Attitudes And Exposure To Illicit Tobacco In England, 2022.

INTRODUCTION: The UK has achieved reductions in illicit tobacco (IT) market size and share. However, there remains a 17.7% tobacco duty gap, contributing to health inequalities. In January 2024, the UK government announced a new strategy to control IT, along with provision of new funding. METHODS: A representative cross-sectional survey of adults in England ran in April 2022 to evaluate attitudes and exposure to IT. Tobacco smokers were asked questions about encounters with IT, while all participants answered questions on knowledge and perspectives on IT. RESULTS: Of 262 tobacco smokers, 18.3% (95% CI 13.8% - 23.6%) had come across IT in the past year. Men had four times the odds of encountering IT recently than women. Among 1,767 adults responding to questions on IT, two-thirds agreed IT harmed children, and more than half agreed IT was linked to organised crime. Younger adults, smokers and those in lower socio-economic groups were less likely to agree IT was harmful. CONCLUSIONS: Exposure to IT, especially among younger males, remains a concern. While most of the public acknowledge its harm, this is not universal, and some population groups are less likely to do so. IMPLICATIONS: The study highlights persistent exposure to illicit tobacco in England, especially among younger males, and varying perceptions of illicit tobacco harm across socio-economic groups. Tackling illicit tobacco requires collaboration between health and enforcement agencies, independent of the tobacco industry's influence. Strategies should include components that shift demand for illicit tobacco and denormalise its presence in communities, particularly in lower socio-economic areas with higher smoking prevalence.

A qualitative study of barriers and motivators to prevent second-hand smoke exposure among pregnant women and children in Egypt: Identifying appropriate approaches for change.

BACKGROUND: The prevalence of daily second-hand smoke (SHS) exposure among pregnant non-smoking women and children in Egypt is estimated to be about 50% and 55%, respectively. This study aimed to explore barriers to preventing SHS exposure among pregnant women/children and smoking in the home in Egypt. METHODS: Six focus group discussions with pregnant women/mothers of children residing in urban/rural areas (n=61) were conducted. Data were managed and analyzed using the Framework Method. RESULTS: Sixty one participants aged 18-49 were recruited. They reported being never smokers and SHS exposure for themselves and their children was mainly at home. Pregnant women/mothers had some general knowledge of the dangers of SHS, but their knowledge appeared incomplete. The most commonly reported barriers to preventing SHS exposure/adopting a smoke-free home or workplace were social acceptance of smoking and SHS exposure, masculinity and gender norms of accepting smoking among men as a normative behavior, fear among women of damaging a relationship with family or even divorce, women resigning themselves to SHS exposure, and doctors not being supportive of smoking cessation. The majority of interviewees' families were reported to allow smoking anywhere in the home. Others implemented some measures to prevent SHS; however, these tended to be inconsistently implemented. CONCLUSION: Changing the norm of accepting smoking among men as a normative behavior within Egyptian society and better enforcement of smoke-free policies, will help to protect pregnant women and children from SHS. IMPLICATIONS: This study suggests promising approaches to support the promotion of smoke-free homes (SFH) and prevention of SHS exposure among pregnant women and children in public places in Egypt. Better enforcement of smoke-free policies is needed. Health care professionals (HCPs) should support smoking cessation services in primary health centers (PHCs). SHS policy, practice and research should focus on husbands/fathers as they are the main source of SHS. There is a need for denormalization of SHS exposure in Egyptian society.

Developing a vape shop-based smoking cessation intervention: a Delphi study.

INTRODUCTION: Providing access to a vape shop-based smoking cessation intervention may simultaneously increase e-cigarette use and increase the effectiveness of e-cigarettes for smoking cessation. The aim of this study was to identify the most important elements of vape shop-based smoking intervention to stakeholders who would be involved in delivering or accessing such an intervention. METHODS: We conducted a three-round Delphi study of vape shop staff (n=40), stop smoking professionals and tobacco control leads (n=30), and smokers, vapers and dual users (n=30) in the United Kingdom in May-August 2021. In each round participants were asked whether they agreed or disagreed statements related to vape shop-based interventions. RESULTS: Forty-six of 95 statements reached consensus in round one, 29 out of 49 in round two and eight out of 20 in round three. There was support for a vape shop-based intervention across stakeholder groups (96%). There was consensus that the service should comprise both product (98%) and behavioural support (97%), and that quitting vaping should not be a goal of the service (79%). Although there was consensus that there should be some free product provision, there was less consensus as to what this should involve. Views were mostly consistent across stakeholder groups. CONCLUSIONS: There was broad consensus on how to deliver a vape shop-based smoking cessation intervention, providing a strong basis for future intervention development and implementation. Challenges around misuse of the service and misperceptions about vaping would need to be addressed for such an intervention to be feasible and effective. IMPLICATIONS: Many smokers who make a quit attempt using e-cigarettes purchase their vaping products in vape shops. Delivering vape-shop based smoking cessation interventions could help to maximise the effectiveness of e-cigarettes for quitting smoking. This study used a Delphi approach to identify the most important elements of a vape shop-based intervention among stakeholders. The findings could be used to help develop future interventions.

Bisphosphonate alternative regimens for the prevention of osteoporotic fragility fractures: BLAST-OFF, a mixed-methods study.

Background: Bisphosphonates are a class of medication commonly used to treat osteoporosis. Alendronate is recommended as the first-line treatment; however, long-term adherence (both treatment compliance and persistence) is poor. Alternative bisphosphonates are available, which can be given intravenously and have been shown to improve long-term adherence. However, the most clinically effective and cost-effective alternative bisphosphonate regimen remains unclear. What is the most cost-effective bisphosphonate in clinical trials may not be the most cost-effective or acceptable to patients in everyday clinical practice. Objectives: 1. Explore patient, clinician and stakeholder views, experiences and preferences of alendronate compared to alternative bisphosphonates. 2. Update and refine the 2016 systematic review and cost-effectiveness analysis of bisphosphonates, and estimate the value of further research into their benefits. 3. Undertake stakeholder/consensus engagement to identify important research questions and further rank research priorities. Methods: The study was conducted in two stages, stages 1A and 1B in parallel, followed by stage 2: • Stage 1A - we elicited patient and healthcare experiences to understand their preferences of bisphosphonates for the treatment of osteoporosis. This was undertaken by performing a systematic review and framework synthesis of qualitative studies, followed by semistructured qualitative interviews with participants. • Stage 1B - we updated and expanded the existing Health Technology Assessment systematic review and clinical and cost-effectiveness model, incorporating a more comprehensive review of treatment efficacy, safety, side effects, compliance and long-term persistence. • Stage 2 - we identified and ranked further research questions that need to be answered about the effectiveness and acceptability of bisphosphonates. Results: Patients and healthcare professionals identified a number of challenges in adhering to bisphosphonate medication, balancing the potential for long-term risk reduction against the work involved in adhering to oral alendronate. Intravenous zoledronate treatment was generally more acceptable, with such regimens perceived to be more straightforward to engage in, although a portion of patients taking alendronate were satisfied with their current treatment. Intravenous zoledronate was found to be the most effective, with higher adherence rates compared to the other bisphosphonates, for reducing the risk of fragility fracture. However, oral bisphosphonates are more cost-effective than intravenous zoledronate due to the high cost of zoledronate administration in hospital. The importance of including patients and healthcare professionals when setting research priorities is recognised. Important areas for research were related to patient factors influencing treatment selection and effectiveness, how to optimise long-term care and the cost-effectiveness of delivering zoledronate in an alternative, non-hospital setting. Conclusions: Intravenous zoledronate treatment was generally more acceptable to patients and found to be the most effective bisphosphonate and with greater adherence; however, the cost-effectiveness relative to oral alendronate is limited by its higher zoledronate hospital administration costs. Future work: Further research is needed to support people to make decisions influencing treatment selection, effectiveness and optimal long-term care, together with the clinical and cost-effectiveness of intravenous zoledronate administered in a non-hospital (community) setting. Limitations: Lack of clarity and limitations in the many studies included in the systematic review may have under-interpreted some of the findings relating to effects of bisphosphonates. Trial registration: This trial is registered as ISRCTN10491361. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127550) and is published in full in Health Technology Assessment; Vol. 28, No. 21. See the NIHR Funding and Awards website for further award information.

Bisphosphonates are drug treatments commonly used to treat osteoporosis. Alendronate is the most used and is taken by mouth, weekly at a specific time of the week, which can be challenging. Less than one in four people continue this treatment beyond 2 years. Alternative bisphosphonates are available, which vary in frequency and how they are administered. The most acceptable and best value-for-money regimen is unclear. Our aim was to determine how effective alternative bisphosphonates are compared to alendronate at preventing fractures and whether reduction in fracture risk was achieved at a reasonable financial cost, but acceptable to patients. The study was conducted in two stages, stages 1A and 1B in parallel, followed by stage 2: Stage 1A: a review of the published evidence on patients' and doctors' views, experiences and preferences regarding different bisphosphonate treatment regimens, followed by interviews with patients and healthcare professionals. Stage 1B: an update of an existing study on how effective bisphosphonates are in preventing fragility fractures caused by osteoporosis and whether they are good value for money. Stage 2: identification of questions that need to be answered about the effectiveness and acceptability of bisphosphonate treatments. Taking bisphosphonate medication often involves quite a lot of effort by patients, particularly when taking alendronate tablets. A yearly infusion of zoledronate treatment was more acceptable, easier to engage with and the most effective treatment compared to alendronate. However, the cost of administering zoledronate in hospital made alendronate better value for money. Bisphosphonates are effective in reducing the risk of fracture, but 'continuing with treatment', particularly alendronate tablets, remains a challenge. A yearly infusion of zoledronate offers an acceptable and effective treatment, but further research is needed to support patients and healthcare professionals in making decisions about the various treatments, benefits and cost savings of administering zoledronate outside of hospital and in the community.

Potential smoke-free dividend across local areas in England: a cross-sectional analysis.

BACKGROUND: The value that might be added to local economies each year through the money that people who smoke tobacco would save if everyone quit smoking is called the 'smoke-free dividend'. This study aimed to estimate the value of the smoke-free dividend across local areas in England, and how it relates to the average income in those areas. METHODS: The study was a cross-sectional descriptive analysis of tobacco expenditure from the Smoking Toolkit Study (STS) matched to income and smoking prevalence data for English local authorities. The STS sample was from 2014 to 2020 and comprised 18 721 adults who smoke cigarettes. Self-reported expenditure estimates from the STS were adjusted for under-reporting. This adjustment aimed to align the total expenditure estimate with figures derived from government tax receipts and national estimates of illicit tobacco use. The smoke-free dividend is calculated as 93% of spending on legal tobacco, which is the percentage estimated to leave the local economy, plus 100% of spending on illicit tobacco. RESULTS: The total dividend in England is estimated to be £10.9 billion each year, which equates to £1776 per person who smokes or £246 per adult regardless of smoking status. The estimated dividend is greater in areas with lower average income, with a correlation coefficient of -0.521 (95% CI -0.629, -0.392) between the average income of local areas and the dividend per adult. CONCLUSIONS: This study has estimated that local economies could gain a substantial dividend if everybody stopped smoking, which is larger in lower income areas, meaning that geographical economic inequalities could be reduced.

How should a vape shop-based smoking cessation intervention be delivered? A qualitative study.

INTRODUCTION: Encouraging smokers to quit smoking tobacco using e-cigarettes could substantially reduce smoking-related diseases. Vape shops therefore have the potential to play an important role in supporting smoking cessation. The aim of this study was to explore how to deliver a vape shop-based smoking cessation intervention in the United Kingdom. METHOD: Semi-structured telephone interviews were undertaken with four stakeholder groups: 20 stop smoking service (SSS) providers, seven tobacco control leads (TCL), seven smokers/vapers and five vape shop staff). Interviews were analysed thematically. RESULTS: Stakeholder groups were positive about the idea of delivering a vape shop-based intervention. Themes that were identified were the characteristics of the intervention (duration and timing; delivery; style and content; and product provisions); barriers to the intervention (challenges for new vapers; false information; tobacco company involvement; and conflicts of interest); facilitators to the intervention (positive views on vaping; cost-effectiveness; popularity; and accessibility); and considerations for the intervention (data protection and privacy; aesthetics; and regulation and management). The results suggest that the intervention should be delivered by vape shop workers with mandatory training with the support of SSS. Most stakeholders agreed quitting vaping was not a priority, but that information on how to reduce nicotine use should be given. Concerns around privacy, GDPR, misinformation about vaping and tobacco company involvement would need to be addressed. CONCLUSIONS: Stakeholders agree that vape shops should offer stop smoking interventions and hold similar opinions on how this should be delivered. IMPLICATIONS: This study suggests that smokers, vapers and other key stakeholders are positive about the idea of a stop smoking vape-shop based intervention and that they hold similar opinions on how this should be delivered. Most participants felt that this should be primarily delivered by trained vape shop staff and run with support from SSS. Participants agreed that a stop smoking vape shop-based intervention should be flexible in terms of the type, duration and frequency of support provided, and that the intervention should comprise both technical guidance on using a vape and behavioural support to prevent a return to smoking.

Clinicians' views of prescribing oral and intravenous bisphosphonates for osteoporosis: a qualitative study.

BACKGROUND: Bisphosphonate medications, including alendronate, ibandronate and risedronate administered orally and zoledronate, administered intravenously, are commonly prescribed for the treatment of osteoporosis based on evidence that, correctly taken, bisphosphonates can improve bone strength and lead to a reduction in the risk of fragility fractures. However, it is currently unclear how decisions to select between bisphosphonate regimens, including intravenous regimen, are made in practice and how clinicians support patients with different treatments. METHODS: This was an interpretivist qualitative study. 23 semi-structured telephone interviews were conducted with a sample of general practitioners (GPs), secondary care clinicians, specialist experts as well as those providing and leading novel treatments including participants from a community intravenous (IV) zoledronate service. Data analysis was undertaken through a process of iterative categorisation. RESULTS: The results report clinicians varying experiences of making treatment choices, as well as wider aspects of osteoporosis care. Secondary care and specialist clinicians conveyed some confidence in making treatment choices including on selecting IV treatment. This was aided by access to diagnostic testing and medication expertise. In contrast GPs reported a number of challenges in prescribing bisphosphonate medications for osteoporosis and uncertainty about treatment choice. Results also highlight how administering IV zoledronate was seen as an opportunity to engage in broader care practices. CONCLUSION: Approaches to making treatment decisions and supporting patients when prescribing bisphosphonates for osteoporosis vary in practice. This study points to the need to co-ordinate osteoporosis treatment and care across different care providers.

Modifiable risk factors for diphtheria: A systematic review and meta-analysis.

Objective: To identify modifiable risk factors for diphtheria and assess their strengths of association with the disease. Methods: This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Electronic databases and grey literature were searched from inception until January 2023. Studies had to report on diphtheria cases and estimates of association for at least one potential risk factor or sufficient data to calculate these. The quality of non-ecological studies was assessed using the Newcastle-Ottawa Scale (NOS), while the quality of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Results: The search yielded 37,705 papers, of which 29 were ultimately included. All the non-ecological studies were of moderate to high quality. Meta-analysis of 20 studies identified three factors increasing the risk of diphtheria: incomplete vaccination (<3 doses) (pooled odds ratio (POR) = 2.2, 95% confidence interval (CI) = 1.4-3.4); contact with a person with skin lesions (POR = 4.8, 95% CI = 2.1-10.9); and low knowledge of diphtheria (POR = 2.4, 95% CI = 1.2-4.7). Contact with a case of diphtheria; sharing a bed or bedroom; sharing utensils, cups, and glasses; infrequent bathing; and low parental education were associated with diphtheria in multiple studies. Evidence for other factors was inconclusive. The quality of evidence was low or very low for all the risk factors. Conclusions: Findings from the review suggest that countries seeking to control diphtheria need to strengthen surveillance, improve vaccination coverage, and increase people's knowledge of the disease. Future research should focus on understudied or inconclusive risk factors.

Research priorities regarding the use of bisphosphonates for osteoporosis: a UK priority setting exercise.

PURPOSE: Worldwide, many people who would benefit from osteoporosis drugs are not offered or receiving them, resulting in an osteoporosis care gap. Adherence with bisphosphonates is particularly low. This study aimed to identify stakeholder research priorities relating to bisphosphonate treatment regimens for prevention of osteoporotic fractures. METHODS: A three-step approach based on the James Lind Alliance methodology for identification and prioritisation of research questions was used. Research uncertainties were gathered from a large programme of related research studies about bisphosphonate regimens and from recent published international clinical guidelines. Clinical and public stakeholders refined the list of uncertainties into research questions. The third step prioritised the questions using a modified nominal group technique. RESULTS: In total, 34 draft uncertainties were finalised into 33 research questions by stakeholders. The top 10 includes questions relating to which people should be offered intravenous bisphosphonates first line (1); optimal duration of treatment (2); the role of bone turnover markers in treatment breaks (3); support patient need for medicine optimisation (4); support primary care practitioner need regarding bisphosphonates (5); comparing zoledronate given in community vs hospital settings (6); ensuring quality standards are met (7); the long-term model of care (8); best bisphosphonate for people aged under 50 (9); and supporting patient decision-making about bisphosphonates (10). CONCLUSION: This study reports, for the first time, topics of importance to stakeholders in the research of bisphosphonate osteoporosis treatment regimens. These findings have implications for research into implementation to address the care gap and education of healthcare professionals. Using James Lind Alliance methodology, this study reports prioritised topics of importance to stakeholders in the research of bisphosphonate treatment in osteoporosis. The priorities address how to better implement guidelines to address the care gap, understanding patient factors influencing treatment selection and effectiveness, and how to optimise long-term care.

Instructor and client views of a community falls prevention service and the impact of the COVID-19 pandemic: A qualitative exploration of a service in England.

Objectives: Falls are the most common cause of injury related deaths in people over 75 years. The aim of this study was to explore the experience of providers (instructors) and service users (clients) of a fall's prevention exercise programme and the impact of the COVID-19 pandemic in Derbyshire, UK. Methods: Ten one-to-one interviews with class instructors and five focus groups with clients (n=41). Transcripts were analysed using inductive thematic analysis. Results: Most clients were initially motivated to attend the programme to improve their physical health. All clients reported improvements in their physical health as a result of attending the classes; additional benefits to social cohesion were also widely discussed. Clients referred to the support provided by instructors during the pandemic (online classes and telephone calls) as a 'life-line'. Clients and instructors thought more could be done to advertise the programme, especially linking in with community and healthcare services. Conclusions: The benefits of attending exercise classes went beyond the intended purpose of improving fitness and reducing the risk of falls, extending into improved mental and social wellbeing. During the pandemic the programme also prevented feelings of isolation. Participants felt more could be done to advertise the service and increase referrals from healthcare settings.

The Impact of the COVID-19 Pandemic on Smoking, Vaping, and Smoking Cessation Services in the United Kingdom: A Qualitative Study.

BACKGROUND: Existing evidence suggests that while the coronavirus disease 2019 (COVID-19) pandemic triggered quit attempts among many smokers, it led some to smoke more and others to relapse back to smoking. These diverse effects have the potential to have a long-term impact on individuals' smoking and vaping behaviors. AIMS AND METHODS: This study explored the effect of COVID-19 on smokers and vapers, vape shops (VS), and stop smoking services (SSS). A total of 39 semi-structured interviews were conducted with stop-smoking practitioners, tobacco control leads, smokers and/or vapers, and vape shop owners. Interviews were transcribed verbatim and analyzed thematically. RESULTS: Four themes were identified: Lockdown as a barrier to becoming or remaining smoke-free; COVID as a catalyst for quitting and remaining smoke-free; changes in vaping and challenges for vapers and VS; and changes and challenges for stop smoking support. Fear of COVID resulting in severe health implications for smokers facilitated behavior change; however, the boredom and monotony of lockdown and associated stress created difficulties in remaining a smoke free. Results showed that the enforced switch from face-to-face to the remote provision of SSS was beneficial for improving engagement, particularly for vulnerable groups such as pregnant women. Stop smoking professionals and vapers disagreed with the forced closure of VS because it created unnecessary difficulties for vapers to access supplies. CONCLUSIONS: COVID-19 was both a barrier and facilitator for smoking cessation. Remote provision of SSS implemented due to lockdown was beneficial for hard-to-reach groups; services should look to incorporate these changes into day-to-day practice. IMPLICATIONS: This study is one of the first to explore how the COVID-19 pandemic directly affected smokers, vapers, SSS, tobacco control leads, and VS. It provides evidence for the continued use of the remote provision of smoking cessation services to increase engagement among hard-to-reach groups and provides information on how pandemics can be a catalyst for health behavior change. This study is unique in that it incorporates the views of different stakeholders.

Acceptability and engagement amongst patients on oral and intravenous bisphosphonates for the treatment of osteoporosis in older adults.

BACKGROUND: Osteoporosis is common in older adults leading to fragility fractures at enormous individual and economic cost. Improving long-term adherence with bisphosphonate treatments reduces fracture risk, but adherence rates for first-line oral bisphosphonate alendronate remains low. Although alternative treatment regimens, including annual intravenous infusions are available, patient acceptability remains unclear. Therefore, understanding patients' acceptability and engagement in different bisphosphonate regimens is important to ensure optimal treatment benefits. METHODS: Semi-structured interviews were conducted with 78 patients with a mean age of 69.9 years, who had taken or received bisphosphonates for osteoporosis within the last 24 months. Data analysis included iterative categorisation and used the theoretical framework of acceptability (TFA) to compare the acceptability of treatments regimens. RESULTS: Treatment acceptability and engagement were influenced by the extent to which patients understood the prescribed treatment, and evidence of the treatment working. Acceptability and engagement were compromised when treatment was perceived as burdensome, personal costs were incurred, and patients' values were incompatible with the regimen. The balancing of these factors contributed to patients' ability to cope with the treatment and their emotional responses. Intravenous treatment was generally perceived as easier to understand, more effective, less burdensome with fewer opportunity costs, and a preferable regimen compared with oral bisphosphonates. CONCLUSIONS: Annual intravenous zoledronate bisphosphonate treatment was generally more acceptable to patients, perceived as more straightforward to engage in, although a small portion of patients on oral bisphosphonates were satisfied with treatment. Further research is needed to identify how acceptability and engagement can be optimised.

Healthcare Professionals' Knowledge, Attitudes and Counselling Practice Regarding Prevention of Secondhand Smoke Exposure Among Pregnant Women/Children in Assiut, Egypt.

Objectives and Methods: A cross sectional study of HCPs working in public MCH clinics in Assiut city was conducted to explore their knowledge, attitudes and counselling practices regarding prevention of SHS exposure among pregnant women and children. Descriptive and regression analyses were performed. Results: 367 HCPs participated in the study, 12% of whom were smokers. The majority were nurses (45%). A considerable proportion of HCPs reported being exposed to SHS in workplace (70%) and home (52%). About half HCP reported high SHS knowledge (56%), supportive attitude towards preventing SHS exposure (53%), and having good counselling practice regarding SHS exposure (52%). Being a GP and serving urban communities were significantly associated with high knowledge. Being female, serving a rural population, receiving training on smoking cessation services, not being exposed to SHS at home, and having a supportive attitude towards prevention of SHS exposure were significantly associated with good counselling practice. Conclusion: Awareness, attitudes and counselling practice of HCPs should be improved. Training for HCPs and enforcement of smoke free polices are needed to improve awareness and facilitate changes in social norms.

Perspectives of attenders and non-attenders to SARS-CoV-2 asymptomatic community testing in England: a qualitative interview study.

OBJECTIVES: In December 2020, Derbyshire County Council in England introduced 'walk-in' asymptomatic community COVID-19 testing sites. Our study aimed to explore people's views of the newly established COVID-19 community testing (CT) sites among those who attended and those who did not attend them, alongside gathering individuals' experiences of attending a CT site to complete a lateral flow test. SETTING: This qualitative research study comprised of one-to-one interviews with those attending a COVID-19 CT sites in Derbyshire and those from the surrounding area who did not attend. PARTICIPANTS: A combination of purposive and convenience sampling was used to recruit those who had (n=18) and those who had not attended (n=15) a walk-in asymptomatic CT site. RESULTS: Employers played a key role in raising awareness of the testing sites, with most attending CT at the request of their workplace. The experience of attending a CT site was overwhelmingly positive and those who got tested spoke about the reassurance a negative result offered, knowing they were not passing on the virus when going about their daily lives. However, there was a perception that awareness of CT sites was low across the county and some confusion about who was eligible to attend and under what circumstances. Individuals linked this to low level of advertising they had seen, in addition to a lack of clarity in the information provided. CONCLUSIONS: People's experience of attending a 'walk-in' asymptomatic CT site in Derbyshire was generally very positive; however, ensuring clear communication for future testing programmes is essential to maximise their uptake.

The epidemiology of diphtheria in Haiti, December 2014-June 2021: A spatial modeling analysis.

BACKGROUND: Haiti has been experiencing a resurgence of diphtheria since December 2014. Little is known about the factors contributing to the spread and persistence of the disease in the country. Geographic information systems (GIS) and spatial analysis were used to characterize the epidemiology of diphtheria in Haiti between December 2014 and June 2021. METHODS: Data for the study were collected from official and open-source databases. Choropleth maps were developed to understand spatial trends of diphtheria incidence in Haiti at the commune level, the third administrative division of the country. Spatial autocorrelation was assessed using the global Moran's I. Local indicators of spatial association (LISA) were employed to detect areas with spatial dependence. Ordinary least squares (OLS) and geographically weighted regression (GWR) models were built to identify factors associated with diphtheria incidence. The performance and fit of the models were compared using the adjusted r-squared (R2) and the corrected Akaike information criterion (AICc). RESULTS: From December 2014 to June 2021, the average annual incidence of confirmed diphtheria was 0.39 cases per 100,000 (range of annual incidence = 0.04-0.74 per 100,000). During the study period, diphtheria incidence presented weak but significant spatial autocorrelation (I = 0.18, p<0.001). Although diphtheria cases occurred throughout Haiti, nine communes were classified as disease hotspots. In the regression analyses, diphtheria incidence was positively associated with health facility density (number of facilities per 100,000 population) and degree of urbanization (proportion of urban population). Incidence was negatively associated with female literacy. The GWR model considerably improved model performance and fit compared to the OLS model, as indicated by the higher adjusted R2 value (0.28 v 0.15) and lower AICc score (261.97 v 267.13). CONCLUSION: This study demonstrates that GIS and spatial analysis can support the investigation of epidemiological patterns. Furthermore, it shows that diphtheria incidence exhibited spatial variability in Haiti. The disease hotspots and potential risk factors identified in this analysis could provide a basis for future public health interventions aimed at preventing and controlling diphtheria transmission.

Experiences and views of parents on the prevention of second-hand smoke exposure in Middle Eastern countries: a qualitative systematic review.

OBJECTIVE: The objective of this review was to identify, appraise, and synthesize the evidence related to experiences and views of parents, children, and professionals on the prevention of second-hand smoke exposure to women and children in Middle Eastern countries. INTRODUCTION: Second-hand smoke exposure is a major health concern. It is problematic during pregnancy because of potential adverse reproductive effects and poor fetal outcomes. Childhood second-hand smoke exposure is linked to increased morbidity and mortality. Smoking prevalence is high among men in Middle Eastern countries and, as a result, large numbers of non-smoking men, women, and children are exposed to second-hand smoke daily. INCLUSION CRITERIA: Studies were considered for inclusion if they explored experiences and views on the prevention of second-hand smoke exposure among women and children in homes, workplaces, schools, personal vehicles, and public places in 17 Middle Eastern countries. This review included studies that focused on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative descriptive, and feminist research. METHODS: MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Scopus databases were searched to identify published studies from inception to January 2021. The search for unpublished studies included EThOS, OpenGrey, and ProQuest Dissertations and Theses. No language restrictions were applied. The JBI guidelines for qualitative systematic reviews were followed in conducting the review. The JBI process of meta-aggregation was used to identify categories and synthesize findings. RESULTS: Of 5229 records identified, two qualitative studies (in three publications) met the eligibility criteria and were included in the review. One study was conducted in Turkey and the other study (reported in two papers) was conducted in Israel. The methodological quality of the studies was high. The participants in the included studies were parents (n = 118 participants) aged between 18 and 42 years. The methods used for data collection were interviews analyzed using thematic content analysis. A total of 50 findings were extracted and aggregated into eight categories, based on the similarity of meaning. Three synthesized finding were generated (all with moderate confidence): i) Parents were aware of second-hand smoke and that exposure to second-hand smoke is harmful, although the health dangers of second-hand smoke exposure were not commonly discussed with parents during pregnancy;ii) Smoking is a socially and culturally accepted norm, with parents reporting cultural beliefs about traditional values as a barrier to reducing second-hand smoke exposure in the home and personal psychological factors to quitting smoking; iii) Parents implemented different physical restrictions on smoking, such as having rules about where smoking can take place, with psychological motivators reported as drivers to decrease second-hand smoke exposure among children in the home, but tended to lack certainty or confidence regarding whether such protective measures were needed or would be effective. CONCLUSIONS: The findings of this study offer an insight into parents' views on second-hand smoke exposure and its prevention in Middle Eastern countries. Parents have conflicting views on second-hand smoke exposure and techniques to minimize it. Interventions are needed to increase parents' knowledge about the harms of second-hand smoke to reduce women's and children's exposure to second-hand smoke. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42019137006.

Assessing the Effectiveness of Bisphosphonates for the Prevention of Fragility Fractures: An Updated Systematic Review and Network Meta-Analyses.

Bisphosphonates have been found to be effective in preventing fragility fractures. However, their comparative effectiveness in populations at risk has yet to be defined. In light of recent clinical trials, we aimed to compare four bisphosphonates (alendronate, ibandronate, risedronate, and zoledronate) and to identify which are the most effective for the prevention of fragility fractures. This is an update of a systematic review previously published as part of a NICE HTA report. We conducted a systematic review and network meta-analysis, updating the estimates regarding the comparative effectiveness of the aforementioned bisphosphonates. Studies identified from published and unpublished sources between 2014 and 2021 were added to the studies identified in the previous review. Screening, data extraction and risk of bias assessment were independently undertaken by two reviewers. Outcomes were fractures, femoral neck bone mineral density (BMD), mortality, and adverse events. We identified 25 additional trials, resulting in a total population of 47,007 participants. All treatments had beneficial effects on fractures versus placebo with zoledronate being the most effective treatment in preventing vertebral fractures (hazard ratio [HR] 0.38; 95% credibility interval [CrI], 0.28-0.49). Zoledronate (HR 0.71; 95% CrI, 0.61-0.81) and risedronate (HR 0.70; 95% CrI, 0.53-0.84) were found to be the most effective treatments in preventing nonvertebral fractures. All treatments were associated with increases in femoral neck BMD versus placebo with zoledronate being the most effective treatment mean difference (MD 4.02; 95% CrI, 3.2-4.84). There was a paucity of data regarding hip and wrist fractures. Depending on its cost-effectiveness, zoledronate could be considered a first-line option for people at increased risk of fragility fractures. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

The Effect of Tobacco Control Mass Media Campaigns on Smoking-Related Behavior Among People With Mental Illness: A Systematic Literature Review.

INTRODUCTION: Tobacco control mass media campaigns (MMCs) can be effective generally, but little is known about their effects among people with mental illness. The objectives of this study were to systematically review: (1) Whether tobacco control MMCs affect smoking-related outcomes among people with mental illness. (2) Cost-effectiveness. AIMS AND METHODS: Data sources: MEDLINE, Embase, PsycInfo, Web of Science, CINAHL, the Cochrane Library (searched March 2021), reference lists of included articles and relevant systematic reviews. Study eligibility criteria: Population: Adults with mental illness and experience of smoking tobacco and/or using other nicotine-containing products. Intervention/exposure: Tobacco control MMC messages. Comparator: No exposure, other tobacco control intervention(s), no comparator. Primary outcome: Changes in quitting behaviors. Study design: All primary research. Quantitative data were appraised using the EPHPP tool, qualitative data using CASP's Studies Checklist. Data were synthesized narratively. RESULTS: Eight studies were included, seven were at high risk of bias. There was inconclusive evidence of the effect of MMCs on quit attempts and intentions to quit among people with mental illness. Increasing advertisement exposure did not increase quit attempts or intentions to quit among those with mental illness, however, increased exposure to an advertisement that addressed smoking and mental health did. None of the studies assessed cost-effectiveness. CONCLUSIONS: Findings should be interpreted with caution as data are limited and of low or moderate quality. There is evidence to suggest that tobacco control MMCs have limited impact on those with mental illness, although campaigns that are specific to smoking and mental health may be effective. IMPLICATIONS: There is a paucity of good-quality evidence of the effect of tobacco control MMC messages among people with mental illness. Careful consideration should be given to the design of future studies that evaluate MMCs in order to minimize the risk of bias, establish causality, and ensure the findings reflect real-world implementation. Further research should examine the need for MMC messages that address mental health.

When is Subnational, Supralocal Tobacco Control "just right"? A Qualitative Study in England.

INTRODUCTION: Subnational, supralocal (or "regional") approaches to tobacco control are often central federal nation tobacco control and can be superfluous for very small nations. However, their relevance to countries with weak intermediate tiers of governance are less clear. This study explores expert and policymaker perceptions on the function, form, footprint, and funding of regional tobacco control (RTC) in England. AIMS AND METHODS: One-to-one semistructured interviews (n = 16) and four focus groups (n = 26) exploring knowledge and perceptions of the past, present, and future of RTC in England were conducted with public health leaders, clinicians, tobacco control practitioners, civil servants, and politicians. Interviews were audio-recorded, transcribed verbatim, and analyzed thematically. RESULTS: Participants reported several key functions for RTC, including illicit tobacco control, media campaigns, advocacy, policy development, and network facilitation for local actors. A small minority of participants reported little role for RTC. Broader perceived features of effective RTC included subject expertise, strong regional ties, systems leadership, and a distinctive program of work. Views varied on whether regional programs should be developed nationally or locally, and their optimal footprint. Participants generally agreed stable funding was a prerequisite for success, although there was lesser agreement on funding sources. CONCLUSIONS: Pooling resources at the regional level in countries with weak intermediate tiers of governance may increase reach, cost-effectiveness and impact of campaigns, policy interventions, and advocacy, whilst retaining the ability to tailor approaches to regional populations. IMPLICATIONS: There are likely to be greater funding and governance challenges associated with introducing or strengthening RTC in countries with weak intermediate tiers of governance. Despite this, evidence from England shows it is possible to develop RTC approaches reported as effective by key stakeholders. Possible benefits of regional approaches in this context include cost-effective delivery of illicit tobacco control, media campaigns, advocacy, research, policy development, and coordinated support for local action on tobacco.