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An association between low socioeconomic status (SES) and lung cancer has been observed in several studies, but often without adequate control for smoking behavior. We studied the association between lung cancer and occupationally derived SES, using data from the international pooled SYNERGY study. Twelve case-control studies from Europe and Canada were included in the analysis. Based on occupational histories of study participants we measured SES using the International Socio-Economic Index of Occupational Status (ISEI) and the European Socio-economic Classification (ESeC). We divided the ISEI range into categories, using various criteria. Stratifying by gender, we calculated odds ratios (OR) and 95% confidence intervals (CI) by unconditional logistic regression, adjusting for age, study, and smoking behavior. We conducted analyses by histological subtypes of lung cancer and subgroup analyses by study region, birth cohort, education and occupational exposure to known lung carcinogens. The analysis dataset included 17,021 cases and 20,885 controls. There was a strong elevated OR between lung cancer and low SES, which was attenuated substantially after adjustment for smoking, however a social gradient persisted. SES differences in lung cancer risk were higher among men (lowest vs. highest SES category: ISEI OR 1.84 (95% CI 1.61-2.09); ESeC OR 1.53 (95% CI 1.44-1.63)), than among women (lowest vs. highest SES category: ISEI OR 1.54 (95% CI 1.20-1.98); ESeC OR 1.34 (95% CI 1.19-1.52)). SES remained a risk factor for lung cancer after adjustment for smoking behavior.

ObjectivesTraditional epidemiological approaches usually assume a constant relationship between cumulative exposure and disease, which implies that exposure duration and intensity contribute equally to the studied outcome. But individuals with the same cumulative exposure but different temporal exposure patterns may show different risks. Trajectory classification is a good way to assess exposure–risk associations and leads to a better understanding of lifetime variability in exposure levels. Therefore, this study aimed to estimate lung cancer risk according to the exposure trajectory classes on welding fumes and cigarette smoking.DesignTwo population-based German case–control studies.Participants3498 male lung cancer cases and 3539 male control subjects.MethodsSeparate latent class mixed models (LCMM) were determined to identify profiles of exposure trajectories of cigarette smoking and occupational exposure to welding fumes. To investigate the risk of lung cancer by class membership, ORs with 95% CI were estimated via multiple logistic regression analyses.ResultsLCMM each identified four latent classes of smoking and welding-fume exposure. Classes of smokers showed much higher risk of lung cancer compared with never smokers or subjects exposed to welding fumes. Smokers in one class characterised with the highest exposure over the past 10 years had the highest adjusted lung cancer risk (OR=39; 95% CI 29 to 53). For welding, the highest lung cancer risks were found for the class in which exposure to welding fumes in the past 10 years prior to the diagnosis of lung cancer was highest and the duration of welding was also quite high (OR=1.71; 95% CI 0.92 to 3.15).ConclusionsIn summary, LCMM opens a new perspective on dose–effect relationships and could be employed to complement established epidemiological methods.

Problem Management Plus (PM+) effectively reduces symptoms of depression, anxiety, and psychological distress, demonstrating efficacy and cost-effectiveness in over 23 randomized controlled trials. However, real-world implementation through lay health workers often encounters significant challenges, particularly concerning intervention fidelity and feasible delivery. To address these challenges, Technology-assisted Problem Management Plus (TA-PM+), a digital adaptation of PM+, was co-developed. This study aims to evaluate the feasibility and acceptability of delivering TA-PM+ through government-employed primary healthcare outreach lay health workers known as Lady Health Workers (LHWs), in Pakistan. A pre-post, non-randomized feasibility study was conducted in Islamabad, Pakistan, involving 12 LHWs delivering TA-PM+ face-to-face to 77 women experiencing psychological distress. TA-PM+ is digital intervention designed to support LHWs in delivering five sessions of PM+, featuring psychoeducational videos for patients, automated assessments, and a guiding interface to enhance participant engagement and experience while ensuring intervention fidelity. Feasibility was assessed through session completion rates, participant retention, and qualitative interviews exploring implementation barriers and facilitators. Fidelity was evaluated using the ENhancing Assessment of Common Therapeutic factors (ENACT) checklist and digital automated session logs. Psychological distress was measured using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) at baseline and post-intervention. Data analysis included descriptive statistics, paired t-tests, and thematic analysis of qualitative data. TA-PM+ demonstrated high feasibility, with 92% of participants completing all five sessions. Fidelity was high, with a mean ENACT score of 48 out of 54. Over 60% of the sessions met the minimum threshold with a mean session length of 45 to 50 min. Psychological distress showed preliminary improvements, with reduction in PHQ-9 (mean reduction: 6.07, p  < 0.0001) and GAD-7 (mean reduction: 5.25, p  < 0.0001). Participants valued structured sessions and psychoeducational videos. Identified challenges included internet connectivity issues, difficulties aligning session times with participants’ household responsibilities, and cognitive fatigue among health workers. TA-PM+ intervention delivery by government-employed primary healthcare outreach staff was feasible, acceptable, and preliminary effective in reducing psychological distress among women in a community setting in Pakistan. The digital adaptation maintained high fidelity and efficiently reduced session durations, indicating its strong potential for scale-up within primary healthcare systems. Further research is necessary to examine long-term outcomes and cost-effectiveness.

This double-blind cluster-randomized controlled study examined the effectiveness of a multilingual physical-digital recruitment strategy to increase the involvement of linguistically diverse households in the German sub-survey of the World Health Organization European Childhood Obesity Surveillance Initiative. Students in primary schools received German study invitations either alone or with a supplemental flyer containing a QR-code for accessing translations online. A total of 114 classrooms (2306 students) received the flyer, while 115 classrooms (2276 students) served as control group. Main outcomes were active of responses to invitations and study participation. Response proportions were 48% overall, 48.6% in the flyer and 47.4% in the control group. Participation proportions were 26.7% overall, 27.8% in the flyer and 25.4% (571/2251) in the control groups. The flyer increased the odds of participation (14.9, 95% CI 1.003–1.315), but not the odds of active responses. In medium-social-level schools, response and participation proportions in the flyer group rose by 1.5% (ROR 1.015, 95% CI 1.003–1.027) and by 2% (ROR 1.020, 95% CI 1.005–1.034), respectively, for each percentage point increase in the proportion of non-German speaking households per classroom. The flyer’s effect in low- and high-social level schools was inconclusive. Although modest in magnitude, the addition of the flyer increased overall participation and, in particular, the involvement of linguistically diverse households in medium-social-level schools.

Abstract Rationale Previous respiratory diseases have been associated with increased risk of lung cancer. Respiratory conditions often co-occur and few studies have investigated multiple conditions simultaneously. Objectives Investigate lung cancer risk associated with chronic bronchitis, emphysema, tuberculosis, pneumonia, and asthma. Methods The SYNERGY project pooled information on previous respiratory diseases from 12,739 case subjects and 14,945 control subjects from 7 case–control studies conducted in Europe and Canada. Multivariate logistic regression models were used to investigate the relationship between individual diseases adjusting for co-occurring conditions, and patterns of respiratory disease diagnoses and lung cancer. Analyses were stratified by sex, and adjusted for age, center, ever-employed in a high-risk occupation, education, smoking status, cigarette pack-years, and time since quitting smoking. Measurements and Main Results Chronic bronchitis and emphysema were positively associated with lung cancer, after accounting for other respiratory diseases and smoking (e.g., in men: odds ratio [OR], 1.33; 95% confidence interval [CI], 1.20–1.48 and OR, 1.50; 95% CI, 1.21–1.87, respectively). A positive relationship was observed between lung cancer and pneumonia diagnosed 2 years or less before lung cancer (OR, 3.31; 95% CI, 2.33–4.70 for men), but not longer. Co-occurrence of chronic bronchitis and emphysema and/or pneumonia had a stronger positive association with lung cancer than chronic bronchitis “only.” Asthma had an inverse association with lung cancer, the association being stronger with an asthma diagnosis 5 years or more before lung cancer compared with shorter. Conclusions Findings from this large international case–control consortium indicate that after accounting for co-occurring respiratory diseases, chronic bronchitis and emphysema continue to have a positive association with lung cancer.

In the wake of smokeless tobacco (SLT) being advocated as a mean of tobacco harm reduction, it is pertinent to establish individual health risks associated with each SLT product. This case-control study was aimed at assessing the risk of oral cancer associated with a smokeless tobacco product (Naswar). The study was conducted from September 2014 till May 2015 in Khyber Pakhtunkhwa, Pakistan. Exposure and covariate information was collected through a structured questionnaire. Conditional logistic regression was used to calculate odds ratios (OR) along with their 95% confidence intervals (CI). 84 oral cancer cases (62% males) and 174 age- and sex-matched controls were recruited. Ever users of Naswar had more than a 20-fold higher risk of oral cancer compared to never-users (OR 21.2, 95% CI 8.4-53.8). Females had a higher risk of oral cancer with the use of Naswar (OR 29.0, 95% CI 5.4-153.9) as compared to males (OR 21.0, 95% CI 6.1-72.1). Based on this result, 68% (men) and 38% (women) of the oral cancer burden in Pakistan is attributable to Naswar. The risk estimates observed in this study are comparable to risk estimates reported by previous studies on other forms of SLT use and the risk of oral cancer in Pakistan. The exposure-response relationship also supports a strong role of Naswar in the etiology of oral cancer in Pakistan. Although still requiring further validation through independent studies, these findings may be used for smokeless tobacco control in countries where Naswar use is common.

The digital environment can pose health risks through exposure to unhealthy content. Yet, little is known about its relation to children’s cognitive functioning . This study investigates the association between digital media (DM) exposure and children’s cognitive functioning. This cross-sectional study is based on examinations of children aged 8–18 years (N = 8673) of the I.Family cohort (2013–2014). Exposure to television, computer, smartphone and internet was self-reported (hours/day). Media multitasking (MMT) was defined as simultaneous use of computers with other digital or non-screen-based activities. Standard instruments were used to assess cognitive inflexibility (score: 0–39), decision-making ability (− 100 to + 100) and impulsivity (12–48). Adjusted regression coefficients and 99.9%CIs were calculated by generalized linear mixed-effects models. In total, 3261 participants provided data for impulsivity, 3441 for cognitive inflexibility and 4046 for decision-making. Exposure to smartphones and media multitasking were positively associated with impulsivity (β smartphone  = 0.74; 99.9%CI = 0.42–1.07; β MMT  = 0.73; 99.9%CI = 0.35–1.12) and cognitive inflexibility (β smartphone  = 0.32; 99.9%CI = -0.02–0.66; β MMT  = 0.39; 99.9%CI = 0.01–0.77) while being inversely associated with decision-making ability. Extensive smartphone/internet exposure combined with low computer/medium TV exposure was associated with higher impulsivity and cognitive inflexibility scores, especially in girls. DM exposure is adversely associated with cognitive functioning in children and adolescents. Children require protection against the likely adverse impact of digital environment.

Background Media use may influence metabolic syndrome (MetS) in children. Yet, longitudinal studies are scarce. This study aims to evaluate the longitudinal association of childhood digital media (DM) use trajectories with MetS and its components. Methods Children from Belgium, Cyprus, Estonia, Germany, Hungary, Italy, Spain and Sweden participating in the IDEFICS/I.Family cohort were examined at baseline (W1: 2007/2008) and then followed-up at two examination waves (W2: 2009/2010 and W3: 2013/2014). DM use (hours/day) was calculated as sum of television viewing, computer/game console and internet use. MetS z-score was calculated as sum of age- and sex-specific z-scores of four components: waist circumference, blood pressure, dyslipidemia (mean of triglycerides and HDL-cholesterol −1 ) and homeostasis model assessment for insulin resistance (HOMA-IR). Unfavorable monitoring levels of MetS and its components were identified (cut-off: ≥ 90 th percentile of each score). Children aged 2–16 years with ≥ 2 observations (W1/W2; W1/W3; W2/W3; W1/W2/W3) were eligible for the analysis. A two-step procedure was conducted: first, individual age-dependent DM trajectories were calculated using linear mixed regressions based on random intercept (hours/day) and linear slopes (hours/day/year) and used as exposure measures in association with MetS at a second step. Trajectories were further dichotomized if children increased their DM duration over time above or below the mean. Results 10,359 children and adolescents (20,075 total observations, 50.3% females, mean age = 7.9, SD = 2.7) were included. DM exposure increased as children grew older (from 2.2 h/day at 2 years to 4.2 h/day at 16 years). Estonian children showed the steepest DM increase; Spanish children the lowest. The prevalence of MetS at last follow-up was 5.5%. Increasing media use trajectories were positively associated with z-scores of MetS (slope: β = 0.54, 95%CI = 0.20–0.88; intercept: β = 0.07, 95%CI = 0.02–0.13), and its components after adjustment for puberty, diet and other confounders. Children with increasing DM trajectories above mean had a 30% higher risk of developing MetS (slope: OR = 1.30, 95%CI = 1.04–1.62). Boys developed steeper DM use trajectories and higher risk for MetS compared to girls. Conclusions Digital media use appears to be a risk factor for the development of MetS in children and adolescents. These results are of utmost importance for pediatricians and the development of health policies to prevent cardio-metabolic disorders later in life. Trial registration ISRCTN, ISRCTN62310987 . Registered 23 February 2018- retrospectively registered.

Knowing the extent to which mental well-being and stressful life events during adolescence contribute to personality characteristics related to risk-taking behaviors, such as emotion-driven impulsiveness, is highly relevant for the development of health promotion measures. This study examined whether psychosocial well-being and different stressful life events are associated with emotion-driven impulsiveness. In total, 3,031 adolescents (52% girls; Mage = 13.6 years) were included from the I. Family Study, a cross-sectional examination on lifestyle-related behaviors conducted across eight European countries in 2013/14. Linear mixed-effects regression models showed that higher psychosocial well-being was associated with lower emotion-driven impulsiveness independent of socio-demographic, health-related, and parental variables. A higher number of stressful life events was associated with higher emotion-driven impulsiveness. Psychosocial well-being and stressful life events need to be further considered in the development and tailoring of health promotion strategies that aim to reduce emotion-driven impulsiveness.

ObjectiveThe association between occupational exposure to chlorinated solvents and lung cancer remains inconclusive. This study investigated this relationship using data from the internationally pooled SYNERGY study.MethodsData from 14 case–control studies conducted in 13 European countries and Canada were pooled, including 28 048 participants (12 329 cases and 15 719 controls). Lifetime occupational exposure to chlorinated solvents was assessed using the ALOHA+job-exposure matrix. ORs and 95% CIs were estimated using unconditional logistic regression, adjusted for study centre, age, sex, smoking (pack-years and cessation), cumulative exposure to five occupational lung carcinogens (asbestos, hexavalent chromium, polycyclic aromatic hydrocarbons, respirable crystalline silica and diesel engine exhaust), cumulative benzene exposure and employment in high-risk occupations (‘List A’ jobs). Associations were estimated across categories of exposure levels, durations and analyses stratified by smoking status and lung cancer subtypes.ResultsWe found no evidence of an association between ever exposure to chlorinated solvents and lung cancer risk (OR 1.03; 95% CI 0.96 to 1.10). Among exposed individuals, a positive trend with cumulative exposure was observed (p=0.031), but not when non-exposed individuals were included (p=0.173). Positive trends were found with exposure duration (p=0.005 for exposed; p=0.048 overall); risks were modestly elevated (OR 1.11) in those exposed for 20 or more years. No increased risk was observed across smoking strata or lung cancer subtypes.ConclusionsThis pooled analysis provides limited evidence of an association between occupational exposure to chlorinated solvents and lung cancer, though exposure-response trends were noted among exposed individuals.