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BackgroundDespite compelling evidence on the health hazards of tobacco products accumulated over the past 70 years, smoking remains a leading cause of death worldwide. Policy action to control smoking requires timely, comprehensive, and comparable evidence on smoking levels within and across countries. This study provides a recent assessment of that evidence based on the methods used in the Global Burden of Disease (GBD) Study.MethodsWe estimated annual prevalence of, and mortality attributable to smoking any form of tobacco from 1970 to 2020 and 1990–2020, respectively, using the methods and data sources (including 3431 surveys and studies) from the GBD collaboration. We modelled annual prevalence of current and former smoking, distributions of cigarette-equivalents per smoker per day, pack-years for current smoking, years since cessation for former smokers and estimated population-attributable fractions due to smoking.ResultsGlobally, adult smoking prevalence in 2020 was 32.6% (32.2% to 33.1%) and 6.5% (6.3% to 6.7%) among men and women, respectively. 1.18 (0.94 to 1.47) billion people regularly smoke tobacco, causing 7.0 (2.0 to 11.2) million deaths in 2020. Smoking prevalence has declined by 27.2% (26.0% to 28.3%) for men since 1990, and by 37.9% (35.3% to 40.1%) for women. Declines have been largest in the higher sociodemographic countries, falling by more than 40% in some high-income countries, and also in several Latin American countries, notably Brazil, where prevalence has fallen by 70% since 1990. Smoking prevalence for women has declined substantially in some countries, including Nepal, the Netherlands and Denmark, and remains low throughout Asia and Africa. Conversely, there has been little decline in smoking in most low- and middle-income countries (LMICs) with over half of all men continuing to smoke in large populations in Asia (China, Indonesia), as well as the Pacific Islands.ImplicationsWhile global smoking prevalence has fallen, smoking is still common and causes a significant health burden worldwide. The unequal pace of declines across the globe is shifting the epidemic progressively to LMICs. Smoking is likely to remain a leading cause of preventable death throughout this century unless smoking cessation efforts can significantly and rapidly reduce the number of smokers, particularly in Asia.FundingXD and EG received funding through grant projects from Bloomberg Philanthropies (funding no. 66-9468) and the Bill & Melinda Gates Foundation (funding no. 63-3452).

Many national and subnational governments need to routinely measure the completeness of death registration for monitoring and statistical purposes. Existing methods, such as death distribution and capture-recapture methods, have a number of limitations such as inaccuracy and complexity that prevent widespread application. This paper presents a novel empirical method to estimate completeness of death registration at the national and subnational level. Random-effects models to predict the logit of death registration completeness were developed from 2,451 country-years in 110 countries from 1970-2015 using the Global Burden of Disease 2015 database. Predictors include the registered crude death rate, under-five mortality rate, population age structure and under-five death registration completeness. Models were developed separately for males, females and both sexes. All variables are highly significant and reliably predict completeness of registration across a wide range of registered crude death rates (R-squared 0.85). Mean error is highest at medium levels of observed completeness. The models show quite close agreement between predicted and observed completeness for populations outside the dataset. There is high concordance with the Hybrid death distribution method in Brazilian states. Uncertainty in the under-five mortality rate, assessed using the dataset and in Colombian departmentos, has minimal impact on national level predicted completeness, but a larger effect at the subnational level. The method demonstrates sufficient flexibility to predict a wide range of completeness levels at a given registered crude death rate. The method can be applied utilising data readily available at the subnational level, and can be used to assess completeness of deaths reported from health facilities, censuses and surveys. Its utility is diminished where the adult mortality rate is unusually high for a given under-five mortality rate. The method overcomes the considerable limitations of existing methods and has considerable potential for widespread application by national and subnational governments.

Background In recent years, there have been adverse trends in premature cardiovascular disease (CVD) mortality rates (35–74 years) in the USA and Australia. Following long-term declines, rates in the USA are now increasing while falls in Australia have slowed rapidly. These two countries also have the highest adult obesity prevalence of high-income countries. This study investigates the role of overweight and obesity in their recent CVD mortality trends by using multiple cause of death (MCOD) data—direct individual-level evidence from death certificates—and linking the findings to cohort lifetime obesity prevalence. Methods We identified overweight- and obesity-related mortality as any CVD reported on the death certificate (CVD MCOD) with one or more of diabetes, chronic kidney disease, obesity, lipidemias or hypertensive heart disease (DKOLH-CVD), causes strongly associated with overweight and obesity. DKOLH-CVD comprises 50% of US and 40% of Australian CVD MCOD mortality. Trends in premature age-standardized death rates were compared between DKOLH-CVD and other CVD MCOD deaths (non-DKOLH-CVD). Deaths from 2000 to 2017 in the USA and 2006–2016 in Australia were analyzed. Trends in in age-specific DKOLH-CVD death rates were related to cohort relative lifetime obesity prevalence. Results Each country’s DKOLH-CVD mortality rate rose by 3% per annum in the most recent year, but previous declines had reversed more rapidly in Australia. Non-DKOLH-CVD mortality in the USA increased in 2017 after declining strongly in the early 2000s, but in Australia it has continued declining in stark contrast to DKOLH-CVD. There were larger increases in DKOLH-CVD mortality rates at successively younger ages, strongly related with higher relative lifetime obesity prevalence in younger cohorts. Conclusions The increase in DKOLH-CVD mortality in each country suggests that overweight and obesity has likely been a key driver of the recent slowdown or reversal of CVD mortality decline in both countries. The larger recent increases in DKOLH-CVD mortality and higher lifetime obesity prevalence in younger age groups are very concerning and are likely to adversely impact CVD mortality trends and hence life expectancy in future. MCOD data is a valuable but underutilized source of data to track important mortality trends.

Over the years, in response to vigorous scientific critique,22 philosophical debate,23 and innovation from authors involved in the study, the GBD Study has continued to grow in scope, relevance, participation, and scale, to the point that it is now arguably the de facto source for global health accounting. In this Viewpoint, we trace the evolution of ten key dimensions of the GBD Study, which, in our view as the two founders of the GBD, have had an important role in increasing the utility, relevance, and integration of the GBD findings in national and global health policy debates, and highlight what we see as some of the principal challenges for the future.

China has undergone rapid demographic and epidemiological changes in the past few decades, including striking declines in fertility and child mortality and increases in life expectancy at birth. Popular discontent with the health system has led to major reforms. To help inform these reforms, we did a comprehensive assessment of disease burden in China, how it changed between 1990 and 2010, and how China's health burden compares with other nations. We used results of the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) for 1990 and 2010 for China and 18 other countries in the G20 to assess rates and trends in mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE). We present results for 231 diseases and injuries and for 67 risk factors or clusters of risk factors relevant to China. We assessed relative performance of China against G20 countries (significantly better, worse, or indistinguishable from the G20 mean) with age-standardised rates and 95% uncertainty intervals. The leading causes of death in China in 2010 were stroke (1·7 million deaths, 95% UI 1·5–1·8 million), ischaemic heart disease (948 700 deaths, 774 500–1 024 600), and chronic obstructive pulmonary disease (934 000 deaths, 846 600–1 032 300). Age-standardised YLLs in China were lower in 2010 than all emerging economies in the G20, and only slightly higher than noted in the USA. China had the lowest age-standardised YLD rate in the G20 in 2010. China also ranked tenth (95% UI eighth to tenth) for HALE and 12th (11th to 13th) for life expectancy. YLLs from neonatal causes, infectious diseases, and injuries in children declined substantially between 1990 and 2010. Mental and behavioural disorders, substance use disorders, and musculoskeletal disorders were responsible for almost half of all YLDs. The fraction of DALYs from YLDs rose from 28·1% (95% UI 24·2–32·5) in 1990 to 39·4% (34·9–43·8) in 2010. Leading causes of DALYs in 2010 were cardiovascular diseases (stroke and ischaemic heart disease), cancers (lung and liver cancer), low back pain, and depression. Dietary risk factors, high blood pressure, and tobacco exposure are the risk factors that constituted the largest number of attributable DALYs in China. Ambient air pollution ranked fourth (third to fifth; the second highest in the G20) and household air pollution ranked fifth (fourth to sixth; the third highest in the G20) in terms of the age-standardised DALY rate in 2010. The rapid rise of non-communicable diseases driven by urbanisation, rising incomes, and ageing poses major challenges for China's health system, as does a shift to chronic disability. Reduction of population exposures from poor diet, high blood pressure, tobacco use, cholesterol, and fasting blood glucose are public policy priorities for China, as are the control of ambient and household air pollution. These changes will require an integrated government response to improve primary care and undertake required multisectoral action to tackle key risks. Analyses of disease burden provide a useful framework to guide policy responses to the changing disease spectrum in China. Bill & Melinda Gates Foundation.

Healthy life expectancy (HALE) summarises mortality and non-fatal outcomes in a single measure of average population health. It has been used to compare health between countries, or to measure changes over time. These comparisons can inform policy questions that depend on how morbidity changes as mortality decreases. We characterise current HALE and changes over the past two decades in 187 countries. Using inputs from the Global Burden of Disease Study (GBD) 2010, we assessed HALE for 1990 and 2010. We calculated HALE with life table methods, incorporating estimates of average health over each age interval. Inputs from GBD 2010 included age-specific information for mortality rates and prevalence of 1160 sequelae, and disability weights associated with 220 distinct health states relating to these sequelae. We computed estimates of average overall health for each age group, adjusting for comorbidity with a Monte Carlo simulation method to capture how multiple morbidities can combine in an individual. We incorporated these estimates in the life table by the Sullivan method to produce HALE estimates for each population defined by sex, country, and year. We estimated the contributions of changes in child mortality, adult mortality, and disability to overall change in population health between 1990 and 2010. In 2010, global male HALE at birth was 59·0 years (uncertainty interval 57·3–60·6) and global female HALE at birth was 63·2 years (61·4–65·0). HALE increased more slowly than did life expectancy over the past 20 years, with each 1-year increase in life expectancy at birth associated with a 10-month increase in HALE. Across countries in 2010, male HALE at birth ranged from 27·8 years (17·2–36·5) in Haiti, to 70·6 years (68·6–72·2) in Japan. Female HALE at birth ranged from 37·1 years (26·8–43·8) in Haiti, to 75·5 years (73·3–77·3) in Japan. Between 1990 and 2010, male HALE increased by 5 years or more in 48 countries compared with 43 countries for female HALE, while male HALE decreased in 22 countries and 11 for female HALE. Between countries and over time, life expectancy was strongly and positively related to number of years lost to disability. This relation was consistent between sexes, in cross-sectional and longitudinal analysis, and when assessed at birth, or at age 50 years. Changes in disability had small effects on changes in HALE compared with changes in mortality. HALE differs substantially between countries. As life expectancy has increased, the number of healthy years lost to disability has also increased in most countries, consistent with the expansion of morbidity hypothesis, which has implications for health planning and health-care expenditure. Compared with substantial progress in reduction of mortality over the past two decades, relatively little progress has been made in reduction of the overall effect of non-fatal disease and injury on population health. HALE is an attractive indicator for monitoring health post-2015. The Bill & Melinda Gates Foundation

Sepsis is life-threatening organ dysfunction due to a dysregulated host response to infection. It is considered a major cause of health loss, but data for the global burden of sepsis are limited. As a syndrome caused by underlying infection, sepsis is not part of standard Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) estimates. Accurate estimates are important to inform and monitor health policy interventions, allocation of resources, and clinical treatment initiatives. We estimated the global, regional, and national incidence of sepsis and mortality from this disorder using data from GBD 2017. We used multiple cause-of-death data from 109 million individual death records to calculate mortality related to sepsis among each of the 282 underlying causes of death in GBD 2017. The percentage of sepsis-related deaths by underlying GBD cause in each location worldwide was modelled using mixed-effects linear regression. Sepsis-related mortality for each age group, sex, location, GBD cause, and year (1990–2017) was estimated by applying modelled cause-specific fractions to GBD 2017 cause-of-death estimates. We used data for 8·7 million individual hospital records to calculate in-hospital sepsis-associated case-fatality, stratified by underlying GBD cause. In-hospital sepsis-associated case-fatality was modelled for each location using linear regression, and sepsis incidence was estimated by applying modelled case-fatality to sepsis-related mortality estimates. In 2017, an estimated 48·9 million (95% uncertainty interval [UI] 38·9–62·9) incident cases of sepsis were recorded worldwide and 11·0 million (10·1–12·0) sepsis-related deaths were reported, representing 19·7% (18·2–21·4) of all global deaths. Age-standardised sepsis incidence fell by 37·0% (95% UI 11·8–54·5) and mortality decreased by 52·8% (47·7–57·5) from 1990 to 2017. Sepsis incidence and mortality varied substantially across regions, with the highest burden in sub-Saharan Africa, Oceania, south Asia, east Asia, and southeast Asia. Despite declining age-standardised incidence and mortality, sepsis remains a major cause of health loss worldwide and has an especially high health-related burden in sub-Saharan Africa. The Bill & Melinda Gates Foundation, the National Institutes of Health, the University of Pittsburgh, the British Columbia Children's Hospital Foundation, the Wellcome Trust, and the Fleming Fund.

Many countries have used the new ANACONDA (Analysis of Causes of National Death for Action) tool to assess the quality of their cause of death data (COD), but no cross-country analysis has been done to verify how different or similar patterns of diagnostic errors and data quality are in countries or how they are related to the local cultural or epidemiological environment or to levels of development. Our objective is to measure whether the usability of COD data and the patterns of unusable codes are related to a country's level of socio-economic development. We have assessed the quality of 20 national COD datasets from the WHO Mortality Database by assessing their completeness of COD reporting and the extent, pattern and severity of garbage codes, i.e. codes that provide little or no information about the true underlying COD. Garbage codes were classified into four groups based on the severity of the error in the code. The Vital Statistics Performance Index for Quality (VSPI(Q)) was used to measure the overall quality of each country's mortality surveillance system. The proportion of 'garbage codes' varied from 7 to 66% across the 20 countries. Countries with a high SDI generally had a lower proportion of high impact (i.e. more severe) garbage codes than countries with low SDI. While the magnitude and pattern of garbage codes differed among countries, the specific codes commonly used did not. There is an inverse relationship between a country's socio-demographic development and the overall quality of its cause of death data, but with important exceptions. In particular, some low SDI countries have vital statistics systems that are as reliable as more developed countries. However, in low-income countries, where most people die at home, the proportion of unusable codes often exceeds 50%, implying that half of all cause-specific mortality data collected is of little or no use in guiding public policy. Moreover, the cause of death pattern identified from the data is likely to seriously under-represent the true extent of the leading causes of death in the population, with very significant consequences for health priority setting. Garbage codes are prevalent at all ages, contrary to expectations. Further research into effective strategies deployed in these countries to improve data quality can inform efforts elsewhere to improve COD reporting systems.

Background Tobacco smoking is a leading cause of cardiovascular disease (CVD) morbidity and mortality. Evidence on the relation of smoking to different subtypes of CVD, across fatal and non-fatal outcomes, is limited. Methods A prospective study of 188,167 CVD- and cancer-free individuals aged ≥ 45 years from the Australian general population joining the 45 and Up Study from 2006 to 2009, with linked questionnaire, hospitalisation and death data up to the end of 2015. Hazard ratios (HRs) for hospitalisation with or mortality from CVD among current and past versus never smokers were estimated, including according to intensity and recency of smoking, using Cox regression, adjusting for age, sex, urban/rural residence, alcohol consumption, income and education. Population-attributable fractions were estimated. Results During a mean 7.2 years follow-up (1.35 million person-years), 27,511 (crude rate 20.4/1000 person-years) incident fatal and non-fatal major CVD events occurred, including 4548 (3.2) acute myocardial infarction (AMI), 3991 (2.8) cerebrovascular disease, 3874 (2.7) heart failure and 2311 (1.6) peripheral arterial disease (PAD) events. At baseline, 8% of participants were current and 34% were past smokers. Of the 36 most common specific CVD subtypes, event rates for 29 were increased significantly in current smokers. Adjusted HRs in current versus never smokers were as follows: 1.63 (95%CI 1.56–1.71) for any major CVD, 2.45 (2.22–2.70) for AMI, 2.16 (1.93–2.42) for cerebrovascular disease, 2.23 (1.96–2.53) for heart failure, 5.06 (4.47–5.74) for PAD, 1.50 (1.24–1.80) for paroxysmal tachycardia, 1.31 (1.20–1.44) for atrial fibrillation/flutter, 1.41 (1.17–1.70) for pulmonary embolism, 2.79 (2.04–3.80) for AMI mortality, 2.26 (1.65–3.10) for cerebrovascular disease mortality and 2.75 (2.37–3.19) for total CVD mortality. CVD risks were elevated at almost all levels of current smoking intensity examined and increased with smoking intensity, with HRs for total CVD mortality in current versus never smokers of 1.92 (1.11–3.32) and 4.90 (3.79–6.34) for 4–6 and ≥ 25 cigarettes/day, respectively. Risks diminished with quitting, with excess risks largely avoided by quitting before age 45. Over one third of CVD deaths and one quarter of acute coronary syndrome hospitalisations in Australia aged < 65 can be attributed to smoking. Conclusions Current smoking increases the risk of virtually all CVD subtypes, at least doubling the risk of many, including AMI, cerebrovascular disease and heart failure. Paroxysmal tachycardia is a newly identified smoking-related risk. Where comparisons are possible, smoking-associated relative risks for fatal and non-fatal outcomes are similar. Quitting reduces the risk substantially. In an established smoking epidemic, with declining and low current smoking prevalence, smoking accounts for a substantial proportion of premature CVD events.

Increasing demand for better quality data and more investment to strengthen civil registration and vital statistics (CRVS) systems will require increased emphasis on objective, comparable, cost-effective monitoring and assessment methods to measure progress. We apply a composite index (the vital statistics performance index [VSPI]) to assess the performance of CRVS systems in 148 countries or territories during 1980–2012 and classify them into five distinct performance categories, ranging from rudimentary (with scores close to zero) to satisfactory (with scores close to one), with a mean VSPI score since 2005 of 0·61 (SD 0·31). As expected, the best performing systems were mostly in the European region, the Americas, and Australasia, with only two countries from east Asia and Latin America. Most low-scoring countries were in the African or Asian regions. Globally, only modest progress has been made since 2000, with the percentage of deaths registered increasing from 36% to 38%, and the percentage of children aged under 5 years whose birth has been registered increasing from 58% to 65%. However, several individual countries have made substantial improvements to their CRVS systems in the past 30 years by capturing more deaths and improving accuracy of cause-of-death information. Future monitoring of the effects of CRVS strengthening will greatly benefit from application of a metric like the VSPI, which is objective, costless to compute, and able to identify components of the system that make the largest contributions to good or poor performance.