The underbelly of E-cigarette advertising: regulating online markets on social media platforms.

Australia prohibits the sale of nicotine-vaping products unless prescribed by medical practitioners. Significant policy reforms were announced on the 28th of November 2023 including a ban on single-use disposable vapes with and without nicotine, and the removal of the personal importation scheme. Despite stringent regulations, loopholes exist such that e-cigarette vendors are getting around it, and online markets provide a route to do so. We discuss strategies used by vendors to covertly market e-cigarettes online through social media. In this perspective, we highlight three proposed policies to strengthen social media regulations that may be feasible to implement. Our proposed strategies to regulate e-cigarette product listings on social media involve implementing robust age verification measures, enhancing the system for flagging and reporting prohibited content, and developing a more effective system to identify and flag content related to e-cigarettes.

Vaping on TikTok: a systematic thematic analysis.

INTRODUCTION: The rising popularity of TikTok among adolescents may influence their awareness and perceptions of e-cigarette use via user-generated content. This study aimed to examine how e-cigarette/vaping-related videos are portrayed on TikTok. METHODS: The nine most viewed hashtag based keywords were used to identify popular e-cigarette/vaping-related videos on TikTok (n=1000) from its inception (earliest upload date: January 2019) to November 2020. Five researchers independently coded the number of views, likes, user category and theme. RESULTS: A final sample of 808 e-cigarette/vaping-related videos that met study criteria were included. Collectively, these videos were viewed over 1.5 billion times, with a median view count of 1 000 000 (range 112 900-78 600 000) and a median 'likes' count of 143 000 (range 10 000-1 000 000). A majority of the videos portrayed e-cigarette use positively (63%; collectively viewed over 1.1 billion times). Neutral depictions of e-cigarette use were viewed a total of 290 million times (24%) and negative depictions of e-cigarettes were viewed a total of 193 million times (13%). The video themes included (not mutually exclusively): 'comedy and joke' (52%; total of 618 million views), 'lifestyle and acceptability' (35%; 459 million), 'marketing' (29%; 392 million), 'vaping tricks' (20%; 487 million), 'nicotine and addiction' (20%; 194 million), 'creativity' (16%; 322 million) and 'warning' (11%; 131 million). CONCLUSION: Our findings illustrated that positively framed e-cigarette and vaping-related postings available without age restrictions on TikTok-a rising video-sharing platform that is popular among adolescents-have been viewed many times. Effective age restrictions are needed to reduce adolescents' potential exposure to videos that portray vaping positively.

Efficacy of smokeless tobacco for smoking cessation: a systematic review and meta-analysis.

OBJECTIVE: Smoking remains prevalent in many countries despite rigorous tobacco control strategies. The use of Swedish snus, a type of low-nitrosamine smokeless tobacco, has been promoted as a tobacco harm reduction strategy. DATA SOURCES AND STUDY SELECTION: Three databases were searched for studies that assessed the effectiveness of snus in promoting smoking abstinence. A total of 28 studies were reviewed (5 randomised controlled trials (RCTs), 7 longitudinal and 16 cross-sectional studies). DATA EXTRACTION: Separate meta-analyses were conducted by study type, pooling effect estimates where outcome measures and design were sufficiently comparable. Study details and quality assessment (Risk of Bias 2 for RCTs, Newcastle-Ottawa Scale for observational studies) are provided for each study. DATA SYNTHESIS: While the meta-analysis of RCTs did not show a significant association between snus use and smoking cessation (risk ratio (RR)=1.33, 95% CI 0.71 to 2.47 and RR=0.62, 95% CI 0.27 to 1.41), the results of the meta-analysis of longitudinal cohort studies (RR=1.38, 95% CI 1.05 to 1.82, p=0.022) and cross-sectional studies (OR=1.87, 95% CI 1.29 to 2.72, p=0.001) indicated that use of snus was associated with an increased likelihood of quitting or having quit smoking. There was significant heterogeneity in the cross-sectional studies, and leave-one-out analysis indicated that the longitudinal cohort results were driven by one study. Most studies examined were subject to an elevated risk of bias. CONCLUSION: There is weak evidence for the use of snus for smoking cessation. Better RCTs and longitudinal studies are needed; meanwhile, existing cessation aids may be better placed than snus to promote abstinence.

Use of flavored cannabis vaping products in the US, Canada, Australia, and New Zealand: findings from the international cannabis policy study wave 4 (2021).

Background: Vaping is an increasingly popular mode of cannabis use. Few studies have characterized the role of flavors in cannabis e-liquids.Objectives: To explore the prevalence of flavored vaping liquids, including differences between countries and correlates of use.Methods: Data were from Wave 4 (2021) of the International Cannabis Policy Study with national samples aged 16-65 in Canada, the United States (US), Australia, and New Zealand. The sample comprised 52,938 respondents, including 6,265 who vaped cannabis e-liquids in the past 12-months (2,858 females, 3,407 males). Logistic regression models examined differences in the use of flavored e-liquids between countries and sociodemographic characteristics.Results: The prevalence of vaping cannabis e-liquids was highest in the US (15.3%) and Canada (10.7%) compared to Australia (4.0%) and New Zealand (3.7%). Among past 12-month cannabis consumers, 57.5% reported using flavored vaping liquids, 34.2% used unflavored vaping products and 8.3% did not know. People who vape in Australia were most likely to report using flavored liquids compared to New Zealand (OR = 2.29), Canada (OR = 3.14), and the US (OR = 3.14) (p < .05 for all). Fruit was the most reported vaping flavor (40.8%), followed by candy/dessert (20.4%) and vanilla (15.2%). Use of flavored vapes was greater among younger, ethnic minorities, female, higher education and income adequacy, and more frequent consumers (p < .05).Conclusion: Many cannabis consumers reported using flavored e-liquids, with highest levels among young people aged 16-35. Given the high prevalence of vaping in legal markets, regulators should consider the role of flavored vaping products in promoting cannabis use among this group.

The experience of physiological and psychosocial alcohol-related harms across adolescence and its association with alcohol use disorder in early adulthood: A prospective cohort study.

BACKGROUND: Different forms of alcohol-related harm (e.g., hangovers, fighting) may confer differential risk of clinically relevant alcohol problems. We examine: (i) patterns of transition in experiencing alcohol-related harms across adolescence; (ii) whether factors in early adolescence predict transition patterns; and (iii) whether transition patterns predict later alcohol use disorder (AUD) symptoms. METHODS: We used a longitudinal Australian cohort (n = 1828) to model latent class transition patterns of alcohol-related harms across three timepoints (Mage  = 13.9, 16.8, 18.8 years). Regression models assessed whether child, peer, and parent factors in early adolescence (Mage  = 12.9) predicted harms transition patterns and whether these patterns predicted AUD symptoms in early adulthood (Mage  = 19.8). RESULTS: Five transition patterns characterized most of the cohort (n ≈ 1609, 88.0%): (i) minimal harms (n ≈ 381, 20.8%); (ii) late physiological harms (n ≈ 702, 38.4%); (iii) early physiological harms (n ≈ 226, 12.4%); (iv) late all harms (n ≈ 131, 7.2%); and (v) gradual all harms (n ≈ 169, 9.2%). With late physiological harms as the reference, females had increased risk of experiencing early physiological harms (relative risk [RR]: 2.15; 99.5% CI: 1.19, 3.90). Late all harms (RR: 1.71; CI: 1.19, 2.47) and gradual all harms (RR: 1.84; CI: 1.37, 2.47) were each associated with increased odds of meeting criteria for AUD, even when patterns of alcohol consumption are considered. CONCLUSIONS: Adolescents display heterogeneous transition patterns across physiological and psychosocial alcohol-related harms. Females are at greater risk of experiencing early physiological harms. Experience of both physiological and psychosocial harms in late adolescence is an important and potentially modifiable precursor to clinically relevant alcohol problems in early adulthood.

Predicting Alcohol Misuse Among Australian 19-Year-Olds from Adolescent Drinking Trajectories.

BACKGROUND: Alcohol use in adolescence predicts future alcohol misuse. However, the extent to which different patterns of adolescent use present risk remains unclear. OBJECTIVES: This study investigated how adolescent trajectories of alcohol consumption during the school years predict alcohol misuse at age 19 years. METHODS: Data were drawn from 707 students from Victoria, Australia, longitudinally followed for 7 years. Five alcohol use trajectories were identified based on the frequency of alcohol use from Grade 6 (age 12 years) to Grade 11 (age 17 years). At age 19 years, participants completed measures indicating Heavy Episodic Drinking (HED), dependency - Alcohol Use Disorders Identification Test (AUDIT) and social harms. RESULTS: At 19 years of age, 64% of participants reported HED, 42% high AUDIT scores (8+), and 23% social harms. Participants belonging to a steep escalator trajectory during adolescence had twice the odds at 19 years of age of high AUDIT scores and social harms, and three times greater odds of HED than participants whose alcohol use slowly increased. Stable moderate consumption was also associated with an increased risk of HED compared to slowly increasing use. Abstinence predicted a reduced likelihood of all forms of misuse at 19 years of age compared to slowly increased alcohol use. CONCLUSIONS: Trajectories of drinking frequency during adolescence predict alcohol misuse at age 19 years. Although rapid increasing use presents the greatest risk, even slowly increasing drinking predicts increased risk compared to abstinence. The findings indicate that alcohol policies should recommend nonuse and reduced frequency of use during adolescence.

An Examination of Gender Differences in the Association of Adolescent Substance use with Eating and Weight Loss Attitudes.

OBJECTIVE: To assess gender differences in the relationship between eating and weight loss attitudes (EWAs), and 30-day tobacco and alcohol use among adolescents, while controlling for potential confounds (age, country of birth, psychological distress, pubertal development, peer alcohol and tobacco use, and sexual activity). METHODS: School students aged between 11 and 17 years (N = 10,273) from high schools in the State of Victoria (Australia) completed surveys in class under conditions of anonymity and confidentiality. RESULTS: The interaction between EWAs and gender was significant for tobacco use but not for alcohol use, indicating that the effect of EWAs on tobacco use, but not alcohol use, vary by gender. CONCLUSIONS: Tobacco use was related to EWAs in adolescent females but not males, and this is consistent with the possibility that females use tobacco in an instrumental fashion to control weight. Implications and Contribution: Female adolescents high in eating and weight loss attitudes were more likely to engage in tobacco use. In contrast, eating and weight loss attitudes were not related to male tobacco use. These results point to the potential importance of developing gender-specific approaches towards addressing problematic behaviors in adolescent populations.

Parental supply of alcohol and adolescent drinking: a multilevel analysis of nationally representative data.

BACKGROUND: Existing research on parental supply of alcohol analyses the effects of self-reported parental supply on adolescent drinking using individual level data. This study examined the contextual effect of parental supply of alcohol on adolescent alcohol use by examining the association between the prevalence of parental supply in each Australian state and adolescent alcohol use using a multilevel analytic framework. METHODS: Adolescent samples (Age: 12-17) were drawn from the four National Drug Strategy Household Surveys (2004, 2007, 2010 and 2013; N = 6803). The prevalence of parental supply of alcohol, defined as the weighted percentage of sample who reported obtaining alcohol from their parents, was estimated in each state and territory across the four surveys. Three multilevel logistic regressions were used to examine the contextual effects of parental supply prevalence on adolescents' alcohol use in the past 12 months, weekly drinking and heavy drinking. RESULTS: Overall, adolescents' rates of past 12 months alcohol use, heavy drinking and weekly drinking between 2004 and 2013 were 40.1, 14.4 and 6.4% respectively. The prevalence of parental supply was significantly associated with past 12 months alcohol use (OR = 1.06, p < .001) and heavy drinking (OR = 1.04, p < .001) but not with weekly drinking (OR = 1.03, p = .189). The results were adjusted for gender, age, socio-economic index for area, place of birth, survey year and prevalence of peer supply. CONCLUSION: A high prevalence of parental supply in a region was associated with heavier adolescent drinking, regardless of whether adolescents primarily obtained their alcohol from their own parents.

Linking eating and weight control attitudes to relationship experiences: A large-scale survey of adolescent females.

OBJECTIVE: To examine the extent to which family conflict, peer bullying and psychological distress account for eating and weight loss attitudes in adolescent females. This study examined the degree to which psychological distress mediated the association between family conflict and eating and weight loss attitudes, and the association of bullying and eating and weight loss attitudes. METHOD: Females aged between 11 and 17 years (N = 5125) were recruited from schools in the State of Victoria (Australia). Key measures included psychological distress, family conflict, and bullying victimisation. RESULTS: A structural model showed good fit, and all predictors were significant. Psychological distress mediated the association between eating and weight loss attitudes, and family problems and bullying. CONCLUSION: Family conflict and peer bullying were associated with eating and weight loss attitudes and this association may occur via psychological distress. Early intervention programs may benefit from a focus on family and peer relationships.

Parental supply of alcohol to Australian minors: an analysis of six nationally representative surveys spanning 15 years.

BACKGROUND: Most adolescents begin alcohol consumption during adolescence, heavy alcohol use by adolescents is common, and alcohol-related harm amongst adolescents is a major public health burden. Parents are a common source of alcohol amongst adolescents, but little is known about how parental supply of alcohol has changed over recent years. This study examines national trends in parental supply of alcohol to adolescent children in Australia since 1998. METHODS: Six Australian National Drug Strategy Household Surveys (1998-2013) yielded rates of parental supply of current and first ever alcohol consumed. Lifetime and current alcohol use were also estimated. The surveys were conducted for households across all Australian states and territories. Surveyed adolescents were aged 14-17 years (N = 7357, 47.6 % male). Measures included the reported source of currently consumed alcohol and first ever alcoholic beverage (parents/friends/others), lifetime alcohol use, number of standard alcohol units consumed on drinking days, and frequency of alcohol use. Corrected Pearson chi-squared tests were used to compare survey years. RESULTS: There was a significant drop in parental supply of current alcohol use from 21.3 % in 2004 to 11.79 % in 2013 (p < .001). The lower prevalence of parental supply coincided with legislative changes on parental supply of alcohol to adolescents, but causality cannot be established because of the variation in the timing and reach of parental supply legislation, and small samples in some states. There were downward trends in adolescent experimentation, quantity and frequency of alcohol use across years, with the largest drop in alcohol use in 2010 and 2013. CONCLUSIONS: In Australia, there has been a substantial reduction in parental supply of alcohol to adolescents from 2010, and this factor may partially account for reductions in adolescent alcohol use.

Trend in alcohol use in Australia over 13 years: has there been a trend reversal?

BACKGROUND: Skog's collectivity theory of alcohol consumption predicted that changes in alcohol consumption would synchronize across all types of drinkers in a population. The aim of this paper is examine this theory in the Australian context. We examined whether there was a collective change in alcohol use in Australia from 2001 to 2013, estimated alcohol consumption in non-high risk and high risk drinkers, and examined the trends in alcohol treatment episodes. METHODS: Data from the 2001-2013 National Drug Strategy Household Surveys (N = 127,916) was used to estimate the prevalence and alcohol consumption of abstainers, high risk drinkers and frequent heavy episodic drinkers. Closed treatment episodes recorded in the Alcohol and Other Drug Treatment Services National Minimum Dataset (N = 608,367) from 2001 to 2013 were used to examine the trends of closed alcohol treatment episodes. RESULTS: The prevalence of non-drinkers (abstainers) decreased to the lowest level in 2004 (15.3 %) and rebounded steadily thereafter (20.4 % in 2013; p < .001). Correspondingly, the per capita consumption of high risk drinkers (2 standard drinks or more on average per day) increased from 20.7 L in 2001 to peak in 2010 (21.5 L; p = .020). Non-high risk drinkers' consumption peaked in 2004 (2.9 L) and decreased to 2.8 L in 2013 (p < .05). There were decreases in alcohol treatment episodes across nearly all birth cohorts in recent years. CONCLUSION: These findings are partially consistent with and support Skog's collectivity theory. There has been a turnaround in alcohol consumption after a decade-long uptrend, as evident in the collective decreases in alcohol consumption among nearly all types of drinkers. There was also a turnaround in rate of treatment seeking, which peaked at 2007 and then decreased steadily. The timing of this turnaround differs with level of drinking, with non-high risk drinkers reaching its peak consumption in 2004 and high risk drinkers reaching its peak consumption in 2010.

Association of different forms of bullying victimisation with adolescents' psychological distress and reduced emotional wellbeing.

OBJECTIVE: The frequency and emotional response to bullying victimisation are known to be associated with adolescent mental ill health. A potentially important under-investigated factor is the form of bullying. Four common forms of bullying behaviours are name-calling, physical threats or harm, rumour spreading and social exclusion. To more comprehensively understand bullying victimisation in adolescence, we examined the association of all three factors (frequency, emotional response, form) to psychological distress and emotional wellbeing. METHOD: A stratified, random sample of adolescents (n = 10, 273; mean age = 14.33 years, standard deviation = 1.68 years) completed validated measures of bullying victimisation (Gatehouse Bullying Questionnaire), psychological distress (K10) and emotional wellbeing (Mental Health Inventory) in classroom time. Associations between the form of bullying victimisation and mental health outcomes were examined. RESULTS: Adolescents reported a high prevalence of all four forms of bullying: teased or called names (30.6%), rumour spreading (17.9%), social exclusion (14.3%) and physical threats or harm (10.7%). Victimisation was independently associated with significantly higher levels of psychological distress and reduced levels of emotional wellbeing for all forms of bullying. In particular, social exclusion had a strong association with mental ill health. Adolescents who experienced frequent bullying that was upsetting reported higher psychological distress and reduced emotional wellbeing. CONCLUSION: Different forms of bullying victimisation were independently associated with psychological distress and reduced emotional wellbeing. In particular, frequent and upsetting social exclusion requires a targeted and measured response by school communities and health practitioners.

Regional versus urban differences in teenage alcohol use: Does parental disapproval account for these differences?

OBJECTIVE: To investigate if parental disapproval of alcohol use accounts for differences in adolescent alcohol use across regional and urban communities. DESIGN: Secondary data analysis of grade-level stratified data from a random sample of schools. SETTING: High schools in Victoria, Australia. PARTICIPANTS: A random sample of 10 273 adolescents from Grade 7 (mean age = 12.51 years), 9 (14.46 years) and 11 (16.42 years). MAIN OUTCOME MEASURES: The key independent variables were parental disapproval of adolescent alcohol use and regionality (regional/ urban), and the dependent variable was past 30 days alcohol use. RESULTS: After adjusting for potential confounders, adolescents in regional areas were more likely to use alcohol in the past 30 days (OR = 1.83, 1.44 and 1.37 for Grades 7, 9 and 11, respectively, P < 0.05), and their parents have a lower level of disapproval of their alcohol use (b = -0.12, -0.15 and -0.19 for Grades 7, 9 and 11, respectively, P < 0.001). Bootstrapping analyses suggested that 8.37%, 23.30% and 39.22% of the effect of regionality on adolescent alcohol use was mediated by parental disapproval of alcohol use for Grades 7, 9 and 11 participants respectively (P < 0.05). CONCLUSIONS: Adolescents in urban areas had a lower risk of alcohol use compared with their regional counterparts, and differences in parental disapproval of alcohol use contributed to this difference.

Through the looking glass: An alcohol advertisement every 3 minutes.

INTRODUCTION: There is growing concern over the lack of regulation of alcohol advertisements on social media platforms frequented by youths. This study aims to build upon existing literature by assessing the frequency with which young Australians (17-25) are shown advertisements promoting alcohol use and the themes utilised in these advertisements. METHODS: A total of 125 Australian youths (mean age 18.74 years; 74.40% female) were recruited in exchange for course credit to participate in an online study. Participants scrolled through Facebook or Instagram for a period of 30 min and screenshotted any alcohol advertisements encountered. Participants then identified the advertisement qualities (or 'themes') present in the advertisements, based on pre-identified categories. Demographic, social media usage and historical personal, peer or familial substance use behaviour data was also collected. RESULTS: Seventy-one university students were exposed to 796 alcohol advertisements across both platforms, and they encountered an advertisement every 2 min and 43 s on average. Most advertisements included call to action features on both Facebook (78.80%) and Instagram (71.17%). Advertisements relating to ease of access (promoting subscription/home delivery; 41.72% and 42.56%) and sales incentives (special offers, promotions, samples or bonuses with purchase; 43.70% and 46.84%) were most common across both platforms. DISCUSSION AND CONCLUSIONS: Alcohol advertisements are highly prevalent online, particularly among Australian youth social media users. Future research should endeavour to identify whether temporal use of alcohol is a predictor of subsequent exposure to alcohol advertising on social media, and whether this exposure is likely to increase successive alcohol use behaviours.

Designing observational studies for credible causal inference in addiction research-Directed acyclic graphs, modified disjunctive cause criterion and target trial emulation.

Randomized controlled trials (RCTs) are considered the gold standard for causal inference. With a sufficient sample size, randomization removes confounding up to the time of randomization and allows the treatment effect to be isolated. However, RCTs may have limited generalizability and transportability and are often not feasible in addiction research due to ethical or logistical constraints. The importance of observational studies from real-world settings has been increasingly recognized in research on health. This paper provides an overview of modern approaches to designing observational studies that enable causal inference. It illustrates three key techniques, Directed Acyclic Graphs (DAGs), modified Disjunctive Cause Criterion and Target Trial Emulation, and discusses the strengths and limitations of their applications.

A systematic review and meta-analysis of the relationship between youth drinking, self-posting of alcohol use and other social media engagement (2012-21).

BACKGROUND AND AIM: Social networking sites (SNS) are interactive internet-based social platforms that facilitate information sharing. A growing body of literature on exposure to, and self-posting of, alcohol-related content on SNS has examined the relationship between SNS use and alcohol consumption in young people. This study aims to synthesise the literature exploring the relationship between exposure (i.e. viewing or listening of alcohol-related media) and self-posting (i.e. uploading images or text of alcohol content) of alcohol-related media on SNS on alcohol consumption. METHODS: A pre-registered systematic review was conducted in June 2022 within PubMed, Scopus, PsycINFO and Web of Science. Original prospective and cross-sectional studies assessing youth and young adults (≤ 24 years of age) that measured exposure to alcohol-related media or posting of alcohol-related content on SNS and self-reported alcohol consumption outcomes were included. Meta-analyses were conducted on comparable methodologies. RESULTS: Thirty studies were included (n = 19,386). Meta-analyses of cross-sectional studies showed both greater exposure (five studies; pooled ß = 0.34, 95% confidence interval [CI] = 0.23, 0.44, i2 = 27.7%) and self-posting of alcohol-related content (six studies; pooled ß = 0.57, 95%CI = 0.25,0.88, i2 = 97.8%) was associated with greater alcohol consumption. Meta-analyses of three prospective studies also identified that greater exposure predicted greater future alcohol consumption (three studies; pooled ß = 0.13, 95%CI = 0.11,0.15, i2 = 0.0%). Narrative analyses of studies that could not be meta-analysed due to incompatible methodologies were also conducted. Most studies (all four prospective, one of two cross-sectional) identified positive associations between exposure to alcohol-related content and greater average consumption. Most studies (three of four prospective, four of six cross-sectional) reported a positive association between of alcohol-related self-posting and greater average alcohol consumption. CONCLUSIONS: Both exposure to, and self-posting of, alcohol-related content on social networking sites are positively associated with current average consumption, problem drinking, and drinking frequency.

"Buy High, Sell Low": A Qualitative Study of Cryptocurrency Traders Who Experience Harm.

The constant, substantial price fluctuations of cryptocurrency allow traders to engage in highly speculative trading that closely resembles gambling. With significant financial loss associated with adverse mental health outcomes, it is important to investigate the impact that market participation has on mental health. Therefore, we conducted interviews with 17 participants who self-reported problems due to trading. Thematic analysis was conducted revealing themes: (1) factors in engagement, (2) impacts of trading and (3) harm reduction. Factors in engagement captured factors that motivated and sustained cryptocurrency trading. Impacts of trading outlined how cryptocurrency trading positively and negatively impacted participants. Harm reduction described methods participants employed to reduce mental distress from trading. Our study provides novel insights into the adverse impacts of cryptocurrency trading across multiple domains, especially mental health, relationships and finances. They also indicate the importance of further research on effective coping strategies for distress caused by financial loss from trading. Additionally, our study reveals the significant role social environments play on participants' expectations and intentions regarding cryptocurrency trading. These social networks extend beyond real-life relationship to include celebrity and influencer endorsement. This encourages investigation into the content of cryptocurrency promotions and the influence they have on individuals' decision to trade.

Seeking order in patterns of polysubstance use.

PURPOSE OF REVIEW: This review provides an overview of recent developments in understanding polysubstance use patterns across the lifespan, and advances made in the prevention and treatment of harm arising from polysubstance use. RECENT FINDINGS: A comprehensive understanding of the patterns of polysubstance use is hampered by heterogeneity across study methods and types of drugs measured. Use of statistical techniques such as latent class analysis has aided in overcoming this limitation, identifying common patterns or classes of polysubstance use. These typically include, with decreasing prevalence, (1) Alcohol use only; (2) Alcohol and Tobacco; (3) Alcohol, Tobacco, and Cannabis; and finally (4) a low prevalence, Extended Range cluster that includes other illicit drugs, New Psychoactive Substances (NPS), and nonmedical prescription medications. SUMMARY: Across studies, there are commonalities present in clusters of substances used. Future work that integrates novel measures of polysubstance use and leverages advances in drug monitoring, statistical analysis and neuroimaging will improve our understanding of how and why drugs are combined, and more rapidly identify emerging trends in multiple substance use. Polysubstance use is prevalent but there is a paucity of research exploring effective treatments and interventions.

Conversational artificial intelligence interventions to support smoking cessation: A systematic review and meta-analysis.

Background: Conversational artificial intelligence (chatbots and dialogue systems) is an emerging tool for tobacco cessation that has the potential to emulate personalised human support and increase engagement. We aimed to determine the effect of conversational artificial intelligence interventions with or without standard tobacco cessation interventions on tobacco cessation outcomes among adults who smoke, compared to no intervention, placebo intervention or an active comparator. Methods: A comprehensive search of six databases was completed in June 2022. Eligible studies included randomised controlled trials published since 2005. The primary outcome was sustained tobacco abstinence, self-reported and/or biochemically validated, for at least 6 months. Secondary outcomes included point-prevalence abstinence and sustained abstinence of less than 6 months. Two authors independently extracted data on cessation outcomes and completed the risk of bias assessment. Random effects meta-analysis was conducted. Results: From 819 studies, five randomised controlled trials met inclusion criteria (combined sample size n = 58,796). All studies differed in setting, methodology, intervention, participants and end-points. Interventions included chatbots embedded in multi- and single-component smartphone apps (n = 3), a social media-based (n = 1) chatbot, and an internet-based avatar (n = 1). Random effects meta-analysis of three studies found participants in the conversational artificial intelligence enhanced intervention were significantly more likely to quit smoking at 6-month follow-up compared to control group participants (RR = 1.29, 95% CI (1.13, 1.46), p < 0.001). Loss to follow up was generally high. Risk of bias was high overall. Conclusion: We found limited but promising evidence on the effectiveness of conversational artificial intelligence interventions for tobacco cessation. Although all studies found benefits from conversational artificial intelligence interventions, results should be interpreted with caution due to high heterogeneity. Given the rapid evolution and potential of artificial intelligence interventions, further well-designed randomised controlled trials following standardised reporting guidelines are warranted in this emerging area.