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ObjectivesThe risk of suicide among UK military veterans remains unclear. Few recent studies have been undertaken, and most studies found no clear evidence of increased risk. We used data from the Trends in Scottish Veterans Health cohort to investigate suicides up to 2017 in order to examine whether there have been any changes in the long-term pattern of veteran suicides since our earlier study to 2012, and to compare trends in the risk of suicide among veterans with matched non-veterans.MethodRetrospective cohort study of 78 000 veterans and 253 000 non-veterans born between 1945 and 1995, matched for age, sex and area of residence, using survival analysis to examine the risk of suicide in veterans in comparison with non-veterans overall and by subgroup, and to investigate associations with specific mental health conditions.ResultsUp to 37 years of follow-up, 388 (0.5%) veterans and 1531 (0.6%) non-veterans died from suicide. The risk of suicide among veterans did not differ from non-veterans overall. Increased risk among early service leavers was explained by differences in deprivation, and the previously reported increased risk in female veterans is now confined to older women. Suicide was most common in the fifth decade of life, and around 20 years postservice. A history of mood disorder or post-traumatic stress disorder was non-significantly more common in veterans.ConclusionsVeterans are not at increased risk of suicide overall. The highest risk for both men and women is in middle age, many years after leaving service.

BackgroundFew studies have examined whether UK military veterans are at an increased risk of dementia. We explored the risk of dementia in Scottish military veterans aged up to 73 years in comparison with people who have never served.MethodsRetrospective cohort study of 78 000 veterans and 253 000 people with no record of service, matched for age, sex and area of residence, with up to 37 years follow-up, using Cox proportional hazard analysis to compare risk of dementia in veterans and non-veterans, overall and by subgroup.ResultsDementia was recorded in 0.2% of both veterans and non-veterans overall, Cox proportional hazard ratio 0.98, 95% confidence interval (CI) 0.82–1.19, p = 0.879 (landmark age: 50 years), with no difference for men but increased risk in veteran women and Early Service Leavers. Post-traumatic stress disorder (PTSD) was associated with a higher risk of dementia in both veterans and non-veterans, although possibly to a lesser degree in veterans. A history of mood disorder was strongly associated with developing dementia, greater in veterans than in non-veterans, odds ratio 1.54, 95% CI 1.01–2.35, p = 0.045.ConclusionsThere was no evidence to suggest that military service increased the risk of dementia, although this may change as the cohort ages. The well-documented association with PTSD shows no evidence of being stronger in veterans; by contrast, the association of mood disorder with dementia is much stronger in veterans. Healthcare providers should carefully assess the cognitive status of older veterans presenting with depressive illness in order to identify early dementia and ensure optimum management.

To compare outcomes in employed people from an enhanced routine management pathway for musculoskeletal disorders within National Health Service Scotland with an existing active case-management system, Working Health Services Scotland.The study comprised a service evaluation using anonymised routinely collected data from all currently employed callers presenting with musculoskeletal disorder to the two services. Baseline demographic and clinical data were collected. EuroQol EQ-5DActive case-management resulted in greater improvement than enhanced routine care. Case-managed service users entered the programme earlier in the recovery pathway; there was evidence of spontaneous improvement during the longer waiting time of routine service clients but only if they had good baseline mental health. Those most disadvantaged through mental health co-morbidity showed the greatest benefit.People with musculoskeletal disorders who have poor baseline mental health status derive greatest benefit from active case-management. Case-management therefore contributes to reducing health inequalities and can help to minimise long-term sickness absence. Shorter waiting times contributed to better outcomes in the case-managed service. Implications for RehabilitationMusculoskeletal disorders are a major cause of inability to work.Case-management is effective in helping people with musculoskeletal disorders to return to work.People who have the poorest mental health are likely to gain the greatest benefit from case-management of their musculoskeletal disorders.

ObjectivesType 2 diabetes is an important public health problem but the risk in UK military veterans is unknown. We used data from the Trends in Scottish Veterans' Health study to investigate the risk in comparison with people with no record of service.DesignRetrospective cohort study of a large national sample in Scotland, with up to 37 years follow-up.SettingPseudoanonymised extract of computerised Scottish National Health Service records, including a disease register and national vital records.Participants78 000 veterans and 253 000 people with no record of service matched for age, sex and area of residence.Outcome measuresCox proportional HRs for first record of type 2 diabetes in veterans compared with non-veterans, overall and by sex and birth cohort. Long-term trend, comorbidity with specific mental health outcomes and risk of limb loss.ResultsOverall, 7.2% of veterans were diagnosed with type 2 diabetes, and were at slightly increased risk compared with non-veterans, Cox proportional HR 1.08, 95%CIs 1.04 to 1.11, pConclusionsOlder veterans in Scotland have an increased risk of type 2 diabetes in comparison with non-veterans, but there is no difference in respect of younger veterans, and the pattern of risk shows no evidence that it is changing. There is a positive association between type 2 diabetes and PTSD, especially in the presence of comorbid mood disorder, an important finding which should be noted by care providers.

ObjectivesTo examine the risk of cardiovascular disease (CVD) in Scottish military veterans in comparison with people who had never served in long-term follow-up to 2017, and to compare the findings with our earlier study to 2012 to assess trends.DesignRetrospective cohort study with up to 37 years follow-up.SettingPseudo-anonymised extract of computerised Scottish National Health Service records and national vital records.Participants78 000 veterans and 253 000 people with no record of service matched for age, sex and area of residence.Outcome measuresRisk of first occurrence of acute myocardial infarction, peripheral arterial disease and stroke in veterans compared with non-veterans, overall and by sex and birth cohort.ResultsA first episode of CVD was recorded in 5.7% of veterans and 4.8% of non-veterans overall, Cox proportional HR 1.16, 95% CIs 1.12 to 1.20, p=0.001. The difference was only significant for men, and for veterans born before 1960, and was highest in veterans with the shortest service. In all categories, the difference in risk was less than at the end of 2012.ConclusionsThe excess burden of CVD in veterans which was evident at the end of 2012 has reduced in the following 5 years from 23% to 16% overall. The increased risk continues to affect only those veterans born prior to 1960, suggesting that improvements in military health promotion since 1978, when veterans born from 1960 joined the armed forces, have had an important and ongoing beneficial effect on the long-term health of veterans.

IntroductionThe UK is the only permanent member of the UN Security Council that has a policy of recruiting 16 and 17 year old individuals into its regular Armed Forces. Little is known about the consequences of enlisting as a Junior Entrant (JE), although concerns have been expressed. We compare the mental health, deployment history, and pre-enlistment and post-enlistment experiences of personnel who had enlisted as JEs with personnel who joined as Standard Entrants (SEs).MethodParticipants from a large UK military cohort study completed a self-report questionnaire between 2014 and 2016 that included symptoms of probable post-traumatic stress disorder (PTSD), common mental disorders, alcohol consumption, physical symptoms and lifetime self-harm. Data from regular non-officer participants (n=4447) from all service branches were used in the analysis. JEs were defined as having enlisted before the age of 17.5 years. A subgroup analysis of participants who had joined or commenced adult service after April 2003 was carried out.ResultsJEs were not more likely to deploy to Iraq or Afghanistan but were more likely to hold a combat role when they did (OR 1.25, 95% CI 1.00 to 1.56). There was no evidence of an increase in symptoms of common mental disorders, PTSD, multiple somatic symptoms (MSS), alcohol misuse or self-harm in JEs in the full sample, but there was an increase in alcohol misuse (OR 1.84, 95% CI 1.18 to 2.87), MSS (OR 1.51, 95% CI 1.04 to 2.20) and self-harm (OR 2.13, 95% CI 1.15 to 3.95) in JEs who had commenced adult service after April 2003. JEs remain in adult service for longer and do not have more difficulties when they leave service.ConclusionsJEs do not have worse mental health than SEs, but there is uncertainty in relation to alcohol misuse, MSS and self-harm in more recent joiners. Monitoring these concerns is advisable.

IntroductionIt has been suggested that ‘junior entry’ to the UK Armed Forces (prior to age 17.5 years) increases the risk of adverse mental health outcomes. We used data from a large cohort of veterans to examine long-term mental health outcomes in veterans by age at entry to the UK Armed Forces, compared with non-veterans.MethodsRetrospective cohort study of 78 157 veterans in Scotland, born between 1945 and 1995 and and 252 637 matched non-veterans, with up to 37 years follow-up, using Cox proportional hazard models to examine the association between veteran status and cumulative risk of major mental health disorder, stratified by birth cohort, and age at recruitment for the veterans.ResultsThe risk of mental health disorder in the veterans increased with age at entry, ranging from HR 1.12, 95% CI 1.06 to 1.18, pConclusionWe found no evidence that early recruitment is associated with adverse impact on long-term mental health. Paradoxically, it was veterans who entered service at age 20–25 years who demonstrated increased risk, although this attenuated in more recent birth cohorts.

IntroductionRecent attention has focused on veterans who have lost limbs in conflict, but the number of UK veterans who lose limbs to disease is unknown. We used data from the Trends in Scottish Veterans’ Health study to explore postservice lower limb amputation.MethodsWe carried out a retrospective cohort study of 78 000 veterans and 253 000 non-veterans born between 1945 and 1995, matched for age, sex and area of residence. We used survival analysis to examine the risk of amputation in veterans compared with non-veterans, and explored associations with antecedent disease.ResultsWe found no difference between veterans and non-veterans in the risk of lower limb amputation, which was recorded in 145 (0.19%) veterans and 464 (0.18%) non-veterans (Cox proportional hazard ratio (HR) 1.00, 95% CIs 0.82 to 1.20, p=0.961). Peripheral arterial disease was recorded in two-thirds of both veteran and non-veteran amputees, and type 2 diabetes in 41% of veterans and 33% of non-veterans, with a dual diagnosis in 32% of veterans and 26% of non-veterans. Trauma was an infrequent cause of amputation.ConclusionsAlthough in later life veterans are no more likely to lose a limb to disease than non-veterans, the number so affected greatly outweighs those who have lost limbs in conflict. The high public profile of conflict-related limb loss risks eclipsing the needs of veterans with disease-related loss. Support for ageing veterans who have lost limbs due to disease will require planning with the same care as that afforded to the victims of conflict if inequalities are to be avoided.

Purpose: \ud Although suicide risk in veterans has been widely studied, there is little information on the risk of non-fatal self-harm in this population. We used data from the Scottish Veterans Health Study to conduct an epidemiological analysis of self-harm in veterans, in comparison with people who have never served.\ud \ud Methods: \ud We conducted a retrospective, 30-year cohort study of 56,205 veterans born 1945–1985, and 172,741 people with no record of military service, and used Cox proportional hazard models to examine the association between veteran status and cumulative risk of non-fatal self-harm, overall and stratified by birth cohort, sex and length of service. We also examined mental and physical comorbidities, and association of suicide with prior self-harm.\ud \ud Results: \ud There were 1620 (2.90%) first episodes of self-harm in veterans, compared with 4212 (2.45%) in non-veterans. The difference was statistically significant overall (unadjusted HR 1.27, 95% CI 1.21–1.35, p

Former Chief Medical Officer Sir Kenneth Calman recently celebrated 50\ud years in medicine. It was a period which saw the evolution of the public\ud health agenda from communicable diseases to diseases of lifestyle, the\ud change from a hospital-orientated health service to one dominated by\ud community-based services, and the increasing recognition of inequalities as a\ud major determinant of health. This paper documents selected highlights from\ud his career including the Aberdeen typhoid outbreak, AIDS, bovine spongiform encephalopathy,\ud foot and mouth disease, radioactive fallout, the invention of computerised tomography and\ud magnetic resonance imaging, and draws parallels between the development of the modern\ud understanding of public health and the theoretical background to the science 100 years earlier.

Road traffic accidents (RTA) are recognised to be an important cause of death and injury in serving military personnel but little is known about the risk in veterans. We used data from the Scottish Veterans Health Study to examine the risk of RTA in a large national cohort of veterans, in comparison with people who had never served. We conducted a retrospective cohort study of 57,000 veterans and 173,000 non-veterans, followed up for up to 30 years, using survival analysis to compare risk of RTA injury. Subgroup analysis was used to explore trends by birth cohort and length of service. Overall, veterans had a higher risk of RTA (Cox proportional hazard ratio (HR) 1.17, 95% confidence intervals (CI) 1.14-1.20). The risk was highest in the veterans with the shortest service (early service leavers), including those who did not complete initial military training (HR 1.31, 95% CI 1.23-1.40). The mean age at first RTA was 34 years, irrespective of age at leaving service, and the greatest increase in risk was in veterans born in the 1960s, but veterans born after 1970 showed no increase in risk. We have therefore demonstrated that the increased risk of RTA observed in serving military personnel persists in veterans through the fourth decade of life. The high risk in early service leavers is likely to be related to risk factors other than military service, including previous childhood adversity. Recent Ministry of Defence road safety programmes may now be reducing the long-term risk of RTA injury.

Background: While traumatic limb loss in military personnel is widely known, the threat posed by peripheral arterial disease (PAD) in those who have served is less well recognized. The aim of our study was to examine the risk of PAD in a Scotland-wide cohort of veterans who served between 1960 and 2012. Methods: Retrospective 30-year cohort study of 56 205 veterans born 1945–85, and 172 741 non-veterans, matched for age, sex and area of residence, using Cox proportional hazard models to examine the association between veteran status, birth cohort, length of service and risk of PAD leading to hospitalization or death. Results: Overall, veterans were at increased risk of PAD compared with non-veterans, unadjusted hazard ratio (HR) = 1.46, 95% confidence intervals (CI): 1.33–1.60, P < 0.001. The highest risk was in veterans born between 1950 and 1954, HR = 1.76, 95% CI: 1.50–2.07, P < 0.001, and in those with the shortest service (early service leavers), HR = 1.84, 95% CI: 1.49–2.27, P < 0.001. Conclusions: The findings provide evidence for a hidden burden of life- and limb-threatening PAD in older veterans and are consistent with the higher rates of military smoking which have been reported previously. The study emphasizes the need for vascular preventive measures in this group.

IntroductionPhysical activity is an important component of military training. Although injuries and musculoskeletal disorders are the most common cause of medical retirement from the Armed Forces, the long-term risk of lower limb osteoarthritis in veterans is unknown. We used data on hip and knee replacement in Scottish military veterans as a proxy measure.MethodsRetrospective cohort study of 78 000 veterans born between 1945 and 1995 and a comparison group of 253 000 non-veterans, matched for age, sex and area of residence, followed up for up to 37 years, using survival analysis to examine the risk of hip and knee replacement.ResultsVeterans were significantly less likely to undergo hip replacement than non-veterans, Cox proportional HR 0.87, 95% CI 0.80 to 0.95, pConclusionsBased on the likelihood of undergoing joint replacement surgery in later life, we found no evidence of a positive association between military service and an increased risk of lower limb osteoarthritis.

Background: Although reassuring data on suicide risk in UK veterans of the 1982 Falklands conflict and 1991 Gulf conflict have been published, there have been few studies on long-term overall suicide risk in UK veterans. Aims: To examine the risk of suicide in a broad population-based cohort of veterans in Scotland, irrespect ive of length of service or exposure to conflict, in comparison with people having no record of military service. Methods: A retrospective 30-year cohort study of 56205 veterans born 1945–85 and 172741 matched non-veterans, using Cox proportional hazard models to compare the risk of suicide and fatal self-harm overall, by sex, birth cohort, length of service and year of recruitment. Results: There were 267 (0.48%) suicides in the veterans compared with 918 (0.53%) in non-veterans. The difference was not statistically significant overall [adjusted hazard ratio (HR) 0.99; 95% confidence interval (CI) 0.86–1.13]. The incidence was lower in younger veterans and higher in veterans aged over 40. Early service leavers were at non-significantly increased risk (adjusted HR 1.13; 95% CI 0.91–1.40) but only in the older age groups. Women veterans had a significantly higher risk of suicide than non-veteran women (adjusted HR 2.44; 95% CI 1.32–4.51, P < 0.01) and comparable risk to veteran men. Methods of suicide did not differ significantly between veterans and non-veterans, for either sex. Conclusions: The Scottish Veterans Health Study adds to the emerging body of evidence that there is no overall difference in long-term risk of suicide between veterans and non-veterans in the UK. However, female veterans merit further study.

Background: The ‘healthy worker effect’ predicts that longer employment is positively associated with reduced mortality, but few studies have examined mortality in military veterans irrespective of exposure to conflict. Aims: To examine mortality in a large national cohort of Scottish veterans by length of service. Methods: Retrospective cohort study comparing survival in up to 30-year follow-up among 57 000 veterans and 173 000 people with no record of service, matched for age, sex and area of residence, who were born between 1945 and 1985. We compared antecedent diagnoses in the two groups to provide information on probable risk factors. Results: By the end of follow-up, 3520 (6%) veterans had died, compared with 10 947 (6%) non-veterans. Cox proportional hazard analysis confirmed no significant difference overall unadjusted or after adjusting for deprivation. On subgroup analysis, those who left prematurely (early service leavers) were at significantly increased risk of death (hazard ratio (HR) 1.16, 95% confidence interval (CI) 1.09–1.24, P < 0.001), although the increase became non-significant after adjusting for socioeconomic status (HR 1.05, 95% CI 0.99–1.12). Longer-serving veterans were at significantly lower risk of death than non-veterans; the risk decreased both with length of service and in more recent birth cohorts. Smoking-related disease was the greatest contributor to increased mortality in early leavers. Conclusion: Among longer-serving veterans, there was evidence of a HWE partly attributable to selective attrition of early service leavers, but birth cohort analysis suggests improvements over time which may also reflect a causal effect of improved in-service health promotion.

OBJECTIVE We used data from the Scottish Veterans Health Study to examine long-term mental health outcomes in a large cohort of veterans, with a focus on the impact of length of service. METHODS We conducted a retrospective, 30-year cohort study of 56,205 veterans born from 1945 through 1985, including 14,702 who left military service prematurely, and 172,741 people with no record of military service, using Cox proportional hazard models, to examine the association between veteran status and length of service and cumulative risk of mental health disorder. We stratified the veterans by common lengths of service, defining Early Service Leavers as those who had served for less than 2.5 years. RESULTS There were 2,794 (4.97%) first episodes of any mental health disorder in veterans, compared with 7,779 (4.50%) in nonveterans. The difference was statistically significant for all veterans (adjusted hazard ratio [HR] = 1.21; 95% CI, 1.16-1.27; P < .001). Subgroup analysis showed the highest risk to be in Early Service Leavers (adjusted HR = 1.51; 95% CI, 1.30-1.50; P < .001), including those who failed to complete initial training. The risk reduced with longer service; beyond 9 years of service, risk of mental health disorder was comparable to or lower than that in nonveterans. CONCLUSIONS The veterans at highest risk of mental health disorder were those who did not complete training or minimum engagement, while those with longest service were at reduced risk, suggesting that military service was not causative. The high risk among the earliest leavers may reflect pre-service vulnerabilities not detected at recruitment, which become apparent during early training and lead to early discharge.

Objective To examine the risk of cervical cancer in a large national cohort of military veteran women followed up for up to 30 years. Methods Retrospective cohort study of 5235 veteran women born between 1945 and 1985, and 20 703 women with no record of service matched for age and area of residence, using Cox proportional hazard models to compare the overall risk of cervical cancer and by year of birth. Results During the follow-up period 1981–2012, there were 18 (0.34%) cases of cervical cancer in the veteran women compared with 81 (0.39%) in the non-veterans. The difference was not statistically significant overall (adjusted HR 0.95, 95% CI 0.57 to 1.59). When analysed by the year of birth, veteran women born in 1958 and earlier had a non-significantly higher risk than non-veterans (adjusted HR 1.24, 95% CI 0.68 to 2.26), while veteran women born after 1958 had a non-significant reduction in risk (adjusted HR 0.51, 95% CI 0.18 to 1.44). Conclusions Women born after 1958 who have served in the Armed Forces are at reduced risk of cervical cancer compared with women who have never served, and compared with older veteran women. Small numbers of cases precluded statistical significance. The change in risk pattern in veteran women coincided with the introduction of cervical screening in the Armed Forces, which predated the UK national programme, and provides evidence for the long-term effectiveness of the Armed Forces’ sexual health strategy. The impact of recent changes in the screening age, and of human papillomavirus immunisation, should be monitored in the future.

Background: \ud \ud Lymphohaematopoietic malignancies are common in the general population. There have been concerns that military service may be associated with increased risk as a result of occupational exposures. To date, few studies have demonstrated an increased risk, although a disability pension is payable to veterans who were present at nuclear tests and who develop leukaemia (other than chronic lymphocytic leukaemia). The aim of the study was to utilise data from the Scottish Veterans Health Study to examine the risk of lymphohaematopoietic malignancy following military service in a large national cohort of veterans.\ud \ud Methods: \ud \ud Retrospective cohort study of 57,000 veterans and 173,000 non-veterans born between 1945 and 1985 matched for age, sex and area of residence, adjusted for areal deprivation and followed up for up to 30 years, using Cox proportional hazard models to compare the risk of lymphohaematopoietic malignancy overall, by diagnosis and by sex and birth cohort.\ud \ud Results: \ud \ud We found no statistically significant difference in risk between veterans and non-veterans either for all leukaemias (Cox proportional hazard ratio 1.03, 95% confidence intervals 0.84–1.27, p = 0.773), Hodgkin lymphoma (hazard ratio 1.19, 95% confidence intervals 0.87–1.61, p = 0.272) or for non-Hodgkin lymphoma (hazard ratio 0.86, 95% confidence intervals 0.71–1.04, p = 0.110).\ud \ud Conclusion: \ud \ud Our findings provide reassurance that service in the UK Armed Forces is not associated with increased risk of lymphohaematopoietic malignancy.

The earliest known use of lead was in the Neolithic period; by Roman times it was in widespread use, despite recognition that it could have adverse effects on human health. The early smelting processes were inefficient, giving rise to atmospheric pollution; as this reduced with modern improvements in furnace design, so pollution due to the addition of tetraethyl lead to motor fuel emerged. The military use of lead was a further source of environmental contamination, while individuals were exposed to lead from water pipes, paint and solder in food cans. Studies of lead in ice cores recovered from Greenland demonstrated a 200-fold increase in lead concentration from 800 BCE to the 1960s, with the greatest increase occurring after 1940. The isotope signatures of lead enabled the sources of environmental contamination to be determined: industrial lead was responsible throughout most of the last millennium, with lead in fuel making the greatest contribution in recent times. The human impact was demonstrated in studies of archaeological and modern skeletal lead levels. This paper explores the history of the use of lead and the development of an understanding of its toxicity, and examines its impact on human health.

Objectives In 2003, it was reported that motor neurone disease was linked to military service in the 1990–1991 Gulf War. A large study in the US confirmed an association with military service but found no association with specific conflicts or length of service. Non-veteran studies have suggested an association with physical activity, smoking and other risk factors. We used data from the Scottish Veterans Health Study to investigate the association between motor neurone disease and military service in UK veterans. Methods Retrospective cohort study of 57 000 veterans born 1945–1985, and 173 000 demographically matched civilians, using Cox proportional hazard models to compare the risk of motor neurone disease overall, and by sex, birth cohort, length of service and year of recruitment. We had no data on smoking prevalence. Results Veterans had an increased risk of motor neurone disease compared with non-veterans (adjusted HR 1.49, 95% CI 1.01 to 2.21, p=0.046). The increase was independent of birth cohort, length or period of service, or year of recruitment. Risk was associated with a history of trauma or road traffic accident in veterans and non-veterans. Conclusions We confirmed an increased risk of motor neurone disease in military veterans, although the absolute risk is extremely low. We found no evidence that the increased risk was associated with any specific conflict. We could not rule out that smoking (and perhaps other lifestyle factors) may be responsible for our findings. Trauma may play a role in the increased risk but further studies are needed.

Public health, the protection of the health of populations through community engagement, is a modern specialty originating in post-Industrial Revolution Britain, while environmental geochemistry is of even more recent origin. The influence of geology on health was first recognized in Classical times, although it was later supplanted by the miasma theory of disease. During the Renaissance, medical teaching began to concentrate more on diagnosis and treatment of the sick individual and less on preserving the health of populations. The concept of geology as a determinant of health re-emerged with the growth of scientific knowledge during the Enlightenment period of the eighteenth century. The nineteenth century saw the first identification of trace element deficiency disease and the publication of a textbook of public health which described geological influences on health. Over the next 100 years both public health and environmental geochemistry became established on a firm footing, although as separate disciplines. Recently the public health focus has been on lifestyle choices, but environmental geochemistry remains a potentially powerful partner in the fight to protect health, and there is much scope to enhance collaborative working. The legacy of the pioneers of both public health and geology must not be forgotten.

Introduction Previous studies have shown that Early Service Leavers (ESL) are at increased risk of adverse socio-economic outcomes such as unemployment, homelessness and crime, as well as poor mental health. The Scottish Veterans Health Study enabled exploration of long-term health outcomes in relation to length of service. This paper presents a comparison of the health of ESL with both longer-serving veterans and with non-veterans, and explores implications for transition. Methods Retrospective cohort study of 57,000 veterans and 173,000 people with no record of service, born between 1945 and 1985 who were resident in Scotland, matched for age, sex and geographical region, and stratified by length of service for veterans, followed up for up to 30 years. Health outcomes were compared using survival analysis methodology (Cox proportional hazards). Results The veteran cohort included 14,000 ESL, of whom 6,000 failed to complete initial training. People who were older at recruitment were more likely to become ESL. ESL were at higher risk of smoking-related disease than either longer-serving veterans or non-veterans. For alcohol-related outcomes, the risk was only increased in ESL who completed training. ESL were not at increased risk of drug misuse. The highest risk of PTSD was in ESL who did not complete training, whilst veterans with the longest service were at lower risk than non-veterans. Conclusion The Scottish Veterans Health Study has confirmed the poorer health outcomes of ESL reported in earlier studies. It is unlikely that military service is causal, and it is more likely that it represents a selection effect. The early weeks of training may act as a filter for those who are unsuited to military service, resulting in a ‘less healthy leaver effect’ which mirrors the ‘healthy worker effect’ in longer-serving people. Ensuring that ESL transition into new employment may help to minimise adverse outcomes.

Many myths have grown up surrounding the figure of the military veteran within the civilian population. But military service is an occupation, like many others, with strong health selection and a specific cluster of physical, chemical, biological, and psychosocial risks, which may have long-term effects. Well-designed epidemiology should create opportunities to explore the factors associated with health in the transition back to civilian life. Chaired by Simon Wessely, this section of the minisymposium will discuss some of the issues in undertaking epidemiological studies in this topical and important area. For example: Identifying veteran populations is an easier task in some countries than in others. Military service entails a specific and diverse cluster of physical, chemical, biological, and psychosocial risks which may, or may not, be well documented. In particular, exposures during combat may be poorly documented. Military populations are strongly selected, particularly in countries without conscription, and the effects of pre-service lifestyle and environmental factors may continue after the return to civilian life. This panel discussion will sum up the issues raised by both the minisymposium speakers and also the participants on the floor.

Background: \ud Serving military personnel are more likely to smoke, and to smoke more heavily, than civilians. The aim of our study was to examine whether veterans have an increased risk of a range of smoking-related cancers compared with non-veterans, using a large, national cohort of veterans.\ud \ud Methods: \ud We conducted a retrospective cohort study of 57,000 veterans resident in Scotland and 173,000 age, sex and area of residence matched civilians. We used Cox proportional hazard models to compare the risk of any cancer, lung cancer and other smoking-related cancers overall, by sex and by birth cohort, adjusting for the potential confounding effect of socioeconomic deprivation.\ud \ud Results: \ud Over a mean of 29 years follow-up, 445 (0.79 %) veterans developed lung cancer compared with 1106 (0.64 %) non-veterans (adjusted hazard ratio 1.16, 95 % confidence intervals 1.04–1.30, p = 0.008). Other smoking-related cancers occurred in 737 (1.31 %) veterans compared with 1883 (1.09 %) non-veterans (adjusted hazard ratio 1.18, 95 % confidence intervals 1.08–1.29, p

Objective Tuberculosis was a major cause of morbidity and manpower loss in the Armed Forces during World War II. Military control programmes commenced in the 1950s but were initially limited in scope by the many recruits who were already tuberculin positive on enlistment. The aim of our study was to examine whether veterans have an increased risk of tuberculosis compared with non-veterans. Methods Retrospective cohort study of 57 000 veterans born 1945–1985, and 173 000 people with no record of military service, resident in Scotland, matched for age, sex and area of residence, using Cox proportional hazard analysis to compare the risk of tuberculosis overall, by birth cohort, length of service and year of diagnosis and to examine comorbidities. Results Over mean 29 years follow-up, 69 (0.12%) veterans were recorded as having tuberculosis, compared with 267 (0.15%) non-veterans (unadjusted HR 0.90, 95% CIs 0.69 to 1.19, p=0.463). Only the 1945–1949 veterans9 birth cohort was at higher risk, unadjusted HR 1.54, 95% CIs 0.98 to 2.45, p=0.061, although the difference in risk did not achieve significance. Veterans born from 1950 were at significantly reduced risk of tuberculosis compared with non-veterans after adjusting for deprivation, HR 0.67, 95% CI 0.47 to 0.95, p=0.026. The most common comorbidities were smoking-related and alcohol-related disease. The risk of comorbid hepatitis B or C was very low, in both veterans and non-veterans. No length of service was associated with an increased risk of tuberculosis in comparison with non-veterans. Conclusions Scottish veterans born before 1950 are at moderately increased risk of tuberculosis compared with age, sex and geographically matched civilians with no record of service, although the difference is not statistically significant. Scottish veterans born from 1950 show a reduction in risk compared with civilians. Tuberculosis should be considered in the differential diagnosis of respiratory disease in the older veteran.

Objective Serving military personnel are more likely to drink heavily than civilians. The aim of our study was to examine whether veterans have an increased risk of alcoholic liver disease and alcohol-related death compared with non-veterans. Design Retrospective cohort study of 57 000 veterans resident in Scotland and 173 000 age, sex and area of residence-matched civilians, using Cox proportional hazard models to compare the risk of alcoholic liver disease and alcohol-related death overall, by sex, birth cohort, length of service and year of recruitment, adjusting for socioeconomic status. Results Over mean 29 years follow-up, 677 (1.20%) veterans developed alcoholic liver disease compared with 2175 (1.26%) non-veterans (adjusted HR=0.91, 95% CIs 0.84 to 0.99, p=0.035). Only the 1945–1949 veterans’ birth cohort was at higher risk, unadjusted HR=1.25, 95% CIs 1.07 to 1.47, p=0.004, although their difference in risk became non-significant after adjusting for socioeconomic status, p=0.052. The pattern was similar for alcohol-related death. Veterans were less likely than non-veterans to have comorbid hepatitis C. Older age at recruitment at a time of high operational activity in the early 1970s was associated with increased risk, but longer service was not. Conclusions Overall, veterans in Scotland had a significantly reduced risk of alcoholic liver disease or alcohol-related death compared with non-veterans, although the risk was higher in those born before 1950. Reasons for the changing pattern are likely to be complex and may reflect operational exposure, social attitudes to alcohol and the impact of recent military health promotion.

Background: Serving military personnel have been shown to be more likely to smoke, and to smoke more heavily, than civilians. Our aim was to examine whether veterans have an increased risk of smoking-related cancer compared with non-veterans. Methods: Retrospective cohort study of 57,000 veterans born 1945-1985, resident in Scotland, and 173,000 age, sex and area of residence matched non-veterans, using Cox proportional hazard models to compare risk of lung cancer and other smoking-related cancers overall, by sex and by birth cohort, adjusting for socioeconomic status. Results: Over mean 29 years follow-up, 445 (0.79%) veterans developed lung cancer compared with 1,106 (0.64%) non-veterans (adjusted hazard ratio 1.16, 95% confidence intervals 1.04-1.30, p = 0.008). Other smoking-related cancers occurred in 737 (1.31%) veterans compared with 1,883 (1.09%) non-veterans (adjusted hazard ratio 1.18, 95% confidence intervals 1.08-1.29, p < 0.001). Risk was significantly increased among veterans born 1950-1954 for lung cancer and 1945–1954 for other smoking-related cancers. Risk of lung cancer was decreased among veterans born 1960 onwards. Conclusion: Veterans living in Scotland born before 1955 were at increased risk of smoking-related cancer compared with non-veterans, but younger veterans were not. This may reflect changing patterns of smoking in military personnel as a consequence of health promotion policy, and a changing operational environment. Primary healthcare providers should be aware of the importance of providing smoking cessation support to veterans.

Few studies of veterans have examined cardiovascular disease as the primary outcome, other than in relation to specific conflicts or hazards. To assess the long-term risk and prognosis of acute myocardial infarction (AMI) in United Kingdom veterans from a broad range of military backgrounds and experience, we conducted a retrospective cohort study of 57,000 veterans resident in Scotland and 173,000 civilians matched on age, sex, and area of residence. Cox proportional hazards models were used to compare the risks of fatal/nonfatal AMI overall, by sex, and by year of birth, adjusting for the potentially confounding effect of socioeconomic status, and to compare rates of case-fatality following AMI at 30-day, 1-year, and 5-year follow-up. Over a mean follow-up period of 29 years between 1981 and 2012, a total of 2,106 (3.8%) veterans experienced an AMI as compared with 5,261 (3.1%) nonveterans (hazard ratio = 1.22, 95% confidence interval: 1.16, 1.29; P < 0.001). There was an increased risk of AMI among veterans born in 1945-1959 but not among those born from 1960 onward. Case-fatality was lower among veterans at 30-day, 1-year, and 5-year follow-up. We conclude that health behaviors such as smoking may have increased the risk of AMI in older veterans but that younger veterans have benefited from in-service health promotion initiatives.

In the UK, armed services personnel are perceived to become institutionalised during service, with negative connotations, especially in the process of transition to veteran status. Beverly P Bergman, Howard J Burdett and Neil Greenberg argue that institutionalisation is an inappropriate model, and that becoming a member of the armed forces is better represented by a model of culture shock, with reverse culture shock being experienced upon leaving. The adoption of this model would be useful both in preparing UK service personnel for civilian life and in supporting them after transition, and may help to predict vulnerability.