National NCD Programmes: Challenge and the Way Forward - Experience in the industrialized countries

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  • Greeting: Good afternoon and thank you for coming to this presentation! Today I would like to talk about our research project titled … Before starting my presentation I would like to thank Simon and Julia for their valuable scientific and social support. Guven araliklarini koyarsan iyi olur results tablosuna CHD icin akis semasini koy Degiskenlerin tanimlarini koy
  • The World Health Report 2002 1 reported that the top 10 global risk factors for premature death are: childhood and maternal underweight; unsafe sex; high blood pressure; tobacco; alcohol; unsafe water, sanitation and hygiene; high cholesterol; indoor smoke from solid fuels; iron deficiency and overweight/obesity. Together, they account for one-third of global loss of healthy life years (DALY; disability-adjusted life years) annually and about 40 per cent of the 56 million deaths that occur worldwide. The burden from many of the risks is borne almost exclusively by the developing world, while other risks have already become global. The report predicts that unless action is taken, by the year 2020 there will be nine million deaths caused by tobacco, compared to almost five million a year now; five million deaths attributable to overweight and obesity, compared to three million now; that the number of healthy life years lost by underweight children will be 110 million, which, although lower than 130 million now, is still unacceptably high. High cholesterol is estimated to cause about 4.4 million deaths (7.9% of total) and a loss of 40.4 million DALYs (2.8% of total), although its effects often overlap with high blood pressure. This amounts to 18% of strokes and 56% of global ischaemic heart disease. Reference 1. World Health Organization. The World Health Report 2002.
  • Some of the risk factors that predispose an individual to the development or progression of CVD are outlined above. Evidence has shown that lifestyles associated with a ‘western’ culture such as a diet rich in saturated fats and high in calories, smoking and physical inactivity, are some of the modifiable risk factors leading to an increase in the prevalence of CVD. Of these, three are considered to be of prime importance: 1 Smoking is responsible for 50% of all avoidable deaths, of which half are due to CVD. Raised blood pressure has been found to be an important risk factor for the development of CVD, cardiac failure and cerebrovascular disease. The greater the increase in blood pressure, the higher the risk. Greatest benefit of blood pressure lowering is seen in those at higher risk. Even modest reductions produce substantial benefits in those with multiple risk factors. Dyslipidaemia, in particular, raised low-density lipoprotein (LDL) cholesterol and triglyceride levels, and low high-density lipoprotein (HDL) cholesterol are associated with increased risk of CVD. Reference 1. Pyörälä K et al. Eur Heart J 1994; 15 :1300–1331.
  • Cardiovascular disease is associated with increased levels of total cholesterol. 1 Other risk factors include an increase in total to HDL-C ratio, hypertension, cigarette smoking, excess weight, elevated blood sugar levels, lack of exercise, stress, and electrocardiographic abnormalities. Intervention trials have shown that identifying and lowering these risk factors may help to reduce the subsequent rate of coronary heart disease, stroke, and other cardiovascular disease. Reference Castelli WP. Am J Med. 1984; 76 :4–12. Adapted from Am J Med 1984; 76 :4–12, with permission from Excerpta Medica Inc.
  • Twenty-five year follow-up data from the Seven Countries study 1 show that serum total cholesterol levels are linearly related to CHD mortality across cultures. The relative increase in CHD mortality rates with a given increase in cholesterol are similar. However, the large between-country difference in CHD mortality rates at a given cholesterol level indicates that other factors, such as diet, also play a role in the development of CVD. The link between high cholesterol levels and increased incidence of CVD has also been shown in the prospective part of the Multiple Risk Intervention study. 2 In epidemiological studies, measurements of serum cholesterol have been routinely used. The relationship between cholesterol levels and the incidence of CVD is almost entirely dependent on low-density lipoprotein (LDL) cholesterol, the main carrier of cholesterol and a major atherogenic lipoprotein. 3 Results from the Framingham study 4 during 26 years of observation show that men have twice the incidence of CHD mortality and morbidity of women. This difference tends to diminish during the later years, after the menopause. Other factors that influence susceptibility to CHD include ethnic background and social class. 5-7 References 1. Verschuren WM et al. JAMA 1995; 274 (2):131–136. 2. Martin MJ et al. Lancet 1986; ii :933–936. 3. Kannel WB et al. In Proceeding of Golden Jubilee International Congress, Minnesota, 1980. Eds Loan MS, Holman RT.Oxford, Pergamon Press 1982;339–348. 4. Lerner DJ, Kannel WB. Am Heart J 1986; 11 (2):383–390. 5. Rosamond WD et al. N Engl J Med 1998; 339 :861–867. 6. Goff DC et al. Circulation 1997; 95 :1433–1440. 7. Poulter N. In Cardiovascular Disease: Risk Factors and Intervention. Eds: Poulter N, Sever P, Thom S. Radcliffe Medical Press, Oxford, 1993. Adapted from JAMA 1995; 274 :131–136, with permission from American Medical Association. All rights reserved.
  • Multiple risk factors for CVD are usually present in an individual; rarely do they occur in isolation. When risk factors co-exist the effect is often exponential; their combined effect is greater than the sum of their individual effects. 1 Multiple risk factors are also associated with the metabolic syndrome which is characterised by dyslipidaemia, hypertension, insulin resistance, visceral distribution of body fat, and a prothrombotic state. 2 References 1. Poulter N. In Cardiovascular Disease: Risk Factors and Intervention. Eds: Poulter N, Sever P, Thom S. Radcliffe Medical Press, Oxford, 1993. 2. Deedwania PC. Am J Med 1998; 105 (1A);1S–3S. Reproduced with permission from Radcliffe Medical Press.
  • The Prospective Studies Collaboration is a collaborative meta-analysis combining data from existing prospective observational studies that recorded both blood pressure and blood cholesterol at baseline and that followed participants for cause-specific mortality. Investigators from around the world have collaborated to combine data from 61 existing prospective studies involving a total of one million participants from Europe, North America, Australia, Israel, China and Japan. During 12.7 million person-years of follow-up there were 120 000 deaths involving more than 55 000 vascular deaths (12 000 stroke, 34 000 ischaemic heart disease [IHD], 10 000 other vascular) and more than 65   000 other deaths.
  • Figure 1(a): IHD mortality (33 744 deaths) versus usual total cholesterol. Age-specific associations The hazard ratios are plotted on a floating absolute scale of risk (so each log hazard ratio has an appropriate variance assigned to it. NOTES: 1 mmol/L lower total cholesterol was associated with about a half , a third and a sixth lower IHD mortality in both sexes at ages 40-49, 50-69 & 70-89, respectively, throughout the main range of cholesterol in most developed countries, with no apparent threshold. Although the proportional differences in risk decrease with age, the absolute effects of cholesterol on annual IHD mortality rates are much greater at older than at younger ages. For example, the absolute difference in the annual risk of IHD death for a 1 mmol/L difference in total cholesterol was about 10 times greater at 80-89 than at 40-49 years of age.
  • Figure 2(c). IHD mortality (33 744 deaths) versus usual total cholesterol by body mass index (BMI). Conventions as in figure 1(b). (The BMI analysis involved just 33 436 deaths because of missing BMI values for 308 people who died of IHD.) NOTES: Similarly, BMI was of little relevance to the proportional effects of cholesterol on IHD mortality within each age group, so the absolute difference in IHD mortality (for a given difference in total cholesterol) was somewhat greater for more obese.
  • Biggest changes will be in Africa, followed very closely by MENA. NAC and Europe will change the least.
  • In a recent study we investigated the combined effect of several midlife vascular risk factors. We were interested in seeing whether the vascular risk factors were independent of each other, or whether ne factor could explain the associations observed for another factor. When bmi, sbp, and cholesterol were all put simultaneously into the same model, they all independently increased the risk of dementia and AD. The Or for each factor was around 2. We know, that risk factors tend to cluster together, and the same person can have several risk factors. This clustering increased the risk of dementia in an additive manner. The more there were risk factors, the higher was the risk, so that those who had all three factors – high sbp, high bmi and high cholesterol had an or of 6 for dementia when compared to persons with none of the risk factors.
  • National NCD Programmes: Challenge and the Way Forward - Experience in the industrialized countries

    1. 1. National NCD Programmes:Challenge and the Way Forward - Experience in the industrialized countries Prof. Jaakko Tuomilehto Department of Public Health, University of Helsinki, Finland and Center for Vascular Prevention,Danube-University Krems, Krems, Austria
    2. 2. Core Public Health Functions to prevent and control NCDs Evidence Action – Health protection andassurance Action – Health promotion Research Financing Training
    3. 3. Factors Contributing to Death Worldwide 10 global risk factors account for more than one third of deaths worldwide Small number of risk factors cause high number of premature deaths and large share of global burden of disease Risk factors causing premature deaths include:  high cholesterol - 4.4 million deaths (7.9% of total)  tobacco - about 4.9 million deaths  elevated blood pressure - 7.1 million deaths The World Health Report 2002.
    4. 4. Risk Factors for CVD and NCDs Modifiable  Non-modifiable  Smoking  Personal history  Dyslipidaemia of CVD • Raised LDL-C  Family history • Low HDL-C of CVD  Age • Raised triglycerides  Gender  Raised blood pressure  Diabetes mellitus  Obesity  Dietary factors  Thrombogenic factors  Lack of exercise  Excess alcohol consumption
    5. 5. Relationship Between Cholesterol and CHD Risk: Framingham Study 150 125 CHD incidence per 1000 100 75 50 25 0 <204 205–234 235–264 265–294 >295 (<5.3) (5.3–6.1) (6.1–6.8) (6.8–7.6) (>7.6) Serum total cholesterol, mg/dL (mmol/L) Castelli WP. Am J Med. 1984;76:4–12.
    6. 6. Most of the people dying from coronary heartdisease have ”intermediate” level of a risk factor
    7. 7. SOUND COMBINATION OF THE POPULATION STRATEGY WITH HIGH RISK STRATEGY 1. Population strategy: - Greatest public health gains - Cost effective - Results also in other health benefits 1. High risk strategy: - Great benefits to the persons concerned - Effective use of health services 1612.09.12
    8. 8. Relationship of Serum Cholesterol to Mortality: Seven Countries Study 35 Northern EuropeDeath rate from CHD/1000 men 30 25 United States 20 15 10 Southern Europe, inland Serbia Southern Europe, Mediterranean 5 Japan 0 2.60 3.25 3.90 4.50 5.15 5.80 6.45 7.10 7.75 8.40 9.05 (100) (125) (150) (175) (200) (225) (250) (275) (300) (325) (350) Serum total cholesterol, mmol/L (mg/dL) Verschuren WM et al. JAMA 1995;274(2):131–136.
    9. 9. Levels of Risk Associated with Smoking,Hypertension and Hypercholesterolaemia Hypertension (SBP 195 mmHg) x3 x4.5 x9 x16 x1.6 x6 x4 Smoking Serum cholesterol level (8.5 mmol/L, 330 mg/dL)
    10. 10. Prospective Studies Collaboration Lancet 2007; 370: 1829-39 Established chiefly to investigate associations of blood pressure and cholesterol with cause-specific mortality Individual data on 900 000 participants without any previous history of vascular disease from 61 prospective cohort studies > 55 000 vascular deaths (34 000 ischaemic heart disease [IHD], 12 000 stroke, 10 000 other) 150 000 participants from 23 studies also had HDL cholesterol (5000 vascular deaths)
    11. 11. IHD mortality (33 744 deaths) versus usual total cholesterolIHD mortality (33 744 deaths) versus usual total cholesterol Age at 1 mmol/L ↓ risk total cholesterol 80-89 15% ↓ risk 70-79 18% ↓ risk Usual total cholesterol (mmol/L) 60-69 28% ↓ risk 50-59 42% ↓ risk 4·0 5·0 6·0 7·0 8·0 40-49 56% ↓ risk 256 128 0·5 64 32 16 8 4 2 1 CI) (floating absolute risks & 95% Hazard ratio
    12. 12. IHD mortality (33 744 deaths) versus usual total cholesterolIHD mortality (33 744 deaths) versus usual total cholesterol by BMI by BMI Age at BMI No. of risk (kg/m2) deaths 70-89 30+ 2369 0·77 (0·73-0·81) 25-29 7198 0·78 (0·75-0·80) <25 6736 0·79 (0·76-0·81) 60-69 30+ 1518 0·74 (0·70-0·79) 25-29 4679 0·72 (0·69-0·74) <25 4123 0·70 (0·68-0·73) 40-59 30+ 827 0·62 (0·57-0·67) 25-29 3105 0·56 (0·54-0·59) <25 2881 0·55 (0·53-0·58) 0·4 0·6 0·81·0 Hazard ratio (& 95% CI) for 1 mmol/L lower usual total cholesterol
    13. 13. Comparison of individual and community approaches in CVD prevention
    14. 14. Health Impact Pyramid
    15. 15. St u 1950 di e s: to b ac co To ca 1960 b us ac c e sc oc an on su c er W mp or t 1970 kin ion gg pe TO ro ak BA up s •A CC to POLICY re 1976 •S dver O A du pu mo tis CT ce bli king in g sm •S b ok ale c pla ban an ing ba ce s: Mid 80’s St nt s pu ud op bli ies er ct :p so ra as ns ns siv un po de rt es an Gu mo r1 d 1985 ide kin 6y lin gc ea es au r s. for se •B sm sc •W an o ok an ce 1995 efr •S ork f ind ee r ale pla ire wo ba ces ct a rk nt sm dve pla •S om ce ok rti s 2000 mo ino el si n •E ke rs fr e TS fr es g ca e e rci ar no eas 2001 ge n i c i n th by e r law est au ra Pla nt n s 2003 re n sta ing ur s an t ag ts eo FC ns m 2005 TC ra ok tif efr ica ee tio n Sm 2007 ok efr eer All es •li re tau ce st a ra •R n 2009 nt es sing uran s( tri gr cti of r ats ad on eta sm ua so lly nt il s oke ) ra ale free ve lle 2010: r’s 17 all ow •Enlargement of smokefree places •Ban on tobacco displays•Objective: to end tobacco consumption •Smokefree Finland by 2040 •Restrictions related to snus an ce s THE HISTORY OF THE FINNISH TOBACCO
    16. 16. THE HISTORY OF THE FINNISH TOBACCO POLICY s nt s ) ce ra lly ing ee an au ua ok er ow law est efr ad sm c s ra ale free gr an all ak by e r ok TOBACCO ACT s( ce sc pe m n i c i n th r’s il s oke •Advertising ban du nt ns e lle ion us ra eta sm re 18 ve no eas •Smoking bans: public ts ge o ca tau t to mp cti of r ats ge n co rci ar transport and public es up nt tio ur g sta su ac es sing uran er ca e e ro so ica on places b an e gg TS efr to oc re nnin on tif efr st a •Sale ban to persons s: • E ok kin ra c ok re di e s ta ac m la TC tri or n Sm under 16 years. All b •S ce u P W FC ToSt •li •R1950 1960 1970 Mid 1985 2000 2001 2003 2005 2009 80’s 1976 1995 2007 2010: •Ban on tobacco displays •Restrictions related to snus •Enlargement of smokefree places •Objective: to end tobacco consumption •Smokefree Finland by 2040
    17. 17. St u 1950 di e s: to b ac co To ca 1960 b us ac c e sc oc an on su c er W mp or t 1970 kin ion gg pe TO ro ak BA up s •A CC to POLICY re 1976 •S dver O A du pu mo tis CT ce bli king in g sm •S b ok ale c pla ban an ing ba ce s: Mid 80’s St nt s pu ud op bli ies er ct :p so ra as ns ns siv un po de rt es an Gu mo r1 d 1985 ide kin 6y lin gc ea es au r s. for se sm sc ok an ce 1995 efr ee r wo rk pla ce s •Sale ban to minors 2000 •Workplaces smokelfree 2001 •Ban of indirect advertising Pla 2003 re nnin s ta ur g sta an ts ge o FC ns m 2005 TC ra ok tif efr ica ee tio n Sm 2007 ok efr ere All es •li re tau ce st a ra •R n 2009 nt es sing uran s( tri gr cti of r ats ad on eta sm ua so lly nt il s oke ) ra ale free ve lle 2010: r’s 19 all ow •Enlargement of smokefree places •Ban on tobacco displays•Objective: to end tobacco consumption •Smokefree Finland by 2040 •Restrictions related to snus an ce s THE HISTORY OF THE FINNISH TOBACCO
    18. 18. St u 1950 di e s: to b ac co To ca 1960 b us ac c e sc oc an on su c er W mp or t 1970 kin ion gg pe TO ro ak BA up s •A CC to POLICY re 1976 •S dver O A du pu mo tis CT ce bli king in g sm •S b ok ale c pla ban an ing ba ce s: Mid 80’s St nt s pu ud op bli ies er ct :p so ra as ns ns siv un po de rt es an Gu mo r1 d 1985 ide kin 6y lin gc ea es au r s. for se •B sm sc •W an o ok an ce 1995 efr •S ork f ind ee r ale pla ire wo ba ces ct a rk nt sm dve pla •S om ce ok rti s 2000 mo ino el si n •E ke rs fr e TS fr es g ca e e rci ar no eas 2001 ge n i c i n th by e r law est au ra nt s 2003 2005 Smokefree (gradually) restaurants 2007 A •li ll re c s 2009 • R e n s t au es ing ran tri cti of r ats on e s s o tail mok n t sal efr ra e ee ve lle 2010: r’s20 all ow •Enlargement of smokefree places •Ban on tobacco displays•Objective: to end tobacco consumption •Smokefree Finland by 2040 •Restrictions related to snus an ce s THE HISTORY OF THE FINNISH TOBACCO
    19. 19. St u 1950 di e s: to b ac co To ca 1960 b us ac c e sc oc an on su c er W mp or t 1970 kin ion gg pe TO ro ak BA up s •A CC to POLICY re 1976 •S dver O A du pu mo tis CT ce bli king in g sm •S b ok ale c pla ban an ing ba ce s: Mid 80’s St nt s pu ud op bli ies er ct :p so ra as ns ns siv un po de rt es an Gu mo r1 d1985 ide kin 6y lin gc ea es au r s. for se •B sm sc •W an o ok an ce 1995 efr •S ork f ind ee r ale pla ire wo ba ces ct a rk nt sm dve pla •S om ce ok rti s 2000 mo ino el si n •E ke rs fr e TS fr es g ca e e rci ar no eas 2001 ge n i c i n th by e r law est au ra Pla nt n s 2003 re n sta ing ur s an t ag ts eo FC ns m 2005 TC ra ok tif efr ica ee tio n Sm 2007 ok efr eer All es •li re tau ce st a ra •R n 2009 nt es sing uran s( tri gr cti of r ats ad on eta sm ua so lly nt il s oke ) ra ale free ve lle 2010: r’s 21 all •Enlargement of smokefree places •Ban on tobacco displays ow •Smokefree Finland by 2040•Objective: to end tobacco consumption •Restrictions related to snus an ce s THE HISTORY OF THE FINNISH TOBACCO
    20. 20. Proportion of daily smokers (%) 1950-2011, age 15-64 80 70 60 50 Men 40% Women 30 20 10 0 50 60 70 80 90 00 5 6 7 8 9 11 Year Sources: * Years -50, -60 and -70: Finnish Gallup The National Institute for Health and Welfare (THL). Health Behaviour and Health among the Finnish Adult Population, Spring 2011. Report 45/2012.
    21. 21. Exposure to environmental tobacco smoke in Finland 1983 - 2011 40 35 Home 30 Workplace 25 20% 15 10 5 0 83 86 89 91 93 95 96 97 98 99 00 01 02 03 04 05 06 7 8 11 year The National Institute for Health and Welfare (THL). Health Behaviour and Health among the Finnish Adult Population, Spring 2011. Report 45/2012.
    22. 22. Cancer mortality trends in Ireland Stomach Intestines Liver/Gallbladder Pancreas
    23. 23. Female smoking prevalence and deaths over a 100-year period
    24. 24. Systolic Blood Pressure Finnish Men 30-59 YearsmmHg Area:
    25. 25. Diastolic Blood Pressure Women 30-59 YearsmmHg
    26. 26. Serum cholesterol in Finnish men aged 25-64 yearsmmol/l 76,5 North Karelia Kuopio Turku/Loimaa 6 Helsinki/Vantaa Oulu5,5 Lapland 5 1982 1987 1992 1997 2002 2007
    27. 27. Smoking –% Men 25-64 years
    28. 28. Smoking – Women 25-64 years%
    29. 29. CVD PREVENTION WORKS Start of the North Karelia Nationwide Project CVD Age-adjusted 700 prevention CHD mortality activity 600in North Karelia and the whole 500 North Karelia of Finland 400Men 35-64 yrs 300 Finland -82% 1969 to 2001 200 Mortality per 100 100 000 population -75% 70 75 80 85 90 95 20 Year M Paimensaari 2.9.2005 32
    30. 30. IMPACT Model: CHD mortality fall in Finland 1982 – 1997 0 Risk Factors -71%-100 Cholesterol - 53% Smoking - 11% Blood pressure - 7%-200 Treatments -24%-300 AMI treatments - 4% 373 fewer deaths Secondary prevention - 8% Heart failure - 2%-400 Angina:CABG & PTCA - 8%1982 1997 Angina: Aspirin etc - 2% Laatikainen et al Am J Epid 2005 162 764
    31. 31. Trends in salt intake in Finland based on dietary surveys and24-h urinary sodium excretion
    32. 32. Salt intake distributions following different foodchoices and cooking practices among Finnish men Ideal target Present situation
    33. 33. International CHD mortality trends in men, 1968-2003Per 100,000 800 Finland 600 400 Ireland Netherlands UK 200 USA France Italy 0 0 3 6 9 2 5 8 1 4 7 0 7 7 7 8 8 9 9 0 7 8 9 9 9 9 9 9 9 9 9 9 9 0 1 1 1 1 1 1 1 1 1 1 2 Source:WHO statistics 2005 Men aged 35 - 74,
    34. 34. BMI in Finnish men aged 25-64 yearsKg/m2 Areas:
    35. 35. BMI in Finnish women aged 25-64 yearsKg/m2 Areas:
    36. 36. Change in 9-year Mortality (%) (from Cohort 1 to Cohort 2) for US Men and Women With and Without DiabetesCohort 1: 1973-75; Cohort 2: 1983-85
    37. 37. Finnish Diabetes Prevention Study: lifestyle goals Weight reduction > 5% Fat intake < 30 Energy-% Saturated fat intake < 10 Energy-% Fibre intake ≥ 15 g/1000 kcal Physical activity > 30 min/dayIntervention group• Individually tailored diet based on 3-day food diaries• 7 dietary counselling sessions during the first year, every 3 monthsthereafter• Free-of-charge gymControl group• General advice about healthy diet and exercise habits• No individualised counselling Tuomilehto et al. 2001
    38. 38. Reduction of the Incidence of DiabetesDuring the Lifestyle Intervention – DPS Risk reduction: 58%
    39. 39. DPS: Diabetes Incidence is SustainedDuring the Extended Follow-Up without a further Intervention 50 Log-rank test: p=0.0001 Control Cumulative incidence of T2D, % Hazard ratio = 0.57 (95% CI 0.43-0.76) 40 30 20 Intervention 10 Intervention ceased 0 0 1 2 3 4 5 6 7 8 Follow-up time, years Lindström J et al. Lancet 2006; 368(9548):1673-79.
    40. 40. Prevention of Type 2 Diabetes byLifestyle Management: The EvidenceDPS - Finland DPP - USA SLIM - Netherlands Risk 58% ↓ Risk 58% ↓ Risk 58% ↓EDIPS Newcastle - UK Da Qing - China IDPP - India Control Risk 55% ↓ Risk 43% ↓ Risk 28,5% ↓ Metformin Lifestyle
    41. 41. Protection against diabeteswhen achieving the intervention targets at the one-year examination - DPS % SUCCESS SCORE Tuomilehto et al. N Engl J Med 2001; 344:1343
    42. 42. Combined effect of midlife vascular risk factors on late-life dementia OR (95% CI) 10 9 8BMI 2.1 (1.2 - 3.8) 6.21 7>30 kg/m2 6 5 4SBP >140mmHg 2.0 (1.0 - 3.8) 3.03 3 1.37 2 1Cholesterol 1.9 (1.0 - 3.5) 1 0 1 2 3 0>6.5 mmol/l Number of risk factors present Adjusted for sociodemographic factors. Kivipelto et al., Arch Neurol 2005
    43. 43. ApoE4 Magnifies Effects of Lifestyle for the Risk of Dementia APOE ε4 non-carriers Active Sedentary APOE ε4 carriers Physical activity Active Sedentary 5.5 IV III II I PUFA intake- IV quartiles III II 4 I 5 I II III SFA intake - quartiles IV I II 7.1 III IV 7.1 Non-drinkers Infrequent Frequent Alcohol Non-drinkers drinking Infrequent Frequent 3.8 Non-smokers Smokers Smoking Non-smokers ORs for dementia Smokers 3.2
    44. 44. Value of primordial or primaryprevention strategies in the USA
    45. 45. Value of primordial or primaryprevention strategies in the USA

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