The risk of knee pain and knee osteoarthritis in professional footballers

Introduction: Knee osteoarthritis (KOA) is a common complex disorder. Although previously believed to be degenerative, KOA is in fact a regenerative condition, compensating against insults sustained at the joint. However, a failure of this compensatory repair process, especially in the presence of constitutional and local joint factors, increases the risk of KOA and inevitably leads to joint-failure (Dieppe and Lohmander, 2005, Arden and Nevitt, 2006, Sandell, 2012). Diagnosis of KOA may be made via clinical presentation, imaging, or using clinical algorithms, which may be a combination both in addition to biochemical diagnostic tests (Brandt et al., 2003). Knee pain (KP) is the most common symptom, and in the general population its prevalence is 25% (Peat et al., 2001a). Patients may also experience early morning stiffness of the joint and reduced function. Physician-observed signs include crepitus, restricted movement, and bony and soft tissue swellings (Abhishek and Doherty, 2013). Although considered the gold standard to diagnose KOA, plain film radiography is not without its limitations (Wick et al., 2012). Clinicians, however, favour radiography because it can easily discern two key features of the condition: joint space narrowing (JSN), a surrogate of cartilage loss, and the formation of osteophytes on the joint margin (Roemer et al., 2014). Assessment of radiographs is most commonly undertaken using Kellgren-Lawrence (KL) grade verbal descriptors (Altman et al., 1986a). The prevalence of radiographic KOA (RKOA) may be higher than KP, but there is a discordance between people reporting symptoms and those with structural change (RKOA) (Peat et al., 2001a, Bedson and Croft, 2008). A plethora of constitutional risk factors and joint-specific biomechanical factors increase the risk of KOA, including joint injury and occupation (Suri et al., 2012, Silverwood et al., 2015). One such occupation, which has a greater risk of injury are professional footballers (Drawer and Fuller, 2002) and knee injuries account for 17% of all footballing injuries (Ekstrand et al., 2011). Football is one of the most common team sports worldwide, with over 265 million people worldwide play the game (FIFA, 2007a), and of these, 110,000 are male professional footballers (FIFA, 2007b). Although perceived that that footballers are at great risk of long-term consequences such as KOA, due to their high risk of injury, the current evidence supporting this is limited (Kuijt et al., 2012, Tran et al., 2016). The previous studies observing KOA in footballers are difficult to generalise to the wider football population. This is for a number of reasons, including recruitment of inadequate sample, absence of inappropriate control groups, and differing case definitions, all resulting in a large variation in prevalence of KOA. Thus, there exists a need for a comprehensive study to determine the true prevalence and risk of KOA in retired professional footballers compared to the general population. Aims: (1) To determine the prevalence and risk of KOA (measured as KP, RKOA and requirement for total knee replacement (TKR)) in retired professional footballers compared to the general population; (2) To determine the specific factors (constitutional, biomechanical and football-specific) that are associated with an increased risk of each of these outcomes (KP, RKOA and TKR) within footballers. Methods: The Nottingham University Hospitals NHS Trust and the Nottingham Research Ethics Committee (Refs 14/EM/0045; 14/EM/0015) approved this study, which was registered on the clinicaltrials.gov portal (NCT02098044; NCT02098070). This study design involved carrying out two cross-sectional studies. The Football Study involved distributing 4775 postal questionnaire surveys to retired professional footballers via multiple sources, including football clubs, their former players’ associations and the Professional Footballers Association (PFA). The Knee Pain and Related Health in the Community Study (KPIC) involved distributing 40,500 postal questionnaires, via 12 general practice surgeries, to both men and women in the East Midlands general population. However, only men formed the control group for this study. The inclusion criteria for both the footballers and control participants was the same: men aged 40 and older. The questionnaires, developed based on previously literature, were similar to capture detailed information about KP, undergoing a TKR and putative risk factors for KOA, including knee injuries, surgery and alignment. The questionnaires also gathered information regarding demographics, medical and occupational history, general health and current medication. Following this, footballers and controls who consented had radiographic assessments of both their knees, including weight-bearing semi-flexed posterior-anterior (PA) view using the Rosen template (Rosenberg et al., 1988) and a seated 30° flexion skyline view. A single observer (GSF) scored all the radiographs as a single mixed batch using HIPAX Dicom software. In addition to the KL grades, the Nottingham Line Drawing Atlas (NLDA) was used (Nagaosa et al., 2000) (Wilkinson et al., 2005), which scored composite joint space narrowing (JSN), composite osteophyte, and a combined global score for each knee. Primary outcomes observed were current KP, RKOA (measured using the NLDA) and TKR. Secondary outcomes observed were ever having KP (chronic), physician-diagnosed KOA, RKOA (measured using KL grades) and radiographic CC. Power calculations determined the sample size for the questionnaire survey and the radiographic survey. Categorical variables presented as frequency and percent and compared using a chi-squared test. Continuous variables presented as mean and standard deviation and compared using a t-test. The risk of KOA (measured for each outcome independently) in footballers compared to the controls was determined using a generalised linear model (GLM) with a Poisson distribution, and adjusted for known risk factors (including age, body mass index (BMI) and previous knee injury). The specific risk factors within footballers associated with outcomes of KOA (namely KP, RKOA and TKR) were determined using multivariate logistic regression. Results: 1207 footballers (response rate of 25.3%) and 4085 control men responded to the Football and KPIC studies respectively, which was far lower than studies previously conducted in both populations. Following this, 470 footballers and 500 men consented to undergoing radiographic assessment of their knees. For participants who returned the questionnaire (footballers and controls), characteristics were compared between those who underwent a knee radiograph and those who did not. Age and sustaining a knee injury were the main factors significantly difference in both. Footballers were significantly older (3.9 years) than the controls, but were gender-matched (males-only) and had a similar BMI. Footballers had a significantly greater number of injuries (64.5% v. 23.3%) compared to the controls. They also had significantly more body pain (74.7% v. 69.8%) and therefore took more pain-relief medication (61.9% v. 28.5%). However, footballers suffered from far fewer comorbidities compared to the controls (29.4% v. 45.7%). Footballers had a far greater prevalence of both primary and secondary outcomes. The prevalence of KP was almost twice as great in footballers (52.2%) compared to the controls (26.9%) and this increased prevalence was regardless of age. The peak prevalence of KP also occurred at least ten years earlier in footballers compared to the controls. Although the prevalence of physician-diagnosed KOA was much lower than the prevalence of KP in footballers (28.3%), it was more than double that of the controls (12.2%). Additionally, footballers (11.1%) had almost three times greater prevalence of TKR compared to the controls. In terms of radiographic measures, the prevalence of NLDA-defined RKOA was much greater in footballers (64.0%) compared to the controls (35.2%) and this remained the case for KL grade-defined RKOA (28.5% v. 14.1%). A stricter KL grade (KL>3) accounts for the lower prevalence compared to NLDA-defined RKOA. Radiographic CC was also just less than three times more prevalent in footballers (24.3%) compared to the controls (8.8%). Within footballers, RKOA (NLDA) was greater in the right (52.6%) compared to the left (45.3%) knee. The greater prevalence conferred an increased risk of KOA for all outcomes. Footballers were almost twice as likely to report KP [aRR 1.92, 95% CI 1.78-2.07], more than twice as likely to report RKOA (NLDA-defined) [aRR 2.14, 95% CI 1.87-2.45] and almost three times more likely to report TKR [aRR 2.79, 95% CI 2.42-3.23] compared to the controls (following adjustment for age and BMI). The risk of having a physician diagnosis of KOA was 2.6 times greater [aRR 2.62, 95% CI 2.32-2.96] and the risk of radiographic CC was 3.4 times greater [aRR 3.36, 95% CI 2.41-4.69] in footballers compared to the controls. RKOA measured using KL grades was also slightly greater compared with the NLDA definition [aRR 2.44, 95% CI 1.88-3.15]. The risk factors for KP, RKOA (NLDA-defined) and TKR within footballers were also analysed. Following adjustment for age and BMI, a number of factors were associated with increased risk of each outcome. The following factors were associated with increased risk of footballers having KP: being overweight [OR 1.55, 95% CI 1.16-2.06] or obese [OR 2.22, 95% CI 1.52-3.24]; having a pattern three digit ratio [OR 1.30, 95% CI 1.02-1.66]; a family history of OA (knee, hip or hand OA); and suffering from gout [OR 2.15, 95% CI 1.48-3.13]. Sustaining a knee injury [OR 4.21, 95% CI 3.27-5.42] and its consequences, surgical intervention [OR 4.37, 95% CI 3.39-5.64] and receiving an intra-articular injection [OR 2.76, 95% CI 2.18-3.50] were most the factors most significantly associated with KP. Age [OR 1.08, 95% CI 1.05-1.10] and familial KOA or knee replacement were significantly associated with RKOA in footballers. Crystal deposition, typically in patients suffering from gout [OR 3.24, 95% CI 1.41-7.45] or with evidence of CC [OR 4.62, 95% CI 2.61-8.05] were also strongly associated with RKOA. As with KP, injury [OR 2.17, 95% CI 1.43-3.30] and its consequences, namely surgical intervention [OR 4.25, 95% CI 2.78-6.50] and receiving intra-articular injections [OR 1.60, 95% CI 1.10-2.35] were strongly associated with RKOA in footballers. A longer duration of playing football [OR 1.04, 95% CI 1.00-1.08] was also strongly associated with RKOA in footballers. For every 1000 hours trained [OR 1.13, 95% CI 1.07-1.19] and 100 matches played [OR 2.41, 95% CI 1.08-5.36], footballers had an increased risk of RKOA. Risk factors significantly associated with footballers who had undergone a TKR, included age [OR 1.09, 95% CI 1.07-1.11], being obese [OR 1.77, 95% CI 1.00-3.12] and having gout [OR 3.11, 95% CI 1.96-4.70]. Sustaining a significant knee injury [OR 3.11, 95% CI 1.94-4.99] and receiving an intra-articular knee injection [OR 2.56, 95% CI 1.76-3.73] were also significant risk factors for footballers who underwent a TKR. However, those footballers with a longer duration of playing the game [OR 0.95, 95% CI 0.92-0.98] had a reduced risk of TKR. Conclusion: These findings show footballers have a greater risk of KOA compared to the general population, reporting up to three times higher prevalence of various outcomes (KP, RKOA, physician-diagnosed KOA and TKR). The age-prevalence of all outcomes of KOA, are greater in footballers compared to the controls. The high prevalence of injuries significantly account the risk of KOA in footballers compared to the controls (even following adjustment of other risk factors). Within footballers, knee injuries, together with subsequent investigations (specifically exploratory and interventional arthroscopy) and management (specifically intra-articular knee injections), were strongly associated with risk of KOA (KP, RKOA and TKR independently). Football’s governing bodies need to set out and implement strategies to reduce or even prevent the risk of serious injury (thus reducing the risk of subsequent investigation). This will reduce the risk of long-term consequences, such as KOA. However, whether the Industrial Injuries Advisory Council considers the risk of KOA in footballers an industrial compensable disease remains a question

Prevalence of knee pain, radiographic osteoarthritis and arthroplasty in retired professional footballers compared to men in the general population: a cross-sectional study

Objectives: To determine the prevalence of knee pain, radiographic knee osteoarthritis (RKOA), total knee replacement (TKR) and associated risk factors in male ex-professional footballers compared to men in the general population (comparison group). Methods: 1207 male ex-footballers and 4085 men in the general population in the UK were assessed by postal questionnaire. Current knee pain was defined as pain in or around the knees on most days of the previous month. Presence and severity of RKOA were assessed on standardised radiographs using the Nottingham Line Drawing Atlas (NLDA) in a sub-sample of 470 ex-footballers and 491 men in the comparison group. The adjusted risk ratio (aRR) and risk difference (aRD) with 95% confidence interval (CI) in ex-footballers compared to the general population were calculated using the marginal model in Stata. Results: Ex-footballers were more likely than the comparison group to have current knee pain [aRR 1.91, 95%CI 1.77-2.06], RKOA [aRR 2.21, 95%CI 1.92-2.54] and TKR (aRR 3.61, 95%CI 2.90–4.50). Ex-footballers were also more likely to present with chondrocalcinosis [aRR 3.41, 95%CI 2.44-4.77]. Prevalence of knee pain and RKOA were higher in ex-footballers at all ages. However, even after adjustment for significant knee injury and other risk factors, there was more than a doubling of risk of these outcomes in footballers. Conclusions: The prevalence of all knee osteoarthritis outcomes (knee pain, RKOA and TKR) were 2-3 times higher in male ex-footballers compared to men in the general population group. Knee injury is the main attributable risk factor. Even after adjustment for recognised risk factors, knee osteoarthritis appear to be an occupational hazard of professional football

Intra-articular Injection Administration in UK Ex-professional Footballers During Their Playing Careers and the Association with Post-career Knee Osteoarthritis

© 2020, The Author(s). Background: The long-term risk from knee intra-articular (KIA) injections in professional athletes such as ex-footballers remains unknown. The use of KIA injections is controversial and remains anecdotally prolific as it is perceived as being safe/beneficial. The aim of this study was to determine the number, type and frequency KIA injections administered to retired professional footballers during their playing careers and the associations with post-career knee osteoarthritis (KOA). Methods: This is a cross-sectional study involving a postal questionnaire (n = 1207) and subsequent knee radiographs in a random sample of questionnaire responders (n = 470). Footballers self-reported in the questionnaire whether they had received KIA injections and the estimated total number over the course of their playing career. Participant characteristics and football career-related details were also recorded. KOA was measured as self-reported knee pain (KP), total knee replacement (TKR) and radiographic KOA (RKOA). Results: 44.5% of footballers had received at least one KIA injection (mean: 7.5; SD ± 11.2) during their professional career. 71% of knee injections were cortisone/corticosteroid based. Multivariate logistic regression, adjusting for age, body mass index (BMI) and significant knee injury identified that footballers with injections weretwo times more likely to have KP (OR 1.81, 95% CI 1.40–2.34) and TKR (OR 2.21, 95% CI 1.43–3.42) than those without injections. However, there was no association with RKOA (OR 1.30, 95% CI 0.85–2.01). Given, the association with KP and TKR, we found a significant dose–response relationship as the more injections a player received (by dose–response groups), the greater the risk of KP and TKR outcomes after adjustment for knee injury and other confounders (p for trend < 0.01). Conclusion: On average, 8 KIA injections were given to the ex-footballers during their professional career. The most commonly administered injections were cortisone based. These injections associated with KP and TKR after they retired. The associations are independent of knee injuries and are dose dependent. The study suggests that there may have been excessive use of KIA injections to expedite return to play and this contributed to detrimental long-term outcomes such as KP and TKR post-retirement from professional football

Risk Factors for Knee Osteoarthritis in Retired Professional Footballers: A Cross-Sectional Study

Objective: To determine risk factors for three knee osteoarthritis (KOA) outcomes, knee pain (KP), radiographic KOA (RKOA) and total knee replacement (TKR), in professional footballers.Design: This was a cross-sectional study involving a postal questionnaire, followed by radiographic assessment in a sub-cohort of responders. Settings and Participants: 4775 questionnaires were sent to retired professional footballers, who had played in the English football league, and 1207 responded. Of these, 470 underwent knee radiographs. Assessment of Risk Factors: Potential factors include age, BMI, knee alignment, a history of football-related knee injury, and training hours (during career) were collected via the questionnaire.Main Outcome Measures: KOA outcomes were current KP (pain for most days of the previous month), TKR (self-reported) and RKOA (observed via radiographs). Results: Football-related injury was the strongest risk factor for KP [aOR 4.22, 95%CI 3.26-5.48], RKOA [aOR 2.88, 95%CI 1.81-4.59] and TKR [aOR 4.83, 95%CI 2.87-8.13]. Footballers had a 7% increased risk of RKOA for every 1000 hours trained. While age and gout were associated with all three KOA outcomes, BMI, nodal OA, a family history of OA, knee malalignment and 2D:4D ratio were associated with one or another of these three KOA outcomes.Conclusion: This study is the first to examine KOA risk factors in retired professional footballers. The study has identified several risk factors, both specific (for example, knee injury and training dose), and non-specific (for example, age and gout) to footballers. This may be used to develop prevention strategies to reduce the risk of KOA in professional footballers following retirement

Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Background Regularly updated data on stroke and its pathological types, including data on their incidence, prevalence, mortality, disability, risk factors, and epidemiological trends, are important for evidence-based stroke care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) aims to provide a standardised and comprehensive measurement of these metrics at global, regional, and national levels. Methods We applied GBD 2019 analytical tools to calculate stroke incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and the population attributable fraction (PAF) of DALYs (with corresponding 95% uncertainty intervals [UIs]) associated with 19 risk factors, for 204 countries and territories from 1990 to 2019. These estimates were provided for ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and all strokes combined, and stratified by sex, age group, and World Bank country income level. Findings In 2019, there were 12·2 million (95% UI 11·0–13·6) incident cases of stroke, 101 million (93·2–111) prevalent cases of stroke, 143 million (133–153) DALYs due to stroke, and 6·55 million (6·00–7·02) deaths from stroke. Globally, stroke remained the second-leading cause of death (11·6% [10·8–12·2] of total deaths) and the third-leading cause of death and disability combined (5·7% [5·1–6·2] of total DALYs) in 2019. From 1990 to 2019, the absolute number of incident strokes increased by 70·0% (67·0–73·0), prevalent strokes increased by 85·0% (83·0–88·0), deaths from stroke increased by 43·0% (31·0–55·0), and DALYs due to stroke increased by 32·0% (22·0–42·0). During the same period, age-standardised rates of stroke incidence decreased by 17·0% (15·0–18·0), mortality decreased by 36·0% (31·0–42·0), prevalence decreased by 6·0% (5·0–7·0), and DALYs decreased by 36·0% (31·0–42·0). However, among people younger than 70 years, prevalence rates increased by 22·0% (21·0–24·0) and incidence rates increased by 15·0% (12·0–18·0). In 2019, the age-standardised stroke-related mortality rate was 3·6 (3·5–3·8) times higher in the World Bank low-income group than in the World Bank high-income group, and the age-standardised stroke-related DALY rate was 3·7 (3·5–3·9) times higher in the low-income group than the high-income group. Ischaemic stroke constituted 62·4% of all incident strokes in 2019 (7·63 million [6·57–8·96]), while intracerebral haemorrhage constituted 27·9% (3·41 million [2·97–3·91]) and subarachnoid haemorrhage constituted 9·7% (1·18 million [1·01–1·39]). In 2019, the five leading risk factors for stroke were high systolic blood pressure (contributing to 79·6 million [67·7–90·8] DALYs or 55·5% [48·2–62·0] of total stroke DALYs), high body-mass index (34·9 million [22·3–48·6] DALYs or 24·3% [15·7–33·2]), high fasting plasma glucose (28·9 million [19·8–41·5] DALYs or 20·2% [13·8–29·1]), ambient particulate matter pollution (28·7 million [23·4–33·4] DALYs or 20·1% [16·6–23·0]), and smoking (25·3 million [22·6–28·2] DALYs or 17·6% [16·4–19·0]). Interpretation The annual number of strokes and deaths due to stroke increased substantially from 1990 to 2019, despite substantial reductions in age-standardised rates, particularly among people older than 70 years. The highest age-standardised stroke-related mortality and DALY rates were in the World Bank low-income group. The fastest-growing risk factor for stroke between 1990 and 2019 was high body-mass index. Without urgent implementation of effective primary prevention strategies, the stroke burden will probably continue to grow across the world, particularly in low-income countries.publishedVersio

Spatial, temporal, and demographic patterns in prevalence of chewing tobacco use in 204 countries and territories, 1990-2019 : a systematic analysis from the Global Burden of Disease Study 2019

Interpretation Chewing tobacco remains a substantial public health problem in several regions of the world, and predominantly in south Asia. We found little change in the prevalence of chewing tobacco use between 1990 and 2019, and that control efforts have had much larger effects on the prevalence of smoking tobacco use than on chewing tobacco use in some countries. Mitigating the health effects of chewing tobacco requires stronger regulations and policies that specifically target use of chewing tobacco, especially in countries with high prevalence. Findings In 2019, 273 center dot 9 million (95% uncertainty interval 258 center dot 5 to 290 center dot 9) people aged 15 years and older used chewing tobacco, and the global age-standardised prevalence of chewing tobacco use was 4 center dot 72% (4 center dot 46 to 5 center dot 01). 228 center dot 2 million (213 center dot 6 to 244 center dot 7; 83 center dot 29% [82 center dot 15 to 84 center dot 42]) chewing tobacco users lived in the south Asia region. Prevalence among young people aged 15-19 years was over 10% in seven locations in 2019. Although global agestandardised prevalence of smoking tobacco use decreased significantly between 1990 and 2019 (annualised rate of change: -1 center dot 21% [-1 center dot 26 to -1 center dot 16]), similar progress was not observed for chewing tobacco (0 center dot 46% [0 center dot 13 to 0 center dot 79]). Among the 12 highest prevalence countries (Bangladesh, Bhutan, Cambodia, India, Madagascar, Marshall Islands, Myanmar, Nepal, Pakistan, Palau, Sri Lanka, and Yemen), only Yemen had a significant decrease in the prevalence of chewing tobacco use, which was among males between 1990 and 2019 (-0 center dot 94% [-1 center dot 72 to -0 center dot 14]), compared with nine of 12 countries that had significant decreases in the prevalence of smoking tobacco. Among females, none of these 12 countries had significant decreases in prevalence of chewing tobacco use, whereas seven of 12 countries had a significant decrease in the prevalence of tobacco smoking use for the period. Summary Background Chewing tobacco and other types of smokeless tobacco use have had less attention from the global health community than smoked tobacco use. However, the practice is popular in many parts of the world and has been linked to several adverse health outcomes. Understanding trends in prevalence with age, over time, and by location and sex is important for policy setting and in relation to monitoring and assessing commitment to the WHO Framework Convention on Tobacco Control. Methods We estimated prevalence of chewing tobacco use as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 using a modelling strategy that used information on multiple types of smokeless tobacco products. We generated a time series of prevalence of chewing tobacco use among individuals aged 15 years and older from 1990 to 2019 in 204 countries and territories, including age-sex specific estimates. We also compared these trends to those of smoked tobacco over the same time period. Findings In 2019, 273 & middot;9 million (95% uncertainty interval 258 & middot;5 to 290 & middot;9) people aged 15 years and older used chewing tobacco, and the global age-standardised prevalence of chewing tobacco use was 4 & middot;72% (4 & middot;46 to 5 & middot;01). 228 & middot;2 million (213 & middot;6 to 244 & middot;7; 83 & middot;29% [82 & middot;15 to 84 & middot;42]) chewing tobacco users lived in the south Asia region. Prevalence among young people aged 15-19 years was over 10% in seven locations in 2019. Although global age standardised prevalence of smoking tobacco use decreased significantly between 1990 and 2019 (annualised rate of change: -1 & middot;21% [-1 & middot;26 to -1 & middot;16]), similar progress was not observed for chewing tobacco (0 & middot;46% [0 & middot;13 to 0 & middot;79]). Among the 12 highest prevalence countries (Bangladesh, Bhutan, Cambodia, India, Madagascar, Marshall Islands, Myanmar, Nepal, Pakistan, Palau, Sri Lanka, and Yemen), only Yemen had a significant decrease in the prevalence of chewing tobacco use, which was among males between 1990 and 2019 (-0 & middot;94% [-1 & middot;72 to -0 & middot;14]), compared with nine of 12 countries that had significant decreases in the prevalence of smoking tobacco. Among females, none of these 12 countries had significant decreases in prevalence of chewing tobacco use, whereas seven of 12 countries had a significant decrease in the prevalence of tobacco smoking use for the period. Interpretation Chewing tobacco remains a substantial public health problem in several regions of the world, and predominantly in south Asia. We found little change in the prevalence of chewing tobacco use between 1990 and 2019, and that control efforts have had much larger effects on the prevalence of smoking tobacco use than on chewing tobacco use in some countries. Mitigating the health effects of chewing tobacco requires stronger regulations and policies that specifically target use of chewing tobacco, especially in countries with high prevalence. Copyright (c) 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.Peer reviewe

Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990-2019 : a systematic analysis from the Global Burden of Disease Study 2019

Background Ending the global tobacco epidemic is a defining challenge in global health. Timely and comprehensive estimates of the prevalence of smoking tobacco use and attributable disease burden are needed to guide tobacco control efforts nationally and globally. Methods We estimated the prevalence of smoking tobacco use and attributable disease burden for 204 countries and territories, by age and sex, from 1990 to 2019 as part of the Global Burden of Diseases, Injuries, and Risk Factors Study. We modelled multiple smoking-related indicators from 3625 nationally representative surveys. We completed systematic reviews and did Bayesian meta-regressions for 36 causally linked health outcomes to estimate non-linear dose-response risk curves for current and former smokers. We used a direct estimation approach to estimate attributable burden, providing more comprehensive estimates of the health effects of smoking than previously available. Findings Globally in 2019, 1.14 billion (95% uncertainty interval 1.13-1.16) individuals were current smokers, who consumed 7.41 trillion (7.11-7.74) cigarette-equivalents of tobacco in 2019. Although prevalence of smoking had decreased significantly since 1990 among both males (27.5% [26. 5-28.5] reduction) and females (37.7% [35.4-39.9] reduction) aged 15 years and older, population growth has led to a significant increase in the total number of smokers from 0.99 billion (0.98-1.00) in 1990. Globally in 2019, smoking tobacco use accounted for 7.69 million (7.16-8.20) deaths and 200 million (185-214) disability-adjusted life-years, and was the leading risk factor for death among males (20.2% [19.3-21.1] of male deaths). 6.68 million [86.9%] of 7.69 million deaths attributable to smoking tobacco use were among current smokers. Interpretation In the absence of intervention, the annual toll of 7.69 million deaths and 200 million disability-adjusted life-years attributable to smoking will increase over the coming decades. Substantial progress in reducing the prevalence of smoking tobacco use has been observed in countries from all regions and at all stages of development, but a large implementation gap remains for tobacco control. Countries have a dear and urgent opportunity to pass strong, evidence-based policies to accelerate reductions in the prevalence of smoking and reap massive health benefits for their citizens. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd.Peer reviewe

Global, regional, and national sex-specific burden and control of the HIV epidemic, 1990-2019, for 204 countries and territories: the Global Burden of Diseases Study 2019

Background: The sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic. Methods: To estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold >75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio threshold <0·03), and the ratio of incident cases to deaths (incidence-to-mortality ratio threshold <1·0). Findings: In 2019, there were 36·8 million (95% uncertainty interval [UI] 35·1–38·9) people living with HIV worldwide. There were 0·84 males (95% UI 0·78–0·91) per female living with HIV in 2019, 0·99 male infections (0·91–1·10) for every female infection, and 1·02 male deaths (0·95–1·10) per female death. Global progress in incident cases and deaths between 2010 and 2019 was driven by sub-Saharan Africa (with a 28·52% decrease in incident cases, 95% UI 19·58–35·43, and a 39·66% decrease in deaths, 36·49–42·36). Elsewhere, the incidence remained stable or increased, whereas deaths generally decreased. In 2019, the global incidence-to-prevalence ratio was 0·05 (95% UI 0·05–0·06) and the global incidence-to-mortality ratio was 1·94 (1·76–2·12). No regions met suggested thresholds for progress. Interpretation: Sub-Saharan Africa had both the highest HIV burden and the greatest progress between 1990 and 2019. The number of incident cases and deaths in males and females approached parity in 2019, although there remained more females with HIV than males with HIV. Globally, the HIV epidemic is far from the UNAIDS benchmarks on progress metrics. Funding: The Bill & Melinda Gates Foundation, the National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH