A qualitative study investigating Australian cancer service outpatients' experience of distress screening and management: what is the personal relevance, acceptability and improvement opportunities from patient perspectives?

PURPOSE: People diagnosed with cancer experience high distress levels throughout diagnosis, treatment, and survivorship. Untreated distress is associated with poor outcomes, including worsened quality of life and higher mortality rates. Distress screening facilitates need-based access to supportive care which can optimize patient outcomes. This qualitative interview study explored outpatients' perceptions of a distress screening process implemented in an Australian cancer center. METHODS: Adult, English-speaking cancer outpatients were approached to participate in face-to-face or phone interviews after being screened by a clinic nurse using the distress thermometer (DT). The piloted semi-structured interview guide explored perceptions of the distress screening and management process, overall well-being, psychosocial support networks, and improvement opportunities for distress processes. Thematic analysis was used. RESULTS: Four key themes were identified in the 19 interviews conducted. Distress screening was found to be generally acceptable to participants and could be conducted by a variety of health professionals at varied time points. However, some participants found "distress" to be an ambiguous term. Despite many participants experiencing clinical distress (i.e., DT ≥ 4), few actioned referrals; some noted a preference to manage and prevent distress through informal support and well-being activities. Participants' diverse coping styles, such as positivity, acceptance, and distancing, also factored into the perceived value of screening and referrals. CONCLUSION AND IMPLICATIONS: Screening models only measuring severity of distress may not be sufficient to direct care referrals, as they do not consider patients' varying coping strategies, external support networks, understanding of distress terminology, and motivations for accessing supportive care services.

Distress screening and supportive care referrals used by telephone-based health services: a systematic review.

PURPOSE: People affected by chronic diseases such as cancer report high levels of distress and a need for psychosocial support. It is unclear whether telephone-based services for people affected by chronic disease are a practical setting for implementing distress screening, referral protocols and rescreening to direct supportive care where it is needed. This systematic review aimed to describe the published literature regarding distress screening and supportive care referral practices in telephone-based services for people affected by chronic diseases such as cancer. METHODS: A systematic literature search of MEDLINE, Embase, PsycInfo, CINAHL, Cochrane and Scopus was conducted in February 2018. Included quantitative studies involved: patients or caregivers affected by chronic diseases including cancer and describe a health service assessing psychosocial needs or distress via telephone. Extracted data included the type of cancer or other chronic disease, sample size, screening tool, referral or rescreening protocols, and type of health service. RESULTS: The search identified 3989 potential articles with additional searches returning 30 studies (n = 4019); fourteen were eligible for full-text review. Of the 14 studies, 13 included cancer patients. Studies were across multiple settings and identified nine distress screening tools in use. CONCLUSION: The reviewed studies indicate that validated distress-screening tools are being used via telephone to identify distress, particularly in relation to cancer. Screening-driven supportive care referrals are also taking place in telephone-based services. However, not all services use an established referral protocol. Ongoing rescreening of callers' distress is also limited despite it being an important recommendation from psycho-oncology guidelines.

A cross-sectional audit of current practices and areas for improvement of distress screening and management in Australian cancer services: is there a will and a way to improve?

BACKGROUND: It is unknown how many distressed patients receive the additional supportive care recommended by Australian evidence-based distress management guidelines. The study identifies the (1) distress screening practices of Australian cancer services; (2) barriers to improving practices; and (3) implementation strategies which are acceptable to service representatives interested in improving screening practices. METHOD: Clinic leads from 220 cancer services were asked to nominate an individual involved in daily patient care to complete a cross-sectional survey on behalf of the service. Questions related to service characteristics; screening and management processes; and implementation barriers. Respondents indicated which implementation strategies were suitable for their health service. RESULTS: A total of 122 representatives participated from 83 services (51%). The majority of respondents were specialist nurses or unit managers (60%). Approximately 38% of representatives' services never or rarely screen; 52% who screen do so for all patients; 55% use clinical interviewing only; and 34% follow referral protocols. The most common perceived barriers were resources to action screening results (74%); lack of time (67%); and lack of staff training (66%). Approximately 65% of representatives were interested in improving practices. Of the 8 implementation strategies, workshops (85%) and educational materials (69%) were commonly selected. Over half (59%) indicated a multicomponent implementation program was preferable. CONCLUSIONS: Although critical gaps across all guideline components were reported, there is a broad support for screening and willingness to improve. Potential improvements include additional services to manage problems identified by screening, more staff time for screening, additional staff training, and use of patient-report measures.

How can we help haematological cancer survivors cope with the changes they experience as a result of their cancer?

Haematological cancer often necessitates that individuals make significant lifestyle and behaviour changes to protect themselves against infections. It is essential that haematological cancer survivors receive the support and information they require to adjust to such changes. This cross-sectional survey of 259 haematological cancer survivors found that over two thirds of haematological cancer survivors would like to receive more detailed information or help with: diet and nutrition that takes into account their diagnosis and treatment, how to manage the symptoms from the cancer and/or treatment, signs and symptoms to be aware of that may indicate a possible infection and appropriate exercise. Over a third of survivors reported that they had to make changes to reduce their chance of infection, with social restriction the most commonly reported area of change survivors made. Improving communication and access to care and providing additional emotional support may assist survivors in making these additional changes. Healthcare providers should use this information to better support haematological cancer survivors in dealing with the effects haematological cancer has on their life.

Prevalence and associates of psychological distress in haematological cancer survivors.

PURPOSE: To explore outcomes of psychological distress, including anxiety, depression and stress, amongst adult haematological cancer survivors, with a specific focus on potential differences between rural and urban survivors. METHODS: One thousand four hundred fourteen urban and rural survivors were recruited from five Australian population-based cancer registries and completed a self-report pen-and-paper survey on their well-being, including the Depression Anxiety and Stress Scale 21-item version. RESULTS: A quarter of survivors were identified as reporting above normal levels of anxiety and depression, respectively, and almost one fifth (17 %) reported above normal levels of stress. There were no statistically significant differences in the percentage of rural and urban survivors reporting above normal levels of anxiety, depression, or stress. Survivors who had experienced financial burden due to their cancer or were of middle age had higher odds of reporting multiple domains of psychological distress, compared to their counterparts. CONCLUSIONS: Haematological cancer survivors diagnosed during middle age or who experience increased financial burden as a result of their diagnosis may require additional support and care with regards to psychological distress.

Reaching the hard-to-reach: a systematic review of strategies for improving health and medical research with socially disadvantaged groups.

BACKGROUND: This study aims to review the literature regarding the barriers to sampling, recruitment, participation, and retention of members of socioeconomically disadvantaged groups in health research and strategies for increasing the amount of health research conducted with socially disadvantaged groups. METHODS: A systematic review with narrative synthesis was conducted. Searches of electronic databases Medline, PsychInfo, EMBASE, Social Science Index via Web of Knowledge and CINHAL were conducted for English language articles published up to May 2013. Qualitative and quantitative studies as well as literature reviews were included. Articles were included if they reported attempts to increase disadvantaged group participation in research, or the barriers to research with disadvantaged groups. Groups of interest were those described as socially, culturally or financially disadvantaged compared to the majority of society. Eligible articles were categorised according to five phases of research: 1) sampling, 2) recruitment and gaining consent, 3) data collection and measurement, 4) intervention delivery and uptake, and 5) retention and attrition. RESULTS: In total, 116 papers from 115 studies met inclusion criteria and 31 previous literature reviews were included. A comprehensive summation of the major barriers to working with various disadvantaged groups is provided, along with proposed strategies for addressing each of the identified types of barriers. Most studies of strategies to address the barriers were of a descriptive nature and only nine studies reported the results of randomised trials. CONCLUSIONS: To tackle the challenges of research with socially disadvantaged groups, and increase their representation in health and medical research, researchers and research institutions need to acknowledge extended timeframes, plan for higher resourcing costs and operate via community partnerships.

The impact of brain cancer care coordinators on healthcare utilization and outcomes in patients with glioblastoma.

Background: Cancer care coordinators (CCCs) are recognized as having an important role in patients' and carers' cancer journey. However, there are no studies investigating the impact of CCCs on quantitative outcomes. We performed a retrospective cohort study investigating the impact of brain cancer care coordinators (BCCCs) on health service resource use and survival in patients with glioblastoma. Methods: All patients diagnosed with glioblastoma between 2012 and 2019 in Hunter New England Local Health District, Australia (HNELHD) were included and the patients were divided into 2 cohorts: before and after the introduction of the BCCC. Any patient diagnosed in 2016, during the introduction of the BCCC, were excluded. The main outcomes assessed were overall survival, health service resource use, odds of being admitted to hospital after the emergency presentation, and cost-offset analysis to examine the economic implications of BCCCs. Results: A total of 187 patients were included. There were no significant differences in overall survival between the 2 groups (mOS 12.0 vs 11.16 months, HR 0.95). However, there was a reduction in the number of ED presentations and admissions. This was associated with a 24% reduction in aggregate length of stay with the BCCC. There was no statistically significant difference in mean patient costs, however our hospital may have saved over AUD$500 000 with BCCCs. Conclusions: The introduction of BCCC did not improve survival but appeared to be associated with reduced health resource utilization. This study provides economic justification, in addition to the established quality of life improvements, to support the presence of BCCCs.

Do we get it right? Radiation oncology outpatients' perceptions of the patient centredness of life expectancy disclosure.

OBJECTIVE: A patient-centred approach to discussing life expectancy with cancer patients is recommended in Western countries. However, this approach to eliciting and meeting patient preferences can be challenging for clinicians. The aims of this study were the following: (i) to examine cancer patients' preferences for life expectancy disclosure; and (ii) to explore agreement between cancer patients' preferences for, and perceived experiences of, life expectancy disclosure. METHODS: Cancer patients undergoing radiotherapy treatment in metropolitan Australia completed a cross-sectional touchscreen computer survey including optional questions about their life expectancy disclosure preferences and experiences. RESULTS: Of the 208 respondents, 178 (86%) indicated that they would prefer their clinician to ask them before discussing life expectancy, and 30 (14%) indicated that they would prefer others (i.e. clinicians, family) to decide whether they were given life expectancy information. Of the 175 respondents who were classified as having a self- determined or other-determined disclosure experience, 105 (60%) reported an experience of life expectancy disclosure that was in accordance with their preferences. Cohen's κ was -0.04 (95% CI, -0.17, 0.08), indicating very poor agreement between patients' preferences for and perceived experiences of life expectancy disclosure (p = 0.74). CONCLUSIONS: In light of patient-centred prognosis disclosure guidelines, our findings of a majority preference for, and experience of, a self-determined approach to life expectancy disclosure amongst radiation oncology patients are encouraging. However, poor agreement between preferences and experiences highlights that additional effort from clinicians is required in order to achieve a truly patient-centred approach to life expectancy disclosure.

The unfulfilled promise: a systematic review of interventions to reduce the unmet supportive care needs of cancer patients.

PURPOSE: This review aimed to examine (a) trends in the number of publications on unmet needs over time and (b) the effectiveness of interventions designed to reduce unmet needs among cancer patients. METHODS: An electronic literature search of Medline to explore trends in the number of publications on patients' unmet needs and an additional literature search of Medline, CINAHL, PsychINFO, and Web of Science databases to identify methodologically rigorous research trials that evaluated interventions to reduce unmet needs were conducted. RESULTS: Publications per year on unmet needs have increased over time, with most being on descriptive research. Nine relevant trials were identified. Six trials reported no intervention effect. Three trials reported that intervention participants had a lower number of unmet needs or lower unmet needs score, compared to control participants. Of these, one study found that the intervention group had fewer supportive care needs and lower mean depression scores; one study found that intervention participants with high problem-solving skills had fewer unmet needs at follow-up; and one study found an effect in favor of the intervention group on psychological need subscale scores. CONCLUSIONS: Reasons for varying results across trials and the limited effectiveness of unmet needs interventions are more broadly discussed. These include inadequacies in psychometric rigor, problems with scoring methods, the use of ineffective interventions, and lack of adherence to intervention protocols.

Australian palliative care providers' perceptions and experiences of the barriers and facilitators to palliative care provision.

OBJECTIVE: People with advanced cancer who may benefit from specialised palliative care (SPC) do not necessarily access such services. METHODS: To obtain a deeper understanding of issues affecting access to SPC, five focus groups were undertaken with nurses (35), physicians (three), allied health professionals (seven) and an academic involved in providing care. RESULTS: Thematic analysis revealed that palliative care providers consistently view palliative care as a broad holistic approach to care benchmarked on good symptom management. Whilst participants themselves perceived SPC as aiming to maximise the quality of life of the patient and family across all domains of care, they perceived that some health professionals and community members viewed palliative care largely as symptom control and terminal care for access after all disease-modifying treatment has been exhausted. Concern was expressed that such misconceptions were an important barrier to timely SPC. Participants did not nominate a time or particular milestone in the disease process which should prompt referral and suggested that SPC be available at any time where needs are complex and/or are not being met. CONCLUSION: Failure to properly recognise and understand the breadth of care provided within the palliative care framework may result in people with advanced cancer and their caregivers not accessing SPC services or accessing them too late to receive maximum benefit. Education may be required to promote the holistic nature of SPC services amongst health professionals and the community and to help realise the potential benefits to patients, families and health professionals resulting from timely access to SPC services.

Feasibility of patient-focused behavioral interventions to support adults experiencing chronic noncancer pain during opioid tapering: a systematic literature review.

Guidelines for chronic noncancer pain prioritize behavioral treatments. In clinical practice transition from opioids to behavioral treatments is often not endorsed by patients or providers. Feasible interventions to support opioid tapering are needed, particularly in primary care. The objectives of this paper is to review the feasibility of behavioral interventions to support opioid tapering. Electronic databases (MEDLINE, Embase, PsycINFO, and CINAHL) were searched from inception to June 2019 to identify original studies reporting feasibility (consent rates; completion rates; patient-reported acceptability; integration into clinical practice; and adverse events) of opioid tapering and transition to behavioral treatments for adults experiencing chronic noncancer pain. Google scholar and contents tables of key journals were also searched. Two authors independently extracted data and assessed methodological quality using The Quality Assessment Tool for Quantitative Studies. Eleven publications met inclusion criteria, of which three were conducted in primary care. Consent rates ranged from 27% to 98% and completion rates from 6.6% to 100%. Four studies rated at least one component of patient acceptability: helpfulness from 50%-81%; satisfaction 71%-94%, and "recommend to others" 74%-91%. Three studies reported provider perspectives and two studies reported adverse events. Quality assessment indicated all 11 studies were moderate or weak, primarily due to selection bias and lack of assessor blinding. There was also considerable heterogeneity in study design. The limited available data suggest that attempts to translate opioid tapering interventions into practice are likely to encounter substantial feasibility challenges. One possible way to ameliorate this challenge may be a clear policy context, which facilitates and support opioid reduction.

WNT11-Conditioned Medium Promotes Angiogenesis through the Activation of Non-Canonical WNT-PKC-JNK Signaling Pathway.

BACKGROUND: We demonstrated that the transduction of Wnt11 into mesenchymal stem cells (MSCs) (MSCWnt11) promotes these cells differentiation into cardiac phenotypes. In the present study, we investigated the paracrine effects of MSCWnt11 on cardiac function and angiogenesis. METHODS AND RESULTS: Conditioned medium was collected from MSCWnt11 (CdMWnt11) and their control cells (CdMGFP). CdMWnt11, especially obtained from MSCWnt11 exposed to hypoxia, significantly promoted human umbilical vein endothelial cells (HUVECs) migration and increased capillary-like tube (CLT) formation, which was blocked by Wnt11 neutralizing antibody. Wnt11 protein was significantly higher in CdMWnt11 compared to that in CdMGFP. Directly treating HUVECs with recombinant Wnt11 protein significantly increased CLT formation, which was abrogated by treating cells with the JNK inhibitor SP600125, as well as the PKC inhibitor Calphostin-C. Moreover, the transfection of Wnt11 to HUVECs (HWnt11) significantly increased CLT formation and HUVEC migration, as well as upregulated p-pan-PKC and p-JNK expression. Injection of CdMWnt11 into the peri-infarct region in a rat acute myocardial infarction (AMI) model significantly improved cardiac function, reduced infarct size, and increased myocardial blood flow and blood vessel density in the ischemic area. CONCLUSION: Wnt11 released from MSCWnt11 increased angiogenesis and improved cardiac function via non-canonical Wnt-PKC-JNK dependent pathways.

Which Type of Antismoking Advertisement Is Perceived as More Effective? An Experimental Study With a Sample of Australian Socially Disadvantaged Welfare Recipients.

PURPOSE: Evaluate the perceived effectiveness of key antismoking messages among highly disadvantaged smokers and assess the impact of nicotine dependence and cessation cognitions on message processing. DESIGN: The experimental crossover trial, undertaken between March and December 2012, randomly exposed participants to two of three antismoking advertisements delivered via touchscreen computer. SETTING: Welfare recipients were recruited from a community service organization in New South Wales, Australia. SUBJECTS: Subjects were 354 smokers (79% response rate). Participants resided in government rental housing (52%), earned less than AUD$400/wk (72%), and received their primary income from government welfare (95%). INTERVENTION: Three 30-second antismoking television advertisements representing common campaign themes: why to quit (graphic imagery), why to quit (personal testimonial), or how to quit. MEASURES: An 11-item scale assessed perceived effectiveness and message acceptance. An eight-item cessation cognitions index assessed motivations and readiness to quit, and the heaviness of smoking index was used to classify nicotine dependence. ANALYSIS: Descriptive statistics, generalized linear mixed models, and multiple linear regression analyses are reported. RESULTS: Why-to-quit advertisements were perceived as significantly more effective than the how-to-quit advertisement (all p < .0001). Smokers with positive cessation cognitions were more likely to accept antismoking messages (p = .0003) and perceive them as effective (p < .0001). Nicotine dependence level did not influence message acceptance (p = .7322) or effectiveness (p = .8872). CONCLUSION: Highly emotive advertisements providing good reasons to quit may be the most effective in promoting the antismoking message among groups with high smoking rates.

To adhere or not to adhere: Rates and reasons of medication adherence in hematological cancer patients.

To conduct a comprehensive review to examine among hematological cancer patients: (1) rates of adherence to self-administered cancer treatments; and (2) factors impacting on their adherence. Fifty two eligible publications were identified. The majority focused on Chronic Myeloid Leukaemia (CML) (n=40) and Acute Lymphoid Leukaemia (ALL) (n=11) patients. Adherence rates varied and depended on the definition and measures used. Patient understanding about their disease and treatment, and forgetting to take their medication impacted on patients' level of adherence; while the use of reminders reduced forgetfulness. There is a lack of valid and reliable information relating to medication adherence of hematological cancer patients. Based on the limited data available we provide a profile of CML and ALL patients at potential risk of medication non-adherence, as well as a proposed checklist that can be used by health care providers in assessing and supporting patients in adhering to their medication.

An organisational change intervention for increasing the delivery of smoking cessation support in addiction treatment centres: study protocol for a randomized controlled trial.

BACKGROUND: The provision of smoking cessation support in Australian drug and alcohol treatment services is sub-optimal. This study examines the cost-effectiveness of an organisational change intervention to reduce smoking amongst clients attending drug and alcohol treatment services. METHODS/DESIGN: A cluster-randomised controlled trial will be conducted with drug and alcohol treatment centres as the unit of randomisation. Biochemically verified (carbon monoxide by breath analysis) client 7-day-point prevalence of smoking cessation at 6 weeks will be the primary outcome measure. The study will be conducted in 33 drug and alcohol treatment services in four mainland states and territories of Australia: New South Wales, Australian Capital Territory, Queensland, and South Australia. Eligible services are those with ongoing client contact and that include pharmacotherapy services, withdrawal management services, residential rehabilitation, counselling services, and case management services. Eligible clients are those aged over 16 years who are attending their first of a number of expected visits, are self-reported current smokers, proficient in the English language, and do not have severe untreated mental illness as identified by the service staff. Control services will continue to provide usual care to the clients. Intervention group services will receive an organisational change intervention, including assistance in developing smoke-free policies, nomination of champions, staff training and educational client and service resources, and free nicotine replacement therapy in order to integrate smoking cessation support as part of usual client care. DISCUSSION: If effective, the organisational change intervention has clear potential for implementation as part of the standard care in drug and alcohol treatment centres. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, ACTRN12615000204549 . Registered on 3 March 2015.

Comparing socially disadvantaged smokers who agree and decline to participate in a randomised smoking cessation trial.

OBJECTIVES: This study examined sociodemographic, smoking and psychosocial characteristics associated with consent to participate in a smoking cessation trial for socially disadvantaged smokers. DESIGN: Baseline data were collected prior to seeking consent for the Call it Quits, a randomised controlled trial. SETTING: An Australian social and community service organisation. Sociodemographic, smoking and psychosocial characteristics were compared between smokers who agreed or declined to participate. PARTICIPANTS: Of the 584 smokers invited to participate, 431 (74%) consented and 153 (26%) declined. RESULTS: Logistic regression modelling indicates the ORs of participation were twice as high for those reporting 'high' motivation to quit compared to the 'moderate' motivation group, and five times higher than the 'low' motivation group (p=0.007). The ORs of consenting were higher for those with a preference for gradual reduction in cigarettes in quit attempts compared with 'no preference'. The ORs were lower for those reporting 'don't know' regarding their enjoyment of smoking compared to 'not at all' enjoying smoking, and reporting that fewer of their family or friends smoked compared to 'most or all'. CONCLUSIONS: This study is the first to examine the characteristics of socially disadvantaged smokers who consent or decline to participate in a smoking cessation trial. Low-income smokers who are motivated to quit, are not enjoying smoking, had family or friends who smoked, and who are interested in gradual cessation approaches may be more likely to participate in a smoking cessation trial. TRIAL REGISTRATION NUMBER: ISRCTN85202510.

Screening for bowel cancer among NSW adults with varying levels of risk: a community survey.

OBJECTIVE: To estimate the extent and modality of screening for colorectal cancer in NSW among community-dwelling adults aged over 40 with varying degrees of familial risk. DESIGN: Cross-sectional telephone survey with participants randomly selected from the electronic NSW telephone directory. MAIN RESULTS: 5.7% of people at average risk aged 40-49 report having had at least one faecal occult blood test (FOBT) in the previous five years, compared with 18.4% of those at average risk aged 50 and over. Of those at above-average risk (by age and familial risk), 7.9% reported that they had had an FOBT in the previous five years. Around 5% of respondents aged 40-49 and 10% of those aged 50+ reported having had a colonoscopy/sigmoidoscopy for screening within the previous five years, compared with 30% of those at above-average risk. People with medical insurance were more likely to have undergone a screening test (either FOBT or sigmoidoscopy/colonoscopy), than those without insurance (PR = 1.30; 95% CI 1.02-1.67). Compared with those employed full time, those who were retired (PR = 1.45 95% CI 1.01-2.09) and those who reported home duties (PR = 1.54 95% CI 1.01-2.36) were slightly, but significantly more likely to report having had a test. As perception of personal risk for colorectal cancer increased, so did the likelihood of having had a screening test within the previous five years (PR = 1.19; 95% CI 1.05-1.35). CONCLUSION: We have reported important baseline data with which to compare the progress of both pilot screening programs and more widespread implementation of colorectal screening in Australia. In particular, we have highlighted the need for greater participation in screening for those at increased familial risk.

Delay in seeking advice for symptoms that potentially indicate bowel cancer.

OBJECTIVES: To document knowledge, behavior and experiences of adults regarding potential signs and symptoms of bowel cancer. METHODS: Telephone interviews with 1332 randomly selected adults, using similar questions to a survey conducted in 1988. RESULTS: Twenty three percent (n=306) of respondents reported that they had experienced blood in bowel motions and about one third of these reported that they did not seek medical advice at all. CONCLUSIONS: As there has been no change in help seeking for potential symptoms of bowel cancer from similar studies conducted 15 years ago, there are concerns for encouraging behaviors that will result in the early detection of colorectal cancer.

Socioeconomically disadvantaged smokers' ratings of plain and branded cigarette packaging: an experimental study.

OBJECTIVES: This study aimed to test the potential impact of plain packaging for cigarettes on brand appeal among highly socioeconomically disadvantaged smokers using the new design for cigarettes implemented in Australia, which combines plain packaging with larger health warning labels. DESIGN: A 2×2 factorial design trial embedded within a cross-sectional computer touchscreen survey. Data were collected between March and December 2012. SETTING: Socially disadvantaged welfare aid recipients were recruited through a large Social and Community Service Organisation in New South Wales, Australia. PARTICIPANTS: N=354 smokers. The majority of the sample had not completed high school (64%), earned less than $A300/week (55%) and received their income from Government payments (95%). INTERVENTIONS: Participants were randomised to one of the four different pack conditions determined by brand name: Winfield versus Benson & Hedges, and packaging type: branded versus plain. Participants were required to rate their assigned pack on measures of brand appeal and purchase intentions. RESULTS: Plain packaging was associated with significantly reduced smoker ratings of 'positive pack characteristics' (p<0.001), 'positive smoker characteristics' (p=0.003) and 'positive taste characteristics' (p=0.033) in the Winfield brand name condition only. Across the four pack conditions, no main differences were found for 'negative smoker characteristics' (p=0.427) or 'negative harm characteristics' (p=0.411). In comparison to plain packaging, the presentation of branded packaging was associated with higher odds of smokers' purchase intentions (OR=2.18, 95% CI 1.34 to 3.54; p=0.002). CONCLUSIONS: Plain packs stripped of branding elements, featuring larger health warning labels, were associated with reduced positive cigarette brand image and purchase intentions among highly socioeconomically disadvantaged smokers.

Associations between alcohol, smoking, socioeconomic status and comorbidities: evidence from the 45 and Up Study.

INTRODUCTION AND AIMS: Understanding how tobacco, alcohol and mental health are related is important for developing population-level policies and individual-level treatments that target comorbidities. The current study aimed to examine sociodemographic characteristics and mental health comorbidities associated with the odds of using tobacco and harmful levels of alcohol concurrently. DESIGN AND METHODS: Data were drawn from the 45 and Up Study, a large cohort study with 267 153 adults aged 45 years and over in New South Wales, Australia. Participants completed a survey assessing alcohol, smoking, psychological distress, treatment for depression and anxiety, and a range of socioeconomic status indicators. Univariate analyses and three multiple-logistic regression models were used to determine associations with (i) tobacco but not alcohol use; (ii) alcohol but not tobacco use; and (iii) concurrent tobacco and risky levels of alcohol use. RESULTS: Being female, younger, lower individual and area-level socioeconomic status (SES) and depression and psychological distress were associated with tobacco use alone. Factors associated with alcohol use alone were older age, male gender, higher SES, and lower psychological distress and no recent depression treatment. Factors associated with concurrent risky alcohol consumption and tobacco use included being 45-64, being male, less education, earning <$30 000, being employed, and living in lower-SES areas, treatment for depression, and high distress on the Kessler-10. DISCUSSION AND CONCLUSIONS: Results suggest strong links between SES, treatment for depression, psychological distress, and concurrent tobacco and alcohol use. This has implications for public health policies and clinical treatment for tobacco and alcohol use, suggesting greater emphasis on addressing multiple health and social concerns. [Bonevski B, Regan T, Paul C, Baker AL, Bisquera A. Associations between alcohol, smoking, socioeconomic status and comorbidities: Evidence from the 45 and Up Study. Drug Alcohol Rev 2014;33:169-176].