Category: intervention

Maximum cigarette pack size: a neglected aspect of tobacco control

Posted on by annablackwell

Written by Anna Blackwell, Senior Research Associate

The manufacturing or importing of packs of cigarettes with fewer than 20 cigarettes per pack was prohibited in the UK when the EU Tobacco Products Directive and standardised packaging legislation were fully implemented in May 2017. This change was aimed at reducing the affordability of cigarettes and thereby discouraging young people from smoking. This directive also required the removal of branding and established a standard shape and dark green colour for packaging, including pictorial health warnings, which prevented the use of packaging for promotion and reduced its appeal.

However, the tobacco industry has been able to exploit loopholes in recent packaging regulations, including the absence of a regulated maximum pack size, by introducing non-standard and larger pack sizes to the market to distinguish products. This is a public health concern given evidence that larger pack sizes are linked to increased smoking, and could undermine existing tobacco control success.

In a recent Addiction Opinion and Debate paper, we proposed that a cap on cigarette pack size should be introduced; a pragmatic solution would be to permit only a single pack size of 20, which is now the minimum in many countries. This approach would reduce the number of cigarettes in packs in several countries such as Australia – where packs up to sizes of 50 are available – and prevent larger sizes being introduced elsewhere.

Capping cigarette pack size therefore has the potential to both reduce smoking and prevent increased smoking. While the health benefits of reducing smoking alone are small, it may have important indirect effects on health through its role in facilitating quitting. Those smoking fewer cigarettes per day are more likely to attempt to quit and succeed in doing so. Trials of smoking-reduction interventions have also found that these can lead to increased quitting when combined with nicotine replacement therapy.

Our Opinion and Debate paper drew on evidence from a range of sources including industry documents and analyses, population surveys, intervention trials and Mendelian randomization analyses. Together these suggest that consumption increases with larger pack size, and cessation increases with reduced consumption. However, direct experimental evidence is not currently available to determine whether pack size influences the amount of tobacco consumed, or whether the association is due to other factors.

People who want to quit may be using smaller packs as a method of self-control, and smokers who successfully cut down and later quit may be more motivated to do so. Cost is also an important factor and larger packs may be linked to increased smoking because they have a lower cost per cigarette. Further research is needed to determine whether the associations between pack size, smoking and cessation are causal to estimate the impact of policies to cap cigarette pack size.

Commentaries on our Opinion and Debate paper, published in the May 2020 Issue of Addiction highlight the need to understand the mechanisms for the associations observed between pack size and smoking in order to identify the optimal cigarette pack size. Although mandating packs of 20 is a pragmatic approach, pack size regulation needs to achieve a compromise between tobacco affordability and smokers’ self-regulation. Nevertheless, the policy debate should start now to address this neglected aspect of tobacco control.

To find out more visit the Behaviour Change by Design website or follow us on Twitter @BehavChangeDsgn @BristolTARG

Understanding Anorexia – Promoting Life through Prevention

Posted on by Will Gawned

An essay by Caitlin Lloyd.

Emma was an anxious child, always worrying. At thirteen, her anxiety became centered on interactions at school – she was terrified of being judged negatively by classmates. Around this time Emma began dieting, intending to lose just a small amount of weight. It turned out she could do so relatively easily, and enjoyed the sense of achievement resulting from the numbers on the scale going down. Her diet continued, becoming more and more extreme. Emma’s weight plummeted.

Eight years later, having had two inpatient hospital admissions, Emma maintains a dangerously low body weight, achieved by setting strict rules around eating. A daily calorie limit is followed, and foods containing fat and sugar avoided. Eating takes place only at certain times, and each mouthful must be chewed ten times before swallowing. Any deviation from these rules, and the day is ruined.

Emma retook two years at school, falling behind her peers, but secured a place at Durham University to study mathematics. It is difficult to concentrate on her work though, because all Emma can think about is food: what she has eaten; and what she will eat. Her focus on food makes it hard to maintain friendships, and Emma has few. Emma spends university holidays with her family, the time dominated by arguments over food.

Sometimes Emma wishes things were different. But that means eating more, which feels impossible. Deviating from the rules makes Emma unbearably anxious. No amount of support can dispel the intense fear of becoming fat, or feelings of self-disgust that accompany weight-gain.

Emma is fictional but typical of someone with anorexia nervosa, an eating disorder characterised by persistent starvation in the context of a low weight and fear of weight-gain. In the UK it is estimated that as many as one in 25 women will experience anorexia in the course of their lifetime. Men develop anorexia too; roughly one in ten people with anorexia is male.

Anorexia usually develops during adolescence, and has many adverse yet long-lasting physical and mental health consequences. Starvation compromises the function of almost all major organ systems, and feelings of despair increase the risk of suicide; anorexia has the highest death rate of any mental health disorder.

Full recovery from anorexia is a lengthy process, and unfortunately not common. Treatments exist but not one is consistently effective. Fewer than half of those diagnosed with anorexia make a full recovery, and relapse rates are high – around 30-40% of people fall back into the disorder’s grip following initial recovery. For some, weight-gain is sustained, but a strict diet and overconcern with eating and weight remains, severely impacting quality of life.

The difficulty treating anorexia makes effective prevention vital. For this we need to target the factors that cause anorexia, requiring knowledge of what those factors are. My research investigates whether anxiety disorders play a causal role in anorexia development, to help us understand whether it would be beneficial to address anxiety in young people to prevent eating disorders.

It has long been suggested that the starvation of anorexia reduces anxiety. This would make dieting helpful (in this narrow sense) to those experiencing anxiety symptoms, encouraging the dieting to continue. Anxiety disorders and anorexia often co-occur. But correlation is not causation, and determining cause-and-effect is notoriously challenging.

As an example, for anxiety to cause anorexia development, anxiety must precede anorexia. Existing findings support this, however studies have tended to ask people with anorexia to recall the time before their illness developed. Experiencing anorexia may affect memory recall; to try and explain how their anorexia developed, someone with anorexia might believe themselves to have been more anxious in childhood than they actually were. In this case the conclusion that anxiety causes anorexia may be invalid. Many sources of potential error exist in research, meaning that many findings could be inaccurate, at least to some degree.

Different research methods have different strengths and limitations, and are thus prone to different biases. This can be used to our advantage: if findings across studies of different research methods point to the same conclusion, we can be more confident the conclusion is correct. I am using a variety of research methods, each designed to minimise the potential for erroneous conclusions, to determine the role of anxiety in anorexia. If a causal role is supported across the different studies, trialing interventions designed to reduce anxiety for eating disorder prevention is encouraged. If not, the search for other factors to target for improved eating disorder prevention continues.

We are at an early stage in understanding anorexia, but we do know that many people with the illness become ill at a young age, with their whole lives ahead – like Emma. My research matters because it aims to stop people losing their lives, and quality of life, to anorexia.

 

The House of Commons Science and Technology Committee reports on e-cigarettes

Posted on by Sarah Burrows-Weeks

Written by Jasmine Khouja, PhD Student, Tobacco and Alcohol Research Group

Today sees the publication of a report on electronic cigarettes (e-cigarettes) by the House of Commons Science and Technology Committee. This compiles evidence from over 100 pieces of written submissions and five oral sessions, and highlights key issues around reducing harm, promoting smoking cessation and effectively regulating e-cigarettes. Since the report is quite long, we’ve tried to extract the main messages.

The report takes a relatively positive stance on e-cigarettes, encouraging use for smoking cessation and suggesting a more accepting approach to e-cigarettes in public spaces. This is in contrast to other countries, such as Australia, where a ban is in place due to the lack of long-term research on the health impact of using e-cigarettes.

Reducing harm

The general consensus from a variety of sources is that e-cigarettes are less harmful than combustible cigarettes. However, a frequent theme is that this does not mean that e-cigarettes are ‘safe’, and the report is careful to emphasise that e-cigarettes are not completely harmless. The relative harm of heat-not-burn tobacco products compared to combustible cigarettes is less clear. There is a lack of independent evidence as the majority of data on the safety and emissions of these product has come from Philip Morris, a major tobacco company.

The long-term effects of using e-cigarettes are currently unknown. It is difficult to assess the comparative harm of e-cigarettes without also measuring the effects of prior smoking, since there are very few long-term e-cigarette users who have never smoked. Exposure to second-hand e-cigarette vapour has been similarly difficult to assess, but since potentially harmful compounds emitted are present only at very low levels second-hand vapour is unlikely to be harmful.

E-cigarettes have become a popular tool for quitting smoking and an estimated 16,000 to 22,000 people who would not have quit using alternative products or willpower alone have successfully quit each year by using e-cigarettes. Although these figures are promising, there is a lack of high-quality evidence from randomised control trials showing how effective e-cigarettes are when quitting smoking. Other evidence has been inconclusive due to the low quality of some studies.

Despite fears that e-cigarettes may act as a ‘gateway’ to smoking, current evidence does not show that using e-cigarettes causes people to start smoking. Although there is a link between e-cigarette use and subsequent smoking initiation, very few never smokers regularly use e-cigarettes, so any causal link would have a limited impact on smoking rates.

Smoking cessation

Providing e-cigarettes on prescription could encourage smokers to try e-cigarettes without barriers such as money as well as give them more confidence in the product being less harmful than cigarettes. The report concludes that e-cigarettes should be available to those in NHS mental health services given high rates of smoking in this group.

NHS England were unable to provide evidence for how they were addressing this issue. They were unable to provide a representative because there is no one individual responsible centrally with ‘oversight’ of e-cigarette policies across NHS mental health trusts. The report criticises this, stating it was concerning and that a position should be created as a matter of urgency.

E-cigarettes are generally prohibited in closed spaces such as workplaces, public transport and restaurants and vapers are usually encouraged to vape outside within designated ‘smoking’ areas. Since second-hand vapour is unlikely to be harmful, these policies may be more harmful than beneficial; frequently exposing vapers to cigarettes and cigarette smoke may increase the likelihood that they will relapse to smoking.

Regulation

E-cigarettes are currently regulated under the Tobacco Products Directive (TPD; see our previous blog) if you want to learn more about these regulations). As part of this directive, the Medicines and Healthcare products Regulatory Agency must be notified before any e-cigarette or e-liquid can be sold in the UK.

Four key criticisms of the TPD were identified in the report: i) unnecessary limits on nicotine strength of refill liquids which may lead to failed quit attempts, ii) unnecessary tank size restrictions which may lead to failed quit attempts, iii) blocking advertising the relative harm-reduction of e-cigarettes which may discourage quit attempts, and iv) the ineffective notification scheme for e-cigarette ingredients which slows innovation.

Some TPD regulations are optional and give freedom to governments to be as restrictive as they feel necessary. Scotland has been more restrictive than England in their regulations by banning certain advertising of vapour products. Currently, health claims are banned from all media advertising of e-cigarettes without a medical license (of which none is currently available). The Advertising Standards Authority is currently reviewing the legislation on e-cigarette advertising and health claims and are considering allowing this in the future.

Unsurprisingly, there is uncertainty about the future regulation of e-cigarettes due to Brexit. Regulation of e-cigarettes may change after leaving the European Union and it is unclear what these changes may be or what potential impact increased flexibility in regulating e-cigarettes could have.

Conclusions

The report is comprehensive and raises some interesting questions particularly about the lack of NHS involvement in developing strategies for smoking cessation that utilise e-cigarettes. It will be interesting to see if the NHS responds to these criticisms by taking action. I am also interested to see what Brexit will mean for the regulation of e-cigarettes in the UK, given the criticisms of TPD regulations.

The full report can be accessed here: [The House of Commons Science and Technology Committee reports on e-cigarettes]

 

Can cognitive interventions change our perception from negative to positive, and might that be useful in treating depression?

Posted on by annablackwell

By Sarah Peters

Have you ever walked away from a social interaction feeling uncomfortable or anxious? Maybe you felt the person you were talking to disliked you, or perhaps they said something negative and it was all you could remember about the interaction. We all occasionally focus on the negative rather than the positive, and sometimes ruminate over a negative event, but a consistent tendency to perceive even ambiguous or neutral words, faces, and interactions as negative (a negative bias), may play a causal role in the onset and rate of relapse in depression.

A growing field of psychological interventions known as cognitive bias modification (CBM) propose that by modifying these negative biases it may be possible to intervene prior to the onset of depression, or prevent the risk of subsequent depressive episodes for individuals in remission. Given that worldwide access to proven psychological and pharmacological treatments for mood disorders is limited, and that in countries like the UK public treatment for depression is plagued by long waiting lists, high costs, side effects, and low overall response rates, there is a need for effective treatments which are inexpensive, and both quick and easy to deliver. We thought that CBM might hold promise here, so we ran a proof of principle trial for a newly developed CBM intervention that shifts the interpretation of faces from negative to positive (a demonstration version of the training procedure can be seen here). Proof of principle trials test an intervention in a non-patient sample, which is important to help us understand a technique’s potential prior to testing it in a clinical population – we need to have a good idea that an intervention is going to work before we give it to people seeking treatment!

In this study, we had two specific aims. Firstly, we aimed to replicate previous findings to confirm that this task could indeed shift the emotional interpretation of faces. Secondly, we were interested in whether this shift in interpretation would impact on clinically-relevant outcomes: a) self-reported mood symptoms, and b) a battery of mood-relevant cognitive tasks. Among these were self-report questionnaires of depressive and anxious symptoms, the interpretation of ambiguous scenarios, and an inventory of daily stressful events (e.g., did you “wait too long in a queue,” and “how much stress did this cause you on a scale of 0 to 7”). The cognitive tasks included a dot probe task to measure selective attention towards negative (versus neutral) emotional words, a motivation for rewards task which has been shown to measure anhedonia (the loss of pleasure in previously enjoyed activities), and a measure of stress-reactivity (whereby individuals complete a simple task under two conditions: safe and under stress). This final task was included because it is thought that the negative biases we were interested in modifying are more pronounced when an individual is under stress.

We collected all of our self-report and cognitive measures at baseline (prior to CBM), after which participants underwent eight sessions (in one week) of either CBM or a control version of the task (which does not shift emotional interpretation). We then collected all of our measures again (after CBM). In order to be as sure of our results as possible, there were a number of critical study design features we used. Our design, hypotheses, and statistical analyses were pre-registered online prior to collecting data (this meant that we couldn’t fish around in our data until we found something promising, then re-write our hypotheses to make that result seem stronger). We also powered our study to be able to detect an effect of our CBM procedure. This meant running a statistical calculation to ensure we had enough participants to be convinced by any significant findings, and their potential to be clinically useful. This told us we needed 104 individuals split evenly between groups. Finally, our study was randomised (participants were randomly allocated to the intervention group or the control group), controlled (one group underwent an identical “placebo” procedure), and double-blind (only an individual who played no role in recruitment or participant contact knew which group any one participant was in).

So, what did we actually find? While the intervention successfully shifted the interpretation of facial expressions (from negative to positive), there was only inconclusive evidence of improved mood and the CBM procedure failed to impact most measures. There was some evidence in our predicted direction that daily stressful events were perceived as less stressful by those in the intervention group post-CBM, and weaker evidence for decreased anhedonia in the intervention group. In an exploratory analysis, we also found some evidence that results in the stress-reactivity task were moderated by baseline anxiety scores – for this task, the effects of CBM were only seen in individuals who had higher baseline anxiety scores. However, exploratory findings like this need to be treated with caution.

Therefore, as is often the case in scientific research, our results were not entirely clear. However, there are a few limitations and directions for future research that might explain and help us to interpret our findings. Our proof of principle study only considered effects in healthy individuals. Although these individuals were clearly amenable to training, and may indeed have symptoms of depression or anxiety without a clinical diagnosis, our observation that more anxious individuals appeared to be more affected by the intervention warrants research in clinical populations. In fact, a reasonable parallel to the effects observed in this study may be working memory training, which does not transfer well to other cognitive operations in healthy samples, but shows promise as a tool for general cognitive improvement in impaired populations.

Future research is also needed to disambiguate the tentative self-report stress and cognitive anhedonia effects observed here. One possibility, for example, is that the 104 participants we recruited were not enough to detect an effect of transference from CBM training to other measures (the size of which is unknown). Given the complexity of any mechanism through which a computerised task could shift the perception of faces and then influence behaviour, it is likely that a larger sample is necessary. While it could be argued that if such a large group of individuals is warranted to detect an effect, that effect is likely too small to be clinically useful, we would argue that even tiny effects can indeed be meaningful (e.g., cancer intervention studies often identify very small effects which can have a meaningful impact at a population level).

Another explanation for our small effects is that while one week was long enough to induce a change in bias, it may not have been long enough to observe corresponding changes in mood. For instance, positive interpretation alone may not be enough – it may be that individuals need to go out into the world and use this new framework to have personal, positive experiences that gradually improve mood, and this process may take longer than one week.

Overall, this CBM procedure may have limited impact on clinically-relevant symptoms. However, the small effects observed still warrant future study in larger and clinical samples. Given the large impact and cost of mood disorders on the one hand, and the relatively low cost of providing CBM training on the other, clarifying whether even small effects exist is likely worthwhile. Even if this procedure fails to result in clinical improvement, documenting and understanding the different steps in going from basic scientific experimentation to intervening in clinical samples is crucial for both the scientific field and the general public to know. The current study is part of a body of research which should encourage all individuals who are directly or indirectly impacted by depression or other mood disorders. Novel approaches towards understanding, preventing, and treating these disorders are constantly being investigated, meaning that we can be hopeful for a reduction in the devastating impact they currently have in the not so distant future.

Read the published study here

Sarah Peters can be contacted via email at: s.peters@bristol.ac.uk