Policy Document

Noncommunicable Diseases BACKGROUND

The Australian Medical Students' Association (AMSA) is the peak representative body of Australia's medical students. AMSA believes that all communities have the right to the highest attainable level of health. Accordingly, AMSA advocates on issues that affect local, national and global health outcomes, including noncommunicable diseases (NCDs). NCDs are a group of diseases that are characteristically chronic in duration, progressive, and are due to a combination of genetic, environmental and behavioural factors [1]. The World Health Organization (WHO) has identified four main NCDs: cardiovascular diseases (CVDs), cancers, chronic respiratory diseases and diabetes mellitus [1]. NCDs are the leading cause of global mortality, killing 40 million people each year (70% of global mortality) [1]. In Australia, NCDs contribute to 91% of total deaths [2]. Of the four main NCDs, CVD is the biggest killer globally and in Australia, causing 17.7 million deaths each year, followed by cancers which cause 8.8 million, respiratory diseases which are responsible for 3.9 million, and diabetes which kills 1.6 million people annually [2,3]. NCDs disproportionately affect low- and middle-income countries (LMICs), with three-quarters of NCD-related deaths occurring in LMICs. Forty-eight percent of these deaths occur before age of 70 [4]. In Australia, the prevalence of NCDs is higher in Indigenous Australians than non-Indigenous Australians [5], which contributes to the significant health inequity that exists between these two groups. For example, the mortality rate from diabetes in 2016 among Indigenous Australians is five times higher than that of non-Indigenous Australians [6]. An Indigenous child born in 2010-2012 is expected to live approximately ten years less than a non-Indigenous child born in the same year [7]. Socioeconomic status is also significantly related to NCD burden, with those with lower socioeconomic status being most affected [4]. Specifically, lower socioeconomic status has been associated with higher rates of hypertension, hypercholesterolaemia, excessive alcohol consumption, physical inactivity, stroke and obesity [8,9]. It is clear that those in lower socioeconomic groups and Indigenous Australians are disproportionately burdened by NCDs, and thus a particular targeted focus on these at risk groups is required to ensure that healthcare is equitably distributed for all Australians. There are common modifiable risk factors that contribute to the development of the four main NCDs, making them important targets for both prevention and treatment-focused lifestyle interventions. These risk factors include tobacco use, alcohol consumption, poor quality diet and physical inactivity [10]. In addition, AMSA recognises poor mental health as having a significant bidirectional relationship with the other physical NCDs [11]. Given that these risk factors are largely modifiable, AMSA recognises the important role of preventative medicine in the field of NCDs, a principle which informs AMSA’s position on these issues. Tobacco The use of tobacco in Australia and worldwide remains a significant cause of morbidity and early mortality, with one in ten deaths attributed to tobacco use globally [12]. The 2013 WHO report on the Global Tobacco Epidemic [13], set a target to reduce global tobacco use by 30% by 2025, which is on track according to the 2017 report [14]. It is particularly noteworthy that smoking prevalence rates are declining in middle-income countries, which house the largest number of smokers, with overall rates down from 23.2% in 2007 to 20.8% in 2015 [14]. This can largely be attributed to strategies which control the usage of tobacco, such as comprehensive surveillance of tobacco use, promotion of smoke-free environments, availability of cessation programs, packaging regulations, mass media campaigns, advertising bans, and taxation on tobacco products [13]. Australia has been particularly proactive in both prevention and cessation of tobacco use, with interventions existing in the majority of these domains, as is outlined in the National Tobacco Strategy 2012-2018 [15]. Given that these

measures have been widely successful in preventing the initiation of smoking, the continuation of these campaigns and taxation measures, along with further expansion into mass media is logical [13,15]. The issues posed by tobacco use have been recently compounded by the increasing popularity of electronic cigarettes or ‘e-cigarettes’ within Australia [16]. Nicotine e-cigarettes are banned in Australia[16], and although the existing non-nicotine e-cigarettes are less harmful than conventional cigarettes, evidence on the short and long-term health implications of the active and passive usage remains inconclusive [17]. Additionally, no e-cigarette product is endorsed by the Therapeutic Goods Administration as an aid for smoking cessation, however e-cigarettes that do not contain nicotine can be sold in retail stores so long as no ‘therapeutic’ claims are made about their benefits[17,18]. There is no compelling evidence that e-cigarettes are effective aids for smoking cessation, and the evidence is currently inconclusive as to whether there is the potential for their use to normalise smoking behaviour [19-21]. This is a particular concern for adolescents and young adults, as e-cigarette companies use marketing strategies to target this younger age group in an attempt to capture an audience which otherwise has a low smoking prevalence [18,22]. In addition, tobacco companies have a vested commercial interest in continuing to promote smoking behaviour due to their dual ownership of major traditional and electronic cigarette brands, which may complicate the policy process [19]. Alcohol Alcohol consumption, in particular chronic harmful alcohol consumption, contributes substantially to the burden of NCDs, contributing to 3.3 million deaths worldwide every year [23]. Australian guidelines recommend that adults drink no more than two standard drinks (2 x 10g of alcohol) on any day to reduce the risk of alcohol-related harm over a lifetime [24]. Despite this fact, harmful alcohol consumption continues to be a central component of social gatherings worldwide, including in Australia [25]. Marketing and advertising of alcohol in particular are known to increase immediate alcohol purchase and consumption in students over 18 [26,27]; and in addition, exposure to alcohol advertising during sporting events causes viewers’ attitudes to alcohol to become more positive [28]. Moves towards an industry-independent regulatory system have begun in Australia over the last 4 years through the Alcohol Advertising Review Board (AARB), with more consumer complaints and removed advertisements than previously [29,30]. Further, deliberate education associating excessive long-term alcohol consumption with harm can reduce consumption[31]. Refer to AMSA’s ‘Alcohol Misuse and Harms’ policy. Prescription and Recreational Drugs Prescription drug abuse is a rising problem in Australia [32], being one of the most frequent contributors to overdose deaths across many states in recent years [33]. Indeed, 4.8% of Australian adults in 2013 had used pharmaceutical drugs for non-medical purposes in the preceding 12 months, rising from 3.8% in 2004, according to the National Drug Strategy Household Survey [33]. The type of drugs abused can change over time, and primarily depends on two main factors: legislative action by governments such as schedule changes, and pharmaceutical company marketing of drug products. For instance, the Australia-wide rescheduling of alprazolam (Xanax) from a schedule 4 to schedule 8 drug in 2014 produced a 35% reduction in prescription dispensation in the first 12 months [33]. More importantly, monthly calls to the Poisons Information Centre involving alprazolam were halved in this 12 month period [34]. The usage of recreational drugs has also increased in Australia in recent years, particularly in those aged in their 40s and 50s [35]. Currently, the 4 most commonly used recreational drugs in Australia are cannabis, cocaine, ecstasy and amphetamines [35]. According to the Australian Institute of Health and Welfare, in 2016, 16% of Australians aged 14 or older had used an illicit drug in the last 12 months [35]. In 2016, the use of such drugs was highest among 20–29 year olds (28%), however the use of any illicit drug has increased most significantly among the 40-49 and 50-59 year old age groups (from 12% to 16% and 6.7% to 12% respectively) between 2001 and 2016 [36,37]. Frequent or regular use of some prescription and recreational drugs can result in drug addiction and abuse, which affects around 1 in 20 Australians, and has a range of

consequences depending on the drug [38]. In the context of NCDs, it is well recognised that drug abuse is associated with mental illness, in some cases in a causative way, while at other times it can simply exacerbate pre-existing mental health conditions [39]. One serious mental health consequence of illicit drug abuse is increased suicide risk in youth, with heavy use of cannabis in particular, being associated with an increased risk of suicide in the younger age groups (14-15 year olds) [39]. Drugs also have systemic effects, and in the long term, their abuse can contribute to the development of NCDs such as cardiovascular disease [40]. Strategic principles for encouraging the safe use and curbing abuse of recreational drugs vary depending on the drug in question. Currently, state health departments fund drug services, which support prevention, harm minimisation and treatment approaches to drug abuse. They are available to those affected by both prescription and recreational drug dependencies [41]. Moreover, the National Drug Strategy identifies formal events and campaigns which educate about the use and abuse of prescription and recreational drugs as integral components of the demand reduction response to this issue [42]. Obesogenic Environments Obesity is identified by the Australian Burden of Disease Study as a risk factor for 22 diseases including NCDs such as diabetes, several cancers, and CVDs [43]. Indeed, it was found to underlie 53% of the diabetes disease burden, and 7% of the total Australian health burden [43]. The obesogenicity of an environment refers to the impact that it has on promoting obesity development in the individuals and communities within it [44]. Two large components of obesogenicity include access to adequate nutrition, and the relationship between available infrastructure and physical activity. As such, knowledge of these environmental factors informs the response to obesity at the urban planning level [44]. Nutrition A poor quality diet is one of the key modifiable risk factors for NCDs identified by the WHO [45]. The disease burden of poor nutrition is considerable, with it contributing to CVDs including coronary heart disease (CHD), type II diabetes, and such cancers as lung and bowel [46]. Indeed, poor quality diets also accounted for 18.8% of the global deaths in 2016 [47]. The Australian Dietary Guidelines developed by the National Health and Medical Research Council [48] characterise a nutritious diet as consisting of limited consumption of saturated fat, added sugars, salt, and alcohol, and also identifies trans-fatty acids as to be avoided. It also comprises daily consumption of vegetables; fruits; grains; lean meats, poultry, fish, eggs, nuts, seeds and legumes; and dairy products. Despite this, non-nutritious diets remain an issue for the Australian population with, for example, over half exceeding the WHO recommendation regarding sugar-derived energy intake [49]. As such, efforts to promote adoption of the above dietary habits are key to the prevention of NCDs. One such measure is the introduction of a Sugar-Sweetened Beverage (SSB) Tax, as suggested by the WHO [50], given that SSBs lack nutritional value and contribute to weight gain [51], metabolic syndrome and type II diabetes [52]. SSB taxes may reduce the incidence of obesity [53], with evidence of reduced SSB purchases following implementation in Mexico [54], and Australian modelling suggesting consequent reductions in health-related expenditure [55]. In addition, SSB tax revenue may be earmarked to subsidise fresh fruit and vegetables to reduce the impact on low-income communities. Such subsidies have been effective in increasing fruit and vegetable consumption in low-income groups [56]. Refer to AMSA’s ‘Food and Nutrition’ policy for further detail. Additionally, there is evidence of the significant influence of junk food advertising, namely via television and the internet, which targets children [57,58]. Indeed, industry self-regulatory mechanisms have been ineffective in reducing the extent of such advertising on Australian television for example [59]. Thus prohibition of advertising such food products to children may be of population health benefit, with regulatory interventions being particularly effective [60], and such measures reducing fast food consumption in Quebec [61], and potentially reducing the prevalence of obesity according to US-based modelling [62]. Also, there have been efforts to extend the above principles regarding diet and nutrition promotion to healthcare settings, for example regarding the sale of SSBs via vending machines in hospitals, clinics and other health service locations. Indeed, an intervention to implement nutrition guidelines for vending machines at New Zealand hospitals proved effective in, for example, reducing the saturated fat and total sugar content of products by 41% and 30% respectively [63]. In the Australian context, NSW Health have developed the Healthy Food and Drink in NSW Health Facilities for

Staff and Visitors Framework, with 95% of SSBs removed from sale in the Murrumbidgee Local Health District in 2016/17 [64]. With regard to sodium intake, the chronic disease consequences of excessive intake include hypertension, each year responsible for 9.4 million deaths globally [65], stroke, and CVD [66]. As such, the adoption of the WHO-developed SHAKE policy initiative [65] to reduce individual salt intake in Australia to within safe limits, would aid in addressing the NCD burden [67]. This initiative includes industry food content reformulation, improvement of front-of-packet nutrition labelling systems, and educational health-awareness programs. In addition, saturated and trans fatty acid consumption increases the risk of a range of NCDs including CHD and type II diabetes [68]. Thus, the above SHAKE measures may also be extended to saturated and trans fatty acids. Furthermore, the Health Star Rating system, currently under review [69], is of limited efficacy in influencing consumer decision making according to product nutritional value [70] and thus may be strengthened by the addition of the above. Refer to AMSA’s ‘Food and Nutrition’ policy for further detail. In light of higher obesity rates, and greater prevalence of diet-related NCDs including CVD, and type II diabetes within Australia’s Indigenous population [71], the above measures are particularly significant. In particular, government-owned Outback Stores administers 36 community food stores across the Northern Territory, Western Australia, and South Australia for Indigenous communities in remote areas [72]. Health strategies implemented for these stores, which include reducing the sale of highly sugared products by 2020, identified in the 2018 Closing the Gap Report have resulted in reduced sugar consumption, and significant provision of fresh fruit and vegetables [72]. Physical activity Physical inactivity is defined as ‘failing to meet the guidelines for recommended physical activity set by WHO which are ‘150 to 300 minutes of moderate intensity physical activity or 75 to 150 minutes of vigorous intensity physical activity (or an equivalent combination) each week’ [73]. Importantly, physical inactivity has been identified as the fourth leading risk factor for mortality globally, causing approximately 3.2 million deaths worldwide [74], and 60% of Australian adults are physically inactive [74]. The impact of NCDs associated with physical inactivity on the Australian economy per year can be quantified as $13.8 billion AUD [75]. Interventions for increasing physical activity have included mandatory sport classes in schools, incentivising participating in social sports or joining a gym, and strategies to increase active transport [75]. Amongst these, active transport, such as walking, cycling and taking public transport [76], has been shown to increase physical activity in a way that is more cost-effective than structured exercise programs[77]. Australian active transport initiatives include the ‘Live Lighter’ campaign, which was run in 2012 in Western Australia and involved a mass media campaign demonstrating simple changes to increase physical activity and adopt a healthy diet [78]. The campaign messages reached the target audience (overweight adults were more likely to intend to exercise), however it was concluded that significant long-term success in increasing active transport requires larger infrastructural changes [78,79]. For example, in the Netherlands, 16% of the total road network is dedicated to cycle paths, which increases active transport, with 55% of women and 41% of men participating in more than the minimum recommended levels of physical activity [80].This suggests that urban planning, and infrastructure which encourage active transport and physical activity, are essential tools in addressing the obesogenic environment and its impacts. Mental Health and Social Isolation Mental illness is an important NCD that has to date not been considered with the four major NCDs identified above. This is in spite of mental illness being the leading contributor to the non-fatal disease burden in Australia [46]. There is a complex and bidirectional interplay between mental health and the physical NCDs, and thus it is important to prevent and address both [11]. For example, individuals with depression are predisposed to myocardial infarction, which reciprocally increases the likelihood of depression[44]. In addition, mental health disorders share common risk factors with the 4 main NCDs, such as physical inactivity and the harmful use of alcohol [45]. Like the physical NCDs, mental illness disproportionately affects disadvantaged and stigmatised groups [8]. Furthermore, the stigma associated with mental illness can act as a barrier to accessing treatment for these [81]. This, compounded with other barriers related to mental illness, can reduce healthcare engagement for treatment of NCDs, and so affected individuals may experience a greater disease burden [82].

Finally, social isolation is an important risk factor for mental and physical NCDs that is currently gaining momentum in research and literature [83]. A 2015 meta analysis associated social isolation with an average 29% increased mortality, placing it on par with established physical predictors of mortality [84]. Social relationships are thought to influence health through their provision of tangible resources to buffer stress, their association with shared healthy behaviours, and their link to self-esteem and a sense of meaning [85]. Improving a community’s connectedness is therefore an important means of tackling NCDs, as individuals with stronger social relationships in one study had a 50% increased likelihood of survival compared to those living alone [85].

POSITION STATEMENT

AMSA believes that:

1. NCDs pose a significant health threat globally and include mental ill health, which has particular relevance to the medical students who AMSA represents.

2. NCDs are not uniformly distributed among the Australian population, with higher representation among lower socioeconomic groups and Indigenous Australians.

3. Australia requires a comprehensive plan to address the increase in incidence of NCDs and associated risk factors, acknowledging that equitable access to primary, secondary and tertiary prevention and treatment is essential.

4. There is a need for a substantially greater focus on evidence-based preventative health care within Australia, at the individual, community and wider systems levels (e.g. addressing the issue of an obesogenic environment).

Policy recommendations

AMSA calls upon:

1. The Federal and State Governments to: a. Implement a comprehensive, evidence-based, long-term strategy to address

NCDs in Australia. i. Address the social determinants of NCDs to ensure health equity

within this strategy. ii. Recognise that NCDs are not uniformly distributed among the

Australian population, with higher representation among lower socioeconomic groups and Indigenous Australians. Health policy efforts and resourcing should be culturally-appropriate and aim to reduce this inequity.

iii. Recognise that this requires an approach that considers commercial, healthcare-related and public interests.

iv. Ensure that medical research regarding the prevention and equitable treatment of NCDs is made a funding priority, and includes research participants from a representative proportion of the population with respect to sex, ethnicity, age and other NCD risk factors.

v. Recognise and frame mental health illness as both a NCD and a risk factor for development of other NCDs.

b. With respect to tobacco control: i. Legislate and enforce smoke-free zones for all hospitals, schools and

government agencies. ii. Ensure that smoke-free zones are available in all public areas, for

example, public parks. iii. Continue to enforce packaging regulations and taxation for tobacco

products. iv. Fund tobacco addiction programmes and public awareness

campaigns to increase knowledge of these. v. Divest, and cease to accept political donations from the tobacco

industry. vi. Continue to fund research investigating the potential health

consequences of long term electronic cigarette use.

vii. Consider the validity of measures to restrict e-cigarette use, including

electronic cigarettes in laws that regulate smoke-free zones and consider legislating to restrict the advertising and promotion of electronic cigarettes, consistent with current tobacco advertising prohibitions

c. With respect to alcohol-related harms: i. Legislate against marketing of alcohol products that are targeted at

young adults. ii. Legislate against marketing of alcohol at sporting events. iii. Enforce the FSANZ Code regarding the displays of alcohol content on

all alcohol packaging. iv. Enforce responsible service of alcohol at all licensed venues. v. Continue to use public awareness campaigns to increase societal

knowledge of safe drinking behaviours and the risks of long-term alcohol abuse.

d. With respect to prescription and recreational drugs i. Consider legislative changes to the scheduling of prescription drugs

which are identified as posing a significant community abuse risk. ii. Implement and support public awareness campaigns to address the

growing issue of inappropriate usage of prescription drugs and its associated harms.

iii. Continue to fund treatment programs which help individuals control or cut down on their use of recreational drugs.

iv. Continue to support public awareness campaigns which address the issue of recreational drug use incidence amongst the age groups most affected.

e. With respect to obesogenic environments: i. Implement guidelines for the sale of food and drink in health care

centres, including hospitals, nationwide, such as an institution-appropriate adaptation of the Healthy Food and Drink in NSW Health Facilities for Staff and Visitors Framework.

ii. Implement a tax on Sugar-Sweetened Beverages (SSBs), with a commitment to regular reviews to assess effectiveness and potential negative impacts.

iii. Consider earmarking revenue from an SSB tax to subsidise the provision of fresh fruit and vegetables.

iv. Legislate against the targeted advertising of energy-dense, nutrient-poor food and beverages to children.

v. Adopt the WHO SHAKE policy recommendations with regard to salt intake.

vi. Extend, and make mandatory, the SHAKE recommendations for front-of-pack labelling to added sugars, saturated and trans fatty acids.

vii. Commit to the regular review and refinement of the Health Star Rating system following its current review period.

viii. Continue to support programs which provide equitable food access to communities in rural and remote areas, including Indigenous communities.

ix. Promote active transport through public health education and awareness campaigns.

x. Invest more heavily in infrastructure to increase access for commuters to safe walking paths and cycleways, as well as public transport.

xi. Ensure that urban planning prioritises access to and promotion of physical activity (e.g. adequate green open spaces).

f. With respect to mental health: i. Continue to implement national strategies and legislation which

addresses stigmatisation, discrimination and human rights violation in society.

ii. Promote, support and fund multifaceted, community-based interventions that provide opportunity to foster meaningful relationships and involve a broad range of people (e.g. ParkRuns and Men’s Shed).

2. International Non-Government Organisations to: a. Critically assess the response of all governments to NCD prevention,

publicise these assessments and make recommendation for future improvements.

b. Establish campaigns and programmes that address NCD prevention. c. Facilitate multi-sectoral cooperation for global action against NCDs. d. Encourage all countries to follow the ‘Global Action Plan for the Prevention

and Control of NCDs’ (2013-2020). 3. Medical students to:

a. Advocate for NCD prevention and risk factor reduction in patients. This should be appropriate to the student’s capacity and under the supervision of a qualified health professional.

b. Advocate for improved food environments for their fellow students by promoting the adoption of an institution-appropriate adaptation of the Healthy Food and Drink in NSW Health Facilities for Staff and Visitors Framework by their universities.

c. Reduce barriers to treatment, including stigma associated with NCD risk factors, by ensuring their conduct is professional and non-judgemental.

d. Promote mental health awareness amongst fellow students. e. Encourage and take on self-care strategies such as organising a personal

GP. f. Engage in the promotion of healthy eating and exercise habits, avoidance of

smoking and excessive consumption of alcohol and other drugs. 4. Health professionals and healthcare providers to:

a. Adopt nutrition guidelines regarding the sale of food and drink, such as an implementing an institution-appropriate adaptation of the Healthy Food and Drink in NSW Health Facilities for Staff and Visitors Framework, in all health care centres.

b. Reduce barriers to treatment, including stigma associated with NCD risk factors, by ensuring their conduct is professional and non-judgemental.

c. Actively engage with evidence-based strategies to screen, treat and prevent NCDs in their patients such as diabetic health screens.

d. Engage in the promotion of healthy eating and exercise habits, avoidance of smoking and excessive consumption of alcohol and other drugs.

e. Incorporate measures of social well-being into preventative health screenings. f. Promote social connectedness as a preventative medical intervention for

chronic diseases, through strategies such as engaging with ParkRun or Men’s Sheds.

g. Recommend and build disease-specific support networks for patients with chronic diseases.

h. Be aware of the risk of dependence and overdose with any drugs they prescribe, but particularly common/currently abused drugs of dependence.

5. Medical schools and societies, universities and educational institutions to: a. Incorporate increased preventative health care and the social determinants of

health into the medical curriculum, including with regard to NCD risk factors. b. Provide an environment that fosters both physical and psychological welfare,

for example, via the provision of counselling services, wellbeing and mindfulness programs, and GP location services.

c. Subsidise student access to physical activity such as memberships for gyms and university sporting programs.

d. Promote the importance of good quality nutrition and physical activity for general health and wellbeing.

e. Ensure campuses adhere to smoke free regulations. f. Reduce the emphasis placed on alcohol use in university and college-related

functions. g. Educate students on the increased risk of NCDs from long-term harmful

alcohol consumption. 6. Private Sector Companies to:

a. Ensure advertising adheres to government regulations and limit advertising of energy-dense foods to vulnerable demographics; in particular, cease the advertising of energy-dense food to children.

b. Ensure food packaging adheres to the relevant government standards and ensure clear display of nutritional and caloric information on food and beverage packaging.

c. Provide front-of-pack labelling of food and beverage item content in accordance with the SHAKE recommendations, with regard to salt, added sugars, sodium, saturated and trans fatty acids.

d. Increase adoption of the Health Star Rating System on the front of all food and beverage product packaging.

e. Engage in food and beverage product content reformulation in accordance

with government, NHMRC, or WHO standards with regard to added sugars, sodium, saturated and trans fatty acids.

f. Abide by the FSANZ Code regarding the displays of relevant health advice and messages on alcohol packaging and advertisements.

g. Ensure workplace design is conducive to primary prevention of NCDs, with the removal of SSBs and other easily accessible ‘occasional’ food, as a workplace-appropriate adaptation of the Healthy Food and Drink in NSW Health facilities for Staff and Visitors Framework.

h. Provide adequate facilities that enable active transport to and from workplaces, such as bike racks and showers.

i. Provide facilities for cooking and storage of pre-prepared lunches and meals. j. Ensure workplaces adhere to smoke free regulations. k. Reduce alcohol provision at workplace events.

REFERENCES

1. World Health Organisation. Noncommunicable diseases [Internet]. Geneva: World Health Organisation; 2017 June [cited 2018 Feb 15]. Available from: http://www.who.int/mediacentre/factsheets/fs355/en/

2. Hay S, Jayaraman S, Truelsen T, Sorensen R. Millear A, Guissani G et al. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study. Lancet [Internet]. 2016 [cited 2018 Feb 15];388:1545-602. Available from: http://discovery.ucl.ac.uk/1524102/1/1-s2.0-S0140673616316786-main.pdf

3. World Health Organization. Noncommunicable diseases country profiles 2014. 2014; Available from http://www.who.int/entity/nmh/countries/aus_en.pdf?ua=1

4. World Health Organization. Global Health Observatory (GHO) Data: NCD Mortality and Morbidity. 2014; Available from: http://www.who.int/gho/ncd/mortality_morbidity/en/.

5. Australian Indigenous HealthInfoNet. Overview of Australian Indigenous Health Status. 2013 [cited 2018 Feb 18]; Available from: http://www.healthinfonet.ecu.edu.au/health-facts/overviews

6. Australian Bureau of Statistics [Internet]. Canberra ACT: Australian Government; 2017. Deaths; 2017 Sep 27 [cited 2018 Feb 2]; [about 12 screens]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0~2016~Main%20Features~Australia's%20leading%20causes%20of%20death,%202016~3

7. Australian Institute of Health and Welfare [Internet]. Canberra ACT: Australian Government; 2017. Deaths; 2017 Feb 7 [cited 2018 Feb 2]; [about 5 screens]. Available from: https://www.aihw.gov.au/reports/life-expectancy-death/deaths-in-australia/contents/life-expectancy

8. Bauman A, Phongsavan P, Shoeppe S, Chey T. Noncommunicable disease risk factors and socioeconomic inequalities - what are the links?. Geneva: World Health Organisation; 2010. 181p. Report No.: 1.

9. Heeley EL, Wei JW, Carter K, Islam MS, Thrift AG, Hankey GJ, Cass A, Anderson CS. Socioeconomic disparities in stroke rates and outcome: pooled analysis of stroke incidence studies in Australia and New Zealand. MJA [Internet]. 2011 Jul [cited 2018 Feb 18];195(1):10-14. Available from: https://www.mja.com.au/journal/2011/195/1/socioeconomic-disparities-stroke-rates-and-outcome-pooled-analysis-stroke

10. World Health Organisation. Risk Factors (Global Health Observatory Data) [Internet]. Geneva: World Health Organisation; 2018 [cited 2018 Feb 15]. Available from: http://www.who.int/gho/ncd/risk_factors/en/

11. Ngo VK, Rubinstein A, Ganju V, Kannelis P, Loza N, Rabadan-Diehl C, Daar AS. Grand Challenges: Integrating Mental Health Care into the Non-Communicable Disease Agenda. PLOS Medicine [internet]. 2013 May [cited 2018 Feb 4]; 10(5):e1001443. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3653779/

12. Reitsma M, Fullman N, Ng M, Salama J, Abajobir A, Abate K, et al. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015. The Lancet [Internet]. 2017 May [cited 2018 Feb 10]; 389(100082):1885-906. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30819-X/fulltext?elsca1=tlpr

13. World Health Organisation. WHO report on the global tobacco epidemic, 2013:

enforcing bans on tobacco advertising, promotion and sponsorship. Geneva Switzerland; World Health Organisation; 2013. 106 p. Report No.: 1.

14. World Health Organisation. WHO report on the global tobacco epidemic, 2017: monitoring tobacco use and prevention policies. Bern (CH): WHO Press, 2017. 135p. Report No.:1

15. The Department of Health. NATIONAL TOBACCO STRATEGY 2012-2018. Canberra (AU): Intergovernmental Committee on Drugs Standing Committee, 2012. pp1-35. Report No.: 1

16. Cancer Council Australia [Internet]. Sydney NSW: Cancer Council Australia; 2017. E-cigarettes; 2017 Nov 9 [cited 2018 Mar 18]; [about 2 screens].Available from: https://www.cancer.org.au/preventing-cancer/smoking-and-tobacco/e-cigarettes.html

17. Dunlop S, Lyons C, Dessaix A & Currow D. How are tobacco smokers using e-cigarettes? Patterns of use, reasons for use and places of purchase in New South Wales. Medical Journal of Australia [Internet]. 2016 May [cited 2018 Feb 11]; 204(9):225. Available from: https://www.mja.com.au/journal/2016/204/9/how-are-tobacco-smokers-using-e-cigarettes-patterns-use-reasons-use-and-places

18. E-cigarettes [Internet]. Quitline. 2018 [cited 2018 Feb 10]. Available from: https://www.quit.org.au/resources/policy-advocacy/policy/e-cigarettes/

19. Australian Medical Association. AMA Submission to the Standing Committee on Health, Aged Care and Sport Inquiry into the Use and Marketing of Electronic Cigarettes and Personal Vaporisers in Australia. Barton ACT: Australian Medical Association; 2017 Jul 6. 5 p. Report No.: 1.

20. Royal Australian College of Surgeons. Inquiry into the Use and Marketing of Electronic Cigarettes and Personal Vaporisers in Australia. Melbourne VIC: Royal Australian College of Surgeons; 2017 Jul. 4 p. Report No.: 1.

21. Bauld L, MacKintosh AM, Eastwood B, Ford A, Moore G, Dockrell M, Arnott D, Cheeseman H, McNeill A. Young People’s Use of E-Cigarettes across the United Kingdom: Findings from Five Surveys 2015-2017. Int J Environ Res Public Health [Internet]. 2017 Aug 29 [cited 2018 Mar 18];14(9):E973. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28850065

22. Tobacco in Australia [Internet]. Sydney NSW: Cancer Council Australia; 2018. Prevalence of smoking - young adults; 2017 Nov [cited 2018 Mar 18]; [about 2 screens]. Available from: http://www.tobaccoinaustralia.org.au/chapter-1-prevalence/1-4-prevalence-of-smoking-young-adults

23. World Health Organisation. Global status report on alcohol and health. Luxembourg: World Health Organisation; 2014. 86p.

24. Commonwealth of Australia. Australian guidelines to reduce health risks from drinking alcohol. Canberra: National Health and Medical Research Council; 2009. 181p.

25. Huntsdale, J. Australia's drinking problem the focus of Australia Medical Association summit in Canberra [Internet]. ABC News. 2014 October 28 [cited 2018 Feb 15]: Available from: http://www.abc.net.au/news/2014-10-28/ama-alcohol-summit/5847186.

26. Pettigrew S, Biagioni N, Jones SC, Daube M, Kirby G, Stafford J et al. Sales promotion strategies and youth drinking in Australia. Soc. Sci. Med [Internet]. 2015 Aug 3 [cited Feb 15];141:115-122. DOI: 10.1016/j.socscimed.2015.07.035

27. Stautz K, Brown KG, King SE, Shemilt I, Marteau TM. Immediate effects of alcohol marketing communications and media portrayals on consumption and cognition: a systematic review and meta-analysis of experimental studies. BMC Public Health [Internet]. 2016 [cited 2018 Feb 16];16:465-83. DOI: 10.1186/s12889-016-3116-8

28. Zerhouni O, Begue L, Duke AA, Flaudias V. Dynamic exposure to alcohol advertising in a sports context influences implicit attitudes. Alcohol Clin Exp Res [Internet]. 2016 [cited 2018 Feb 16];40(2):422-428. DOI: 10.111/acer.12966

29. Pierce HL, Stafford JM, Daube M. Developing an alternative alcohol advertising complaint review system: lessons from a world-first public health advocacy initiative. Public Health Res. Pract [Internet]. 2017 July [cited 2018 Feb 18];27(3):e2731729. DOI: 10.17061/phrp2731729

30. Alcohol Advertising Review Board. Alcohol Advertising Review Board: Home [Internet]. 2018 [cited 2018 Feb 10]. Available from: https://www.alcoholadreview.com.au/

31. Riordan BC, Conner TS, Flett JA, Scarf D. A brief orientation week ecological momentary intervention to reduce university student alcohol consumption. J Stud Alcohol Drugs [Internet]. 2015 Jul [cited 2018 Feb 16]; 76(4):525-529. DOI: 10.15288/jsad.2015.76.52

32. Roxburgh A, Hall WD, Burns L, Pilgrim J, Saar E, Nielsen S, Degenhardt L. Trends

and characteristics of accidental and intentional codeine overdose deaths in Australia. Med J Aust [Internet]. 2015 Oct 5 [cited 2018 Mar 18];203(7):299. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26424067

33. Monheit B, Pietrzak D & Hocking S. Prescription drug abuse – A timely update. Australian Family Physician [Internet]. 2016 Dec [cited 2018 Mar 13]; 45(12):862-6. Available from: https://www.racgp.org.au/afp/2016/december/prescription-drug-abuse-a-timely-update/

34. Schaffer A, Buckley N & Cairns R. Interrupted Time Series Analysis of the Effect of Rescheduling Alprazolam in Australia- Taking Control of Prescription Drug Use. JAMA Intern Med [Internet]. 2016 Aug [cited 2018 Mar 13]; 176(8):1223-5. Available from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2530900

35. Illicit Use of Drugs [Internet]. Australian Institute of Health and Welfare. 2016 [cited 2018 Feb 10]. Available from: https://www.aihw.gov.au/reports-statistics/behaviours-risk-factors/illicit-use-of-drugs/overview

36. Drug trends and statistics [Internet]. Australian Government- Department of Health. 2016 [cited 2018 Feb 11]. Available from: https://campaigns.health.gov.au/drughelp/drug-trends-and-statistics

37. Drug abuse [Internet]. Australian Government- Department of Health. 2017 [cited 2018 Feb 10]. Available from: https://www.healthdirect.gov.au/drug-abuse

38. Health Direct [Internet]. Sydney NSW: Australian Government; 2018. Substance abuse; 2016 Nov [cited 2018 Mar 18]; [about 5 screens]. Available from: https://www.healthdirect.gov.au/substance-abuse

39. Mental Health Council of Australia. Where there’s smoke … Cannabis and Mental Health. Deakin ACT: Mental Health Council of Australia; 2006. 76 p. Report No.: 1.

40. American Heart Foundation [Internet]. Dallas TX, USA: American Heart Foundation; 2018. Illegal Drugs and Heart Disease; 2017 May 17 [cited 2018 Mar 18]; [about 2 screens]. Available from: http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Illegal-Drugs-and-Heart-Disease_UCM_428537_Article.jsp#.Wq5TtahuZyw

41. Health.VIC [Internet]. Melbourne VIC: Department of Health and Human Services, State Government of Victoria; 2018. Alcohol and other drug treatment services; 2018 [cited 2018 Mar 18]; [about 3 screens]. Available from: https://www2.health.vic.gov.au/alcohol-and-drugs/aod-treatment-services

42. Government of Australia. National Drug Strategy 2010-2015. Perth (AU): Ministerial Council on Drug Strategy, 2010. 32p. Report No.:1

43. Australian Institute of Health and Welfare [Internet]. Canberra ACT: Australian Government; 2017. Impact of overweight and obesity as a risk factor for chronic conditions; 2017 Apr 13 [cited 2018 Feb 2]; [about 2 screens]. Available from: https://www.aihw.gov.au/reports/burden-of-disease/impact-of-overweight-and-obesity-as-a-risk-factor-for-chronic-conditions/contents/summary

44. Lake A, Townshend T. Obesogenic environments: exploring the built and food environments. J R Soc Promot Health [Health]. 2006 Nov [cited 2018 Feb 18];126(6):262-267. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17152319

45. World Health Organisation. Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020. Geneva Switzerland; World Health Organisation; 2013. 109 p. Report No.: 1.

46. Australian Institute of Health and Welfare. Australian Burden of Disease Study: Impacts and causes of illness and death in Australia 2011. Canberra ACT: Australian Government; 2016. 290 p. Report No.: 3.

47. Gakidou E, Afshin A, Abajobir A, Abatte KH, Abbafati C, Abbas K, et al. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet [Intenet]. 2017 Sep [cited 2018 Feb 18];290(10100):1345-1422. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32366-8/fulltext

48. National Health and Medical Research Council. Australian Dietary Guidelines. Canberra ACT: National Health and Medical Research Council; 2013. 226p. Report No.: 1.

49. Australian Bureau of Statistics [Internet]. Canberra ACT: Australian Government; 2016. Australian Health Survey: Consumption of Added Sugars, 2011-2012; 2016 Apr 27 [cited 2018 Feb 18]; [about 1 screen]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4364.0.55.011main+features12011-12

50. World Health Organisation. Fiscal Policies for Diet and Prevention of

Noncommunicable Diseases. Geneva, Switzerland: World Health Organisation; 2015. 36 p. Report No.: 1.

51. Malik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr [Internet]. 2013 Aug [cited 2018 Feb 18];98(4):1084-1102. Available from: https://academic.oup.com/ajcn/article/98/4/1084/4577098

52. Malik VS, Popkin MB, Bray GA, Despres J, Willett WC, Hu, FB. Sugar-Sweetened Beverages and Risk of Metabolic Syndrome and Type 2 Diabetes: A meta-analysis. Diabetes Care [Internet]. 2010 Nov [cited 2018 Feb 18];33(11):2477-2483. Available from: http://care.diabetesjournals.org/content/33/11/2477

53. Escobar MAC, Veerman JL, Tollman SM, Bertream MY, Hofman KJ. Evidence that a tax on sugar sweetened beverages reduces the obesity rate: a meta-analysis. BMC Public Health [Internet]. 2013 Apr [cited 2018 Feb 18];13(1):1072. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-13-1072

54. Colchero MA, Popkin BM, Rivera JA, Ng SW. Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. BMJ [Internet]. 2016 Jan [cited 2018 Feb 18];352:h6704. Available from: http://www.bmj.com/content/352/bmj.h6704

55. Veerman JL, Sacks G, Antonopoulos N, Martin J. The Impact of a Tax on Sugar-Sweetened Beverages on Health and Health Care Costs: A Modelling Study. PLoS One [Internet]. 2016 Apr [cited 2018 Feb 18]. Available from: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0151460#pone.0151460.ref006

56. Herman DR, Harrison GG, Afifi AA, Jenks E. Effect of a Targeted Subsidy on Intake of Fruits and Vegetables Among Low-Income Women in the Special Supplemental Nutrition Program for Women, Infants, and Children. Am J Public Health [Internet]. 2007 Mar [cited 2018 Feb 18];98(1):98-105. Available from: http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2005.079418

57. Folkvard F, Anschutz DJ, Boyland E, Kelly B, Buijzen M. Food advertising and eating behavior in children. Curr Opin Behav Sci [Internet]. 2016 Jun [cited 2018 Feb 18]; 9(1):26-31. Available from: https://www-sciencedirect-com.ezproxy1.library.usyd.edu.au/science/article/pii/S2352154615001564

58. Boyland EJ, Whalen R. Food advertising to children and its effects on diet: review of recent prevalence and impact data. Pediatr Diabetes [Internet]. 2015 Apr [cited 2018 Feb 18];16(5):331-337. Available from: http://onlinelibrary.wiley.com.ezproxy1.library.usyd.edu.au/doi/10.1111/pedi.12278/full

59. Watson WL, Lau V, Wellard L,Hughes C, Chapman K. Advertising to children initiatives have not reduced unhealthy food advertising on Australian television. J Public Health [Internet]. 2017 Feb [cited 2018 Feb 18];39(4):787-792. Available from: https://academic.oup.com/jpubhealth/article-abstract/doi/10.1093/pubmed/fdx004/2966185/Advertising-to-children-initiatives-have-not?redirectedFrom=fulltext

60. Chambers SA, Freeman R, Anderson AS, MacGillivray S. Reducing the volume, exposure and negative impacts of advertising for foods high in fat, sugar and salt to children: A systematic review of the evidence from statutory and self-regulatory actions and educational measures. Prev Med [Internet]. 2015 Jun [cited 2018 Feb 18];75(1):32-43. Available from: https://www-sciencedirect-com.ezproxy1.library.usyd.edu.au/science/article/pii/S0091743515000626

61. Dhar T, Baylis K. Fast-Food Consumption and the Ban on advertising Targeting Children: The Quebec Experience. J Mark Res [Internet]. 2011 Oct [cited 2018 Feb 18];48(5):799-813. Available from: http://journals.ama.org/doi/abs/10.1509/jmkr.48.5.799

62. Veerman JL, Van Beeck EF, Barendregt JJ, Mackenbach JP. By how much would limiting TV food advertising reduce childhood obesity?. Eur J Pub Health [Internet]. 2009 Aug [cited 2018 Feb 18];19(4):365-369. Available from: https://academic-oup-com.ezproxy1.library.usyd.edu.au/eurpub/article/19/4/365/493457

63. Gorton D, Carter J, Cvjetan B, Ni Mhurchu C. Healthier vending machines in workplaces: both possible and effective. NZ Med J [Internet]. 2010 Mar [cited 2018 Feb 18];123(1311):43-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20360795

64. Centre for Population Health. Healthy Food and Drink in NSW Health facilities for Staff and Visitors Framework. Sydney NSW: NSW Ministry of Health; 2017. 110 p. Report No.: 1.

65. World Health Organisation. SHAKE the Salt Habit: The SHAKE Technical Package for

Salt Reduction. Geneva Switzerland: World Health Organisation; 2016. 60 p. Report No.: 1.

66. Strazzullo P, D’Elia L, Kandala N, Cappuccio FP. Salt intake, stroke and cardiovascular disease: meta-analysis of prospective studies. BMJ [Internet]. 2009 Nov [cited 2018 Feb 18];339:b4567. Available from: http://www.bmj.com.ezproxy1.library.usyd.edu.au/content/339/bmj.b4567.full

67. Land M, Neal BC, Johnson C, Nowson CA, Margerison C, Petersen KS. Salt consumption by Australian adults: a systematic review and meta-analysis. MJA [Internet]. 2018 Jan [cited 2018 Feb 18];2018(2);75-81. Available from: https://www.mja.com.au/journal/2018/208/2/salt-consumption-australian-adults-systematic-review-and-meta-analysis?utm_source=tiles&utm_medium=web&utm_campaign=homepage

68. Food and Agriculture Organisation of the United Nations. Fats and fatty acids in human nutrition: Report of an expert consultation. Geneva Switzerland: Food and Agriculture Organisation of the United Nations; 2008. 180 p. Report No. 91.

69. Health Star Rating System [Internet]. Canberra ACT: Commonwealth of Australia; 2017. Reviews of the Health Star Rating System; 2017 Oct 20 [cited 2018 Feb 18]; [about 1 screen]. Available from: http://healthstarrating.gov.au/internet/healthstarrating/publishing.nsf/Content/reviews

70. Hamlin R, McNeill L. Does the Australasian “Health Star Rating” Front of Pack Nutritional Label System Work?. Nutrients [Internet]. 2016 Jun [cited 2018 Feb 18];8(6):327. Available from: http://www.mdpi.com/2072-6643/8/6/327

71. Avery JC, Bowden JA, Dono J, Gibson OR, Brownbill A, et al. Sugar-sweetened beverage consumption, correlates and interventions among Australian Aboriginal and Torres Strait Islander communities: a scoping review protocol. BMJ Open [Internet]. 2017 Jun [cited 2018 Feb 18];7(7):e016431. Available from: https://search-proquest-com.ezproxy1.library.usyd.edu.au/docview/1924774110?pq-origsite=gscholar

72. Department of the Prime Minister and Cabinet. Closing the Gap: Prime Minister’s Report 2018. Canberra ACT: Australian Government; 2018. 132 p. Report No.: 1. https://closingthegap.pmc.gov.au/sites/default/files/ctg-report-2018.pdf?a=1

73. 4364.0.55.001 - National Health Survey: First Results, 2014-15 [Internet]. 2015 [Cited 2018 Feb 10]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4364.0.55.001~2014-15~Main%20Features~Exercise~29

74. Physical activity [Internet]. World Health Organization. 2018 [Cited 2018 Feb 11]. Available from: http://www.who.int/topics/physical_activity/en/

75. Encouraging regular physical activity [Internet]. Vic health. 2018 [cited 2018 Feb 15]. Available from: https://www.vichealth.vic.gov.au/our-work/encouraging-regular-physical-activity

76. Design principle: active transport [Internet]. Healthy places. 2009. [cited 2018 Feb 17]. Available from: https://www.healthyplaces.org.au/userfiles/file/Design%20elements/design%20element%20-%20active%20transport%201.pdf

77. Active transport: adults [Internet]. Vic health. 2009 [cited 2018 Feb 14]. Available from: https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=6&ved=0ahUKEwjI27vJo6zZAhXEpZQKHe2FAPwQFghSMAU&url=https%3A%2F%2Fwww.vichealth.vic.gov.au%2F~%2Fmedia%2Fresourcecentre%2Fpublicationsandresources%2Factive%2520travel%2Factive_transport_adults_final.ashx&usg=AOvVaw2A9L5yvQrzB9KHp-ETlZr7

78. Live lighter [Internet]. Live lighter. 2018 [cited 2018 Feb 14]. Available from: https://livelighter.com.au

79. Population-based evaluation of the ‘LiveLighter’ healthy weight and lifestyle mass media campaign [Internet]. NCBI. 2016. [cited 2018 Feb 15]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4802349/

80. Adult active transport in the Netherlands: An analysis of its contribution to physical activity requirements [Internet]. NCBI. 2018 [Cited 2018 Feb 16]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388541/

81. World Health Organisation. Mental Health Action Plan 2013 - 2020. Geneva, Switzerland: WHO Document Production Services; 2013. 50p. Available from http://apps.who.int/iris/bitstream/10665/89966/1/9789241506021_eng.pdf?ua=1

82. National Centre for Chronic Disease Prevention and Health Promotion [Internet]. Mental Health and Chronic Diseases; 2012 Oct [cited 2018 Feb 19]. Available from: https://www.cdc.gov/workplacehealthpromotion/tools-resources/pdfs/issue-brief-no-2-mental-health-and-chronic-disease.pdf

83. The Conversation [Internet]. Saeri A, Sibley CG, Barlow FK, Strong S, Cruwys T. Are

you part of a social group? Making sure you are will improve your health [Internet]; 2017 Sep 6 [cited 2018 February 4]. Available from https://theconversation.com/are-you-part-of-a-social-group-making-sure-you-are-will-improve-your-health-81996

84. Holt-Lunstard J, Smith TB, Baker M, Harris T, Stephenson D. Loneliness and Social Isolation as Risk Factors for Mortality: A Meta-Analytic Review. Perspectives on Psychological Science [internet]. 2015 March [cited 2018 February 4]. 10 (2). Available from http://journals.sagepub.com/doi/abs/10.1177/1745691614568352

85. Holt-Lunstard J, Smith TB, Layton JB. Social Relationships and Mortality Risk: A Meta-analytic Review. PLOS [internet]. 2010 July [cited 2018 February 4]. Available from: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000316

POLICY DETAILS Name: Noncommunicable Diseases Policy Category: G- Global Health History: Adopted Council 1, 2015. The previous version of the policy was repealed and updated version was adopted at First Council, 2018

C. Masterson, J. Daniele, A.Srinivas, J. Bredhauer, C. Wright, J. Zhang, R. Mahesh