Tag: Policy

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

A Summary of the E-cigarettes Summit 2016

Posted on by rebeccalawn

by Jasmine Khouja @jasmine_khouja

On the 17th November I attended the E-cigarette Summit 2016 at the Royal Society in London. The summit brought together researchers, policy-makers, smoking cessation services and industry members to hear about the latest research, developments and challenges in the e-cigarette domain.

The summit was a one-day event packed full of information with 20 fast-paced (10-20 minutes) talks and 4 panel discussions. My five take home points from the summit were:

  1. Communication

One point which was raised on multiple occasions was that good communication of the research into e-cigarettes is key to the public understanding the risks and benefits of e-cigarette use. Unfortunately, the consensus was that the communication of e-cigarette research to the public is poor. Astonishingly, one speaker commented that someone had asked their daughter: “Is your dad still selling e-cigarettes and killing people?” This demonstrates how badly e-cigarettes have been portrayed, despite general consensus that they are much less harmful than cigarettes. Researchers are trying to communicate their research but face hurdles; some journals may be less likely to publish articles that are positive about vaping, meaning that it is harder to publish evidence that vaping is not as bad for you as cigarettes. The media are also hampering researchers’ efforts as they prefer stories which are anti-vaping and sometimes draw inaccurate conclusions from the evidence, which makes for more interesting stories. However, effective communication of the research is possible: Professor Peter Hajek and Dr Alex Freeman provided some useful advice to researchers which included not inferring human risks from animal studies, ensuring risks are directly compared to those of smoking, being a trustworthy source by being competent, honest and reliable, and providing neutral information without recommendations allowing the public to make their own informed decisions.

  1. The British Medical Association’s Guidelines

Communication of the benefits and risks of e-cigarettes isn’t limited to publications and the media; doctors are being asked about e-cigarettes by patients. Despite the evidence that the research community has provided that e-cigarettes are less harmful than cigarettes, the British Medical Association are yet to update their guidelines to encourage smokers to switch to e-cigarettes. There seemed to be apprehension stemming from the lack of known long-term effects, despite the fact that we know there are vastly fewer and reduced amounts of toxicants in e-cigarettes compared to cigarettes meaning the likelihood of long-term effects as bad as or worse than smoking are extremely unlikely.

  1. Recent Research

Many new studies were presented but the study that really caught my attention was discussed by Dr Lynne Dawkins. Lynne provided evidence for increased puffing behavior when participants are given lower doses of nicotine in their e-cigarettes [1]. She concluded that inhaling more vapour to receive the same amount of nicotine exposes vapers to unnecessary amounts of toxicants. This is very topical as the regulations set out by the Tobacco Products Directive (TPD) which will be fully implemented by May 2017 limit doses to 20 mg/mL meaning that some higher dosage (36 mg/mL) users may expose themselves to extra toxicants to receive the levels of nicotine they need when the higher dosage product become unavailable in the next six months.

  1. The Tobacco Products Directive

The TPD provides some form of regulation for e-cigarette manufacturers and distributors. The inclusion of e-cigarettes in the TPD was controversial due to e-cigarettes not containing tobacco and the restrictive nature of the regulations which were seen as unnecessary by some users and industry members. Part of the regulations included the thorough testing of e-cigarette products to ensure they were safe and the publication of the contents (including toxicants) so that the public could make informed decisions. To my dismay, I was informed that the information submitted by the e-cigarette companies so far will not be made publically accessible for roughly six months due to a system error. I was also informed that compliance with the regulations was low and that age of sale restrictions in particular did not seem to be being enforced. The system and enforcement of the TPD in relation to e-cigarettes needs improving so that consumers can access the information which the TPD states they should have access to and to protect young people whose brain development may be adversely affected by consuming nicotine.

  1. New Systems

As restrictive as the TPD is, new products are still being developed. A new type of e-cigarette is emerging onto the market called pods. These devices are small and similar in size to older less effective designs of e-cigarettes (cigalikes) but have the power and nicotine delivery of the newer more effective tank systems. The sleek, compact designs combined with the improved nicotine delivery systems which prevent overheating (which is associated with harmful byproducts such as formaldehyde) are likely to be very popular. These systems can also record information on how the devices are used (how long individuals puff for and how many puffs they take etc.) which could provide essential information to researchers on how e-cigarettes are used in real life situations.

The day culminated in a key note speech by the Attorney General for Iowa, Tom Miller. He commended the UK’s focus on e-cigarette research and the general positive stance our public health officials have taken in terms of e-cigarettes. He concluded his speech by asking for help from the UK to bring the US up to the same standards.

References

  1. PMID: 27650300

Alcohol brief interventions: how can content, provider and setting reduce alcohol consumption?

Posted on by rebeccalawn
by Olivia Maynard @OliviaMaynard17
This blog originally appeared on the Mental Elf site on 23rd September 2016.
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Alcohol brief interventions (ABIs) provide structured advice on alcohol use. They involve an assessment of individual risk with feedback and advice, brief motivational interviewing, or a combination of these techniques.

While the Government’s Alcohol Strategy (HM Government, 2012) recommends that ABIs be implemented increasingly inprimary care settings and accident and emergency (A&E) departments, the National Institute for Health and Care Excellence (NICE) calls for alcohol brief interventions to be offered by a range of practitioners and in a range of different settings.

Given national-level support for increasing and wider use of ABIs, this systematic review and multi-level meta-regression by Platt and colleagues assessed the effectiveness of ABIs on alcohol consumption and how effectiveness of ABIs differs by:

  1. Content of intervention,
  2. Provider group and
  3. Setting.
Alcohol brief interventions usually involve a combination of risk assessment, feedback, advice and brief motivational interviewing.

Alcohol brief interventions usually involve a combination of risk assessment, feedback, advice and brief motivational interviewing.

Methods

Studies were peer-reviewed randomised controlled trials (RCTs) where participants were randomly allocated to a control group (such as treatment as usual) or a group which received an alcohol brief intervention.

Brief interventions were defined as person-to-person discussions on alcohol, with between 1 and 4 sessions and a total of 2 hours intervention time. ABIs which were delivered in groups or via a computer were excluded as were those which included participants with complex health problems where it is difficult to generalise findings to the general population.

The primary outcome measure was a quantitative continuous measure of total alcohol consumption, reported as the standardised mean difference between ABI group and control group measured at follow-up. The authors also examined how ABIs influenced the frequency of alcohol consumption.

Different types of setting, provider and content were examined and these are shown (along with the number of studies in each category) in the Results section below.

A multi-level meta-analysis method was used, which allowed the authors to include a number of different effect sizes from individual studies (i.e. amount of alcohol consumed per unit of time and/or amount of alcohol consumed per drinking occasion) rather than just trying to selecting one comparable effect size for each study).

Results

Study characteristics

50 studies were included in the analyses, with 29,891 individuals contributing data. 45% of studies were conducted in the USA and 22% in the UK.

The percentage of studies which examined alcohol brief interventions with different types of content, providers and settings are shown below:

Intervention content:

  1. Motivational interviewing (MI) (48%)
  2. Enhanced motivational interviewing (MI+) (40%)
  3. Brief advice approaches (24%)

Intervention providers:

  1. Counselors (44%)
  2. General practitioners (22%)
  3. Nurses (18%)
  4. Different providers (12%)
  5. Peer-delivered (4%)

Setting of intervention delivery:

  1. Primary or ambulatory care in clinical settings such as outpatient services (38%)
  2. A&E services (20%)
  3. University (20%)
  4. Community-based delivery (12%)
  5. Hospital inpatient services (10%)

Quality of the evidence

71% of studies were classified as having a low risk of bias regarding randomisation and allocation concealment strategies. However, the method of allocation concealment was unclear in most of the studies. An intention-to-treat analysis was conducted in 47% of the studies and loss to follow-up was assessed in 80% of studies.

The overall impact of ABIs as compared with control conditions

ABIs reduced alcohol consumption by -0.15 SDs (95% confidence interval (CI) = -0.20 to -0.10) a result the authors describe as a ‘small but statistically significant effect’. However, the extent to which this is clinically meaningful is less clear.

Note: The authors present the effect sizes as SDs because they have summarised their data as standardised mean differences. This method is used when included studies all assess the same outcome, but measure it in a variety of ways. Although this makes sense statistically, it does make understanding how important these effects are clinically a little more difficult.

The authors found that this effect persisted after controlling for covariates and when conducting sensitivity analyses. The studies included in this analysis were found to have a small to medium level of heterogeneity (I2 = 37%; this figure is the percentage of variation between trials which is due to actual variation between studies as opposed to variation due to chance. A small I2 value means that the majority of the differences observed between studies was due to chance).

ABIs reduced frequency of alcohol consumed by a similar amount (-0.15 SDs, 95% CI = -0.20 to -0.11).

Content

Splitting studies by ABI content didn’t reduce the heterogeneity between studies (I2 = 39%: no, or little change in this I2 value from when all studies are considered together (I2 = 37%) indicates that this categorisation by content does not adequately explain the heterogeneity between studies).

However, it did appear that all content types were effective at reducing amount of alcohol consumed, and there was some evidence that while brief advice is more effective than MI or MI+ for amount of alcohol consumed, brief advice did not appear to reduce the frequency of consumption while MI and MI+ did.

Providers

Splitting studies by ABI provider was not found to reduce the heterogeneity between studies (I2 = 34%).

ABIs delivered by a range of different providers or by peers were not found to be effective at reducing amount consumed or frequency of consumption (although it’s important to note that very few studies were included in these categories).

There was evidence that interventions delivered by counselors, physicians and nurses were effective, with those delivered by nurses the most effective (-0.23 SDs amount consumed, 95% CI = -0.33 to -0.13).

Setting

Splitting studies by ABI setting didn’t reduce the heterogeneity between studies (I2 = 34%).

There was no evidence that ABIs delivered in hospital inpatient services and in community settings were effective in reducing either amount or frequency of alcohol consumed.

Interventions delivered in A&E, ambulatory care settings and in universities were found to reduce alcohol both amount and frequency of alcohol consumed.

This review suggests that alcohol brief interventions have a ‘small but statistically significant effect’, but it's unclear whether or not this is clinically meaningful.

This review suggests that alcohol brief interventions have a ‘small but statistically significant effect’, but it’s unclear whether or not this is clinically meaningful.

Conclusions

The authors conclude that their study provides:

important new evidence on how the effectiveness of brief alcohol interventions differs by setting, provider and content.

While this analysis does show that ABIs reduce amount of alcohol consumed and frequency of consumption, the size of this effect is small. It will be important to determine to what extent this is a clinically meaningful effect.

Although the authors claim that their findings suggest that the “provider of interventions may matter” (with nurses providing the best results) there is only weak evidence for this. As the categorisation of studies by provider (and setting and content for that matter) didn’t really have any impact on the heterogeneity (as measured by I2) between studies, there is little evidence that the effectiveness of ABIs differed meaningfully across providers.

Interventions delivered by nurses appeared the most effective, although further work is needed to confirm this finding.

Interventions delivered by nurses appeared the most effective, although further work is needed to confirm this finding.

Strengths and limitations

Strengths

As the authors used a multi-level meta-analysis, they were able to include all relevant outcomes into their analysis, rather than just picking one outcome (and consequently having to exclude studies which did not assess this outcome). This is also likely to have reduced study level heterogeneity.

Limitations

As the authors were interested in the difference in effectiveness of a range of different ABI settings, providers and contents, the number of studies included within each of these categories was small. This makes drawing firm conclusions regarding the effectiveness of particular forms of ABIs difficult.

Implications

Given that there is little evidence to suggest that the effectiveness of alcohol brief interventions differs meaningfully according to setting, provider or content, the authors do note that this indicates that resources should be allocated to those settings, providers and contents where ABIs are likely to be most cost-effective and feasible.

For example, A&E may not be the best setting for ABIs given the lack of privacy, the brevity of the visit and the fact that the patient is likely to be suffering from a severe injury at the time.

Nurses are likely to be well placed to provide ABIs given their repeated contact with patients, although appropriate training should be provided to nurses so that they can embed these practices into their care.

Focusing on interventions that are feasible and cost-effective seems like the biggest practical advice from this evidence.

Focusing on interventions that are feasible and cost-effective seems like the biggest practical advice from this evidence.

Links

Primary paper

Platt L, Melendez-Torres GJ, O’Donnell A, Bradley J, Newbury-Birch D, Kaner E, et al. (2016) How effective are brief interventions in reducing alcohol consumption: do the setting, practitioner group and content matter? Findings from a systematic review and metaregression analysis. BMJ Open. 2016;6(8).

Other references

HM Government (2012) The Government’s Alcohol Strategy PDF. CM 8336, March 2012.

Photo credits

Institutional smoking bans reduce secondhand smoke exposure and harms, but more research is needed

Posted on by rebeccalawn
by Olivia Maynard @OliviaMaynard17
This blog originally appeared on the Mental Elf site on 12th July 2016.

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It’s been almost 9 years since the introduction of SmokeFree legislation in the UK (although we elves still return from a night out smelling of campfire smoke). However, secondhand smoke is still accountable for 600,000 deaths annually.

Smoke free policies can be implemented at the micro-level (i.e. the individual level or in homes), the meso-level (i.e. in organisations, such as public healthcare facilities, higher education centres and prisons) or the macro-level (i.e. in an entire country). In many countries, smokefree legislation is at the macro-level, although exemptions exist at the meso-level. For example, in the UK, specific rooms in prisons and care homes are exempt from this legislation.

In their Cochrane review, Frazer and colleagues review the evidence for meso-level smoking bans (in venues not typically included in smokefree legislation) on 1) passive smoke exposure, 2) other health-related outcomes and 3) active smoking, including tobacco consumption and smoking prevalence.

Worldwide, secondhand smoke is still accountable for 600,000 deaths annually.

Worldwide, secondhand smoke is still accountable for 600,000 deaths annually.

Methods

Identification of included studies

The authors searched online databases of clinical trials, reference lists of identified studies and contacted authors to identify ongoing studies. Studies were included if they:

The introduction of smoking bans in psychiatric hospitals and prisons is extremely controversial.

The introduction of smoking bans in psychiatric hospitals and prisons is extremely controversial.

Results

Characteristics of included studies

No randomised controlled trials (RCTs) were found. 17 observational studies were identified (three using a controlled before-and-after design with another site for comparison and 14 using an uncontrolled before-and-after design). Of these 17 studies:

  • 12 were based in hospitals;
  • 3 in prisons;
  • 2 in universities.

Five studies investigated the impact of smoking bans on two participant groups (i.e. staff and either patients or prisoners).

The 17 studies were conducted in 8 countries: the USA (6 studies), Spain (3 studies), Switzerland (3 studies), Australia, Canada, Croatia, Ireland and Japan (all 1 study). Eight of these were conducted in US states or countries with macro-level (i.e. national) smoke-free legislation, eight with no legislative bans and one which compared all 50 US states (some with national bans and others without).

Main findings

There was considerable heterogeneity between the 17 studies and so a meta-analysis of all studies was not conducted. Instead studies were analysed using aqualitative narrative synthesis according to each of the outcome measures:

Reducing secondhand smoke exposure

Four studies assessed secondhand smoke exposure, finding that a reduction in exposure was observed in all three settings after smoking bans. However, none of the studies in the review used a biochemically validated measure of smoke exposure such as cotinine or carbon monoxide levels.

Other health outcomes

Four studies examined the impact of partial or complete smoking bans on health outcomes including smoking-related mortality. Two were conducted in prisons, one in a hospital and one in a secure mental hospital (Etter et al, 2007). All of these studies observed improvements in smoking-related morbidity and mortality after smoking bans. One of these assessed the impact of smoking bans in prisons in all 50 US states and found that smoking-related mortality was reduced in those prisons that had a smoking ban for more than 9 years.

Tobacco consumption and smoking prevalence

Thirteen studies reported data on the effect of smoking bans on smoking prevalence and five of these reported data on two populations within settings (i.e. prisoners and prison staff).

Eleven of these studies were included in a meta-analysis (using the Mantel-Haenszel fixed-effect method) and the data from the 12,485 participants in these studies was pooled. Although there was considerable heterogeneity between these studies (I2 = 72%; where a higher I2 value is evidence of higher levels of heterogeneity), this heterogeneity was lower within subgroups (e.g. in prisoners or hospital staff).

Ten studies conducted in hospital settings found mixed evidence for the impact of smoking bans on smoking prevalence. Eight of these studies were included in the meta-analysis and there was evidence that smoking bans reduced active smoking rates among hospital staff (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.64 to 0.78, n = 4,544, I2 = 76%) and patients (RR 0.84, CI 0.76 to 0.98, n = 1442, I2 = 20%).

The one study in a prison setting found no evidence of a change in smoking prevalence among staff or prisoners after a smoking ban (RR 0.99, CI 0.84 to 1.16, n = 130).

Two studies in university settings observed reductions in smoking prevalence after smoking bans (RR 0.72, CI 0.64 to 0.80, n = 6,369, I2 = 59%), although one study only observed this among male ‘frequent’ smokers.

Quality of the evidence

The evidence was judged to be of low quality as all of the studies wereobservational (none used a RCT design) and the risk of bias was rated as high.

Banning smoking in hospitals and universities increased the number of smoking quit attempts and reduced the number of people smoking.

Banning smoking in hospitals and universities increased the number of smoking quit attempts and reduced the number of people smoking.

Conclusion

Overall, this review finds evidence of smoking bans on:

  • reducing smoking prevalence in hospitals and universities, with the greatest reductions among hospital staff;
  • reduced mortality and exposure to secondhand smoke in hospitals, universities and prisons.

Limitations

The quality of the evidence was low and the authors conclude that ‘we therefore need more robust studies assessing evidence for smoking bans and policies in these important specialist settings’. Limitations with the studies included in the review include: small sample sizes in some studies, a lack of a control location for comparison in all but three studies and a high level of heterogeneity between and within the different settings (e.g. the hospital settings included a cancer hospital, psychiatric hospitals and general hospitals).

We need more robust studies assessing the evidence for smoking bans and policies in specialist settings.

We need more robust studies assessing the evidence for smoking bans and policies in specialist settings.

Discussion

The authors report that given this evidence, smoking bans at the meso-level should be considered as part of multifactorial tobacco control activities to reduce secondhand smoke exposure and smoking prevalence.

Given that the introduction of these bans particularly in psychiatric hospitals and prisons is controversial, the introduction of these bans should be sensitive to the needs of populations. For example, bans in psychiatric hospitals should be implemented in consultation with psychiatrists to ensure that the improved health outcomes of patients is considered first and foremost. As the evidence is currently weak, with a high risk of bias, any interventions should be closely monitored.

More robust studies are needed, using a control group for comparison, assessing smoke exposure using biochemically validated measures, using long-term follow-ups of at least 6 months and reporting smoking prevalence both before and after the introduction of the ban.

It is not possible to draw firm conclusions about institutional smoking bans from the current evidence.

It is not possible to draw firm conclusions about institutional smoking bans from the current evidence.

Links

Primary paper

Frazer K, McHugh J, Callinan JE, Kelleher C. (2016) Impact of institutional smoking bans on reducing harms and secondhand smoke exposure. Cochrane Database of Systematic Reviews 2016, Issue 5. Art. No.: CD011856. DOI: 10.1002/14651858.CD011856.pub2.

Other references

Etter M, Etter JF. (2007) Acceptability and impact of a partial smoking ban in a psychiatric hospital.. Preventive Medicine 2007;44(1):64–9. [PubMed abstract]

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The European Tobacco Products Directive and the future of e-cigarettes in the UK

Posted on by rebeccalawn

By Jasmine Khouja @Jasmine_Khouja

E-cigarettes have become a popular product among smokers and ex-smokers, and Action on Smoking and Health (ASH) estimates that there are 2.6 million current users of e-cigarettes in the UK. As an alternative to tobacco smoking, research commissioned by Public Health England estimates that e-cigarettes are likely to be roughly 95% less harmful. The evidence supporting these popular and effective quitting aids suggests that e-cigarettes could be a powerful tool for harm reduction amongst current smokers but there is still uncertainty over the safety of e-cigarettes. Limited research concerning the effects of long-term use and the current lack of strict regulation of the products has fuelled this uncertainty but new regulations have been introduced into the pre-existing European Tobacco Products Directive (TPD) to rectify this. The updated TPD will come into force on 20th May 2016 with a transitional period allowed by the TPD. UK e-cigarettes and refill containers which are not in compliance with the TPD will be allowed to be released for sale on the UK market until 20th November 2016, but from 20th May 2017 all products sold to consumers will need to be fully compliant with the TPD. The alternative to following the regulations set by the TPD will be for e-cigarettes to gain a medical licence from the Medicines and Healthcare products Regulatory Agency (MHRA) and be regulated as licenced medicinal products to be sold in the UK.

jaz blog

As I am about to commence a PhD investigating the reasons for e-cigarette use, I am interested in what the implications of the directive will be in the UK; will it encourage smokers to switch to e-cigarettes, consequently reducing harm to themselves and others, or will it result in a reduction of available products and cause an increase in relapses to smoking?

I have read the directive and listed some of the key changes that will happen and added my own thoughts on what may happen as a result.

  1. CHANGE: New e-cigarette products must be notified to the MHRA six months before their release to the public. E-cigarette companies will be charged £150 to notify MHRA of a new product and £80 for a modification to an existing product, and will then be charged £60 annually thereafter. POSSIBLE OUTCOMES: The MHRA should have more control over the products on the market and be able to prevent unsafe products entering the market but it may take longer for new products to become available to buy. Additionally, some existing products will be unavailable from 20th May 2017 if they do not to comply with the regulations by 20th November 2016.
  1. CHANGE: Under the TPD, e-liquids will only be allowed where the nicotine concentration does not exceed 20 mg of nicotine per ml of liquid. E-liquids containing more than 20 mg of nicotine per ml of liquid will have to gain a medical licence authorised by the MHRA. POSSIBLE OUTCOMES: People may reduce their doses of nicotine and reduce their addiction if their preferred dosage is no longer available. Fewer high dosage products may be available as gaining a medical licence is an expensive process (estimated between £87,000 and £266,000 annually over ten years for a single device). When current products with high dosages such as 36 mg of nicotine per ml of liquid become unavailable, people may use lower dosages such as 20 mg of nicotine per ml of liquid as a substitute and inhale twice as much vapour to get the same nicotine hit. Nicotine is not the only constituent of vapour though; there are low concentrations of other toxicants, so inhaling more vapour means inhaling more toxicants. Alternatively, current higher dosage users may relapse to tobacco smoking if they feel the lower dosages do not effectively deliver the nicotine hit they need.
  1. CHANGE: Products regulated under the TPD must provide information to the MHRA on the safety and contents of e-cigarette products (including ingredients, toxicants and emissions). Health warnings, instructions for use, information on addictiveness and toxicity must also appear on the packaging and accompanying information leaflet. POSSIBLE OUTCOMES: This should allow e-cigarette users to make informed choices. The notification fees mentioned above will include the storage of this information but the companies may have to bear extra costs in testing their products for the amount of toxicants and emissions produced. These tests will have to comply with the standards set in the TPD and by the MHRA which may prove too costly for smaller e-cigarette companies, forcing them to withdraw products from the market. This could leave the market open to the tobacco industry who generally have greater financial resources available to them. The tobacco industry have to also sustain the tobacco market; a consequence of this may be the deliberate placement of ineffective e-cigarette products on the market to encourage current smokers continue to smoke tobacco and ex-smokers using e-cigarettes relapse.
  1. CHANGE: E-cigarette products will be child-safe, will not break or leak during the refill process, and containers will not exceed 10 ml (refill cartridges will not exceed 2 ml). POSSIBLE OUTCOMES: This should prevent accidents involving children consuming dangerous levels of nicotine. Most changes will be made to newer devices, which require e-liquid refills. If these modifications aren’t made by 20th November 2016 the products will be removed from the market by 20th May 2017.
  1. CHANGE: Under the TPD, cross-border advertising will be banned, which includes in newspapers, radio and TV, but not on billboards and posters. Products will not be allowed to make smoking cessation or health claims. Advertising of products with a medicinal license will be allowed under “over the counter” medicine rules. POSSIBLE OUTCOMES: This should minimise the amount of e-cigarette advertising seen by those who should not use e-cigarettes such as children and non-smokers. However, only e-cigarette companies who can afford a medical licence will be able to advertise on TV and this could mislead people into thinking that these products are more effective than other products.

A possible outcome for many of these changes is the loss of products from the market because of non-compliance with the regulations. Although increased reassurance that e-cigarettes on the market meet certain quality standards may encourage new users, the removal of any e-cigarette product from the market will provide an opportunity for e-cigarette users to relapse to smoking; without their favourite brand or flavour, it may be easier for them to resume smoking again than to find a replacement that suits their needs and taste. This in turn could lead to increased levels of smoking, and therefore harms to both individuals and society as a whole. Additionally, high nicotine dosage e-cigarette users may be encouraged to inhale more vapour and therefore unnecessary amounts of other constituents. However, recent preliminary research findings from ASH UK suggest there are few high dosage users meaning that this should not affect many.

The withdrawal of products is likely to be determined by the cost of making products compliant. Tobacco companies generally have greater financial resources than e-cigarette companies, with the top companies making billions in profit each year, meaning they can afford to make the necessary changes to meet the new regulations. The few e-cigarette companies that are owned by tobacco companies mainly produce ‘cigalikes’ which are the least effective design of e-cigarettes and there is a higher chance of relapsing to smoking when using them compared to later-generation devices. Given that the tobacco-owned e-cigarette companies will probably have greater resources available to them, they could end up with a monopoly on the e-cigarette industry. In fact, this may already be happening; the first medically licensed e-cigarette is a ‘cigalike’ owned by British American Tobacco. This means British American Tobacco could own the only TV-advertised e-cigarette (until another company gains a licence). Consequently, smokers looking to try e-cigarettes may choose less effective devices because they are more widely advertised.

These changes may reassure the general public that the devices will be safe but may lead to many ex-smokers relapsing because they are forced to use e-cigarettes and e-liquids that do not meet their needs, all the while lining the pockets of the tobacco industry by allowing them a monopoly on higher nicotine dosage products. Of course, the possible outcomes stated here are speculative; research will need to be undertaken to evaluate the ongoing impact of the new guidelines.

Links

  1. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/489981/TPD_Cons_Gov_Response.pdf).
  2. http://www.telegraph.co.uk/news/health/news/12079130/E-cigarettes-win-first-approval-as-a-medicine-opening-way-for-prescription-by-the-NHS.html
  3. https://www.gov.uk/government/consultations/regulatory-fees-for-e-cigarettes
  4. http://ash.org.uk/files/documents/ASH_1011.pdf
  5. https://nicotinepolicy.net/documents/reports/Impacts%20of%20medicines%20regulation%20-%2020-09-2013.pdf

Photo Credits

http://ecigarettereviewed.com/ – Lindsay Fox

New alcohol guidelines: what you need to know

Posted on by meryemgrabski

by Olivia Maynard @OliviaMaynard17

This blog originally appeared on the Mental Elf site on 9th Febraury 2016.

Last month the UK Chief Medical Officers (CMOs) published new guidelines for alcohol consumption. These are the first new guidelines since 1995 and are based on the latest evidence on the effects of alcohol consumption on health.

The guidelines provide recommendations for weekly drinking limits, single drinking episodes and recommendations for pregnant women, drawing heavily on the Sheffield Alcohol Policy Model, which uses the most up to date evidence on both the short- and long-term risks of alcohol.

What are the new guidelines?

Guidelines for weekly drinking

For the new weekly drinking guidelines, the CMOs recommend that:

  • It’s safest for both men and women to not regularly drink more than 14 units of alcohol per week;
  • It’s best to spread these units over 3 days or more;
  • Having several drink-free days each week is a good way of cutting down the amount you drink;
  • The risk of developing a range of illnesses increases with any amount you drink on a regular basis.

There are two key changes here from the guidelines we’ve been used to:

First, there’s no difference in recommendations for men and women. This is because there is increasing evidence that although women are more at risk from the long-term health effects of alcohol, men are more at risk from the short-term effects of drinking (they’re more likely to expose themselves to risky situations while drinking).

Second, there is an explicit statement that there is no ‘safe’ level of alcohol consumption. Over the past 21 years, the link between alcohol and cancer has become much clearer. For example, we now know that while the lifetime risk ofbreast cancer is 11% among female non-drinkers, the lifetime risk for a woman drinking within the new guidelines is 13%. A woman drinking over 35 units a week increases her risk of breast cancer to 21%.

In their report, the CMOs are also at pains to point out that the evidence supporting alcohol’s protective effects on ischaemic heart disease is now weaker than in 1995. Furthermore, any potential protective effect of alcohol is mainly observed among older women at very low levels of consumption. Previously some have used this to claim that drinking is better than abstinence – the new guidelines refute this.

The new guidance says it's safest for men and women to drink no more than 14 units each week.

The new guidance says it’s safest for men and women to drink no more than 14 units each week.

Guidelines for single drinking episodes

The new guidelines are the first to provide guidance on drinking on single occasions, recommending drinkers:

  • Limit the total amount consumed on any occasion;
  • Drink slowly, with food and alternating with water;
  • Avoid risky places and activities and ensure they have a safe method of getting home.

These new recommendations reflect the fact that many alcohol consumers may drink heavily on occasion and provide guidance to avoid the risk of injury and ischaemic heart disease which increase with heavy drinking.

Heavy drinking episodes are linked with a higher risk of injury.

Heavy drinking episodes are linked with a higher risk of injury.

Guidelines for drinking during pregnancy

The new guidelines suggest that:

  • The safest approach for pregnant women is not to drink alcohol at all, to keep risks to the baby to a minimum.
  • Drinking during pregnancy can lead to long-term harm to the baby, with the risk increasing with the more alcohol consumed;
  • The risk of harm to the baby is likely to be low if a woman has drunk only small amounts of alcohol before she knew she was pregnant or during pregnancy.

The CMOs report that while the evidence on the effects of low alcohol consumption during pregnancy remains ‘elusive’, taking a precautionary approach is most prudent when it comes to a baby’s long term health. However, given the elusive evidence, the guidance is also careful to note that mothers should not be too concerned if they have drunk early in their pregnancy, as this kind of stress may be even more harmful to the developing baby.

Pregnant women are advised not to drink alcohol at all.

Pregnant women are advised not to drink alcohol at all.

A note on risk

These recommendations are based on a level of alcohol consumption which confers a 1% lifetime risk of death from alcohol. Their purpose is therefore tominimise risk from alcohol, rather than eliminate it. Indeed, the guidelines explicitly state that there is no safe level of alcohol consumption. So what does a 1% lifetime risk mean and how does this compare to other health behaviours?

Lifetime mean risks

  • Being killed through BASE jumping (0.3%);
  • Being killed in a car accident (0.4%);
  • Being diagnosed with bowel cancer from eating three rashers of bacon every day (1%);
  • Dying from an alcohol related disease, if drinking within the new guidelines (1%);
  • Smokers dying from a smoking related disease (50%, although new estimates suggest that this may be as high as 67%).

Put in the context of smoking, the risk posed by drinking within the new guidelines seems tiny (although it’s still more risky than BASE jumping!) However, it’s important to note that alcohol consumption and smoking are quite different. Alcohol consumption is perceived as normal in our society and is much more prevalent than cigarette smoking. By contrast, the acceptability of smoking is reducing and unlike social alcohol consumers, smokers are constantly being told to quit smoking.

This 1% risk level is that which is deemed ‘acceptable’ by the CMO. However, everyone will have a different ‘acceptable’ level of risk, which depends in part on how much pleasure is obtained from drinking. While some will think that increasing their risk of death from alcohol to 5% is acceptable, others will not accept any risk and will use these guidelines to cut out alcohol completely.

Criticisms of the new guidelines

As expected, the ‘nanny state’ criticism has been bandied around in pubs, on message boards and on social media since the publication of these guidelines. Others claim that these new guidelines are simply scaremongering. However, it’s important to remember that these are recommendations, not rules.

The last word must go to CMO Professor Dame Sally Davies, who addressed this criticism by saying that:

What we are aiming to do with these guidelines is give the public the latest and most up- to-date scientific information so that they can make informed decisions about their own drinking and the level of risk they are prepared to take.

What do you think? Are these new guidelines useful? Will they help reduce alcohol related harm?

What do you think? Are these new guidelines useful? Will they help reduce alcohol related harm?

Links

Primary paper

Department of Health (2016) Health risks from alcohol: new guidelines. Open Consultation, 8 Jan 2016 (Consultation closes on 1 April 2016)

Department of Health (2016). Alcohol Guidelines Review – Report from the Guidelines development group to the UK Chief Medical Officers.

Other references

Centre for Public Health (2016). CMO Alcohol Guidelines Review – A summary of the evidence of the health and social impacts of alcohol consumption. Liverpool John Moores University.

Centre for Public Health (2016). CMO Alcohol Guidelines Review – Mapping systematic review level evidence. Liverpool John Moores University.

Department of Health (1995). Sensible drinking: Report of an inter-departmental working group.

Photo credits

 

Research Responsibly: Things to Consider when Science and Politics Meet

Posted on by meryemgrabski

By Meryem Grabski

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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.

– See more at: http://www.thementalelf.net/mental-health-conditions/substance-misuse/alcohol-minimum-unit-pricing-time-to-take-action/#sthash.hAkkpG2g.dpuf