New evidence on the effects of plain cigarette packaging in Australia

By Olivia Maynard @OliviaMaynard17 

This blog originally appeared on the Mental Elf site on 27th March 2015

Last week I was lucky enough to attend the 15th Annual World Conference on Tobacco or Health in Abu Dhabi. With both Ireland and the UK announcing in the weeks leading up to the conference that they would implement plain (or ‘standardised’) packaging of cigarettes, it wasn’t surprising that this was one of the conference’s hot topics.

One of the sessions that focused on plain packaging was organised by Professor Melanie Wakefield’s team at the Cancer Council Victoria in Australia. As the first country in the world to introduce plain packaging, Australian data on its real-world effectiveness is of keen interest to policy-makers worldwide.

These researchers published a supplement to the journal Tobacco Control last week, including 12 new studies on plain packaging in Australia (more details about each of the 12 studies and their methodologies are given at the end of this blog). The majority of these used a ‘pre-post’ methodology, which means that they assessed behaviours and attitudes to smoking before plain packaging was introduced and compared with these same attitudes and behaviours afterwards.

At their conference session, some of these studies were discussed in more detail, with one in particular (Durkin et al., 2015), which investigated the impact of plain packaging on quitting-related cognitions, catching my attention. This study seemed like the logical extension of my most recently published paper on plain packaging, which reports the results of randomising UK smokers to use either a branded or a plain pack of cigarettes for a day and measuring smoking behaviour and attitudes to smoking and quitting.

As I’ll discuss later on, it’s important that we use a range of methodologies, including laboratory based experiments (such as those I’ve conducted) and real-world investigations (such as those conducted by the Australian researchers) to investigate the possible impact of plain packaging.

Plain (or ‘standardised’) packaging would mean standardising the size, shape, colour and method of opening of all tobacco products.


Data for this study were obtained as part of a continuous cross-sectional telephone based survey. Participants were called twice, one month apart, first for a baseline survey and then for a follow-up. Participants were aged between 18 and 69 and all participants were required to be cigarette smokers at the baseline call.

All calls were made between April 2012 and March 2014 and participants were split into 4 groups according to when their two phone calls were made:

  1. Those who had both their baseline and follow-up phone calls before plain packaging was introduced
  2. Participants’ baseline call was made before plain packaging was introduced and their follow-up was during a transitional period where both plain and branded packs were available for purchase
  3. Baseline phone calls were made during the transitional period, whilst follow-up calls were made either during the transitional period or after plain packaging had been fully implemented (November 2012)
  4. Both baseline and follow-up calls were made within the first year of plain packaging being fully implemented

At both the baseline and follow-up stages, participants were asked about quitting related cognitions, micro-indicators of concern and quit attempts. Logistic regression was used to analyse the data and participants’ baseline scores were included as predictors for their follow-up scores (after accounting for potential confounders). Essentially, this means that follow-up scores between participants in the four groups could be directly compared, accounting for any differences at baseline. Responses from participants in Groups 2, 3 and 4 were compared with those of the participants in Group 1.


In total, 5,137 participants completed both the baseline and follow-up calls. At follow-up, approximately 6% of participants across all groups had quit smoking. The following results were found for each of outcome measures:

Quitting related cognitions

  • No differences in thoughts about quitting, or plans to quit in the next month were observed between the groups. However, higher intentions to quit were observed among those in Group 3 as compared with those in Group 1

Micro-indicators of concern

  • Participants in Groups 3 and 4 were more likely to conceal their pack than those in Group 1
  • Those in Group 4 reported higher levels of stubbing out cigarettes early than those in Group 1
  • Higher rate of forgoing cigarettes were observed amongst participants in Group 2 than Group 1

Quit attempts

  • More quit attempts were reported among participants in Groups 2 and 4 as compared with those in Group 1

Given that results are likely to be closely scrutinised by researchers, policy makers and the tobacco industry, it is important to carefully consider their implications and not overstate the findings.


This study provides modest statistical evidence that plain packaging in Australia has increased micro-indicators of concern, increased quit attempts and increased some quitting related cognitions among smokers.

The authors describe the outcomes they measured in the current study as being ‘downstream’ from the more immediate effects of plain packaging, which they have found evidence for in their other studies. These include:

It is possible that more substantial changes in the downstream effects such as those measured in this study may take longer to emerge.

Plain packaging: putting these results in context

Investigating the impact of plain packaging in the ‘real-world’ using this pre-post technique has its limitations. Unlike the laboratory, the real-world isn’t tightly controlled and although the researchers tried to account for other factors which may have influenced the results, such as changes in the price of tobacco and other tobacco control measures such as mass media campaigns, it’s impossible to completely control for the effect of these, making causal interpretations difficult.

Obviously we cannot randomise whole countries to either introduce or not introduce plain packaging (which would address these limitations), and examine what happens to smoking prevalence in these countries. Studies like that by Durkin and colleagues are therefore probably the best that we can do in the real world. Moreover, no one piece of research will give us the full picture when it comes to the potential impact of plain packaging.

Although, on their own, these findings do not provide overwhelming support for a beneficial impact of plain packaging, when they are considered together with the other studies in theTobacco Control supplement, and with data from the Australian government (which this year reported record lows in tobacco sales and smoking prevalence) along with findings fromlaboratory-based experiments and surveys, the evidence looks more compelling.

Now that both the UK and Ireland have announced plans to introduce plain packaging in May 2016, with other countries likely to follow suit, it will be important to continue to monitor the longer-term impacts of this tobacco control measure, making use of the wide range of research tools and methodologies available to us.

Plain packaging will become


Primary study

Durbin S, Brennan E, Coomber K, Zacher M, Scollo M, Wakefield M. Short-term changes in quitting-related cognitions and behaviours after the implementation of plain packaging with larger health warnings: findings from a national cohort study with Australian adult smokersTobacco Control 2015;24:Suppl 2 ii26ii32 doi:10.1136/tobaccocontrol-2014-052058

Other references

Research papers included in the Tobacco Control plain packaging Supplement:

Two paper-based surveys of adolescents:

Six telephone survey-based studies:

One in-depth interview:

One analysis of tobacco retailer journals:

Two observational studies:

High potency cannabis and the risk of psychosis

By Eleanor Kennedy @Nelllor_

This blog originally appeared on the Mental Elf site on 24th March 2015


Smoking higher-potency cannabis may be a considerable risk factor for psychosis according to research conducted in South London (Di Forti, et al., 2015).

Cannabis is the most widely used illicit drug in the UK and previous research has suggested an association between use of the drug and psychosis, however the causal direction and underlying mechanism of this association are still unclear.

This recent case-control study published in Lancet Psychiatry, aimed to explore the link between higher THC (tetrahydrocannabinol) content and first episode psychosis in the community.

To compare the impact of THC content on first episode psychosis, participants were asked whether they mainly consumed skunk or hash. Analysis of seized cannabis suggests that skunk has THC content of between 12-16%, while hash has a much lower THC content ranging from 3-5% (Potter, Clark, & Brown, 2008; King & Hardwick, 2008).

Cannabis hash and skunk have very different quantities of the active THC component.


The researchers used a cross-sectional case-control design. Patients presenting for first-episode psychosis were recruited from a clinic in the South London and Maudsley NHS Foundation Trust; patients who had an identifiable medical reason for the psychosis diagnosis were excluded. Control participants were recruited from the local area using leaflets, internet and newspaper adverts. There were 410 case-patients and 370 controls recruited.

Researchers gathered data on participants’ cannabis use in terms of lifetime history and frequency of use as well as type of cannabis used, i.e. skunk or hash. Participants were also asked about their use of other drugs including alcohol and tobacco, as well as providing demographic information.


The case-patients and control participants were different in a couple of key areas (note: psychosis is more common in men and in ethnic minorities):

Case patients Control participants 
Male 66% 56%
Age 27.1 years 30.0 years
Caribbean or African ethnic origin 57% 30%
Completed high level of education 57% 90%
Ever been employed 88% 95%
Lifetime history of ever using cannabis 67% 63%

Participants with first episode psychosis were more likely to:

  • Use cannabis every day
  • Use high-potency cannabis
  • Have started using cannabis at 15 years or younger
  • Use skunk every day

A logistic regression adjusted for age, gender, ethnic origin, number of cigarettes smoked, alcohol units, and lifetime use of illicit drugs, education and employment history showed thatcompared to participants who had never used cannabis:

  • Participants who had ever used cannabis were not at increased risk of psychosis
  • Participants who had used cannabis at age 15 were at moderately increased risk of psychotic disorder
  • People who used cannabis or skunk everyday were roughly 3 times more likely to have diagnosis of psychotic disorder

A second logistic regression was carried out to explore the effects of a composite measure of cannabis exposure which combined data on the frequency of use and the type of cannabis used.Compared with participants who had never used cannabis:

  • Individuals who mostly used hash (occasionally, weekends or daily) did not have any increased risk of psychosis
  • Individuals who smoked skunk less than once a week were nearly twice as likely to be diagnosed with psychosis
  • Individuals who smoked skunk at weekends were nearly three times as likely to be diagnosed with psychosis
  • Individuals who smoked skunk daily were more than five times as likely to be diagnosed with psychosis

The population attributable factor (PAF) was calculated to estimate the proportion of disorder that would be prevented if the exposure were removed:

  • 19.3% of psychotic disorders attributable to daily cannabis use
  • 24.0% of psychotic disorders attributable to high potency cannabis use
  • 16.0% of psychotic disorders attributable to skunk use every day

These findings raising awareness among young people of the risks associated with the use of high-potency cannabis


The results of this study support the theory that higher THC content is linked with a greater risk of psychosis, with daily use of skunk conferring the highest risk. Recruiting control participants from the same area as the case participants meant that the two groups were more likely to be matched on not only demographic factors but also in terms of the actual cannabis that both groups were consuming.

The study has some limits, such as the cross-sectional design which cannot be used to establish causality. Also the authors have not included any comparison between those who smoke hash and those who consume skunk so no conclusions can be drawn about the relative harm of hash.

Media reports about the study have mainly focussed on the finding that ‘24% of psychotic disorders are attributable to high potency cannabis use’. This figure was derived from a PAF calculation which assumes causality and does not allow for the inclusion of multiple, potentially interacting, risk factors. Crucially the PAF depends on both the prevalence of the risk factor and the odds ratio for the exposure; the PAF can be incredibly high if the risk factor is common in a given population.

In this case, the prevalence rate of lifetime cannabis use was over 60% in both participant groups. According to EMCDDA, the lifetime prevalence of cannabis use in the UK is 30% among adults aged 15-64, so it is arguable that this study sample is not representative of the rest of the UK. The authors themselves note that “the ready availability of high potency cannabis in south London might have resulted in a greater proportion of first onset psychosis cases being attributed to cannabis use than in previous studies”, which is a more accurate interpretation than media reports claiming that “1 in 4 of all new serious mental disorders” is attributable to skunk use.

Future studies looking at the relationship between cannabis and psychosis should also aim to differentiate high and low potency cannabis. Longitudinal cohort studies are particularly useful as they have the same advantages as a case-control design but data about substance use could be more reliable as ‘lifetime use’ can be gathered from multiple measurements collected at a number of time points across the lifetime.

This innovative study is the first to distinguish between different strengths of cannabis in this way.


Primary study

Di Forti M. et al (2015). Proportion of patients in south London with first-episode psychosis attributable to use of high potency cannabis: a case-control study (PDF). The Lancet Psychiatry, 2(3), 233-238.

Other references

King L, & Hardwick S. (2008). Home Office Cannabis Potency Study (PDF). Home Office Scientific Development Branch.

Potter DJ, Clark P, & Brown MB. (2008). Potency of Delta(9)-THC and other cannabinoids in cannabis in England in 2005: Implications for psychoactivity and pharmacology (PDF). Journal of Forensic Sciences, 53(1), 90-94.

Screening of A Royal Hangover: TARG goes to the movies

By David Troy @DavidTroy79 

I recently hosted a documentary screening of ‘A Royal Hangover’ on behalf of the Tobacco and Alcohol Research Group at the University of Bristol. The film documents anecdotes from all facets of the drinking culturpic1e in the UK, from politicians to police, medical specialists to charities, the church and scientists, and addicts and celebrities, with high profile personalities such as Russell Brand and controversial figures such as sacked Government Drugs Advisor Professor David Nutt. The director Arthur Cauty kindly agreed to take part in a question and answer session after the film to discuss his experience making the film and debate the issues raised in the film.

The film begins with Arthur talking about his own relationship with alcohol (or his lack of one).  He preferred to shoot silly films, play music or wrestle than go out drinking with his friends. The film deals with the history of alcohol starting off in the 16th and 17th century when it was safer to drink beer than water. Even babies were given what was called “small beer for small people”. In the early 18th century, gin became the drink of choice and reached epidemic levels, famously depicted in William Hogarth’s ‘Gin Lane’. pic2Gin was unregulated and sold not just in public houses but in general stores and on the street. Moving on to the 20th century, Lloyd George recognised the danger of alcohol to the war effort in World War 1, and was quoted as saying that “we are fighting Germany, Austria and drink; and as far as I can see, the greatest of these deadly foes is drink”. Around this time, restrictions on the sale of alcohol were introduced by government. During World War 2, beer was seen as important to morale and a steady supply of it was seen as important to the war effort. Since then, we have seen a steady increase in consumption levels through the ‘hooligan/lager lout’ phenomenon of the 1980’s and the binge drinking of the 1990’s and the early 2000’s. Consumption levels have been falling slightly since the mid 2000’s but there are still 10 million people drinking above the government’s recommended level.

During the film, Arthur investigates how different societies treat alcohol. French and American drinkers describe a more reserved and responsible attitude to alcohol. This is somewhat contradicted by 2010 data in a recent report by the World Health Organisation which reports that French people over the age of 15 on average consume 12.2 litres of pure alcohol a year compared to Britons at 11.6 and Americans at 9.2 litres respectively. The drinking culture of France and the United States is certainly different to that of the UK. The French consume more wine, less beer, and tend to drink alcohol whilst eating food. The US (outside of ‘Spring Break’ culture) is more disapproving of public intoxication. However, neither society should be held up as a gold standard when it comes to alcohol use.

The film talks about the enormous cost of alcohol to England; approximately £21 billion annually in healthcare (£3.5 billion), crime (£11 billion) and lost productivity (£7.3 billion) costs. These are the best data available, but costs of this nature are difficult to calculate. Arthur talked to professionals on the front line – he interviewed a GP who said that a huge proportion of her time is devoted to patients with alcohol problems and their families. She has to treat the “social and psychological wreck” that comes when one family member has an alcohol addiction. A crime commissioner from Devon and Cornwall police states that 50% of violence is alcohol-related in his area.

The film attempts to understand the reasons why alcohol use is at current levels, and offers some possible solutions. Alcohol is twice as affordable now as in the 1980’s and is more freely available than ever. This needs to be curtailed. Evidence suggests that alcoholic beverages were 61% more affordable per person in 2012 than in 1980, and the current number of licensed premises in England and Wales is at the highest level repic3corded in over 100 years. Licensed premises with off sales only alcohol licences have also reached a record high, more than doubling in number compared with 50 years ago. The evidence shows that price increases and restrictions on availability are successful in reducing alcohol consumption. More alcohol education in schools was highlighted as being necessary. The evidence suggests that alcohol education in schools can have some positive impact on knowledge and attitudes. Overall, though, school-based interventions have been found to have small or no effects on risky alcohol behaviours in the short-term, and there is no consistent evidence of longer-term impact. Alcohol education in schools should be part of the picture but other areas may prove more fruitful. The film suggests that parental and peer attitudes towards alcohol affect drinking norms, and these attitudes need to change. In multiple surveys, it has been found that the behaviour of friends and family is the most common influential factor in determining how likely and how often a young person will drink alcohol. Alcohol marketing was cited as a problem and it needs to regulated more stringently. Alcohol marketing increases the likelihood that adolescents will start to use alcohol and increases the amount used by established drinkers, according to a report commissioned by the EU. The exposure of children to alcohol marketing is of current concern. A recent survey showed that primary school aged children as young as 10 years old are more familiar with beer brands, than leading brands of biscuits, crisps and ice-cream.

David Nutt discussed research he conducted with colleagues, which assessed the relative harms of 20 drugs, including both harms to the individual and to others. They found that alcohol was the most harmful drug overall. Professor Nutt also covered the circumstances surrounding his sacking as government’s chief drug advisor; he claimed that ecstasy and LSD were less dangerous than alcohol, which led to his dismissal. This highlights the inherent tension between politics and science. Evidence can diverge from government policy and popular opinion, and scientists can lose their positions when reporting evidence that is politically unpopular. In my view, the reluctance of governments to implement evidence-based alcohol policies is frustrating; minimum unit pricing (MUP) being the latest example. Despite good evidence supporting how MUP can reduce alcohol-related harms, lobbying by the alcohol industry has halted its progress.

The film deals with the human cost of alcohol misuse, with personal stories of addiction permeating the film. Carrie Armstrong (who writes a blog discussing her battle with alcohol addiction), as well as Persia Lawson and Joey Rayner (who write a lifestyle blog ‘Addictive Daughter’), discussed the havoc alcohol caused in their lives, and explained how young men and women come to them for help with their own alcohol dependencies. Russell Brand talked about his own alcohol addiction during the film. He contends that his drug and alcohol use was medicinal and thinks that alcohol and drug addicts “have a spiritual craving, a yearning and we don’t the language, we don’t have the code to express that in our society”. Arthur interviewed Chip Somers of Focus 12, who talked about the low levels of funding to treat alcohol addiction. Only a small minority (approximately seven per cent) of the 1.6 million alcohol dependants in the UK can get access to treatment compared to two-thirds of addicts of other drugs.


Arthur recorded over 100 hours of footage of drinkers on nights out during the course of filming. He described it as follows: “As the sun goes down, society fades away and what emerges from the shadows is a monster of low inhibition, aggression and casual chaos”. He sums it up as us “going to war on ourselves. On one side is the police, the emergency services, the council and various groups of volunteers and on the other side you’ve got everybody else”. He was assaulted three times and witnessed multiple scenes of violence close up. His bravery is admirable – there were many scenes I found difficult to watch. The scenes of senseless violence were horrible to look at, as were the images of individuals who were so intoxicated as to be helpless and in need of medical attention.

The Q&A after the screening was quite illuminating. Arthur spoke about the reception the film has been receiving at home and abroad. The reception has been great in the United States, where the film has had successful showings at film festivals. The interest in the UK has been a little disappointing, however, which Arthur puts down to the reluctance of society at large to acknowledge our dysfunctional relationship with alcohol. Nevertheless, there has been positive feedback from viewers of the film. Many people have contacted Arthur to tell him how the film has opened their eyes to their own relationship with alcohol and prompted them to make a change. The audience was keen to engage in the conversation. One person, who has a family member with an alcohol addiction, said how important it is to raise awareness of these issues. Another person called for policy measures to be implemented such as MUP to curb use across the population.


Arthur came across as someone who is acutely aware of the damage alcohol is causing in the UK, and is doing what he can to raise the public’s consciousness about it. He has presented a unique look at booze Britain, in equal parts shocking, hilarious, sympathetic and thought provoking – a film we can all relate to. It was a very enjoyable and informative evening and I hope the audience took something away from it. I believe the arts and sciences need to work together to improve how knowledge is communicated. It was my hope that by showing this documentary, information on alcohol harms in society would be more accessible to a general audience. Change begins with the acknowledgement of new information that alters the view of ourselves and our behavior. It has been estimated that over 7 million people in the UK are unaware of the damage their personal alcohol use is doing. I believe the blame lies on both sides. Alcohol researchers need to communicate the harms of alcohol in more engaging and accessible ways and members of the general public need to seek out such information. All too often scientists get the reputation as being cold, boring, and amoral. Collaborating with filmmakers and other proponents of the arts on events such as the one I hosted can assist in changing that stereotype.

Is moderate alcohol consumption good for you?

By Marcus Munafo @MarcusMunafo 

This blog originally appeared on the Mental Elf site on 13th March 2015


This is something many of us would like to be true – the idea that the occasional glass of wine has health benefits is compelling in a society like the UK where alcohol consumption is widespread.

Certainly the observational data indicate a J-shaped associationbetween alcohol consumption and mortality (O’Keefe et al, 2007), with the lowest mortality observed at low to moderate levels of alcohol consumption (equivalent to perhaps a pint of beer a day for men, and about half that for women).

However, observational studies like this are fraught with difficulties.

  1. First, people may not report their alcohol consumption reliably.
  2. Second, and more importantly, alcohol consumption is associated with a range of other lifestyle behaviours, such as diet and smoking, which will themselves influence mortality, so that isolating any specific association of alcohol is extremely difficult.
  3. Third, how non-drinkers are defined may be important – lifetime abstainers may be different from former drinkers (who could have stopped drinking because of health problems).

The last point illustrates the problem of reverse causality; alcohol consumption may be causally associated with a range of health outcomes, but some of those health outcomes may also be causally associated with alcohol consumption.

In a recent study in the BMJ, the authors argue that the problems associated with the choice of an appropriate referent group of non-drinkers are often overlooked in research into alcohol-related mortality.

They also argue that age is not adequately considered, which may be relevant because of physiological changes to the ageing body that influence elimination of blood alcohol. Knott and colleagues explored the association between alcohol consumption and all cause mortality for people aged less than 65 years and aged 65 or more, and separated never and former drinkers.

The lowest mortality observed is at low to moderate levels of alcohol consumption (equivalent to perhaps a pint of beer a day for men, and about half that for women).


The authors used data from the Health Survey for England, an annual, nationally-representative cross sectional survey of the general population, linked to national mortality registration data.

The analysis focused on adults aged 50 years or older, and investigated two measures of alcohol consumption: self-reported average weekly consumption over the past year, and self-reported consumption on the heaviest day in the past week. The outcome was all cause mortality (i.e., any death recorded during the period of data collection).

The primary statistical analyses were proportional hazards analyses for each of the two age groups of interest (less than 65 years and 65 years or more). They tested for whether any associations observed differed between males and females and, given strong evidence of a sex-dose interaction, reported sex-specific models for each age group of interest.

Statistical adjustment was made for a comprehensive list of potential confounders, such as geographical location, ethnicity, cigarette smoking, obesity and a range of socio-demographic variables.


Protective associations were only observed with statistical significance (a point I’ll return to below) among younger men (aged 50 to 64 years) and older women (65 years or older), using a never drinker referent category after full adjustment.

Among younger men a protective relationship between alcohol consumption and all cause mortality was observed among those who reported consuming 15.1 to 20 units per week (hazard ratio 0.49, 95% confidence interval 0.26 to 0.91).

Among older women, the range of protective use was broader but lower, with reductions in hazards of all cause mortality observed at all consumption levels up to 10 units per week of less.

The study supports a moderate protective effect of alcohol.


The authors conclude that observed associations between low levels of alcohol consumption and reduced all cause mortality may in part be due to inappropriate selection of a referent group (all non-drinkers, rather than never drinkers) and inadequate statistical adjustment for potential confounders.

They also conclude that beneficial dose response relationships between alcohol consumption and all cause mortality may be specific to women aged 65 years or older.

There is a relative lack of data on older populations in relation to the association between alcohol consumption and all cause mortality, which this study addresses. The consideration of different definitions of the referent category is also valuable – the authors are correct that conventional definitions of “non-drinker” may be problematic.

However, to what extent should we believe the conclusion that beneficial dose response relationships may be age- and sex-specific?

As David Spiegelhalter has pointed out, the authors base their conclusion on which associations achieved statistical significance and which did not. However, the hazard ratios for all cause mortality are consistently lower for alcohol consumers than non-consumers in this study. Although the confidence intervals are wider for some consumption levels and in some sub-groups (males vs females, or younger vs older), the individual hazard ratios are all consistent with each other.

The wide confidence intervals reflect a lack of statistical power, principally due to the small number of never drinkers, and the small number of deaths. Although the data set is relatively large, by carving it up into a number of sub-groups, the statistical power for the individual comparisons is reduced. Spiegelhalter points out that the entire comparison for participants in the younger age group is based on 17 deaths in the male baseline group and 19 deaths in the female group.

As Andrew Gelman and Hal Stern have said, the difference between “significant” and “non-significant” is not (necessarily) itself significant. Indeed, focusing on statistical significance (rather than effect size and precision) can lead to exactly the problems encountered here. Low statistical power is also a problem, reducing the likelihood that a statistically significant finding is true, and (perhaps more importantly) dramatically reducing the precision of our effect size estimates.

Should we believe that beneficial dose response relationships are age- and sex-specific?

Strengths and limitations

There are some strengths to this study, notably the use of a more considered referent category of never drinkers, and the statistical adjustment for a broad range of potential confounders.

However, the primary conclusion of the authors does not seem to be borne out by their own data – hazard ratios for all cause mortality are lower for alcohol consumers than non-consumers at all levels of consumption, for both men and women, and for both the younger and older age groups.

Is moderate alcohol consumption good for us then? The observational data, including that from this study, continues to suggest so.

However we should also remain wary of evidence from observational studies, which can be notoriously unreliable, and cannot confirm that an association is causal. Ultimately, we may need to use novel methods to answer this question, such as Mendelian randomization which utilized the properties of genetic variants to enable stronger causal inference.

We should be wary of evidence from observational studies, which can be notoriously unreliable, especially in underpowered studies like this one.


Knott CS, Coombs N, Stamatakis E, Biddulph JP. (2015) All cause mortality and the case for age specific alcohol consumption guidelines: pooled analyses of up to 10 population based cohorts (PDF). British Medical Journal, 350, h384. doi: 10.1136/bmj.h384

O’Keefe HF, Bybee KA, Lavie CJ. (2007) Alcohol and cardiovascular health: the razor-sharp double-edged sword. J Am Coll Cardiol. 2007;50(11)

Spiegelhalter D. (2015) Misleading conclusions from alcohol protection study. Understanding Uncertainty website, last accessed 11 Mar 2015.

Financial incentives for smoking cessation in pregnancy

By Meg Fluharty @MegEliz_

This blog originally appeared on the Mental Elf site on 11th March 2015.


Smoking during pregnancy is thought to cause approximately 25,000 miscarriages per year in the United Kingdom (Health and Social Care Information Centre, 2010).

Additionally, smoking while pregnant is attributable to 4-7% of stillbirths (Flenady et al., 2011), and 3-5% of infant deaths (Gray et al., 2009) with these rates even higher in deprived areas, where remaining a smoker during pregnancy is more common (Gray et al., 2009).

In 2009, 24% of women attending antenatal appointments in Scotland were smokers (NHS, 2009). However only 1 in 10 reported using cessation services, and 3% were abstaining by four weeks (Tappin et al., 2010).

A recent Cochrane systematic review suggested financial incentives may be beneficial in helping pregnant women stop smoking, although it concluded that further evidence was needed (Chamberlain et al., 2013). Tappin et al (2015) investigated the effectiveness of shopping vouchers in addition to NHS Stop Smoking Services to aid quit attempts in pregnant women.

Nearly 1 in 4 women attending antenatal appointments in Scotland were smokers (NHS, 2009).


The authors conducted a randomised controlled trial of 609 pregnant smokers recruited from NHS Greater Glasgow and Clyde. Women were randomly allocated to routine smoking cessation care (control group) or to routine care and up to £400 in shopping vouchers if they engaged with services and successfully quit smoking (incentives group).

Routine care

Routine specialist pregnancy care involved an initial meeting to discuss quitting smoking and set a quit date. This was followed by 4 weekly telephone calls, and free nicotine replacement therapy for 10 weeks.

Incentives group

The incentives group received £50 in shopping vouchers for attending the initial meeting to set a quit date. If participants were smoke-free 4 weeks later, they would receive another £50 voucher, and if smoke-free at 12 weeks, participants received £100 in gift vouchers. Between 34-38 weeks gestation, women were once again asked smoking status, and those who had quit received a final £200 voucher. In all instances, smoking status was verified by a carbon monoxide breath test. 

Women who successfully quit smoking in this study received up to £400 in shopping vouchers.


  • More women successfully quit smoking in the incentives group (22.5%) than the routine care group (8.6%).
  • There was a higher quit rate at 4 weeks in the incentives group compared to the routine care group.
  • 12 months after quit date, there was still large difference in self-reported quit rates (15% incentives, 4% control).
  • Women lost to follow-up were assumed to be smokers, which was validated by analysing residual routine blood samples for cotinine.



This study demonstrated that financial incentives with routine care could be beneficial in motivating quit attempts in pregnant smokers, as well as aiding them in continuing to abstain up to 12 months after their quit date. Furthermore, the quit rates reported in this trial were larger than many pharmaceutical (Coleman et al., 2012) or behavioural (Chamberlain et al., 2013) intervention trials in pregnant women. Although, it should be noted that women in the control group had higher nicotine addiction scores than those in the incentives group.

While the evidence from this study suggests using financial incentives may be beneficial in helping pregnant smokers to stop, there may be practical and ethical issues in implementing this as an intervention.

Additionally, other studies are needed to determine the generalizability and possible cost effectiveness of this intervention, as well as what cessation services are best suited to pair with financial incentives. However, it will be interesting to see how this study may be used to inform future policy.


Tappin D, Bauld L, Purves D, Boyd K, Sinclair L, MacAskill S et al. Financial incentives for smoking cessation in pregnancy: randomised controlled trial (pdf). BMJ 2015; 350:h134

Health and Social Care Information Centre, Infant feeding survey 2010 (pdf). HSCIC, 2012.

Flenady V, Koopmans L, Middleton P, Frøen JF, Smith GC, Gibbons K, et al. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. Lancet 2011;377:1331-40. [Abstract]

Gray R, Bonellie SR, Chalmers J, Greer I, Jarvis S, Kurinczuk J, et al. Contribution of smoking during pregnancy to inequalities in stillbirth and infant death in Scotland 1994-2003: retrospective population based study using hospital maternity records. BMJ 2009;339:b3754.

Information Services Division, NHS National Services Scotland. Births and babies: smoking and pregnancy, 2009.

Tappin DM, MacAskill S, Bauld L, Eadie D, Shipton D, Galbraith L. Smoking prevalence and smoking cessation services for pregnant women in Scotland. Subst Abuse Treat Prev Policy 2010;5:1.

Coleman T, Chamberlain C, Davey MA, Cooper SE, Leonardi-Bee J. Pharmacological interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 2012;9:CD010078. [Abstract]

Chamberlain C, O’Mara-Eves A, Oliver S, Caird JR, Perlen SM, Eades SJ, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev 2013;10:CD001055

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Research doesn’t just happen in the lab anymore: Mechanical Turk, Prolific Academic, and online testing.

By Michael Dalili @michaeldalili

Over the years, from assessment to analysis, research has steadily shifted from paper to PC. The modern researcher has an ever-growing array of computer-based and online tools at their disposal for everything from data collection to live-streaming presentations of their work. While shifting to computer- or web-based platforms is easier for some areas of research than others, this has proven to work especially well in psychology. These platforms can be used for anything from simply hosting an online version of a questionnaire, to recruiting and testing participants on cognitive tasks. Throughout the course of my PhD, I have increasingly used online platforms for multiple purposes, ranging from participants completing questionnaires online on Bristol Online Survey, to recruiting participants using Amazon Mechanical Turk and completing a task hosted on the Xperiment platform. And I’m not alone! While it’s impossible to estimate just how many researchers are using computer- and web-based platforms to conduct their experiments, we have a better idea of how many researchers are using online crowdsourcing platforms such as Mechanical Turk and Prolific Academic for study recruitment. Spoiler alert: It’s A LOT! In this blog post I will describe these two platforms and give an account of my experiences using them for online testing.


Amazon Mechanical Turk, or MTurk for short, is the leading online crowdsourcing platform. Described as an Internet marketplace for work that requires human intelligence, MTurk was publicly launched in 2005, having previously been used internally to find duplicates among Amazon’s product webpages.  It works as follows: workers (more commonly known as “Turkers”), who are individuals who have registered on the service, complete Human Intelligence Tasks (known as HITs) created by Requestors, who approve the completed HIT and compensate the Workers. Prior to accepting HITs, Workers are presented with information about the task, the duration of the task, and the amount of compensation they will be awarded upon successfully completing the task. Right now there are over 280,000 HITs available, ranging widely in terms of the type and duration of task as well as compensation. Amazon claims its Workers number over 500,000 ranging from 190 countries. They can be further sub-divided into “Master Categories”, who are described by Amazon as being “an elite group of Workers who have demonstrated superior performance while completing thousands of HITs across the Marketplace”. At time of writing, there are close to 22,000 Master Workers, with about 3,800 Categorization Masters and over 4,500 Photo Moderation Masters. As you might imagine, some Requestors can limit who can complete their HITs by assigning “Qualifications” that Workers must attain before participating in their tasks. Qualifications can range from requiring Master status to having approved completion of a specific number of HITs. While most Workers are based in the US, the service does boast an impressive gender balance,  with about 47% of its users being women.  Furthermore, Turkers are generally considered to be younger and have a lower income compared to the general US internet population, but possess a similar race composition. Additionally, many Workers worldwide cite Mechanical Turk as their main or secondary sources of income.

Since its launch, MTurk has been very popular, including among researchers. The number of articles on Web of Science with the search term “Mechanical Turk” has gone from just over 20 in 2012 to close to 100 in 2014 (see Figure 1). A similar search on PubMed produces 15 publications since the beginning of 2015.

Figure 1. The number of articles found on the Web of Science prior to 2015 with the search term ‘Mechanical Turk’ within the ‘psychology’ research area. Used with permission fromWoods, Velasco, Levitan, Wan, & Spence (in preparation).

However, the popularity of MTurk has not come without controversy. Upon completing a HIT, Workers are not compensated until their task has been “approved” by the Requestor. Should the Requestor reject the HIT, the Worker receives no compensation and their reputation (% approval ratings) decreases. Many Turkers have complained about having had their HITs unfairly rejected, claiming Requestors keep their task data while withholding payment. Amazon has refused to accept responsibility for Requestors’ actions, claiming it merely creates a marketplace for Requesters and Turkers to contract freely and does not become involved in resolving disputes. Additionally, Amazon does not require Requestors to pay Workers according to any minimum wage, and a quick search of available HITs reveals many tasks requiring workers to devote a considerable amount of time for very little compensation. However, MTurk is only one of several crowdsourcing platforms, including CloudCrowd, CrowdFlower, and Prolific Academic.


Launched in 2014, Prolific Academic describes itself as “a crowdsourcing platform for academics around the globe”. Founded by collaborating academics from Oxford and Sheffield, Prolific Academic markets itself specifically as a platform for academic researchers. In fact, until August 2014, registration to the site was limited to UK-based individuals with academic emails (* until it was opened up to everyone with a Facebook account (for user authentication purposes). Going a step further than its competition in appealing to academic researchers, Prolific Academic offers an extensive list of pre-screening questions (including questions about sociodemographic characteristics, levels of education or certifications, and more) that researchers can use to determine if someone is eligible to complete their study. Therefore, before someone can access and complete their study, they have to answer screening questions selected by the researcher. Individuals who have already completed screening questionnaires (available immediately upon signing up) will only be shown studies they are eligible for under the study page. At the time of writing this blog, according to the site’s homepage there are 5,081 individuals signed up to the site, with over 26,000 data submissions to date. Additionally, the site reports that participants have earned over £26,000 overall thus far. According to the site’s own demographics report from November 2014, 62% of users are male and the average age of users is about 24. Users are predominantly based in the US or UK. However, 1,500 users have joined since this report alone! Unlike MTurk and most other crowdsourcing platforms, Prolific Academic stipulates that researchers must compensate participants appropriately, which they term “Ethical Rewards”, requiring that participants be paid a minimum of £5 an hour.#


I have had experience using both MTurk and Prolific Academic in conducting and participating in research. With the assistance of Dr Andy Woods and his Xperiment platform, where my experimental task is hosted online, I was able to get an emotion recognition task up and running online. This opened up the possibility of studies on larger and more diverse samples, as well as studies being completed in MUCH shorter time frames. With Andy’s help in setting up studies on MTurk, I have run three studies on the platform since July 2014, ranging in sample size from 100 to 243 participants. Most impressively, each study was completed in a matter of hours; conducting the same study in the lab would have taken months! Similarly, given the short duration of these tasks, and the speed and ease of completing and accessing study documents on a computer, these studies cost less than they would have had they been conducted in the lab.

My experience with Prolific Academic has only been as a participant thus far but has been very positive. All the studies I completed have adhered to the “Ethical Rewards” requirement, and all researchers have been prompt in compensating me following study completion. Study duration estimates have been accurate (if anything generous) and compensation is only withheld in the case of failed catch trials (more on that below). The site is very easy to use with a user-friendly interface. It is easy to contact researchers as well, which is helpful for any queries or concerns. I know several colleagues as well who have had similar experiences and I hope to run a study on the platform in the near future.

While there have been several criticisms of conducting research on these crowd-sourcing platforms, the most common one amongst researchers is that data acquired this way will be of lesser quality than data from lab studies. Critics argue that the lack of a controlled testing environment, possible distractions during testing, and participants completing studies for compensation as quick as possible without attending to instructions are all reasons against conducting experiments on these platforms. Given the fact that research using catch trials (trials included in experiments to assess whether participants are paying attention or not) has shown failure rates ranging from 14% to 46% in a lab setting, surely participants completing tasks from their own homes would do just as badly, if not worse? We decided to investigate for ourselves. In two of our online studies, we added a catch trial as the study’s last trial, shown below.


Out of the 343 people who completed the two studies, only 3 participants failed the catch trial. That is less than 1% of participants! And we are not the only ones who have found promising results from studies using crowdsourcing platforms. Studies have shown that Turkers perform better on online attention checks than traditional subject pool participants and that MTurk Workers with high reputations can ensure high-quality data, even without the use of catch trials. Therefore, the quality of data from crowdsourcing platforms does not appear to be problematic. However, using catch trials is still a very popular and useful way of identifying participants who may not have completed tasks with enough care or attention.

Since the launch of MTurk, many similar platforms have appeared and advances have been made. MTurk has been used for everything from getting Turkers to write movie reviews to helping with missing persons searches. It’s safe to say that crowdsourcing is here to stay and has changed the way we conduct research online, with many of these sites’ tasks working on mobile and tablet platforms as well. While people have been using computers and web platforms in testing for a long time now, using crowdsourcing platforms for participant recruitment is still in its infancy. Since the launch of MTurk, many similar platforms have appeared and advances have been made. With many new possibilties emerging with the use of these platforms, it is an exciting time to be a researcher.

Reducing alcohol consumption in illicit drug users: new Cochrane review on psychotherapies

By Olivia Maynard @OliviaMaynard17

This blog originally appeared on the Mental Elf site on 28th January 2015


Whilst we all know that excessive alcohol consumption is bad for our health, illicit drug users are one group for whom problem alcohol use can be especially harmful, causing serious health consequences.

The prevalence of the hepatitis C virus is high among illicit drug users and problem alcohol use contributes to a poorer prognosis of this disease by increasing its progression to other diseases. In addition, rates of anxiety, mood and personality disorders are higher among illicit drug users, each of which is exacerbated by problem alcohol use.

Despite these health consequences, the prevalence of problem alcohol use is high among illicit drug users, with around 38% of opiate- and 45% of stimulant-using treatment-seeking individuals having co-occurring alcohol use disorders (Hartzler 2010; Hartzler 2011).

Previous Cochrane reviews have investigated the effectiveness of psychosocial interventions (or ‘talking therapies’) for either problem alcohol use, or illicit drug use alone. However, none have investigated the effectiveness of these therapies for individuals with concurrent problem alcohol and illicit drug use. Given the significant health risk and the high prevalence of concurrent problem alcohol and illicit drug use, a Cochrane review of this kind is long over-due.

Luckily, Kilmas and colleagues have done the hard work for us and their comprehensive Cochrane review of the literature evaluates the evidence for talking therapies for alcohol reduction among illicit drug users (Klimas et al, 2014).

This updated Cochrane review looks at psychotherapy for concurrent problem alcohol and illicit drug use.

The talking therapies we’re concerned with here are psychologically based interventions, which aim to reduce alcohol consumption without using any pharmacological (i.e. drug-based) treatments. Although there’s a wide range of different talking therapies currently used in practice, the ones which are discussed in this Cochrane review are:

  • Motivational interviewing (MI): this uses a client-centered approach, where the client’s readiness to change and their motivation, is a key component of the therapy.
  • Cognitive-behavioural therapy (CBT): this focuses on changing the way a client thinks and behaves. To address problem alcohol use, CBT approaches identify the triggers associated with drug use and use behavioural techniques to prevent relapse.
  • Brief interventions (BI): often BIs are based on the principles of MI and include giving advice and information. However, as implied by the name, BIs tend to be shorter and so are more suitable for non-specialist facilities.
  • The 12-step model: this is the approach used by Alcoholics Anonymous and operates by emphasising the powerlessness of the individual over their addiction. It then uses well-established therapeutic approaches, such as group cohesiveness and peer pressure to overcome this addiction.


  • The Cochrane review included all randomised controlled trials which compared psychosocial interventions with another therapy (whether that be other psychosocial therapies (to allow for comparison between therapies), pharmacological therapies, or placebo). Participants were adult illicit drug users with concurrent problem alcohol use
  • Four studies were included, involving 594 participants in total
  • The effectiveness of these interventions were assessed and the authors were most interested in the impact of these therapies on alcohol use, but were also interested in their impact on illicit drug use, participants’ engagement in further treatment and differences in alcohol related harms
  • The quality of the studies was also assessed

The quality of trials included in this review could certainly have been a lot better.


The four studies were very different, each comparing different therapies:

  • Study 1: cognitive-behavioural therapy versus the 12-step model (Carroll et al, 1998)
  • Study 2: brief intervention versus treatment as usual (Feldman et al 2013)
  • Study 3: group or individual motivational interviewing versus hepatitis health promotion (Nyamathi et al, 2010)
  • Study 4: brief motivational intervention versus assessment only (Stein et al, 2002)

Due to this heterogeneity, the results could not be combined and so each study was considered separately. Of the four studies, only Study 4 found any meaningful differences between the therapies compared. Here, participants in the brief motivational intervention condition had reduced alcohol use (by seven or more days in the past month at 6-month follow up) as compared with the control group (Risk Ratio 1.67; 95% Confidence Interval 1.08 to 2.60; P value = 0.02). However, no other differences were observed for other outcome measures.

Overall, the review found little evidence that there are differences in the effectiveness of talking therapies in reducing alcohol consumption among concurrent alcohol and illicit drug users.

The authors of this review also bemoan the quality of the evidence provided by the four studies and judged them to be of either low or moderate quality, failing to account for all potential sources of bias.

The review found no evidence that any of the four therapies was a winner when it came to reducing alcohol consumption in illicit drug users.


So, what does this all mean for practice?

In a rather non-committal statement, which reflects the paucity of evidence available, the authors report that:

based on the low-quality evidence identified in this review, we cannot recommend using or ceasing psychosocial interventions for problem alcohol use in illicit drug users.

However, the authors suggest that similar to other conditions, early intervention for alcohol problems in primary care should be a priority. They also argue that given the high rates of co-occurrence of alcohol and drug problems, the integration of therapy for these two should be common practice, although as shown here, the evidence base to support this is currently lacking.

And what about the comparison between the different talking therapies?

Again, rather disappointingly, the authors report that:

no reliable conclusions can be drawn from these data regarding the effectiveness of different types of psychosocial interventions for the target condition.

How about the implications for research? What do we still need to find out?

This review really highlights the scarcity of well-reported, methodologically sound research investigating the effectiveness of psychosocial interventions for alcohol and illicit drug use and the authors call for trials using robust methodologies to further investigate this.

Choosing a therapy for this group of patients is difficult with insufficient evidence to support our decision.


Klimas J, Tobin H, Field CA, O’Gorman CSM, Glynn LG, Keenan E, Saunders J, Bury G, Dunne C, Cullen W. Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD009269. DOI: 10.1002/14651858.CD009269.pub3.

Hartzler B, Donovan DM, Huang Z. Comparison of opiate-primary treatment seekers with and without alcohol use disorderJournal of Substance Abuse Treatment 2010;39 (2):114–23.

Hartzler B, DonovanDM,Huang Z. Rates and influences of alcohol use disorder comorbidity among primary stimulant misusing treatment-seekers: meta-analytic findings across eight NIDA CTN trialsThe American Journal of Drug and Alcohol Abuse 2011;37(5):460–71.

Carroll, K.M., Nich, C. Ball, S.A, McCance, E., Rounsavile, B.J. Treatment of cocaine and alcohol dependence with psychotherapy and dislfram. Addiction 1998; 93(5):713-27. [PubMed abstract]

Feldman N, Chatton A, Khan R, Khazaal Y, Zullino D. Alcohol-related brief intervention in patients treated for opiate or cocaine dependence: a randomized controlled studySubstance Abuse Treatment, Prevention, and Policy 2011;6(22):1–8.

Nyamathi A, Shoptaw S,Cohen A,Greengold B,Nyamathi K, Marfisee M, et al. Effect of motivational interviewing on reduction of alcohol useDrug Alcohol Dependence 2010;107(1):23–30. [1879–0046: (Electronic)]

Stein MD, Charuvastra A, Makstad J, Anderson BJ. A randomized trial of a brief alcohol intervention for needle exchanges (BRAINE). Addiction 2002;97(6):691. [:09652140] [PubMed abstract]

Mikhail Pogosov /

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Helping people with depression return to work

By Meg Fluharty, @MegEliz_

This blog originally appeared on the Mental Elf blog on 27th January 2015.


Depression is a major public health concern, with a wide range of symptoms, including hopelessness, fatigue, impaired concentration, feelings of inadequacy, as well as slowed thought and movement processing (APA 2013).

These symptoms not only impact upon an individuals’ personal life, but can impair social functioning and the ability to work (Hirschfeld 2000, Lerner 2008).

Within the US, depression was related to 27.2 lost workdays per ill worker per year, and a total of $36.6 billion capital lost in the US labour force (Kessler, 2006).

A new Cochrane systematic review and meta-analysis aims to evaluate the effectiveness of the current interventions available for reducing workplace disability in depressive disorder (Nieuwenhuijsen et al, 2014).

A US study from 2006 found that depression was related to 27.2 lost workdays per ill worker per year.


The authors searched the following databases between January 2006 and January 2014: CENTRAL, MEDLINE, psychINFO, EMBASE, and CINAHL. Studies were included if they were:

  • Randomised controlled trials (RCT) or cluster RCTs
  • Participants were adults (17+)
  • Participants were from occupational health, primary care, or outpatient care settings
  • Depressive criteria met diagnostic criteria, was assessed by a self-reported symptom scale, or by a clinical rated instrument.

Studies were excluded if participants had a primary diagnosis of a psychiatric disorder other than depressive disorder including bipolar depression and depression with psychotic tendencies.

The authors included both workplace (modify the task or hours) and clinical (antidepressant, psychological, or exercise) interventions, and the primary outcome examined was the number of illness-related absences from work during follow up (Nieuwenhuijsen et al, 2014).

Workplace adjustments


The original search yielded a total of 11,776 studies, and resulted in a full text assessment of 73 studies. 50 studies were excluded at the full-text stage- resulting in 1 study included in qualitative synthesis only, and 22 studies included within the meta-analysis.

Overall there were 20 RCTs and 3 Cluster RCTs, totalling 6,278 participants ranging from 20-200 participants between studies. 7 studies recruited from primary care settings, 10 from outpatient, 2 from occupational health, 1 from a managed care setting, and 1 was conducted in a community mental health centre (Nieuwenhuijsen et al, 2014).

Work directed interventions

5 work-directed interventions were identified:

  • There was moderate evidence that a work-directed intervention plus a clinical intervention reduced sick days when compared to clinical intervention alone or a work intervention alone
  • There was low evidence that an occupational therapy and return to work program was beneficial over occupational care as usual

The review found evidence to support a combination of work-directed interventions and clinical interventions.


6 studies investigated and compared the effectiveness of different antidepressant use, including SSRI, SNRI, TCA, MAO, and placebo:

  • There was no difference between SSRIs and TCAs in reducing sickness absence, while another study found low quality evidence that either TCAs or MAOs reduced absences over placebo
  • Overall, the results of this category were inconsistent

Psychological therapies

  • There was moderate evidence of online or telephone CBT against occupational care as usual for reduction of absences
  • Two studies displayed no evidence that community health nurse interventions helped any more than care-as-usual

Psychological therapies combined with antidepressants

  • Two studies found that enhanced primary care did not decrease sick days over 4-12 months, and another longer term study found similar results
  • However, there was high quality evidence that a telephone outreach management program can be effective in reducing sick leave compared to care-as-usual


  • There was low quality evidence that exercise was more effective than relaxing in sickness absence reduction
  • However, there was moderate evidence that aerobic exercise was not more effective than relation or stretching

The review found evidence to support the use of telephone outreach management programs (stern Matron optional).


This review evaluated a number of RCTs investigating work or clinical interventions. However, in each category, there was a large amount of variation between the studies and very few studies per category making comparisons difficult.

There was moderate evidence that work-directed interventions combined with a clinical intervention reduced sick leave, and that primary or occupational care combined with CBT also reduced absences. Additionally, there was evidence that a telephone outreach management program with medication reduced absences from work compared to care as usual.

This suggests the need for more research on work-directed interventions to be paired with clinical care, as they have the potential to reduce illness-related absences, but there are currently limited studies evaluating these interventions (Nieuwenhuijsen et al, 2014).

primary or occupational care combined with CBT also reduced absences.


Nieuwenhuijsen K, Faber B, Verbeek JH, Neumeyer-Gromen A, Hees HL, Verhoeven AC, van der Feltz-Cornelis CM, Bültmann U. Interventions to improve return to work in depressed people. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD006237. DOI: 10.1002/14651858.CD006237.pub3.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.

Hirschfeld RM, Montgomery SA, Keller MB, Kasper S, Schatzberg AF, Moller HJ, et al. Social functioning in depression: a review. Journal of Clinical Psychiatry 2000; 61 (4):268–75. [PubMed abstract]

Lerner D, Henke RM. What does research tell us about depression, job performance, and work productivity? (PDF) Journal of Occupational and Environmental Medicine 2008; 50(4):401–10.

Kessler RC, Akiskal HS, Ames M, Birnbaum H, Greenberg P, Hirschfeld RM, et al. Prevalence and effects of mood disorders on work performance in a nationally representative sample of U.S. workers. American Journal of Psychiatry 2006; 163(9):1561–8.

Department of Health (2012). Advice for employers on workplace adjustments for mental health conditions (PDF). Department of Health, May 2012.

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Research Responsibly: Things to Consider when Science and Politics Meet

By Meryem Grabski

It might not come as a surprise that doing a PhD is not always fun. One thing that gets me through those difficult, yet inevitable, times is the idea that the research I am doing could potentially make a difference for the better. I am sure this is true for many people involved in research fields that touch upon big societal questions such as health, climate change, economics, or education.

Surprisingly though, I realized a little while ago that I have given little thought to how relevant findings make their way to those who implement societal changes, such as policy makers. Usually scientists are trained to communicate their findings to other scientists, not politicians (or the general public, the people that empower the policy makers in the first place, but I will leave this important issue to one side for now). So what should scientific advice to policy makers look like? Is a brief summary of the research outcomes adequate or should a preference for the implementation of the findings be stated?

I started thinking about this after a discussion in our weekly lab meeting about an article published by Tamsin Edwards, a climate scientist. She describes how her refusal to give specific recommendations for political courses of action has sometimes been met with criticism – from environmentalists and members of the public, as well as fellow climate scientists. She gets accused of having a hidden political agenda, not fulfilling her role as an expert sufficiently, and failing to act and therefore delaying important and pending decisions. Even if some of these points are valid, a counter-argument could equally be made that openly stating political preferences could impact scientific impartiality and lead to the abuse of science to serve political agendas.

This complex issue is described in a model by Pielke, which characterizes four ways in which scientists can position themselves towards policy making. These roles, described in more details in Pilke’s book The Honest Broker: Making Sense of Politics and Policy are briefly summarized below, as well as their potential benefits and pitfalls.

The “pure scientists” do research for the sake of research only and have no further interest in the application of the findings. In reality, this type of “ivory tower” scientist is very rare today, especially in fields where findings might have a potential impact on society.

Pros: Maximal impartiality; because pure scientists are not interested in engaging in political decision-making, they are least likely to be biased towards one specific outcome.

Cons: Since pure scientists are not motivated to make scientific findings accessible, they are not facilitating the implementation of their findings, therefore making them useless for society. Even the publication of findings in scientific journals is often trapped behind expensive paywalls and therefore not accessible by interested members of the public.

issue advocatThe “issue advocates” can be placed on the other end of the continuum of involvement with politics. They believe that participating in the political decision making process is an important part of their role as a scientist. The issue advocate is dedicated to a specific political agenda or outcome, and therefore more likely to narrow the view of the advice seeker to one specific course of action, in line with their own views.

Pros: As the political opinion of the issue advocates is laid out openly, they might be less suspected of having a “hidden political agenda” (even though, in the case of “stealth advocacy”, the opposite could be the case as explained below). Acting as an expert with a specific goal in mind, an issue advocate might be more efficient in aiding policy makers with the fast implementation of findings.

Cons: Issue advocates might be more likely to be biased towards specific research outcomes (as they strongly favour one political outcome they are likely to be in a dilemma when their research findings do not support this outcome). Pielke describes the danger of “stealth issue advocacy”, which refers to a scientist hiding a political agenda while claiming to focus on the science. This usually results in scientific “facts” being manipulated for political debate. This behaviour can harm the credibility of scientific claims in general.

The “science arbiters” believe that science should not be directly involved in political decision making, but are willing to act as experts to inform policy making. Science arbiters focus on narrow, scientifically testable questions in order to stay removed from political debate.

Pros: More useful to society than “pure scientists”, as they are willing to act as scientific experts if specific questions are asked.

Cons: Science arbiters could be accused of being too passive, as they are only reacting to requests, but not actively engaging in sharing their knowledge.

honest brokerThe “honest broker of policy alternatives” is, as compared to the science arbiter, actively seeking to integrate scientific findings in policy decision making by providing policy makers with clarification on specific questions and presenting several alternatives of political action. The honest broker is, in contrast to the issue advocate, not interested in a specific political outcome but in simply engaging with policy decision makers in order to integrate scientific knowledge into the decision making process. Tamsin Edward’s stance towards policy making could be described as “honest brokering”.

Pros: The honest broker is a great facilitator of scientific expertise to society.

Cons: The role of the honest broker seems difficult to maintain for one person alone as they are very actively engaged in politics but at the same time have to remain completely impartial to one specific political outcome and furthermore should examine the issue from several aspects. Pielke suggests that committees and bodies of several experts could act as an honest broker together.

Pielke further elaborates on which role might be most suitable, taking into account the degree of consensus on political values and the degree of uncertainty in scientific knowledge. Admittedly the different roles described are idealized and in reality might not quite fit into this abstract framework.

I personally found two important points to take away from this discussion: Firstly, it is crucial to understand that there are different options regarding how to discuss scientific findings with policy makers. Secondly, there is no perfect one-size-fits-all approach concerning which option to choose, as each option has advantages and disadvantages. I believe that reflecting on the issue and discussing it, privately, like we did in our lab group or, like Edwards, in an open debate, are a good start to finding a personal stance towards policy making. This might seem laborious and time consuming but, in my opinion, should be integral to all scientists, who pride themselves with doing science that matters.