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Background The health consequences of the use of Swedish snus, including its relationship with mortality, have not been fully established. We investigated the relationship between snus use and all-cause and cause-specific mortality (death due to cardiovascular diseases, cancer diseases and all other reasons, respectively) in a nationwide collaborative pooling project. Methods We followed 169 103 never-smoking men from eight Swedish cohort studies, recruited in 1978–2010. Shared frailty models with random effects at the study level were used in order to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of mortality associated with snus use. Results Exclusive current snus users had an increased risk of all-cause mortality (aHR 1.28, 95% CI 1.20–1.35), cardiovascular mortality (aHR 1.27, 95% CI 1.15–1.41) and other cause mortality (aHR 1.37, 95% CI 1.24–1.52) compared with never-users of tobacco. The risk of cancer mortality was also increased (aHR 1.12, 95% CI 1.00–1.26). These mortality risks increased with duration of snus use, but not with weekly amount. Conclusions Snus use among men is associated with increased all-cause mortality, cardiovascular mortality, with death from other causes and possibly with increased cancer mortality.

This study used the Stockholm Youth Cohort, a total population cohort ( N = 364,957), to describe patterns and predictors of qualification for upper secondary education, defined by passing graduation grades in core compulsory school subjects in contemporary young individuals diagnosed with autism spectrum disorders without intellectual disability ( n = 6138). At the expected age for graduation, 16 years, 29% (adjusted rate difference 95% confidence interval (28.0–30.0)) fewer autistic than non-autistic individuals were qualified for upper secondary education (57% and 86%, respectively). Comorbid attention-deficit hyperactivity disorder further increased this difference. Within the group of autistic students without intellectual disability, female sex and lower family income were associated with non-qualification for upper secondary education. The proportion of students with autism without intellectual disability who qualified for upper secondary education increased at age 20. These findings underline the need for improved support for students with a diagnosis of autism without intellectual disability in mainstream education. Lay abstract Obtaining a quality education is important for any individual’s chances of leading a healthy and thriving life. Currently, educational policies in many countries underscore the rights of students with autism to be educated in mainstream schools. While there is some knowledge on school outcomes among students with autism from older studies, little is known about rates of qualification for upper secondary education among children with autism in mainstream schools today. This lack of knowledge is problematic since autism is diagnosed more widely, and prior evidence may not be relevant for individuals with autism and their families today. Using Swedish registers, we therefore examined this in a study including all children and young people in Stockholm County in 2001 through 2011. We found that about two thirds of children with autism without intellectual disability qualified for upper secondary education at the expected age, in comparison with about nine in ten among typically developing peers. We also found that girls with autism had further difficulties obtaining such qualification than boys and that those who were additionally diagnosed with attention-deficit hyperactivity disorder were particularly at risk of non-qualification. Finally, students with autism without intellectual disability had a greater chance of completing compulsory education if given an extended period to graduate. These findings underline the need for supportive interventions for children with autism during compulsory school. They may also challenge the inclusive education policy adopted by majority of western countries, at least in the wake of addressing special needs in mainstream schooling.

Particulate matter air pollution and diesel engine exhaust have been classified as carcinogenic for lung cancer, yet few studies have explored associations with liver cancer. We used six European adult cohorts which were recruited between 1985 and 2005, pooled within the “Effects of low-level air pollution: A study in Europe” (ELAPSE) project, and followed for the incidence of liver cancer until 2011 to 2015. The annual average exposure to nitrogen dioxide (NO 2), particulate matter with diameter 2.5), black carbon (BC), warm-season ozone (O 3), and eight elemental components of PM 2.5 (copper, iron, zinc, sulfur, nickel, vanadium, silicon, and potassium) were estimated by European-wide hybrid land-use regression models at participants' residential addresses. We analyzed the association between air pollution and liver cancer incidence by Cox proportional hazards models adjusting for potential confounders. Of 330 064 cancer-free adults at baseline, 512 developed liver cancer during a mean follow-up of 18.1 years. We observed positive linear associations between NO 2 (hazard ratio, 95% confidence interval: 1.17, 1.02-1.35 per 10 μg/m 3), PM 2.5 (1.12, 0.92-1.36 per 5 μg/m 3), and BC (1.15, 1.00-1.33 per 0.5 10 −5/m) and liver cancer incidence. Associations with NO 2 and BC persisted in two-pollutant models with PM 2.5. Most components of PM 2.5 were associated with the risk of liver cancer, with the strongest associations for sulfur and vanadium, which were robust to adjustment for PM 2.5 or NO 2. Our study suggests that ambient air pollution may increase the risk of liver cancer, even at concentrations below current EU standards.

Although exposure to overweight and obesity at different ages is associated to a higher risk of type 2 diabetes, the effect of different patterns of exposure through life remains unclear. We aimed to characterize life-course trajectories of weight categories and estimate their impact on the incidence of type 2 diabetes. We categorized the weight of 7203 participants as lean, normal or overweight at five time-points from ages 7–55 using retrospective data. Participants were followed for an average of 19 years for the development of type 2 diabetes. We used latent class analysis to describe distinctive trajectories and estimated the risk ratio, absolute risk difference and population attributable fraction (PAF) associated to different trajectories using Poisson regression. We found five distinctive life-course trajectories. Using the stable-normal weight trajectory as reference, the stable overweight, lean increasing weight, overweight from early adulthood and overweight from late adulthood trajectories were associated to higher risk of type 2 diabetes. The estimated risk ratios and absolute risk differences were statistically significant for all trajectories, except for the risk ratio of the lean increasing trajectory group among men. Of the 981 incident cases of type 2 diabetes, 47.4% among women and 42.9% among men were attributable to exposure to any life-course trajectory different from stable normal weight. Most of the risk was attributable to trajectories including overweight or obesity at any point of life (36.8% of the cases among women and 36.7% among men). The overweight from early adulthood trajectory had the highest impact (PAF: 23.2% for woman and 28.5% for men). We described five distinctive life-course trajectories of weight that were associated to increased risk of type 2 diabetes over 19 years of follow-up. The variability of the effect of exposure to overweight and obesity on the risk of developing type 2 diabetes was largely explained by exposure to the different life-course trajectories of weight.

Background Transportation noise is increasingly acknowledged as a cardiovascular risk factor, but the evidence base for an association with stroke is sparse. Objective We aimed to investigate the association between transportation noise and stroke incidence in a large Scandinavian population. Methods We harmonized and pooled data from nine Scandinavian cohorts (seven Swedish, two Danish), totaling 135,951 participants. We identified residential address history and estimated road, railway, and aircraft noise for all addresses. Information on stroke incidence was acquired through linkage to national patient and mortality registries. We analyzed data using Cox proportional hazards models, including socioeconomic and lifestyle confounders, and air pollution. Results During follow-up ( median = 19.5 y ), 11,056 stroke cases were identified. Road traffic noise ( L den ) was associated with risk of stroke, with a hazard ratio (HR) of 1.06 [95% confidence interval (CI): 1.03, 1.08] per 10-dB higher 5-y mean time-weighted exposure in analyses adjusted for individual- and area-level socioeconomic covariates. The association was approximately linear and persisted after adjustment for air pollution [particulate matter (PM) with an aerodynamic diameter of ≤ 2.5 μ m ( PM 2.5 ) and NO 2 ]. Stroke was associated with moderate levels of 5-y aircraft noise exposure (40-50 vs. ≤ 40 dB ) ( HR = 1.12 ; 95% CI: 0.99, 1.27), but not with higher exposure ( ≥ 50 dB , HR = 0.94 ; 95% CI: 0.79, 1.11). Railway noise was not associated with stroke. Discussion In this pooled study, road traffic noise was associated with a higher risk of stroke. This finding supports road traffic noise as an important cardiovascular risk factor that should be included when estimating the burden of disease due to traffic noise. https://doi.org/10.1289/EHP8949.

Background Overweight and obesity are risk factors for type 2 diabetes (T2D) with a cumulative effect. However, individuals experience important variation throughout life. We aimed to identify life-course trajectories of changes in weight categories among men and women and their association with T2D. Methods 4,820 women and 3,128 men participants of the Stockholm Diabetes Preventive Program (1992-2017) provided self-reported weight status at age 7 and 18, BMI 10 and 5 years before the study and measured BMI at baseline. Exposure was categorized as low weight, normal weight and high weight. Diagnosis of T2D was assessed with an oral glucose tolerance tests (OGTT) or taken from inpatient and outpatient registries. The life course trajectories were estimated using latent group mixture models, risk of T2D and population attributable fractions with Poisson regression. Results We found five trajectories in women and men: stable normal (44.8%, 34.2%), low increasing (17.4%, 18.7%), high in early adulthood (18.6%, 27.8%), high in late adulthood (14.7%, 14.5%), and stable high (4.5%, 4.5%). Compared to stable normal, the risk of T2D was higher in the low increasing (RR: 1.4 (95%CI: 1.0-2.0), RR:1.54(95%CI: 1.0-2.2)), high in early adulthood ((RR: 2.79 (95%CI: 2.1-3.7), RR: 2.8 (95%CI: 2.0-3.6)), high in late adulthood ((RR: 1.6 (95%CI: 1.1-2.2), RR: 1.6 (95%CI: 1.1-2.3)) and stable high groups ((RR: 2.9 (95%CI: 1.9-4.3), RR: 2.7 (95%CI 1.8-4.0)), and 48.2% (95% CI: 36.3% - 57.8%) of the cases of T2D in women and 41.2% (95%CI: 27.4% - 52.3%) in men could have been avoided if participants had been in the stable normal group. PAF was higher for the high in early adulthood group -25.5% (19%-31%) and (27.2% (19%-35%)-. Conclusions We identified five life course trajectories of changes in weight status. Risk of T2D was greater in the stable high and high in early adulthood groups but the proportion of T2D cases that can be attributed to the high in early adulthood group was greater. Key messages Different life-course trajectories of high body weight are associated to the risk of diabetes in late adulthood. The largest proportion of cases of T2D can be attributed to weight gain in early adulthood.

Background Type 2 diabetes (T2D) is an important cause of mortality, disability and health care expenditures. Prevention is crucial to counter global trends, but individual variability of different risk factors leading to T2D has made prevention difficult to achieve. We aimed to identify clusters of individuals based on individual level characteristics of different risk factors using a data driven approach. Methods We used data from the Stockholm Diabetes Prevention Program. A population-based, prospective study. Healthy participants who were born in Sweden and aged 35 to 55 years old were recruited between 1992 and 1998 and followed up after 10 and 20 years. At each visit, participants answered extensive questionnaires, anthropometric measures, laboratory examinations and an oral glucose tolerance test. We used age, sex, family history of diabetes, fasting and two hours glucose and insulin, body mass index (BMI), systolic and diastolic blood pressure, and level of education were at baseline to group participants using the k-prototype algorithm. We then examined the risk of diabetes between clusters using survival analysis. Results A total of 7,173 participants representing 138,942 person years of follow-up were included in this study. Among them, 998 (14%) developed T2D. We identified six stable clusters: the group with the lowest cumulative incidence of T2D (2.3%) was used as reference (n = 1,265). In the group with the highest risk, 47% developed T2D (n = 772, HR 26.3, 95%CI 17.9-38.5) followed by 17.1% (n = 1,146, HR 7.6, 95%CI 5.1-11.22), 15.2% (n = 1,453, HR 6.7, 95%CI 4.5-9.8), 9.5% (n = 1,384, HR 4.1, 95%CI 2.8-6.2) and 5.2% (n = 1,157, HR 2.0, 95%CI 1.3-3.1) in the remaining groups. Conclusions There is important variability between individuals regarding the effect of different risk factors on the incidence of T2D. Data driven categorization strategies can be useful epidemiological tools to pave the way for more precise T2D intervention programs. Key messages Prevention strategies for T2D usually follow a one-size fits all approach, ignoring the important variability of risk factors and their consequences among individuals. It is possible to identify subgroups of people with different risk of T2D based on simple clinical and phenotypical characteristics, and could help to improve prevention and treatment of T2D.

Aims: Worldwide, smokeless-tobacco use is a major risk factor for oral cancer. Evidence regarding the particular association between Swedish snus use and oral cancer is, however, less clear. We used pooled individual data from the Swedish Collaboration on Health Effects of Snus Use to assess the association between snus use and oral cancer. Methods: A total of 418,369 male participants from nine cohort studies were followed up for oral cancer incidence through linkage to health registers. We used shared frailty models with random effects at the study level, to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for confounding factors. Results: During 9,201,647 person-years of observation, 628 men developed oral cancer. Compared to never-snus use, ever-snus use was not associated with oral cancer (adjusted HR 0.90, 95% CI: 0.74, 1.09). There were no clear trends in risk with duration or intensity of snus use, although lower intensity use (⩽ 4 cans/week) was associated with a reduced risk (HR 0.65, 95% CI: 0.45, 0.94). Snus use was not associated with oral cancer among never smokers (HR 0.87, 95% CI: 0.57, 1.32). Conclusions: Swedish snus use does not appear to be implicated in the development of oral cancer in men.

Dominika Seblova,1,2 Maria Lopez Quiroga,3 Stefan Fors,1 Kristina Johnell,1 Martin Lövdén,1 Antonio Ponce de Leon,2,4 Anna Christina Svensson,2 Susanne Wicks,2,4 Anton Lager1,2,4 1Aging Research Center, Karolinska Institutet, Stockholm, Sweden; 2Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; 3Complutense University of Madrid, Madrid, Spain; 4Center for Epidemiology and Community Medicine, Stockholm County Council, Stockholm, Sweden Background: The continuous growth of the current dementia epidemic is contingent on the stability of age- and sex-specific trends over time. However, recent evidence suggests declining or stable trends. The aim of this study was to evaluate the real-world changes in the burden of dementia in older adults in Sweden from 1987 to 2016 by estimating age- and sex-specific incidence of dementia diagnosis in hospital inpatient records (dementia incidence). Differences in trends by sex, age, and educational levels were also examined.Methods: The entire Swedish population aged 65 years and older was followed up from 1987 to 2016. Age-, sex-, and education-stratified dementia incidence rates for every follow-up year were estimated using the National Patient Register. Hazard ratio of receiving a dementia diagnosis in the inpatient records per 1 calendar year increase was estimated with discrete time logistic models with a complementary log–log link.Results: After increase, especially in those >85 years of age, dementia incidence started to decrease in the last 5 years of the study period. After 2011, 1 calendar year increase was associated with lower hazard ratio of receiving a hospital diagnosis of dementia. The decrease had the highest magnitude in 70–74-year-olds (–5.5%), followed by 75–79-year-olds (–4.5%) and 80–84-year-olds (–4.0%). The decrease was present in both sexes and at all educational levels up to 90 years of age. Age was associated with the level of dementia incidence, and the trends differed by age group. Educational gradient was observed. University-educated older adults had the lowest rates of dementia. However, the trend over time did not substantially differ by sex or educational level.Conclusion: Our results provide more evidence that dementia incidence may be declining. They also suggest that at least in hospitals, the number of new patients with dementia may decrease in the future. Keywords: incidence, Alzheimer’s, hospitalization, population study, heterogeneous association, education

Objective There is a paucity of data on disordered eating among adoptees. The aim of the present study was to explore the prevalence of symptoms of disordered eating and body image concerns among international adoptees in a large representative community survey on health-related behaviours. Method Combining survey data from the Stockholm Public Health Cohort and Swedish population data, adult international adoptees were compared with total participant data to assess differences in disordered eating and body dissatisfaction. Results International adoptee women displayed significantly higher levels of self-induced vomiting, loss-of-control eating, food preoccupation, underweight, and wish for thinness compared with nonadoptee women, albeit with small or very small effect sizes. No significant differences were found in terms of mean body mass index, cognitive restraint, or emotional eating. Conclusion International adoptee women were disproportionally affected on several measures of disordered eating, although the magnitude of these differences were generally small in absolute terms.

While smoking is a well-established risk factor for pancreatic cancer, the effect of smokeless tobacco is less well understood. We used pooled individual data from the Swedish Collaboration on Health Effects of Snus Use to assess the association between Swedish snus use and the risk of pancreatic cancer. A total of 424,152 male participants from nine cohort studies were followed up for risk of pancreatic cancer through linkage to health registers. We used shared frailty models with random effects at the study level, to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for confounding factors. During 9,276,054 person-years of observation, 1,447 men developed pancreatic cancer. Compared to never-snus use, current snus use was not associated with risk of pancreatic cancer (HR 0.96, 95% CI 0.83-1.11) after adjustment for smoking. Swedish snus use does not appear to be implicated in the development of pancreatic cancer in men. Tobacco smoke constituents other than nicotine or its metabolites may account for the relationship between smoking and pancreatic cancer.

Background and aims Frequent back, neck and/or shoulder pain (BNSP) are common conditions which pose high burden for the society. Results from previous studies suggest that diabetes and hyperlipidaemia may be associated with a higher risk of getting such conditions, but there is in general, few studies based on longitudinal designs. The aim of this study was therefore to compare the risk of developing frequent BNSP in men and women with and without diabetes and/or hyperlipidaemia. Methods A longitudinal study based on the Stockholm Public Health Cohort was conducted based on subjects aged 45–84, who were free from pain at the mentioned sites in 2006 and followed up until 2010. The data in the current study is based on questionnaires, except socioeconomic status which was derived from Statistics Sweden. The exposure diabetes and hyperlipidaemia was self-reported and, a categorical variable was created; without any of the conditions, with hyperlipidaemia only, with diabetes only and with both conditions. The outcome frequent BNSP was defined using the following questions in the questionnaire in 2010: “During the past 6 months, have you had pain in the neck or upper part of the back?”, “During the past 6 months, have you had pain in the lower back?”, and “During the past 6 months, have you had pain in the shoulders/arms?”. All questions had three possible response options: no; yes, a couple of days per month or less often and; yes, a couple of days per week or more often. Those who reported weekly pain to at least one of these questions were considered to having frequent BNSP. Binomial regressions were run to calculate the crude and adjusted risk ratio (RR) in men and women separately. Additional analysis was performed in order to control for potential bias derived from individuals lost to follow-up. Results A total of 10,044 subjects fulfilled the criteria to be included in the study. The mean age of the sample was 60 years and evenly distributed by sex. After adjusting for age, body mass index, physical activity, high blood pressure and socioeconomic status, the RR for frequent BNSP among men with diabetes was 1.64 (95% CI: 1.23–2.18) and 1.19 (95% CI: 0.98–1.44) for hyperlipidaemia compared to men with neither diabetes nor hyperlipidaemia. Among women the corresponding RRs were 0.92 (95% CI: 0.60–1.14) and 1.23 (95% CI: 1.03–1.46). Having both diabetes and hyperlipidaemia at baseline was not associated with increased risk of frequent BNSP. Diabetes and hyperlipidaemia seems to be associated with an increased risk for frequent BNSP and the risk may differ between men and women. Behaviours and/or biological underlying mechanisms may explain the results. Conclusions This study suggests that metabolic diseases such as diabetes and hyperlipidaemia may have an impact on the pathophysiology of frequent BNSP and thus, contributes to the knowledge in musculoskeletal health. Furthermore, it confirms that men and women may differ in terms of risk factors for BNSP. Implications Health professionals should contemplate the results from this study when planning primary prevention strategies.

Intervening on modifiable risk factors to prevent dementia is of key importance, since progress-modifying treatments are not currently available. Education is inversely associated with dementia risk, but causality and mechanistic pathways remain unclear. We aimed to examine the causality of this relationship in Sweden using, as a natural experiment, data on a compulsory schooling reform that extended primary education by 1 year for 70% of the population between 1936 and 1949. The reform introduced substantial exogenous variation in education that was unrelated to pupils’ characteristics. We followed 18 birth cohorts (n = 1,341,842) from 1985 to 2016 (up to ages 79–96 years) for a dementia diagnosis in the National Inpatient and Cause of Death registers and fitted Cox survival models with stratified baseline hazards at the school-district level, chronological age as the time scale, and cohort indicators. Analyses indicated very small or negligible causal effects of education on dementia risk (main hazard ratio = 1.01, 95% confidence interval: 0.98, 1.04). Multiple sensitivity checks considering only compliers, the pre-/post- design, differences in health-care-seeking behavior, and the impact of exposure misclassification left the results essentially unaltered. The reform had limited effects on further adult socioeconomic outcomes, such as income. Our findings suggest that without mediation through adult socioeconomic position, education cannot be uncritically considered a modifiable risk factor for dementia.

A low intake of fruit and vegetables is a significant contributor to the global burden of disease. The aim of this study was to estimate the size of the risk of type 2 diabetes (T2D) of a low intake and to investigate possible sex differences. In this regard, this study used a longitudinal data from the Stockholm Public Health Cohort located in Sweden, collected in 2010 and 2014. The analysis included 14 718 men and 20 589 women aged 25 to 84 years. Fruit and vegetable intake, separately P < 0⋅001) less fruit and vegetables compared with women. A 62 % higher risk to develop T2D over the 4-year period was observed in men who had low vegetable intake compared with high intake after adjusting for age, education, BMI, smoking, alcohol and physical activity (OR 1⋅62; 95 % CI 1⋅00, 2⋅63). In women, a significantly higher risk of T2D was also observed with a low intake of vegetables, but not after adjustment. The present study suggests that higher consumption of vegetables seems to be protective for the onset of T2D in men. Thus, increasing the intake of vegetables in men should be a public health priority.

Aims To study if machine learning methodology can be used to detect persons with increased type 2 diabetes or prediabetes risk among people without known abnormal glucose regulation. Methods Machine learning and interpretable machine learning models were applied on research data from Stockholm Diabetes Preventive Program, including more than 8000 people initially with normal glucose tolerance or prediabetes to determine high and low risk features for further impairment in glucose tolerance at follow-up 10 and 20 years later. Results The features with the highest importance on the outcome were body mass index, waist-hip ratio, age, systolic and diastolic blood pressure, and diabetes heredity. High values of these features as well as diabetes heredity conferred increased risk of type 2 diabetes. . The machine learning model was used to generate individual, comprehensible risk profiles, where the diabetes risk was obtained for each person in the data set. Features with the largest increasing or decreasing effects on the risk were determined. Conclusions The primary application of this machine learning model is to predict individual type 2 diabetes risk in people without diagnosed diabetes, and to which features the risk relates. However, since most features affecting diabetes risk also play a role for metabolic control in diabetes, e.g. body mass index, diet composition, tobacco use, and stress, the tool can possibly also be used in diabetes care to develop more individualized, easily accessible health care plans to be utilized when encountering the patients., Machine Learning, Interpretable Machine Learning, SHAP, Risk screening, Type 2 Diabetes, Individual Healthcare Plan.

Background: Long-term exposure to particulate matter (PM) in ambient air has been associated with cardiovascular mortality, but few studies have considered incident disease in relation to PM from different sources. Objectives: We aimed to study associations between long-term exposure to different types of PM and sources, and incident ischemic heart disease (IHD) and stroke in three Swedish cities. Methods: Based on detailed emission databases, monitoring data, and high-resolution dispersion models, we calculated source contributions to PM with aerodynamic diameter ≤10μm (PM10), PM with aerodynamic diameter ≤2.5μm (PM2.5), and black carbon (BC) from road wear, traffic exhaust, residential heating, and other sources in Gothenburg, Stockholm, and Umeå. Registry data for participants from four cohorts were used to obtain incidence of IHD and stroke for first hospitalization or death. We constructed time windows of exposure for same-year, 1- to 5-y, and 6- to 10-y averages preceding incidence from annual averages at residential addresses. Risk estimates were based on random effects meta-analyses of cohort-specific Cox proportional hazard models. Results: We observed 5,166 and 3,119 incident IHD and stroke cases, respectively, in 114,758 participants. Overall, few consistent associations were observed between the different air pollution measures and IHD or stroke incidence. However, same-year levels of ambient locally emitted BC (range: 0.01−4.6 μg/m3) were associated with a 4.0% higher risk of incident stroke per interquartile range (IQR), 0.30 μg/m3 [95% confidence interval (CI): 0.04, 7.8]. This association was primarily related to BC from traffic exhaust. PM10 (range: 4.4−52 μg/m3) and PM2.5 (range: 2.9−22 μg/m3) were not associated with stroke. Associations with incident IHD were observed only for PM2.5 exposure from residential heating. Discussion: Few consistent associations were observed between different particulate components and IHD or stroke. However, long-term residential exposure to locally emitted BC from traffic exhaust was associated with stroke incidence. The comparatively low exposure levels may have contributed to the paucity of associations. https://doi.org/10.1289/EHP4757

Background: Education is related to dementia risk. Researchers in public health often treat education as a modifiable risk factor, implying that prolonging education may reduce dementia incidence. This reasoning rests on the largely untested assumption that education has causal effects on dementia risk. Methods: We used variance in education induced by a compulsory schooling reform, which extended Swedish primary school (Folkskola) from 6 to 7 years as a tool for studying direct causal effects of education on dementia risk. The reform was implemented gradually in school districts and had minor spillover effects. We studied 18 birth cohorts (1920-1937), excluding individuals with unknown reform status, those who died, emigrated, or received dementia diagnosis prior to 65 years of age. The outcome was dementia diagnosis in the National Inpatient and Cause of Death Registers. The reform allowed us to study direct effects of prolonged education with high validity and statistical precision. In the main analyses, we employed sex-stratified Cox survival models with stratified baseline hazards at the school-district level, used chronological age as the time scale, and dummy-coded cohort effects. Findings: 1,341,842 individuals were included. The reform did not affect the risk of dementia diagnosis in a statistically significant way. The estimates and associated confidence intervals (women: HR = 1.01; 95% CI = 0.97-1.04; men: HR = 1.02; 95% CI = 0.99-1.06; all: HR = 1.01; 95% CI = 0.98-1.04) indicate that any direct effect is likely of a negligible or very small magnitude. Sensitivity analyses targeting pre-post changes, differences in healthcare-seeking behavior, and impact of exposure misclassification left results essentially unaltered. Interpretation: Longer education, at least in the absence of sizable spillover effects to adult socio-economic factors, cannot be uncritically assumed to substantially reduce the risk of moderate to severe dementia. Funding Statement: FORTE (2013-2277) and Swedish Research Council (446-2013-7189) to ML. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The study was approved by the Regional Ethical Review Board in Stockholm (Case number: 2010/1185-31/5).

Aims: We investigate (a) alcohol consumption in association with type 2 diabetes, taking heavy episodic drinking (HED), socioeconomic, health and lifestyle, and psychosocial factors into account, and (b) whether a seemingly protective effect of moderate alcohol consumption on type 2 diabetes persists when stratified by occupational position. Methods: This population-based longitudinal cohort study comprises 16,223 Swedes aged 18–84 years who answered questionnaires about lifestyle, including alcohol consumption in 2002, and who were followed-up for self-reported or register-based diabetes in 2003–2011. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated in a multivariable-adjusted logistic regression model for all participants and stratified by high and low occupational position. We adjusted for HED, socioeconomic (occupational position, cohabiting status and unemployment), health and lifestyle (body mass index (BMI), blood pressure, smoking, physical inactivity, poor general health, anxiety/depression and psychosocial (low job control and poor social support) characteristics one by one, and the sets of these factors. Results: Moderate consumption was inversely associated with type 2 diabetes after controlling for health and lifestyle (OR=0.47; 95% CI: 0.29–0.79) and psychosocial factors (OR=0.40; 95% CI: 0.22–0.79) when compared to non-drinkers. When adjusting for socioeconomic factors, there was still an inverse but non-significant association (OR=0.59; 95% CI: 0.35–1.00). In those with high occupational position, there was no significant association between moderate consumption and type 2 diabetes after adjusting for socioeconomic (OR=0.67; 95% CI: 0.3–1.52), health and lifestyle (OR=0.70; 95% CI: 0.32–1.5), and psychosocial factors (OR=0.75; 95% CI: 0.23–2.46). On the contrary, in those with low occupational position, ORs decreased from 0.55 (95% CI: 0.28-1.1) to 0.35 (95% CI: 0.15–0.82) when adjusting for psychosocial factors, a decrease that was solely due to low job control. HED did not influence any of these associations. Conclusions: Moderate alcohol consumption is associated with a lower risk of type 2 diabetes, after adjusting for HED, health and lifestyle, and psychosocial characteristics. The association was inverse but non-significant after adjusting for socioeconomic factors. When stratified by occupational position, there was an inverse association only in those with low occupational position and after adjusting for low job control.

Aims: Although smoking is considered to be an established risk factor for colorectal cancer, the current evidence on the association between smokeless tobacco and colorectal cancer is scant and inconclusive. We used pooled individual data from the Swedish Collaboration on Health Effects of Snus Use to assess this association. Methods: A total of 417,872 male participants from nine cohort studies across Sweden were followed up for incidence of colorectal cancer and death. Outcomes were ascertained through linkage to health registers. We used shared frailty models with random effects at the study level to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Results: During 7,135,504 person-years of observation, 4170 men developed colorectal cancer. There was no clear association between snus use and colorectal cancer overall. Exclusive current snus users, however, had an increased risk of rectal cancer (HR 1.40: 95% CI 1.09, 1.79). There were no statistically significant associations between snus use and either all-cause or colorectal cancer-specific mortality after colorectal cancer diagnosis. Conclusions: Our findings, from a large sample, do not support any strong relationships between snus use and colorectal cancer risk and survival among men. However, the observed increased risk of rectal cancer is noteworthy, and in merit of further attention.

Smoking and nicotine exposure increase insulin resistance and the risk of type 2 diabetes. Swedish smokeless tobacco (snus) is high in nicotine, and its use is prevalent in Scandinavian countries, but few studies have investigated snus use in relation to diabetes risk.To explore the association between snus use and risk of type 2 diabetes using pooled data from five cohorts.Analyses were based on prospective studies conducted between 1990 and 2013 including 54 531 never-smoking men and 2441 incident cases of type 2 diabetes identified through screening, self-reporting and hospital and prescription registries. Hazard ratios (HRs) and 95% confidence intervals (CIs) were assessed and adjusted for age, body mass index, educational level, alcohol consumption and physical activity.Compared to never users, the HR of type 2 diabetes was 1.15 (95% CI: 1.00-1.32) in current users of snus. In individuals consuming 5-6 boxes per week, the HR was 1.42 (95% CI: 1.07-1.87); in those consuming ≥7 boxes per week, the HR was 1.68 (95% CI: 1.17-2.41). Each additional box of snus consumed per week yielded an HR of 1.08 (95% CI: 1.01-1.16).Our findings indicate that high consumption of snus is a risk factor for type 2 diabetes. The risk was similar to that in smokers, implying that smokers will not reduce their risk of type 2 diabetes by changing to snus use. The results also support the notion that nicotine increases the risk of type 2 diabetes.

Aim: To test the feasibility of a system for monitoring children's obesity and overweight based on data from electronic health records in the school health services. Methods: Data on weight and height from electronic health records at school health services were collected for 10-year-olds in 2003—2004, 2004—2005 and 2005—2006. School health personnel extracted group-level data with a simple program installed on the computer containing the health records. Four Swedish municipalities were included in the study: Karlstad, Umeå, Västerås, and Ystad. Results: The system achieved coverage of 92—96% of all children in 2005—2006. The overall prevalence rates were 4.2% (3.8—4.7%) obese and 22.0% (21.1—23.0%) overweight, including obesity. Conclusions: A system based on electronic health records from the school health services can successfully provide data. The system has practical, economical and ethical strengths.

Summary Over 18 per cent of Sweden’s population – approximately 1.8 million people – are 65 years of age or older. The proportion of elderly people in the population has been growing for more than a century and is expected to continue to rise given the gains in average life expec tancy and the fact that large age cohorts are reaching retirement age. The average remaining life expectancy among those who had reached the age of 65 in 2011 was 21 years for women and 18 years for men. The most common causes of death among elderly people are cardiovascular diseases and cancer. The risk of suffering a stroke or heart attack has declined and morbidity has shifted to the upper age groups. On the other hand, the cancer incidence has increased, while cancer mortality has declined, owing to earlier detection and more effective treatment. The most common forms of cancer among elderly people are prostate cancer, breast cancer, colorectal cancer, and lung cancer. There has been a rise in the proportion of elderly people who perceive their general state of health as good. In the case of women, however, the increase is mainly noticeable among younger pensioners, while in men, it is spread across all age groups, according to the Statistics Sweden’s Survey of Living Conditions (ULF). The percentage of elderly people reporting long-term illness has risen, while the proportion with illnesses or complaints that interfere with daily life activities has declined. The percentage of people suffering from impaired mobility has fallen since the 1980s, while pain issues have remained at about the same level. Reports of nervousness, anxiety and sleeping

Background Long-term exposure to outdoor air pollution increases the risk of cardiovascular disease, but evidence is unclear on the health effects of exposure to pollutant concentrations lower than current EU and US standards and WHO guideline limits. Within the multicentre study Effects of Low-Level Air Pollution: A Study in Europe (ELAPSE), we investigated the associations of long-term exposures to fine particulate matter (PM2.5), nitrogen dioxide (NO2), black carbon, and warm-season ozone (O-3) with the incidence of stroke and acute coronary heart disease.Methods We did a pooled analysis of individual data from six population-based cohort studies within ELAPSE, from Sweden, Denmark, the Netherlands, and Germany (recruited 1992-2004), and harmonised individual and area-level variables between cohorts. Participants (all adults) were followed up until migration from the study area, death, or incident stroke or coronary heart disease, or end of follow-up (2011-15). Mean 2010 air pollution concentrations from centrally developed European-wide land use regression models were assigned to participants' baseline residential addresses. We used Cox proportional hazards models with increasing levels of covariate adjustment to investigate the association of air pollution exposure with incidence of stroke and coronary heart disease. We assessed the shape of the concentration-response function and did subset analyses of participants living at pollutant concentrations lower than predefined values.Findings From the pooled ELAPSE cohorts, data on 137 148 participants were analysed in our fully adjusted model. During a median follow-up of 17.2 years (IQR 13.8-19.5), we observed 6950 incident events of stroke and 10 071 incident events of coronary heart disease. Incidence of stroke was associated with PM2.5 (hazard ratio 1.10 [95% CI 1.01-1.21] per 5 mu g/m(3) increase), NO2 (1.08 [1.04-1.12] per 10 mu g/m(3) increase), and black carbon (1.06 [1.02-1.10] per 0.5 10(-5)/m increase), whereas coronary heart disease incidence was only associated with NO2 (1.04 [1.01-1.07]). Warm-season O-3 was not associated with an increase in either outcome. Concentration-response curves indicated no evidence of a threshold below which air pollutant concentrations are not harmful for cardiovascular health. Effect estimates for PM2.5 and NO2 remained elevated even when restricting analyses to participants exposed to pollutant concentrations lower than the EU limit values of 25 mu g/m(3) for PM2.5 and 40 mu g/m(3) for NO2.Interpretation Long-term air pollution exposure was associated with incidence of stroke and coronary heart disease, even at pollutant concentrations lower than current limit values. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd.