Category: Mental elf

Motivational interviewing may help people quit smoking, but more research is needed

Posted on by meryemgrabski

by Olivia Maynard @OliviaMaynard17

This blog originally appeared on the Mental Elf site on 30th April 2015.

Both pharmacological (i.e. bupropion and varenicline) and non-pharmacological (i.e. brief advice from physicians) interventions have been shown to be effective in assisting people to stop smoking. Evidence also suggests that combining both these types of interventions can help people to stop smoking and both are considered equally important in quitting success.

Motivational interviewing (MI) is a counselling-based intervention which focusses on encouraging behaviour change by helping people to explore and resolve their uncertainties about changing their behaviour. MI avoids an aggressive or confrontational approach and aims to increase the self-belief of the individual. MI was initially developed to treat alcohol abuse, but may be helpful in encouraging smoking cessation.

In a recent Cochrane systematic review, Lindson-Hawley and colleagues from the Cochrane Tobacco Addiction Group aimed to determine whether or not MI is an effective method of smoking cessation (Lindson-Hawley et al, 2015).

Motivational interviewing focusses on encouraging behaviour change by helping people to explore and resolve their uncertainties about changing their behaviour.

Methods

The authors searched online databases and studies were included if:

  • Participants were tobacco users and were not pregnant or adolescents;
  • The intervention was based on MI techniques;
  • The control group received brief advice or usual care;
  • Some monitoring of the quality of the MI intervention was included;
  • Smoking abstinence was reported at least 6 months after the start of the programme.

The main outcome measure was smoking abstinence, using the most rigorous definition of abstinence for each study. Biochemically-validated measures of abstinence (i.e., carbon monoxide breath testing or saliva cotinine samples) were also used where available. Those participants lost to follow-up were considered to be continuing to smoke.

Results across studies were combined in a meta-analysis.

Results

Twenty eight studies published between 1997 and 2014 were found to match the strict inclusion criteria.

The total dataset included over 16,000 participants and studies varied in:

  • The length of the MI sessions (ranging from 10 to 60 minutes)
  • The number of sessions (one to six sessions)
  • Who the sessions were delivered by (primary care physicians, hospital clinicians, nurses or counsellors)

Some of the main findings included:

  • A modest (26%) increase in quitting among those receiving MI as compared with control (although the true value is likely to lie between 16-36%).
  • Sub-group analyses found that:
    • MI delivered by primary care physicians increased the likelihood of successful quitting by 349% (53-794%) as compared with control
    • When it was delivered by counsellors, quit rates increased by only 25% as compared with control
    • MI delivered by nurses was not found to be more effective than control
  • Shorter sessions (less than 20 minutes) increased the chances of quitting relative to control by 69%, as compared with longer sessions, which only increased the chances of quitting by 20%.
  • There was little difference in the likelihood of quitting between single MI sessions (26%) and multiple sessions (20%) as compared with control.
  • There was little difference between MI delivered face-to-face as compared with via the telephone only.
  • There was no evidence for a difference for MI delivered to smokers who were motivated to quit as compared with those with low levels of motivation.

Compared with brief advice or usual care, motivational interviewing yielded a significant increase in quitting. However, study quality means that these results should be interpreted with caution.

Strengths

This review adds 14 additional studies to a previous review conducted in 2010. The addition of these new studies altered the results of the original review very little, providing strong support for the validity of these findings.

Two previous systematic reviews have also examined the effectiveness of MI for smoking cessation, observing modest positive effects of MI (Heckman et al., 2010, Hettema and Hendricks, 2010), although these studies used a broader inclusion criteria than used here and therefore may have underestimated the effects of MI.

The majority of studies included in this review adequately reported their design and methods. Some studies did not report information about blinding of the outcome assessment or how participants were allocated to conditions. However, sensitivity analyses indicated that these factors did not influence the findings of the review.

Limitations

The authors report some evidence for publication bias, such that studies reporting a positive effect of MI were more likely to be published, potentially compromising the results of this systematic review.

Eight of the 24 studies did not use biochemically-validated measures of abstinence. When analyses excluded these studies, the size of the beneficial effect of MI increased. Future research should use the biochemically-validated abstinence measures so as to ensure that smoking cessation is reliably reported.

Conclusions

These results indicate that MI is more effective at promoting smoking cessation than usual care or brief advice, although the effect is modest.

Some components of MI counselling appear to increase the effectiveness of MI for smoking cessation, including delivery by a primary care physician. The reviewers suggest that physicians may be better placed to use the MI approach given their established rapport with the patient. However, this effect is based on only two studies and therefore the importance of physician delivery should not be overstated.

Shorter sessions and fewer follow-ups were also found to be more effective than longer sessions with more follow-up sessions. One explanation given by the authors is that a single session is enough to motivate someone to quit smoking. Prolonging the time before the quit date may mean participants lose focus on their goal to stop smoking.

While MI seems to be effective in promoting smoking cessation, future research should continue to explore the components of MI which optimise the success of this intervention. The relationship between non-pharmacological interventions such as MI and pharmacological interventions should also be considered.

This review confirms that motivational interviewing for smoking cessation is supported by moderate level evidence.

Links

Primary paper

Lindson-Hawley N, Thompson TP, Begh R. Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD006936. DOI: 10.1002/14651858.CD006936.pub3.

Other references

Heckman, C. J., Egleston, B. L. & Hofman, M. T. (2010). Efficacy of motivational interviewing for smoking cessation: a systematic review and meta-analysis. Tobacco Control, 19, 410-416.

Hettema, J. E. & Hendricks, P. S. (2010). Motivational interviewing for smoking cessation: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78, 868-884. [DARE summary]

 

E-cigarettes and teenagers: cause for concern?

Posted on by meryemgrabski

By Marcus Munafo @MarcusMunafo 

This blog originally appeared on the Mental Elf site on 20th April 2015

shutterstock_208797175

Electronic cigarettes (e-cigarettes) are a range of products that deliver vapour which typically contains nicotine (although zero-nicotine solutions are available). The name is misleading because some products are mechanical rather than electronic, and because they are not cigarettes. While first-generation products were designed to be visually similar to cigarettes, second- and third-generation products are visually distinctive and come in a variety of shapes and sizes. Critically, these products do not contain tobacco, and are therefore intended to deliver nicotine without the harmful constituents of tobacco smoke.

There has been rapid growth in the popularity and use of e-cigarettes in recent years, accompanied by growth in their marketing. At present they are relatively unregulated in many countries, although countries are introducing various restrictions on their availability and marketing. For example, a ban on sales to under-18s will be introduced in England and Wales in 2015.

These products have stimulated considerable (and often highly polarized) debate in the public health community. On the one hand, if they can support smokers in moving away from smoking they have enormous potential to reduce the harms associated with smoking. On the other hand, the quality and efficacy of these products remains largely unknown and is likely to be highly variable, and data on the long-term consequences of their use (e.g., the inhalation of propylene glycol vapour and flavourings) is lacking. There is also a concern that these products may re-normalise smoking, or act as a gateway into smoking.

E-cigarettes and teenagers: a gateway

Methods

This study reports the results of a survey conducted by Trading Standards in the North-West of England on 14 to 17 year-old students. The survey focuses on tobacco-related behaviours, and a question on access to e-cigarettes was introduced in 2013. This enabled identification of factors associated with e-cigarette use among people under 18 years old.

The study used data from the 5th Trading Standards North West Alcohol and Tobacco Survey among 14 to 17 year-olds in North-West England, conducted in 2013. The questionnaire was made available to secondary schools across the region through local authority Trading Standards departments, and delivered by teachers during normal school lessons. Compliance was not recorded, and the sample was not intended to be representative but to provide a sample from a range of communities.

The survey consisted of closed, self-completed questions covering sociodemographic variables, alcohol consumption and tobacco use. There were also questions on methods of access to alcohol and tobacco, as well as involvements in violence when drunk. E-cigarette access was assessed by the question “Have you ever tried or purchased e-cigarettes?”.

The study used data from the North West Alcohol and Tobacco Survey, which asked 14 to 17 year-olds lots of questions about their substance use behaviour.

Results

A total of 114 schools participated, and the total dataset included 18,233 participants, of which some were removed for missing data or spoiled questionnaires (e.g., unrealistic answers), so that the final sample for analysis was 16,193. Some of the main findings of the survey included:

  • In total, 19.2% of respondents reported having accessed e-cigarettes, with this being higher in males than females, and increasing with age and socioeconomic deprivation.
  • Level of e-cigarette access was higher among those who had smoked, ranging from 4.9% of never smokers, through 50.7% of ex-smokers, 67.2% of light smokers and 75.8% of heavy smokers.
  • E-cigarette use was associated with alcohol use, with those who drank alcohol more likely to have accessed e-cigarettes than non-drinkers, as well as with smoking by parents/guardians.

Nearly 1 in 5 of the young people surveyed

Conclusion

The authors conclude that their results raise concerns around the access to e-cigarettes by children, particularly among those who have never smoked cigarettes. They argue that their findings suggest that the children who access e-cigarettes are also those most vulnerable to other forms of substance use and risk-taking behavior, and conclude with a call for the “urgent need for controls on e-cigarette sales to children”. The study has some important strengths, most notably its relatively large size, and ability to determine which respondents were living in rich and poor areas.

Understanding the determinants of e-cigarette use, and patterns of use across different sections of society, is important to inform the ongoing debate around their potential benefits and harms. However, it is also not clear what this study tells us that was not already known. The results are consistent with previous, larger surveys, which show that young people (mostly smokers) are trying e-cigarettes. Critically, these previous surveys have shown that while some young non-smokers are experimenting with electronic cigarettes, progression to regular use among this group is rare. Product labels already indicate that electronic cigarettes are not for sale to under-18s, and in 2014 the UK government indicated that legislation will be brought forward to prohibit the sale of electronic cigarettes to under-18s in England and Wales (although at present no such commitment has been made in Scotland).

This study does not add anything significant to our knowledge about e-cigarettes.

Limitations

There are a number of important limitations to this study:

  • As the authors acknowledge, this was not meant to be a representative survey, and the results can therefore not be generalized to the rest of the north-west of England, let alone the wider UK.
  • As a cross-sectional survey it was not able to follow up individual respondents, for example to determine whether never smokers using e-cigarettes progress to smoking. This problem is common to most e-cigarette surveys to date.
  • The question asked does not tell us whether the participants actually used the e-cigarette they accessed, or what liquid was purchased with the e-cigarette (e.g., the concentration of nicotine). Zero-nicotine solutions are available, and there is evidence that these solutions are widely used by young people.
  • The results are presented confusingly, with numerous percentages (and percentages of percentages) reported. For example, 4.9% of never smokers reported having accessed e-cigarettes, but this is less than 3% of the overall sample (fewer than 500 out of 16,193 respondents). This is potentially an important number to know, but is not reported directly in the article.

Summary

This study does not add much to what is already known. Young people experiment with substances like tobacco and alcohol, and as e-cigarettes have become widely available they have begun to experiment with these too. However, to describe electronic cigarette use as “a new drug use option” and part of “at-risk teenagers’ substance using repertoires” is probably unnecessarily alarmist, given that:

  1. There is evidence that regular use of e-cigarettes among never smokers is negligible
  2. There is little evidence of e-cigarette use acting as a gateway to tobacco use
  3. The likelihood that e-cigarette use will be associated with very low levels of harm

It's alarmist to suggest

Links

Primary reference

Huges K, Bellis MA, Hardcastle KA, McHale P, Bennett A, Ireland R, Pike K. Associations between e-cigarette access and smoking and drinking behaviours in teenagers. BMC Public Health 2015; 15: 244. doi: 10.1186/s12889-015-1618-4

Other references

Young Persons Alcohol and Tobacco Survey 2013. Lancashire County Council’s Trading Standards.

New evidence on the effects of plain cigarette packaging in Australia

Posted on by meryemgrabski

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.

Methods

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.

Results

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.

Conclusions

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

Links

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 smokers. Tobacco Control 2015;24:Suppl 2 ii26–ii32 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

Posted on by meryemgrabski

By Eleanor Kennedy @Nelllor_

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

shutterstock_27220114

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.

Methods

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.

Results

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

Conclusions

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.

Links

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.

Is moderate alcohol consumption good for you?

Posted on by meryemgrabski

By Marcus Munafo @MarcusMunafo 

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

wine

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).

Methods

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.

Results

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.

Conclusions

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.

Link

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.

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

Posted on by meryemgrabski

By Olivia Maynard @OliviaMaynard17

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

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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.

Methods

  • 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.

Results

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.

Conclusions

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.

Links

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 disorder. Journal 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 trials. The 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 study. Substance 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 use. Drug 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 / Shutterstock.com

– See more at: http://www.thementalelf.net/mental-health-conditions/substance-misuse/reducing-alcohol-consumption-in-illicit-drug-users-new-cochrane-review-on-psychotherapies/#sthash.DgftSUSM.dpuf

Helping people with depression return to work

Posted on by meryemgrabski

By Meg Fluharty, @MegEliz_

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

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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.

Methods

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

Results

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.

Antidepressants

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

Exercise

  • 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).

Discussion

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.

Links

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.

– See more at: http://www.thementalelf.net/mental-health-conditions/depression/helping-people-with-depression-return-to-work/#sthash.7fnmUfRX.dpuf

One new drug a week: club drugs and novel psychoactive substances

Posted on by oliviamaynard

By Meg Fluhart, @MegEliz_

This blog originally appeared on the Mental Elf blog on 24th October 2014

A recent report from the Faculty of Addictions at the Royal College of Psychiatrists has highlighted the changing face of drug abuse in the UK.

While drug abuse was previously dominated by crack, heroin, and ecstasy, an increasing number of people are being admitted to treatment for harm related to club drugs and novel psychoactive substances.

Club drugs are:

Psychoactive substances that are recreationally used in nightclubs, bars, festivals, music events, circuit and house parties.

Novel Psychoactive Substances (NPS) are synthesised to mimic traditional drugs and are marketed “not for human consumption” to avoid detection. They are sold under the guise of bath salts or other chemicals (Royal College of Psychiatrists, 2014).

The

Current problems

Serious harm

  • There is increasing evidence of risks and long-term effects of these drugs. For example:
    • GHB has a very small degree of dosing between euphoria and one resulting in coma or death (Club Drug Clinic, 2013)
    • Long term methamphetamine use may result in psychotic states
    • Ketamine can cause kidney and bladder problems
    • Mephedrone use can result in heart problems

New users, more drugs

  • Each year 1 million adults are estimated to use club drugs per year in the UK (National Treatment Agency for Substance Misuse, 2012), and this population of users has not just switched from crack and heroin but has emerged from a diverse population of students, ‘clubbers’ and LGBT communities
  • Additionally, the number of available drugs is growing, with a new NPS per week becoming available in Europe via the internet outlets (European Monitoring Centre for Drugs and Drug Addiction, 2012)

Unprepared services

  • Club drug and NPS users tend to not perceive current drug services as for them and are therefore more likely to receive treatment in alternative care facilities such as sexual or mental health clinics (National Treatment Agency for Substance Misuse, 2012)
  • Staff in these non-specialists centres have reported feeling unconfident in club drug and NPS assessment, intervention, and referrals
  • Furthermore, even specialist services have historically focused on crack and heroin related harm reduction and need further guidance and training to provide support to individuals with these emerging drug problems

The

Possible solutions

Widen the front door

  • Services need to encourage individuals to engage and seek treatment for club drugs and NPS-related problems, by understanding the population and drug specific problems they may come encounter with (e.g. gay men using mephedrone for sexual enhancement)

Support the front line

  • Information and clinical networks can be established in order to share information, develop knowledge, and keep on top of the rapidly emerging new drugs

‘Connect’ the front line

  • As club drug/NPS users are more apt to wind up in non-specialist treatment, it would be beneficial to integrate all different health centres into a clinical network. This would allow specialised centres to support non-specialist centres, as well as gather information across all different bases

Watch all horizons for harm

  • As many club drugs and novel psychoactive substances are new, little is known about the possible short and long term effects. Therefore healthcare centres from a range of clinical areas should be monitoring and recording club drug/NPS incidences (e.g. emergency/acute care, primary care, sexual health, and mental health services)

Promote research into club drugs and novel psychoactive substances

  • With the increase of new drugs on the market, funders should consider prioritising resources towards club drugs and novel psychoactive substances
  • Due the diverse population of users and context of club drugs, we cannot assume the same interventions that are established with crack and heroin will work with these drugs. Therefore, future research proposals should consider club drug/NPS treatment interventions

Empower users through education

  • A main priority should be to provide the public with high quality and comprehensive information on the risks of club drugs and novel psychoactive substances in order to prevent initiation
  • In addition, information on harm reduction must be provided, including advice on safe injection, warnings on increased sexual health risks when using, and material on support and recovery

The report calls for non-specialist staff

Summary

This faculty report has brought to attention the rising problem of club drugs and novel psychoactive substances in the UK, which are popular amongst students, clubbers, and the LGBT community.

The large number of users (estimated at 1 million people per year) has subsequently resulted in new drugs becoming rapidly available via online markets (National Treatment Agency for Substance Misuse, 2012; European Monitoring Centre for Drugs and Drug Addiction, 2012).

The report authors highlight several key points:

  1. Users of club drugs and novel psychoactive substances are likely to seek alternative treatment to traditional drug specialist centres. Therefore, it is important to train and educate staff in these non-specialist centres so they can confidently provide support and referrals to users
  2. All healthcare centres should work together to monitor and share information on club drug/NPS cases in order to monitor the possible side effects of these rapidly emerging new drugs
  3. Funding bodies should consider shifting the attention from traditional drug use (crack/heroin) to club drugs to determine whether different treatment interventions are needed

Should research funding be directed away from 'traditional' street drugs to these new club drugs and novel psychoactive substances?

Links

One new drug a week: Why novel psychoactive substances and club drugs need a different response from UK treatment providers (PDF). Royal College of Psychiatrists, 2 Sep 2014.

Club Drugs: Emerging Trends and Risks (PDF). National Treatment Agency for Substance Misuse, 2012.

Annual Report 2012 on the State of the Drugs Problem in Europe. European Monitoring Centre for Drugs and Drug Addiction, 2012.

GHB/GBL. Club Drug Clinic, 2013.

– See more at: http://www.thementalelf.net/mental-health-conditions/substance-misuse/one-new-drug-a-week-club-drugs-and-novel-psychoactive-substances/#sthash.LrMnqRPK.dpuf

Smoking cessation in the emergency setting

Posted on by oliviamaynard

By Olivia Maynard @OliviaMaynard17

This blog originally appeared on the Mental Elf site on 20th October 2014

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The prevalence of smoking among patients in emergency departments (ED) is reported to be higher than in the general population, so encouraging smoking cessation in these settings has been recommended. However, 57% of ED staff believe that smoking cessation treatments are inappropriate for the ED setting, citing time constraints, lack of patient interest and treatment ineffectiveness as the main causes of these beliefs (Tong et al., 2010).

A systematic review published in the American Journal of Emergency Medicine (Pelletier et al., 2014), has recently analysed the most up to date research on the effectiveness, feasibility and appropriateness of smoking cessation interventions in ED settings.

The primary outcome measure was:

  • Self-reported and/or biomarker-assessed smoking cessation.

Secondary outcomes were:

  • All-cause mortality;
  • Cost per quit;
  • Patient satisfaction;
  • Practitioner time spent and non-practitioner time spent (these last two were considered together).

Methods

The authors included all original studies of smoking cessation interventions performed in either adult or paediatric ED settings that assessed at least one of the outcome measures outlined above.

One investigator conducted the literature search (on the Medline and CINAHL databases), identifying 17 articles which were then examined for sources of bias (such as lack of randomisation, non-blinding of participants or study personnel and incomplete outcome data reporting). Four studies were excluded due to a high or unclear risk of bias, leaving 13 studies to undergo full systematic review.

Although a meta-analysis of these studies was planned, their heterogeneity precluded this and therefore only a systematic review was conducted. All studies were also rated on a three point scale for quality, using 19 quality criteria questions.

This review looked at a range of

This review looked at a range of interventions for helping people to quit smoking in the emergency setting.

Results

Of the 13 studies, 11 were conducted in the USA, one in Germany and one in Turkey. Six studies used a single time-point follow-up for assessing smoking cessation, three had two follow-ups, three studies had three follow-ups and one had four follow-ups.

The smoking cessation interventions varied between studies and fell into six broad categories:

  1. Administration of self-help materials;
  2. Faxed referrals to other programmes;
  3. Brief advice;
  4. Counselling;
  5. Nicotine replacement therapy (NRT);
  6. Motivational interviewing-based interventions.

Eleven studies included at least two of these interventions and there was no consistent control group across the studies.

The main findings of the systematic review were as follows:

  • The overall quality of the studies was relatively poor:
    • Quality ratings ranged from 31 to 81% (where 100% refers to a study scoring top marks on all 19 quality criteria)
    • The average quality rating was 57% (SD = 15.1%).
    • Studies generally scored poorly on the documentation of participant retention and follow-up, justification of sample size and appropriate follow-up.
    • Data on all-cause mortality and cost per quit were absent or inadequate in the majority of studies and therefore these two secondary outcome measures were dropped from further consideration.
  • The majority of studies found no difference between intervention and control groups in terms of cessation rates (the primary outcome measure):
    • Twelve studies reported cessation rates and 10 of these reported no beneficial effect of the intervention.
    • Two studies reported a beneficial effect of smoking cessation intervention (Bock et al, 2008; Bernstein et al, 2013), however, this was only observed at three months in the first study and only one and three months, but not six months in the second study.
    • The authors of the systematic review note that these two studies used motivational interviewing-based techniques, and suggest that these techniques may be particularly effective. However, it is important to note that four other studies also used motivational interviewing, but did not find any beneficial effect.
    • Although the majority of these studies did not observe a beneficial effect of smoking cessation interventions, the authors note that many did find that overall smoking cessation rates (in both intervention and control arms) was higher than that reported among the general population in the USA (according to the 2010 National Health Interview Survey [NHIS]). This is a crude comparison however, as the 13 studies included in this review were conducted between 2000 and 2014, and were conducted in Turkey and Germany as well as the USA, whereas the NHIS survey was conducted in 2010 only in the USA.
  • Patient satisfaction was high, but was not often reported:
    • In the two studies reporting patient satisfaction, this was found to be 90% or above.
    • Both of these studies used motivational interviewing-based interventions and both considered paediatric patients or their parents, rather than adult patients receiving treatment for themselves.
  • Intervention time varied, but was not often reported:
    • A faxed referral was reported to take an average of 3 minutes, brief advice 5 minutes and motivational interviewing-based interventions 37 minutes.

MOst studies found no difference between intervention and control groups in terms of cessation rates.

Most studies found no difference between intervention and control groups in terms of cessation rates.

Conclusions and implications for practice

The authors of this systematic review conclude that:

ED-based cessation interventions may be effective, but the available data are somewhat limited and heterogeneous.

Only two of the 13 studies included in the review found any benefit of smoking cessation intervention in the ED settings, with both using motivational interviewing. This led the authors of this review to further conclude that:

Motivational interviewing may prove to be a promising strategy where feasible.

However, it is important to note that four of the six studies which used motivational interviewing did not find any beneficial effect of this intervention.

The authors recommend that:

ED providers ask about smoking status, provide brief motivational interviewing or brief advice to quit as time allows, and provide a pamphlet with information about the benefits of smoking cessation and information about the benefits of smoking cessation and information for verified smoking cessation programs to all patients.

The evidence supporting emergency based interventions for smoking cessation is limited and heterogeneous. Further research is required to determine whether smoking cessation interventions are more effective in encouraging cessation than simply visiting the ED alone, and if so, which interventions are most effective.

The evidence-base is not yet of sufficient quality for us to draw any conclusions about the best course of action for smoking cessation in emergency departments.

The evidence-base is not yet of sufficient quality for us to draw any conclusions about the best course of action for smoking cessation in emergency departments.

Limitations

  • The reviewers only searched two databases (Medline and CINAHL) so are likely to have missed studies published in journals not indexed on those databases.
  • The general quality of the studies included in the systematic review was weak to moderate, even after studies with high risk of bias were excluded. Future research should use rigorous designs with large sample sizes.
  • No studies investigated time-effectiveness, all-cause mortality, or cost per quit as outcomes and these factors should be considered in future research.
  • Only four studies pre-registered study information, meaning that the degree to which the remaining studies fully reported all study outcomes cannot be guaranteed.
  • Smoking cessation was assessed by the majority of studies using self-report, rather than through biometrically confirmed abstinence, potentially artificially increasing cessation success.
  • The lack of a standardised control group meant that study findings could not be pooled into a meta-analysis.
  • None of the studies included in this systematic review were conducted in the UK, with the focus on EDs in the USA.

The reviewers could have done more to find studies to include in their review.

The reviewers could have done more to find studies to include in their review.

Links

Pelletier JH, Strout TD, Baumann MR. A systematic review of smoking cessation interventions in the emergency setting. Am J Emerg Med. 2014 Jul;32(7):713-24. doi: 10.1016/j.ajem.2014.03.042. Epub 2014 Apr 2. [PubMed abstract]

Bernstein SL Bijur P, Cooperman N et al. Efficacy of an ED-cased multi-component intervention for smokers with substance use disorders. Journal of Substance Abuse Treatment, 2013; 44(1): 139-42.

Bock BC, Becker BM, Niaura RS et al. Smoking cessation among patients in an emergency chest pain observation unit; outcomes of the Chest Pain Smoking Study (CPSS). Nicotine and Tobacco Research, 2008; 10(10):1523-31. [PubMed abstract]

Quitting Smoking Among Adults – United States, 2001-2010. Centers for Disease Control and Prevention; 2011 [11/11/2011]

– See more at: http://www.thementalelf.net/mental-health-conditions/substance-misuse/smoking-cessation-in-the-emergency-setting/#sthash.SCNL87pV.dpuf

Alcohol minimum unit pricing: time to take action?

Posted on by oliviamaynard

By Olivia Maynard @OliviaMaynard17

This blog originally appeared on the Mental Elf site on 3rd October 2014

The UK government’s minimum pricing policy for alcohol has been hotly debated over the last couple of years and this week a new study describing the potential benefit of minimum unit pricing over the governments’ current ban on below cost selling has started sparks flying once more.

In the paper, published on Wednesday in the British Medical Journal (BMJ), Brennan and colleagues (2014) use sophisticated modelling to compare the expected effects of the two policies on the following outcomes:

  • Alcohol consumption
  • Health harms, including deaths, illness, admissions to hospital, quality of life and costs to the NHS
  • Drinkers’ expenditure
  • Tax and duty revenues

However, before we get our teeth stuck into the study itself, what’s the difference between the two policies?

Minimum unit pricing is about setting a floor price (e.g. 45p) for a single unit of alcohol.

Minimum unit pricing is about setting a floor price (e.g. 45p) for a single unit of alcohol.

Minimum unit pricing (MUP)

  • A ‘unit’ of alcohol (roughly half a pint of low strength beer, a measure of spirits or half a regular sized glass of wine) would have to be sold at a set price, such as 45p
  • This policy was initially supported in 2012 by the UK government, but was later rejected
  • The Scottish government passed legislation to introduce MUP at 50p per unit in June 2012, but as yet this has not been introduced due to a legal challenge from the Scotch Whiskey Association which has now gone all the way to the European Court of Justice. The outcome of this legal challenge is not expected until late 2015
  • Canada, Russia and Uzbekistan have all introduced MUP

A ban on below cost selling (BBCS)

  • Alcoholic drinks must not be sold for less than the tax payable on the product
  • Under this policy, the price of alcohol does not necessarily increase with the strength of the alcohol and for drinks like high strength cider, a unit of alcohol can be sold for as little as 6p under this policy
  • The UK government favoured this policy over MUP in 2013 and introduced it in May 2014

The authors answer the following question in their study:

What would the differential potential impact of a BBCS versus a MUP policy of 40p, 45p or 50p if the policies were to be implemented in 2014-2015?

Despite once publicly supporting a minimum unit pricing of 40p. David Cameron's government has decided instead to put in place a ban on the sale of “below cost” drinks.

Despite once publicly supporting a minimum unit pricing of 40p. David Cameron’s government has decided instead to put in place a ban on the sale of “below cost” drinks.

Methods

As I said, the authors used some pretty sophisticated modelling techniques (using the Sheffield Alcohol Policy Model [version 2.5]) to answer their research question, but in brief, in order to work out the likely effects of these two alcohol policies, the following information was entered into the model:

  • Baseline data on:
    • Alcohol consumption for different population subgroups in England (split by sex, age, mean consumption level and income)
    • Prices paid for 10 different beverage types and quantity of each purchased, for the different subgroups
  • An estimate of the effect that price increases for these 10 beverages would have on consumption levels for the subgroups (given that different subgroups spend and drink different amounts of the 10 beverages)
  • The effects of this estimated change in consumption on death and disease rates at one and 10 years post implementation

Results

Given that harmful drinkers are a policy priority group, (consuming on average 58 units for females and 80 for males per week and spending £1,800 and £3,400 per year respectively), the authors focus in particular on the effects of the two policies on this group. Also, whilst MUP at 40p, 45p and 50p were all assessed, I will focus on MUP at 45p, as this is the level initially proposed by the UK government.

Proportion of the market affected by the policies

  • Under a BBCS, only 0.7% of all units of alcohol sold in the UK would see a price increase, whilst MUP would affect 23.2% of all units sold
  • MUP would disproportionately affect harmful drinkers, increasing the price of 30.5% of the units they purchase, as compared with only 12.5% of units purchased by moderate drinkers

Alcohol consumption

  • A BBCS was estimated to reduce the number of units consumed by harmful drinkers by only 3 units per year
  • By contrast, MUP was estimated to reduce this by 137 units; a 45-fold reduction as compared with a BBCS

Health harms, including deaths, admissions to hospital, quality of life and costs to the NHS

  • The estimated effects on the general population of the two policies after 10 years of implementation are shown below:
BBCS MUP
Annual reduction in number of deaths 14 624
Annual reduction in hospital admissions 500 23,700
Annual reduction in alcohol-related illness 300 12,500
Total number of quality adjusted life years gained 500 24,200
Total saving in healthcare costs £9.5 million £417.2 million
  • Based on these estimates, MUP will reduce deaths attributable to alcohol by 40 times more than BBCS
  • The majority of this harm reduction is likely to be among harmful drinkers, with 89% of the reduction in deaths after 10 years among this group

The study findings suggest that harmful drinkers would be helped most by minimum unit pricing

The study findings suggest that harmful drinkers would be helped most by minimum unit pricing.

Drinkers’ expenditure

  • Due to the high price elasticity of alcohol (higher prices mean people lower their consumption to a level which ensures they continue to spend the same amount) neither policy is expected to greatly affect spending

Tax and duty revenues

  • A BBCS is estimated to increase revenues in shops and supermarkets by 0.3% (£5.4m)
  • By contrast, MUP is estimated to result in a 5.6% (£201.1m) increase in revenues, although the effects on actual profits is unknown
  • The effects of the two policies on government tax revenue is small, as although VAT will rise (because this is charged as a percentage of product price and products will be sold at higher prices), alcohol duty revenue will fall (as this is related to the volume of alcohol sold)

Discussion

Professor Alan Brennan, professor of Health Economics and Decision Modelling at the University of Sheffield, who led the study said:

Despite some study limitations we found that a minimum unit price of 45p would be expected to have 40-50 times larger reductions in consumption and health harms.

The limitations Professor Brennan alludes to include the fact that certain assumptions about alcohol price elasticity and actual alcohol consumption and expenditure had to be made in order to run the model. However, the authors state that the sensitivity analyses they have conducted show that the relative scale of the impact of a BBCS versus MUP is robust to these assumptions and uncertainties and, if anything, the scale of the difference is likely to be conservative.

In the editorial accompanying the paper (Stockwell, 2014), Tim Stockwell, the director of the Centre for Addictions Research at the University of British Columbia, Canada, notes that one way to test whether the model is conservative is to compare the model’s predicted effects with actual reported effects in a country where MUP has been introduced. Indeed, when the model is applied to two Canadian provinces with MUP policies, the model underestimates the number of deaths by 2.3 times and the number of hospital admissions by almost 5 times.

It seems therefore that the model is robust enough to assess the effects of the two policies and if anything, underestimates the true likely effect of MUP. These data suggest that MUP would be a far more effective method of reducing consumption and preventing alcohol related harm than the BBCS implemented earlier this year in the UK.

Minimum unit pricing in Canada has been associated with significant reductions in alcohol related harm

Minimum unit pricing in Canada has been associated with significant reductions in alcohol related harm.

Implications for policy

  • The UK government introduced a BBCS in May 2014
  • The Scottish legal case will likely pave the way for alcohol pricing policies in other EU jurisdictions interested in introducing MUP, including the Republic of Ireland, Estonia and regional governments in the UK
  • Given the potential effectiveness of MUP as compared with a BBCS, the outcome of this legal case is likely to have important implications for public health across Europe

Response from government, industry and others

Perhaps unsurprisingly, this study has not found favour among the alcohol industry, with Miles Beale, Chief Executive of the Wine and Spirits Association arguing that the government should not be “punishing responsible drinkers through higher prices”, a statement which seems at odds with the study’s results which shows that MUP would specifically target harmful drinkers. Indeed, this is what makes MUP different from more indiscriminate policies, such as general price or tax increases, which would indeed punish moderate drinkers.

By contrast, Sir Ian Gilmore, chairman of the Alcohol Health Alliance, warmly received the results of the study and urged Westminster politicians to back the Scottish plans for MUP and “help push it through the European Court of Justice for the good of the public’s health.”

However, the response from the Department of Health was lukewarm, with a spokeswoman reiterating the fact that the government is “taking action to tackle cheap and harmful alcohol such as banning the lowest priced drinks” and noting that the government is “working with industry to promote responsible drinking.”

This close relationship between UK government and the alcohol industry is well documented and alcohol industry lobbying has been cited as the main reason for the government U-turn on MUP in 2013 (Gornall, 2014). Unlike tobacco control policies in the UK, which are protected from the tobacco industry and other commercial interests through a World Health Organisation framework (WHO FCTC, 2005), this is not the case for alcohol policies. John Holmes, a Public Health Research Fellow at the Sheffield Alcohol Research Group, and one of the authors of this study, has previously acknowledged that the alcohol industry should have some say in alcohol policies, but that he is also concerned that the industry is “not particularly interested in . . . engaging in any kind of debate about whether their arguments are accurate. It’s all about creating doubt about what we’re saying.”

Whether the alcohol industry will continue to cast doubt on this research and whether the government will choose to listen to the researchers or the industry, remains to be seen.

In late 2015, the European Court of Justice will decide if the Scottish parliament’s 2012 legislation can be passed, which will have a massive impact on public health in Europe.

In late 2015, the European Court of Justice will decide if the Scottish parliament’s 2012 legislation can be passed, which will have a massive impact on public health in Europe.

Links

Brennan A, Meng Y, Holmes J, Hill-McManus D, Meier PS. (2014). Potential benefits of minimum unit pricing for alcohol versus a ban on below cost selling in England 2014: modelling study. BMJ, 349(g5452).

Gornall J. (2014). Under the influence: 1. False dawn for minimum unit pricing. BMJ 2014;348:f7435.

Stockwell D. (2014). Editorial: Minimum unit pricing for alcohol. BMJ, 349(g5617).

WHO FCTC. (2005). WHO Framework Convention on Tobacco Control (PDF). World Health Organisation.

Radu Bercan/Shutterstock.com, Peter Fuchs/Shutterstock.com.

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