Macroeconomic changes and trends in dental care utilization in Estonia and Lithuania in 2004-2012: a repeated cross-sectional study.

BACKGROUND: The aim of this study was to assess trends and inequalities in dental care utilization in Estonia and Lithuania in relation to large-scale macroeconomic changes in 2004-2012. METHODS: Data on 22,784 individuals in the 20-64 age group were retrieved from nationally representative cross-sectional surveys in 2004, 2006, 2008, 2010 and 2012. Age- and sex-standardized prevalence estimates of past 12-month dental visits were calculated for each study year, stratified by gender, age group, ethnicity, educational level and economic activity. Multivariable logistic regression analysis was used to assess the independent effect of study year and socioeconomic status on dental visits. RESULTS: The age- and sex-standardized prevalence of dental visits in the past 12 months was 46-52% in Estonia and 61-67% in Lithuania. In 2004-2008, the prevalence of dental visits increased by 5.9 percentage points in both countries and fell in 2008-2010 by 3.8 percentage points in Estonia and 4.6 percentage points in Lithuania. In both countries the prevalence of dental care utilization had increased slightly by 2012, although the increase was statistically insignificant. Results from a logistic regression analysis showed that these differences between study years were not explained by differences in socioeconomic status or oral health conditions. Women, the main ethnic group (only in Estonia), and higher educated and employed persons had significantly higher odds of dental visits in both countries, but the odds were lower for 50-64 year olds in Lithuania. CONCLUSIONS: In European Union countries with lower national wealth, the use of dental services is sensitive to macroeconomic changes regardless of the extent of public coverage, at the same time, higher public coverage may not relate to lower inequalities in dental care use.

Mental disorders among Chernobyl cleanup workers from Estonia: A clinical assessment.

OBJECTIVE: To assess, at a clinical level, the mental health of former Chernobyl cleanup workers from Estonia by comparing them with same-age controls. METHOD: The Mini International Neuropsychiatric Interview (MINI) was administered during 2011-2012 to 99 cleanup workers and 100 population-based controls previously screened for mental health symptoms. RESULTS: Logistic regression analysis showed that cleanup workers had higher odds of current depressive disorder (odds ratio [OR] = 3.07, 95% confidence interval [CI: 1.34, 7.01]), alcohol dependence (OR = 3.47, 95% CI [1.29, 9.34]), and suicide ideation (OR = 3.44, 95% CI [1.28, 9.21]) than did controls. Except for suicide ideation, associations with Chernobyl exposure became statistically nonsignificant when adjusted for education and ethnicity. CONCLUSION: A quarter of a century after the Chernobyl accident, Estonian cleanup workers were still at increased risk of mental disorders, which was partly attributable to sociodemographic factors. (PsycINFO Database Record

Mammography use and mode of detection among breast cancer patients in Estonia.

The aim of this study was to examine past mammography use and mode of detection among breast cancer (BC) patients in Estonia, a country that has low screening coverage and high BC mortality. Women newly diagnosed with primary BC in Estonia in 2008-2010 were interviewed. Determinants of past mammography use and the detection of BC by mammography were studied using multivariate logistic regression. Among 977 participants, almost half reported no mammograms prior to the detection of BC. Overall, 22% of the cases were detected by mammography (16% by screening mammography). Detection by mammography was strongly related to age, past mammography use, and obesity. Among cases detected by mammography, 10% were stage III/IV at diagnosis (32% among cases detected by other modes). This study showed low mammography utilization and high rate of self-detection of BC in Estonia. Increased detection by mammography would help diagnose the disease at an earlier stage and consequently avoid premature BC deaths. Efforts should be undertaken to increase participation in screening and improve the availability of mammography among older and high-risk women. The results are likely to be relevant for other countries and population groups with low screening coverage.

Chernobyl cleanup workers from Estonia: cohort description and related epidemiological research.

The Estonian study of Chernobyl cleanup workers was one of the first investigations to evaluate the possible health consequences of working in the Chernobyl area (the 30 km exclusion zone and/or adjacent territories) after the 1986 reactor accident. The cohort consists of 4831 men who were dispatched in 1986-1991 for tasks involving decontamination, construction of buildings, transport, radiation measurement, guard duty or other activities. By 31 December 2012, the follow-up of the cohort yielded 102 158 person-years of observation. Exposure and health data were collected by postal questionnaires, biodosimetry evaluations, thyroid screenings, and record-linkages with cancer, causes of death and health insurance reimbursement registers and databases. These data cover socio-demographic factors, employment history, aspects of health behaviour, medical history, work and living conditions in the Chernobyl area, biomarkers of exposure, cancer and non-cancer disease occurrence and causes of death. Cancer incidence data were obtained for 1986-2008, mortality data for 1986-2011 and non-cancer morbidity data for 2004-2012. Although the cohort is relatively small, it has been extensively examined and benefited from comprehensive nationwide population and health registers. The major finding was an increased risk of suicide. Thyroid examinations did not reveal an association with thyroid nodular disease and radiation dose, but did indicate the importance of accounting for screening when making comparisons with unscreened populations. No risk of leukaemia was observed and risks higher than 2.5-fold could be excluded with 95% confidence. Biodosimetry included GPA analyses and chromosomal translocation analyses and indicated that the Estonian cleanup workers experienced a relatively low mean exposure of the order of 0.1 Gy. One value of the Estonian study is in the methodologic processes brought to bear in addressing possible health effects from the Chernobyl accident. Twenty-five years of research are summarised and opportunities for the future listed.

Mental health and alcohol problems among Estonian cleanup workers 24 years after the Chernobyl accident.

PURPOSE: To study the long-term mental health consequences of the 1986 Chernobyl nuclear accident among cleanup workers from Estonia. METHODS: In 2010, 614 Estonian Chernobyl cleanup workers and 706 geographically and age-matched population-based controls completed a mail survey that included self-rated health, the Posttraumatic Stress Disorder Checklist (PCL), alcohol symptoms (AUDIT), and scales measuring depressive, anxiety, agoraphobia, fatigue, insomnia, and somatization symptoms. Respondents were dichotomized into high (top quartile) and low symptom groups on each measure. RESULTS: Logistic regression analysis detected significant differences between cleanup workers and controls on all measures even after adjustment for ethnicity, education, marital status, and employment status. The strongest difference was found for somatization, with cleanup workers being three times more likely than controls to score in the top quartile (OR = 3.28, 95% CI 2.39-4.52), whereas for alcohol problems the difference was half as large (OR = 1.52, 95% CI 1.16-1.99). Among cleanup workers, arrival at Chernobyl in 1986 (vs. later) was associated with sleep problems, somatization, and symptoms of agoraphobia. CONCLUSION: The toll of cleanup work was evident 24 years after the Chernobyl accident among Estonian cleanup workers indicating the need for focused mental health interventions.

The recent economic recession and self-rated health in Estonia, Lithuania and Finland: a comparative cross-sectional study in 2004-2010.

BACKGROUND: The late-2000s financial crisis had a severe impact on the national economies on a global scale. In Europe, the Baltic countries were among those most affected with more than a 20% decrease in per capita gross domestic product in 2008-2009. In this study, we explored the effects of economic recession on self-rated health in Estonia and Lithuania using Finland, a neighbouring Nordic welfare state, as a point of reference. METHODS: Nationally representative cross-sectional data for Estonia (n=10 966), Lithuania (n=7249) and Finland (n=11 602) for 2004-2010 were analysed for changes in age-standardised prevalence rates of less-than-good self-rated health and changes in health inequalities using logistic regression analysis. RESULTS: The prevalence of less-than-good self-rated health increased slightly (albeit not statistically significantly) in all countries during 2008-2010. This was in sharp contrast to the statistically significant decline in the prevalence of less-than-good health in 2004-2008 in Estonia and Lithuania. Health disparities were larger in Estonia and Lithuania when compared to Finland, but decreased in 2008-2010 (in men only). In Finland, both the prevalence of less-than-good health and health disparities remained fairly stable throughout the period. CONCLUSIONS: Despite the rapid economic downturn, the short-term health effects in Estonia and Lithuania did not differ from those in Finland, although the recession years marked the end of the previous positive trend in self-rated health. The reduction in health disparities during the recession indicates that different socioeconomic groups were affected disproportionately; however, the reasons for this require further research.

Educational differences in cigarette smoking among adult population in Estonia, 1990-2010: does the trend fit the model of tobacco epidemic?

BACKGROUND: In developed countries, smoking spreads through society like an epidemic in which adults from higher socioeconomic groups are the first to adopt and earlier to quit smoking, and in which exists a lag in adoption of smoking between men and women. The objective of this study was to describe trends in daily and occasional smoking, to investigate association between smoking status and education, and to examine if the associations in 1990-2010 in Estonia fit the pattern predicted by the model of tobacco epidemic. METHODS: The study was based on a 20-64-year-old subsample (n = 18740) of nationally representative postal cross-sectional surveys conducted every second year in Estonia during 1990-2010. Cigarette smoking and education were examined. χ2 test for trend was used to determine daily and occasional smoking trends over study years. Multinomial logistic regression model was used to test educational differences in daily and occasional smoking for every study year. Adjusted relative risk ratios (RRRs) with 95% confidence intervals were calculated. RESULTS: In 1990-2010, daily smoking varied largely between genders showing decreasing trend among men, but not among women. In 2010, one third of men and one fifth of women were daily smokers. Daily smoking was not clearly associated with education among men in 1990-1994 and among women in 1990-2000. Men revealed inverse relationship between daily smoking and education since 1996, but women since 2002. In 2010, compared to men and women with higher education, relative risk ratio of daily smoking was 2.92 (95% CI = 2.01-4.25) among men and 2.29 (95% CI = 1.65-3.17) among women with secondary education, but 4.98 (95% CI 3.12-7.94) among men and 6.62 (95% CI = 4.07-10.76) among women with basic education.In 1990-2010, occasional smoking was stable and similar (varying between 7-10%) among men and women, no association with education was found. CONCLUSIONS: Daily smoking patterns in Estonia fit the model of tobacco epidemic in developed countries. Educational differences in daily smoking highlight the importance of addressing smoking behaviour in the general population by educational subgroups in Estonia.

Identifying women at risk for delayed presentation of breast cancer: a cross-sectional study in Estonia.

BACKGROUND: Survival from breast cancer remains lower in Estonia than in most other European countries. More advanced stage and larger tumors that have impact on survival may be a result of delay in seeking help for breast cancer symptoms. The aim of this study was to identify determinants of delayed presentation among breast cancer patients in Estonia. METHODS: The study population included women with primary breast cancer diagnosed in Estonia in 2008-2010. All data were collected using structured personal interviews carried out by trained nurses in the hospital setting. Only patients with self-discovered symptoms were included in this analysis. Patient delay was measured as time elapsing from symptom self-discovery to first medical consultation. The effect of different factors on the likelihood of prolonged delay (>90 days) was evaluated using logistic regression. RESULTS: Among 703 eligible patients, median patient delay was 16 days (interquartile range 5-54 days). Seventeen percent of the patients had their first medical consultation more than three months after self-detection of symptoms. In multivariate analysis, the risk of prolonged delay was significantly associated with age 65 years and over (OR 2.27, 95% CI 1.23-4.20), current smoking (OR 2.09, 95% CI 1.21-3.61), symptoms other than painless breast lump or breast pain (OR 1.84, 95% CI 1.08-3.16), no history of mammograms (OR 1.83, 95% CI 1.13-2.95), having received no information on breast cancer during past year (OR 1.77, 95% CI 1.05-2.99), and previous benign breast problems (OR 1.65, 95% CI 1.01-2.67). Non-significant risk increase was seen with lower education. CONCLUSIONS: This study provides evidence that factors associated with delayed presentation of breast cancer in Eastern Europe are similar to those observed in Western countries. The results suggest that educational messages to general population should aim at increasing awareness of "non-lump" symptoms of breast cancer and encouraging women of all ages to present in a timely manner. Women at risk for delayed presentation such as smokers and women with no history of mammograms could be identified in the primary care setting.

Chernobyl cleanup workers from Estonia: follow-up for cancer incidence and mortality.

This study examined cancer incidence (1986-2008) and mortality (1986-2011) among the Estonian Chernobyl cleanup workers in comparison with the Estonian male population. The cohort of 4810 men was followed through nationwide population, mortality and cancer registries. Cancer and death risks were measured by standardised incidence ratio (SIR) and standardised mortality ratio (SMR), respectively. Poisson regression was used to analyse the effects of year of arrival, duration of stay and time since return on cancer and death risks. The SIR for all cancers was 1.06 with 95% confidence interval 0.93-1.20 (232 cases). Elevated risks were found for cancers of the pharynx, the oesophagus and the joint category of alcohol-related sites. No clear evidence of an increased risk of thyroid cancer, leukaemia or radiation-related cancer sites combined was apparent. The SMR for all causes of death was 1.02 with 95% confidence interval 0.96-1.08 (1018 deaths). Excess mortality was observed for mouth and pharynx cancer, alcohol-related cancer sites together and suicide. Duration of stay rather than year of arrival was associated with increased mortality. Twenty-six years of follow-up of this cohort indicates no definite health effects attributable to radiation, but the elevated suicide risk has persisted.

Risk of thyroid cancer among chernobyl liquidators.

After the Chernobyl accident in 1986, the "liquidators" or clean-up workers were among those who received the highest radiation doses to the thyroid from external radiation. Some were also exposed to radioiodines through inhalation or ingestion. A collaborative case-control study nested within cohorts of Belarusian, Russian and Baltic liquidators was conducted to evaluate the radiation-induced risk of thyroid cancer. The study included 107 cases and 423 controls. Individual doses to the thyroid from external radiation and from iodine-131 ((131)I) were estimated for each subject. Most subjects received low doses (median 69 mGy). A statistically significant dose-response relationship was found with total thyroid dose. The Excess Relative Risk (ERR) per 100 mGy was 0.38 [95% confidence interval (CI): 0.10, 1.09]. The risk estimates were similar when doses from (131)I and external radiation were considered separately, although for external radiation the ERR was not statistically significantly elevated. The ERR was similar for micro carcinomas and larger size tumors, and for tumors with and without lymph node involvement. Although recall bias and uncertainties in doses could have affected the magnitude of the risk estimates, the findings of this study contribute to a better characterization the risk of thyroid cancer after radiation exposure in adulthood.

Place of residence predicts breast cancer stage at diagnosis in Estonia.

BACKGROUND: Stage at diagnosis is one of the most important predictors of breast cancer survival. The objective of this population-based study was to examine the impact of age, period of diagnosis and place of residence on breast cancer stage at diagnosis in Estonia. METHODS: Female breast cancer cases reported to the Estonian Cancer Registry in 1995-2006 with a known extent of disease were included. Logistic regression was used to estimate the risk of advanced stage (non-localized) disease. RESULTS: Overall, 56% of the 6936 women included in the analysis were diagnosed at advanced stage. The risk of advanced disease at diagnosis decreased over the study period in all age groups, but the change was much larger among women aged 50-69 years than among women in younger and older age groups. Multivariate analysis indicated that the strongest predictor of advanced stage disease was the place of residence. Compared with Tallinn (the capital of Estonia), living in Tartu (a small town with a university hospital) was associated with a significant 36% reduction in risk while the odds ratio associated with living in a marginal industrial county (Ida-Viru) was 1.52 (95% confidence interval 1.29-1.79). CONCLUSIONS: The observed regional variations are most likely due to differences in education, unemployment and health care access. Younger and elderly women, those living in remote areas and of lower socio-economic status should be addressed with specific measures to promote earlier detection of breast cancer, particularly in view of current economic difficulties and a sharply rising unemployment rate.

Alcohol consumption in Estonia and Finland: Finbalt survey 1994-2006.

BACKGROUND: Alcohol consumption has been regarded as an important contributor to the high premature mortality rates. The objective of this paper was to provide an overview and comparison of alcohol consumption and its socio-demographic determinants among adults in Estonia and Finland. METHODS: The study was based on a 25-64-year-old subsample of nationally representative postal cross-sectional surveys conducted in Estonia (n = 10,340) and Finland (n = 19,672) during 1994-2006. Abstinence, frequency, and the amount of alcohol consumed were examined. Logistic regression models were used to test the socio-demographic differences in alcohol consumption at least once a week. The effect of socio-demographic factors on pure alcohol consumed per week was calculated using linear regression. RESULTS: The proportion of abstainers was 1.5 times higher among women than men in both countries. Throughout the study period, the amount of alcohol consumed per week increased for both genders in Estonia and for women in Finland, but was stable for men in Finland. In the final study year, medium risk amount of alcohol consumed per week was nearly 1.5 times higher among men in Estonia than in Finland, but about half that among women in Estonia than in Finland. Compared to ethnic majority in Estonia, alcohol consumption at least once a week was lower among men, but amount of pure alcohol drunk per week was higher among women of ethnic minority. In Finland, alcohol consumption at least once a week was more prevalent among women of ethnic minority, but the amount of pure alcohol drunk per week was lower for both gender groups of ethnic minority. Compared to married/cohabiting respondents, alcohol consumption at least once a week was less pronounced among single respondents in Finland, divorced or separated women in both countries, and widowed respondents in Estonia. Greater amount of alcohol consumed per week was more prevalent among single and divorced or separated respondents in Finland, but only among divorced or separated men in Estonia. Frequency of alcohol consumption was lower among less educated than higher educated respondents in Finland, but not in Estonia. The amount of consumed alcohol per week was higher among less educated men in Estonia, but lower among women with basic education in Finland. CONCLUSIONS: Alcohol consumption has increased in Estonia and Finland. National alcohol policies should reflect findings of alcohol epidemiology in order to introduce measures that will reduce alcohol related harm in the population effectively.

BRCA1 mutations in women with familial or early-onset breast cancer and BRCA2 mutations in familial cancer in Estonia.

BACKGROUND: The aim of this study was to identify BRCA1 and BRCA2 mutations in the Estonian population. We analyzed genetic data and questionnaire from 64 early-onset (< 45 y) breast cancer patients, 47 familial cases (patients with breast or ovarian cancer and a case of these cancers in the family), and 33 predictive cases (patients without breast or ovarian cancer, with a family history of such diseases) from Estonia for mutations in the BRCA1 gene. A sub-set of familial cases and predictive cases were also analyzed for mutations in the BRCA2 gene. METHODS: For mutation detection, we used the Polymerase Chain Reaction-Single Stranded Conformation Polymorphism Heteroduplex Analysis (PCR-SSCP-HD), followed by direct DNA sequencing. RESULTS: We identified three clinically important mutations in the BRCA1 gene, including seven occurrences of the c.5382insC mutation, three of c.4154delA, and one instance of c.3881_3882delGA. We also detected six polymorphisms: c.2430T>C, c.3232A>G, c.4158A>G, c.4427T>C, c.4956A>G, and c.5002T>C. Four sequence alterations were detected in introns: c.560+64delT, c.560+ [36-38delCTT, 52-63del12], c.666-58delT, and c.5396+60insGTATTCCACTCC. In the BRCA2 gene, two clinically important mutations were found: c.9610C>T and c.6631delTTAAATG. Additionally, two alterations (c.7049G>T and c.7069+80delTTAG) with unknown clinical significance were detected. CONCLUSIONS: In our dataset, the overall frequency of clinically important BRCA1 mutations in early-onset patients, familial cases, and predictive testing was 7.6% (144 cases, 11 mutation carriers). Pathogenic mutations were identified in 4 of the 64 early-onset breast cancer cases (6.3%). In familial cases, clinically important mutations in the BRCA1 gene were found in 6 of the 47 individuals analyzed (12.8%). In predictive cases, 1 clinically important mutation was detected in 33 individuals studied (3%). The occurrence of clinically important mutations in BRCA2 in familial cases of breast cancer was 2 of the 16 individuals analyzed (12.5%).

Changes over fourteen years in adult obesity in Estonia: socioeconomic status and use of outpatient health services.

It has been noted that great socioeconomic and lifestyle changes have triggered an epidemic of obesity among Eastern Europeans. The objective of this study was to assess the change of adult obesity in Estonia by socioeconomic status and the use of outpatient healthcare services among obese individuals over time. It can be maintained that obesity distribution in Estonia in 1990-2004 developed similarly to an average Western country and, regardless of an increasing level of male obesity, obesity prevalence for 16-64 year-olds was on the average level in Europe in 2004 - 14.0% for men and 14.9% for women. Change in obesity prevalence correlates quite well with changes in the economy in Estonia. From studied socioeconomic variables only age and education (among women) strongly affect the change in obesity level. Obese individuals used outpatient medical care slightly differently compared to individuals with a normal BMI.

Oral contraceptive use and BRCA penetrance: a case-only study.

BACKGROUND: Women with deleterious mutations in BRCA genes are at increased risk of breast cancer. However, the penetrance of the genetic trait may be regulated through environmental factors. This multinational case-only study tested the interaction between oral contraceptive use and genetic susceptibility in the occurrence of breast cancer. METHODS: We recruited 3,123 patients diagnosed with breast cancer before the age of 45 years. Participants were classified according to their probability of carrying a BRCA mutation on the basis of their family history of breast and ovarian cancer. According to a case-only approach, the frequency of relevant exposures among breast cancer cases with high probability of BRCA mutation ("genetic cases") was compared with the frequency of the same exposures among breast cancer cases with a low probability of BRCA mutation ("sporadic cases"). The interaction odds ratios (OR) and 95% confidence intervals (CI) for oral contraceptive use were estimated by unconditional logistic regression, after controlling for potentially confounding variables. RESULTS: The analysis was carried out comparing 382 "genetic" and 1,333 "sporadic" cases. We found a borderline significant interaction between genetic breast cancer and oral contraceptive use for ever users compared with never users (OR, 1.3; 95% CI, 1.0-1.7). The greatest interaction OR was found for women who started using pill at 18 to 20 years (OR, 1.6; 95% CI, 1.1-2.3). CONCLUSION: These results suggest that BRCA mutation carriers, as well as women with a significant family history of breast and ovarian cancer are more vulnerable to exogenous hormones in oral contraceptives.

Risk of hematological malignancies among Chernobyl liquidators.

A case-control study of hematological malignancies was conducted among Chernobyl liquidators (accident recovery workers) from Belarus, Russia and Baltic countries to assess the effect of low- to medium-dose protracted radiation exposures on the relative risk of these diseases. The study was nested within cohorts of liquidators who had worked around the Chernobyl plant in 1986-1987. A total of 117 cases [69 leukemia, 34 non-Hodgkin lymphoma (NHL) and 14 other malignancies of lymphoid and hematopoietic tissue] and 481 matched controls were included in the study. Individual dose to the bone marrow and uncertainties were estimated for each subject. The main analyses were restricted to 70 cases (40 leukemia, 20 NHL and 10 other) and their 287 matched controls with reliable information on work in the Chernobyl area. Most subjects received very low doses (median 13 mGy). For all diagnoses combined, a significantly elevated OR was seen at doses of 200 mGy and above. The excess relative risk (ERR) per 100 mGy was 0.60 [90% confidence interval (CI) -0.02, 2.35]. The corresponding estimate for leukemia excluding chronic lymphoid leukemia (CLL) was 0.50 (90% CI -0.38, 5.7). It is slightly higher than but statistically compatible with those estimated from A-bomb survivors and recent low-dose-rate studies. Although sensitivity analyses showed generally similar results, we cannot rule out the possibility that biases and uncertainties could have led to over- or underestimation of the risk in this study.

The sociodemographic patterning of drinking and binge drinking in Estonia, Latvia, Lithuania and Finland, 1994-2002.

BACKGROUND: Despite the relatively low recorded alcohol consumption level, the Baltic countries (Estonia, Latvia and Lithuania) and neighbouring Finland suffer from similar harmful consequences related to the use of alcoholic beverages, including socio-economic inequalities in alcohol related mortality. Comparative evidence is needed to understand harmful drinking patterns and to implement preventive alcohol policies also in the Baltic countries. This study compared heavy and binge drinking by sex, age, education, urbanisation and marital status in the Baltic countries and Finland. The data were nationally representative postal surveys conducted in Estonia (n = 6271), Latvia (n = 6106), Lithuania (n = 7966) and Finland (n = 15764) during 1994-2002. The criterion for heavy drinking was at least 15 portions weekly among men, and at least five among women, and for binge drinking at least six portions per one occasion. Heavy drinking was more common among younger participants in all countries, and in Latvia among the less-educated. Among Finnish men, and among women from all countries except Latvia, the better-educated were more often heavy drinkers. In Latvia and Finland, urban men, and in all countries, urban women, were more often heavy drinkers. Heavy drinking was more common among non-married Lithuanian and Finnish men, and Finnish women. Binge drinking was more common among less-educated Estonian and Latvian men, and among younger and less-educated women in all countries. Our results support the continued power of traditional drinking habits in the North Eastern part of Europe. In the future the target groups for prevention of excessive drinking should also include young and less-educated women in all four countries studied.

Social determinants of ever initiating smoking differ from those of quitting: a cross-sectional study in Estonia.

BACKGROUND: To study the association of socioeconomic and demographic indicators with ever initiating regular smoking and quitting smoking among ever regular smokers in Estonia in order to identify target groups for equity-oriented tobacco control policies. METHODS: Data for 4277 individuals in the 25-64 age group come from three cross-sectional studies conducted in 2000, 2002 and 2004. Age-standardized prevalence rates and odds ratios with 95% confidence intervals were calculated. RESULTS: High rates of ever initiation were observed for lower educated men and women after controlling for other socioeconomic indicators. This association was not observed for women above age 50. Independent, although weaker associations were found among men who were unemployed or with a low occupational status. Low cessation rates were observed among men who were unemployed, who had a lower occupational position or who had a low income. These associations remained after controlling for other socioeconomic variables. The effect of income became stronger in the older age groups among men. Rates of ever initiation and cessation also varied strongly in relationship to some demographic variables. The highest initiation rates were found among divorced women and among women living in the capital city. The lowest cessation rates were found among divorced women, and among Russian men. CONCLUSIONS: While educational level was the strongest predictor of ever initiating regular smoking, smoking cessation was related more directly to aspects of social disadvantage originating in adult life. To be effective, tobacco control interventions should not only target lower educated, but also those in material disadvantage.

Use of mammography and Pap smear in Estonia, a country without organized cancer screening.

OBJECTIVES: To analyze mammography and Pap smear status in Estonia where no organized population-based cancer screening is available. METHODS: 5000 individuals (aged 16-64) were randomly chosen from the national population register; among them, 1755 women filled out postal questionnaires. RESULTS: 50% of respondents aged 45-64 reported having taken a mammogram, 51% of women aged 25-64 had the Pap smear at least once in their lifetime. Corresponding figures for the past two years were 37% and 30%. Irrespective of age, women taking fewer tests over the past two years were rural workers, unemployed, and health behavior recommendations ignorers. In most cases, initiative for mammogram came from women, and from the physician in the case of Pap smear. Moderate increase in mammography use occurred after a project for early detection of breast cancer was launched. CONCLUSION: Women must continuously be informed that early detection of breast and cervical cancer is possible. Young women should be encouraged to ask for Pap testing. Knowledge of family physicians should be improved.

Suicide risk among Chernobyl cleanup workers in Estonia still increased: an updated cohort study.

PURPOSE: The aim of the study is to examine the mortality experience among Chernobyl cleanup workers. METHODS: A cohort study of 4786 men from Estonia who participated in the Chernobyl cleanup from 1986 to 1991 and were traced until December 31, 2002. Standardized mortality ratio (SMR) and adjusted mortality rate ratio (RR) derived through Poisson regression analysis were calculated. RESULTS: During follow-up, 550 deaths occurred, yielding an SMR of 1.01 (95% confidence interval [CI], 0.92-1.09). Increased risks were observed for suicide alone (SMR, 1.32; 95% CI, 1.03-1.67) and suicide combined with undetermined injury (SMR, 1.29; 95% CI, 1.03-1.60). One leukemia death occurred, and no thyroid cancer deaths were found. Elevated mortality also was observed for brain cancer (SMR, 2.78; 95% CI, 1.02-6.05). The adjusted RR for suicide remained stable over the time passed since return from the Chernobyl area, showing RRs of 1.09 (95% CI, 0.56-2.10) for 5 to 9 years and 1.00 (95% CI, 0.48-2.05) for 10 or more years compared with less than 5 years. CONCLUSIONS: During the 17 years after the accident, suicide risk in the cohort was greater than in the general male population. No elevated risk in overall mortality and radiation-related cancers was observed. The long-term nature of this elevated risk provides concrete evidence that psychological consequences represent the largest public health problem caused by the accident to date.