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1.  Smoking in young women in Scotland and future burden of hospital admission and death: a nested cohort study 
The British Journal of General Practice  2013;63(613):e523-e533.
Many women smoke, yet few longitudinal studies have examined the non-fatal burden of smoking in women.
To investigate smoking in young women, and hospital admission and death in Scotland; and to compare mortality risk with elsewhere in the UK.
Design and setting
Nested cohort study: Royal College of General Practitioners’ Oral Contraception Study, UK.
A total of 4121 women categorised by smoking habits and living in Scotland at recruitment (1968–1969) were followed until March 2009. Cox regression was used to investigate smoking and survival time; mortality from cancer, circulatory, or respiratory disease, and all other causes; and hospitalisation for any reason, and for specific reasons. The number and type of hospital admissions and bed-days were examined by smoking status. Life tables and Cox regression were used to compare the mortality risk of women living in Scotland with that of women living elsewhere.
All-cause mortality was increased in women who smoked <15 cigarettes daily (adjusted hazard ratio = 1.99, 95% confidence interval [CI] = 1.74 to 2.27) and those who smoked ≥15 cigarettes daily (adjusted HR = 2.81, 95% CI = 2.47 to 3.20). Smoking any amount increased death from cancer, circulatory, respiratory, and other causes. Increased risk estimates were seen in one or both smoking groups for hospitalisation for any cause, and for several specific causes. More smokers than non-smokers were admitted to hospital, for four or more reasons, and had a longer total stay. The median survival age among smokers was lower in Scotland than elsewhere. Higher adjusted hazard ratios for mortality were found among smokers in Scotland.
This study provides a powerful reminder of the burden of smoking in young women. In the UK, harmful effects appear to be worse in smokers in Scotland.
PMCID: PMC3722829  PMID: 23972193
cohort studies; general practice; hospitalisation; mortality; smoking; women
2.  Impact of lifestyle in middle-aged women on mortality: evidence from the Royal College of General Practitioners' Oral Contraception Study 
Although many individuals have multiple lifestyle risk factors, few studies have investigated the impact of lifestyle risk factor combinations among women.
To investigate the relationship between individual and combinations of lifestyle risk factors in middle-aged women with subsequent mortality, and to estimate the associated population attributable risks.
Design of study
Prospective cohort study.
Royal College of General Practitioners' (RCGP) Oral Contraception Study, UK.
In 1994–1995, women remaining under follow-up in the RCGP Oral Contraception Study were sent a lifestyle survey, from which modifiable risk factors were identified: pack-years smoked, physical inactivity, never drinking versus consuming at least 7 units of alcohol weekly, and being underweight, overweight, or obese. The cohort was followed to December 2006 or death. Population attributable risks were calculated.
Of 10 059 women studied, 896 died. Pack-years smoked (11–20 years: adjusted hazard ratio [HR] = 1.82, 95% confidence interval [CI] = 1.46 to 2.27; >20 years: adjusted HR = 2.34, 95% CI = 2.00 to 2.74); never drinking alcohol (adjusted HR = 1.66, 95% CI = 1.34 to 2.05); being underweight (adjusted = HR 1.66, 95% CI = 1.03 to 2.68); and physical inactivity (<15 hours/week: adjusted HR = 1.73, 95% CI = 1.46 to 2.04) were significantly associated with mortality compared with their respective reference group. Women with multiple lifestyle risk factors had higher mortality risks than those reporting one factor. The population attributable risk of the combination of smoking, physical inactivity, body mass index outside normal range, and alcohol (never drinking or excess intake) was 59% (95% CI = 31% to 78%).
Assuming a causal relationship between lifestyle and mortality, avoidance of four lifestyle risk factors would have prevented 60% of the deaths. The importance of avoiding smoking and undertaking physical inactivity during midlife should continue to be emphasised.
PMCID: PMC2913736  PMID: 20822689
epidemiology; follow-up studies; lifestyle; mortality; women
4.  Mortality among contraceptive pill users: cohort evidence from Royal College of General Practitioners’ Oral Contraception Study 
Objective To see if the mortality risk among women who have used oral contraceptives differs from that of never users.
Design Prospective cohort study started in 1968 with mortality data supplied by participating general practitioners, National Health Service central registries, or both.
Setting 1400 general practices throughout the United Kingdom.
Participants 46 112 women observed for up to 39 years, resulting in 378 006 woman years of observation among never users of oral contraception and 819 175 among ever users.
Main outcome measures Directly standardised adjusted relative risks between never and ever users for all cause and cause specific mortality.
Results 1747 deaths occurred in never users of oral contraception and 2864 in ever users. Compared with never users, ever users of oral contraception had a significantly lower rate of death from any cause (adjusted relative risk 0.88, 95% confidence interval 0.82 to 0.93). They also had significantly lower rates of death from all cancers; large bowel/rectum, uterine body, and ovarian cancer; main gynaecological cancers combined; all circulatory disease; ischaemic heart disease; and all other diseases. They had higher rates of violent deaths. No association between overall mortality and duration of oral contraceptive use was observed, although some disease specific relations were apparent. An increased relative risk of death from any cause between ever users and never users was observed in women aged under 45 years who had stopped using oral contraceptives 5-9 years previously but not in those with more distant use. The estimated absolute reduction in all cause mortality among ever users of oral contraception was 52 per 100 000 woman years.
Conclusion Oral contraception was not associated with an increased long term risk of death in this large UK cohort; indeed, a net benefit was apparent. The balance of risks and benefits, however, may vary globally, depending on patterns of oral contraception usage and background risk of disease.
PMCID: PMC2837145  PMID: 20223876
5.  Cancer risk among users of oral contraceptives: cohort data from the Royal College of General Practitioner's oral contraception study 
BMJ : British Medical Journal  2007;335(7621):651.
Objective To examine the absolute risks or benefits on cancer associated with oral contraception, using incident data.
Design Inception cohort study.
Setting Royal College of General Practitioners' oral contraception study.
Participants Directly standardised data from the Royal College of General Practitioners' oral contraception study.
Main outcome measures Adjusted relative risks between never and ever users of oral contraceptives for different types of cancer, main gynaecological cancers combined, and any cancer. Standardisation variables were age, smoking, parity, social class, and (for the general practitioner observation dataset) hormone replacement therapy. Subgroup analyses examined whether the relative risks changed with user characteristics, duration of oral contraception usage, and time since last use of oral contraception.
Results The main dataset contained about 339 000 woman years of observation for never users and 744 000 woman years for ever users. Compared with never users ever users had statistically significant lower rates of cancers of the large bowel or rectum, uterine body, and ovaries, tumours of unknown site, and other malignancies; main gynaecological cancers combined; and any cancer. The relative risk for any cancer in the smaller general practitioner observation dataset was not significantly reduced. Statistically significant trends of increasing risk of cervical and central nervous system or pituitary cancer, and decreasing risk of uterine body and ovarian malignancies, were seen with increasing duration of oral contraceptive use. Reduced relative risk estimates were observed for ovarian and uterine body cancer many years after stopping oral contraception, although some were not statistically significant. The estimated absolute rate reduction of any cancer among ever users was 45 or 10 per 100 000 woman years, depending on whether the main or general practitioner observation dataset was used.
Conclusion In this UK cohort, oral contraception was not associated with an overall increased risk of cancer; indeed it may even produce a net public health gain. The balance of cancer risks and benefits, however, may vary internationally, depending on patterns of oral contraception usage and the incidence of different cancers.
PMCID: PMC1995533  PMID: 17855280
6.  A qualitative study in rural and urban areas on whether – and how – to consult during routine and out of hours 
BMC Family Practice  2006;7:26.
Patients vary widely when making decisions to consult primary care. Some present frequently with trivial illness: others delay with serious disease. Differences in health service provision may play a part in this. We aimed to explore whether and how patients' consulting intentions take account of their perceptions of health service provision.
Four focus groups and 51 semi-structured interviews with 78 participants (45 to 64 years) in eight urban and rural general practices in Northeast and Southwest Scotland. We used vignettes to stimulate discussion about what to do and why. Inductive analysis identified themes and explored the influence of their perceptions of health service provision on decision-making processes.
Anticipated waiting times for appointments affected consulting intentions, especially when the severity of symptoms was uncertain. Strategies were used to deal with this, however: in cities, these included booking early just in case, being assertive, demanding visits, or calling out-of-hours; in rural areas, participants used relationships with primary care staff, and believed that being perceived as undemanding was advantageous. Out-of-hours, decisions to consult were influenced by opinions regarding out-of-hours services. Some preferred to attend nearby emergency departments or call 999. In rural areas, participants tended to delay until their own doctor was available, or might contact them even when not on call.
Perceived barriers to health service access affect decisions to consult, but some patients develop strategies to get round them. Current changes in UK primary care are unlikely to reduce differences in consulting behaviour and may increase delays by some patients, especially in rural areas.
PMCID: PMC1523347  PMID: 16640780
7.  Long term effects of hysterectomy on mortality: nested cohort study 
BMJ : British Medical Journal  2005;330(7506):1482.
Objectives To investigate the long term risk (mean > 20 years) of death from all causes, cardiovascular disease, and cancer in women who had or had not had a hysterectomy.
Design Nested cohort study.
Setting Royal College of General Practitioners' oral contraception study.
Participants 7410 women (3705 flagged at the NHS central registries for cancer and death who had a hysterectomy during the oral contraception study and 3705 who were flagged but did not have the operation).
Main outcome measures Mortality from all causes, cardiovascular disease, and cancer.
Results 623 (8.4%) women had died by the end of follow-up (308 in the hysterectomy group and 315 in the non-hysterectomy group). Older women who had had a hysterectomy had a 6% reduced risk of death compared with women of a similar age who did not have the operation (adjusted hazard ratio 0.94, 95% confidence interval 0.75 to 1.18). Compared with young women who did not have a hysterectomy those who were younger at hysterectomy had an adjusted hazard ratio for all cause mortality of 0.82 (0.65 to 1.03). Hysterectomy was not associated with a significantly altered risk of mortality from cardiovascular disease or cancer regardless of age.
Conclusion Hysterectomy did not increase the risk of death in the medium to long term.
PMCID: PMC558457  PMID: 15930026
8.  Long term outcomes in men screened for abdominal aortic aneurysm: prospective cohort study 
Objective To determine whether there is a relation between aortic diameter and morbidity and mortality in men screened for abdominal aortic aneurysm.
Design Prospective cohort study.
Setting Highland and Western Isles (a large, sparsely populated area of Scotland).
Participants 8146 men aged 65-74.
Main outcome measures Morbidity and mortality in relation to presence of abdominal aortic aneurysm and three categories of aortic diameter (≤24 mm, 25-29 mm, and ≥30 mm).
Results When screened, 414 men (5.1%) had an aneurysm (diameter ≥30 mm), 669 (8.2%) an aortic diameter of 25-29 mm, and 7063 (86.7%) an aortic diameter of ≤24 mm. The cohort was followed up for a median of 7.4 (interquartile range 6.9-8.2) years. Mortality was significantly associated with aortic diameter: 512 (7.2%) men in the ≤24 mm group died compared with 69 (10.3%) in the 25-29 mm group and 73 (17.6%) in the ≥30 mm group. The mortality risk in men with an aneurysm or with an aorta measuring 25-29 mm was significantly higher than in men with an aorta of ≤24 mm. The increased mortality risk in the 25-29 mm group was reduced when taking confounders such as smoking and known heart disease into account. After adjustment, compared with men with an aortic diameter of ≤24 mm, the risk of hospital admission for cardiovascular disease and chronic obstructive pulmonary disease was significantly higher in men with aneurysm and those with aortas measuring 25-29 mm. Men with an aneurysm also had an increased risk of hospital admission for cerebrovascular disease, atherosclerosis, peripheral arterial disease, and respiratory disease. In men with aortas measuring 25-29 mm, the risk of hospital admission with abdominal aortic aneurysm was significantly higher than in men with an aorta of ≤24 mm (adjusted hazard ratio 6.7, 99% confidence interval 3.4 to 13.2) and this increased risk became apparent two years after screening.
Conclusions Men with abdominal aortic aneurysm and those with aortic diameters measuring 25-29 mm have an increased risk of mortality and subsequent hospital admissions compared with men with an aorta diameter of ≤24 mm. Consideration should be given to control of risk factors and to rescreening men with aortas measuring 25-29 mm at index scanning.
PMCID: PMC3344734  PMID: 22563092

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