of social deprivation (assessed by postcode) had lower height and weight than their contemporaries (mean standard deviation score −0.26 (SD 1.02) and −0.18 (1.15) respectively, P<0.001 for both). Children who were receiving ⩾400 μg daily of inhaled steroids and who were attending both hospital and general practice for asthma care had lower height and weight than average, independent of the effect of deprivation (mean standard deviation score −0.62 (1.01), P=0.002, for height and −0.58 (0.94), P=0.005, for weight). Children receiving high doses of inhaled corticosteroids also showed lower growth rates (mean change in standard deviation score −0.19 (0.51), P=0.003). However, no other children with asthma showed growth impairment.
Conclusion: Most children with asthma were of normal height and weight and had normal growth rates. However, children receiving high doses of inhaled steroids and requiring both general practice and hospital services had a significant reduction in their stature. This effect was independent from but smaller than the effect of socioeconomic group on stature.
Key messages Social deprivation has an adverse effect on the height and weight of children irrespective of any disease process Neither asthma nor its treatments had any noticeable effect on the height and weight of most of the children in this primary care study Children who received high doses of inhaled corticosteroids and used hospital services for asthma were shorter and lighter than their contemporaries after social deprivation was allowed for Children receiving high doses of inhaled corticosteroids had lower than normal growth rates
PMCID: PMC28474  PMID: 9522793
7.  The facilitator effect: results from a four-year follow-up of children with asthma. 
BACKGROUND: A long-term evaluation of the process and outcomes of primary and secondary care is required to establish whether audit facilitators can improve the care of childhood asthma. AIM: To examine the long-term effect of an intervention by an audit facilitator on the management of children with asthma, and to investigate the implications for health service costs. METHOD: A 4-year follow up was conducted of an intervention and control group totalling 2557 children aged 1-15 years from 12 general practices in the Tayside region. Primary care consultations, prescriptions, hospital contacts and health service costs 1 year before and 3 years after a facilitator visited practices were recorded. The facilitator encouraged the diagnosis and treatment of childhood asthma in the intervention group. RESULTS: Favourable changes in consultation patterns, prescriptions and reduced hospital admissions seen during the intervention year did not persist in subsequent years. Two and three years after the facilitator visit the process and outcome of care was similar in both groups. The reduction in health service costs seen in the intervention group was equivalent to the cost of employing a facilitator. CONCLUSION: The effect of a facilitator lasts only for the period of intervention. Enthusiasts will say that improving patient care without increasing health service costs justifies the widespread deployment of facilitators. Others more interested in long-term outcomes may disagree.
PMCID: PMC1312922  PMID: 9167319
9.  Cervical screening: the optimum visit plan for contacting users and non-users in Scotland. 
OBJECTIVE--To investigate the numbers of visits required to obtain interviews with users and non-users of cervical screening, and to determine the workload involved to enable an optimum visit plan to be developed. DESIGN--Case-control study of users and non-users of cervical screening using a flexible visit plan that involved up to eight attempts at contact. Visits were made in mornings, afternoons, and evenings, the visit pattern being determined by information gained from local sources. PATIENTS--Altogether 660 non-users of cervical screening (cases), aged 20-64 and registered with 23 randomly selected general practitioners (GPs), were identified from the Tayside computerised register of cervical smears. These women were selected from the computerised lists of 18 GPs in Dundee and five in Perth. A total of 417 women recorded as having a smear within the previous three years (controls), matched by age and GP, were also identified from the computerised register. RESULTS--Altogether 1834 attempts were made to contact the cases, of whom 339 were interviewed, giving a workload of 18 interviews per 100 attempts. For the controls 1359 attempts were made at contact to yield 339 interviews, a workload of 25 interviews per 100 attempts. Refusals (19%) and incorrect addresses (23%) were the two major reasons for failing to achieve interview. Only for four (0.6%) of the cases and one (0.2%) of the controls was no information gained. The proportion of attempts which led to interview remained constant with increasing numbers of call-backs (up to six for the cases and eight for the controls). CONCLUSIONS--A flexible approach to visit scheduling that takes account of local knowledge can lead to interviews with 66% of non-users of health screening, when incorrect addresses are removed. It is preferable to plan for many (up to six) visits to achieve interview. This will minimise non-response bias without increasing the workload per successful interview.
PMCID: PMC1060037  PMID: 7830014
10.  Failure of cigarette smoking to explain international differences in mortality from chronic obstructive pulmonary disease. 
STUDY OBJECTIVE--The study aimed to explain international differences in rates and trends of chronic obstructive pulmonary disease (COPD) using two measurements of cigarette smoking, the major risk factor for this disease. DESIGN--Mortality data for COPD were obtained from the World Health Organisation for 31 countries from 1979 to 1988. Smoking data were obtained for most countries. COPD rates were compared to the percentage of current smokers and past levels of cigarette consumption. COPD trends were compared to past consumption trends. MAIN RESULTS--In men, Romania had the highest COPD mortality and Greece the lowest throughout the period. English speaking countries occupy most of the other top positions, and southern European countries and Japan the low positions. Women show a similar ranking to men (r = 0.75; p < 0.01 (1988)). Mortality rates in men are, in general, two to four times those in women. Most countries show either a decrease or no change in COPD mortality over the period. In women the opposite is true--no clear relationships are seen when comparing rates and trends of COPD with measures of smoking. CONCLUSION--This failure to explain international COPD differences suggests that national data on COPD may be unreliable or national cigarette smoking data are inadequate, or both.
PMCID: PMC1059921  PMID: 8189166
11.  The impact of quitting smoking on symptoms of chronic bronchitis: results of the Scottish Heart Health Study. 
Thorax  1991;46(2):112-116.
Scotland has high rates of death from diseases of the respiratory system and high rates of smoking, especially among women. Data on self reported smoking and prevalence of chronic cough and chronic phlegm among 10,359 men and women aged 40-59 years were obtained from the Scottish Heart Health Study. Overall, current cigarette smokers had rates of chronic cough and chronic phlegm four to five times those of never smokers after standardisation for age (32.3% v 6.5% for men and 24% v 5.5% for women for chronic cough; 31% v 8.3% for men and 21% v 5.5% for women for chronic phlegm). Ex-smokers' symptom rates were a little above those of never smokers and were significant for chronic cough among women and chronic phlegm among men. Men had higher symptom rates than women and this was true for smokers, ex-smokers, and never smokers. The higher rates among men could not be explained by higher cotinine concentrations. Tests to detect "deceivers" among ex-smokers and never smokers using biochemical validation suggested that 87 (1.5%) respondents were in fact smoking; they were excluded from analyses. There were substantially lower rates of chronic cough and chronic phlegm within a year of stopping smoking, and two to four years after stopping 89-99% of the difference between current smokers and never smokers was accounted for (99% and 93% for men and women with chronic cough, 96% and 89% for men and women with chronic phlegm). Even 10 years after stopping, rates of symptoms among ex-smokers remained a little above those of never smokers (except for women with chronic phlegm), though these differences were not statistically significant. Former heavy smokers continued to have rates of chronic cough and chronic phlegm that were higher than those of former light and moderate smokers (though not significantly so). These are cross sectional data, but they emphasise the importance for chronic bronchitis symptoms of giving up cigarette smoking, though the amount previously smoked continues to exert a small influence.
PMCID: PMC462964  PMID: 2014491
12.  Diagnosis and treatment of asthma in children: usefulness of a review of medical records. 
In order to tackle the problems of underdiagnosis and undertreatment of asthma in childhood general practitioners need to be aware of which children in their practices have or might have asthma. In an effort to identify a cohort of asthmatic or potentially asthmatic children a trained audit facilitator studied all the medical records of children aged between one year and 15 years who were registered with 12 Tayside general practices. From a total of 10,685 medical records the frequency of 'key items' sometimes associated with asthma were as follows: one or more episodes of bronchospasm or wheeze 23.7% of children, persistent cough 23.2%, treatment with anti-asthma therapy in the past 20.0%, exercise induced cough or wheeze 5.2% and history of 'wheezy bronchitis' 4.6%. However, in only 896 children (8.4%) had a formal diagnosis of asthma been made. Of all the children, 5.4% had received a prescription for anti-asthma medication within the past three months. Only 1.2% were taking an inhaled corticosteroid and 1.0% sodium cromoglycate, but many more were taking inhaled bronchodilators (3.1%) and oral bronchodilators (1.7%). The findings suggest that a systematic review of medical records by a trained facilitator can identify those children who could benefit from clinical review. Practices who wish to know which of their children have or might have asthma should consider using medical record review to search for key items associated with asthma.
PMCID: PMC1372140  PMID: 1297369
13.  Cigarette tar content and symptoms of chronic bronchitis: results of the Scottish Heart Health Study. 
STUDY OBJECTIVE--The aim was to determine if there was a relationship between cigarette tar yield and rates of chronic cough and chronic phlegm. SETTING--22 districts across Scotland were used for the Scottish Heart Health Study (SHHS) which was conducted between 1984 and 1986 and from which the data for this analysis were obtained. SUBJECTS--10,359 men and women aged 40-59 years were studied. Of these, 2801 current cigarette smokers whose brand of cigarette smoked was known were selected. MEASUREMENTS AND MAIN RESULTS--Data on self reported smoking habits and prevalence of chronic cough and chronic phlegm were obtained from the SHHS. Tar yield was divided into three groups: low (less than or equal to 12 mg/cigarette); middle (13-14 mg/cigarette); high (greater than or equal to 15 mg/cigarette). The average tar yield consumed per person was 13.2 mg/cigarette. Women in the middle and high tar groups had smoked for longer and had significantly higher breath carbon monoxide levels, serum thiocyanate levels, serum cotinine levels, and daily cigarette consumption than the women in the low tar group. This pattern was not seen in men for any of these five smoking variables. Rates of chronic cough and chronic phlegm were higher with higher tar yield of cigarettes smoked for women (low tar v high tar: p less than 0.001) but not for men. Daily cigarette consumption and the number of years of smoking were the most significant risk factors for chronic cough and chronic phlegm for both men and women. Tar was still a significant risk factor (p less than 0.05) for women after controlling for these two risk factors and social class. CONCLUSIONS--Both sexes show strong effects of daily cigarette consumption and years of smoking on respiratory symptoms; women show an additional effect of cigarette tar content while men do not. The spread of tar yield in both sexes was small but there were more women on low tar cigarettes and this may have enabled a weak effect of tar to be seen better in them. On the other hand, tar level in women was confounded with other factors. Statistical methods of controlling for this may not have removed this confounding completely.
PMCID: PMC1059462  PMID: 1795148
14.  Prevalence of coronary heart disease in Scotland: Scottish Heart Health Study. 
British Heart Journal  1990;64(5):295-298.
Data from 10,359 men and women aged 40-59 years from 22 districts in the Scottish Heart Health Study were used to describe the prevalence rates of coronary heart disease in Scotland in 1984-1986 and their relation to the geographical variation in mortality in these districts. Prevalence was measured by previous history, Rose chest pain questionnaire, and the Minnesota code of a 12 lead resting electrocardiogram. The prevalence of coronary heart disease in Scotland was high compared with studies from other countries that used the same standardised methods. A history of angina was more common in men (5.5%) than in women (3.9%), though in response to the Rose questionnaire 8.5% of women and 6.3% of men reported chest pain. A history of myocardial infarction was three times more common in men than women, as was a Q/QS pattern on the electrocardiogram. There were significant correlations between the different measures of coronary prevalence. District measures of angina correlated well with mortality from coronary heart disease, and these correlations tended to be stronger in women than in men. There was no significant correlation between mortality from coronary heart disease and measures of myocardial infarction. The study provides data on the prevalence of coronary heart disease in men and women that are valuable for the planning of cardiological services.
PMCID: PMC1216805  PMID: 2245107
15.  An investigation into factors that may influence tonsil morphology. 
To investigate whether tonsillar size was related to human morphology, age or duration of disease, 100 consecutive patients undergoing tonsillectomy for recurrent tonsillitis were investigated. The lengths, widths and volumes of each resected tonsil were measured and compared with patient characteristics ascertained on the day before surgery. The volume of tonsillar tissue was directly related to height (p = 0.46, P less than 0.001) and weight (p = 0.45, P less than 0.001) and age, but at any age (or body size) there was a wide range of tonsil size. A weak inverse relationship was found with the duration of recurrent tonsillitis. Tonsil size is of no relevance in the assessment of recurrent tonsillitis or adenoid hypertrophy.
PMCID: PMC1292458  PMID: 2304049
16.  Unemployment, socioenvironmental factors, and coronary heart disease in Scotland. 
British Heart Journal  1989;61(2):172-177.
Scotland, which has one of the highest death rates in the world from coronary heart disease, also has considerable regional variation in mortality from this cause. The relation between standardised mortality ratios for coronary deaths (1979-83) for 56 local government districts and a range of socioeconomic factors from the 1981 Census as well as climatic factors and water hardness were investigated. Strong associations were seen with several measures of social disadvantage, the strongest being with percentage of male unemployment. A fitted multiple regression model with mortality from coronary heart disease in men found independent effects of two social variables (percentage male unemployment and percentage social class III-V) and one climatic factor (rainfall). The model explained much (73%) of the geographical variation in mortality from coronary heart disease, but part of the geographical pattern, in particular some of the east-west gradient in mortality, remained unexplained by it. Explanations for the geographical variation and the association with economic factors are currently being sought in terms of individual risk factors in a large screening study, the Scottish Heart Health Study.
PMCID: PMC1216636  PMID: 2923755
17.  Urinary electrolyte excretion, alcohol consumption, and blood pressure in the Scottish heart health study. 
BMJ : British Medical Journal  1988;297(6644):329-330.
As part of a study of risk factors for coronary heart disease 24 hour urine collections were obtained from 7354 men and women aged 40-59 selected at random from 22 districts throughout Scotland (Scottish heart health study). The mean of two standardised measurements of blood pressure was related to the reported consumption of alcohol and measurements of height, weight, pulse rate, and electrolyte excretion. Several significant correlations were found with both systolic and diastolic pressure, but only the coefficients for age, body mass index, and pulse rate were greater than 0.1. Alcohol consumption showed a weak positive correlation with blood pressure in men. Sodium excretion showed a weak positive correlation with blood pressure in both sexes, and potassium excretion showed weak negative correlations. In multiple regression analysis age, pulse rate, body mass index, alcohol consumption, and potassium excretion had significant independent effects but sodium excretion did not. Although measuring blood pressure twice on one occasion and 24 hour urinary sodium excretion only once may have weakened any potential correlation, the most likely explantation of these results is that the relation between sodium and blood pressure in the population is weak and that potassium and alcohol are of greater importance.
PMCID: PMC1834048  PMID: 3416163
18.  Trends in suicide in Scotland 1974-84: an increasing problem. 
A detailed investigation of trends in suicide rates in Scotland from 1974 to 1984 showed a complex pattern. Overall rates for men increased by 40% with the greatest increases in those aged 45-64. In contrast, rates for women showed a small decline, which was most noticeable in those aged 15-24. The well recognised decline in poisoning by domestic gas was seen over this period, and suicide by this method virtually stopped. Both sexes showed a decline in suicide by poisoning with drugs, although the decrease was larger among women. The fall in suicide rates among young women was almost all due to the decrease in this method. The rise in rates for men was largely due to increases in hanging and poisoning with vehicle exhaust gases, although all methods except drugs and domestic gas showed some increase. These findings indicate that suicide is an increasing problem with causes that are far from understood, so that prevention may be difficult.
PMCID: PMC1257762  PMID: 3117266
19.  Coronary heart disease and water hardness in Scotland--is there a relationship? 
Scotland has a mortality rate from coronary disease which is one of the highest in the world. There is also a considerable variation in this mortality rate within Scotland. Data on water hardness throughout Scotland have been collected from Regional Water Authorities to see whether variations in coronary mortality rates can be explained by variations in water hardness. Analysis demonstrates a much weaker negative association than has been demonstrated in studies in other countries. The geographical variation in coronary mortality rates in Scotland cannot be explained by variations in water hardness, and weak association between these in Scotland is discussed.
PMCID: PMC1052625  PMID: 3443816
20.  Comparison of response rates to a postal questionnaire from a general practice and a research unit. 
A postal questionnaire study was carried out in an urban general practice to determine the effect of the introductory letter being sent by the participants' own general practitioner compared with that from a letter sent directly from a research unit. By sequential sampling 409 individuals aged between 40 and 59 were assigned to one of two groups. The people in one group were written to by their own general practitioner and those in the other by a doctor from a research unit. Husbands and wives were paired and were always sent the same letter. A second letter was sent to nonresponders after one month. The response rate to the general practitioner was significantly higher than that to the doctor in the research unit (85% compared with 75%) and differed by age and sex. The results have important implications for other research workers and suggest that general practitioners are in a key position in the conduct of medical and epidemiological research.
PMCID: PMC1418119  PMID: 3933719
21.  Five-year age-specific incidence rates. II: The accuracy of calculations of expected number of tumours. 
Five-year age-specific incidence rates were shown to produce small but systematic errors in the calculation of the expected number of tumours in a hypothetical but realistic study population. Underestimates occurred at younger ages (under 55) and overestimates at older ages, with a small overestimate (0.22%) overall. Larger errors (up to 12%) were obtained when there was a rapid change in the single-year age structure of the study population. Interpolation between five-year rates will normally produce an inaccurate set of one-year rates. It is shown, with the example of a logarithmic interpolation, that these rates tend to produce errors of similar size to the five-year rates but with a small underestimate overall (0.37%). However, the interpolated rates produced the smaller errors (up to 1%) when the study population age structure undergoes rapid change. A method is suggested for partially correcting the error in the interpolated rates.
PMCID: PMC1052142  PMID: 7299340
22.  Distribution of malignant melanoma on the body surface. 
British Journal of Cancer  1981;43(6):842-849.
The distribution of malignant melanoma among the 4 major body sites (head, upper limb, lower limb and remainder (trunk) was investigated for 37 white populations. Although UV radiation is generally considered to be the major aetiological agent, it was found that approximately 75% of the tumours occurred on the relatively unexposed body sites. However, the sex differences in the incidence of melanoma at the various sites corresponded in direction and magnitude with the patterns of exposures of the sexes. The greatest difference between the sexes was the higher incidence on the female lower limb (the regular wearing of skirts results in a considerable exposure), and the next largest was the higher incidence on the male trunk (men can remove their shirts easily, but do not do so regularly). The results indicate that UV radiation is a major cause of malignant melanoma, but suggest that the mechanism of induction may be complex. Several hypotheses, as well as the types of additional evidence required, are discussed.
PMCID: PMC2010705  PMID: 7248161
23.  Five-year age-specific incidence rates. I. Their nature and limitations. 
The effect of population structure on five-year age-specific incidence rates was investigated using the one-year population data from life tables and a theoretical age incidence curve of the form: I = btk - where I is the incidence at age t, and b and k are constants. The five-year incidence rates differed systematically from the one-year rates of the central year of the five-year period. This difference depended on the change with age of both the population size and the incidence rate. Thus at ages 20-24 the five-year rate overestimates the mid-period one-year rate by about 4%, but the overestimate progressively decreases to become an underestimate of 0.5% at ages 75-79. In consequence the one-year and five-year rates produce fitted age incidence curves with different slopes; the value of k in the incidence equation is about 0.7% greater for the one-year rates. The population structures of developed and underdeveloped countries are markedly different and these were found to affect the five-year incidence rates, but never by more than 0.5%. The effect of the irregularities in one-year age structure of real populations on the observed five-year rates is also small, of the order of 0.5%. However, when incidence rates are calculated by recording tumours over several calendar years, these irregularities can create difficulties for the estimation of the appropriate denominator population. The use of the census population, even that of the central year of the observation period, can be in error by over 2%. A good method is to calculate the mean annual population of the observation period, estimating the intercensal year populations by interpolation between flanking censuses.
PMCID: PMC1052082  PMID: 7441146
24.  Variation of melanoma incidence with latitude in North America and Europe. 
British Journal of Cancer  1979;40(5):774-781.
The relationship between melanoma incidence and latitude was investigated in North American and Europe, using the data collected by 43 population-based cancer registries. In North America melanoma incidence increased with decreasing latitude, supporting the role of UV light in the induction of melanoma. Within England the data from the National Cancer Registration scheme also showed that trend of decreased frequency of melanoma with decreasing latitude. In contrast, across Europe the trend was in the opposite direction, of increasing melanoma incidence with increasing latitude. It is suggested that across Europe there is a range of skin colour from dark in the south to light in the north, which gives rise to a range of susceptibility to the induction of melanoma by UV. The effect of this susceptibility must be large enough to overwhelm the opposing effect of decreased UV intensity at higher latitudes, and this emphasizes the dangers of excessive solar exposure to fair-skinned individuals. The populations of England may be a sufficiently random mix of skin colour, owing to repeated invasions, for the effect of UV intensity to be observed.
PMCID: PMC2010099  PMID: 508580
25.  Racial differences in melanoma incidence. 
British Journal of Cancer  1979;40(2):185-193.
The incidences of malignant melanoma recorded by 59 population-based cancer registries were investigated to determine the effects of racial and skin-colour differences. White populations exhibited a wide range of melanoma incidences and females commonly, though not invariably, had a higher incidence than males. Non-white populations experienced in general a much lower incidence of melanoma although there was some overlap of white and non-white rates. No predominant sex difference emerged among non-whites. Populations of African descent were found to have a higher incidence than those of Asiatic origin, but it was concluded that this was due largely to the high frequency of tumours among Africans on the sole of the foot. A clear negative correlation between degree of skin pigmentation and melanoma incidence emerged for the exposed body sites. These data provide strong support for the hypotheses that UV radiation is a major cause of malignant melanoma and that melanin pigmentation protects against it. Further research is required to elucidate the aetiology of melanoma of the sole of the foot.
PMCID: PMC2010011  PMID: 475965

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